In January 2019, the Department of Health and Senior Services (DHSS) MCH Epidemiology Team contacted the MCH Evidence Project to request technical assistance on enhancing ESMs identified for MCH block grant activities: in particular, the team is interested in receiving guidance from the project to develop ESMs that can be smoothly transitioned over the course of the five-year grant cycle from measuring activities to measuring outcomes and impacts. The MCH Evidence Project will continue to provide technical support to the Missouri Title V program as new ESMs are developed based on capacity evaluations and needs assessment findings in the next 12-18 months.

DHSS began the next Five-Year Needs Assessment process in Spring 2019. This statewide needs assessment will include both qualitative and quantitative methods to identify state MCH priorities. DHSS has contracted with Southeast Missouri State University to conduct focus groups throughout the state, including known areas of need (City of St. Louis , the Bootheel region), and additional effort to gather qualitative information from regions underrepresented in the 2014 needs assessment qualitative data (e.g., Hispanic population, northern MO). The qualitative data collection efforts have been integrated with the required MIECHV Statewide Needs Assessment, and include targeted outreach to individuals receiving or eligible for home visiting efforts in identified areas of elevated risk. There will be a special listening/focus group session at the Family Partnership Parent and Caregiver Retreat for families of children with special health care needs in September 2019. Specifically, these groups will target women of childbearing age, pregnant women, mothers of infants, and caretakers of children. Additionally, the MCH Epidemiology Team will be reaching out to hospitals throughout the state to request their most recent community health needs assessments to integrate smaller-scale and clinical-side perspectives into the Five-Year Needs Assessment.

The MCH Epidemiology Team is developing an analysis plan for the wide variety of data that will be used in the needs assessment process. For the previous Five-Year Needs Assessment, over 100 indicators were analyzed, including MCH, chronic disease, SDOH, and population demographics. For the current statewide needs assessment, similar analyses will be done, with a focus on assessing health equity at various geographies. Analysis will consist of extensive trend analysis on national/state performance and outcome measures, service capacity, and health status indicators.

Organizational Structure/Leadership/Program Capacity

The past year resulted in several changes to Missouri’s Title V Program. The DHSS Division of Community and Public Health (DCPH) acquired a new director in October, 2018. This position also serves as the Chief Division Director leading the team of Division Directors to increase collaboration and coordination between divisions and further departmental services to the people of Missouri. This leadership change included plans to restructure DCPH, with the first major reorganization involving the creation of a new section.

In March 2019, a new section in DCPH was formed, the Section for Women’s Health (SWH). Programs from both DCPH and the DHSS Director’s Office were combined in an effort to consolidate women’s health programs under common supervision. Staff of the Office of Women’s Health, Show Me Healthy Women, WISEWOMAN, the Title V Block Grant (including the Maternal Child Health Services Program and Childcare Health Consultation Program), Perinatal Hepatitis B Prevention, and the Pregnancy Associated Mortality Review Program transitioned into the new section. Efforts to provide streamlined services, concentrated program management, greater collaboration among programs and their associated activities and service delivery methods are the driving factors for this realignment. Overall, staff involved with the programs listed above remained the same as did their position tasks and responsibilities. One exception is that the MCH Services Program Manager was named as the new Title V MCH Director. Her previous years of experience with the Title V Program, education, and experience as a Child/Family Clinical Nurse Specialist make her well-suited for this role. In addition, the SWH Administrator previously served as the Title V Director and is familiar with the programs and services provided through the block grant. Discussions regarding the history of Missouri’s Title V Program and efforts to both analyze and improve current capacity have already begun.

Partnerships

A brief list of the partners/programs that the Title V program works with includes:

• Local Public Health Agencies;
• Missouri’s Healthy Start grantees
  • Mother & Child Health Coalition of Greater Kansas City
  • Missouri Bootheel Regional Consortium;
• Generate Health
  • FLOURISH;
• MO Women’s Health Council;
• Project LAUNCH;
• State and regional Safe Kids Coalitions;
• MO Injury & Violence Prevention Advisory Committee;
• MO Council for Activity & Nutrition;
• University of MO;
• Training in Interdisciplinary Partnerships and Services (TIPS) for Kids
  • Leadership Education in Neurodevelopmental and Related Disabilities (LEND) training program; and
• Other state agencies.

