The development of the 2020 five-year Needs Assessment is being conducted in accordance with Title V legislation (Sec 505(a)(1)) which requires that the Territory-wide five-year Needs Assessment identifies needs in three key areas, as is consistent with articulated health status goals and national health objectives. The three areas of need that the Needs Assessment is to address are:

1. Preventive and primary care services for pregnant women, mothers, and infants up to age one.
2. Preventive and primary care services for children.
3. Services for children with special health care needs.

Given this scope, the CERC team held regular meetings with key USVI Title V MCH & CSHCN (herein after, Title V) personnel to obtain information from key administrative and secondary data sources that were available and could be accessed to cull relevant data to inform the development of the Title V Needs Assessment.

Because of the foundational role of the Needs Assessment in the development of the Title V grant application, it was crucial to the CERC team that the most current and relevant administrative and secondary data available to utilized in delineating the Territory’s needs in the key areas of focus.

Vision and Mission – Title V

In its description of the Maternal and Child Health & Children with Special Health Care Needs (MCH & CSHCN), MCH & CSHCN Vision and Mission, the V.I. Department of Health notes the vision of the MCH & CSHCN program: to see all children and families receiving as their right, quality, holistic health care and the mission: to provide the clients and community we serve with accessible, family-centered health services that promote the well-being of children and families in an environment that is inviting, courteous, respectful and values patient confidentiality.

Goals – Title V

 The goals of the USVI’s MCH & CSHCN program focus on areas that align with the priority areas for the (to be completed)

1. Facilitate development of a system of care in the territory that improves the health of women of childbearing age, infants, children, and adolescents through availability of appropriate services that optimize health, growth and development.
2. Assure access to quality health care for women and infants, especially those in low income and vulnerable populations, in order to promote and improve pregnancy and birth outcomes.
3. Improve the health status of children and adolescents to age 21, including those with special health care needs, disabilities or chronic illnesses diagnosed at any time during childhood, through comprehensive, coordinated, family-centered, culturally competent, primary and preventive care.
4. Provide a system of care that eliminates barriers and health disparities for vulnerable and unserved or underserved populations. 
5. Provide on-going and continuous evaluation of services and systems throughout the territory related to improving the health status of women, infants, children, children with special health care needs, adolescents and families.  
6. Enhance program planning and promote policies that will strengthen MCH infrastructure.
7. Optimize perinatal outcomes through prevention of maternal and infant deaths and other adverse outcomes by promoting preconception health, utilization of appropriate services, assuring early entry into prenatal care and improving perinatal care

Leadership

 The 2020 Title V needs assessment efforts were led by the USVI’s MCH & CSHCN Administrative team, guided by a Territorial Director, who reports to the Deputy Commissioner for Health Promotion and Disease Prevention. Key MCH & CSHCN team members, along with members of the CERC team formed a Needs Assessment Committee which met regularly throughout the needs assessment process. Additionally, the Title V Community Advisory Group was identified to provide feedback on working drafts and to participate in the prioritization of needs.

Methodology

 The team relied on administrative and secondary data to complete the Needs Assessment. However, though no primary data were collected during the course of the completion of the Title V Needs Assessment, much of the secondary data utilized represented data collected by the CERC team for previously completed Needs Assessments, updates to earlier environmental scans completed on the Head Start and Early Head Start programs in the Territory, or fulfillment of data and reporting requirements of the V.I. Department of Health (YRBS and BRFSS) survey data. The administrative and secondary data utilized reflected both quantitative and qualitative data – from key information interviews and focus group discussions. Additionally, a recently completed needs assessment of the Territory’s Project LAUNCH served as a resource, along with data from the most recent MCH Jurisdictional survey conducted by National Opinion Research Center (NORC) at the University of Chicago.

 Descriptive statistics were generated to summarize key findings and are highlighted in the Findings section of this summary. Findings most relevant to the three areas of focus with respect to needs for the Territory, within the framework of the goals and priorities of the USVI Title V program are noted.

Stakeholder Involvement in the Needs Assessment

 Key stakeholder involvement in the completion of the Needs Assessment will include the engagement of the Territory’s Title V Community Advisory Group which is comprised of representatives that reflect the diversity of the clients served by the Title V program and also represent organizations and stakeholder groups that advocate for, support, and provided services to clients served by Title V. The Title V Community Advisory Group reviewed the Summary Needs Assessment and provided feedback that is reflected in this final document.  The Title V Community Advisory Group will also be actively engaged and will provide feedback on the more expansive and expended version of the Needs Assessment.

 Other stakeholder input will be sought and included as the summary Needs Assessment as well as the more expansive Needs Assessment will be posted to the Department’s website and a Comment Period will be provided for community members to offer comments on the documents. All comments received will be reviewed and, as appropriate, the documents will be revised to reflect consideration of feedback received from various stakeholders/stakeholder groups.

Methods for Assessing Priority Needs

 Feedback was sought from key stakeholder groups, to include the Title V Community Advisory Group, which is comprised of persons representing key groups in the USVI community. Additionally, representatives of key collaborating and partner agencies have been identified for participating in the determination of priority needs. Prioritization considers current program goals, available resources, program capacity, and clients’ needs and challenges.

