Delaware’s 2020 Title V Needs Assessment benefited from the commitment and engagement of its stakeholder community.   Our Title V MCH workforce realized the need to approach the process with a holistic and comprehensive strategy.  Instead of relying solely upon data to drive the assessment and prioritization process, the Delaware Division of Public Health employed multiple methods to engage partners and consumers, valuing their unique perspectives, contributions and assessment of the state of MCH in Delaware.  Through the Needs Assessment process, Title V was looking to determine Delaware’s population health status, Title V’s program capacity (organizational structure, agency capacity and MCH workforce capacity), as well assess Delaware’s partnerships and ability to collaborate and coordinate efforts.    The Needs Assessment helped Title V establish priority needs for the State of Delaware to improve the health and well-being of Delaware’s women, mothers, children - including children with special health care needs, and families.

The Title V team recognized the need for Delaware to seek and obtain a broad spectrum of input and obtained many voices throughout the process – men, women, families, stakeholders, MCH workforce, partners, health experts, advisory boards, and more.  Delaware partnered with John Snow Inc. (JSI) to conduct the Title V Needs Assessment closely following the steps of the State Title V MCH Needs Assessment Conceptual Framework which consisted of the following major tasks:

Establish Assessment Advisement Process. DPH established a MCH Needs Assessment Steering Committee that was convened on a monthly basis for the purpose of reviewing the proposed assessment methodology, monitoring assessment progress and reviewing draft primary data collection tools, and topic briefs.

Develop Plan for Public Input Process.  Several methods were used to gather public input including regular email updates to stakeholders, surveys, community forums/listening sessions, key informant interviews and focus groups.  Qualitative data such as focus groups and key informant interviews can be considered to be the stories behind the data.  The timing and sequence of gathering public input was iterative with each activity laying the groundwork for subsequent activities.

Community Forums/listening sessions.  Division staff attended coalition, program, and special initiative meetings across the state to discuss the assessment process and solicit input.

Focus Groups.  The Title V team also worked with Aloysius Butler & Clark (AB&C) to conduct 12 consumer Focus Groups regarding several MCH issues related health care and their community.  A total of 92 women and men participated.  Four maternal health groups focused on questions related to women’s health.  Three groups were conducted in English and one group was in Spanish.  Four groups focused on mothers and children and youth with special health care needs.  Two of those groups were in English and two were conducted in Spanish.  Two father/partner groups were conducted.  And lastly, two preconception groups were held with African American women without children.  Discussion guides were created for each set of focus groups and were translated in Spanish.  Participants received handouts for which they were asked to review and identify priorities for women’s health, a father’s role in their child’s live and children and youth with special health care needs.

Surveys.    MCH worked with JSI to craft a Professional Stakeholder Survey that was distributed to more than 800 stakeholders of MCH service agencies, organizations, coalitions and programs for input on MCH population needs, system gaps and leverage points.  The survey also provided stakeholders an opportunity to rank the fifteen national priority areas.  Unfortunately, because the COVID-19 pandemic occurred, responses were not as robust as we had originally hoped.  The Stakeholder Survey, for example, was distributed to more than 800 stakeholders, but after many repeat requests, only 109 usable surveys were obtained.  Although this was still a good mix of responses, we had hoped for more.  Many internal and external partners were unavailable as they were addressing other critical needs within the maternal and child health community related to Delaware’s response to COVID-19. The findings informed our decision-making efforts to select our National Performance Measures, State Performance Measures and Evidence-Based Strategy Measures. 

Key Informant Interviews.  In order to learn more about system strengths and needs and to better understand the landscape of services and supports, DPH identified stakeholders to participate in key informant interviews.  Thirteen Key Informant Interviews were conducted with partners representing every population domain and a Workforce Capacity Analysis was completed by 15 MCH leaders currently in the workforce. 

Conduct Inventory of Relevant Quantitative Data for Review.  Our Title V team reviewed state and national data that was specific to Delaware’s MCH populations.  The team used the following data sources:

Behavioral Risk Factor Surveillance System (BRFSS); Youth Risk Behavior System (YRBS); National Immunization Survey; National Survey of Children’s Health (NSCH); Pregnancy Risk Assessment Monitoring Systems (PRAMS); Delaware Health Statistics (birth records, death records, hospital discharge data).  The Title V team used the data to create detailed and specialized Health Infographics for each of the 15 National Performance Measures.  The aim was to provide our stakeholders and partners with a snapshot of Delaware’s health status as it related to each measure.  Information such as Delaware’s goals and objectives, Delaware’s baseline data, how Delaware compares to our neighboring states as well as nationally, and more. 

Select Final Priorities and Performance Measures.  The MCH Title V team carefully selected and assembled fellow DPH peers to be members of our Steering Committee where an intense review and scrutiny was conducted on our Five-Year Needs Assessment data collection.  The Steering Committee reviewed each Infographic, the Focus Group Study, our Stakeholder Survey Report as well as the Key Informant Interview Analysis.  In addition, our group was diverse with field expertise, a robust discussion developed after each National Performance Measure was presented.        

Upon conclusion of our Steering Committee Summit, in order to assess the needs of our MCH population, we tasked our members to prioritize and rank each National Performance Measure based on:

• Size of the Health Issue;
• Seriousness of the Health Issue;
• Disparities in Outcomes;
• Current Level of Intervention;
• Community Support;
• Political Will;
• Importance to Consumer; and
• Alignment with National/State Goals.    

All our Needs Assessment information is found in one central location, our DEThrives website, https://dethrives.com/title-v.  Here MCH has all the detailed Title V information, including infographics on each of our 15 National Performance Measures, a framework of the Needs Assessment process, reports on our Focus Group studies, results of the Stakeholder Survey and more.  We encourage families, partners and stakeholders to check back often for updated information and resources and to reach out with any questions.  During the month of March alone, our Title V page on DEThrives received 275 pageviews.

