Cross-Cutting/Systems Building - Annual Report

 

Illinois’ priorities for the Cross-Cutting Domains are:

• Strengthen workforce capacity and infrastructure to screen for, assess, and treat mental health conditions and substance use disorders. (Priority #8)
• Support an intergenerational and life course approach to oral health promotion and prevention. (Priority #9)
• Strengthen MCH epidemiology capacity and data systems. (Priority #10)

 

Priority #8 - Mental Health and Substance Use

 

Illinois’ mothers and infants continue to experience adverse outcomes related to mental health disorders and substance use. Mental health and substance use disorders remain a common source of hospitalization among women of reproductive age (SOM #2), causing 135 hospitalizations per 10,000 population in 2020. Approximately 1 in 10 Illinois women experience postpartum depression symptoms following a recent live birth (NOM #24). This indicator has remained stagnant over the last 6 years; however, Illinois has improved its ranking to 5th best among all states (because other states have experienced declines in this measure). The rate of neonatal abstinence syndrome (NAS; NOM #11) in Illinois has continued to decline since peaking in 2017. Non-Hispanic White infants continue to be two times more likely than non-Hispanic Black infants and 5 times more likely than Hispanic infants to experience NAS. Overall, Illinois has the 6th lowest NAS rate among all states.

 

Among Illinois children and adolescents, mental health is also a priority. Mental health services were especially difficult to access, with only 55% of children who needed treatment or counseling able to receive them in 2019-2020. (NOM #18). demonstrating difficulties with accessing the services that are needed. Alarmingly, the adolescent suicide rate (NOM #16.3) in Illinois has remained persistently high in recent years and is currently the ninth highest rate in the country. Recent analyses done by the Title V program have demonstrated a steady rise in death by suicide among groups traditionally at lower risk, including female adolescents and adolescents of color. This calls for suicide prevention resources responsive to a diverse groups of teens.

 

In FY21, Title V utilized the following strategies to strengthen workforce capacity and infrastructure to screen for, assess, and treat mental health conditions and substance use disorders:

 

8-A.  Partner with the Illinois Children’s Mental Health Partnership to develop and to implement a model for children’s mental health consultations for local health departments and other public and private providers in the public health and health care delivery system.

 

Infant and early childhood mental health consultation is a multi-level, proactive approach that partners multi-disciplinary infant early childhood mental health professionals with people who work with young children and their families. The pairing of these partners seeks to support and enhance children’s optimal social emotional development, health, and well-being. More specifically, the approach aims to build the capacity of public health programs to prevent, to identify, and to reduce the impact of mental health concerns among infants, young children, and their families. Title V partnered with the Illinois Children’s Mental Health Partnership (ICMHP) to integrate a model for infant and early childhood mental health consultation (IECMHC) into public health settings.

 

Title V supported the IECMHC public health pilot program that launched in FY20. The pilot provided for 10-12 hours a month of reflective consultation by an infant/early childhood mental health consultant to the selected local health departments (Stephenson County, Winnebago County, Southern Seven counties, and the city of East St. Louis). The programs also included monthly professional development and reflective supervision to promote fidelity to the IECMHC model. A comprehensive report of the pilot program was completed at the end of FY21 and included details on the evaluation completed, including impact and outcomes of the pilot, comprehensive list of resources required to be successful, and roles/responsibilities of key personnel. Title V has reviewed the report and discussing opportunities to leverage lessons learned with key stakeholders.

 

8-B.  Partner with the Illinois Department of Corrections and Logan Correction Center on health promotion activities for incarcerated women focused on substance use recovery and trauma health education.

 

This strategy is similar to strategy 1-B. Information about this activity is available in the narrative for the Women’s and Maternal Health Domain.

 

8-C.  Partner with UIC Center for Research on Women and Gender to implement a program at two clinic sites to expand the capacity of health care providers to screen, to assess, to refer, and to treat pregnant and postpartum women for depression and related behavioral health disorders.

 

This is the same as strategy 1-D. Information about this activity is available in the narrative for the Women’s and Maternal Health Domain.

 

8-D.  Convene and facilitate state Maternal Mortality Review committees (MMRC and MMRC-V) to review pregnancy-associated deaths and develop recommendations to improve quality of maternal care as well as reduce disparities and address social determinants of health.

 

This is the same as strategy 2-A. Information about this activity is available in the narrative for the Women’s and Maternal Health Domain.

 

8-E.  Support the Perinatal Mental Health Program that includes a 24-hour telephone consultation for crisis intervention for women suffering from perinatal depression.

 

This is the same as strategy 2-J. Information about this activity is available in the narrative for the Women’s and Maternal Health Domain.

 

8-F.  Support the Illinois Perinatal Quality Collaborative (ILPQC) in its implementation of obstetric and neonatal quality improvement initiatives in birthing hospitals.

 

This is the same as strategy 2-I. Information about this activity is available in the narrative for the Women’s and Maternal Health Domain.

 

8-G.  Collaborate with other state and national initiatives to address opioids and substance use to ensure a focus on women of reproductive age, including participation in the ASTHO Opioid Use Disorder, Maternal Outcomes, Neonatal Abstinence Syndrome Initiative (OMNI) Learning Collaborative.

