NC Needs Assessment Process Goals, Framework, and Methodology

Process Goals

The WCHS conceives of needs assessment and priority-setting 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 priorities and the activities of the Section as appropriate. The data capacity of WCHS is strong. There is an MCH Epidemiologist and SSDI Project Coordinator in the Section Office, and each Branch within WCHS has staff members whose roles and responsibilities include coordinating data collection and analysis activities to guide effective monitoring, evaluation, and surveillance efforts and to help with program policy development and program implementation. These staff members also work directly with statisticians and data analysts in the NC State Center for Health Statistics (SCHS) who provide further analyses, as necessary. In addition to these ongoing analyses of relevant inputs, the Section utilizes formal needs assessment processes, such as the five year MCH Block Grant needs assessment, to review and adjust Section priorities and activities. Throughout its work on the 2020 NC Title V Needs Assessment, the goal was to ensure that the needs assessment process worked in alignment with Section, Division, and Department strategic planning efforts and priorities so that Title V resources could be leveraged as much as possible. The 2015 priority needs, which had only been tweaked slightly since they were selected back in 2005, were 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 to promote a common vision among staff. They have worked well in that regard, but the 2020 NC Title V Needs Assessment afforded the WCHS an opportunity to reexamine those priority needs and determine whether they were still useful or needed to be changed entirely.

Framework

A WCHS 2020 NC Title V Needs Assessment Leadership Team was created in February 2019 which consisted of the Title V Director, who is the WCHS Chief; the CYSHCN Director, who is the C&Y Branch Head; the Women’s Health Branch Head; and the State Systems Development Initiative (SSDI) Project Coordinator. This group met monthly to create and implement a work plan of needs assessment activities, engaging the Section Management Team (SMT) throughout the process as necessary for input and ideas. One of its first activities was to determine the 2020 NC Title V Needs Assessment Framework shown below (Figure 5) which emphasizes the team’s guiding principles as well as the life course perspective.  The intent from the start was to leverage other efforts and to align with strategic plans, programs, and projects that are already in place in NC to serve the MCH population across the life course. The MCHBG Needs Assessment was built within the context of multiple collaborative efforts, some of which are listed below:  

• NC Early Childhood Action Plan
• NC Opioid Action Plan
• Maternal Mortality Review Committee
• NCIOM Perinatal System of Care Task Force
• NCIOM Maternal Health Task Force
• NC Public Health Genomics Plan
• NC Early Home Visiting Landscape Assessment
• NC Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Needs Assessment
• Healthy NC 2020 and 2030
• Integrated Care for Kids (InCK)
• Perinatal Health Strategic Plan
• NC Infant-Toddler Program State Systemic Improvement Plan (SSIP)
• NC Child Fatality Task Force
• Pathways to Grade Level Reading
• Think BabiesTM NC
• Children & Youth Branch Strategic Plan
• Children & Youth with Special Health Care Needs Strategic Plan
• NCIOM Essential for Childhood Task Force Recommendations

Figure 5

Methodology

The methodology used in the 2020 NC Title V Needs Assessment was a mix of qualitative and quantitative data collection from stakeholders, families, and other partners. It was an iterative process that started with a big questions survey conducted in spring 2019, then moved to focus groups and key informant interviews which were held that summer. The analyses resulting from these qualitative data collection efforts informed the creation of a stakeholder survey that was conducted in winter 2019. An expanded SMT meeting was held in March 2020 to discuss the results of the partner survey and previous data collection efforts, and eight final priority needs were determined through a voting process using prioritization criteria established by SMT.  The general process is shown in the below figure:

Stakeholder Involvement, Including Families (Individuals and Family-Led Organizations)

The 2020 NC Title V Needs Assessment included lots of opportunity for involvement by Title V stakeholders, including families and community representatives, program participants, and programmatic partners and providers which are highlighted below in the descriptions of the quantitative and qualitative assessment methods.

Quantitative and Qualitative Assessment Methods

General MCHBG Big Questions Needs Assessment Survey

The MCHBG Big Questions Needs Assessment Survey, which was based on the Minnesota Department of Health’s Discovery Survey, was administered between February and April 2019 at conferences and meetings of programs supported by Title V. All surveys were completed by hand and entered into SurveyMax, apart from the Be Smart survey results which were completed electronically. In total, 168 people responded to the survey which was conducted at the following conferences and meetings:

• Preconception Health Peer Educator Training
• Perinatal Health Strategic Plan Coordinator Meeting
• Building Bridges Conference
• Adolescent Parenting Program Networking Meeting
• NC Sickle Cell Provider Meeting
• Northeast Preconception Health Summit, and
• "Be Smart" Family Planning Medicaid Strategic Planning Partners Meeting

Survey participants were asked to respond to the following four questions and provide some demographic information (age, gender, ethnicity, race, and primary county of work):

1. What is the most important thing women, children, and families need to live their fullest lives?
2. What are the biggest unmet needs of women, children, and families in your community?
3. What is the greatest disparity – whether racial, geographic, or other – that affects women, children, and families in NC?
4. What health and other life challenges are specific to your age group?