Fortunately, our Title V program is housed in the same section as our MIECHV program within the Division of Public Health.  We were able to easily coordinate efforts, sharing data analysis and consumer feedback.   In completing our 2020 MIECHV Needs Assessment, we chose to adopt an independent method for identifying communities at risk. Making use of diverse and highly vetted data sources, several indicator measures were developed for the State of Delaware. The indicators chosen for this report tended to center slightly more on socioeconomic wellbeing and less on health status since more timely data was available on the former than on the latter and due to the state’s vested interest in focusing on the social determinants of health. Using these indicators, an analysis was then conducted on aggregated zip codes – or “zones” – as the geographic unit of interest. The indicator results at the zone level were compared across zones and the top five zones for each indicator were highlighted. The zones most frequently highlighted among the top five indicators were classified as “at-risk” communities.

Relatively recent zip code level data was available for the following indicators, were ultimately used to determine the at-risk zones:

• Adults with No Dental Visit in Past Year
• Adults who Binge Drink
• Adults who Smoke
• Age-Adjusted Mortality Rate
• Chronic Conditions (3 Sub-Indicators)
  • Adults with Diabetes
  • Adults with High Blood Pressure
  • Adult Obesity
• Educational Attainment (Less Than High School Graduate)
• Health Insurance (No Coverage)
• Limited Access to Health Care
  • Adults Delaying/Not Seeking Care
  • Adults with No Usual Source of Care
• Limited English Proficiency
• Low Birth Weight
• Poverty (Below 100% FPL)
• Unemployment

The zones identified during our MIECHV Needs Assessment process closely algin with the high-risk zones identified in when determining areas of need for our HWHB Zones program.  The HWHB Zones program is discussed in detail under the Women/Maternal Health Domain reports.  These areas will be considered as we implement programs to address our identified Title V priorities. 

The following section presents key findings of Delaware’s MCH population health status including CYSHCN, based on primary and secondary data collected through public health surveillance systems, surveys, key informant interviews and focus groups.  The findings are organized by population domains.  As mentioned, the infographics provide a summary of all the16 national performance measures and 3 additional priorities evaluated for each population domain.  This infographics can be found, https://dethrives.com/title-v.

Maternal Health/Women’s Health:

In 2015, only 72.6% of Delaware women, ages 18-44, had a preventive medical visit each year.  The percentage rose slightly through the years and in 2018, 78.3% of women had the preventive medical visit according to the NSCH.  Black women had the highest rate of receiving a preventative well visit compared to other races.  Patterns of decline are seen by income level.

Our infant mortality rates have been improving over the years, however the disparity as persistent and our stakeholders selected reducing black infant mortality as a priority for the next 5 years.  The annual infant mortality rate for 2018 was 5.9 per 1,000 as compared to 5.7 for the U.S. The provisional 2019 annual rate for DE was 6.4 per 1,000. The five-year infant mortality rate (2014-2018) was 7.3 (12.2 for non-Hispanic blacks, 8.4 for Hispanics, and 4.5 for non-Hispanic whites).  The provisional 2015-2019 five-year infant mortality rate was 7.2 (12.3 for non-Hispanic blacks, 8.0 for Hispanics, and 4.3 for non-Hispanic whites).  The annual black infant mortality saw a 15% (19% if provisional data are included) decline in annual rates. For instance, the annual non-Hispanic IMR has been declining from a high of 13.5 per 1,000 live births to 11.5 and 2018 and 10.9 in 2019 (provisional data).

Women receiving an annual preventative well-visit was seen as of high importance; ranked #3 among the 15 priority areas by our stakeholders. Our Focus Group Study results stressed that women collectively understood that providers played a key role in their lives and had a deep desire for conversation and encouragement on “how to” health conditions and concerns.  Participants described a variety of clinical encounters (positive and negative) in which the clinician is directive – do this, do that, read this; the interaction is didactic in nature. On the one hand, this is acknowledged as indicative of competent advocacy, but in many instances, there are a whole host of issues that go unspoken because the interaction is not conversational in nature. These issues are slightly “off topic” but highly related to the topic: for example, referrals may prompt worry over the severity of illness; anti-depressant/antianxiety medications may prompt worry over a parent finding out about it. This phenomenon is very apparent for informational material, such as for nutrition and physical activity. Handouts are informative in a general way but prompts deeper questions about HOW to implement the guidance in their own lives, which are not discussed – patients are just sent home with the information. This issue may also be related to the Insurance Theme; patients come in for brief problem-focused issues, not an annual preventive care exam, during which there could be more time to talk. This issue may be amplified when providers are residents/medical students. Not being able to converse is very important for mental health, nutrition/exercise, and (exceptionally important) for family planning.  This feedback during the focus groups validated our decision to incorporate community health workers to worker with providers to ensure better communication.

Extensive data show that unplanned pregnancies have been linked to increased health problems in women and their infants, lower educational attainment, higher poverty rates, and increased health care and societal costs.  According to PRAMs data, between 2012-2015 34.5% of women either wanted to become pregnant later or didn’t want to be pregnant then or at any time in the future. PRAMs data between 2016-2018 indicates unintended pregnancies are decreasing in Delaware with 27.5% of women either wanted to become pregnant later or didn’t want to pregnant then or in the future. In working with or stakeholders, we are going to continue to prioritize decreasing unintended pregnancies even with the decreases.  Based on the consumer feedback, we clearly have more work to do to promote a better relationship with women among providers and to address issues such as implicit bias with our providers.

Perinatal/Infant Health:

According to the National Immunization Survey, Delaware infants who are ever breastfed in 2018 was at 77.4% compared to 77.2%.  When you view the percent of Delaware infants who are breastfed exclusively through six months, the numbers are significantly lower.  In 2016, 18.9% of infants were exclusively breastfed through six months, compared to 20.5% in 2017 and 23.6% in 2018.      