 

During FY21, IDPH served as a member of the Illinois team invited to participate in the ASTHO Opioid Use Disorder, Maternal Outcomes, Neonatal Abstinence Syndrome Initiative (OMNI) Learning Collaborative. The Illinois team was comprised of representatives from IDPH, HFS (Medicaid), DHS, DCSF (child welfare), and the Illinois Perinatal Quality Collaborative. The team’s OMNI project focused on Illinois having a “recovery-oriented system of care that enables women planning pregnancy and pregnant and postpartum women to receive medication-assisted treatment (MAT) and needed support services to have healthy pregnancies and deliveries and be supported in the postpartum period for the development of healthy families.” The team identified several barriers to MAT for women with substance use disorder (SUD), including lack of providers, lack of provider awareness/training, lack of care coordination and a fragmented system, lack of identification/ screening, reimbursement issues, prenatal care providers lacking experience and process to link women to MAT providers, stigma, and the social determinants of health (transportation, housing, child care). The goals of the project were:

• Expand access to MAT for pregnant women with SUD by increasing the number of providers trained to screen/diagnose SUD, administer MAT, and counsel patients.
• Develop a cross-system communication plan for the health care, Medicaid, substance use prevention/treatment, and child welfare systems that reduces stigma around substance use disorder and creates standardized systems of support for pregnant women with SUD and their infants.
• Develop cross-system training for providers delivering prenatal care, labor/delivery staff in hospitals, and the child welfare system to establish standardized protocols and practices that would assure optimal care to infants born with neonatal abstinence syndrome (NAS).

 

This project ended in FY21 with an OMNI Virtual Summit. At the summit, state teams came together and highlighted their respective successes, innovations, and sustainable solutions regarding care for pregnant and postpartum women with opioid use disorder and infants prenatally exposed to opioids. Teams also engaged in state-to-state learning and federal partner presentations. These events allowed the teams to discuss next steps for improving access to care and treatment for this population as well as building capacity to address new and emerging issues.

 

Although the program ended in FY21, OWHFS and Title V will continue to increase support and education for health care providers and patients around the use of LARC. These efforts include working with Illinois Department of Corrections to expand the efforts of ILPQC’s immediate postpartum LARC initiative.

 

8-H.  Identify gaps in mental health programs and resources for Illinois children, develop partnerships with and within organizations focused on improving mental health among children and adolescents, and support the implementation of mental wellness programs that facilitate system level improvements as well as address social determinants of health.

 

This is the same as strategy 4-D. Information about this activity is available in the narrative for the Child Health Domain.

 

8-I.  Participate on and collaborate with statewide Adolescent Suicide Prevention Ad Hoc Committee to develop a strategic plan to reduce suicide ideation and behavior among youth.

 

This is the same as strategy 5-C. Information about this activity is available in the narrative for the Adolescent Health Domain.

 

8-J.  Collaborate with organizations and programs to address the impact of adverse childhood experiences (ACE) and toxic stress on mental and physical health in children and adolescents.

 

This is the same as strategies 4-F and 5-F. Information about this activity is available in the narratives for the Child Health Domain and the Adolescent Health Domain.

 

8-K.  Convene and partner with key stakeholders to identify gaps in mental health and substance abuse services for women that include difficulties encountered in balancing multiple roles, self-care and parenting after childbirth, and leverage expertise to develop recommendations for system level improvements for Title V consideration and implementation.

 

This is the same as strategy 2-G. Information about this activity is available in the narrative for the Women’s and Maternal Health Domain.

 

Priority #9 - Oral Health

 

Access to dental healthcare is a priority and a challenge in Illinois. Less than half of Illinois’ pregnant persons receive a preventative dental visit during pregnancy (NPM #13.1), and there was a considerable drop in this indicator from 48.1% in 2019 to only 40.8% during 2020. The percent receiving preventive dental care during pregnancy was even lower (less than 30%) for women with a high school degree or less, women who were Non-Hispanic Black, women on Medicaid, women participating in WIC, and women younger than 25 years old. The sudden decrease in 2020 is likely explained by the COVID-19 pandemic, when many dental offices were shut down for non-emergencies for several months, and then there were long wait times to be seen once offices re-opened. In addition to this, pregnant women may have avoided seeking certain types of care that they deemed “less important” due to fear of COVID-19, and dental visits may have been especially prone to this. We hope to see this measure resume to “normal” in 2021. Nevertheless, we will continue to monitor changes over time.

 

Many children also lack dental health services; approximately 77% of children received a preventive dental visit in 2019-2020 (NPM #13.2). There was not a significant change in this figure from the 2018-2019 average to the 2019-2020 average, but this may be due to unreliability of the estimates from the data source used for this measure. Among uninsured children, only 60% received a preventive dental visit, compared to more than 80%v of children with private insurance. Racial/ethnic disparities persist as well; non-Hispanic Black and Hispanic children were less likely to have a preventive dental visit than non-Hispanic White children.

 

During FY21, Title V utilized the following strategies to support an intergenerational and life course approach to oral health promotion and prevention:

 

Title V supports the Oral Health Section (OHS) in its various population health activities improving the oral health, and ultimately, the overall health of women, children, and families. It is important to note that OHS is not a new entity at IDPH but, due to reorganization, the Division of Oral Health’s name was changed, and it is now housed within the Division of Community Health and Prevention. Aside from these changes, OHS’s vision, mission, duties, and commitment to oral health stakeholders remain the same.

 

9-A.  Partner with IDPH Oral Health Section (OHS) to expand oral health outreach to the most at-risk maternal populations by engaging local programs and organizations.

 

In FY21, OHS focused on programs working directly with pregnant women through the WIC programs within local health departments. These activities focused on bringing a greater awareness of the oral systemic link between low birth weight and pre-term labor.  By working directly with WIC programs, OHS sought to help the most at-risk maternal population.