Survey results showed that, not surprisingly, most of the unmet needs, challenges, and disparities that women, children, and families in NC face reported by respondents are related to social determinants of health. Numerous respondents highlighted that unmet needs of accessible, affordable, high quality health care posed challenges and perpetuated health disparities within communities. Furthermore, limited access to transportation, housing, and nutritious foods were also among the most frequently discussed unmet needs and challenges among the MCH population.

Focus Groups and Key Informant Interviews

The WCHS hosted a Title V MCH Internship Team supported by the National MCH Workforce Development Center during summer 2019 which allowed two MCH students, one in graduate school and the other an undergraduate, to assist in qualitative data collection activities for the 2020 NC Title V Needs Assessment. Based on their analysis of the MCHBG Big Questions Needs Assessment Survey (see Appendix A), they worked with WCHS staff members to create focus group and key informant questions. They then conducted the interviews and focus groups and analyzed the results. The significant work of these interns greatly contributed to a comprehensive and informative qualitative data collection portion of the 2020 NC Title V Needs Assessment.

Three key informant interviews were conducted with leadership from the following WCHS programs: Healthy Start Baby Love Plus – Fatherhood Initiative; Child Maltreatment Prevention; and Healthy Beginnings and the Infant Mortality Reduction Initiative. The three focus groups, which focused on hearing from youth and parents/caregivers, were conducted with Adolescent Parenting Program Participants (n=33), Branch Family Partners (n=11), and the Innovative Approaches – Parent Advisory Council of Columbus County (n=6).

After conducting these interviews and focus groups, the interns cleaned and transcribed the data, stripping the participant identifiers to maintain the confidentiality of the respondents. Once everything was transcribed, they began memoing – recording reflective notes about what one is learning from the data regarding emerging concepts and relationships. Themes generated from the MCHBG Big Questions Needs Assessment Survey were used to develop the initial codebook for the project, but new codes were added when necessary as each transcript was analyzed. All transcripts were coded using the Atlas TI software. Once coding was complete, the interns independently analyzed each code across the various data sources (e.g., analyzing the “Education” code across all focus group, survey, and key informant interview transcripts) to generate code-specific themes. They compared their themes and addressed any discrepancies that arose, then synthesized the emergent themes and created two PowerPoint presentations (one for the C&Y Branch and one for the SMT) and a written report (see Appendix A) which proposed preliminary priority needs for each population domain.

NC MCHBG Partner Survey

The final step in the qualitative data collection process of the 2020 NC Title V Needs Assessment was to conduct an electronic survey (see Appendix A) of WCHS partners and stakeholders to identify priorities and guide planning within the five MCHBG population domains. Partners and stakeholders received a personal invitation from the NC MCH Title V Director and or WCHS Branch Heads to respond to the survey through a link to SurveyMax. The survey, open from December 16, 2019 through January 10, 2020, had 934 completed responses from at least 99 counties. The responders were predominantly LHD employees (44%), health care professionals (30%), or community service providers - social worker, home visitor, infant-toddler specialist, etc. (15%). Advocacy organization employees (4%), parents of children with special health care needs (3%), members of WCHS advisory councils or coalitions (1%) also responded as well as a few insurance or managed care organization employees and consumers (1% combined). The majority of responders were 40 years or older (65%), female (88%), and non-Latinx White (72%). Eleven percent of the respondents identified as non-Latinx Black and three percent as Latinx. Only five percent were younger than 30 years of age.  Future efforts will be made to amplify the youth voice, parent/caregiver voice, and those from historically marginalized communities. 

Respondents were asked to rank their top three priorities in addressing health needs or concerns for six different population domains based on the HRSA domains (women before becoming pregnant; women during and/or after a pregnancy; infants; children; youth; and children with special health care needs). A list of several concerns was provided for each domain along with a request to mention additional priorities that might not have been included.

The SSDI Project Coordinator and the MCH Epidemiologist analyzed the survey data and created tables by population domain with the concern areas sorted from the most often prioritized in the top three to the least (See Appendix A). The lower the mean, the more respondents who ranked the concern first versus third. Overall, the most common concerns crossing all population domains were improving access to healthcare services, improving access to mental and behavioral services, and promoting safe and nurturing relationships.