Emerging Issues

Adolescent Suicides

MO consistently reports higher rates of injury-related deaths than the US as a whole, including injury-related deaths due to suicide (intentional self-harm). In 2014, the suicide death rate for youths aged 10-19 was 5.71 per 100,000 population, and the intervening years have seen a near-doubling in the rate among this age group, to 11.99 in 2018 (provisional data). In 2016, DHSS received funding from the Centers for Disease Control and Prevention (CDC) to implement the National Violent Death Reporting System (VDRS) in Missouri. This system collects information on the demographics and circumstances surrounding violent deaths, including suicides, homicides, and unintentional firearm deaths. MOVDRS was piloted in 22 counties and the City of St. Louis, and began collecting data for deaths beginning in January 2017. For 2018 deaths, data collection has expanded to 55 counties, comprising 81% of all violent deaths in the state. Preliminary data from the first year of data collection indicates that, among individuals aged 25 and under (including the Title V adolescent population), mental health problems were found to contribute to 41.2% of suicides, and 38.2% of victims had a reported depressed mood in the month leading up to the event; 16.2% have a history of previous suicide attempts, and an equal proportion were receiving treatment for mental health problems. This suggests that 25% of young individuals who commit suicide may not have adequate access to mental health treatment services, such as counseling or medication. Findings also suggest that young people may benefit from enhanced care coordination and/or community resources to ensure appropriate referral to mental health treatment. MOVDRS staff have partnered with the Department of Mental Health suicide prevention program to provide targeted data to improve suicide prevention initiatives at various levels.

Opioid Abuse and Neonatal Abstinence Syndrome (NAS)

An analysis of death certificate information reveals that, between 2001 and 2017, the opioid-related death rate increased eightfold, from an age-adjusted rate of 1.8 per 100,000 population in 2001, to 16.5 per 100,000 in 2017. While 2018 data is still provisional, the expected rate is about 19% higher than 2017 at 19.6 per 100,000. Just over 100 ER discharges due to opioid misuse involved patients less than 18. Despite relatively few visits, teenagers are still at risk of opioid misuse as are younger children that may accidentally ingest opioids. Opioid misuse visits are highest amongst the younger adult age groups, with the 25 to 34 age group having the highest rate of 38.4 per 10,000 (28.6 for females only). Overall, females have lower opioid misuse rates compared to males and represent approximately 39% of all ER visits in 2017. However, females experienced a very large increase in ER visits between 2001 and 2017, increasing by 339%. Females of child bearing age (15-44) represent over 75% of all female opioid overdose visits. These trends indicate that a growing number of women of childbearing age are involved with opioids, both illicit drugs and legally-prescribed narcotic pain medications.

NAS is a drug withdrawal condition that occurs in infants that have been exposed to opioids in utero. NAS can occur in infants exposed to illegal opioids, such as heroin, those exposed to pharmaceuticals such as methadone through the mother’s medication-assisted treatment, or through the use of prescription opioid pain relief medications such as oxycodone. Between 1999 and 2009, the rate of NAS births in MO increased by 242%, from 0.7 per 1,000 live births to 2.4 per 1,000 (compared to a national average increase of 183%). MO data for 2016 and 2017 births indicate continued increase in the number of NAS cases compared to pre-2016 data. In MO, the rates of NAS have increased for all races, but the increase has been most striking and rapid among babies born to African American mothers. Among babies born to White mothers, the rate of NAS increased from 52.9 NAS births per 10,000 population in 2011 to 109.3 per 10,000 in 2015; among babies born to African American mothers, the rate increased from 89.8 per 10,000 population in 2011 to 170.4 per 10,000 in 2015. Between 2014 and 2015 alone, the NAS rate among infants born to African American mothers more than doubled. Missouri DHSS staff were extensively involved in the Council of State and Territorial Epidemiologists’ (CSTE) efforts to establish a consistent, shared clinical and public health definition of NAS to standardize case identification and reporting in retrospective and forthcoming reporting. It is likely that, as Missouri adopts the new definition of NAS, incidence estimates will change significantly from current trends, as the new definition is stricter than the definition currently used in DHSS statistics reporting.