Our Stakeholder Survey ranked Breastfeeding the eighth highest of Most Important NPMs, overall.  In addition, Breastfeeding was ranked second in terms of Community Awareness, Desire to Address and Progress has Been Made on the Issue. 

While Stakeholders ranked Risk-Appropriate Perinatal Care as the fourth highest Most Important National Performance Measure, it was not selected as one of Delaware’s priority areas.  This is because there was no political will behind this measure.  In addition, neither MCH or DPH has influence over a physician referring their higher risk mothers to deliver at a hospital with a level III or higher Neonatal Intensive Care Unit that can provide the proper care the newborn requires.  Instead, the Title V team is focused on areas where we can align our collaboration and resources to make an impact on the maternal and child health population.    

Based on available data, the percentage of Delaware infants placed to sleep on their backs was generally increasing from 77.2% in 2012 to 81.9% in 2017.  In 2018, it took a dip, though, to 79.8%.  The percentage of Delaware infants who sleep alone on an approved surface has increased from 36.0% in 2016 to 38.7% in 2018.  Our Stakeholders ranked Safe Sleep as first among the percent who Agree Progress has Been Made on the Issue. 

Delaware historically has a high infant mortality rate and significant racial disparities exist as well.  While the state experienced a 22% reduction in infant mortality between 2000 and 2017, Delaware’s infant mortality rate of 7.3 deaths per 1,000 live births in 2013-2017 is still significantly higher than the national rate of 5.9 deaths per 1,000 live births in 2013-2017.  

The leading cause of infant mortality is premature birth, and such births have both short-term and long-term negative impacts, and disproportionately impact women of color.  Black infants in Delaware are more than twice as likely as white infants to die before their first birthday.  Factors such as obesity, diabetes, hypertension, chronic disease, smoking, stress, race and racism, genetics, infection, and maternal age, along with multiple social determinants, all contribute to premature death and infant mortality.

In Delaware, black women have an infant mortality rate of 12.5 deaths per 1,000, which is approximately two and a half times that of white women, for which the infant mortality rate is 5.1 deaths per 1,000 live births.

As a result of our Steering Committee Summit, the Title V team selected Breastfeeding as the top priority for Delaware to address in the coming five years for the Perinatal/Infant Health Domain. 

Child Health:

Based on available data, Delaware is among the lowest of its surrounding states when comparing children, ages 9-35 months, who received a developmental screening in the past year, where only 25.5% of these children received the screening.  Delaware is also below the national average of 33.5% of children with the screening.  Developmental Screening was selected as the Most Important NPM in the Child Health Domain as a result of our Stakeholder Survey.  In addition, it was ranked as the second highest priority overall. 

The Preventive Dental Visit (child/adolescent) was another priority that is important to Delaware stakeholders.  Ranking second is this population domain and tenth overall. Our stakeholders recognize that dental health equals overall health and the Title V team has identified that MCH is able to align our collaborations and resources to make an impact.  According to the 2017/2018 National Survey of Children’s Health (NSCH), 18.0% of Delaware children, ages 0 through17, have not had a preventive dental visit in the past year.  The Preventive Dental Visit (child/adolescent) was another priority that is important to Delaware stakeholders. 

As a result of our Steering Committee Summit, the Title V team selected Developmental Screening and Preventive Dental Visit as top priorities for Delaware to address in the coming five years for the Child Health Domain.  

Delaware’s stakeholders ranked Injury Hospitalization as the lowest priority when ranking overall priorities and ranked it the lowest among all priorities in the Child Health Domain.  Similarly, the other National Performance Measures in the Child Health Domain did not score high. 

Adolescent Health:

The percentage of adolescents who have had a preventive medical visit in the past year has been declining in Delaware.  In 2016, the percentage was 89.5%, while in 2017 the percentage declined to 84.2% and in 2018, Delaware’s percentage of adolescents who have had a preventive medical visit in the past year fell to 70.2%. 

As with the Child Health Domain, Injury Hospitalization was the lowest priority when ranking overall. 

Based on available data, Delaware is among the lowest of its surrounding states when comparing the percentage of adolescents, ages 12-17, who are physically active at least 60 minutes per day.  15.3% of Delaware’s adolescents are physically active zero days per week.  Additionally, Delaware is also the lowest of its surrounding states when it comes to those adolescents being physically active every day, at only 11.6%. 

The Adolescent Well-Visit ranked the Most Important National Performance Measure within the Adolescent Health Domain and the seventh priority overall.  As a result of our Steering Committee Summit, the Title V team selected Physical Activity and Adolescent Well-Visit as top priorities for Delaware to address in the coming five years for the Adolescent Health Domain. 

Our Title V team selected the Adolescent Well-Visit because of the versatility of the measure.  The team selecting this measure with the goal of incorporating other Adolescent Health Domain priorities within the well-visit measure.  Priorities like bullying, mental health, smoking, healthy lifestyles, transition and trauma could all be bundled within this measure. 

Children with Special Health Care Needs:

According to the 2017/2018 National Survey of Children’s Health, only 70.0% of Delaware’s children, ages 0 through 17, with special health care needs are adequately and continuously insured.  Access to high quality health care, including having adequate health insurance that reduced barriers to primary and specialty care was chosen as the Most Important thing that women, children and families need to live their fullest lives by our stakeholders.  In addition to the Most Important, Adequate Insurance was also selected by our stakeholders as the Most Unmet need of women, children, and families in Delaware communities. 

According to the 2017/2018 National Survey of Children’s Health, only 46.0% of Delaware children with special health care needs have a medical home.  Additionally, 77.6% of Delaware adolescents, ages 12 through 17, with special health care needs, have not received services necessary to make transitions to adult health care.  