Quantitative Data Sources

The main quantitative data sources of the NC 2020 Title V Needs Assessment, as well as the MCHBG annual reports, are the data systems that WCHS staff members routinely use for ongoing surveillance and needs assessment. These include the following:

• Vital Statistics (e.g., birth and death files) from the NC State Center for Health Statistics (SCHS) including:
  • NC Composite Linked Birth File
  • Tracking Maternal and Child Health Data in North Carolina
  • Tracking Preconception Health in North Carolina
• National Survey of Children’s Health (NSCH)
• Federally Available Data (FAD) for National Performance and Outcome Measures
• Behavioral Risk Factor Surveillance System (BRFSS)
• Pregnancy Risk Assessment Monitoring System (PRAMS)
• US Census Data
• Local Health Department - Health Systems Analysis (LHD-HSA)
• School Health Center Annual Report
• Healthy NC 2030 A Path Toward Health Data Book
• The NC Child Health Report Card
• WCSWeb Database
• NC Crossroads WIC System
• Title V CSHCN Help Line Data
• QuitlineNC Data

Interface between Collection of Data, Finalization of the Priority Needs, and Development of NC’s State Action Plan

In March 2020, an expanded SMT meeting, which included unit supervisors and other critical WCHS members invited by SMT, was held to review the qualitative and quantitative data and determine the 2020 NC Title V Needs Assessment Priority Needs. The Title V Director led the meeting, sharing a PowerPoint presentation which highlighted the data collection results and provided an overview of the current context of the NCDHHS priorities and how Title V activities were aligned. Based on stakeholder feedback, she shared potential priorities by domain that the Leadership Team had gleaned from the data collection activities, and staff members were given the opportunity to add to or modify these potential priorities. Prior to the meeting, the Leadership Team developed prioritization criteria (see Appendix A) which were summarized into this image (Figure 6) and shared with staff along with an overview of the Title V Performance Measure Framework.

Figure 7

A simple dot voting process was then used to determine the top priority needs, with every person receiving ten dots to use as they wished, although they had to vote for at least one priority in each of the domains. After the initial voting, there was a bit more discussion to come to consensus on the priority needs and the corresponding National and State Performance Measures. The Leadership Team finalized the wording of the priority needs, then the Branch Heads worked with their staff and the SSDI Project Coordinator to draft the strategies, objectives, performance measures, and evidence-based or -informed strategy measures for the State Action Plan which was revised and completed by the Leadership Team.

Women/Maternal Health

Access to quality health care services, including mental health services, and, in particular, preconception health services, was one of the emerging priority needs based on the qualitative data collection and analysis for the Women/Maternal Health domain, and a review of quantitative data collection supports this need. 2018 Census data shows that the state’s uninsured rate is the ninth highest in the country at 10.7%. Per NC BRFSS data, while the rate of women age 18 to 44 years reporting that they have some type of health care coverage has increased from 73.5% in 2013 to 79.9% in 2018, there are still disparities by race/ethnicity, with 87.9% of white, non-Hispanic women reporting coverage, but only 79.8% of Black, non-Hispanic women, and only 35.8% of Latinx women. Table 1 shows that while some additional preconception health indicators have improved over time for the total population, such as percent of women who had a routine checkup in the past year and the percent of women who smoke, several indicators related to chronic health conditions (overweight/obesity, hypertension, and binge drinking) and the percent of women taking a daily multivitamin have gotten worse over time. Disparities between race/ethnicities still exist. The BRFSS data indicate that Black women were more likely to have a routine checkup in the past year than White or Latinx women, but are more likely to experience overweight/obesity and hypertension. They are also less likely to take a daily multivitamin. Improving access to and quality of preconception and well-woman care continue to be an important part of the PHSP as it gets updated for 2021-2025. Emphasis on improving determinants of health through Medicaid transformation should also improve women’s health.

Other priority needs that surfaced in the qualitative and quantitative needs assessment activities were related to reproductive justice and intended pregnancies. NC PRAMS data show that close to 60% of women responded that their pregnancy was intended (wanted to be pregnant then or sooner) and this is a small increase from the 2014 rate of 55.8%.  Annual rates broken down by race/ethnicity fluctuated a lot because of smaller sample size, but white and Hispanic women were more likely to respond that their pregnancy was intended than Black women. NC is pleased to be able to partner with Upstream and the NC Reproductive Life Planning Stakeholders group to be able to ensure that women have access to the highly effective contraceptive method of their choice when they want it.

Maternal morbidity and severe maternal mortality rates were also concerning. Fortunately, in 2019, NC was one of nine states receiving a five-year cooperative agreement under HRSA’s State Maternal Health Innovation Program which will assist the state in addressing disparities in maternal health and improving maternal health outcomes. A Maternal Health Task Force, which is an outgrowth of the work of the Perinatal Systems of Care Task Force and aligned with the PHSP, NC ECAP, and Maternal Mortality Review Committee has been convened. Other program activities include implementation of a Provider Support Network, the 4th Trimester Project (improve postpartum care), and expansion of telehealth, doula, and community health worker services, along with implicit bias training for providers.

