The WCHS conceives of needs assessment as a continuous process, in which useful data, both quantitative and qualitative, relevant to the broad mission of the Section are continuously being gathered and analyzed with an eye to adjusting the program priorities and activities as appropriate.  Most of the programs and initiatives provided by the WCHS require local community action teams or advisory councils comprised of community members who provide input throughout the course of the project regarding emerging and ongoing needs.  Often programs conduct focus groups and key informant interviews to gain more information from consumers, providers, and partners.  Descriptions of how input from community groups, focus groups and other stakeholders was obtained and was used during FY19 can be found in the state action plan narrative domain reports.

The priority needs identified for the MCH Block Grant are intentionally written quite broadly as they were originally defined as core WCH Indicators to be used to communicate the value of the work done by the WCHS with policymakers, stakeholders, and the general public and promote a common vision among staff.  There are not any major changes in the health status and needs of the MCH population.  A Public Health Metric dashboard was created and posted on the DPH website at this link: http://publichealth.nc.gov/docs/DPH-Dashboard-052118-Goals.pdf in March 2018.  These metrics were identified by the Public Health Management Team as aligning with NC public health initiatives across stakeholders in order to support the Division’s mission and strategic planning to improve the health and well-being of North Carolinians.  The metrics, listed below, directly impact NC’s Title V priority populations.

1. Number of opioid overdose visits to hospital emergency departments
2. Percent of adults who are overweight or obese
3. Percent of adults who are current smokers
4. Percent of women who do not smoke during pregnancy
5. Percent of pregnancies that were intended
6. Percent of women who begin prenatal care in the first trimester
7. Percent of all adolescents (males and females) who were up to date with the HPV vaccination series
8. Percent of persons living with HIV who are virally suppressed
9. Number of Acute Hepatitis C cases
10. Number of children with Blood Lead level ≥5 ug/dl at or after confirmation

North Carolina’s infant mortality rate (# of infant deaths per 1,000 live births) decreased from 7.9 in 2009 to 7.0 in 2010.  Since then, however, the rate has plateaued, with the 2017 rate being 7.1.  More disturbing, however, is that the ratio of Black to White infant mortality rates remained disparate, reaching its highest rate of 2.9 in 2009 and remaining at 2.4 in 2017.  In 2017, the Black infant mortality rate was 12.5 while the White rate was 5.0.  Similar disparities exist among American Indian infants, with the 2013-2017 five-year rate being 9.1. Overall for North Carolina in 2017, one in five infant deaths (20%) were due to prematurity and low birth weight, and two-thirds of all infant deaths (68%) occurred within the first 28 days after birth.  While prematurity and low birthweight sometimes occur in the absence of risk factors, poor birth outcomes may result from women not being in optimal health before and during pregnancy. Unfortunately, about one in five women of reproductive age in NC is uninsured, making it difficult to access preventive services and maintain good health.  In addition, Black and American Indian families in North Carolina are more than twice as likely to experience extreme poverty (below 50% of the Federal Poverty Level) than White families.  Structural and institutional racism, which are hard to quantify but certainly contribute to the racial disparity in infant deaths, must also be addressed.

Child death rates for children under 18 years of age have experienced the same plateauing trend as infant mortality rates, which is to be expected as infants comprised 65% of all child deaths in 2017.  The child death rate in 2017 was 57 per 100,000 children which does show a slight decline from the rate of 59.2 in 2016, but there has not been much of a decline since 2010 when the rate dropped from the 2009 rate of 65.4.to 57.5.  The disparity between White and Black child deaths is also similar with the rate for Black children being 2.2 times greater than that of White children.  In fact, the Black rate of 94.5 per 100,000 in 2017 is 23% greater than the White rate of 77.1 in 1992.

