Ongoing Needs Assessment Activities

VDH MCH programs continuously assess the needs of Virginia’s MCH populations through ongoing monitoring, surveillance, and collaboration. Ongoing assessment involves monitoring progress and measures/trends, discussion of work plans and execution, and emerging issues for MCH populations not reflected in the plan. This review (e.g., environmental scans, surveys, formal and informal input from families and stakeholders) informs efforts to adjust and realign to the direction of the Title V program with shifting population and resource needs.

The ongoing mechanisms that provide data and/or information that inform Title V are:

1. In depth collaboration with the Division of Population Health Data’s (DPHD) ongoing surveillance analysis and evaluation efforts, including population health surveys (PRAMS, BRFSS, YRBS), participation in Environmental Public Health Tracking, Community Health Assessments (CHAs), and State Health Assessments (SHA), creation of data products and dashboards.
2. Staff participation on state and regional boards, councils, workgroups, and task forces. MCH staff provide expertise, consultation, and support on epidemiology, data collection, analysis, interpretation, and reporting.
3. In collaboration with the DPHD MCH Epidemiology Unit and Virginia Commonwealth University, the CYSHCN Program conducts a standardized survey of families of CYSHCN served by regional Care Connection for Children (CCC) Centers. The statewide survey is conducted every 5 years to assess family satisfaction and utilization of services, and to identify areas of program improvement. An updated assessment was disseminated in Summer 2023.

Virginia has created tools and mechanisms used by programs, local health districts, and stakeholders to monitor MCH outcome and performance measures.

1. Public-facing Dashboards: The population health data portal provides data on common indicators at the state, region, district, and locality level. The MCH Dashboard was revamped and launched in May 2024 to include updated data to 2022, visualizations, and racial/ethnic/geographic stratifications. The Health Behavior dashboard provides BRFSS profiles for health districts in Virginia, and is undergoing active updates. Updated PRAMS dashboards were also launched for commonly requested indicators. The Injury and Violence dashboard provides hospitalization and, as of 2024, death data by mechanism and intent at the state, region, district, and locality levels. In conjunction with the Office of Epidemiology, the Firearm-Related Deaths dashboard provides data by year, age group, race/ethnicity, sex, health district, and intent of injury on all types of firearm-related deaths to resident Virginians using Vital Records data. MCH staff also contribute to the Opioid Addiction dashboard, providing subject matter expertise on the Overdose Surveillance and Prevention Workgroup and data on substance misuse, hospitalizations, and Neonatal Abstinence Syndrome (NAS).
2. Development of data briefs/fact sheets: The DPHD often develops epi reports, data briefs, and annual reports that are widely shared via presentations and accessed on the VDH website, including Virginia PRAMS and YRBS Annual Surveillance Data.
3. Performance Measure Update: The MCH epidemiology team provides an annual presentation to Title V staff and collaborators on updates to performance measures and their related outcome measures, utilizing the Federally Available Data (FAD) Resource Document.

These tools have allowed the team to readily identify trends and monitor progress related to state plan measures and objectives. Utilizing these tools, we raise awareness and increase capacity for staff and partners to identify and discuss emerging issues, target programming efforts, and act as appropriate.

Plan for Well-Being (PfWB): Virginia Department of Health recently conducted a state health assessment (SHA) and is in the final stages of releasing a new state health improvement planning (SHIP), known as the Virginia Plan for Well-Being (PfWB), for 2023-2027. Additionally, all 35 health districts in the Commonwealth have completed or are engaged in the process of completing of a community health assessment (CHA) and a community health improvement plan (CHIP). The PfWB and CHIPs have a particular focus and emphasis on addressing the social determinants of health and the root causes of health inequities and disparities at the state and community level. Title V MCH staff were involved to provide insights, data, and expertise regarding MCH populations, and infant mortality was selected as a state priority. The MCH staff continue to provide ongoing annual updates to important indicators.

Operationalizing Five-Year Needs Assessment Process and Findings

The VDH MCH team continues to maximize the input of internal and external partners, and engagement of families and consumers regarding work related to the Title V Needs Assessment and State Action Plan for coordinated cross-sector strategic planning. State Title V efforts to operationalize needs assessment findings through strategic planning and workforce capacity training include participation in the following:

• CityMatCH Alignment for Action Learning Collaborative: The purpose of this project is to better align state- and local-level MCH work. Blue Ridge Health District (BRHD) and Birth Sisters of Charlottesville, community-based doula collective supporting people of color, were selected to participate in this learning collaborative. Virginia’s Title V leadership is providing consultation to assist BRHD in their plan of providing opportunities for anti-racism and implicit bias training for OB-GYN, Family Medicine, and Pediatric providers as well as to facilitate maternal child health career paths for persons of color. To meet one of the goals of the learning collaborative, Title V leadership and BRHD supported the Birth Sisters of Charlottesville to hold “Listening to the Living”, an online learning event that centered black women’s birth experiences to address racial disparities. This work was presented at CityMatCH in 2022. Although this ended in March 2023, the group continues to meet, recognizing the value and alignment of the work with Title V priorities. More information can be found in our MCH Workforce Development section (III.E.2.b.i.).

