The following is a summary of the South Carolina (SC) Title V Needs Assessment activities to date. The Comprehensive 5-Year Needs Assessment Report can be accessed here.

 

The overall goal of this assessment was to identify community needs and desired outcomes for specific maternal and child health (MCH) populations, focusing on the 5 population health domains as outlined by HRSA as well as the existing capacity of programs and organizations across the state to address the identified areas of need. The needs assessment aimed to identify assets, key strengths, resources and services available to serve MCH populations and identify needs and gaps across the state’s communities to better serve MCH populations. The leadership structure for the entire process, from initial planning to the development of the state action plan, included the DHEC MCH Bureau and Title V Director, MCH Bureau Division Directors for Child Health & Perinatal Services and CYSHCN, and the MCH Epidemiology team, housed within DHEC’s Bureau of Population Health Data Analytics and Informatics. The work was complemented with expertise from the University of South Carolina, Core for Applied Research and Evaluation. This leadership team will be referred to as the MCH Leadership Team hereafter.

 

A mixed-method systems approach was used for this process, wherein programs, policies and statewide organizations were considered as parts of a whole MCH serving system. The needs assessment is viewed as a continuous process that will continue to engage stakeholders into and beyond the data gathering and prioritization process, in accordance with HRSA’s Title V Needs Assessment Framework, with annual stakeholder engagement. The HRSA framework guided this needs assessment process, and the summary will describe SC’s first six steps: engaging stakeholders, assessing needs, examining needs and capacity, selecting priorities, setting measures, and developing the state action plan.

 

1. Engaging Stakeholders

The Title V Advisory Committee was formed in the Spring of 2019. The committee included 45 stakeholders and partners representing various organizations, including DHEC and other state agencies, community-based organizations, social services, the SC Hospital Association, nurses, physicians, non-profit organizations, and academia. The roles of these individuals within their organization ranged from direct service providers to senior-level executives.

 

The MCH Leadership Team made a concerted effort to ensure active stakeholder participation of the Advisory Committee by facilitating a Kick-Off Meeting in April 2019, in which the purpose, goals, and timeline of the needs assessment process were outlined. From the very start of the process, the MCH Leadership Team introduced a health equity framework that was implemented throughout the needs assessment (see Figure 1 in Appendix A).

 

2. Assessment of Needs and Strengths  

Quantitative data were used to assess the current burden and disparities among key MCH indicators. Data were collected and analyzed from a wide range of existing sources, including the National Survey of Children’s Health (NSCH), Behavioral Risk Factor Surveillance Systems (BRFSS), Pregnancy Risk Assessment Monitoring System (PRAMS), American Community Survey (ACS), National Immunization Survey, SC Vital Statistics, SC hospitalization data, KIDS COUNT and various MCH-related programs to inform Title V Outcome and Performance Measures, Social Determinants of Health (SDoH), and other MCH indicators for each population health domain. Data were also collected through an extensive public input survey to identify domain-specific needs and administered using a convenience sampling approach to gather information on all Title V population health domains.

 

Qualitative data were used to illuminate the barriers and challenges that have led to the identified burdens and disparities, and they contributed to the needs assessment as follows:

• Key Informant Interviews: A variety of roles and perspectives were represented in the interviews including health care providers, public health professionals, and community health workers/navigators. A semi-structured interview guide was designed to gather stakeholder’s perspectives on strengths of the programs, policies, and organizations that serve MCH populations, as well as challenges, barriers, and needs to continue serving MCH populations and improve their health and wellbeing.
• Focus Groups: Focus groups yielded qualitative data from a variety of MCH populations, including those being served by Power in Changing, Midlands Fatherhood Coalition, Family Connection of SC, and representatives for Latino and Immigrant groups. Discussion guides were developed to obtain information around concerns and challenges faced in accessing needed support, services and resources.

 

3. Examination of Needs and Capacity

This was accomplished by a dynamic partnership between the MCH Leadership Team and the Advisory Committee working towards common, established goals through a series of major activities, all of which informed the next step: 

 

Wave Trend Analysis—The 1st Needs Assessment Retreat was held in July 2019. Advisory Committee members were asked to self-select into workgroups based on Title V population health domains, and through a facilitated Wave Trend Analysis, each group proposed and discussed top issues or concerns/needs based on recent quantitative data and their relevant experiences and perspectives specific to each domain. This approach provided an interactive and brief way to get the groups focused on the realities and concerns surrounding MCH populations. As shown in Figure 2 in Appendix A, the “wave” is used as a metaphor because at any given time, there are incoming and outgoing practices, approaches and paradigms. Each group pushed forth 5-8 issues or concerns/gaps as priorities from the “HORIZON” category of the wave, defined as new ideas that are not yet “making waves,” and the “EMERGING” category of the wave, defined as trends at the “crest of the wave” and practices that are picking up momentum and acceptance; any priorities from the “ESTABLISHED” category, defined as trends at the “crest of the wave” and practices that are mainstream could be pushed forth with strong justification. A total of 38 priorities were presented to the entire committee for discussion and prioritization.

 

Prioritization of MCH Needs—The MCH Leadership Team presented the priorities from each workgroup using an electronic platform that employed a voting procedure in which committee members were asked to classify potential MCH priorities into one of four quadrants, as shown in Figure 3 in Appendix A, based on:

 a) Need: How much of a need is there in the community for interventions in this topic area? Members were asked to consider existing services and resources, the importance of the problem, and the impact it has on the population; and

b) Feasibility: How feasible is it to implement interventions regarding this topic area? Members were asked to consider existing services and resources, cost, additional population barriers, and agencies/organizations that work in this area and have the capacity to implement these interventions.