Methods for Assessing State Capacity

Data Sources

 Most of the data sources used in the development of the Needs Assessment were referenced in the discussion of the Methodology utilized for completing the Title V Needs Assessment. However, they are again presented here, but at a more granular level of detail. To complete the Title V Needs Assessment, several data sources were used to ensure that the most relevant data would be used to address key areas within the Needs Assessment. First, two recently completed needs assessments were used, specifically the Needs Assessment of the Territory’s Early Childhood Care and Education Mixed Delivery System (August 2020) and the Community Needs Assessment focused on the needs of vulnerable children and families in the Territory in the aftermath of Hurricanes Irma and Maria (2019). Additionally, the most recent administration of the MCH Jurisdictional Survey (NORC, 2019-2010) and the Youth Risk Behavior Survey (YRBS) in the Territory (2018) were used to inform the Needs Assessment.  Finally, relevant data from the most recent KidsCount Data Book for the USVI (CFVI, 2020), relevant FQHC UDS data from HRSA’s website for the past three fiscal years (2017-2019), as well as Title V program data provided by staff were used in the development of the Needs Assessment.

Women/Maternal Health

Getting early and regular prenatal care improves the chances of a healthy pregnancy. This care can begin even before pregnancy with a pre-pregnancy care visit to a health care provider (NICHC/NIH).  In the USVI between 2017 and 2019, the FQHCs served 2131 prenatal patients, of which more than 60% consistently access prenatal care in their first trimester. Both FQHCs have witnessed modest increases in the number of prenatal patients served at their facilities in 2018 and 2019, at STEEMCC there was a 13% (368 -- 416) increase while FHC the increase was 11% (323 -- 359). Of the women ages 18-44 who participated in the MCH Jurisdictional survey (NORC 2019), 77% indicated having a preventive medical visit in the past year (n=143).

Perinatal/Infant Health

The MCH & CSHCN program had three key performance indicators (KPIs) for FY2020 related to perinatal/infant health and both indicators were met during the first quarter of the fiscal year (VIDOH FY2021 Budget Hearing Testimony). Specifically, the KPIs related to newborn screenings: 1) Ensure 80% of newborns receive a hearing screen within the first 30 days of birth; achievement: 82% of newborns screened within timeframe set during the first quarter; 2) Ensure 85% of genetic screening performed prior to hospital discharge; achievement in first quarter of FY2020: 94% of newborns had genetic screening prior to leaving the hospitals; 3) Reduce the percent of infants lost to follow-up after not passing a physiologic newborn hearing screening exam prior to discharge from newborn nursery by utilizing targeted and measurable interventions annually. Target 90%; achievement 100%.

The FHQCs data show that on St. Thomas the percentage of newborns with low or very low birth weight is less than 10% annually, while in St. Croix the percentage of newborns with low or very low birth weight is consistently higher with16% of newborns classified as such in 2018. 

Based on the 2019 MCH Jurisdictional survey, respondents indicated that 15% of children included in the sample (n=207) were low birth weight infants and the same percentage were born pre-term. Further, of the children born pre-term, the largest percentage (28%) were to mothers 35 years of age and older.

Child Health – 2019 MCH Jurisdictional Survey Results

 With respect to children’s health status, respondents identified 83% of children as being in “excellent or very good” health and 15% as being in “good” health (n=207). For children not identified as having special health care needs, responses revealed approximately 11% of children classified as having decayed teeth or cavities in the past year. Of 82 adolescents in the sample, while 45% were classified as “normal weight”, 20% were classified as “overweight” and 28% were classified as “obese”. With respect to health insurance, respondents reported that, at the time of the survey, 88% of children were insured (n=207). With respect to access to heath needed health care, respondents indicated that, in the past year, 10% of children did not receive needed heath care.

Children with Special Health Care Needs – 2019 MCH Jurisdictional Survey Results

 Of the survey respondents, 13% indicated having children with special healthcare needs [n=207 children in sample]. In response to a query regarding receipt of care in a “well-functioning system”, responses reflected that only 11% of CSHCN were receiving care in a “well-functioning system” (n=38). Further, respondents identified 63% of children as not having a medical home. With respect to access to needed health care, respondents indicated that, in the past year, 20% of CSHCNs did not receive health care needed (n=38). For adolescents (ages 12-17) with special health care needs, respondents reported that 62% have received the necessary services to make the necessary transitions to adult health care (n=12).

Adolescent Health – 2018 YRBS

The 2017 State Youth Risk Behavior Survey and the 2017 Middle School Youth Risk Behavior Survey (CDC), modified by adding questions of interest to the local Department of Health-Division of Mental (Behavioral) Health, Substance Abuse and Drug Dependency Services-State Prevention Framework Partnership for Success Grant.

The results reveal that USVI youth may be engaging in health-related behaviors that may have implications for health outcomes that increase risk of unintentional injuries and violence; sexual and reproductive health, to include exposure to infectious disease and unintended pregnancies; social problems; tobacco and drug use; unhealthy dietary behaviors and physical inactivity and a range of health conditions such as overweight and obesity, diabetes, and cardiovascular disease.

