State Health Agency’s Roles and Delivery of Title V

The Mississippi State Department of Health (MSDH) is the lead state entity providing core public health functions and essential services. MSDH’s mission is to protect and advance the health, well-being and safety of everyone in Mississippi.

As the leading public health agency in the state, the central office is located in Jackson, the state’s capital. The public health system includes policy guidance from the State Board of Health, the State Health Officer, and programmatic/administrative personnel distributed across seven main programmatic divisions: Health Administration, Health Services, Health Protection, Public Health Field Services, Public Health Regions, Communicable Disease, and Public Health Laboratory. In 2017, the state underwent public health transitions. The state decreased from nine public health districts to three public health regions (north, central and south) with regional offices, and county health departments (See MSDH Regional Map).

The public health system includes policy guidance from the State Board of Health, the State Health Officer, and programmatic/administrative personnel distributed across seven main programmatic divisions: Health Administration, Health Services, Health Protection, Public Health Field Services, Public Health Regions, Communicable Disease, and Public Health Laboratory.

The major operations of the MSDH include the following:

• Disease Surveillance
• Environmental Protection
• Disease and Injury Prevention
• Standards of Care
• Immunizations
• Emergency Preparedness
• Community and Emergency Health Communications
• Licenses and Records
• Social Services

The Health Services division of the MSDH is responsible for the administration of programs under Title V MCH Block Grant. Health Services oversees provision of the Women, Infants and Children's Nutrition Program (WIC); Child and Adolescent Health, including the genetic disease screening program; Women’s Health; Oral Health; the Office of Tobacco Control. This division also includes the Office of Health Data and Research (OHDR). OHDR provides scientific integrity and quality assurance in management, surveillance, data analysis, reporting, and program evaluation related to MCH, chronic disease, and tobacco control. Title V aligns with the MSDH mission to provide services and programs that promote and improve the health and well-being of the Mississippi’s mothers, children, including children with special needs, and their families.

Health Indicators and Outcomes

The social determinants of health, such as geographical, economic, and social factors, contribute to the overall health and health equity of Mississippi’s MCH population. With the socioeconomic disadvantages facing many Mississippi residents, there are consistent poor health outcomes in communities, contributing to some of the nation’s highest rates across many health indicators. However, there has been some improvement in such areas such as the decreasing infant mortality and teen birth and pregnancy rates. The following provides a snapshot of key factors that relate to the MCH population, providing state-specific context for consideration of the challenges facing the state’s MCH population.

*Please See Chart in Appendix for additional details related to health indicators and outcomes.

Health Insurance:

According to U.S. Census Bureau data, 85.5% of Mississippians under 65 years have health insurance of some kind, and 14.4% were uninsured. Among the uninsured population, 5.0% are under 19 years, 12.5% of the White non-Hispanic and 15.8% of Black/African Americans.

State’s Strengths and Challenges

Access to comprehensive, quality health care services is important for the achievement of health equity and for increasing the quality of a healthy life for everyone. Health care access impacts overall physical, social, and mental health status; prevention of disease and disability; detection and treatment of health conditions; quality of life; preventable death; and life expectancy.

The health care delivery system in Mississippi includes services for long-term care, care for the aged and those with intellectual disabilities; mental health care, including psychiatric, chemical dependency, and long-term residential treatment facilities; perinatal care; acute care, including various types of diagnostic and therapeutic services; ambulatory care, including outpatient services and freestanding ambulatory surgical centers; comprehensive medical rehabilitation; home health services; and end stage renal disease facilities. Mississippi has 32 critical access hospitals, 19 rural hospitals with 49 beds or less, 21 Federally Qualified Community Health Centers, and 160 Rural Health Clinics.

Efforts are being made to support and expand Mississippi’s MCH infrastructure and health care delivery system. Strengths include strong partnerships and collaboration with private sectors, other state agency and local departments; Increasing access to quality health care for mothers and children, especially for people with low incomes and/or limited availability of care; Health promotion efforts that seek to reduce maternal mortality, infant mortality, and teen pregnancy; and Family-centered, community-based systems of coordinated care for children with special healthcare needs.

Despite these strengths and efforts, significant challenges still exist. Mississippi is still ranked last among all states for overall health system according to the Commonwealth Fund. Mississippi ranks 50th for access and prevention and treatment, 51st for avoidable hospital use and costs, 43rd for disparity, and 50th for healthy lives. Mississippians, including our children, are routinely ranked as the fattest in the country and we lead the nation in high blood pressure, diabetes, and adult inactivity. The Delta region which is well known for its poverty and rural characteristics in the country, is at even greater risk for health problems because of lack of accessibility and availability of medical care. An estimated 60% of residents live below the poverty level here. In 2013, as part of the Behavioral Risk Factor Surveillance System (BRFSS), 21.8% of Mississippians surveyed said they were unable to see a doctor at some point in the prior twelve months because of cost.

Besides poverty, Mississippi’s healthcare system mal-distribution of providers contributes to the poor overall health. High quality health care services depend not only on an adequate supply of fully qualified health care professionals, but also require appropriate distribution of these providers for adequate

access. The HRSA Data Warehouse current listing of Health Professional Shortage Areas (HPSAs) for Mississippi includes 109 primary care (75 of which are single county designations), 110 dental (77 of which are single county designations), and 42 mental health (29 facility and 13 catchment areas).