 

In Champaign-Urbana, OHS collaborated with the Champaign–Urbana Public Health District (C-UPHD) on a five-state pilot entitled, “Partnership for Integrating Oral Health Care into Primary Care.” The project plan included promoting “Smiles for Life” and other oral health training opportunities at C-UPHD, especially for new staff, in an effort to integrate oral health risk assessments, education, and referrals to WIC participants (virtually or by phone) and to pregnant persons receiving services at C-UPHD. Finding dentists who participated in Medicaid in the area and are willing to see pregnant people was a challenge. The COVID-19 pandemic further reduced the capacity of dental offices and clinics to see pregnant people with low incomes. To address this challenge, C-UPHD partnered with the local dental association to provide COVID-19 vaccinations to oral health professionals, which helped build relationships and improve trust.  C-UPHD will continue to build local professional relationships to expand its oral health referral network for pregnant and postpartum people.

 

Additionally, OHS piloted a new grant opportunity for local health departments that completed an Oral Health Needs Assessment and Planning Grant (OHNAP) within the previous three years. The original OHNAP grant provided grantees with the opportunity to evaluate and to determine the oral health status of their jurisdiction through a comprehensive community-based assessment. This process produced action plans and/or next steps. The second phase of the grant, known as OHNAPP II, provided grantees with funding and technical assistance to implement their action plans.

 

The OHS will continue to reach out to local health departments to provide technical assistance and guidance for oral health programs. These programs include fluoride varnish trainings, medical dental integration, and referrals to care programs.

 

9-B.  Partner with OHS to support and to assist MCH populations and key stakeholders, which include women of reproductive age, school personnel and families, to access oral health education, dental sealants, fluoride varnish, Illinois All Kids (Medicaid) enrollment, dental home referrals, and to comply with Illinois’ mandatory school dental examinations for children in kindergarten, second, sixth, and ninth grades.

 

In FY21, Oral Health in Illinois: A Focus on Pregnancy and Early Childhood (OHI: FPEC) was published in the Maternal and Child Oral Health section of the Oral Health webpage. This resource guide and toolkit provides specific ways to improve the oral health status of individuals of childbearing age, pregnant persons, and for babies to the young child. These resources have been gathered from national, state, and local experts and have been modified for use in Illinois. The focus of Oral Health During Pregnancy and Early Childhood in Illinois is to improve the health of women of childbearing age and young children. Receipt of preventive oral health care, education of the importance of effective self-care practices, and timely access to corrective treatments that address dental diseases are good for both the health of the woman and for the future oral health of their child.

 

OHS has initiated the Illinois County Health Resources Map for partners and public use. The project started at the southern tip of Illinois and is moving north. To date, resources for the 26 most southern Illinois counties have been completed and mapped. Once completed, the oral health resource map will provide an interactive visualization of the state’s available oral health and other health and wellness resources. In addition, contact information, hours of operation, and other pertinent details will be able to be viewed for each resource. Resources can also be filtered by categories, such as food distribution centers, grocery stores, FQHCs, dental providers, medical providers, local health department clinics, and other sources of health and well-being.

 

Another noteworthy activity was OHS’s online oral health resources. OHS staff compiled and reviewed 77 online oral health resources (videos, lesson plans, curricula, facts sheets, and practical tips) designed to support local health departments and to be used by teachers, school nurses, parents, health care professionals, classrooms, individual children, and community members. This resource listing can be found on the IDPH Oral Health webpage.

 

OHS’s webpages also includes sections on OHS programs, Oral Health Plan Fast Facts on Oral Health, Where/How to Access Oral Health Care, and Oral Health Data. A total of 34 Fast Facts on Oral Health were published on the Oral Health webpage. The process included researching current topics and writing approximately 40 “Fast Facts on Oral Health” that include Accessing Oral Health Care in Illinois, What to Expect During Your Oral Care Visit? For the Adult Patient, and Careers in Oral Health Care. Plain language “Fast Facts on Oral Health” are directed at public and professional audiences.

 

It is important to note that Title V previously funded the Dental Sealant Grant, as a fee-for-service grant, but in FY21, the program was revamped into a population-based grant named the Oral Health Promotion Program Grant (OHPP). OHS used the data analysis and recommendations from the 2020 published Healthy Smiles Healthy Growth 2018-2019 Report to determine areas in Illinois that need resources to address oral health disparity gaps. Through the OHPP funding opportunity, 14 entities across Illinois are developing and implementing innovative programs that address the oral health needs of children and families through high-quality education, integration into medical visits, and disease mitigating prevention services. The program will primarily reach low-income vulnerable families with a focus on early prevention to reduce oral disease burdens and to help people obtain timely oral health care services. It is also designed to assist school personnel and families in accessing oral health education, fluoride varnish, All Kids enrollment, and care services through a dental home relationship.

 

OHS retained its membership in the ISBE School Health Advisory Committee and works with IDPH’s Office of Women’s Health and Family Services (OWHFS) on supporting optimal oral health for school-aged children. Discussions revealed several avenues of potential collaboration, including speaking at the ISBE Wellness Conference, presenting at IDPH’s School Health Days, data sharing, links to local and regional contacts, review of nutrition in the school curriculum, school-based program support, standardized messaging, support of health equity issues found through the ISBE Strategic Plan, and bolstering communication about oral health at school and district levels. The first collaboration resulted in a joint statement geared towards school administrators and school nurses stating support and importance of the school-based oral health program in the health, education, and well-being of the school-aged child. Several presentations were conducted on the oral health status of school-aged children during this reporting period and have reached more than 800 school nurses through online presentations and recordings made available for asynchronous review.