30% reported using marijuana at least once and when asked about the number of times they used marijuana during the 30 days prior to the survey, while 83.9% reported no use, 16.1% reported using marijuana at least 1 time, with 4.3% reporting using marijuana 20 or more times. While only 6.6% ever tried smoking a cigarette, the majority tried smoking before the age of 17. With regards to the use of e-cigarettes 21% self-reported ever using an electronic vapor product but only 3.9% reported current (past 30-day) use.

Among youth responding to the question regarding their first sexual experience, 7.2% reported having sexual intercourse for the first time at 15 years old, followed by 6.7% at 16 years old. Notably, 7.9% reported sexual intercourse at 13 years or younger. The most frequently reported pregnancy prevention method was condoms, reported by approximately 18% of participants, while 5.1% reported using no method and 57.1% of the sexually active youth reported using a condom at last sexual intercourse.

Cross-cutting/Life Course

Oral Health

Both FQHCs have expanded their offerings of dental services in the past few years. In CY 2017 over one-third of clients received dental services at FHC and at STEEMCC, just over one-fourth of clients received dental services. FHC is set to add another 12 chairs soon (KI, FHC CEO, November 2018) because the current capacity cannot meet the existing demand for dental services. STEEMCC added a separate dental facility due to the high demand for these services from clients and the recognition that the needed dental services were not being provided.  In 2019, FHC served 3909 dental patients, a 13% increase over 2017. Similarly, at STEEMCC 2631 dental patients were served. This represents a 61% increase in the number of dental patients served in 2017. (HRSA UDS Data, 2017-2019)

Dental health is also important for the HS and EHS populations and an indicator of access to health care that is captured for children from vulnerable families participating in both programs and the FQHCs provide valuable preventive dental care screening services to this population. In the school tear following hurricanes Irma and Maria, SY2017-2018, only 2 of 65 HS children identified as needing additional dental treatment received the needed treatment – compared to 100% of HS children identified as needing preventive dental care receiving such care during SY2016-2017. (CFVI CAN, 2019).

Based on the MCH Jurisdictional survey (2020), of 198 children ages 1 through 17 for which data were available, 12% reported “frequent or chronic tooth decay or cavities”.

Health Insurance

In the USVI, access to healthcare needs and services are addressed through Medicaid, Medicare, personal finances (uninsured) or third-party healthcare insurance.  The 2015 VICS reported that 22% of the population did not have health insurance coverage. In 2016, approximately 55% of children younger than 9 years old were receiving medical services through Medicaid and 61% of children in the Territory between the ages of 10 and 19 years old were uninsured (Health Resources and Services Administration UDS Data Center, 2016).

Access to health care is one of the core elements of both the HS and EHS programs. The literature shows that HS participation increases the chances of children from low income families obtaining dental care, health insurance coverage and positive health outcomes (Lee, 2016). For school years 2015-2016 and 2016-2017, 99% of children had insurance at the end of the school years. However, for SY 2017-2018, the school year in which the USVI experienced significant disruptions due to the passage of Hurricanes Irma and Maria, only about 2 in 5 HS children had insurance coverage at the beginning of the school year and approximately 87% (775 of 894) had health insurance at the end of the school year. (CFVI CNA pgs. 105-106).

Based on the results of the BRFSS 2016, 75% of Virgin Islanders reported having a personal doctor or health care provider and eight out of every ten indicated having health care coverage (n=1266).

Behavioral Health -- Children and Youth

A total of 34 schools with students enrolled in intermediate elementary grades (4th through 6th) participated in the study, a total of 1,344 students attended private and parochial schools and 2,606 attended public schools completed a 10-item survey, the Child Trauma Screening Questionnaire (CTSQ). As previously shared, this instrument is designed to assess traumatic stress reactions in children following a potentially traumatic event and serves as a risk assessment tool to predict the likely onset of PTSD.  Based on the findings from the survey, there is evidence that elementary aged students across the Territory may have future issues with PTSD as a result of experiencing Hurricane Irma and/or Hurricane Maria and that girls may have more challenges with future PTSD than boys.

Additionally, 633 students ranging in age from 11-19 years completed the Child PTSD Screening Scale (CPSS), a 24-item survey designed for use with children to screen for the presence of post-traumatic stress symptoms.  According to findings of this study, approximately 42.5% of the secondary students with enough data to compute a total score (n=501) may be at risk for PTSD.

The Virgin Islands Department of Health (VIDOH) is the official Title V agency for the U.S. Virgin Islands. Based on this designation, the VIDOH is the designated agency in the USVI for administering the MCH & CSHCN Program in the Territory (V.I.C., Title 19, Chapter 7, Section 151). By administering the Title V MCH & CSHCN Program as one integrated program, the VIDOH can better and more efficiently coordinate services to full range of clients.  The program provides health care services for mothers, infants, children, youth and adolescents and their families. The program also provides and coordinates a system of preventive and primary health care services for the targeted population.