 

Reverse Data Walk to Assess and Examine Factors that Affect Health—The MCH Leadership Team held a 2nd Needs Assessment Retreat November 2019 in which Advisory Committee members were presented with results from an analysis of six SDoH factors grouped by the following categories: education, employment and income, racism and social isolation, living conditions—housing and food insecurity, access to quality medical care, and social and emotional well-being (see Figure 4 in Appendix A). Members were then asked to visit each SDoH “station” and share their ideas and top concerns for mothers and babies related to that category and state any feasible modifications that could be implemented to make positive impact. These qualitative results were assessed and grouped together by common themes using an induction methodology.

 

Ranking of Identified MCH Needs—Results of the prioritization exercise and the SDoH reverse data walk were analyzed by the MCH Leadership Team and 15 broader topics were created to capture all needs. These were presented electronically to the Advisory Committee, and each member was asked to rank these priorities in order of importance from 1-15, with 1 being most important to address with Title V.

 

A 3rd Needs Assessment Retreat held January 2020 focused on an exercise designed to:

Connect the Dots—For each population health domain, the MCH Leadership Team mapped the corresponding top committee needs/priorities with the public input survey results showing the most improvement needed and assigned each to the 15 broader topics. Domain-specific posters (Figure 5 in Appendix A) were created to graphically show the connection of these needs along with a set of proposed strategies drafted by the MCH Leadership Team; strategies were based on knowledge of current work/activities in SC and examples from other states found in the MCH Navigator resource. 

And Turn the Curve—Organized by domains, the workgroups were asked to participate in an exercise in which proposed strategies were examined using a Results-Based-Accountability (RBA) tool in effort to “Turn the Curve” across the MCH Title V outcome measures (see Figure 6 in Appendix A). Facilitators walked the workgroups through the RBA tool to obtain information on valuable partners who have a role to play, what resources are needed, and what process-level or systems-level activities can be employed (see Figure 7 in Appendix A). The information obtained was used to assess capacity and identify resources that could be leveraged to develop a Title V State Action Plan addressing selected priority needs.  

 

4-6. Priority Setting & Development of State Action Plan

Each step of this needs assessment was designed to build on the previous results and step. The process utilized a wide array of qualitative and quantitative data to inform final selection performance measures.  Retreat 3 of the process offered the Advisory Committee proposed measures for consideration and elimination. The MCH Leadership used the feedback provided to draft a preliminary state action plan.

Women/Maternal Health Domain

Health Status Overview:

Women's health and maternal health are both central to the success of individuals and families throughout the life course. An analysis of quantitative 2016-2017 data for selected NPMs showed:

• Percent of non-Hispanic black women aged 18-44 with a preventive medical visit in the past year was significantly higher than in non-Hispanic white women (NPM 1)
• Strong decreasing trend in the percent of cesarean deliveries among low-risk first births was noted, but disparities exist by maternal age, race/ethnicity and education (NPM 2)
• Percent of women who had a preventive dental visit during pregnancy was significantly higher in women having higher educational attainment (NPM 13.1)
• A significant decreasing trend in the percent of women who smoke during pregnancy was noted, disparities exist by maternal age, race/ethnicity, marital status, educational attainment, health insurance, urban/rural residence and WIC participation (NPM 14.1)

 

Disparities in Major Health Outcomes and Experiences:

• Racial/ethnic disparities in pregnancy intention exist; 53.0% of non-Hispanic white mothers reported their pregnancy as intended compared to only 28.1% of non-Hispanic black mothers
• The SC infant mortality rate (IMR) is higher than the HP target and the racial disparity remains a concern (the IMR is twice as high among black and other mothers compared to white mothers)

• The maternal mortality rate is 24.7 per 100,000 live births; however, the rate is more than triple for minority women
• Receipt of adequate prenatal care has increased overall, but differences in race/ethnicity exist (81.4% among non-Hispanic white mothers compared to 72.0% of non-Hispanic black and 63.6% of Hispanic/Latina mothers)

• The rate of infants born with NAS has increased over the past decade with the average hospital charge for an infant born with NAS 7.7 times higher
• Among SC women 18-44 years of age,

• 26% report being diagnosed with depression, and 35% report experiencing two or more adverse child events (ACEs)
• 78% report receiving social or emotional support, but the prevalence is lower among non-Hispanic black women (68.9%) compared to almost 85% of non-Hispanic white women

 

Needs and Challenges:

• Need for better access to affordable healthcare, including preventive, prenatal, postpartum, chronic disease management, oral/dental and especially for mental health and behavioral health issues 
• Need for extended postpartum care, as one informant expressed the need to “look at care for women as a continuum…Ob/Gyns disconnect from moms after birth and if they don’t have primary care, many women aren’t getting care during interconception even if they’ve had previously bad outcomes.”
• Need to strengthen community-based education, care and resources development/linkages

 

Strengths and Successes:

• Home visiting programs were frequently suggested as an effective strategy for reaching families across the state; DHEC’s postpartum home visiting program was found to be an asset that should continue to be supported and expanded for potential impact on postpartum depression and maternal morbidity/mortality
• Better access to contraception was noted as a strength for women’s health; this includes efforts from the Choose Well Initiative to easily and conveniently connect women to effective birth control with “no drama” as well as the Birth Outcomes Initiative’s to increase LARC insertion prior to hospital discharge after delivery

 

Perinatal/Infant Health Domain

Health Status Overview:

Unaddressed perinatal and infant health issues may lead to short- and long-term health risks

for mothers and their babies. An analysis of 2017-2018 quantitative data on selected NPMs data showed:

• Over 85% of very low birth weight infants were born in a Level III+ NICU (NPM 3)
• Percent of infants who are ever breastfed has been increasing significantly over the past decade, though disparities persist by maternal race and poverty (NPM 4a)
• Percent of infants who are exclusively breastfed through 6 months has been on the rise, though disparities still exist by maternal race and income (NPM 4b)
• Percent of infants placed to sleep on their backs has significantly increased (NPM 5a)

 