As mentioned earlier, Mississippi is one of the most rural states in the nation with 79% of the counties classified as rural as defined by the federal Office of Management and Budget. Rural areas face more challenges with recruitment and retention of health care professionals. Eighty-four percent of the single county primary care HPSA designations are for these rural counties. Approximately 2,304 (41%) of the state's active medical doctors are primary care physicians, and near 60% of primary care physicians are serving the 17 counties in the state’s federal Metropolitan Statistical Areas (MSAs). According to the Mississippi State Board of Dental Examiners there are 1,049 licensed (1,022 “active” and 27 “inactive”) dentists in the state, and 65% of the state’s dentists are serving the 17 counties in the state’s federal MSAs. Four counties (Claiborne, Franklin, Jefferson, and Quitman) have only one active dentist. Two counties (Benton and Issaquena) have no active dentists.

These challenges particularly impact the state’s most vulnerable residents, including CYSHCN’s and their families, Medicaid recipients, the working poor, undocumented immigrants, and rural residents. Mississippi has a high percentage of CYSHCN, a high percentage of CYSHCN living in poverty, and more severe health care provider shortages than most states. In addition to those challenges are Medicaid changes to MCOs, closure of the Title V Children’s Special Health Services clinic, and the decision not to expand Medicaid within the state of Mississippi. Also, Mississippi still faces challenges as a result of health care reform with the rising cost of health care. In the absence of any intervention, the burden of high health care costs will worsen, as health care spending per capita in Mississippi is projected to nearly double between 2010 and 2020.

Components of the state’s systems of care

The Mississippi State Department of Health's mission is to promote and protect the health of the citizens of Mississippi. To fulfill its mission, MSDH partners with various public and private sectors including community health centers. A primary care cooperative agreement with the MSDH Bureau of Primary Health Care has been administered by the MSDH since 1985. The cooperative agreement provides a mechanism for joint perinatal planning and provider education between the state MCH program and Community Health Centers. Perinatal providers are placed in communities of greatest need through a joint decision-making process of the Mississippi Primary Health Care Association and the MSDH Primary Care Development Program. Community Health Centers also participate in MS SEALS to increase utilization of sealants among eight-year-old children. MSDH partners with Community Health Centers on the Empowering Communities for a Healthy MS Conference each May. MSDH and its partners at the community levels are committed to promote health care access, strengthen leadership for addressing health disparities, and improve cultural and linguistic competency in delivering health services, particularly in underserved area.

Health Care Reform

With the passage of the ACA, MS has had the opportunity to make substantial changes in the availability of health insurance coverage to its citizens. MS’s present uninsured rate is forecasted to be near 21% with some counties rates as high as 27 %. Under the ACA in MS, 50% of currently uninsured non-elderly people are eligible for financial assistance in gaining coverage (Kaiser Family Foundation, 2014). A small number of uninsured adult parents are eligible for Medicaid in MS under the eligibility pathways in place before the ACA. The passage of the Affordable Care Act has also created pathways to coverage for Mississippi’s MCH and CYSHCN populations, but the state did not choose to participate in Medicaid expansion, which may leave gaps in coverage among that population. According to the Robert Wood Johnson Foundation, variation and change in the uninsured rate by state could be related to whether the state expanded Medicaid. Data show that in 2014, the uninsured rate in states that expanded Medicaid eligibility (9.8%) was lower than in states that did not expand eligibility (13.5%).

Integration of Services

Children and youth with special health care needs (CYSHCN) are probably one the most vulnerable populations as health care delivery evolves. Timely access to comprehensive, coordinated patient/family-centered care in a medical home is critical for CYSHCN. It may potentially minimize the prevalence of chronic physical, developmental, behavioral, and emotional conditions, maximize their independence as they transition to adulthood and more importantly, improve their quality of life. The National Survey of Children with Special Health Care Needs estimates that MS has about 169,815 CYSHCN, and nearly 27.5% of MS CSHCN live below 200% of the Federal Poverty Level.

The CYSHCN Program provides quality care coordination services to meet clients' needs and preferences. Regional care coordinators and care coordinators recently secured by participating healthcare systems (federally qualified health centers (FQHC), rural health clinics, and UMMC hospital clinics) work within many settings to assist families and connect them to a medical home.

To broaden our reach, CYSHCN parents and caregivers are involved at every level of decision making, from the central office to clinical to hospital-based services. The CYSHCN Program increased its efforts in strengthening parent engagement with a CYSHCN Parent Consultant (PC) was hired (part‐ time) and housed within MSDH Central Office. The PC provides feedback on programmatic policies, strategic planning, educational material and designing and conducting parent surveys with other CYSHCN families. Approximately 40% CYSHCN parents serve as members/subject matter experts on the CYSHCN Leadership Team. Lastly, a CYSHCN PC was placed in each of the five participating CYSHCN Cares 2 healthcare systems. All PCs were trained as Community Health Workers and other parent leadership trainings will follow.

State Statutes Relevant to Title V

The Mississippi Legislature passed House Bill 494 in March 2017 authorizing the Mississippi State Department of Heath to establish the Maternal Mortality Review Committee to review maternal deaths and establish strategies to prevent maternal deaths. The Mississippi Maternal Mortality Review Panel is a multidisciplinary committee whose geographically diverse members represent various specialties, facilities and systems that interact with and impact maternal health. The panel

consists of approximately 8-10 members who commit to serve a 2-year term. Maternal Mortality Review Panel will review and make decisions about each case based upon the case narrative and abstracted data. The purpose of the review is to determine the causes of maternal mortality in Mississippi and identify public health and clinical interventions to improve health systems of care. Maternal mortality includes deaths occurring during pregnancy and up to one year after pregnancy. Information is gathered from death certificates, birth certificates, medical records, autopsy reports, and other pertinent resources. Records are abstracted by a trained abstractor and de- identified case narratives are reviewed by the committee of experts from diverse disciplines.