Maternal Mortality

MO continues efforts to address the state’s high maternal mortality rate. In 2017, MO’s maternal mortality rate was higher than the national average, ranked at 42 for highest in the country - in 2017, there were 32.6 maternal deaths (within 42 days of pregnancy or childbirth) per 100,000 live births. This rate fell to 15.0 deaths per 100,000 live births (within 42 days of pregnancy or childbirth) in 2018 (provisional data). This drastic decrease can be partially attributed to improved monitoring of the pregnancy checkbox on the death certificate for likely false-positives, and intensive follow-up with certifiers to cross-check the decedent’s pregnancy status. Maternal mortality, and associated underlying health conditions, continue to be one of DHSS’s strategic priorities for 2020. The MO Pregnancy-Associated Mortality Review (PAMR) uses expanded criteria to identify cases: 71 mortality cases were identified for board review from 2018 death certificates, down slightly from 86 cases in 2016. The PAMR board meets 6 times each year, reviewing 15-20 cases per meeting. The Missouri legislature also passed HB447, which is waiting to receive the Governor’s signature. This legislation includes a provision statutorily establishing a PAMR board, including a requirement to issue a yearly report, and instructing record-holding parties (e.g., hospitals, coroners) to provide data and documentation to the PAMR board as requested for case review and abstraction.

Access to Care

Though over 26,000 physicians (MD and DO) are licensed to practice in Missouri, nearly 70% are concentrated in seven counties, which include the major metropolitan centers of St. Louis and Kansas City, and the mid-size cities of Springfield, Columbia, St. Joseph and Cape Girardeau. In 2015, five Missouri counties had only one practicing physician of any sort. Health care resources in rural Missouri are limited, even for those who have health insurance, no financial difficulty, and access to transportation. Of the 164 licensed hospitals in Missouri, 72 (45%) are located in rural areas. Of those hospitals, nearly half (35) are Critical Access Hospitals which have 25 beds or less and provide a limited scope of service. In regards to access to primary health care services, the vast majority of rural counties are designated as Health Professional Shortage Areas (HPSAs). Of the 101 rural counties, 99 are Primary Medical HPSAs, 97 are Mental Health HPSAs, and 95 are Dental HPSAs. Since 2014, five rural hospitals have closed in Missouri, four of which were located in Missouri’s Bootheel, an area with a high rate of medical and social challenges. In 2017, MO promulgated first-of-its-kind rules allowing Assistant Physicians (medical school graduates who have passed required examinations and who have not entered into postgraduate residency), to apply for a limited license to practice in HPSAs through a collaboration agreement with a licensed physician; there are currently 194 assistant physicians in Missouri, but the program’s impact on healthcare access in HPSAs has not yet been assessed.

Adolescent Electronic Nicotine Product Use

In 2017, 5.2% of adults reported that they regularly used electronic nicotine products (ENPs); however, ENPs have much higher rates of use among youth. After years of declining tobacco use among adolescents, rates have begun to increase again, due in large part to the growing popularity of ENPs. In 2017, 39.9% of high school students had ever tried an ENP, down slightly from 40.6% in 2015; there was a much more significant drop in the number of adolescents reporting that they currently used ENPs, falling from 22.0% in 2015 to 10.9% in 2017. However, while e-tobacco use among high school students seems to be declining, the rate is stable or increasing for middle school students. Almost one-quarter (22.3%) of 8th grade students reported that they had ever used an electronic vapor product in 2017. By 12th grade, slightly more than half (50.1%) of students reported that they had tried an ENP at least once, and 14% of high school seniors reported that they used such a product on a regular basis. MO does not impose any restrictions on the sale of electronic vapor products other than those restrictions that also apply to traditional tobacco products. Additionally, MO spends the least of all fifty states on tobacco control efforts ($48,500 in FY2018), limiting the reach and capacity of dedicated state-level tobacco control programs.