 

With the Illinois State Fair back in 2021, OHS resumed its annual free dental exam program for children at the fair. From August 17-19th, IDPH oral health consultants were joined by several Illinois dental providers and a team of dental students from Southern Illinois University. Proof of exam forms for schools were available for those that needed them. Currently, the ISBE requires proof of an oral health exam for all children entering kindergarten, second grade, sixth grade, and ninth grade. Over the course of three days, IDPH’s dental partners were able to provide 41 examinations, provide oral health education for other family members present, and provide oral health supplies. Most patients were school-aged children, but some families brought their infants for their first-ever dental exams.

 

9-C.  Collaborate with OHS to design and implement the first Basic Screening Survey (BSS) for Pregnant Women that will assess the burden of oral diseases and barriers to access care.

 

Using established methodology, the first Basic Screening Survey (BSS) for Pregnant Women in Illinois will be implemented to assess the burden of oral diseases and barriers to access care.  Data will be collected, validated, cleaned, and results will be compiled.  A comprehensive and detailed report of the findings will be completed and disseminated to stakeholders.

 

In FY21, OHS found it necessary to pivot this initiative to the immediate needs associated with the COVID-19 pandemic. However, progress was obtained as a data collection tool was finalized and the protocol manual was drafted. Connections were also made to submit the IDPH IRB application for exempt status.

 

9-D.  Participate in the “Implementation of Quality Indicators to Improve the Oral Health of the Maternal and Child Health Population” Pilot Project with OHS to pilot a series of measures to inform the creation of a national set of indicators.

 

The Illinois Oral Health Surveillance Plan (IOHSP) was completed and published in FY21. This plan provides a strategic approach to the development and implementation of the Illinois oral health surveillance system (IOHSS). The plan aligns with the Illinois Oral Health Plan IV: Eliminating Inequities in Oral Health (2021 – 2025) and Healthy People 2030 (HP2030) Oral Conditions Objectives.

 

OHS continues to develop the framework and infrastructure for the IOHSS. The goal of the surveillance system is to monitor state-specific, population‐based oral disease burden and trends, and measure changes in program capacity and community water fluoridation quality. The surveillance system will include oral health data sets/measures that inform partners statewide. The first wave of data will include non-traumatic use of the emergency department and help community partners to better understand community needs and create plans to address the needs. Title V epidemiologists and staff are supporting these efforts.

 

9-E.  Participate in the Partnership for Integrating Oral Health Care into Primary Care project with OHS and a local health department to integrate the interprofessional oral health core clinical competencies into primary care practice, particularly for pregnant women and adolescents.

 

OHS worked with local health departments, federally qualified health centers, and other Medicaid providers to encourage them to implement fluoride varnish as part of their routine standard of care for infants. Staff were encouraged to have an open dialogue with the infant’s caregiver as it is the best way to evaluate and monitor the oral health needs of the rest of the family. 

 

Another notable activity is the Illinois Oral Health Plan IV. OHS completed and published the Illinois Oral Health Plan IV (2021-2025): Eliminating Inequities in Oral Health (IOHP IV). This was the result of eight community meetings and four active participation webinars with an estimated 300-400 attendees and contributors. Through implementation of the plan, IDPH hopes to increase the health knowledge of the public, expand health promotion, strengthen primary prevention efforts, and improve access to timely professional services. It is equally important that local, county, and state stakeholders have regular updates of emerging concerns and disease burdens to act quickly in mitigating health issues.      

 

Priority #10 - MCH Epidemiology Capacity and Data Systems

 

Illinois developed SPM #5 to monitor data capacity over time. This measure considers 10 potential MCH data sources and whether the Title V epidemiology staff have direct access to these sources, whether the team conducted any specific analyses of these data files (beyond standard reporting requirements), and whether the findings were disseminated through presentations, reports, or other data products. A total score of 30 points is possible if all 10 data sources were available, analyzed, and had a related data product within one year.

 

During 2016-2020 when Illinois was building its internal data capacity, this SPM showed steady improvement over time, rising from 15/30 in 2016 to a high of 27/30 points in 2019 when 5-year needs assessment activities were underway. The data capacity score in 2020 was 25/30 points, slightly lower than 2019 because the needs assessment analyses were previously completed. In 2021, the MCH data capacity score was 24/30 points, 9/10 points for data access, 8/10 points for analysis, and 7/10 points for dissemination. For both 2020 and 2021, Title V epidemiology staff were detailed to work on issues related to COVID-19 and could not complete all the analyses that would have otherwise been planned for the year. Thus, the analysis and dissemination scores for those two years were slightly lower than might be expected if the pandemic had not occurred.

 

Despite the disruption of the pandemic to the normal surveillance, needs assessment, and program evaluation activities for the MCH epidemiology team, it is noteworthy that we have been able to maintain a high level of data capacity and use. The Illinois Title V epidemiology team has maintained direct access to 9/10 target datasets. Medicaid claims data are the one dataset not currently available to Title V epidemiology staff, though discussions with the Illinois Department of Healthcare and Family Services are underway to determine if this access could be allowed in the future. During 2021, 8/10 high-priority datasets were used for customized analyses to inform Title V work and programs, and data products were disseminated based on 7 of these datasets.

 

During FY21, Title V employed the following strategies to strengthen MCH epidemiology capacity and data systems:

 

10-A.  Enhance staff capacity for data management, analysis, and translation through training and workforce development.