Other than the ongoing work in assisting with development of the plan for Medicaid Transformation and considering how it will impact the work of the LHDs and the WCHS, as well as the individuals served, there have not been any major changes in NC’s Title V program capacity or its MCH systems of care.  The C&Y Branch is finalizing its CYSHCN Strategic Plan which uses the Standards for Systems of Care for CYSHCN as its framework.  During FY20, the WHB will be responding to the recommendations of the Perinatal Systems of Care Task Force.  This NC Institute of Medicine Task Force, which works in partnership with the WCHS, will complete its work responding to Session Law 2018-93 requiring a study of the current perinatal system of care in NC in an effort to improve maternal and birth outcomes.  The Task Force, which is made up of more than 30 providers, advocates, health educators, policy makers and consumers, has been meeting monthly since January 2019 and scheduled to continue meeting through Summer 2019.  To date, discussions have centered on adopting the AAP/ACOG/SMSM guidelines on levels of neonatal and maternal care; increasing access to first trimester prenatal care; and strengthening engagement with individuals with lived experiences.  The final report of the Task Force including recommendations will be submitted to the NC General Assembly prior to their short session in Spring 2020 and the recommendations will definitely be considered as part of the MCHBG 2020 Needs Assessment.

As stated previously, with the Title V Program being housed in the WCHS and the Title V Director serving as Section Chief and serving as administrator of so many state and federal programs (e.g., Title X, WIC, early intervention, etc.), collaborations between these programs serving the MCH populations is assured.  The Title V Director serves on a variety of DHHS committees and work groups that bring public and private partners together as do other WCHS staff members.

WCHS also collaborates on a number of activities with several professional organizations in the state including but not limited to: NC Medical Society; North Carolina Pediatric Society (NCPS); NC Obstetrical and Gynecological Society; Midwives of North Carolina; NC Friends of Midwives; and the NC Academy of Family Physicians. WCHS partners with the NC Institute of Medicine, the NC Hospital Association, and the NC Area Health Education Centers.  The WCHS works closely with the NC Partnership for Children, Prevent Child Abuse NC, the NC Chapter of the March of Dimes (MOD), SHIFT (Sexual Health Initiatives For Teens) NC, NC Child, Community Care of North Carolina (CCNC), and many other organizations.

There are many accredited schools of public health and medicine in NC, and WCHS maintains close working relationships with many of them, particularly the UNC-Chapel Hill Gillings School of Global Public Health, but also with the Department of Public Health at East Carolina University and the Departments of Public Health Education at NC Central University and UNC-Greensboro.

WCHS and NC DHHS are involved in many statewide collaborations to address maternal, perinatal and child health.  An example is the NC Pathways to Grade-Level Reading Initiative, which created partnerships among the state’s early learning and education, public agency, policy, philanthropic and business leaders to define a common vision, shared measures of success and coordinated strategies that support children’s optimal development beginning at birth.  The vision is that all NC children, regardless of race, ethnicity, or socioeconomic status, are reading on grade-level by the end of third grade and have the greatest opportunity for life success. 

Working under its philosophy of continuous quality improvement, the WCHS is making progress on formalizing its process of both routinely reaching out to strategic partners and stakeholders and incorporating their feedback into the MCHBG application and needs assessment.  The Perinatal Health Strategic Planning Team, which meets every two months, provides opportunity for many stakeholders to provide input into the plan and specific action steps.  The Team presents annually to the NC Child Fatality Task Force.  The Data and Evaluation Work Group is working on process and outcome measures for the prioritized action steps, and the Program Coordinator continues to provide updated environmental scan survey to new stakeholders which helps determine all the efforts being done around the strategies.  An evaluation project on the Perinatal Health Strategic Plan conducted by a graduate student interning with the CIMH will be released in the summer of 2019. Work to operationalize the C&Y Branch Strategic Plan continues and includes the formation of three committees to review practices across all Branch programs related to communication, training, and quality assurance efforts.  The development of the CYSHCN strategic plan, which began with the work leading up to and during the October 2017 Summit, is ongoing.  2020 MCH Block Grant Needs Assessment efforts have begun, which includes incorporating the feedback already gained from stakeholders and partners to identify potential priority needs.  Through a summer internship program by the National MCH Workforce Development Center, there are two student interns helping the WCHS with gathering and analyzing qualitative data for the needs assessment.  The internship is a paired practicum with one graduate student about to enter her second year of an MCH Master’s in Public Health at UNC Gillings School of Global Public Health working with the other intern, a senior undergraduate majoring in public health at the University of Florida.