Perinatal/Infant Health

While NC’s infant mortality rate has slowly declined over the past ten years from 8.6 deaths per 1,000 live births in 2000 to 6.8 in 2018, mortality rates of Black infants continue to be more than twice those of white infants, with the Black:white disparity ratio in 2018 being 2.44 (Figure 7). Disparity ratios are also high among non-Hispanic American Indians, with rates 1.6 to 2 times higher than non-Hispanic white infants over the same period. A Perinatal Periods of Risk (PPOR) analysis done recently by the SCHS for 2014 to 2017 showed that while in all four periods of risk (Maternal Health/Prematurity, Maternal Care, Newborn Care, and Infant Health), non-Hispanic Black infants had higher fetal-infant mortality that the other race/ethnicity study groups, the most excess deaths for non-Hispanic Black infants occurred during the Maternal Health/Prematurity period, which means that efforts to reduce low and very low birthweight and prematurity must continue and expand, including addressing root causes such as structural racism and improving determinants of health.

Additional priorities that surfaced from the qualitative data for the Perinatal/Infant Health domain included promoting postpartum care and support, improving access to prenatal care, preventing substance use (including tobacco and alcohol), supporting father involvement, and increasing breastfeeding. All of these items are also found in the PHSP, and many are in the NC ECAP. In addition, the recently released recommendations from the NCIOM’s Task Force on Developing a Perinatal Systems of Care should help drive some improvement in birth and maternal outcomes.

Child Health

The qualitative data collection process overwhelmingly highlighted the priority needs in the Child Health domain to be to promote safe and nurturing relationships and improve access to mental and behavioral health programs as well as access to health care and dental care. Quantitative data also support these priorities. While NC has always prided itself on high childhood immunization rates for children age 19 to 35 months, which is an important part of a well-child visit, the state has seen these levels plateau over the past several years, and that was before the effects of the COVID-19 pandemic. In addition, according to the Children’s Health Care Report Card for NC created by Georgetown University Health Policy Institute Center for Children & Families, while the percentage of children without health insurance had been going down between 2008 and 2015, from 9.9% to 4.6%, it slowly ticked back up annually to 5.3% in 2018. There were an estimated 130,000 children uninsured in NC in 2018, an increase of approximately 13 percent since 2016. The Georgetown researchers found that loss of coverage was higher for white and Latinx children, children age five years and younger, and children from low- and moderate-income households.

Children thrive in safe, stable, and nurturing environments. Children who experience adverse childhood experiences (ACEs), such as death of a parent, witnessing violence, living with someone with severe depression or a problem with alcohol or drugs, having parents who have separated or divorced, or having been treated or judged unfairly due to race/ethnicity, have an increased risk of greater physical and mental health challenges as one grows up. According to the NSCH data from 2016-17 and 2017-18, NC is doing somewhat worse than the US as a whole with regard to the percentage of children with ≥ 2ACEs (19.2% in NC in 2017-18 as compared to 18.6% - although the confidence intervals for NC are wider than for the US because of smaller sample size), but both the US and NC showed declines since 2016-17 (Figure 8). Breaking down the NC sample by race/ethnicity is not advised due to small sample sizes except for white and Hispanic children, and in 2017-18, the percentage of children with ≥ 2ACEs was 14.4% and 16.6%, respectively. Partners within and outside of NCDHHS are working to decrease this percentage for all children and promote resilience, particularly through the efforts of the NC Essentials for Childhood (NCE4C) Initiative. Given the importance, this indicator was chosen as one of the Healthy NC 2030 goals, and it is included in the NC ECAP.

Increasing the number of children who receive appropriate developmental, psychosocial, social determinants of health, and behavioral health screening tools is another way to promote children being raised in a safe, nurturing environment. While NSCH data indicate that NC has a higher percentage of children, ages 9 through 35 months, who received a developmental screening using a parent-completed screening tool in the past year (43% vs. 33.5%), there is still much room for improvement. A breakdown by race/ethnicity is not available. Through a variety of programs, the C&Y Branch not only offers training opportunities on developmental screening to providers but also assists parents in child health clinics and home visiting programs as well as the Triple P – Positive Parenting Program.

Adolescent Health

Not surprisingly, the qualitative data results for the Adolescent Health domain were very similar to the Child Health domain as improving access to mental and behavioral health services and promoting safe and nurturing relationships ranked at the top along with preventing teen suicide and injuries. Ensuring that youth receive well visits inclusive of mental and behavioral health screenings and related referrals continues to be a priority for the C&Y Branch. According to the 2016-17 NSCH, which is the most recent year available due to changes in the measure between the 2017 and 2018 surveys, 81% of adolescents in NC received a preventive medical visit in the past year which is higher than the national rate of 78.7% (Figure 9). More females (82.5%) than males (79.4%) had a preventive medical visit, and more YSHCN (88.6%) had a visit than non-YSCHN (78.4%). While more non-Hispanic White youth (87.1%) and Hispanic youth (76.1%) had a visit than non-Hispanic Black youth (72.7%), the confidence intervals for Black and Hispanic youth survey data were wide, so should be interpreted with caution. Additionally, 2017-18 NSCH data did show that 55.5% of NC adolescents age 12-17 without special health care needs had a medical home while only 47.5% did nationwide. Teen suicide rates for NC have risen over the past decade just as they are for the nation, with NC rates for youth ages 10 to 17 increasing from 2.3 per 100,000 youth population in 2010 to 4.9 per 100,000 in 2018.