 

Training Opportunities

 

In May 2021, Illinois Title V hired two epidemiologists to support state MCH programs: Ashley Horne, MSPH, as Maternal and Infant Health Epidemiologist and Julia Howland, MPH, as Child and Adolescent Health Epidemiologist. These epidemiologists have been integrated into the Title V team and will be supported with professional development activities during 2022. The Title V epidemiology team began monthly meetings in mid-2021 to provide opportunities for peer sharing, collaboration, coordination of work, and technical support.

 

Title V staff are encouraged to attend professional development activities and conferences to increase knowledge of best practices, to become aware of emerging issues, and to develop professional and scientific skills. During FY2021, MCH epidemiology team members virtually attended the Council of State and Territorial Epidemiologists (CSTE) annual conference (June 2021) and the Illinois Maternal Health Summit (September 2021).

 

In December 2020, UIC-DSCC regrouped with the regional Quality Champions to discuss next steps since their quality roles had paused since the start of the COVID-19 pandemic.  Quality Champions are members of various regional teams across UIC-DSCC programs who have taken on a role  to facilitate discussion on quality topics and to develop peer level action plans on a topic of choice.  Quality Champions have a couple hours per month dedicated to their quality work and spend the remainder of their time working in their primary role. In January 2021, refresher training was provided to the Quality Champions on Plan Do Study Act methodology, facilitation of discussion, use of the Quality Champion Action Plan, and on how to interpret various data available in Power BI reports.  The Quality Champions have resumed quarterly support meetings with the UIC-DSCC Quality Improvement Teams.  At each quarterly meeting, education is provided on various topics pertaining to their role. 

 

Workforce Development for Interns, Fellows, and Early Career Professionals

 

During FY21, Illinois Title V hosted two CSTE Applied Epidemiology Fellows in MCH epidemiology. Bria Oden, MPH, continued her fellowship into her second year, mentored by Dr. Amanda Bennett and by Dr. Jane Fornoff, epidemiologist and manager for the Adverse Pregnancy Outcomes Reporting System (APORS; state birth defects registry). Her projects during 2021 were to develop a youth suicide surveillance report, analyze data on neonatal abstinence syndrome, evaluate the utility of syndromic surveillance data for pregnant persons, and assist with writing reports and grant applications for various programs. Jelena Debelnogich, MPH, began her two-year fellowship with Illinois Title V in August 2021, and is mentored by Dr. Cara Bergo and Dr. Amanda Bennett. The primary focus of Ms. Debelnogich’s fellowship is maternal health.  Many of her projects will focus on aspects of maternal morbidity and mortality. During FY21, she led the development and analysis of the evaluation survey for the state Maternal Health Summit.

 

The Title V program continues to host students seeking internships in maternal and child and/or epidemiology. The MCH epidemiology team for Illinois Title V increased its applied epidemiology capacity by hosting six students for various internships during 2020 (5 MPH students in epidemiology; 1 PhD student in epidemiology). These students completed projects on a wide variety of topics, including infant mortality, severe maternal morbidity, maternal mortality, breastfeeding, child mental health, and women’s mental health and substance use. They significantly contributed to the work of IDPH through the development of one data linkage, six quantitative data analyses, one qualitative data analysis, one fact sheet, four formal data reports, and three conference abstracts.

 

10-B.  Improve data infrastructure and systems, including initiatives to improve accuracy, timeliness, and quality of data.

 

Data Linkage

 

Linkage of data systems has long been identified as a need to improve MCH surveillance, assessment, and evaluation. The Illinois Title V epidemiology team supports the data linkage needs of state programs but is limited by staff capacity. During FY21, the Illinois Title V epidemiology team successfully completed various matches using vital records data.

 

The Title V epidemiology team performs ongoing evaluation and validation of the matched infant birth-death records that are produced by the IDPH Division of Vital Records. Validation is done through a probabilistic linkage in LinkPlus software to search for matches not identified by the state’s automated vital records matching software, or for incorrect matches that need to be “unlinked.” Updated information is provided to the IDPH Division of Vital Records so it can improve the matching system. During FY21, the matching process for the 2018 birth cohorts was completed. This additional validation of the matching process has improved the matching rate for resident infant deaths from about 90% to about 99%. This is an annual activity of the data team to ensure that high-quality matched infant birth and death records are available for detailed analyses of infant mortality.

 

Additionally, deaths among women of reproductive age were matched to births and fetal death certificates to identify pregnancy-associated deaths, serving as a check to ensure all maternal deaths are identified using the primary, manual matching process. Correct identification of all pregnancy-associated deaths is crucial to Illinois’ maternal health efforts. During FY21, the maternal mortality epidemiologist linked vital records data to identify pregnancy-associated deaths occurring during 2019 and 2020. This linkage identified six deaths during 2019 and 10 deaths during 2020 that were missed through other case ascertainment methods (e.g., death certificate pregnancy checkbox, facility reporting, newspaper review).

 

Linkage of birth certificates and hospital discharge data is a relatively new process in Illinois that began in 2018 after a multi-year process to gain access to identifiable hospital discharge files. Since that time, staff have developed linkage protocols for matching infant birth hospitalizations to birth certificates and maternal delivery hospitalizations to birth certificates. Due to limited staff capacity, no new data years were linked during FY21. These processes are being resumed in 2022 with the hopes of catching up the discharge-birth linkages to be as close to real-time as possible. The team did develop procedures to ensure this linkage will continue in future years of data and resume linking the 2018 birth cohorts during FY22. The team also drafted plans to use the available linked records to study infant conditions, such as neonatal abstinence syndrome, and maternal conditions, such as chronic diseases and comorbidities affecting pregnancy.  The team will also use the linked records to complete several data quality projects, including an analysis of hospitalization records currently missing in counties bordering other states and comparisons of demographic information across datasets.  These projects using the linked data records both allow for a more complete picture of maternal and infant health in the state and help to ensure ongoing state investment in data access through a demonstration of the usefulness of the linked files.