Disparities in Major Health Outcomes and Experiences:

• Prevalence of preterm birth has remained fairly steady over the past decade; however, 15.0% of non-Hispanic black infants were born preterm compared to non-Hispanic white and Hispanic/Latino infants (about 9.5% for both groups)
• Prevalence of low birthweight deliveries has remained steady overall; but disparities exist (15.1% of non-Hispanic black infants born weighing <2500 grams, compared to 7.0% among non-Hispanic white infants and 7.3% among Hispanic/Latino infants)
• Over three-fourths of infants were placed to sleep on their backs, but this practice was much lower among non-Hispanic black mothers (53.9%) compared to 80.0% of non-Hispanic white mothers and 75.9% of Hispanic/Latina mothers

 

Needs and Challenges:

• Provider screening and education/discussions around behavioral health issues, specifically substance use, not widespread or standardized
• More education and social/family/peer support needed for breastfeeding, including access to appropriate spaces to breastfeed/pump
• More education and support from providers and family needed for safe sleep practices to be implemented and maintained

 

Strengths and Successes:

• The Baby Friendly Hospital Initiative was shown to have value for successfully promoting breastfeeding initiation, and DHEC’s WIC program was cited as being very supportive for breastfeeding mothers to continue
• Screening and early intervention programs, including BabyNet and Help Me Grow, were suggested as assets to the state as well as DHEC’s Newborn Screening Program, which was noted as a strong, effective program helping connect families to services/education
• The SC Birth Outcomes Initiative is an incredible asset and credited with many MCH successes (e.g., CenteringPregnancy for improved prenatal care utilization, reduction in rates of non-medically necessary c-sections and promotion of SBIRT screening through a Medicaid reimbursement policy)

 

Child Health Domain

Health Status Overview:

The skills developed in childhood have the potential to affect them for the rest of their lives, and good physical and emotional health early on lends to a strong foundation for good behaviors and practices in adulthood. Quantitative data from 2016-2017 for selected NPMs shows:

• Rate of hospitalization for non-fatal injury in children under 10 years was higher among males than females in 2016 (NPM 7.1)
• Children (9-35 months) from lower income-level households received more developmental screenings using a parent-completed screening tool in the past year than children from higher income-level households in (NPM 6)
• Disparities exist for physical activity in children; 33.5% of non-Hispanic White children and 21.3% of non-Hispanic Black children were physically active at least 60 minutes per day (NPM 8.1)
• Just over half of children without special health care needs had a medical home (NPM 11)
• Four out of 6 children were continuously and adequately insured (NPM 13.2); older children (12-17 years) were more likely to have a preventive dental visit in the past year than younger children (1-5 years) (NPM 15)
• Almost 18% of children lived in a household where someone smoked (NPM 14.2)

 

Disparities in Major Health Outcomes and Experiences:

• Children ages 3-17 with a mental or behavioral condition less likely to receive treatment or counseling (33.6%) compared with the US estimate of 50.7%
• Racial/ethnic disparities exist in the percentage of children less than 18 that reported having had two or more ACEs
• While 24% of children ages 0-5 live in extreme poverty, this varies by race/ethnicity: 12.0% of non-Hispanic white children 0-5 live in extreme poverty compared to 36.0% of Hispanic/Latino children and 43% of African American children
• Disparities are seen in 4th grade reading proficiency in SC: 60% of white children fell below the standard; 78% of Hispanic/Latino children fell below the standard; and 85% of African American children did not meet the standard
• Overall health status differs by race/ethnicity as 6% of non-Hispanic white children reported not being in excellent or very good health compared to 13% of African American children  

 

Needs and Challenges:

• Need for better access to affordable, quality mental health care
• More services and resources needed for children who are victims of bullying, abuse, neglect or other violence (including increased protective factors for ACEs)
• More widespread coordination for accessing developmental screenings and linking/referring for appropriate follow up
• Need for increased access to affordable oral/dental health care, including prevention

 

Strengths and Successes:

• SC’s State Health Improvement Plan focuses on Child Resiliency as a priority; Title V’s role identified as helping improve the social and emotional health of children and their families through changes at the system and community level
• The Quality through Technology and Innovation in Pediatrics (QTIP) program was praised for their work to improve health care for children, working on issues including preventive oral health, increasing immunizations and well-child visits, obesity, and chronic conditions, such as asthma; DHEC’s Pediatric Advisory Committee is a strong ally and partner to help ensure the success of the program
• DHEC’s Birth Defects Program has recently added referral activities to their workplan, promoting the follow-up of qualified patients with partner organizations and tracking intake appointments

 

Adolescent Health Domain

Health Status Overview:

According to the U.S. Department of Health and Human Services, the five essentials for

health adolescents include positive connections with supportive people; safe and secure

places to live, learn, and play; access to high-quality, teen-friendly healthcare; opportunities

for teens to engage; and coordinated, adolescent- and family-centered services.

Quantitative data from 2016-2017 showed:

• Hospitalization for non-fatal injury was significantly higher in adolescents 15-19 years than in adolescents 10-14 years (NPM 7.2)
• Females less likely to be physically active at least 60 minutes per day than males (NPM 8.2)
• In 2016-2017, 22.4% of adolescents were victims of bullying whereas 8.4% were the perpetrators of bullying (NPM 9)
• 80% of adolescents 12-17 years had a preventive medical visit in the past year;

additionally, only 10.8% of adolescents without special health care needs in this age

group received services necessary to make transitions to adult health care (NPMs 10, 12)

• 50.3% of children had a medical home in 2016-2017 (NPM 11)
• 67.4% of children were continuously and adequately insured; older children (12-17 years)

were more likely to have a preventive dental visit in the past year than younger children (1-5 years) in 2016-2017 (NPMs 13.2, 15)

 

Disparities in Major Health Outcomes and Experiences:

• Among SC teens ages 16-19 years old, 8% are not enrolled in school or employed, and disparities exist by race/ethnicity: 6% of non-Hispanic white teens and 7% of Hispanic or Latino teens are not in school or employed, while 12% of African American teens are not in school or in the work force
• The teen death rate (15-19 years per 100,000) from all causes varies by race and ethnicity, and was highest at 74.0 in the black population compared to Hispanic/Latino (41.0) and white populations (47.0)
• Education achievement levels show racial/ethnic disparities exist: 59% of white 8th graders scored below the math proficiency standard; 78% of Hispanic/Latino 8th graders and 90% of African American 8th graders scored below the standard

• Teen births have decreased over the past decade, but the rate significantly increased among non-Hispanic black teens in the past year

 

Needs and Challenges:

• More prevention activities, including better education, to prevent substance use and abuse
• Better access to services for teens who are victims of bullying, abuse, neglect or other violence
• Improved access to screening and services, as well as increased family/peer support for teens who are at risk of suicide
• Increased utilization needed for comprehensive adolescent well-child visits, including reproductive health education and services

 

Strengths and Successes:

• The SC Youth Advocacy Program was praised for providing a range of programs and services to children and families dealing with serious emotional, behavioral, psychological and/or developmental issues; DHEC was seen as a partner by helping to connect families to these services, providing education on what is developmentally appropriate, and focusing on the entire family
• Efforts to enhance access to care, especially in rural areas or areas with a shortage of providers, were noted as a successful start with the implementation of telehealth, school-based clinics and integrating mental health services into primary care; DHEC values this initiative and will continue to provide support

 

CYSHCN

Health Status Overview:

Generally, CYSHCN require health and related services of a type or amount beyond that required by children without special health care needs. An analysis of quantitative 2016-2017 data showed:

• Younger children with special health care needs more likely to have a medical home compared to older children with special health care needs (NPM 11)
• Doctors more likely to work with CYSHCN to gain skills and understand changes in their health care compared to children without special health care needs (NPM 12)
• Among children and youth with special health care needs, 66% were continuously and adequately insured as compared to 67.8% of children without special health care needs (NPM 15)

 

Disparities in Major Health Outcomes and Experiences:

• CYSHCN are at increased risk for chronic physical, developmental, behavioral or emotional conditions compared with children and youth without special health care needs
• Caretakers and families of CYSHCN report having many and substantial challenges, including stigma, and the public needs more education around disabilities
• Findings show that education and services for CYSHCN are not always culturally appropriate

 

Needs and Challenges:

• Access to timely, affordable health care and social/supportive services needs to improve
• Enhanced care coordination is needed

• Many parents explained that they felt lost or overwhelmed when trying to get the information and resources they needed as one mother stated, “it is overwhelming and frustrating because the information is not readily available…getting information is very challenging and it makes the situation even more frustrating and overwhelming.”
• Some explained the information is difficult to understand, especially the process to apply for government support programs

• Transition assistance for moving from pediatric/adolescent care and services to adult care needs improvement

 

Strengths and Successes:

• SC CYSNCH program served over 5,500 children in FY19 providing care coordination, financial assistance, referrals, transition planning, parent education/resources along with a highly praised residential summer camp
• The program is working on building a robust family-centered care coordination system and has successfully transitioned from clinic-based model to a systems of care model

 

Cross-Cutting Domain

A synthesis of 3 key themes and ideas that emerged are shown below.

 

Increase Access to Quality Health Care:

• No assistance to help navigate the health care system
  • Services/resources/support are available, but many are unaware or unsure how to get connected
• Many residents lack adequate health insurance or are underinsured
  • Medicaid coverage ends too soon at six weeks postpartum (problematic for postpartum challenges/depression) 
• Rural access to care is severely limited
  • One person explained this impact on access to care, “Large systems are buying small rural practices and moving them to more central locations…5 minutes to the doctor [and] now it is an hour.” 
• Lack of transportation to access available care
  • Urban areas still have challenges with transportation as many DHEC programs are located in cities, are not near where people reside

 

Mental Health is a Critical Area of Need:

• Mental health needs for individuals and families
  • Parents may not be equipped to identify early mental health issues as, “young children under age 5 are already showing mental health issues…there is need for early intervention. Families don’t know where to start.” 
• Increased access to mental/behavioral health services
  • Incorporate mental health and substance abuse screening in primary care; More school-based mental health programs and mobile units needed
• Suicide and violence prevention efforts are critically needed
  • Suicide rates among youth could be attributed to bullying, unhealthy school environments, and traumatizing family environments
• Additional Prevention Efforts are Needed
  • Provide services to build parenting skills/healthy families; Increase father engagement/support for fatherhood programs; More protection for the vulnerable (e.g., human trafficking victims and foster kids)

 

Addressing Social Determinants of Health (SDoH) and Health Inequities:

Public input survey results show the following:

• Demographics
  • 344 total participants—majority 30-49 years of age; average of 2 children living in the home; most live in Midlands Public Health Region
  • Race/Ethnicity

• 72.2% White
• 16.1% Black or African American
• 5.9% Hispanic or Latina
• 1.2% Asian
• 4.7% Other or Multiple Races Selected

• 23.3% had difficulty paying their mortgage, rent or utility bills on time
• 18.4% struggle with food insecurity

• 42.2% report not having any social or financial support in their community
• 11.7% report their neighborhood is unsafe or extremely unsafe from crime
• 18.3% report food didn’t last the entire month and not enough money to buy more
• 28.4% could not afford to eat balanced/healthy meals
• 11.1% could not get needed supplies in the past 12 months (diapers, wipes, etc.)
• 11.5% report that they usually do not have enough money to makes ends meet each month
• 21.5% have felt intense stress within the past 30 days