In addition to supporting local health departments and school health centers to provide youth health care and behavioral health services, the C&Y Branch will continue to provide technical assistance to school health nurses, partner with the Department of Public Instruction with the Leadership Exchange for Adolescent Health Promotion, and engage youth and hear their voices through the Youth Public Health Advisor Program, as well as partner with the NC Pediatric Mental Health Care Access Program.

Children and Youth with Special Health Care Needs

Ensuring that CYSHCN receive coordinated, comprehensive, ongoing medical care was the top priority identified through the qualitative portion of the needs assessment, along with other related items such as improved access to mental and behavioral health services, respite care, and community-based services as well as empowering families to become equal partners in making decisions. Transitioning from a pediatric doctor to a doctor for adults was not selected as a priority in the partner survey, but it was discussed frequently during the focus group held with parents of CSHCN. While having a medical home should help ensure that CYSHCN receive coordinated, comprehensive care, data from the NSCH (Figure 10) indicate that CSHCN are less likely to have a medical home that non-CSHCN. This is true for NC and the nation, although NC had higher rates than the US for both groups of children. Percentages for all groups decreased in the most recent 2017-18 survey. Another important part of coordinated care is making sure that transition services to adult health care are available for CYSHCN. NSCH data for 2017-18 indicate that only 24.1% of adolescents with special health care needs in NC received such services, leaving lots of room for improvement.

The C&Y Branch has a very active Branch Family Partnership which enables families with CSHCN to voice their challenges and successes routinely to Branch staff members. Work to ensure coordinated, family-centered care will continue through them, the Family Liaison Specialists, the CYSHCN Help Line and outreach team, and the Innovative Approaches Initiative, as well as through the Commission on CSHCN. In addition, the strong linkage with the NC Infant-Toddler Program will incorporate priorities related to family engagement, developmental screening, and ensuring safe, nurturing environments.

The NCDHHS is one of ten agencies in the NC Governor’s Cabinet and is divided into 30 divisions and offices which fall under four broad service areas – health, human services, administrative, and support functions. Divisions and offices include: Administrative Divisions and Offices (e.g., Budget and Analysis, Controller, and General Counsel); Aging and Adult Services; Services for the Blind; Child Development and Early Education; Services for the Deaf and the Hard of Hearing; Council on Developmental Disabilities, Economic Opportunity; Education Services; Environmental Health; Health Service Regulation; Medical Assistance (state Medicaid); Mental Health, Developmental Disabilities, and Substance Abuse Services; Public Health; Office of Rural Health and Community Care (ORHCC); Office of the Secretary; Social Services; State Operated Healthcare Facilities; Vital Records; and Vocational Rehabilitation Services. DHHS also oversees 14 facilities: alcohol and drug abuse treatment centers; developmental centers; neuro-medical treatment centers; psychiatric hospitals; and two residential programs for children.

The Secretary of NCDHHS reports to the Governor and within her office has one Chief Deputy Secretary, a Chief Financial Officer, the State Health Director and Chief Medical Officer, and five Deputy Secretaries, including the Deputy Secretary for Health Services under which the NC Division of Public Health (NC DPH) is located. The Assistant Secretary for Public Health serves as the Director of NC DPH.

The NC DPH is composed of the Director's Office and nine other offices and sections: Administrative, Local, and Community Support; Chronic Disease and Injury; Epidemiology; Human Resources; Oral Health; State Center for Health Statistics; State Laboratory of Public Health; Vital Records; and WCHS. NC DPH works collaboratively with a network of 85 sub-state administrative units (single- and multi-county LHDs). Each local public agency enters into an annual Consolidated Agreement with the DPH that governs many public health services delivered by the local agency. Each individual service that agencies provide using state or federal pass-through funding is managed by an Agreement Addendum to this contract which contains a scope of work and specifies the standards of the services to be provided. The LHDs, which have local autonomy, have a longstanding commitment to the provision of multidisciplinary perinatal, child health, and family planning services, including prenatal care, care management, health education, nutrition counseling, psychosocial assessment and counseling, postpartum services, care coordination for children, well-child care, and primary care services for children. They are also instrumental in providing leadership for evidence-based programs county wide such as Nurse Family Partnership, Healthy Families America, Teen Pregnancy Prevention Initiatives (TPPI), Triple P, Reach Out and Read, and other programs dictated by the needs of the county.