Led by a Director who is supported by a team of credentialed, experienced clinical, administrative, and supervisory personnel, the MCH & CSHCN Program focuses on improving and maintaining the health status of women, infants, children, and adolescents (including children and adolescents with special healthcare needs) through a range of services. These services include prenatal and high-risk prenatal care clinics, postpartum care, well childcare, high risk infant and pediatric clinics, care coordination and access to pediatric sub-specialty care for children and adolescents with special health care needs.  Services are provided in accordance with SSA -Title V law related to children with special health care needs.

Title 3, Title 19, and Title 27 of the Virgin Islands Code designate the VI Department of Health (VIDOH) as the local government agency responsible for providing public health services to USVI residents. This responsibility involves protecting and improving the community’s health through health promotion and preventative initiatives. Preventative measures are aimed at improving overall health and reducing health care costs, particularly related to chronic disease.

The VIDOH functions as the Territory’s regulatory agency as well as the Territory’s public health agency.  In its dual capacity, VIDOH has oversight of twenty-six programs; serves as the lead agency for Emergency Services Function 8 or (ESF-8); and oversees hospitals during a declared emergency or disaster. Currently, VIDOH also serves as the lead agency relative to the COVID-19.

The VIDOH operates health clinics on St. Croix, St. Thomas and St. John and see clients based on appointments, though walk-ins are accepted. The agency’s capacity to deliver services to children and families remains limited and below pre-hurricane levels, though some progress has been made in both the capacity and timeliness of service provision.

On St. Croix, the VIDOH administrative offices and clinics are located at the Charles Harwood Memorial Complex (CHMC) in Estate Richmond, near the town of Christiansted. Because of damage sustained from Hurricanes Irma and Maria, the VIDOH is currently operating administrative functions as well as clinics from modular facilities. Emergency Medical Services (EMS) previously based at the Juan F. Luis Hospital and Medical Center (JFL) are now based at CHMC.

On St. Thomas, VIDOH provides services out of three main sites: (1) the Schneider Regional Medical Center [community health, behavioral health, and emergency medical services]; (2) the ElaineCo building [MCH & CSHCN program]; and (3) Knud Hansen Memorial Complex [other programs such as the HIV/AIDS program, environmental health, and vital records].

On St. John, in the aftermath of Hurricane Irma, the VIDOH is functioning out of the Morris F. deCastro Clinic in Cruz Bay, which sustained minimal damage, unlike the Myrah Keating Smith Community Health Center (MKS), which was rendered unfit for use due to severe wind and water damage.  VIDOH services on St. John have not yet returned to pre-hurricane levels, though significant progress has been made to restore service capacity over the past year.

In the USVI, the VIDOH is the designated for administering the MCH & CSHCN program pursuant to Title 19, Chapter 7, §151 of the Virgin Islands Code (VIC). The MCH & CSHCN Program offers preventive and primary health care services for mothers, infants, children, and adolescents. These services include prenatal and high-risk prenatal care clinics, postpartum care, well child clinic, immunization, high risk infant and pediatric clinics, care coordination and access to pediatric sub-specialty care for children and adolescents with special health care needs. Other services provided by skilled public health nurses include assessments, anticipatory guidance, parental counseling, education regarding growth and developmental milestones, proper nutrition practices, service/care coordination, and home visiting services to high risk children and their families.

USVI residents are not eligible for the Supplemental Security Income (SSI) Program which provides assistive devices, therapeutic or rehabilitative services beyond acute care to children under the age of 16 with disabilities. The Medical Assistance Program (MAP) does not provide these services, due to the Medicaid Cap imposed by Congress. Yet, on a limited, case by case basis, these services are provided by the Title V Program.

Public health nurses assess the developmental needs of infants and toddlers who are considered at-risk due to psychosocial or biological risk factors. The entry point is a referral to the early intervention services program Infants and Toddlers' (Part C of IDEA) service coordinator to identify newborns as part of the Infants and Toddlers (Part C) Child-Find system. Nursery referrals are received on all high-risk newborns to the MCH & CSHCN clinics in both districts, while infants without any high-risk factors are referred to well child clinics. As a standard practice, high-risk referral patients are screened to receive a home visit and family assessment.

Prenatal services provided through MCH include prenatal intake for new patients in which the history, physical, risk assessment, PAP smear, and laboratory referrals are completed, routine follow-up and counseling, teen prenatal, and perinatal/high risk clinic for the management of obstetrically or medically complex cases. Patients with emergencies are referred to the Obstetrical Unit at the hospital for evaluation and treatment. Diagnostic services, such as ultrasounds and laboratory services, are provided for MCH clients by the hospitals or private facilities. Patients are referred to the WIC Special Nutrition Program for dietary assessments, counseling, and follow-up.

The MCH & CSHCN Program engages in outreach activities to identifies children who have health problems that require intervention, are diagnosed with disabling, or chronic medical conditions, or are at risk. Sources of child find include referrals from the Queen Louise Home for Children, Early Childhood Education, Head Start, Early Head Start, and private providers. Pediatricians, nurses, social workers, a Physical Therapist Assistant, an audiologist, and speech pathologist are the major providers of direct services. The Infants and Toddlers Program employs service coordinators on each island.