• Among non-white respondents only,

• 42% reported that they think about their race constantly
• 28% felt their healthcare experiences in the past year were worse than other races
• 23% recently experienced physical symptoms as a result of how they were treated (race)
• 44% recently felt emotionally upset as a result of how they were treated (race)

 

Qualitative results focused on key social determinants with informant perspectives below:

• Low education, poverty and unemployment
  • Parental literacy, need for improved parent/school interaction and relationship; Cost of living increasing while pay is not, Less employment opportunities, no affordable access to childcare
• Cultural differences and experiences of discrimination
  • Feelings of not being heard; Institutional racism and multigenerational/cumulative stress; Programs need to better promote their services to the Latino population, and use simple messages in Spanish
• Lack of social support, community connections, and trust
  • Stigma about seeking mental health services; Lack of support in the post-partum period, especially with breastfeeding; Lack of trust in health care providers and care that’s culturally inappropriate

 

Strengths and Successes:

• SC State Health Improvement Plan addresses 4 of the 5 challenges (child resiliency, behavioral health, factors that affect health and healthcare transformation)

• Alliance for a Healthier SC’s Health Equity Workgroup has developed a strategic plan to better understand/address root causes of health inequities by increasing capacity and building infrastructure to respond to equity-based issues
• DHEC is in the process of creating an Office of Equity, Diversity and Inclusion that will work across all Public Health bureaus to promote the attainment of the highest level of health for all

The Title V MCH and CYSHCN programs in SC are housed within the MCH Bureau at the state’s public health agency, the Department of Health and Environmental Control (DHEC). DHEC is overseen by a Board consisting of eight members, one from each congressional district, and a Chairman from the state at large appointed by the Governor, currently Henry McMaster. The SC Board of Health and Environmental Control selects the SC DHEC Director, who must be confirmed by the SC State Senate. Dr. Rick Toomey has served as the Director of DHEC since February 2019 but has recently resigned effective June 10, 2020. Marshall Taylor, Chief Counsel for DHEC, will serve as acting director.

 

DHEC is comprised of eight operational areas: Human Resources, Finance and Business Management, Healthcare Quality, Public Health, General Counsel, Environmental Affairs, Communication and Legislative Services, and Information Technology. All Title V MCH and CYSHCN programs are housed within the MCH Bureau, which sits alongside 7 other bureaus to include: 1) Chronic Disease and Injury Prevention; 2) Communicable Disease Prevention & Control; 3) Community Health Services; 4) Community Nutrition Services; 5) Public Health Laboratory; 6) Public Health Preparedness; and 7) Population Health Data Analytics & Informatics, the bureau in which the MCH Epidemiology Team is housed. These 8 bureaus form DHEC’s Public Health Sector, in which Dr. Joan Duwve was recently appointed as Director on April 16, 2020. In this capacity, she provides strategic direction for SC’s public health, ensures the delivery of quality services at DHEC’s facilities across the state and monitors performance of the central office bureaus. With more than 20 years of experience in public health, she has served as the Associate Dean of Practice for the Indiana University Richard M. Fairbanks School of Public Health and as the Chief Medical Officer with the Indiana State Department of Health and the Medical Director for the Department’s Division of Public Health and Preparedness. Before transitioning to full-time public health work, she practiced family medicine for 11 years, as having earned a Medical Doctor Degree (MD) from Johns Hopkins and a Master of Public Health (MPH) from the University of Michigan.

 

Lisa Davis continues to serve as Chief of Staff for Public Health reporting directly to the Public Health Director and provides direct management of the Director of the MCH Bureau, Kimberly Seals. The MCH Bureau administers all Title V Block Grant programs through the Divisions of Women’s Health, Children’s Health & Perinatal Regionalization, and Children and Youth with Special Health Care Needs, directed by Tammy McKenna. The MCH Bureau is responsible for the supervision and delivery of programs carried out with allotments under rehabilitative services, medical equipment for CYSHCN, Camp Burnt Gin, newborn blood spot screening, newborn hearing screening, lead screening surveillance and intervention, perinatal regionalization, among other efforts. Data analysis and epidemiological support are carried out by the MCH Epidemiology Team, led by Kristen Shealy, who also serves as the SSDI Principal Investigator, housed within Population Health Data Analytics & Informatics.

SC DHEC is a centralized state public health and environmental protection agency. The agency has at least one public health clinic in each of SC’s 46 counties, for a total of 76 facilities across the state’s four regions: Upstate, Midlands, Lowcountry, and Pee Dee. As a centralized public health system, the programmatic activities in these regions, counties, and clinics are coordinated by the agency’s central office, located in Columbia, SC. This structure allows DHEC to have the capacity to promote and protect the health of all SC mothers and children, including CYSHCN.

 

Women/Maternal Health:

The Division of Women’s Health within the MCH Bureau includes the Preventive Health Program, the Rape and Sexual Assault Prevention Program, and the Personal Responsibility Education Program (PREP). The Division of Women’s Health has active collaborations with the SC Medicaid agency as well as with local physician practices and hospitals. At the state level, collaboration with the Medicaid agency has led to the streamlining of policies between the Title X Family Planning Program and the SC Medicaid Program to improve efficiency and reduce duplication. At the local level, contracts with local physician practices and hospitals allow for male and female sterilizations to be performed through a network of referrals for clients who desire a permanent form of contraception.

 

Perinatal/Infant Health:

The MCH Bureau includes the statewide Newborn Blood Spot Screening, First Sound, and Postpartum Newborn Home Visiting programs. Each public health region has an MCH Program Manager to oversee responsibilities associated with these and other programs within the DHEC clinics around the state. The MCH Bureau also oversees the SC Perinatal Regionalization System (PRS). PRS manages a series of contracts with Perinatal Centers to assure risk-appropriate care is received for high-risk pregnancies, deliveries, and neonates regardless of demographic characteristics, rurality of residence, or ability to pay.

