III.C.2.a. Process Description
Since 2010, the Department has completed a more data-driven Title V Needs Assessment (NA). Our stakeholder and capacity surveys were quantitative tools used to help identify performance measures and develop five-year work plans. A major emphasis was placed on coordinating the selected priorities with the Department’s State Health Improvement Plan (SHIP), Agency Strategic Plan, the Collaborative Improvement and Innovation Network (CoIIN) priorities, and the partners engaged in the activities addressing the priorities. The intent was to focus efforts across the Department and state for collective impact. A comprehensive explanation of the Maternal and Child Health (MCH) Section’s NA can be found as an attachment, with a brief overview below.
As the MCH Section began the 2020 Five-Year NA process, an internal advisory workgroup and a statewide advisory workgroup were established. The internal workgroup included staff from sections and divisions across the Department. The statewide advisory workgroup consisted of Department staff and various partners throughout the state, including local health departments, Healthy Start Coalitions, local advocacy organizations, and university partners.
A public input survey was disseminated to obtain feedback from stakeholders and the public on how to prioritize MCH and Children and Youth with Special Health Care Needs (CYSHCN) matters in Florida. A total of 404 responses were received. A second survey was sent to assess Florida’s capacity to carry out the 10 essential services of maternal and child health. This survey was distributed to 43 MCH partner organizations in Florida, of which 24 responded.
Finally, a Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis was conducted of priority topics using the Capacity Assessment for State Title V tool. The statewide advisory workgroup recommended that Florida should keep the priority areas and corresponding national and state performance measures from the previous five-year NA. The advisory group also recommended the state give serious consideration to the following three performance measures: (1) risk appropriate perinatal care, (2) adequate insurance, and (3) adolescent physical activity.
Recognizing there is still work to do on many of the priorities identified from the 2015 NA the Florida Department of Health decided to (1) continue working on the National Performance Measures (NPMs) and State Performance Measures (SPMs) selected in 2015 and (2) add risk appropriate perinatal care and adolescent physical activity to our final list of 2020 MCH priorities given the results from the general input survey and CAST-V process as well as recommendations from the Title V state advisory workgroup.
The Office of Children’s Medical Services Managed Care Plan and Specialty Programs (CMS) underwent a multi-phase NA process, specific to the CYSHCN Domain. Keeping in line with the overarching goal of improving the system of care that serves CYSHCN, guiding principles from the National Standards for Systems of Care for CYSHCN, the Title V Maternal & Child Health (MCH) Pyramid of Health Services, and the Public Health Pyramid of Prevention served as the underpinnings of this process. While the NA phases themselves, aligned with the State MCH Block Grant Needs Assessment, Planning, Implementation, and Monitoring Process Framework, coined by the Federal MCH Bureau. These phases included: (1) assessing needs; (2) examining strengths and capacity; (3) priority selection; and (4) setting performance objectives and development of a five-year action plan to achieve these aims. To ensure goals were achieved and tasks were tracked and fulfilled, a Gantt chart was constructed and sustained throughout the process.
To foster objective and inclusive progression, stakeholder engagement (including families, field experts, and Department leadership/staff) and mixed data collection practices were critical components of the NA process. In addition to analyzing secondary data sources like the National Survey of Children’s Health and Florida Charts, surveys and focus groups were quantitative and qualitative methodologies utilized to comprehensively inform the process.
To adequately assess needs, strengths, and be intentional about stakeholder voice, caregivers of CYSHCN and young adults that identified as having special needs were asked to participate in primary data collection processes. A total of 247 parent/caregiver and 65 young adult questionnaires were administered. Additionally, over 75 participants, inclusive of caregivers, providers, and champions, participated in nine focus groups and key informant interviews-conducted virtually and face-to-face across the State of Florida.
Also, a CYSHCN NA statewide workgroup was formed and met monthly to provide their knowledge base and advisement throughout the NA process. Representation for this group was extensive and included leadership from CMS, Florida Health and Transition Services, Florida Family Leaders Network, University of South Florida College of Public Health, Family Network on Disabilities, Leadership Development in Neurodevelopmental Disabilities (LEND) training program, Broward Health Specialty Program, National Alliance on Mental Illness, Department of Children and Families, Agency for Health Care Administration, Florida Healthy Kids, Florida Chapter of American Academy Pediatrics, Florida Association of Children’s Hospitals, Florida Military Family Special Needs Network, and other key players. Eleven potential priority areas (mental health, family partnership, medical home, early screening, adequate insurance, access to care, adult transition, obesity, suicide, health promotion, and workforce development) were determined with the assistance of the aforementioned stakeholders and procedures.
To evaluate strengths and capacity, workgroups, comprised of internal CMS staff and family support specialists, were assembled to undertake the CAST-V Process. These groups added their area of expertise, reviewed issue briefs (outlined the issue, trend data, national/state goals, current initiatives, evidence-based practices and capacity), conducted SWOT analyses, which were converted into an appreciative inquiry approach using strengths, opportunities, aspirations and results (SOAR), and completed capacity worksheets (have or need certain structural resources, data/information systems, organization relationships, and competencies) for each of the 11 potential priority areas.
During the priority selection phase, a NA Scoring Team, including lived family experience, was provided the CAST-5 materials and a scoring tool, for ranking the 11 potential priorities. Medical home and mental/behavioral health were identified as the priority areas for the CYSHCN domain. The above-mentioned approaches resulted in two action planning workgroups launching with the role of thinking collaboratively, to develop priority specific performance objectives, strategies, and activities. Participants were CMS staff and external partners like volunteers from the statewide workgroup, physicians, and CYSHCN experts, including family leaders. Many of those emergent themes from the focus groups were included in the action plans. Action plans also integrated the following priority-inclusion areas: Transition, Family partnership, Health Equity, Workforce Development, Life Course/Cross-Cutting and leveraging core Public Health functions, these inclusion areas were embedded within various activities of the plans.