The Focus Group Study results showed that parents are concerned that their children with special health care needs are uncomfortable changing providers and may not accept care easily from a new doctor.  Parents stressed the importance of transitioning to an adult world and that it is a process of teaching the child behavioral rules all over again, where there is one set of rules for children and one set for adults. 

However, transition ranked relatively low among our Stakeholders as the Most Important performance measures to address.  The team felt to focus more on areas where we can align our collaboration and resources to make an impact on children with and without special health care needs.  For example, with the selection of adolescent well-visit, we plan to address transition with our SBHC and providers.

As a result of our Steering Committee Summit, our Title V team selected Adequate Insurance as a top priority for Delaware to address in the coming five years for the Children and Youth with Special Health Care Needs Health Domain.     

In Delaware, the executive branch of state government is headed by Governor John Carney who took office as Delaware’s 74th Governor in January 2017.  Within the executive branch, the Delaware Department of Health and Social Services (DHSS) is a cabinet-level agency and is led by Secretary Molly Magarik.  The Delaware Department of Health and Social Services is the largest state agency employing more than 4,000 individuals in a wide range of public service jobs.  The Department consists of 11 divisions, which provide services in the areas of public health, social services, substance abuse and mental health, child support, developmental disabilities, long-term care, visual impairment, aging and adults with physical disabilities, state service centers, management services, financial coaching, and Medicaid and medical assistance.  The divisions are united by an overarching mission, which is simple yet profound: to improve the quality of life for Delaware's citizens by promoting health and well-being, fostering self-sufficiency, and protecting vulnerable populations.

The Division of Public Health (DPH) is one of the largest divisions within DHSS, serves as the Title V agency in Delaware.  Under the direction of Karyl T. Rattay, MD, MS, the mission of DPH is to protect and promote the health of all people in Delaware. 

Because Delaware does not have county or local health departments, DPH administers both state and local public health programs.  DPH is structured into three main strands: Operations, Health Information and Science (HI&S), and Community Health Services.  Each strand is comprised of a multitude of sections.  HI&S is led by Cassandra Codes-Johnson, MPA, and the Family Health Systems (FHS) section falls within HI&S.  The Section Chief of FHS is Leah Woodall, MPA.  The Title V Maternal and Child Health (MCH) and Children and Youth with Special Health Care Needs (CYSHCN) programs are part of FHS, within the HI&S strand. 

The Family Health Systems Section is the home of many of the programs funded by Delaware’s Title V federal-state partnership.  As such, the section chief for FHS, Leah Woodall, MPA, also serves as the state Title V MCH Director.  The section is comprised of three units.  The Bureau of Maternal & Child Health is led by the MCH Deputy Director, Crystal Sherman, BS.  The MCH Bureau is responsible for direct administration of the Title V Block Grant, and includes the following programs: Children and Youth with Special Health Care Needs; Newborn Screening (metabolic and hearing) ; Birth Defects and Autism Registries; Early Childhood Comprehensive Systems Impact; State Systems Development Initiative; and Home Visiting (MIECHV and state funded).  The Bureau of Adolescent and Reproductive Health, led by Gloria James, Ph.D. includes the Adolescent Health Program (School-Based Health Centers and Teen Pregnancy Prevention) and the Title X Family Planning Program.  The Center for Family Health Research and Epidemiology, led by Mawuna Gardesey, M.B.A. includes the Infant Mortality Elimination Program, the Healthy Women, Healthy Babies Program, and the Pregnancy Risk Assessment Monitoring System. (See Section VI. Organizational Chart for reference). 

As the Title V agency, DPH operates a comprehensive array of programs and services to promote and protect the health of Delaware’s mothers and children, including children and youth with special health care needs.  Within, DPH, the Family Health Systems Section houses many of these programs, as described above.  However, the capacity to support the MCH population extends throughout all sections of the Division, including services such as the WIC program, immunizations and lead testing through State Service Centers and supports for healthy lifestyles (physical activity, nutrition, tobacco cessation), to name a few.  An overview of DPH’s programs and services for the MCH population is summarized below by the Title V MCH population domains.   

Women/Maternal Health:  Programs, services and information are available to women in three broad categories - general health, sexual and reproductive health, and maternal health. 

In the category of general health, DPH’s Office of Women’s Health (OWA) offers education to the public regarding a variety of women’s health issues via outreach. The OWH’s focus spans the lifetime of a woman, from adolescents through postmenopausal stages.  In the area of sexual and reproductive health, the Title X program offers family planning, testing for sexually transmitted diseases, birth control supplies, pap smears, breast exams, and HIV testing and counselling. Finally, to support maternal health, DPH operates the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program which provides evidence-based home visiting for pregnant women, statewide. The WIC program is also available to low-income pregnant women and provides nutritious foods to supplement diets, information on healthy eating, and referrals to other services. 

In Delaware, many programs, campaigns and services in the area of maternal health stem from the work of the Delaware Healthy Mother and Infant Consortium (DHMIC). The mission of the DHMIC is to provide statewide leadership and coordination of efforts to prevent infant mortality and to improve the health of women of childbearing age and infants throughout Delaware. The Family Health Systems Section of DPH is responsible for the DHMIC and administration of related programs and initiatives. One such program is the Healthy Women, Healthy Babies 2.0 program, which facilitates extra services for women who are pregnant, planning to become pregnant, or want to live healthier lives. These services include weight and stress management, mental health treatment, prenatal care, and more. The DHMIC also develops educational materials and tools to promote reproductive life planning, breastfeeding and the dangers of substance use while pregnant.  

Perinatal/Infant Health:  Much of our capacity to promote maternal health extends to the support of perinatal and infant health.  For example, Delaware’s Perinatal Quality Cooperative (DPQC) falls under the DHMIC umbrella and works to enhance communication and collaboration across birth hospitals to improve delivery of care.  Related to infant health and the prevention of infant mortality, the DHMIC develops educational messages to promote important practices like breastfeeding and safe sleep environments; similarly, WIC and the MIECHV reinforce these messages.  With state funding, we have been able to contract with outside agencies to expand evidence-based home visiting giving Delaware a continuum with the ability serve families prenatally through a child’s fifth birthday. 