• National Maternal Child Health Workforce Development Center cohort:  VDH’s Title V staff participated in the National MCH Workforce Development Center cohort to initiate a robust strategic process to strengthen programmatic relationships with the Reproductive Health and Injury/Violence Prevention teams. Through this process, the team agreed to center the work around updating the 2021 Maternal Health Strategic Plan for the Office. More information can be found in our MCH Workforce Development section (III.E.2.b.i.).

Changes in MCH Population Health Status, Emerging Public Health Issues & MCH Program Response

The Title V team remains nimble and flexible to adjust program goals and activities to meet new and emerging health concerns that arise. Significant emerging issues may require realignment of Title V staff scopes of work and the action plan.

Maternal/Infant Morbidity and Mortality

A focus of the MCH initiative continues to be the reduction of infant mortality and maternal mortality disparities. The rates of infant and maternal mortality among the black population continue to remain twice and nearly three times that of their White counterparts, respectively. To address these disparities, overall MCH efforts are focusing on contributing factors to mortality such as access to care (e.g., increasing home visiting, doula support, pregnancy loss support), family planning (e.g., increased access to highly and moderately effective contraceptives), maternal/caregiver behaviors (e.g., safe sleep environments and substance use disorder), and community and family engagement. These efforts are partially funded by Title V and are supported mostly by other federal grants (e.g., MIECHV, Title X).

Maternal Health: Maternal mortality in Virginia due to direct and indirect obstetric causes has continued to have an upward trend. Data in 2022 indicate a maternal mortality rate of 47.1 per 100,000 live births, 1.7 times higher than the rate in 2020 (28.5 per 100,000 live births). Increases continue to be driven by rates among non-Hispanic Black women. Preliminary data from the Pregnancy-Associated Mortality Surveillance System indicate that the top two causes of deaths were attributed to infections and accidental overdoses. Late maternal deaths due to obstetric causes have also continued to increase, which provides insight into deaths occurring in the “4th Trimester” and helps to inform efforts related to postpartum care. In preparation for the new five-year cycle and reporting of the new universal performance measure on postpartum visits, planning is underway to determine how local health districts can be supported related to postpartum care activities.

Infant Health: In 2022, the top three most prevalent causes of infant mortality in Virginia included congenital malformations/chromosomal abnormalities, sudden unexpected infant death (SUID), disorders related to short gestation and low birthweight. Five hundred ninety-three infants died before their first birthday in Virginia, making the overall infant mortality rate across all races 6.2 per 1,000 live births. This rate is an increase from an infant mortality rate of 5.9 in 2019. Since 2011, the overall infant mortality numbers have remained relatively consistent; however, this rate varies by race and ethnicity. For example, the infant mortality rate among the non-Hispanic white population was 4.9, while the rate among non-Hispanic Black infants was 12.1, making the black/white infant mortality ratio 2.5. Emerging public health issues continue to be assessed. Current disease surveillance efforts within the Office of Epidemiology have indicated a rise in congenital syphilis in the Commonwealth, matching similar increases in national trends. As a result, an Incident Management Team setup was launched in November 2023, following a similar structure to Virginia’s response efforts to COVID-19 and monkeypox. Members of Title V and MCH Epidemiology are participating. Efforts from the IMT are underway to improve education of providers and screening of the pregnant population. In March 2024, a syphilis testing environmental scan was distributed to gain insights on processes implemented by local health departments pertaining to syphilis testing within STI clinical spaces with a focus on testing, screening, referral, and follow-up processes.

Mental Health, Substance Use, Injury and Violence

Virginia’s 2020 Needs Assessment revealed a cross-cutting priority in mental health across populations, which states to promote mental health across MCH populations, including reducing injury/suicide and substance use.