 

The WIC Program, housed within the Bureau of Community Nutrition Services, provides educational classes, nutrition, counseling, and vouchers for healthy food to pregnant, breastfeeding, and postpartum women and to infants and children. WIC also partners with hospitals around the state to integrate WIC breastfeeding peer counselors and breast pump distribution with in-hospital breastfeeding support.

 

The Division of Surveillance, housed within the Bureau of Population Health Data Analytics and Informatics, manages the SC Birth Defects Program. The Birth Defects Program conducts active data collection from medical records from all delivering hospitals in SC for nearly 50 different congenital anomalies.

 

Child Health:

The school nursing consultant, housed within the MCH Bureau’s Division of Children’s Health and PRS, provides education for and coordination of school nursing activities across SC through a contract with the Department of Education. In addition, this division houses the postpartum newborn home visit program, newborn blood spot screening, newborn hearing screening, lead screening and intervention, and Care Line monitoring.

 

The Division of Oral Health within DHEC’s Bureau of Chronic Disease Prevention includes a School-Based Oral Health Program, in which oral health providers conduct screenings within schools across SC, and a Fluoridation Program, in which DHEC’s Bureau of Water and municipalities across SC provide data and consultation for implementing community water fluoridation programs. Currently, 94% of SC’s public water systems are fluoridated.

 

Adolescent Health:

The MCH Bureau’s Division of Women’s Health includes the SC Adolescent Health Coordinator. This role helps to ensure that programs such as the Title X program and the Personal Responsibility and Education Program (PREP) are providing services that meet the needs of adolescents in SC. Some of these initiatives include the piloting of teen-friendly Preventive Health clinics in different areas of the state and collaborating with the SC Campaign to Prevent Teen Pregnancy to select PREP educational offerings and oversee the implementation of PREP activities.

 

Children and Youth with Special Health Care Needs:

Key CYSHCN programmatic activities include care coordination, services for individuals with hemophilia, special formula, orthodontia, hearing assistance, support for craniofacial and sickle cell clinics, support for sickle cell foundations, and Camp Burnt Gin, and Children’s Rehabilitative Services (CRS). A parent-to-parent mentor program is facilitated through a contract with Family Connections of SC.

 

The CYSHCN Program has financial assistance programs for orthodontia, special formula, hearing devices, CRS, and hemophilia and has contracts with three healthcare systems throughout the state to fund services to CYSHCN with severe craniofacial disorders. Additionally, the CYSHCN Program maintains contracts to provide support to four sickle cell organizations that provide services to individuals and families affected by the disease. This program also provides payment for office visits, durable medical equipment, prescriptions, and other needs under CRS for SC residents from birth through 18 years of age with a qualifying diagnosis.

 

Cross-Cutting/Life Course:

The MCH Bureau is actively participating in the National Infant Mortality CoIIN, in which MCH staff and partners share best and promising practices with other teams from around the nation, focusing on Social Determinants of Health. SC’s MCH Bureau is partnering with Healthy Start, WIC clinics, and PASOs to develop and implement a financial literacy curriculum for their clients.

 

In collaboration with the Chronic Disease Bureau’s Division of Substance Abuse and Injury, the MCH Bureau has outlined plans to: (1) strengthen the referral network for woman who screen position for substance misuse and abuse, (2) develop/adopt training materials for providers to have “non-punitive” conversations regarding substance abuse, (3) educate women about the risk of NAS and infants exposed to other drugs and alcohol in utero and (4) provide education to providers on need to standardize diagnosis of NAS and protocols for intervention/treatment.

A skilled workforce is essential to advancing MCH in a rapidly changing public health system.  Qualitative data from the needs assessment suggest provider shortages and the need to build more community-based support workers are key issues. It was noted that newer members of the workforce may not have the experience necessary to address the complex needs of families or the pay is too low to attract qualified experienced professionals. Resources, such as training, education and increased funding are required to recruit qualified experienced people into the MCH workforce.

 

DHEC is partnering with several agencies across SC to addresses these issues, including the Community Health Workers Institute, Home Visiting Consortium and the Telehealth Alliance.  Most recently, the MCH Bureau offered its collaborating support for the Division of MCH Workforce Development’s MCH Public Health Catalyst Program. This program trains masters and doctorial graduates on MCH competencies, focusing on family- and community-based approaches. Seeking to build SC’s MCH workforce pipeline, this partnership will provide practicum opportunities for students enrolled in the MCH Certificate Program working closely with the Univ. of SC’s Arnold School Public Health’s Office of Practice and Workforce Development.

 

Stakeholders also explained the need for more leadership and infrastructure to promote collaboration and coordination for MCH. Increased funding to support MCH initiatives and discouraging silos for increased interagency connections could be very beneficial. DHEC continues to participate in several interagency collaborations, and one includes working with SC First Steps to implement interventions associated with their Preschool Development Grant (PDG) in the areas of oral health, well-child visits and resiliency. DHEC recognizes that improvements cannot be achieved in silos and encourages collaboration and coordination with its partners.

 

Additionally, data and evaluation are areas for improvement. As mentioned elsewhere, the MCH team have received technical assistance on enhancing data metric and performance measures. Moreover, through the MCH Dashboard, informatics has now been introduced when evaluating both programmatic and Title V measures. The MCH Leadership Team continues to collaborate with the State Data Team, Arnold School of Public Health and Revenue and Fiscal Affairs on data and evaluation projects and is committed to making data-driven programmatic decisions focused on increasing transparency and accountability.

 

The experience brought by the MCH Bureau’s Leadership is fitting for the current needs across the MCH Bureau and DHEC as shown below:

 

Kimberly Seals, MSPH, MPA, serves as the MCH Bureau Director since 2017 is the former State Director of Maternal and Child Health for the March of Dimes Healthy Babies Alabama Chapter and previously served as a Public Health Advisor for the Centers for Disease Control and Prevention. Ms. Seals received her Masters in Public Administration from Texas Southern University and her Masters in Science of Public Health degree from Meharry Medical College. 