DPH’s Newborn Screening program offers both metabolic and hearing screening for every infant born in Delaware.  The program also provides follow-up case management of positive screens to ensure identified infants and their families are linked to appropriate treatment services.  Delaware screens for all the disorders recommended by the Uniform Screening Panel.  

Child Health:  To support healthy growth and development in both infants and children, Delaware continues to implement the Help Me Grow model to improve early identification of developmental issues and timely connection to services.  Help Me Grow is a partnership of many organizations throughout the state and has four key areas of activity: Central 2-1-1 Telephone Access, Physician Outreach, Community Outreach and System Improvement.  Help Me Grow call specialists provide families with connections to existing resources statewide as well as providing a developmental screening utilized the validate tool, ASQ.

A component of our effort to increase developmental screening is providing physicians with online access to the Parents’ Evaluation of Developmental Status (PEDS) validated screening tool.   Delaware’s Early Childhood Comprehensive Systems program (ECCS) shares the vision of the State’s early childhood community to support a coordinated, comprehensive and sustainable early childhood framework.  For that reason, the ECCS program collaborates with its place-based community partners and stakeholders to improve outcomes in population-based children’s developmental health and family well-being.  This approach entails closer relationship and integration of early childhood and education settings and health sector. 

DPH also offers lead testing, physicals, and immunizations through child health clinics at state service centers across the state.

Adolescent Health:  School Based Health Centers (SBHCs) are core to our capacity to support adolescent health.  For the past 30 years, Delaware School Based Health Centers, located in 32 public high schools, have contributed to the health of the state’s high school adolescents and have been an essential strategy to support women’s overall physical and mental health.  SBHCs provide at-risk assessment, diagnosis and treatment of minor illness/injury, mental health counseling, nutrition/ health counseling and diagnosis and treatment of STDs, HIV testing and counseling and reproductive health services (27/32 sites) with school district approval as well as health education.

In addition, Delaware’s SBHCs provide important access to mental health services and help eliminate barriers to accessing mental health care among adolescents. Over the last couple of years, school boards voted and approved to add Nexplanon as a birth control method, and 14 sites now offer at their health center.

Delaware’s Personal Responsibility Education Program (PREP) focuses on building capacity of teachers and volunteers to implement two evidence-based pregnancy prevention and risk-reduction programs delivered at middle and high schools in addition to community sites throughout the state.  Alliance for Adolescent Pregnancy Prevention also offer evidence-based curricula and implementation of programs that assist in reducing the instances of teenage pregnancy and sexually transmitted diseases throughout the state, targeted to middle and high school aged adolescents. ​ 

Children and Youth with Special Health Care Needs Health: For children identified as highest risk for developmental delays, physicians can refer directly to Child Development Watch (CDW), the statewide early intervention program under the Birth to Three Early Intervention System.  CDW is a collaborative effort with staff from DPH, the Department of Services for Children, Youth and Their Families, the Department of Education (Part B) and the Alfred I. DuPont Hospital for Children working together to provide early intervention to young children with special health care needs and their families.

Another source of support for this population is Family SHADE (Support and Healthcare Alliance of Delaware).  Delaware’s Family SHADE is a collaborative alliance of family partners and organizations committed to improving the quality of life for children and youth with special health care needs (CYSHCN) by connecting families and providers to information, resources and services.

DPH also supports two surveillance efforts related to CYSHCN.  The Birth Defects Registry uses active surveillance to collect and analyze data on children diagnosed with a birth defect under the age of five.  A data committee under the DHMIC reviews the data and determines any prevention strategies that could be deployed.  The Autism Registry is a passive surveillance registry that collects basic descriptive information on the individuals with autism, tracking changes in prevalence over time to inform planning of services and supports.

The Division for the Visually Impaired (DVI) works to strengthen the capacity of our agency, consumers, and community so that those who are blind and visually impaired may become and/or remain, employed, independent and self-sufficient. The Child Development Watch Program works with DVI to provide service coordination for children who are blind or visually impaired.

The total federal-state MCH partnership budget reported in this application includes Title V funds, state general funds, and appropriated special funds.  The state portion of the MCH partnership is $10,128,656.00, which includes funds appropriated for state infant mortality reduction initiatives and supports 53.0 FTEs (46.4 from general funds and 6.6 from appropriated special funds).  The Title V federal allotment is estimated at $2,027,826.00 for FY 20.

In Delaware, the majority of Title V block grant funding is used to support approximately 18.75 positions (FTEs) across the division that are involved with MCH programs and services, including Child Development Watch, adolescent health, child health, health education, and primary care.  In this way, Title V funding has historically been leveraged to bolster the capacity of many DPH programs that serve mothers, children, and families.  Most of these positions do not report directly to the Title V program, but rather to the Administrator of the specific program or clinic that they work within.  As we consider our recent Five-Year Needs Assessment findings and develop our 5-year State Action Plan, we will need to work with the Program Managers of these positions to assess job responsibilities and ensure alignment with our new Title V priorities.

Family Health Systems Section Chief:  Leah Woodall, MPA, was appointed as the Section Chief of the Family Health Systems Section in 2013 and serves as the state’s Title V Director.  Leah has worked for DPH since April 2010, serving as the Title V/MCH Deputy her first three years. and served three years in the MCH area as the MCH Bureau Chief and Deputy Director.    

Maternal and Child Health Bureau Chief/Title V MCH Deputy Director:  Crystal Sherman, BS, has served in the role of MCH Bureau Chief and Deputy Director since October 2015.  Before this promotion, Crystal was also in the MCH unit and served as the Home Visiting Program Administrator.   