Substance Use: In 2022, almost seven Virginians died by drug overdose approximately every day. Virginia saw a 72% increase in the number of drug overdose deaths from 2018 to 2022; over eight out of 10 drug overdose deaths each year from 2018 to 2022 involved opioids. There was also an average of 7,590 nonfatal drug overdose hospitalizations among Virginians each year from 2018 to 2022; in 2022 alone, nonfatal drug overdose hospitalizations cost an average of almost $40,000 and a length of stay of almost five days per hospitalization, with a total cost of over $285 million.

Maternal opioid use is also a public health issue, as this can lead to withdrawal symptoms and opioid dependency of the newborn, known as neonatal abstinence syndrome (NAS). In 2022, there were 6.1 maternal opioid related diagnoses (MOD) per 1,000 delivery hospitalizations and 4.8 NAS cases in Virginia per 1,000 birth hospitalizations. Although this is a decrease since 2020, higher MOD and NAS rates continue to be seen in the Southwest health region and among the non-Hispanic White population. VDH’s Injury and Violence Prevention Program (IVPP) has leveraged Title V funding to expand Project Echo®: Neonatal Abstinence Syndrome (NAS) prevention labs equipping providers with the skills to provide case management and harm reduction services to women at risk for, or with a history of, substance misuse, abuse, and addiction during childbearing age; all with the goal for prevention of NAS.

IVPP also leads Project Patience Version 2.0 is an initiative advancing statewide delivery of prenatal and postpartum education on child maltreatment and infant injury prevention to newborn and infant parents and caregivers prior to their maternity hospital discharge to home or setting after birth and/or as they access community level settings, inclusive of service receipt from libraries and health departments. Priority populations include mothers of NAS infants and pregnant women at risk for or with a history of addiction.

The Code of Virginia § 32.1-73.12 directs VDH to serve as the lead agency for the development, coordination, and implementation of a plan for services for substance-exposed infants (SEI) in the Commonwealth. The Plan for Services for Substance Exposed Infants was approved by the Commissioner of Health in FY21, which is undergoing evaluation and updates under the direction of the Maternal and Infant Health Consultant.

Self harm and suicide: In 2022, there were 1,200 suicide deaths, which is approximately three Virginians who died by suicide every day. Deaths by suicide in 2022 among Virginians resulted in 34,812 years of potential life lost before the age of 75. On average from 2018 to 2022, suicide was the 10th leading cause of death in Virginia. The average number of deaths by suicide in Virginia from 2018 to 2022 was 1,193 deaths each year; deaths by suicide were relatively stable in the five-year time period. Self-harm is also a public health issue, as self-harm and suicidal ideation remains a significant risk factor for suicide death. There was an average of 2,706 nonfatal self-harm hospitalizations each year in Virginia from 2018 to 2022, costing an average of over $40,000 and a length of stay of over four days per hospitalization, with a total cost of over $547 million.

IVPP staff supporting ongoing suicide prevention efforts partnered with the Department of Education (DOE) to develop school guidance on suicide prevention including detailed planning of resources related to prevention, intervention, and postvention in schools. Additionally, staff worked to connect and expand individuals working in the suicide prevention field, identifying additional partners to participate in the Suicide Prevention Interagency Advisory Group (SPIAG). SPIAG serves as the primary mechanism for connecting and disseminating best practice suicide prevention information and data. Work has also included the Virginia Suicide Prevention Plan across the Lifespan, which has resulted in a partnership with the Campus Suicide Prevention Center of Virginia to ensure a comprehensive suicide prevention program statewide by increasing the number of gatekeepers serving disparate populations. 

Mental health assessment and coordination of support services are a priority of Title V supported programs. In close collaboration with other state agencies and organizations, they help to address the mental health needs of women, children, adolescents and families through screening and education. These include, but not limited to, pregnancy loss, home visiting, Resource Mothers, adolescent family life programs, and CYSHCN child development centers work. A recent survey that was implemented to ascertain how prepared youth (14-22) are to transition to adult care identified mental health as a prevalent issue among respondents. Local health districts also continue to have the opportunity to focus on mental health in their MCH work plans for FY24. In addition, the MCH Epidemiologist Lead and IVPP Senior Epidemiologist previously participated in the Policy Center for Maternal Mental Health Governmental Fellows Program, representing the Virginia Department of Health. This 12-months-long learning collaborative brought fellows from agencies across the nation in order to assist localities in closing gaps in maternal mental health using a multi-agency approach. The deliverable from this participation was an office-specific maternal mental health action plan that serves as a guide to break silos, build staff capacity, and close gaps to reduce and prevent adverse health outcomes associated with maternal mental health. Additional funding opportunities have also been sought to support maternal mental health and substance use initiatives.