 

Tammy McKenna, MSN, RN, has served as the Director of the Children and Youth with Special Health Care Needs since 2018. She has worked with DHEC for over 29 years in a variety of roles including clinic nurse, team leader, supervisor and program manager in several public health specialty areas. Tammy has served as an adjunct instructor in Community Health Nursing and has significant experience in oversight for public health nursing, large scale contact investigations, emergency preparedness activities and building partnerships.

 

Mark Schwartz, MSPH, currently serves as Director of the Children’s Health and Perinatal Services Division. He has worked in the MCH field for more than 15 years in a wide variety of areas including National Medical Associations, State Level non-profit work as well as working for national health care providers. Mark has significant experience in directing and managing public health programs, building coalitions and partnerships and in quality improvement leadership work within the health care setting.

 

Stephanie R. Derr, MSN, RN, has served as the Director of the Division of Women's Health since 2014. She has worked with DHEC for over 17 years in a variety of roles including clinic nurse, team leader, and site supervisor. Stephanie has experience in policy development and serves as expert faculty for the SC Adolescent Reproductive Health Leadership Institute. She also developed the SC Contraceptive Leadership Summit.

 

Dr. Kobra Eghtedary is the Director for DHEC’s Bureau of Population Health Data Analytics & Informatics (PHDAI) which covers comprehensive public health data analytic, interpretation and visualization functions across the fields of MCH, chronic and communicable disease and houses Syndromic Epidemiology, SC’s Cancer Registry, SCVDRS, PRAMS, BRFSS, MMRC abstraction and analysis, Birth Defects, and MD STARnet. Dr. Eghtedary has 22 years of public health leadership experience in MCH Data Analytics and Technology Management.

 

Kristen Shealy, MSPH, is the Lead MCH Epidemiologist, housed in PHDAI, and works closely with the MCH Bureau, serving as the Project Director and Principal Investigator for Title V’s discretionary State Systems Development Initiative (SSDI) grant since September 2018. She has served in the field of MCH for over 20 years and has extensive experience working with state health departments to promote the utilization of data to inform program planning and evaluation and policy development.

 

DHEC MCH and MCH Epidemiology staff have joined a new Birth Equity Workgroup of the SC Birth Outcomes Initiative. While the goals and mission of this workgroup are currently being established, consensus is that work will be action-focused to address birth inequities among the African American population. The MCH Bureau is hosting a training from the Racial Equity Institute for DHEC staff to proactively understand and address racism, across the organization and among the communities we serve.

 

MCH staff and family leaders have recently received training, both in orientation and ongoing professional development, for staff, family leaders, volunteers, contractors and subcontractors in the area of cultural and linguistic competence. CYSHCN and Family Connection of SC offer trainings to staff that promote cultural competency within the context of transition and care coordination. Family and community engagement are incorporated into multiple MCH programs and committees at DHEC, such as the Newborn Screening Advisory Committee, the SC Birth Defects Program Advisory Committee, the Fetal Infant Mortality Review HIV Committee, the Sickle Cell Disease State Plan Committee and the CYSHCN Parent Advisory Board.

Collaboration is essential to moving the needle on MCH issues. Interview participants described several examples of successful collaborations across the state. One repeatedly mentioned includes the SC Birth Outcomes Initiative (BOI). According to participants, the BOI is effective because it brings together stakeholders across disciplines to share and learn about best practices, identify gaps and raise awareness. In addition, the Child Wellbeing Coalition was noted by many, as one stated, “the level and caliber of their work is very good and impactful and has ‘might’ so they have the clout to engage high level people.”

 

Leadership among agencies that collaborate and partner with DHEC, including the Department of Disability and Special Needs (DDSN), the Department of Education (DOE), the Department of Alcohol and other Drug Abuse Services (DAODAS) and the Department of Social Services (DSS) were described as key resources. The Department of Health and Human Services (DHHS) was noted for their role in administering Medicaid and other support programs. The Department of Mental Health (DMH) was also noted as an asset, specifically for their county-based mental health services, but stakeholders emphasized more funding and support are needed.

 

Another collaboration includes the Quality through Technology and Innovation in Pediatrics (QTIP) program designed to improve health care for children in SC by working on quality measures and incorporating mental health into a medical home. The group has worked on a variety of issues including oral health, immunizations, well child visits, obesity, asthma, STD screening and awareness about resources available for families. One discussed the value of this collaboration, stating “QTIP is the most innovative thing we have in SC. We have been doing it 10 years and have accomplished a lot and people all over the country are watching us.”

 

Other key collaborations noted as strengths include the Preschool Development Grant (administered by SC First Steps) and the SC Children’s Hospital Collaborative. Lastly, perinatal regionalization was mentioned often for their work to care for high-risk mothers and babies. A collaboration among DHEC, DHHS and others, one stakeholder explained the value of the program as, “an enormous strength…it is more than just a protocol…people count on it to move women to the care that they need and it saves the lives of moms and babies. It is unique to SC….and provides opportunities to collaborate, develop protocols, share resources, build a network of providers to provide a better quality of care.”

 

An array of other DHEC partners and collaborators was cited as key assets for MCH. Among those mentioned include the Children’s Trust of SC, PASOs, BabyNet, Help Me Grow, the SC Hospital Association, Sexual Trauma Services of the Midlands, and Family Connection of SC. Other specific programs mentioned as an asset include the Choose Well’s contraceptive access program, United Way’s Youth in Transition program (for homeless youth), the SC Center for Fathers and Families and the March of Dimes. Other organizations, including Boys and Girls Clubs, Girls Scouts and faith-based organizations were suggested as assets for the support they provide to communities across the state, especially for adolescents. The SC Youth Advocacy Program was also praised for their work to provide a range of programs and services to children and families dealing with serious emotional, behavioral, psychological and/or development issues. However, it was noted that there are some promising programs, strategies and initiatives across the state that can be built upon. Among these are school-based mental health clinics across the state, telehealth and integration of mental health services into primary care. These efforts are further bolstered by partner organizations leading the charge such as the SC Youth Suicide Prevention Initiative and the SC Chapter of the National Alliance on Mental Illness (NAMI). 