II.C.2.b Findings
III.C.2.b.i MCH Population Health Status
Women/Maternal Health
Several indicators provide insight into the health of women, pregnant women, mothers, and infants as they relate to Women/Maternal Health and Perinatal/Infant Health domains. The most recent Pregnancy Risk Assessment Monitoring System (PRAMS) Report provides insight into the health and behaviors of women in Florida. A total of 28.8 percent of women were dieting before pregnancy and 44.2 percent were exercising three or more days a week. PRAMS showed 16.8 percent of women used prescription medications before pregnancy, 8.8 percent were being checked/treated for diabetes, 10.4 percent were checked for high blood pressure, 9.7 percent were checked/treated for depression/anxiety, and 25.3 percent had discussions about family medical history with a health care worker before pregnancy. A total of 33.7 percent of new moms reported they were uninsured before pregnancy, and 58.1 percent participated in WIC. A total of 21.4 percent of women reported smoking cigarettes before pregnancy, while 8.6 percent smoked during pregnancy. A total of 51.2 percent of women reported that they drank alcohol before pregnancy, while 7.9 percent drank during pregnancy.
Three goals of the Department are: reduce the rate of maternal deaths per 100,000 live births from 16.3 to 16.0; increase from 17 percent to 21 percent women having a live birth who received preconception counseling about healthy lifestyle behaviors and prevention strategies from a health care practitioner prior to pregnancy; and increase from 76 percent to 84.5 percent of pregnant women receiving prenatal care during the first trimester.
The Department is funding interconception care (ICC) and early entry into prenatal care through Florida’s Healthy Start program. ICC is provided to a woman who has previously been pregnant and has risk factors that may lead to a future poor pregnancy outcome or a mother who is receiving services on behalf of her Healthy Start infant. Healthy Start Coalitions are responsible for assisting a pregnant woman with obtaining early access to prenatal care to mitigate risk factors and improve outcomes for mother and baby.
Perinatal/Infant Health
In Florida, infant mortality rates (IMR) have declined slightly from 6.2 infant deaths per 1,000 live births in 2015 to 6.0 infant deaths per 1,000 live births in 2019. Non-Hispanic white infant mortality has remained relatively flat with an IMR of 4.9 infant deaths per 1,000 live births in 2009 and 5.0 infant deaths per 1,000 live births in 2013. Between 2015 and 2019, non- Hispanic black IMR declined significantly from 11.0 to a low of 10.4 infant deaths per 1,000 live births. With Florida’s recent declines in non-Hispanic black infant mortality, the infant mortality disparity between non-Hispanic black and non-Hispanic white infants have decreased from a ratio of 2.6:1 in 2015 to 2.4:1 in 2019. It is important to note that despite this decline in the magnitude of disparity, non-Hispanic black IMR has consistently remained more than two times higher than non-Hispanic white and Hispanic IMR.
The Department is addressing black-white disparities in infant mortality by providing and facilitating preconception care and counseling, prenatal care, infant health services, ICC and counseling, and other preventive health services. The Department, MCH practitioners, and community partners realize confronting inequities in health care access, interventions and outcomes requires examining care systems, individual risk factors, community resources and deficit and cultural factors that interact to influence and/or determine health outcomes, including infant mortality.
Florida Healthy Start Coalitions conduct planning and service delivery approaches that incorporate Florida communities as partners and participants in disparity elimination. To help reduce infant mortality, Florida has established safe infant sleep as a priority in the State Health Improvement Plan with the following objectives related to infant sleep position and bed-sharing: (1) By December 31, 2021, reduce percent of black mothers in Florida whose infant sleeps in bed with a parent or anyone else from 26.4% (2014) to 24.8%. (2) By December 31, 2021, increase percent of black mothers in Florida who placed their infant on their back to sleep from 56.4% (2014) to 58.4%.
In 2019, 78.9 percent (2,737 out of 3,469) of Very Low Birth Weight (VLBW) infants in Florida were delivered at facilities for high-risk deliveries and neonates, an increase from 75.8 percent (2,652 out of 3,497) in 2015. No clear or consistent racial/ethnic disparities were observed.
The Department provides statewide access to high-risk perinatal care through 11 designated Regional Perinatal Intensive Care Centers (RPICCs) and two obstetrical satellite clinics. RPICCs provide perinatal intensive care services that contribute to the well-being and development of a healthy society. This regionalized network of hospitals also includes obstetrical care for high-risk pregnant women at obstetrical satellite clinics in rural areas.
Through community and provider education, the RPICCs increase awareness of services provided, which enhances accessibility to appropriate levels of care. Many RPICCs also participate in the Florida Perinatal Quality Collaborative (FPQC), a collective of perinatal-related organizations, individuals, health professionals, advocates, policymakers, hospitals and payers. RPICCs also provide staffing for the emergency medical transportation of high-risk pregnant women and sick or low birth weight newborns from outlying hospitals to the appropriate level facility for care.
The Department will continue to support services to increase the percentage of VLBW infants who deliver and receive care at hospitals with Level III neonatal intensive care units (NICUs). Plans include the continuation of high-risk obstetrical satellite clinics, continued encouragement of participation in the FPQC by designated RPICC staff, and the continuation of the designated RPICCs. The Department will continue to monitor the RPICCs to ensure appropriate placement of neonates in the Level III NICUs.
Child Health and Adolescent Health
Each year in Florida, one in 10 children (ages 19 and younger) are injured seriously enough to require a visit to the emergency room or admission to the hospital. While statewide unintentional injury rates remained steady in recent years, Florida’s age-adjusted injury death rates are higher than the national average. In 2011, Florida’s age-adjusted injury death rate for all unintentional injuries (41.8 per 100,000) was higher than the national average (39.0 per 100,000) by 7.2 percent. Among children, the trend worsens. Florida’s age-specific injury death rate for unintentional drowning among children ages 1-4 was 7.2 per 100,000, and was 166.7 percent higher than the national average of 2.7 per 100,000. Racial/ethnic disparities exist such that unintentional injury rates are substantially higher among non-Hispanic black children than among non-Hispanic white and Hispanic children.