The Title V Program in NC is housed in the WCHS, with the Title V Director serving as Section Chief and the CYSHCN State Director serving as the C&Y Branch Head. WCHS is responsible for overseeing the administration of the programs carried out with allotments under Title V and for other programs including Title X, Early Intervention, nutrition services (including the state WIC program), and immunization. In addition to the C&Y Branch, the WCHS includes four other branches: Women’s Health (WHB), Early Intervention, Immunization (IB), and Nutrition Services. Members of the WCH Section Office in addition to the Section Chief include the Operations Manager, the Executive Director of Child Maltreatment Prevention Leadership Team, the SSDI Project Coordinator, the MCH Epidemiologist, and an Administrative Assistant.

A list of the major programs/activities of WCHS by funding source(s) and population domain, including all those that are funded by the federal-state MCH Block Grant, can be found in Appendix B.

The NC Title V Program’s capacity to promote and protect the health of all mothers and children, including CSHCN is strong, but the WCHS continually strives to improve this capacity.

Since January 1, 1995, all SSI beneficiaries <16 years old have been eligible for Medicaid in NC. In fact, NC provides Medicaid coverage to all elderly, blind and disabled individuals receiving assistance under SSI. The NC child health insurance program (Health Choice) serves as an additional payment source for these children. The Title V program continues to assure that all SSI beneficiaries receive appropriate services. Each month, WCHS receives approximately 335 referrals of newly eligible SSI children. Infants and children under five years of age are referred to the Care Coordination for Children program. The parents of those ages 5 and older are contacted by letter to let them know about our toll-free Help Line. The purpose of both contacts is to make families aware of the array of services offered under Medicaid, as well as other programs for which their child may qualify. NC also provides Medicaid coverage for pregnant women with incomes equal to or less than 196% of the federal poverty guidelines. Family planning services to men and women of childbearing age with family incomes equal to or less than 195% of the federal poverty guidelines are also provided by Medicaid.

The WCHS continues to leverage its Title V funding to ensure a statewide system of comprehensive, community-based, coordinated, family-centered care services. Descriptions of collaborations with other public and private organizations and how services are coordinated at the community level can be found in Section C (Partnerships, Collaboration, and Coordination) and throughout the State Action Plan.

As of July 2020, the WCHS oversees and administers an annual budget of over $625 million and employs 927 people. This is 47% of the DPH staff, along with 67% of the budget. The WCHS's broad scope promotes collaborative efforts while discouraging categorical approaches to the complex challenge of promoting maternal and child health. The Section is committed to ensuring that services provided to families are easily accessible, user-friendly, culturally appropriate, and free from systemic barriers that impede utilization. While many staff members work in the central office in Raleigh, there are a number of regional consultants who work from home and regional offices. The EIB has a network of 16 Children's Developmental Service Agencies (CDSAs) serving all 100 counties.

The Title V Block Grant funds 26 WCHS state-level employees, with many others funded in part per the cost allocation plan. These positions are primarily nurse consultants, public health genetic counselors, and public health program consultants within the WCHS, but also funds staff members in the SCHS, the Chronic Disease and Injury Section (CDIS), and the Oral Health Section. The funding that goes directly to LHDs is used to provide services for individuals without another payer source, as well as enabling services and population health education.

Key senior management level employees in the Title V Program include the following:

Title V Director/Section Chief – Dr. Kelly Kimple became the Title V Program Director in August 2016 and served as Acting State Health Director from January-August 2017. Her undergraduate work included a dual major in Biological Basis of Behavior and Spanish from the University of Pennsylvania. She completed her MD and MPH at UNC-CH. She holds certification in both the American Board of Preventive Medicine and the American Board of Pediatrics. Prior to becoming the Title V Director, she was an Assistant Professor in the UNC Department of Pediatrics and a pediatrician at the Siler City Community Health Center. She also served as Director of the UNC Children’s Readmissions Reduction Program and Transition Clinic with Medical-Legal Partnership and as a faculty member for the Leadership Education in Neurodevelopmental Disorders at the UNC Carolina Institute for Developmental Disabilities.

Section Business Operations Manager – Sarah Dozier assumed this position in January 2020. Prior to this role, she was with the Office of the Internal Auditor evaluating various initiatives, programs, systems and projects across NCDHHS. She previously served as the Budget Director of the Department of Public Instruction, the CFO and Accounting/Budget Director of the Department of Natural and Cultural Resources, and has worked at the NC Office of the State Auditor. She earned her Bachelor of Business Administration in Accounting and Information Technology at Campbell University.

CYSHCN State Director/C&Y Branch Head – Marshall Tyson became Branch Head in January 2017 after serving as Acting Branch Head since June 2016. Prior to becoming Branch Head, Marshall served as the Health and Wellness Unit Manager in the C&Y Branch. He earned his undergraduate degree at East Carolina University and received his MPH in Public Health Leadership from UNC-CH in 2000. In addition, in 2014 he graduated from the Maternal and Child Health Public Health Leadership Institute.