The Virginia Mental Health Access Program (VMAP) focuses on the connection of pediatricians to local/regional child psychiatrists to advise them on mental health concerns of young children with the goal of reduced wait time for mental health assessment and treatment of young children.  Due to the lack of resources and low number of child psychiatrists in Virginia, this program strives to minimize barriers to treatment and provide support to local pediatricians who see children with mental health issues. This initiative is led by the Virginia Department of Behavioral Health and Developmental Service (DBHDS) and VDH provides consultation and funding that focuses on the educational components of the program. During this reporting period, the program recently received additional state funding to expand its reach to include pregnant and postpartum mothers, known as VMAP for Moms+. This expansion will allow training both OBGYNs and pediatric clinicians on screening and early recognition of maternal mental health.

Title V Program Capacity

Virginia’s Title V capacity continues to grow in terms of state leadership, vision, organizational structure, and resource mobilization to reach program goals.

Leadership

Since the Department of Health is within the Executive Branch of Virginia’s Government, the issues impacting MCH populations have a direct linkage to the Governor and subsequently Secretary of Health and Human Resources for Virginia. Executive Branch leadership has strategic focus on women’s health, children, and youth, and has initiated several efforts to expand state capacity to improve the health and well-being of MCH populations and families. Current work of the Governor includes the Right Help, Right Now initiative to address the behavioral health care challenges facing the Commonwealth, and it is designed to address issues involving mental health and substance use.

Organizational Structure

The Health and Human Resources Secretariat oversees the state health and human services agencies (i.e., Department of Health, Department of Medical Assistance Services, Department of Behavioral Health and Developmental Services, and Department of Social Services). The Code of Virginia authorizes the Department of Health to prepare and submit the Title V plan. The Commissioner of Health is authorized to administer the plan and expend the funds. The grant is administered within the Office of Family Health Services, Division of Child and Family Health. The Title V/MCH Director manages the state programs, provides strategic direction, and ensures coordination with other state and federal MCH programs. The Title V/MCH Director reports to the Director of the Division of Child & Family Health and is responsible for strategic and day-to-day operations (e.g., overseeing grant activities, liaising with program managers, monitoring grant expenditures) and prepares and submits the Title V grant. The Director of the Children and Youth with Special Healthcare Needs program also reports to the Director of the Division of Child & Family Health. The CYSHCN Director provides oversight and management of the Child Development Centers, Care Connection for Children Centers, and Bleeding Disorders programs in Virginia. The Operations Division of the Office of Financial Management has a grant fiscal team that submits fiscal reports on behalf of agency programs. Title V funding supports a dedicated grant fiscal team member to monitor the MCH block grant budget and provide fiscal guidance related to funding. Funded teams are described in the MCH Workforce Development section (III.E.2.b.i.) of this submission. See attached organizational chart for details on how funded programs are organized within the VDH.

Agency Capacity

Title V funds are used to improve the health of women, pregnant women, infants, children and adolescents with and without special health care needs, and families in Virginia. An emphasis is placed on reaching populations with fewer resources, programs and services and those communities most greatly impacted by adversity and the root causes of disparities.

Virginia’s MCH program, including the CYSHCN program, prioritizes quality improvement and sustainability of the statewide coordinated comprehensive system of care that reflects a family-driven, data-informed, community-based approach to care. This comprehensive complex system of care is composed of state agencies, regional partners (the Child Development Centers or CDCs, Care Connection for Children Centers or CCCs, Health Systems), local partners (e.g., local providers, faith community, businesses, schools etc.) and families for cross-sector strategic planning.

The CYSHCN program includes a network composed of five CDCs and six CCCs. The CDCs provide a range of health and developmental screenings for children 0-21 years of age and referral to treatment. The CCCs provide comprehensive care coordination and wrap-around services to children 0-21 years of age and their families, with an emphasis on providing high quality, cost-efficient comprehensive care.

The VDH infrastructure includes 35 health districts. Each district received an allotment of the federal Title V funds to address the needs of MCH populations in the local communities.

The Title V team is composed of staff representing a multi-disciplinary approach to MCH. The skills represented include public health practice, research, and service in the areas of data collection and analysis, program development, implementation and evaluation, stakeholder engagement, policy development, community mobilization, clinical services, and care coordination.

Title V Partnerships and Collaborations

Virginia Title V has prioritized increasing diversity and inclusiveness of local partners as well as an emphasis on authentic inclusion of families and community-based organizations. Virginia’s partnerships are described in the Public/Private Partnerships section (III.E.2.b.v.a.).