Safe Kids Florida, led by the Department’s Injury Prevention Program, uses local coalitions to provide and promote leadership to reduce unintentional childhood injury and death. Safe Kids Florida works to reduce unintentional injury and death by promoting community awareness and education, supporting public policies and programs that reduce injury, and providing safety education on various risk areas including traffic and water safety. Currently, there are 13 Safe Kids coalitions across the state covering 81 percent of Florida’s 19 and under population.
Florida leads the country in drowning deaths of children ages 1-4. In 2011, the Injury Prevention Program launched the Waterproof FL: Pool Safety is Everyone’s Responsibility initiative. This campaign, focusing on early childhood drowning prevention, identifies supervision, barriers, and emergency preparedness as three layers to increase pool safety.
The WaterproofFL website (http://www.floridahealth.gov/alternatesites/waterprooffl/) offers an online toolkit for partners, advocates, and parents across the state. Since the program was launched, the age-adjusted drowning rate has dropped from 1.82 per 100,000 in 2011, to 1.79 per 100,000 in 2012, and to 1.77 per 100,000 in 2013.
The adolescent age group has lower well care visit rates compared to adults and young children. These rates likely reflect the challenges of reaching and engaging adolescents in preventive and primary health care. In 2011-2012, the prevalence of children ages 12-17 with no preventative medical care visits during the past 12 months was 19.8 percent in Florida and 18.2 percent in the nation. According to 2011-2012 data from the National Survey of Children’s Health, no significant racial/ethnic disparities existed among children younger than 18 regarding preventative medical care visits.
In 2013, Florida male public high school students (34.1 percent) had a significantly higher prevalence of meeting the current federal physical guidelines for aerobic physical activity than females (16.4 percent). Non-Hispanic (NH) white (28.0 percent) public high school students had a significantly higher prevalence of this behavior than NH black (23.6 percent) and Hispanic 21.3 percent) public high school students.
According to the Behavioral Risk Factor Surveillance System (BRFSS), 65.9 percent of Florida residents age 18 and older were overweight or obese in 2018. This percentage ranked Florida 23rd in the nation. The Department has many initiatives and programs in place to increase physical activity among children and adolescents. Ongoing projects include working with early childhood education centers and schools to develop and implement policies relating to physical activity of the children and adolescents while they are in the centers/schools. Programs such as the Alliance for a Healthier Generation’s Healthy Schools Program and the Healthier United States Schools Challenge emphasize the importance of incorporating physical activity into the school day and teaching children and their parents about the importance of physical activity.
Children with Special Health Care Needs
The literature tells us that a patient centered medical home (PCMH) is of importance to children with special health care needs. Data from the 2009-2010 National Survey of Children with Special Health Care Needs (CSHCN) shows that 36.2 percent of children in Florida have a PCMH, compared to 43 percent nationally. The survey data also shows that 37 percent of Florida’s CSHCN are receiving appropriate transition services, compared to 40 percent nationally. Transition services are vital to children and youth with special health care needs as it improves lifelong functioning and well-being. In addition to medical home and transition being top priorities for Florida, mental health was also identified through the needs assessment to be of extreme importance. The CDC estimates that one in five children under age 18 has a diagnosable mental health disorder and one in 10 youths have a serious mental health problem that is severe enough to impair their function; yet four out of five children who need mental health services do not receive them.
Other Findings/Strengths/Needs
Maternal deaths are increasing in Florida. From 2001–2003 there were 63 maternal deaths (ratio: 10.1 per 100,000 live births). From 2016–2018 there were 100 maternal deaths (ratio: 14.9 per 100,000 live births). In 2017, Florida PAMR began the transition to implementing the new Maternal Mortality Review Information Application (MMRIA). MMRIA is an electronic data system designed to support standardized data collection and help Maternal Mortality Review committees organize available data and begin the critical steps necessary to comprehensively identify, access, and abstract cases.
During state FY 2013-2014, the Public Health Dental Program implemented a statewide oral health surveillance system to collect data on specific oral health indicators to provide information about unmet dental needs, workforce deficiencies, access to care barriers, and populations at risk for poor oral health outcomes. Specific goals of the surveillance system include: monitor the status of high risk populations; identify unmet dental needs and barriers to care for disparate populations; assess workforce shortages and the distribution of Medicaid providers; and develop policies and programs to address barriers to care and service limitation. In 2016-2017 school year, the second Florida Third Grade Oral Health Surveillance Survey was conducted. The surveillance survey was conducted in a representative sample of schools screening over 1,200 third-grade students for evidence of caries experience, untreated decay, and presence of dental sealants. This data indicated that 25.1 percent had untreated caries, 45.5 percent had the presence of either untreated or treated (restored or filled) tooth decay, 40.5 percent had sealants present, three percent needed urgent care, and 20.6 percent needed early dental care. The Program completed its second Head Start Surveillance Project during the 2017-2018 school year. Preliminary data indicates 24 percent of Head Start children had untreated decay and 34.3 percent had caries experience.
Through the issue briefs and SWOT analyses, current efforts for the CSHCN population were examined for each priority need. Through the Children’s Health Insurance Reauthorization Program Act (CHIPRA) grant project, Florida identified medical home strategies that worked well in several Florida locations. Florida’s CHIPRA report will be utilized to determine what strategies should be encouraged as well as utilizing other recognized tool kits. CMS has implemented care coordination guidelines and performance standards that outline transition education standards for CMS care coordinators to follow. Further education and training across professions needs to occur to raise awareness about the importance of transition activities.