Hospital newborns with biological, established, or environmental risks are referred to the Infant or Pediatric High-Risk clinics based on established criteria. At one year of age, infants are reassessed and transition to the Well Child Clinic or the Pediatric High-Risk Clinic. The Infant and Pediatric High-Risk Clinics offer comprehensive, coordinated, family-centered services. Screening is done for developmental delays using the Ages and Stages (ASQ) Screening Tool. Social workers complete an assessment of the family and home environment, existing support structures, and financial status and clinical staff develop appropriate diagnostic assessment and therapeutic plans. Children with special health care needs are referred to the sub-specialty clinics by the primary care physician and are seen based on appointment.

Additional services and activities under the MCH umbrella include: the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program; Early Hearing Detection and Intervention (EHDI); HRSA-funded Zika MCH Services; and Project LAUNCH (Linking Actions for Unmet Needs in Children’s Health), a system that addresses the needs of children ages 0–8 and allows them to thrive in safe, supportive environments and enter school with the social, emotional, cognitive, and physical skills they need to succeed. The MCH & CSHCN Program works collaboratively with several key programs within and outside the VIDOH.

For the completion of the Territory’s ECD MDS Needs Assessment, the Maternal and Child Health and Children with Special Health Care Needs (MCH & CSHCN) Program described the program’s partnerships, collaborations, and coordination efforts integral to effectively leading efforts across the Territory to support a comprehensive, coordinated system of preventive and primary care and services for children birth through 21, as well as for pregnant women. Partnerships and collaborations exist with several public/governmental, private, and non-profit organizations.

Current collaborations and partnerships – both formal and informal, exist to support the delivery of services to children B – 5.  Formal collaborations exist with entities outside VIDOH and take the form of Memoranda of Agreement (MOAs) or Interagency Agreements (IAs).  MOAs with the two FQHCs and IAs with the two local hospitals and the Medical Assistance Program (MAP) (housed in VIDHS), have been established primarily for data sharing, recruitment, and referrals. The MCH & CSHCN program also coordinates with the hospitals to conduct and record results of health and hearing screening for newborns, track the result of genetic testing, and provide needed follow up support to parents.  

Currently, though the MCH & CSHCN program collaborates with EHS through an informal collaboration around data, services (hearing screenings), and recruitment, both entities are working on formalizing the collaborative relationship through an MOA. Other informal collaborations are primarily intra-agency support data sharing, services, and/or referrals. Units within VIDOH that collaborate with the MCH & CSHCN program include the WIC program; immunization; nursing services, the Infant and Toddlers Program (Part C), and vital statistics.

There are plans to develop and execute an MOA with VIDE for hearing and vision screening to be provided in the public-school setting for Kindergarten population (5-year old children).

Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV)

The MIECHV Program is authorized by Social Security Act, Title V, Section 511 (42 U.S.C. Section 711). The funding supports voluntary, evidence-based home visiting services for at-risk pregnant women and parents of children birth through five years (or through when the child/children enter Kindergarten). Home visits are made by the DOH MCH staff, and all services are performed in the child’s natural environment to the extent possible.

States Supplemental Data Initiative (SSDI)

The stated purpose of SSDI is to develop, enhance and expand State Title V MCH data capacity to allow for informed decision making and resource allocation that supports effective, efficient, and quality programming for women, infants, children and youth. Three goals have been set forth to: Build and expand State MCH data capacity to support Title V program efforts and contribute to data driven decision making in MCH programs; Support the State’s Collaborative Improvement and Innovation Network (CoIIN) to Reduce Infant Mortality through improved availability and reporting of timely data; and Advance the utilization of both the minimum and core data sets (M/CDS) for State Title V MCH programs. To date, elements of these goals are still being developed and have not been fully implemented.

Early Hearing Detection and Intervention (EHDI)

The purpose of the EHDI project is to reduce the percent of infants lost to follow-up after missed initial screening or referral for repeat screening, and the development of a tracking system to ensure infants are rescreened and referred for timely diagnostic evaluation, treatment, and early intervention services. Appointments are made for re-screen prior to the infant’s discharge. Educational material, which includes information to increase awareness on the EHDI program, is provided to the mother on discharge. Any newborn missed prior to hospital discharge is identified, and the family is contacted through various modalities- phone calls, text, and email. Weekend hearing screenings are completed if needed.

Several Title V staff received training in the Use of the OZ newborn hearing screening database to fill the gaps in the newborn hearing screening program. Prior to this training, a significant number of newborns were being missed in the hospital or were inadequately followed up in the outpatient setting.

Early Childhood Comprehensive Systems (ECCS)

The purpose of the US Virgin Islands Early Childhood Comprehensive Systems (ECCS) Grant is to mitigate toxic stress in infancy and early childhood through the development of a trauma-informed child and family service system and by promoting a protective factors approach to strengthen and support families in their roles as nurturers of their infants and young children. The first Project LAUNCH program to support the social emotional development of children 0-8 was funded after the 2017 hurricanes, and after research evidence that children who experienced the hurricanes are at risk for PTSD. Project LAUNCH grants are designed to build the capacities of adult caregivers of young children to promote healthy social and emotional development; to prevent mental, emotional and behavioral disorders; and to identify and address behavioral concerns before they develop into serious emotional disturbances (SED).