WHB Head – Belinda Pettiford assumed this position in March 2012 after serving as a WHB Unit Supervisor. She has undergraduate degrees in psychology and community health education from UNC-Greensboro and earned her MPH in health policy and administration from the UNC School of Public Health in 1993. Prior to becoming the Unit Supervisor in 2000, she served as the Program Manager of the Healthy Start Baby Love Plus Program and as the Program Manager for the Healthy Beginnings Program.

NSB Head – Mary Anne Burghardt became Branch Head in May 2016 after serving as Interim Branch Head since May 2015. Prior to this role, she was the Public Health Nutrition Unit Supervisor. She has an undergraduate degree in Nutrition from Pennsylvania State University, earned an MS in Foods and Nutrition from Marywood College, and is a Registered Dietitian. She has also served as a Nutrition Program Consultant, a Pediatric Dietitian with a CDSA, and has held positions in acute care hospitals, rehabilitation centers, the WIC Program and long term care.

EIB Head – Sharon Loza assumed this position in January 2020. Prior to this role, she served as a Consultant at the Frank Porter Graham Child Development Institute. She formerly served as the Data Manager and Lead for the NC ITP State Systemic Improvement Plan and also worked as an Implementation Specialist with the NC Race to the Top-Early Learning Challenge grant. She holds a MEd in Early Intervention and Family Support from the UNC-CH, a MA in Liberal Studies from the UNC-Greensboro, and is currently pursuing her PhD in at NC State University in the Department of Educational Leadership, Policy, and Human Development.

SSDI Project Coordinator – Sarah McCracken Cobb began working in this position on July 1, 2000. She completed her undergraduate degree in chemistry at the UNC-CH in 1987 and earned an MPH from Boston University in 1989. After serving in the US Peace Corps, she has held assessment positions with NC DPH in HIV/AIDS, immunization, and maternal health programs.

MCH Epidemiologist – Kathleen Jones-Vessey became the MCH Epidemiologist in July 2019 after working with the National Center for Health Statistics for about two years. She has over 20 years of experience working with the SCHS, most recently the Head of the Statistical Services Branch which implements both PRAMS and BRFSS. She has a BA in Sociology from George Mason University and a Master’s in Sociology from Virginia Tech.

Pediatric Medical Consultant for the C&Y Branch – Dr. Gerri Mattson joined WCHS in August 2005. She received her MD from the Medical College of Virginia in 1993, completed her internship and residency at Emory University in 1996, and received her MSPH from the UNC School of Public Health in 2004. Her expertise is available to a wide range of public and private providers on best and promising practices in policy, program development, and evaluation related to child and adolescent health.

Medical Consultant for the WHB - Dr. Rachel Urrutia was hired in 2018. She is board certified in both obstetrics and gynecology and preventive medicine. She is an Assistant Professor in the Department of Obstetrics and Gynecology at UNC-CH. She practices OB/Gyn at Reply OB/Gyn and Fertility in Cary, NC. She earned her medical degree at Harvard University and completed an MS in in Clinical Research, Epidemiology at UNC-CH.

Family Liaison Specialists (FLSs) – The C&Y Branch has 1.5 Full-Time Equivalents (FTEs) for parents of CYSHCN. One full time position (Family Liaison Specialist) is supported fully by Title V funding; the other part-time position is through EHDI federal funding. Holly Shoun served as the EHDI Parent Consultant for nine years, beginning in 2011, but she is now serving as the interim Family Liaison Specialist with a new person hired for the EHDI position. In addition to being the parent of a child with special health care needs, she has a degree in Biology from UNC-CH and a MA in Secondary Education and Teaching from East Tennessee State University.

The WCHS is committed to providing culturally competent approaches in its delivery of services. This begins with hiring staff from various racial and ethnic backgrounds to staff training and development. Managers are committed to recruiting staff utilizing non-traditional approaches and ensuring that interview teams are also diverse. Members of the WCHS also participate in a Reading Circle which includes books from multiple cultural perspectives; various team members lead the book discussions. WCHS partners with numerous community based organizations for program design and implementation. Educational and outreach materials utilized by the programs are also reviewed for health literacy and cultural appropriateness. Feedback is obtained from culturally diverse focus groups, surveys, and parents to provide culturally sensitive services across NC. Committees and taskforces include representatives from a wide range of ethnic and cultural backgrounds. Language to assure culturally appropriate services are included in all contracts and monitored in deliverables. Translators, including those for the hard of hearing and deaf populations, are also mandated in all direct service contracts.