III.C.2.b.ii. Title V Program Capacity
III.C.2.b.ii.a. Organizational Structure
The Department is directed by the State Surgeon General, Secretary of Health, who is appointed by and directly reports to the Governor. The Surgeon General is responsible for overall leadership and policy direction of the Department. The Surgeon General is assisted by the following key staff:
Chief of Staff: oversees the offices of Communications and Legislative Planning
Deputy Secretary for Operations: oversees many of the Department’s key support functions including the Office of Budget and Revenue Management, Division of Administration, which includes the Bureaus of Finance and Accounting, General Services, and Personnel and Human Resource Management; the Division of Disability Determination; the Office of Information Technology; and the Division of Medical Quality Assurance.
Deputy Secretary for County Health Systems: provides oversight and direction to the state’s 67 local health department directors/administrators.
Deputy Secretary for Health: provides oversight to the divisions of Public Health Statistics and Performance Management; Emergency Preparedness and Community Support, Community Health Promotion, Disease Control and Health Protection, the Office of Minority Health and Health Equity and the Office of Medical Marijuana use.
Deputy State Health Officer for Children’s Medical Services: oversees the division of Children’s Medical Services and 22 CMS Regional/Area Offices.
The Department is responsible for the administration of programs carried out with allotments under Title V, as authorized under Section 383.011(1)(f), Florida Statutes. Many of these programs fall within the auspices of the Division of Community Health Promotion and the Division of Children’s Medical Services. The Title V Maternal and Child Health and Children with Special Health Care Needs programs are located within these divisions. Shay Chapman, BSN, MBA, Chief of the Bureau of Family Health Services, serves as the Title V MCH Director. Robert Karch, M.D. was named as Deputy Secretary for Children’s Medical Services in March 2020. Jeffrey P. Brosco, MD, PhD, in a physician consultant role with the Department, continues as the Title V CYSHCN Director.
The Division Director of Community Health Promotion provides leadership, policy, and procedural direction for the Division, which includes the Bureaus of Child Care Food Programs, Chronic Disease Prevention, Family Health Services, Tobacco Free Florida, and WIC Program Services.
The Bureau of Family Health Services is responsible for many of the Title V activities related to pregnant women, mothers, infants, and children. The Bureau Chief provides oversight and direction for the Public Health Dental Program; Violence and Injury Prevention Section; the Maternal and Child Health Section; and the School Health Services Section and the Adolescent and Reproductive Health Section.
The MCH Section includes the Healthy Start Program; the MCH Program which has, among other responsibilities, Pregnancy Associated Mortality Review and Fetal and Infant Mortality Review; and the Grants/Data/Budget/Procurement unit, which has primary responsibility for coordinating and collating information for the Title V MCH Block Grant application.
Below is the organizational table for the Florida Department of Health. The table is also included as an attachment.
III.C.2.b.ii.b. Agency Capacity
Children’s Medical Services is charged to administer the Children with Special Health Care Needs program in accordance with Title V of the Social Security Act. Additionally, CMS is responsible for providing CYSHCN a family-centered, comprehensive, and coordinated statewide managed system of care that links community-based health care with multidisciplinary, regional, and tertiary pediatric specialty care. This is in line with Florida’s Department of Health mission to protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
CMS is also able to serve CYSHCN as an optional specialty plan through the Statewide Medicaid Managed Care (SMMC) Managed Medical Assistance (MMA) Program for CYSHCN who meet clinical eligibility criteria.
Florida KidCare is Florida’s Children Health Insurance Program (CHIP) and has four partner agencies: Medicaid, DCF, CMS, and Florida Healthy Kids Corporation. CMS is an option for children who meet clinical eligibility criteria. The Florida KidCare Coordinating Council reviews and makes recommendations concerning the implementation and operation of the Florida KidCare program. Council membership includes representatives from the Department, DCF, the AHCA, the Florida Healthy Kids Corporation, the Department of Insurance, local governments, health insurance companies, health maintenance organizations, health care providers, families participating in the program, and organizations representing low-income families.
The CMS Safety Net Program serves CYSHCN from birth to 21 years of age who do not qualify for Medicaid or Title XXI, but who are unable to access, due to lack of providers or lack of financial resources, specialized services that are medically necessary or essential family support services. Families are required to contribute financially in the cost of care based on a sliding fee scale. The CMS Safety Net Program is not health insurance. The program provides a limited health services package for the enrollee’s primary and secondary qualifying conditions, selected by the parent or legal guardian, and are provided based on the availability of funds. All services require prior authorization.
Infants identified through the Newborn Screening Program with a positive screen may also receive confirmatory testing through CMS, as a payer of last resort, if needed.
Early Steps is Florida's early intervention system that offers services to eligible infants and toddlers, birth to 36 months, with significant delays or a condition likely to result in a developmental delay. Early intervention is provided to support families and caregivers in developing the competence and confidence to help their child’s development. Early Steps uses a Team Based Primary Service Provider approach that aims to empower each eligible family by providing a comprehensive team of professionals from the beginning of services through transition. The goal is for families to receive strong support from one person, provide a comprehensive team of professionals from beginning to end, and for the family to have fewer appointments and more time to be a “family.” Services are provided to the family and child where they live, learn, and play, to enable the family to implement developmentally appropriate learning opportunities during everyday activities and routines. There are 15 Early Steps offices in Florida.
CMS also works closely with Florida’s university systems, hospitals, hospices, pediatricians, and specialists through established statewide programs to ensure quality health care services are provided to children with special health care needs. These programs include the CMS Cardiac Program; the CMS Craniofacial, Cleft Lip/ Cleft Palate Program; the Comprehensive Children’s Kidney Failure Centers Program; the CMS Hematology/Oncology Program; the CMS HIV Program; the Partners in Care: Together for Kids Program, Florida’s Pediatric Program for All Inclusive Care; and the RPICC Program.