Infant and Toddlers Program (Part C)

The program is fully funded by Part C of the Individuals with Disabilities Education Act (IDEA) with the Department of Health as the Lead Agency. It supplements the Maternal Child Health and Children with Special Health Care Needs (MCH & CSHCN) Program, when public or private resources are otherwise unavailable.

The Infants and Toddlers Program Part C services developmental needs of infant or toddler with special needs. Part C requires that each child's Individualized Family Service Plan (IFSP) must be developed within 45 days of the Infants and Toddlers Program receipt of the referral. Public health nurses assess the developmental needs of infants and toddlers who are at-risk due to psychosocial or biological risk factors. Referrals are made to the early intervention services program Infants and Toddlers' (Part C of IDEA) service coordinator to identify newborns as part of the Infants and Toddlers (Part C) Child-Find system. The lack of qualified professionals on-island and the inability to offer competitive pay for specialized services is a major challenge in providing service to this population.

Women, Infants, and Children Program (WIC)

WIC, administered by the DOH, is the Special Supplemental Nutrition Program for Women, Infants and Children that are designed to improve the health of families who participate by supporting the purchase of specific foods that are designed to supplement their diets with specific nutrients. The program is designed for pregnant, postpartum and breastfeeding women, infants, and children up to age five. To be eligible for WIC the applicant must meet income guidelines, residency requirement, and individual determination as being at "nutritional risk" by a health professional. The DOH reports that an 86% partial breast-feeding rate among WIC post-partum participants was maintained.

 To be eligible based on income, applicants' gross income before taxes must fall at or below the U.S. Poverty Income Guidelines for the Territory. A family that participates in the Supplemental Nutrition Assistance Program, Medicaid, or Temporary Assistance for Needy Families is eligible for the WIC program.

Family Planning Program

The Family Planning Clinics offer comprehensive, compassionate, and confidential sexual and reproductive health services for women, men, and adolescents. These include a spectrum of sexual and reproductive health services, including birth control methods, testing and treatment for sexually transmitted infections, well-woman exams, preconception care, pregnancy testing, breast and cervical cancer screening, and postpartum care.  Tailored community-based clinical outreach and education programs are also offered.

Medicaid Program

Medicaid (MAP) is a government-sponsored program that helps with health care coverage to people with low-incomes that meet Virgin Islands residency and citizenship criteria. Patients receive assistance paying for things like doctor visits, long-term medical, custodial care costs, hospital stays, and more. All the services provided by the Children’s Health Insurance Program (CHIP) for children under 19, are free including doctor visits and check-ups, vaccinations, hospital care, dental and vision care, lab services, X-rays, prescriptions, and emergency services. VI Enrollees do not have the freedom of choice (FOC) to go to any provider that they want to receive services as do Medicaid enrollees in the States.

Income standard for the categorically eligible for a family of one is $15,654. For Aged, Blind or Disabled, for a family of one the standard income level is $20,833. The poverty threshold requirement causes difficulty for uninsured families to qualify for Medical Assistance and creates barriers to health care resources and services. These uninsured individuals are generally unable to afford health insurance premiums.

One limitation of the expanded Medicaid program is that income eligibility will remain fixed at $5,500 for new enrollees—mostly adults without children. This provision will limit the availability of health insurance coverage among lower-income residents. Medicaid coverage is also limited by the federal match formula that requires the Virgin Islands to cover much of the costs of providing coverage.

Role of Parents

The MCH & CSHCN Program is guided by an advisory council, which is charged with the responsibility of advising the Administrative Unit of the MCH & CSHCN Program. Members of the Council include parents and guardians of children with special health care needs and play a vital role in the program planning and evaluation, quantitatively and qualitatively. Parents are involved in preliminary planning and implementation of each program. As members of the Advisory Council, parents assist in developing goals and objectives, long range program planning, identifying service gaps, locating resources, and monitoring the quality of provided services. In line with The DHS commitment towards parent involvement and engagement, the program was successful in hiring the first paid family representative in 2018. Parents are encouraged and invited to attend trainings, workshops, and to join the different special needs councils.

V.I. Interagency Coordinating Council on Homelessness (VIICH)

The Virgin Islands Interagency Council on Homelessness (VIICH) was established within the Department of Human Services by an Executive Order. The VIICH serves as a public/private sector collaboration to prevent and end homelessness in the Virgin Islands through policy and resource development. The Virgin Islands Continuum of Care on Homelessness (CoC) works collaboratively with VIICH to implement the Territorial Crisis Response System. The goals of the VI Interagency Council on Homelessness are to ensure homelessness is a rare experience, a brief experience, and to work toward an end to homelessness in the territory.

The VIICH comprises 26 members appointed by the Governor, with the Commissioner of Human Services and Housing Finance Authority (VIHFA) Executive Director serving as Co-Chairpersons and is responsible for advising the Governor and the Legislature on issues related to the problems of persons who are homeless or at risk of becoming homeless and provide recommendations for joint cooperative efforts and policy initiatives in carrying out programs to meet the needs of the homeless.