 

Finally, infant and fetal death certificates were linked to records of COVID-19 positive specimens among women of reproductive age to identify COVID-19 cases occurring during a pregnancy. Due to high frequencies of missing or unknown values in the pregnancy field on the COVID-19 case reporting form, this linkage identified 50% more pregnant COVID-19 cases than the use of the infectious disease reporting system alone. The identified cases are being reported to the CDC Surveillance of Emerging Threats to Mothers and Newborns Network (SET-NET) and detailed case abstraction is occurring for a random sample of these cases. The resulting linked data will be a robust data file that enables rich study of the impact of COVID-19 on pregnant persons and infants.

 

Maintenance and Improvement of Data Systems

 

During FY21, Title V supported the implementation of the ePeriNet data system, which collects data to inform quality improvement work for the Illinois regionalized perinatal system. Birthing hospitals and administrative perinatal centers are required to enter information related to key maternal and infant quality and health outcomes, such as mortalities, transfers, and specific morbidities. For example, ePeriNet is the data system that collects the VPT review forms to track barriers to antenatal maternal transports. Due to contractual issues in Illinois, Title V was not able to make any major changes or enhancements to the ePeriNet system during 2021, but the system continues to be maintained.

 

Since late 2019, Illinois has used the CDC Maternal Mortality Review Information Application (MMRIA) system for storing data on pregnancy-associated deaths. Data from death certificates, birth certificates, and fetal death certificates are entered for all pregnancy-associated deaths since 2015. Cases that are reviewed by the MMRCs have additional forms entered, such as the committee decisions form and information from autopsies, prenatal care, mental health profiles, and social and environmental profile. During FY21, data in MMRIA were finalized for deaths occurring during 2018 and preliminary information for deaths during 2019-2020 was entered.

 

Illinois PRAMS and OWHFS collaborate to improve survey response rates by using Title V funds to cover the cost of a reward for respondents. Until 2017, respondents received a small spiral bound note pad for completing the survey, but steadily declining response rates were beginning to threaten Illinois PRAMS ability to meet the CDC’s minimum response rate threshold. Innovative strategies were needed to stabilize the response rate and ensure validity of Illinois PRAMS data. In 2018, Title V began funding Illinois PRAMS to provide a $15 diaper gift card rewards for survey respondents. In FY21, Illinois PRAMS increased the reward to a $25 gift card.

 

The implementation of the gift card reward increased Illinois PRAMS response rates and enabled Illinois to continue exceeding the CDC’s minimum response rate threshold (currently 50%). Comparing the CY2017 response rate (54.8%) to response rates in CY2018 (60.1%), CY2019 (57.9%), CY2020 (60.3%), and CY2021 (55.4%) demonstrates increased response rates. More specifically, mail response rates were higher after gift card implementation (33.8% in CY2017 versus 42.3% in CY2020 and 37% in CY 2021). Mail mode is the preferred data collection method because it enables surveys to be returned faster, decreases the number of phone interviews, and decreases staff time spent on follow-up. With the implementation of the gift card reward, response rates increased for all racial and ethnic groups, though the largest response rate increases were among White women.

 

Beginning in FFY2020, UIC-DSCC began the development of various performance reports using Microsoft Power BI.  During FFY 2021, 13 new Power BI reports were completed. The implementation and use of these reports have been helpful for monitoring care coordination activities at an individual and organizational level as well as monitoring performance on key indicators, including items related to the current CYSHCN statewide priorities. 

 

Innovative Data Collection

 

In October 2020, Illinois PRAMS began to include the new COVID-19 supplement for six months of births (covering births during July-December 2020). This supplement was developed by CDC and includes questions about the direct and indirect effects of the COVID-19 pandemic on maternal health and health care services. For example, it asks questions about how the pandemic affected the ability to receive and to attend prenatal and postpartum care, and about whether telemedicine was available for these services. It also asks about ways the pandemic affected employment, income, mental health, and social support. These data will be useful for evaluating how the pandemic affected both medical and social factors in women’s lives and help inform future emergency preparedness activities for pregnant and postpartum women.

 

During 2021, Illinois continued to abstract information on social determinants of health (SDOH) for maternal deaths. This includes completing standardized fields in the CDC MMRIA “social and environmental profile,” but also supplementing this information with more details about topics not covered by MMRIA. To provide even more information about the social and community context for the women who experienced pregnancy-associated death, Illinois continued to participate as a pilot state for the “community vital signs dashboard” developed by Emory University in partnership with the CDC Maternal Mortality Team. This dashboard uses the woman’s last known residential address to generate a summary of community-level data on various state departments of health, such as health care providers per capita, housing stability, violence, segregation, and more. The dashboards were included in a case abstract packet for maternal mortality reviews during FY21. These data are used to help the committees evaluate community-level and systems-level factors that may have contributed to the woman’s death and to identify potential recommendations to address these factors. Illinois staff and MMRC members participated in evaluation activities with Emory University staff to provide feedback on the tools and to share how the dashboards were influencing case review discussions.