As part of the objectives of the Title V MCH Program, the Public Health Dental Program (PHDP) continues to collaborate with other state agencies and not-for-profit organizations to plan and implement programs that address the oral health needs of children and families. The PHDP continues to help implement and develop a state oral health action plan with the AHCA to increase the number of children who receive dental services through Medicaid and CHIP programs. Policy development for the Medicaid State Action Plan includes; revising billing codes and dental services to expand coverage for preventive services, such as dental sealants and fluoride varnish, and the integration of dental care with medical and behavioral health care provided through medical managed care plans to assist families in identifying a medical/dental home for services.
The PHDP also participates in dental health initiatives planned by the Oral Health Florida, Inc. coalition. This organization is comprised of a wide group of individuals and agencies that work in partnership to address their mission to promote and advocate for optimal oral health and well-being of all persons in Florida. The PHDP works with the coalition on several initiatives to increase oral health services for children and families in Florida.
Through the support of funding from the MCHBG and in collaboration and partnership with the Florida Dental Hygienists’ Association, the Association of State and Territorial Dental Directors, various primary schools and Head Start Centers throughout the state, the PHDP conducted Third Grade and Head Start Oral Health Surveillance Projects. These projects are important for identifying the unmet dental needs of children and for assisting high risk families with establishing a dental home and identifying local resources for continuing dental care. The Third Grade Oral Health Surveillance Project was completed in 2017 and the results were posted in 2018. The Head Start Surveillance Project was completed in 2018 and results will be posted in the Fall of 2020.
The PHDP, in conjunction with the Oral Health Florida Sealant Action Team, continues to promote the use of a cost-efficient dental hygienist workforce model for School-based Sealant Program service delivery. The local health department dental programs, Federally Qualified Health Centers, and local oral health coalitions across the state provide preventive services to children in Title I schools, Head Start, Early Head Start and Early Learning Centers and Women Infant and Children (WIC) sites. Providing these services to the children in school settings eliminates many barriers that impact access to dental care. School-based sealant programs are supported by MCHBG funding making it possible to reach high risk children in need of dental services and to improve dental outcomes for all children in the state.
During the state fiscal year (SFY) 2018-2019, school-based sealant programs provided services across 48 counties in Florida.
Dental sealant programs served over 1,250 schools, Early Head Start Centers, Head Start Centers, Early Learning Centers and WIC sites resulting in 146,535 children served. This resulted in the following services provided: 240,747 sealants, 35,320 cleanings and 136,983 fluoride varnish applications. In the first year of this initiative (SFY 2014-2015) three local health department programs developed and implemented a school-based sealant program with the support of MCHBG. Since 2014-2015, 37 local health department programs have received funding to initiate or expand school-based sealant programs. Currently, in SFY 2020-2021 eight school-based sealant programs received funding. At the time of this application, 50 out of the 67 Florida counties operate a school-based sealant program, many in part, due to MCHBG funding support for the start-up and expansion costs of programs.
CMS works closely with several sister agencies, including AHCA, DCF, the Agency for Persons with Disabilities, the Department of Education, Florida’s Office of Early Learning, the Guardian Ad Litem Program, and the Department of Juvenile Justice to ensure services are delivered through a seamless, coordinated system. CMS also works with the Family Network on Disabilities and the Family Café to educate families about engaging in health care decisions. Additionally, CMS works closely with the Florida Health and Transition Services (FloridaHATS) to educate and promote awareness related to health care transition. Additional partners of CMS working to improve the quality of care and outcomes for children with special health care needs include Florida Hospices, Florida School for the Deaf and Blind, Easter Seals, Centers for Autism and Related Disorders, and the Florida Developmental Disabilities Council.
III.C.2.b.ii.c. MCH Workforce Capacity
At the Florida Department of Health Central Office, there are 20 full-time staff within the Maternal and Child Health Section. Title V provides funding for 17 of those positions. Within the Adolescent, and Reproductive Health Section, there are 13 positions, one is funded by Title V. There are 11 positions within the Public Health Dental Program, one of which is funded by Title V. Statewide, there are approximately 2,900 Department staff working in positions directly related to Title V.
In Children’s Medical Services, there are a total of 710 full-time positions. Of that total, 679 are within the Children’s Medical Services Managed Care Plan, 12 are with the Child Protection Teams, 12 are with the Newborn Screening Program, and seven are with the Early Steps Program. None of these positions are funded with Title V funds.
Executive level and senior level management employees who support MCH activities and program staff who contribute to the state’s program and health policy planning, evaluation, and data analysis capabilities include the following:
Scott Rivkees, MD, was appointed by Governor DeSantis as Florida State Surgeon General and Secretary of Health in April 2019. Before his tenure as Florida’s Surgeon General, Dr. Rivkees served as chair of the department of pediatrics at the University of Florida College of Medicine and physician-in-chief of UF Health Shands Children’s Hospital, part of UF Health Shands Hospital and the University of Florida’s Academic Health Center. He also served as academic chair of pediatrics at Orlando Health and the University of Florida College of Medicine pediatric chair at Studer Family Children’s Hospital at Sacred Heart in Pensacola.
Shamarial Roberson, DrPH, MPH, was appointed as the Deputy Secretary for Health in Fall 2019. Dr. Roberson most recently served as the Department’s Director for the Division of Community Health Promotion.
Robert D. Karch, MD was appointed as the Deputy Secretary for Children’s Medical Services in Fall 2019. Dr. Karch joined The Nemours Foundation in 2011. He served as the President of the Medical Staff at Nemours Children’s Hospital and as the Chairman of the Medical Executive Committee. Dr. Karch is board certified by the American Board of Pediatrics and the American Board of Physician Nutrition Specialists and is a fellow of the American Academy of Pediatrics.
Melissa Jordan, MS, MPH, is the Director of the Division of Community Health Promotion, which includes the Bureaus of Child Care Food Programs, Chronic Disease Prevention, Tobacco Free Florida, Family Health Services, and WIC Program Services. Ms. Jordan also serves as the Director of the Office of Public Health Research.