The organizational structure of the WCHS has not changed over the past year, but the WCHS Business Operations Manager, who had been in that position for seventeen years and served as the interim Title V Director during 2014 to 2016, retired in December 2017.  The position was briefly filled and then vacated, so active recruitment for that position is underway.  The MCH Epidemiologist left her position in January 2019 and that position was filled July 1, 2019 by a former member of the NC State Center for Health Statistics management team.

There are a number of emerging public health issues which impact WCHS and its priority populations.  Along with Medicaid transformation, which is discussed elsewhere in this application, the Secretary of the NC DHHS has made combating the opioid crisis and improving early childhood health and wellbeing, inclusive of infant mortality reduction, priorities for the department.  North Carolina’s Opioid Action Plan 2017-21 was released in June 2017.  It was developed with community partners and is meant to be a living document that will be updated as progress is made on the epidemic.  A data dashboard was developed to help track and monitor the metrics in the plan. The Title V Program is leading the focus on pregnant women in the plan. Strategies included in the plan are to:

• Reduce the oversupply of prescription opioids.
• Reduce diversion of prescription drugs and the flow of illicit drugs.
• Increase community awareness and prevention.
• Make naloxone widely available and link overdose survivors to care.
• Expand access to treatment and recovery oriented systems of care.
• Measure the impact and revise strategies based on results.

An updated NC Opioid Action Plan 2.0 was released in June 2019 at the NC Opioid Misuse & Overdose Prevention Summit.  The updated plan includes a menu of local strategy ideas including improving naloxone access, advancing supporting housing, and promoting public awareness and stigma reduction.  In addition, the Title V program, through the Essentials for Childhood funding, worked to include an ACEs focus for the Summit. 

With regards to improving early childhood health and education, the Secretary shared her vision at the Child Fatality Prevention System Summit in April 2018, as well as multiple other venues.  She wants to give all children a strong start by keeping children healthy, keeping children safe and secure, and promoting child learning and development.  DHHS work to keep children healthy includes increasing access to health insurance, building a strong Medicaid program through transformation, and addressing social determinants of health.  To keep children safe and secure, DHHS is implementing the Opioid Action Plan, social services and child welfare reform, and addressing adverse childhood experiences.  To promote child learning and development, the Department is working to continue to expand access to NC’s Pre-Kindergarten program despite challenges in finding spots in high quality programs and finding qualified teachers.

The Early Childhood Action Plan (ECAP) was launched at the NC Early Childhood Summit on February 27, 2019.  The ECAP was developed with input from over 350 stakeholders from across the state, including many from the WCHS, and more than 1,500 people provided feedback on the draft plan before it was finalized and released.  Work on the plan started in August 2018 when Governor Cooper issued an executive order to the Department to develop it.  The ECAP’s vision statement is: “All North Carolina children will get a healthy start and develop to their full potential in safe and nurturing families, schools and communities.”   The ECAP provides a framework to help NC create change for its young children by 2025.  The overall goal of the plan is:

By 2025, all North Carolina young children from birth to age eight will be:

1. Healthy: children are healthy at birth and thrive in environments that support their optimal health and well-being.
2. Safe and Nurtured: Children grow confident, resilient, and independent in safe, stable, and nurturing families, schools, and communities.
3. Learning and Ready to Succeed: Children experience the conditions they need to build strong brain architecture and skills that support their success in school and life.