As the NC Title V Program is housed in the WCHS and the WCHS Chief is responsible for administering both the Title V Program and the other federal and state programs located in the five Branches, the Title V Program’s relationship with other MCHB investments (e.g., SSDI, MIECHV, ECCS, etc.) and other Federal investments (e.g., PREP, WIC, Immunizations, etc.) is very strong. Through the SMT weekly meetings and other opportunities, the Title V Director and Branches discuss plans and activities to work with partners. The weekly DMT meetings provide an avenue for the Section Chief to partner with administrators of other HRSA programs and other programs within the NC DPH (e.g., chronic disease, vital records, injury prevention, etc.). The NC Association of Local Health Directors (NCALHD) meets monthly, and, on the day prior to each of these meetings, committee meetings are held which include staff members from WCHS and other DPH Sections which enable the Title V Program to work collaboratively with NCALHD on matters that pertain to all LHDs. WCHS staff members, particularly the Regional Nurse, Social Work, Immunization, and Nutrition Services Consultants, also visit the LHDs regularly to perform monitoring and consulting duties and to provide technical assistance.

The NC DHHS houses the state’s Medicaid, Social Services/Child Welfare programs, so within the management structure of the Department interagency coordination is expected and facilitated between the Title V Program and those programs. A copy of the current Inter-Agency Agreement between the state’s Medicaid agency and the Title V program is included in this application. As highlighted in other sections of this application, NC is in the midst of transitioning from a predominantly fee-for-service Medicaid delivery system to managed care, and the WCHS has been in partnership, and will continue to be in partnership, with NC Medicaid throughout that transition.

Additionally, the DPH is signatory to a formal written agreement with the Division of Vocational Rehabilitation (assumes responsibility for Supplemental Security Income eligibility determination). Programs within the WCHS also collaborate with the Division of Public Instruction (DPI); ORHCC (works with federally qualified health centers and other primary care providers); and Division of Child Development and Early Education (DCDEE). The WCHS also collaborates with the Department of Insurance closely on ACA and the Department of Corrections around incarcerated parents and other issues.

There are fourteen accredited schools of public health in NC and WCHS maintains close working relationships with many of them, particularly the UNC-Chapel Hill Gillings School of Global Public Health with its Department of MCH, but also with the Departments of Public Health at UNC-Greensboro and East Carolina University and the Department of Public Health Education at NC Central University. Division staff members serve as adjunct faculty members and are frequent lecturers, in addition to serving on advisory committees. Faculty members are asked to participate in DPH and WCHS planning activities to provide review and critique from an academic and practice perspective.  The Title V Director also serves on the Residency Advisory Committee for the UNC Preventive Medicine Residency at the UNC School of Medicine, facilitating networking and public health rotations. 

WCHS also collaborates on a number of activities with several professional organizations in the state including: NC Medical Society: NCPS; NC Obstetrical and Gynecological Society; Midwives of NC; 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 Section works closely with the NC Partnership for Children (SmartStart), Prevent Child Abuse NC, NC Child, the NC Chapter of the March of Dimes, SHIFT (Sexual Health Initiatives For Teens) NC, CCNC, and many other organizations.

The Section’s capacity in implementing family/consumer partnership and leadership programs is strong, but certainly has areas for ongoing work. The C&Y Branch established a new model for its Branch Family Partnership (BFP) in FY12 in an effort to develop more meaningful partnerships with families using the services administered by the Branch and to ensure that the family voice was heard and integrated both at the state and the local levels as much as possible. More information about the BFP can be found in Section III.E.2.b.ii. (Family Partnership) of the State Action Plan.

In addition to the BFP, the C&Y Branch obtains family input through the EHDI Family Partnership, EHDI parent staff position, and communication received through the CSHCN Hotline. Qualitative data are obtained through focus groups with various programs as described in the work done on the C&Y Strategic Plan and in ongoing planning. There are also the FLS positions which have always been filled by people who have a CSHCN. The EIB also has staff members serving on the BFP. The WHB includes consumers with review of local family planning materials and frequently conducts focus groups to ensure family feedback is part of program design and implementation. Healthy Beginnings, Baby Love Plus, ICO4MCH, and TPPI all require consumer members on their community advisory councils and the Governor’s Council on Sickle Cell Syndrome entails consumer participation on its 15-member Council. Village 2 Village is a community and consumer education work group created to help advance the work of the PHSP. Family/consumer partnership also remains a hallmark of the work of our partnering organizations.

As noted earlier, an expanded SMT meeting was held to determine the priority needs for the 2021-25 reporting cycle. Along with the priority needs, the group also drafted a revised WCHS mission statement that SMT finalized later which is support and promote the health and well-being of NC individuals including mothers, infants, children, youth, and their families to reduce inequities and improve outcomes. While WCHS works to increase health equity throughout its programs and within each population domain, it was decided that a separate priority need specific to health equity and social determinants of health was also necessary. Table 2 lists the eight priority needs and the accompanying performance measures by population domain.