Shay Chapman, BSN, MBA, serves as the Chief for the Bureau of Family Health Services, under which the Title V programs are located, and is the Title V MCH Director in Florida.
Anna Simmons, MSW, joined the MCH Section in 2013 and was promoted to her current position as Section Administrator in December of 2019. Ms. Simmons has spent her time at the Department in the Maternal and Child Health section.
Andrea Gary currently serves as the Interim Director for the Office of Children’s Medical Services Managed Care Plan and Specialty Programs, previously having served as the Bureau Chief for Administration under the Office. Ms. Gary joined the department in 2015, her expertise includes 14 years in state government with a background in business and communications.
Jeffery Brosco, MD PhD, previous Deputy Secretary for CMS, continues to serve in a contracted position as the Title V CYSHCN Director. Dr. Brosco completed his MD and a PhD at the University of Pennsylvania, he is board-certified in Pediatrics and in Developmental-Behavioral Pediatrics. He continues to teach and practice medicine at the University of Miami; his research focuses on ethics and health policy. Dr. Brosco is active in state and national health policy groups, including the National Workgroup on Standards for Systems of Care for Children and Youth with Special Health Care Needs (Association of Maternal and Child Health Programs/National Academy for State Health Policy).
Joni Hollis, RN, MSN, CNL, CCM has been with CMS since 2002 and is the Bureau Chief, Director of Clinical Operations, for the Office of Children’s Medical Services Managed Care Plan and Specialty Programs. She supports Dr. Brosco in his role as the Title V Children with Special Health Care Needs Director.
Robert W. Brooks, PhD, has been an epidemiologist within the Division of Children’s Medical Services since 2017. He serves as the Project Director of the State Systems Development Initiative (SSDI) grant, which funds supplemental data support to Florida’s Title V CYSHCN program.
III.C.2.b.iii. Title V Program Partnerships, Collaboration, and Coordination
The Department continues to cultivate several collaborative partnerships aimed at furthering its MCH goals and objectives, several of which are discussed below.
Since 1993, the Department has been awarded the SSDI grant, which serves as a complement to the Title V MCHBG Program. The primary goal of the SSDI grant is to promote the use of data and analytical work to support evidence-based MCH decision-making.
The Division of Public Health Statistics and Performance Management has the primary responsibility for facilitating the collection, analysis, and dissemination of health statistical data; the implementation of the local health department clinic management system; and coordination of community health assessment and health improvement planning processes. The MCH Section works closely with this division in several areas including: review of requests for MCH data; review of research proposals; and performing analyses and evaluations of MCH initiatives and programs.
The Department receives funding each year from the Administration for Children and Families to administer the Title V State Sexual Risk Avoidance Education Program. The goal of the program is to reduce the incidence of teen births and sexually transmitted infections through education on building healthy relationships and avoiding risky behaviors.
The Department receives funding each year from the federal Office of Population Affairs for the Title X Family Planning Grant. The Department’s Family Planning Program provides services using minimum guidelines for routine contraceptive management. Services include: education and counseling; history and physical assessment; provision of contraceptives; and treatment of related problems such as anemia and sexually transmitted infections. Florida has a robust statewide program with 67 local health departments and 143 clinic sites throughout the state. All women and men of childbearing age can receive services. Priority is given to teens and women ages 20-44 that are at or below 150 percent of the federal poverty level.
There are two federally recognized tribes in Florida - the Miccosukee Tribe of Indians of Florida and the Seminole Tribe of Florida. While these are the two main tribes whose governmental headquarters are in Florida, there are people of American Indian descent from more than 150 different tribes, each with their own distinct set of cultural beliefs. In total, the federally-recognized tribes comprise less than an estimated 5 percent of the American Indian population in the state.
The Office of Minority Health and Health Equity supports and provides resources to a volunteer committee called the American Indian Health Advisory Council (AIHAC). The AIHAC was formed initially in the HIV/AIDS Program Prevention Section. Since its inception, the AIHAC has grown to serve as a resource for agencies and officials such as the Florida Department of Health and its various programs, Florida American Indian governments, American Indian non-governmental organizations, and other organizations that serve American Indian persons, households and/or descendants in Florida. The AIHAC serves by providing a forum for discussion of the health, health care needs, and concerns of American Indian persons.
The Department partners with Florida State University (FSU) to encourage nursing students to intern with the Department. The Department also has a partnership with Florida Agricultural and Mechanical University (FAMU) to encourage students working towards their Masters of Public Health degree to participate in a summer rotation between their first and second years.
The Department participates in and contracts with the Florida Perinatal Quality Collaborative (FPQC), which is located at the University of South Florida, Lawton and Rhea Chiles Center for Healthy Mothers and Babies. The FPQC seeks to create an all-inclusive culture of cooperation and transparency across the specialties of obstetrics, neonatology, pediatrics and all fields engaged in maternal and infant health care by bringing together the specific expertise of physicians, nurses, nurse-midwives and all specialists involved with perinatal-related health care. Over recent years, the Department has partnered with the FPQC on the following initiatives, Access LARC, Mother’s Own Milk, Obstetric Hemorrhage, and Hypertension in Pregnancy.
CMS contracts with the University of South Florida (USF) for the Florida Health and Transition Services (FloridaHATS) Program to collaborate with communities to develop local/regional health care transition coalition sites in Pensacola, Jacksonville, and Tampa.
CMS area offices may choose to employ a Family Support Worker who has personal experience raising a child with special needs. Additionally, each Early Steps program has a Family Resource Specialist.
The Family Network on Disabilities is Florida’s Family to Family Health Information Center. CMS works with this organization and the Family Café to promote family involvement in health care decision-making.