Director of Children & Youth with Special Health Care Needs:  Isabel Rivera-Green, MSW, has been serving as the Director of Children & Youth with Special Health Care Needs since September 2018.  Before this role, Isabel served as the Early Hearing Detection Intervention (EHDI) Coordinator from October 2015 until she was hired as the CYSHCN Director.

Title V Block Grant Coordinator, Project Director of State Systems Development Initiative:  Elizabeth Orndorff is new starting in DPH and MCH in August 2018 as the Title V Coordinator and the SSDI Director.  She is also responsible for coordinating the 2020 Title V Five-Year Needs Assessment. 

Maternal and Child Health Epidemiologist, Centers for Disease Control and Prevention Assignee:  Khaleel S. Hussaini, PhD.  In addition to his routine analyses of quantitative and qualitative population health data available at DPH to support MCH Block Grant, and other program initiatives and evaluation, Dr. Hussaini provides scientific and technical assistance to Division staff and stakeholders in the areas of maternal and child health outcomes.

Having a well-prepared work force is critical to meet the maternal and child health needs of the people of Delaware.  Having a committed, empowered workforce, with a wide-range of expertise, is necessary to create a resilience-oriented, trauma-informed system of care.  As part of our Five-Year Needs Assessment, MCH conducted a Workforce Capacity Analysis where the objective was to identify Delaware’s Title V program capacity.

The strengths of the MCH leadership and core team lie in our depth of professional experience, educational background, and passion for the work however the dedicated team recognizes the need for continuous professional development.  They recognize a need to learn how: to balance the needs of diverse stakeholders, to find evidence, to learn quality improvement methods, and to understand health disparities.  Regarding specialized cultural and linguistic competency training, DPH offers internal training opportunities.  In addition, DPH offers training opportunities through a collaborative agreement with Johns Hopkins Bloomberg School of Public Health/Med-Atlantic Public Health Training Center.

The Delaware Title V MCH program can meet the needs of women, mothers, infants, children, CYSHCN and adolescents through partnership, collaboration and coordination with other entities. Delaware has many advisory boards, councils and coalitions that our MCH program works with to extend the reach of Title V, guide our work and expand on the overall capacity to support mothers, children and families.  Two of the largest groups of partners coming together around MCH issues in Delaware are the DHMIC and Family SHADE. 

MCH’s finest collaboration, the Delaware Healthy Mother & Infant Consortium (DHMIC).  The DHMIC pursues the health of women, infants and families through a life course approach.  The DHMIC approach includes planning with the community, thinking holistically about women’s health and addressing inter-generational health.  The DHMIC supports a continuum of services promoting optimal health from birth throughout the lifespan, from one generation to the next.

Formed as a statewide vehicle to address infant mortality, the consortium includes approximately 19 Executive Committee members, including representatives from the House of Representatives, State Senate, DPH, hospital systems, universities, faith-based communities, and more.  The DHMIC invites over 150 partners and stakeholders to the quarterly meetings.  In December 2018, the consortium developed a three-year strategic plan with one- and three-year objectives.  One of the goals was to create three workgroup committees: Well-Woman, Social Determinants of Health, and Maternal Infant Morbidity and Mortality.  Delaware’s Perinatal Quality Cooperative is a subcommittee of the consortium.  Staff from the Family Health Systems Section of DPH staff these committees and support the partners in advancing shared work.  For more information on the DHMIC, please visit this website, https://dethrives.com/dhmic.

In the domain of CYSHCN, a key partnership group is Family SHADE (Support and Healthcare Alliance Delaware), a collaborative alliance of family partners and organizations committed to supporting families of children with disabilities and chronic medical conditions.  The DHMIC and Family SHADE represent two of the largest groups of partners coming together around MCH issues, but there are many other advisory boards, councils, and coalitions that our MCH program works with to extend the reach of Title V, guide our work, and expand the overall capacity to support mothers, children, and families.  For example, the Help Me Grow Advisory Committee, convened by DPH, consists of representatives from organizations across the state.  Similarly, the Home Visiting Community Advisory Board pull together home visiting and partnering programs from across the state to ensure a coordinated continuum of home visiting services.  In addition, the Governor’s appointed Early Hearing Detection and Intervention (EHDI) Board was created by legislation passed in 2012.  The Newborn Screening Advisory Council, formed in 2000, helps the Division determine best practices for the program including the addition of new conditions to the Delaware panel.

Additional key partnerships and collaborations include Delaware’s Early Childhood Council (ECC), the Safe Kids Coalition, the Family Coordinating Council, the Sussex County Health Promotion Coalition, and the Breastfeeding Coalition of Delaware.

As outlined in our organizational structure, our Title V program is intimately connected with federal investments, such as the State Systems Development Initiative (SSDI), Maternal and Infant Early Childhood Home Visiting (MIECHV), Early Childhood Comprehensive Systems (ECCS), and Personal Responsibility Education Program (PREP) Partners by virtue of the location of these grant programs within the same section - Family Health Systems.  In addition, we have partnered with Project LAUNCH and the Division of Substance Abuse and Mental Health in combating the opioid epidemic.  The State of Delaware created a committee bringing together the Division of Public Health, Division of Family Services, and the Division of Substance Abuse and Mental Health. The group is made up key leadership including all three Division Directors, two Deputy Directors and senior program directors including both the Title V Director and Deputy Director/MIECHV Project Director. The group decided to work on three key goals, a MOU, training for direct service staff and education.

The purpose of the MOU stems from both The Department of Health and Social Services and The Department of Services for Children, Youth and Their Families recognizing that each has an important role to improve the lives of families impacted by substance use disorder. The MOU was jointly developed for the agencies:

• To work as a team on shared client cases to attain the most positive outcome;
• To provide each client with the most comprehensive care; and
• To prevent duplication of activities.