 

CDPH epidemiologists collaborated with Lurie Children’s Hospital on the development and implementation of a child-focused component of the Health Chicago Survey, dubbed Healthy Chicago Survey, Jr. This survey asked adults, including parents and non-parents from all 77 Chicago community areas, which issues they considered to be the greatest problems for Chicago children and adolescents. The survey was administered by web and paper from June to December 2020. The sample included 4,517 adults, 862 of whom were the parent, stepparent, or guardian of at least one child under 18 years old living in the household. The survey response rate was 38% and analyses were weighted to be representative of the adult population of the city of Chicago. Findings from this report were published in FY22 by Lurie Children’s Hospital.

 

10-C.  Analyze data, translate findings, and disseminate epidemiologic evidence to support MCH decision-making.

 

The MCH epidemiology team conducted many analytic projects to inform decision-making, particularly as related to the Title V priorities. Some of the topics represented in the analyses and epidemiologic studies completed during 2021 are as follows:

• Maternal morbidity and mortality.
• Health insurance stability before, during, and after pregnancy.
• Obstetric hospital closures and maternity care deserts.
• Perinatal depression and social support.
• Neonatal abstinence syndrome.
• Infant mortality, especially related to Sudden Unexpected Infant Death.
• Youth suicidal ideation, suicide attempts, and suicide mortality.
• Mental health and substance use hospitalizations among women of reproductive age.
• COVID-19 infection during pregnancy.
• Impact of COVID-19 pandemic on variety of MCH health services and outcomes.

 

The MCH epidemiology team tracks products resulting from data analyses as one way of monitoring productivity and impact. Dissemination of findings through reports, presentations, fact sheets, manuscripts, and other mechanisms is important for informing MCH practice in the state and promoting evidence-based decision-making.

 

During 2021, the team produced a total of 46 data products:

• 7 oral presentations at conferences
• 1 poster presentation at a conference
• 4 abstracts accepted to conferences but ultimately withdrawn due to virtual nature of conference during COVID-19 pandemic
• 5 manuscripts prepared for peer-reviewed journals (1 published)
• 2 data reports
• 2 master’s level theses
• 2 fact sheets, including infographics
• 23 presentations at national, state, or regional meetings

 

The epidemiology team represented the work of Illinois at various state and national meetings during 2021. Team members presented two oral presentations and one poster presentation at the Council of State and Territorial Epidemiologists conference and five oral presentations at the CityMatch / Maternal and Child Health Epidemiology conference. The topics of these presentations included youth suicide, adolescent health, COVID-19 during pregnancy, social determinants of health in maternal mortality review, and severe maternal morbidity. Four other abstracts were submitted and accepted to the CityMatch / Maternal and Child Health Epidemiology Conference, but ultimately withdrawn due to the virtual format during the COVID-19 pandemic and competing demands on staff time.

 

During 2021, the MCH epidemiology team were co-authors on five manuscripts developed and/or submitted for publication in peer-reviewed journals. (Illinois Title V staff bolded in citations):

• Manning SE, Bennett AC, Ellington S, Goyal S, Harvey E, Sizemore L, Wingate H (2022). Sensitivity of pregnancy status on the COVID-19 case report form among pregnancies completed through December 31, 2020 — Illinois and Tennessee. Maternal and Child Health Journal, 26: 217-223.
• Goyal S, Gerardin J, Cobey S, Son C, McCarthy O, Dror A, Lightner S, Ezike NO, Duffas W, Bennett AC (2022). SARS-CoV-2 infection among pregnant people at labor and delivery and changes in infection rates for the general population: Lessons learned from Illinois. Public Health Reports. [e-pub ahead of print]
• Phillips-Bell, G, Rohan AM, Hussaini K, Hansen KD, Bennett AC, Fuchs E, Goyal S… et al. Preterm Birth Rates during the COVID-19 Pandemic in 2020 Compared with 2017–2019 Across 12 U.S. States. (submitted to Paediatric and Perinatal Epidemiology in 2021, was not accepted.)
• Oden B, Fornoff J. Characteristics of infants with neonatal abstinence syndrome compared to other births in Illinois, 2015-2016. (submitted to Journal of Substance Abuse and Treatment in early 2022; awaiting decision)
• Holicky A, Anderson-Reeves T, Bennett AC, Lightner S, McRae K, Handler A. Childcare as a barrier to perinatal health care in Illinois. (manuscript under development, will be submitted to Maternal and Child Health Journal in 2022.)

 

Another notable data product from 2021 was the second Illinois Maternal Morbidity and Mortality Report, which was released in April 2021. This report is the most extensive report Illinois has released on maternal health and includes information on chronic disease during pregnancy, severe maternal morbidity, pregnancy-associated deaths, pregnancy-related deaths, and a detailed list of MMRC recommendations to prevent future maternal deaths. Due to the COVID-19 pandemic, IDPH created a press release for the report in place of a formal press conference. Multiple newspapers throughout Illinois wrote articles referencing the report and the OWHFS Deputy Director was interviewed for a local news station. In addition, Title V epidemiology staff members presented key findings from this report at 14 state and regional meetings.

 

CDPH collects and maintains current MCH-related data for residents of the city of Chicago. These data are published to the Chicago Health Atlas (https://chicagohealthatlas.org/). As new data become available, these resources are routinely updated. In FY21, there were 19 indicators in the “Maternal, Infant, Child, and Adolescent Health” section of the Chicago Health Atlas.