The Department's Public Health Dental Program, in partnership with the Florida Dental Hygiene Association and Head Start, conducted the two Head Start Oral Health Surveillance Projects in 2014-2015 and 2017-2018 to provide oral health screenings in more than 47 Head Start centers across 29 counties for each project. Screening teams consisting of a dental hygienist and a recorder reached over 2,000 Head Start children during both projects and provided screenings, oral health education and referrals for follow-up care through providers in local health departments, Federally Qualified Health Centers, and private dentists registered as Medicaid providers.
The PHDP promotes prevention and emphasizes the importance of public health measures such as dental sealants and community water fluoridation through collaborative activities implemented by dental partner organizations.
III.C.2.c. Identifying Priority Needs and Linking to Performance Measures
Linkage of State Selected Priorities with National Performance and Outcome Measures
- NPM 1 - Percent of women, ages 18 through 44, with a past year preventive medical visit.
- NPM 3 – Percent of very low birth weight (VLBW) infants born in a hospital with a Level III+ Neonatal Intensive Care Unit (NICU).
- NPM 4 - A) Percent of infants who are ever breastfed and B) Percent of infants breastfed exclusively through 6 months.
- NPM 5 - Percent of infants placed to sleep on their backs.
- NPM 8 - A) Percent of children ages 6 through 11 and B) adolescents 12 through 17 who are physically active at least 60 minutes per day.
- NPM 9 - Percent of adolescents, ages 12 through 17, who are bullied or who bully others.
- NPM 11 - Percent of children with and without special health care needs having a medical home.
- NPM 14 - A) Percent of women who smoke during pregnancy and B) Percent of children who live in households where someone smokes.
Priority needs identified by the state’s needs assessment process helped the Department select the eight national performance measures chosen for programmatic focus by the Title V program. Following is a discussion of the measures, why they were selected, and their linkage to the selected state priorities.
NPM 1: Percent of women with a past year preventive medical visit
This measure was chosen because of the link to the state’s priority to improve access to health care for women, to improve preconception health. The Title V program focuses on both preconception and interconception health, fully recognizing the importance of improving the health of all reproductive age women to ensure better birth outcomes and healthier babies. Women’s health at all ages of the lifespan is important and contributes to the well-being of Florida families as too often women are the primary caregiver for families.
NPM 3: Percent of very low birth weight (VLBW) infants born in a hospital with a Level III+ Neonatal Intensive Care Unit (NICU)
This measure was chosen because of the link to the state’s priority to promote the health and well-being of pregnant women and the most fragile newborns to reduce maternal and fetal/infant mortality as well as reduce the risk of developmental disabilities in infants. CMS contracts with 11 Regional Perinatal Intensive Care Centers (RPICCs) and two obstetrical satellite clinics across the state to deliver optimal medical care to high-risk pregnant women and sick or low birth weight infants. With Title V funding support from the Department, participation of RPICCs in the Florida Perinatal Quality Collaborative (FPQC) has grown.
NPM 4: A) Percent of infants who are ever breastfed, and B) Percent of infants breastfed exclusively through 6 months
This measure was chosen because of the link to the state’s priority to promote breastfeeding to ensure better health and reduce low food security for infants and children. Promoting breastfeeding is an important focus of the Title V program. It has also been recognized as a major health benefit to both infant and mother, as well as an enhancement of maternal/child bonding. The Department provides breastfeeding promotion and support activities through many programs, including WIC, the Child Care Food Program, Healthy Start, and the Bureau of Chronic Disease Prevention (BCDP). The BCDP utilizes funding from the Preventive Health and Health Services Block Grant to support hospitals in counties that have prioritized breastfeeding in their Community Health Improvement Plan and support women living in counties with low breastfeeding initiation rates. The Title V program also has a long history of coordinating with the Department’s WIC program on many of their breastfeeding initiatives, such as breastfeeding peer counseling and establishing local health department policies to protect, promote, and support breastfeeding as the preferred, normal method of infant feeding. The Florida SSDI project has published and presented data on the benefits of breastfeeding practices.
NPM 5: Percent of infants placed to sleep on their backs
This measure was chosen because of the link to the state’s priority to promote safe and healthy infant sleep behaviors and environments, including improving support systems and the daily living conditions that make safe sleep practices challenging. The Department formed a Statewide SUID Workgroup that provides input on the state work plan to reduce sleep-related infant deaths, and created a logic model for conducting training efforts on safe sleep practices for health care providers, the Florida Hospital Association and other birthing centers, parents, caretakers, and the public. These activities, along with data showing that safe sleep initiatives have a significant impact on reducing infant mortality, made the selection of this measure a valid choice for the Title V program.
NPM 8: Percent of children ages 6-11 and adolescents ages 12-17 who are physically active at least 60 minutes per day
This measure was chosen because of the link to the state’s priority to promote activities to improve the health of children and adolescents and promote participation in extracurricular and/or out-of-school activities in a safe and healthy environment. Studies have shown that for many children, a decline in physical activity begins in middle school, and those children who continue to be physically active through middle school and high school have a much better chance of being physically active adults. Focusing on children and adolescents to increase physical activity can have a tremendous impact on improving health throughout the life span, by reducing obesity and the risk of many chronic diseases.
NPM 9: Percent of adolescents, ages 12-17, who are bullied or who bully others
Bullying is a priority for the Title V program. This focus can have an impact on improving health throughout the life span, by looking at adverse childhood experiences and the long-term impact and risk factors associated with many chronic diseases. Bullying is defined as: attack or intimidation with the intention to cause fear, distress, or harm that is either physical (hitting, punching), verbal (name calling, teasing), or psychological/relational (rumors, social exclusion); a real or perceived imbalance of power between the bully and the victim; and repeated attacks or intimidation between the same children over time. Bullying is a serious detriment to a child’s health, sense of wellbeing, safety, education, and emotional development, and greatly increases the risk of self-injury and suicide.