State Advisory Council (SAC) Early Childhood Advisory Committee

A multidisciplinary group of governmental, non-governmental and non-profit organizations persons are members of the SAC. Members collectively engage in deliberative dialog to discern best practice approaches to improve the delivery of quality services to children and their families.

V.I. University Center for Excellence in Developmental Disabilities (VIUCEDD)

The Virgin Islands University Center for Excellence in Developmental Disabilities (VIUCEDD) was established in October 1994 and is funded by the U.S. Department of Health and Human Services, Administration on Community Living (ACL), Administration on Intellectual and Developmental Disabilities (AIDD) and National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR). Its mission is to enhance the quality of life for individuals with disabilities and their families and to provide them with tools necessary for independence, productivity, and full inclusion into community life. VIUCEDD continues to be a proactive community partner offering workshops, trainings and community town halls to engage and dialogue with the special needs population and fulfill its goal to coordinate, implement and supervise support services for the families with children with disabilities that promote their independence, self-advocacy and integration in the community.

Vocational Rehabilitation Program (VRP)

The Vocational Rehabilitation Program, administered by the Department of Human Services, is authorized by the Rehabilitation Act of 1973, Public Law 93-112, and its amendments. The VRP assists individuals with disabilities, physical or mental impairments that constitute or result in substantial impediment(s) to employment, by providing those services which will help them to achieve an employment outcome.

Services are offered to eligible individuals with disabilities in preparation for competitive employment including: supportive employment through Work-Able, a non-profit placement agency; independent living services; provision of a vending stand program for visually impaired individuals; and in-service training programs for staff development.

The Special Services Unit of this program provides services to Disabled Adults and Adult Foster Care, administers the Disabled Persons Fund and provides support for the Community Rehabilitation Facility, Developmental Disabilities Council and cancer care programs, and assists disabled persons in obtaining handicapped parking permits.

Developmental Disabilities Council (DDC)

The DDC’s purpose is to improve service systems for individuals with developmental disabilities and to assure that individuals with developmental disabilities and their families participate in the design of, and have access to needed community services, individualized supports, and other forms of assistance that promote self-determination, independence, productivity, and integration and inclusion in all facets of community life.

Comprised of individuals with disabilities, representatives of the business community, and agency professionals serving the disabled and other interested persons, the DDC reviews and approves proposals for special projects serving persons with developmental disabilities. Council members also assist in the planning of service provider training workshops and related activities.

Office of Child Care & Regulatory Services

This office combines the Child Care Fund Program (CCFP), which provides subsidies for childcare, and the Office of Regulatory Services, that license and ensures quality control of childcare facilities and group homes. In collaboration with several partner agencies, it works to improve the quality of childcare in the territory and to ensure that quality childcare is accessible to all families in the Virgin Islands.

The Child Care Fund is a federal program which provides childcare subsidies to lower income working parents for infant, preschool, and for before- and after-school care, for children up to age 12. It also provides support for quality improvement in the private childcare sector. The program supports both licensed facilities and informal providers who have been selected by parents and approved by DHS.

Regulations as they pertain to the licensing of child care facilities and group homes are accomplished by enforcing the minimum standards for the safety and protection of children in child care facilities, in-home care, group homes, summer camps, and after school programs; insuring compliance with these standards, and regulating such conditions in such facilities through a program of licensing. The CCFP offers protection from unsupervised access to inappropriate television programming and inappropriate internet sites by keeping children of working parents in safe, stimulating, and healthy environments.

Identifying Priority Needs and Linking to Performance Measures

Eight areas have been identified in the application as priority needs for the Virgin Islands. 

They are:

1. Increased the number of women that have well women visits (NOM 1):  

5,203 women between the ages of 13-50 received well-women visits by the FQHCs, Family Planning, and the MCH Prenatal clinics. The total female population in 2015 ages under 5 to 85 was 54,908 (2015 United States Virgin Islands Community Survey). By statistics and excluding the private providers we could be serving approximately 10% of the female population in the territory. By 2024 we would like to see an increase of 10% of women receiving well women’s visits at our three sites. This could be attained by adding another Obstetrics and Gynecology position to the staff and the possibility extending services beyond the 8 am to 5 pm hours for working women.

2. Increase the number of families educated on safe sleep practices (NOM 9.5):

No cases of Sleep-related Sudden Unexpected Infant Death (SUID) were reported in the hospital's statistical data of 2019 (Nurse Liaison Reports 2019). This trend should continue into the next reporting years as education into the prevention of death is critical to maintaining the low numbers in the Virgin Islands. Mothers in the Maternal, Infant, Early Home Visiting program continue to report that their babies sometimes sleep with soft bedding. The hospital educates 100 % of the mothers prior to discharge on safe sleep practices for babies providing handouts. The same is continued in the MCH clinics by the providers of newborn health care services.

3. Decrease the number of children with BMI>85% (NOM 14, NOM 18, NOM 20 & NOM 21):

Poor self-esteem has been linked to mental and behavioral conditions. Bullying of overweight children has been linked to increased mental health challenges. Children in the Virgin Islands receive physical education that includes physical activity from ages 5 to 21 while enrolled in a public-school program. Most parochial and private schools offer a similar health education curriculum. However, most children make their own decisions on choices of food to eat outside of partaking in a school lunch program.  Childhood obesity more likely carries over to adulthood taking the same self-esteem and health issues into adulthood.