The MOU states that each agency agrees to establish a multi-disciplinary coordination committee. The focus for the committee was training, messaging, case management, and the development of procedures. Since the development of this MOU, it has been decided that each of Delaware’s counties will have a committee focused on the above-mentioned items.

Home visiting supervisors, treatment providers, Division of Family Services administrators, supervisors, and caseworkers have come together to form the Delaware Multisystem Healthy Action Committees (MSHAC) in each county. The initial kick off was held in September 2016 and quarterly meetings in each of our three counties continue to collaborate. The charge of MSHAC is to plan how to serve families with substance use disorder better through a multi-agency approach.

Agenda topics for these meetings have included sharing resources and educational materials, updates from local treatment providers, coordination of services and referrals, tips for using DFS hotline reporting, related state legislation, and even walking through substance abuse specific cases in each agency. Supervisors and agency representatives are asked to refer information back to their staff of professionals who work directly with substance abuse clients and families. Guest speakers have been invited quarterly and continue to enrich the knowledge of the committee. Topics and speakers relevant to this work are listed in Table 13.

In addition to the wide range of organizational collaborations listed above, we also value partnership with families and consumers.  As part of our Five-Year Needs Assessment process, we commissioned 12 discussion groups statewide, with a total of 92 women and men participating.  Four maternal health groups focused on questions related to women’s health.  Three groups were conducted in English and one group was in Spanish.  Four groups focused on mothers and children and youth with special health care needs.  Two of those groups were in English and two were conducted in Spanish.  Two father/partner groups were conducted.  And lastly, two preconception groups were held with African American women without children. 

Parents continue to be engaged through the Families Know Best Surveys administered by Family SHADE.  Families Know Best is a voluntary parent advisory group. Participating families are asked to fill out monthly online or print surveys about the services they receive. Information gained through these surveys is shared with Family SHADE organizations, policy makers and agencies statewide.

A very important activity for partnering with families is the Managed Care Organization Health calls facilitated by Delaware Family Voices, with the phone line provided by DPH. These regularly scheduled calls give family members an opportunity to ask a question or discuss an issue. On the call are representatives from various agencies and organizations to listen and help problem solve. These calls give families a non-adversarial venue discuss to share their concerns, and as a result many families get a better understanding of how the system works and the providers and policymakers hear how a family is impacted by rules and regulations. 

In the spirit of Title V, we are committed to continuing these efforts to partner with families and consumers of our programs and services to ensure that our efforts and resources are aligned with the priority needs of Delaware’s mothers, children, and children and youth with special health care needs.

The selection of the State health priorities was completed as a result of a thorough examination of the findings from the state’s Five-Year Needs Assessment. Based on the assessment process, Delaware has chosen the following seven priorities as the focus of our efforts in the coming 2020-2025 grant period:

1. Woman have access to and receive coordinated, comprehensive services before, during and beyond pregnancies.
2. Improve breastfeeding rates.
3. Children receive developmentally appropriate services in a well-coordinated early childhood system.
4. Empower adolescents to adopt healthy behaviors (healthy eating and physical activity).
5. Increase the number of adolescents receiving a preventative well-visit annually to support their social, emotional and physical well-being.
6. Increase the percent of children 0-17 with and without special health care needs who are adequately insured.
7. Improve the rate of Oral Health preventive care in children. 

Delaware’s 2020 Title V needs assessment and priority selection process benefited from the commitment and engagement of its committed and engaged stakeholder (including families) community. Instead of relying solely upon data to drive the assessment and prioritization process, the Steering Committee employed multiple methods to engage partners and consumers, valuing their unique perspectives, contributions and assessment of the state of MCH in Delaware. The goals of the prioritization process were to 1.) Use a data-informed method to identify and prioritize Delaware’s top health issues related to the health of women, infants, children and youth, including children and youth with special health care needs; and, 2.) Incorporate stakeholder and public input into finalizing the priority areas by population domain for action planning. The Needs Assessment Steering Committee was responsible for reviewing and understanding the data, and then assigning scores for each of the sixteen national health areas in order to rank them.  

A set of 7 variables were considered in this prioritization process, including size and seriousness of the health issue; disparities in outcomes; stakeholder support; importance to the community; and alignment with national and state goals.  Once all individual rankings were completed, the findings were combined to determine the overall priority ranking.  The final step was to ensure that each of the 6 Title V population domains was represented in the priority health area selection, and that all rules outlined in the Title V guidance had been considered. In addition to selecting priorities that aligned with the National Performance Measures, the Steering committee also took in to account additional suggestions from the stakeholders for priorities that were outside of the scope outlined in the guidance.  Some of those health issues highlighted were infant mortality, social determinants of health and mental health.  Where possible, the Committee incorporated those suggestions as a feed to the National Performance Measures to ensure that the objectives and strategies focused not only on the stated measure, but also an additional perspective of the measure that was closely related.  An example of such was the inclusion of a mental health component for addressing well woman and adolescent well-visit where a mental health services are provided (HWHB 2.0 and SBHCs).  The performance measure addresses the need to for adolescents to receive a preventative well-visit annually to support their social, emotional well-being.   Similarly, we received feedback from our stakeholders and community members regarding the importance of nutrition and obesity and therefore modified our objectives for physical activity to incorporate healthy lifestyles and healthy eating.

The continuation of our focus on priorities from the past five years includes areas that focus on increasing the number who have a preventative well-woman visit, improving breastfeeding rates, improving rates of developmental screening. improving the rate of oral health care in children and increasing the percent of children with and without special health care needs who are adequately insured. 