NPM 11: Percent of children with and without special health care needs having a medical home
This measure was chosen because of the link to the state’s priority to increase access to medical homes and primary care for children with special health care needs. A patient-centered medical home (PCMH) provides accessible, continuous, comprehensive, family-centered, coordinated, compassionate, culturally effective medical care. All children should have a PCMH, but the PCMH is especially advantageous for children with special health care needs as they typically require coordination of care between primary care providers and specialists.
NPM 12: Percent of adolescents with and without special health care needs who received services necessary to make transitions to adult health care
This measure was chosen because of the link to the state’s priority to improve health care transition for adolescents and young adults with special health care needs to all aspects of adult life. Transition from pediatric to adult health care has become a priority nationwide and effective health care transition is especially important for children with special health care needs as they are less likely to finish school, go to college, or secure employment. When transition is successful, it can maximize lifelong functioning and well-being.
NPM 14: A) Percent of women who smoke during pregnancy and B) Percent of children who live in households where someone smokes
This measure was chosen because of the link to the state’s priority to promote tobacco cessation to reduce adverse birth outcomes and secondhand smoke exposure to children. Smoking during pregnancy increases the risk of miscarriage and certain birth defects such as cleft lip or cleft palate. It can cause premature birth and low birth weight. Smoking during pregnancy is a risk factor for SIDS, and secondhand smoke doubles an infant’s risk of SIDS. Exposure to SHS increases a child’s risk of respiratory infections and common ear infections. Children with asthma who are exposed to secondhand smoke are likely to experience more frequent and more severe attacks, which can put their lives in danger.
Linkage of State Selected Priorities with State Performance and Outcome Measures
Based on the findings from assessing the needs and examining strengths/capacity phases, a scoring tool worksheet was developed. The tool entailed scores for issue brief packets (completed topic briefs, SOARs, capacity needs scoring sheets), and a section for public health impact based on the recommendation of an advisory workgroup member. To remain objective, a three-member Needs Assessment Scoring Team (CMS staff, including one with lived-experience as a CYSHCN caregiver) were asked to review the materials and use the tool to submit anonymous and individual scores, to rank the eleven priorities. To ensure inter-rater reliability, project managers of the needs assessment process individually computed the averages from the scorers. After, a one-page ranking document, containing the average scores for each scoring tool section and total score for all potential priority areas, was created and presented to leadership. After a debriefing, leadership selected Patient Centered Medical Home (PCMH) and Mental/Behavioral Health (MH) as the 2020 Title V Needs Assessment priorities.
Adequate insurance, transition, access to care, and workforce development were the additional top-scoring priorities. Adequate insurance was not selected as a final priority for CYSHCN because Medicaid and KidCare have specific roles in insurance coverage for the State of Florida. Likewise, there is also the Florida Covering Kids & Families at the University of South Florida’s Chiles Center that focuses on insurance coverage; CMS does participate on their hard-to-reach subcommittee and will continue to partner and collaborate with statewide stakeholders pertaining to adequate insurance for children and youth with special health care needs. Although not identified as final priorities, transition, early screening, family partnership, access to care, and workforce development, are enveloped as tenets under the umbrella of the PCMH concept, along with family partnership, and early screening.
Sustainment of MH and PCMH as state priorities from the previous five-year reporting cycle is backed by a review of literature, findings from stakeholder input, ongoing regional needs assessment efforts, and the successful initiation and planning of interventions that will be evaluated for effectiveness.
Over the past several years, CMS has transitioned towards making a greater impact on population health by focusing efforts on the infrastructure-building level of the MCH Health Services Pyramid. Hence the focus on National Outcome Measure 17.2 Systems of Care as the foundation for this most recent needs assessment process; PCMH is associated with NOM 17.2, linked to NOM 19 (health status) and NOM 25 (able to obtain care) a component of the National Standards for Systems of Care, and overtly derives from national performance measure (NPM) 11, with the aim of increasing access to medical homes and primary care. PCMH will drive improvement by: 1) Providing Education and/or technical assistance; 2) Increase the number of caregivers that feel like partners in their child’s care; 3) Increase number of designated PCMHs in underserved areas; and 4) Increase the number of adult care providers that will accept CYSHCN.
Mental/Behavioral Health is a state performance measure (SPM) that is directly derived from NOM 18, concerned with increasing access to behavioral health services. The focus of this priority will be education and/or technical assistance, behavioral health integration, and prevention of these conditions. The needs assessment findings coupled with prior investments and fruitful collaborative efforts, upholds continuing Patient-Centered Medical Home and Mental/Behavioral Health as priority needs for Children and Youth with Special Health Care Needs.
- SPM 1 - The percentage of children with a behavioral health condition who receive treatment consistent with their diagnosis.
- SPM 2 - The percentage of low-income children under age 21 who access dental care.
- SPM 3 - The percentage of parents who read to their young child age 0-5 years
SPM 1: Percent of children with a behavioral health condition who receive treatment consistent with their diagnosis
This measure was chosen because of the link to the state’s priority to improve access to appropriate mental health services to all children. Increasing the number of children who are referred to timely and appropriate treatment will improve health outcomes and the child’s ability to function optimally at home, at school, and in society.
SPM 2: The percentage of low-income children under age 21 who access dental care
This measure was chosen because of the link to the state’s priority to improve dental care access for children and pregnant women. Oral health is vitally important to overall health and well-being. Research has shown a link to diabetes, heart and lung disease, stroke, respiratory illnesses, and other conditions for pregnant women, including the delivery of preterm and low birth weight infants.
SPM 3: Increase the percentage of parents who read to their young children
This measure was chosen because of the link to the state’s priority to address social determinants of health that influence the relationship between health status and biology, individual behavior, health services, social factors, and policies. Encouraging parents to read to their children has a positive impact, including improvement in the parent-child bond, improved language development in children, and increased positive parenting.
To Top
Narrative Search