The MCH-CSHN Program would like to increase awareness of the issue in the child-wellness clinics, link parents and children to the Project LAUNCH program for children 0-8 for support services in behavioral health, and continue to support the community to reduce obesity by sponsoring physical activity events, good cooking and eating habits that have taken place this year with the Project LAUNCH program. Increases in healthy eating and exercise should lead to increase in good dental health also.

4. Increase the percent of developmental screenings done in the territory (NOM 17.2 NOM 17.4, NOM 21):

Attention Deficit Disorder/Attention Deficit Hyperactivity is a silent illness that does not show up until well into the development of infants to the toddler stage. Without a medical home, the disorder may go untreated in children until school age. Developmental screening should be as critical to care like immunizations. Lack of insurance prevents parents from asking for additional services and lack of knowledge in the developmental stages by parents may lead to interventions taking place when the child begins school. Utilizing the CDC’s Learn the Signs Act Early campaign families are provided with the booklets to self-educate on development stages 0 to three. The Zero to Three program serves the population in the territory needing intervention services as soon as a referral is made. ASQ screening are completed several times a year for every child in the Maternal, Infant, Early Childhood home visiting programs.  ASQ screening are also conducted by the clinicians in the clinics as needed.  Cross training for non-clinical staff on the use of the ASQ tool is a part of the intervention plan for the MCH-CHSH Program to build developmental screening capacity.

5. Increase access to comprehensive primary and preventative health care for adolescents and pre-adolescents (NOM 13, NOM 14, NOM 18, & NOM 21):

During the 2017-2019 school year several public schools were consolidated onto one school campus. This allowed for each school to have a school nurse on hand to serve the school population.  MCH works with the school nurses to provide preventative health care services on site to school based program.  Currently the EDHI program provides hearing screenings at the school sites for the Kindergarten and Sixth grade populations. This outreach has continued since 2015. MCH received two mobile health vans in 2020 via the CMS-Zika grant.  These vans will be utilized by the program to provide off-site primary and preventative health care in the schools and neighborhoods of the territory.

It is expected that a pediatrician, nurses, and other support staff will be trained to utilize the van to full capacity so that outreach can be provide on an annual schedule to high risk communities and school sites.

6. Increase percentage of families that participate in transition planning (NOM 17.1, NOM 21, & NOM 25):

Pre-teens and pre-adolescence subgroup in the 0-17 populations are the target groups to identify in transition planning.  This group once they passed the child-wellness visits stage tend to go into the categories of children without health insurance, children who were not able to obtain needed health care in the last year, and are the population of children with special health care needs that receive limited to no service.  Most of the children in this sub-group receive services from the ER or walk-in clinics for critical but nonemergency need, the visits are generally for a one-time issue. The Community Foundation of the Virgin Islands 2019 Kids Count Handbook, p. 45, “Between 2016 and 2017, the number of children under 18 who received Medicaid benefits increased by almost 77%.” However, once a child reaches age 18 and is not a person with Special Health Care Needs a young person is without insurance until they join the military, get a job with insurance benefits.  Transition planning includes the Family Planning Clinic, continued services with MCH from ages 15 to 20, 21 is the transitional year from the MCH clinic.  Young adults can continue to receive services at MCH and Community Health from age 17 without parental consent.  Young adults with Special Needs can continue to receive services at MCH or Community Health

7. Increase access to oral health care for the Maternal Child health population (NOM 14):

MCH clinics have been without dental services for several years.  The FQHCs provide pediatric dental services by appointment.  Emergency dental care is provided in the ER.

Parents in MIECHV home visiting program are encouraged to identify a dental home for their child from while enrolled in the program.  MIECHV supports oral health care by providing toothbrushes for all dental states; stage 1 gum care, stage 2 first teeth care and stage three full tooth brushing with toothpaste.  Dental care education is provided to families.  Families are encouraged to make the first dental appointment by the child’s first birthday and to continue to treat dental care as important as any other child well visit and should be scheduled twice a year at minimum.

MCH will continue to provide dental care education to parents, provide early age appropriate toothbrushing tools and soon add a part-time dental hygienist to provide oral health care education in the schools and clinics.

8. Increase the number of women breastfeeding up to six months (NOM 4)

The number of women in the Virgin Islands who continue to breastfeed to six months is very small.  A CQI project undertaken by the MIECHV program indicated that mothers may continue to breastfeed if - One, they do not have to return to work or school. Two they have received appropriate lactation training and understand the importance of breastfeeding to baby’s health and development.  They are trained in alternatives to support breastfeeding such as pumping and storage of breastmilk. Finally, employer support for maternal health issues and time provided to pump and store breastmilk in the workplace would enhance support to breastfeeding mothers. 

MCH programs provide mothers with lactation training, baby bottles, and pumps to support breastfeed and breastfeeding education. While our mothers may not breastfeed to six months the majority of MCH prenatal mothers are provided with breastfeeding education and support tools.