 

DHEC provides valuable education, outreach and health care services. These services include the Women, Infants, and Children (WIC) nutrition program, family planning services, safe sleep programs, vital health records and vaccinations. Stakeholders suggested that DHEC’s role to lead statewide coordination for MCH issues is essential and should continue. Further, some noted their appreciation for DHEC investing in focus groups and related activities to ensure the voices of families and communities are heard. DHEC’s Newborn Screening Program was noted as a strong, effective program to identify diseases or conditions early on and connect families with appropriate referrals. The value of various home visiting programs across the state was noted, and in particular, “DHEC’s postpartum newborn home visits are [an asset]…they head off issues by checking in on mom and baby, but many families need continued visits.” 

As mentioned in the process summary, data were collected and synthesized from various sources and exercises to form a list of 15 broader topic areas, including: access to care, mental/behavioral health, systems of care, community resources & linkages, developmental screenings & early intervention, maternal mortality, rural health (to include telehealth), well woman, safe sleep and infant death, care coordination and transition for CYSHCN, substance abuse/misuse (to include NAS), family/fatherhood engagement, breastfeeding support, and STDs. Several needs that were considered to be emerging (mental/behavioral health, rural health, fatherhood engagement, SDoH) rose to the top during the process, but rural health, fatherhood involvement and addressing SDoH (to include racism) were priority needs the MCH Leadership Team had identified as gaps prior to the assessment process. Also, because the MCH Leadership Team included a health equity lens across components health equity was added as a 16th topic.

 

Taking a different approach, the MCH Leadership Team worked backwards to develop the State Action Plan Table, starting with activities identified as “proposed strategies” from Retreat #3. Initial Advisory Committee domain-specific priorities (from the 38 original priorities) and domain-specific top public input survey results were visually mapped with proposed strategies the MCH Leadership Team had identified as activities that SC’s Title V programs has the potential to implement. Each element in this exercise was assigned to one of the 15 broader topics to ensure each dot was connected.

 

The first draft State Action Plan Table included the revised Strategies (with Advisory Committee feedback during and after the 3rd retreat) by domain. The next step was to select at least one NPM that would align with the SC’s Title V proposed strategies, pass the teams equity checkpoint, and fit within the scope of SC’s MCH capacity. State Performance Measures were added as needed to better inform on progress throughout the 5-year cycle. The ESMs were then drafted, thoroughly discussed and refined to be most meaningful and measurable. The final step was to draft a priority need that was inclusive of the Strategies, selected National and State Performance Measures, ESMs and associated broader topic areas.  

 

The final State Action Plan Table includes 8 Priority Needs, listed below along with a summary of changes from the previous 5-year cycle:

1. Increase developmental screenings and referral to early intervention services for children.

This priority need was retained (with a minor change in wording) as developmental screenings are essential for all children, and early intervention is the key to improved outcomes for those children with an identified need.

 

2. Improve utilization of preventive health visits to promote women’s health before, during, and after pregnancy.

This priority is considered new. Last cycle’s need to “Improve health promotion among the maternal and child populations” was dropped and new priority need’s focus is on utilization of health care visits to improve women’s health throughout the life course—before pregnancy to ensure the woman is healthy prior to conception and manage chronic conditions; early in the pregnancy for appropriate monitoring, screenings and education; and postpartum to ensure mom is recovering from delivery and any risks can be identified and managed (e.g., maternal mortality, postpartum depression).

 

3. Improve access to risk- appropriate care through evidence- based enhancements to perinatal systems of care.

This priority need was revised from last cycle’s need to “Improve access to risk-appropriate care through evidence-based enhancements to the perinatal regionalization system (PRS).” One of SC’s identified strengths included the PRS; however, identified gaps include racial/ethnic disparities in risk-appropriate care and the need for increased, standardized screening and treatment of substance use within the system of care.

 

4. Strengthen implementation of evidence-based practices that keep infants safe, healthy and prevent mortality.

Safe sleep practices and breastfeeding promotion/support were listed as two stand-alone priority needs last cycle, and the decision was made to cast a wider net and address disparities and focus on creating culturally appropriate messaging, increased awareness/education and promotion of provider and family support for best practices in the first year of life.

 

5. Improve coordinated and comprehensive health promotion efforts among the child and adolescent populations.

This is a new priority need as needs assessment results show a need to focus on the health promotion efforts for child and adolescent populations in a more coordinated and comprehensive approach to address complex issues (e.g., build resiliency by providing support services at the community level, address mental/behavioral health issues in a variety of settings, ensure well-child visits for adolescents are comprehensive and include certain provisions).

 

6. Improve care coordination for CYSHCN; and

7. Enhance and expand transition in care/services for CYSHCN from pediatric/adolescent to adulthood.

Care Coordination was identified as a continued need and is retained from the last cycle; however, transition from pediatric/adolescent care for CYSHCN is also an area that needs improvement and was added as a priority needs this cycle.

 

8. Reduce racial/ethnic disparities in social determinants of health, including insurance coverage, other barriers to medical care, especially behavioral and mental health care, fatherhood involvement, and racism/discrimination.

This needs assessment process focused heavily on disparities and health inequities across all population health domains, including an examination of the root causes looking at various social determinants of health. It is evident that real work in this area is just beginning but is a priority for MCH. This priority need was expanded to specifically include behavioral/mental health, fatherhood involvement and racism.