 

Performance Management and Program Evaluation Activities

 

In July 2020, UIC-DSCC initiated an organizational action plan related to care coordination performance called Connecting the Dots. Topics identified through Power BI reports or through record reviews as statewide areas of needed improvement were prioritized in the action plan.  Connecting the Dots ran through the end of October 2020 and covered 17 different topics. Every week a member of the leadership team provided an introductory message on the topic of the week to help relate that topic to the care of a CYSHCN and their family. The UIC-DSCC educators released a corresponding brief educational module on the topic. Management teams were asked to make sure they were spending time each week with their teams reviewing the topics. A main measurement used for this initiative is compliance with completion of a signed Person-Centered Care Plan. As of October 2020, DSCC was 32% compliant. Progress was shared quarterly across DSCC.

 

Based on feedback from the UIC-DSCC team, a replay of Connecting the Dots started in November 2021 and ran through March 2021 covering the same 17 topics. The previous feedback was that weekly topics were too much to keep up with. At the end of April, DSCC was 65% compliant with completion of signed Person-Centered Care Plans. 

 

Given the success of the Connecting the Dots initiative, in July 2021, UIC-DSCC kicked off the next phase called Connecting the Dots Planning Pathways. For this action plan, performance data from Power BI reports (at this time record review results were also available in Power BI) along with feedback from other stakeholders helped to again identify and prioritize topics. The previous feedback on frequency of topics was also taken into consideration. For Connecting the Dots Planning Pathways a leadership message introduces a topic monthly. This is followed by an educational module developed by the UIC-DSCC educators with reinforcement/review from managers. This initiative will run through the fall 2022. As of July 2021, DSCC was 71% compliant and by October 2021 progress had increased further to 80% compliant.  

 

10-D.  Forge partnerships that will increase the availability, analysis, and dissemination of relevant and timely MCH data.

 

Partnerships to Increase Epidemiology Capacity

 

Illinois continued to serve as an assignment site for a CDC Maternal and Child Health Epidemiology Program (MCHEP) field assignee, Amanda Bennett, PhD, MPH. Dr. Bennett began her CDC assignment with IDPH in December 2014, after working with Title V in various capacities since 2007. She provides technical assistance and scientific leadership to the Illinois MCH programs by conducting research and surveillance and building MCH epidemiology capacity. During FY21, she led the epidemiology team, ensured timely reporting of Title V measures, designed and implemented epidemiologic studies, and mentored interns, fellows, and other IDPH epidemiology staff. She presented at national conferences and state meetings and provided technical assistance to various state advisory committees.

 

To assist with surveillance activities during the COVID-19 pandemic, Title V hosted an additional CDC epidemiology until September 2021. Sonal Goyal, PharmD, MPH, began her assignment with IDPH in July 2020 through the CDC’s COVID-19 State, Territorial, and Local Health Department Task Force. During FY21, she led the design and implementation of a sentinel surveillance system for COVID-19 among pregnant persons that allowed perinatal hospitals to report aggregate testing results. She also helped to develop and to implement data linkage plans to identify confirmed COVID-19 infections during pregnancy by using vital records and infectious disease data. She led Illinois’ implementation of the Surveillance for Emerging Threats to Mothers and Newborns (SET-NET) COVID-19 surveillance by developing the state workplan, identifying processes for case identification and medical chart abstraction, and developing a REDCap data system to store and enter data on all cases in the state. Dr. Bennett served as her site supervisor during her assignment.

 

During FY21, Title V continued its partnership with the University of Illinois at Chicago (UIC) Center of Excellence in Maternal and Child Health. Through an Intergovernmental agreement (IGA) first enacted in 2013, UIC faculty, staff, and students conduct analytic projects on behalf of Title V. The CDC MCHEP assignee serves as the main coordinator and liaison for the collaborative projects between Title V and UIC. The MCH epidemiology team meets monthly with the UIC team to discuss project priorities, progress on activities, discussion of study findings, and feedback on analytic plans, methodology, and data products.

 

During FY21, UIC primarily focused on two analytic activities:

• Development of an evaluation plan to monitor the impact of Illinois’ extension of Medicaid through 12-month postpartum. This evaluation plan will use population-based data sources, such as PRAMS and BRFSS, to examine changes over time in insurance coverage, stability, and MCH outcomes. The plan outlines the data sources, indicators, and methodology that will be employed to track changes for Illinois’ MCH populations. Because it requires several years of data “post-intervention,” the analysis for this project has not yet begun.
• Development of an analytic plan to use SET-NET data to examine outcomes related to prenatal SARS-CoV-2 infection. The implementation of this analytic plan began in FY22.

 

Partnerships to Improve Access and Quality of MCH Data

 

During FY21, Title V maintained relationships with other internal IDPH data staff (e.g., PRAMS, BRFSS, vital records, hospital discharge data) through collaborative data sharing agreements. Through these agreements, Illinois Title V has access to population-based data to monitor the health of women, infants, children, and adolescents, and provide a mutual benefit in the analysis, data translation, and interpretation of findings.

 

Specifically, Title V and PRAMS actively partnered to ensure high-quality data collection during FY21. These activities include participating on the Illinois PRAMS Advisory Committee, continuing to fund gift card rewards for survey respondents, and collaborating to provide CDC with feedback on proposed phase 9 survey questions.

 

During FY21, the MCH epidemiology team provided technical assistance to various external partners on data projects. This includes HFS (Medicaid agency), Illinois Perinatal Quality Collaborative, state advisory committees (e.g., Perinatal Advisory Committee, Statewide Quality Council), Healthy Start programs, the Illinois Maternal Health Innovations Grant Program (I PROMOTE-IL), and various other state projects. By participating in such workgroup and collaborating with these partners, the MCH epidemiology team can meaningfully contribute by interpreting/translating data to inform decision-making and are able to influence plans for data collection and analysis.