The need to increasing the number of women who receive preventive care services remained a priority among stakeholders and consumers. The health priority need for woman to have access to and receive coordinated, comprehensive services before, during and beyond pregnancy is considered a continuation of the strategies we have developed over the last 5 years including new programming within the last year. For those efforts, our stakeholders noted the increased messaging and initiatives in the state around promoting well woman care contributed to the progress being made.  Other strategies included engaging partnerships in community such as the HWHB Zones project and the implementation of mini grants.  Suggestions were made by our key informants that emphasized the importance of incorporating weight management, diabetes prevention/management in preconception and interconception care and highlighted the impact of these services have on lowering infant mortality rate in the state. Key informants also proposed reframing the idea of well woman care to transform it from being episodic to creating a continuum of care as a strategy for addressing women’s’ health.  Taking into consideration these and other feedback, it was decided to address National Performance #1 from a life course approach to addressing women’s health before, between and beyond pregnancies versus addressing only women who receive a well woman visit in the past year.

The input gathered through our needs assessment process showed support from partners to continue to address breastfeeding rates.  Through a survey of MCH stakeholders, breastfeeding was ranked as the number nine national performance measure for our Title V program to address in the perinatal/infant domain, and over 50% indicated that there was a strong desire among stakeholders to address the issue. Stakeholders’ assessment of the capacity of the Delaware Maternal and Child Health System to address improving breastfeeding for children indicated a strong desire to address this issue and that evidence-based programs existed in this area.  It was also noted the need to reduce the disparity that exists for black women.  These and other suggestions from our stakeholder community make this a very important need for MCH to address for our mothers and children in Delaware.

The feedback received from our stakeholder survey and key informant interviews highlighted our previous successes in developmental screening, however the data also showed that the need was high to continue to focus on this area. Stakeholder survey results revealed developmental screening as ranked #3 among the 15 priority areas and ranked #1 among the three priority areas within the children’s health domain. Stakeholders’ assessment of the state’s capacity to improve developmental screening for children was very positive with about three-fourths indicating that there was a strong desire to address this issue and that evidence-based programs existed in this area.  As a result of the state’s commitment to and work on developmental screening, significant progress has been made however consumers and stakeholders alike recognize that there is still more work to be done. The objectives to continue the progression of success includes building on existing efforts to promote the adoption of PEDS screening tool by providing participating pediatric practices with technical assistance, practice-level data, and CQI tools to optimize their screening rates.  We also feel it is important to educated parents about developmental milestones and the importance of developmental screening, empowering them to request that their pediatrician perform screening.  Improving developmental screening and coordination of care is also a priority for the statewide Early Childhood Council per the draft strategic plan which will be unveiled this Fall. 

In the past our focus was on the ensuring that oral health preventive services and treatment were available for children, including children with special health care needs. Great strides were made in the past year to advance the goal of ensuring oral health preventive services for children using various methods of outreach and community partnerships. There has been a significant increase in the utilization of the dental Medicaid program in Delaware can be directly correlated the program’s coverage for children under age 21.  Stakeholder survey results point to oral health as a relatively important issue but noted that there are limited resources available to address the issue. There remain important opportunities for Delaware – in terms of partnerships, and education in communities, especially on the concept of a “dental home” and therefore our work will continue in this area for the next grant period.

The last area of interest that will be continued from previous years will be the focus on Adequacy of insurance coverage is an issue of high importance among our survey respondents as well as key informants and consumers. The stakeholder survey showed this issue was ranked #2 of 15 priority areas and ranked #1 among the CYSHCN domain.  Almost 80% of respondents agree/strongly agree that there is a strong desire in the state to address the issue and 48% indicated agreement that progress is being made. Qualitative data collected as part of the needs assessment process point to the importance of this issue, particularly for families with CYSHCN. In focus groups, surveys and key informant interviews for the CYSHCN population, respondents pointed to the lack of or inadequate coverage for needed services for their children. Expenses ranged from respite care to medications and equipment. Financial strains due to out of pocket expenses and having to travel out of state for appropriate care was listed among the top challenges that CYSHCN families faced. We feel there remain opportunities in the state to address the adequacy of insurance coverage for all populations.

The remaining priority needs are new to the focus of our work in the coming years both fall under the Adolescent Domain, NPM 8.2 and NPM 10.   

According to the 2017/2018 National Survey of Children’s Health (NSCH), Delaware is among the lowest of its surrounding states when comparing the percentage of adolescents, ages 12-17, who are physically active at least 60 minutes per day.  15.3% of Delaware’s adolescents are physically active zero days per week.  Our stakeholders selected increasing physical activity among this population as the number one priority for this population domain and was ranked 5th overall.

The National Survey for Children’s Health (NSCH) shows that the percentage of Delaware adolescents who have had a preventive medical visit in the past year has been declining.  In 2016, the percentage was 89.5%, while in 2017 the percentage declined to 84.2% and in 2018, Delaware’s percentage of adolescents who have had a preventive medical visit in the past year fell to 70.2%.  The survey also revealed that 24.0% of Hispanic adolescents and 23.7% Black adolescents did not have a preventive medical visit in the last year.  This is significantly higher compared to 13.4% of White adolescents who did not have a preventive medical visit in the last year.  Our stakeholders identified the adolescent well visit as the number two priority for this population domain and was ranked 7th overall.

National Performance Measure 8 seeks to increase the percentage of adolescents, ages 12-17, who are physically active at least 60 minutes per day and therefore we have replaced or “reframed” our objectives related to obesity by incorporating strategies that will not only address physical activity but also healthy eating as part of a complete plan to healthier lifestyles.  Disparities exist in both measures with the percentage of black adolescents being physical active lower than their white peers.

Working with our School Based Health Centers will be a key strategy to addressing the number of adolescents that receive comprehensive and coordinated services addressing their social, emotional and physical well-being.  Addressing SODH will be an overall strategy for Delaware in addressing every priority selected in the next five years.  Responses were a clear call to address social determinants of health (SDOH); in our stakeholder survey, with 88 respondents noting one or more aspects of SDOH.