The NC Title V Program approaches the needs assessment as a continuous process, in which useful data, both quantitative and qualitative, relevant to the broad mission of the Program are continuously being gathered and analyzed with an eye to adjusting the Program priorities and activities as appropriate. The data capacity of the NC Title V Program is strong. There is a Perinatal Epidemiologist and SSDI Project Coordinator in the Title V Office, and the WICWS and DCFW/WCHS have staff members whose roles and responsibilities include coordinating data collection and analysis activities to guide effective monitoring, evaluation, and surveillance efforts and to help with program policy development and program implementation. DCFW is also leading a group across NCDHHS to pull together a child mental health dashboard. These staff members also work directly with statisticians and data analysts at the NC SCHS who provide further analyses, as necessary. In addition, most of the programs and initiatives provided under the Title V Program require local community action teams or advisory councils comprised of community members who provide input throughout the course of the project regarding emerging and ongoing needs. Often programs conduct focus groups and key informant interviews to gain more information from consumers, providers, and partners. Descriptions of how input from community groups, focus groups and other stakeholders was obtained and was used during FY22 can be found in the state action plan narrative domain reports.

The priority needs chosen during the 2020 Needs Assessment Process by Population Domain are:

Changes in the Health Status and Needs of NC’s MCH Population

There were no specific major changes in the overall health status and needs of NC’s MCH population over the past three years other than the ongoing effects of the COVID-19 pandemic (including potential increases in maternal morbidity/mortality that are still being investigated) and the mental health crisis.

Women/Maternal Health

Per data from the 2021 Behavioral Risk Factor Surveillance System (BRFSS) in the FAD, 75.9%% of women ages 18 to 44 surveyed had received a preventive medical visit in the past year which is higher than the national rate (69.7%) and is a bit lower than the 2018 NC rate of 77% (although confidence intervals overlap for the two years). Pregnancy intendedness data from the 2020 Pregnancy Risk Assessment Monitoring System show that 59% of survey respondents either wanted to be pregnant then or sooner which is similar to the survey results for the past five years. Unfortunately, this is the most recent PRAMS data available at this time. As shown in the table below, there were no major changes over the past year in most of the other Core State Preconception Health Indicators available from BRFSS, and inequities between racial and ethnic population groups persist. The increase in the number of women who currently have some type of health care coverage does seem to have increased significantly (confidence intervals don’t overlap) between 2018 and 2021 and for NH Black women and for the total respondents. There does seem to be an increase in those women who were overweight or obese.

Perinatal/Infant Health

While the state is still working to update to the American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologist/Society for Maternal-Fetal Medicine (ACOG/SMFM) designations of birthing hospitals’ levels of care, based on the current self-designated levels of care, which do not align with the AAP guidelines, data for 2021 show that 73.9% of very low birthweight infants received care at currently designated Level III+ neonatal intensive care units (NICUs), which is lower than the 2019 percentage of 80.1%.

In 2021, North Carolina’s infant mortality rate returned to a historic low of 6.8 infant deaths per 1,000 live births from a rate of 6.9 in 2020, but that means that 820 infants (a figure equal to about 11 school buses of 72 students each) died before reaching their first birthday. While the state has experienced declines in overall infant mortality over the last two decades, reprehensible racial disparities in infant mortality persist. Consistent with national reporting standards, racial classifications were modified in 2023 to include a multi-racial classification and single race reporting. Files were modified dating back to CY2014, the first year the North Carolina death certificate included multi-racial reporting options through the revised death certificate. The disparity ratio between non-Hispanic Black and non-Hispanic white infant death rates decreased slightly from 2014 to 2021, from 2.51 to 2.37, but this disparity ratio fluctuated from a low of 2.29 in 2015 to a high of 2.83 in 2020. Fetal death rates per 1,000 deliveries continue to tell the same story, as in 2021, the non-Hispanic Black rate (9.7) was 1.9 times that of the non-Hispanic white rate (5.1) with a total state rate of 6.0.

The latest data from the National Immunization Survey (NIS) show that 83.4% of infants born in NC in 2019 were ever breastfed which is slight decrease from the previous year and is almost the same as the national rate of 83.2%. Breastfeeding initiation data obtained from birth certificates for infants born in 2021 indicate that 80.8% of all infants were breastfed at hospital discharge. However, Hispanic infants (86.7%) and non-Hispanic Asian infants (89.1%) were more likely to be breastfeeding than non-Hispanic Black (69.9%), non-Hispanic white (83.7%), or non-Hispanic American Indian (52.2%) infants. While birth certificate data on mothers who reported smoking during pregnancy continues to trend down (5.6% of all live births in 2021 as opposed to 10.9% of all births in 2011), this is probably underreported, and there is still room for improvement.

Child Health

According to data from the 2020-21 National Survey of Children’s Health (NSCH), 89% of NC parents surveyed responded that their child was in excellent or very good health, which is approximately the same as the 2018-19 result of 91.1%. Younger children (<6 years) and children whose parents had more education and higher income were more likely to be considered in very good or excellent health as well as those who were receiving care which met the criteria for a medical home. Percentages were higher for non-Hispanic white (94.2%) children than Hispanic (86.3%) and non-Hispanic Black (80.1%) children. The percentage of children ages two through four receiving WIC services in NC who were overweight or obese (had a body mass index [BMI] ≥ 85th percentile) remained at just over 30% in 2019, which is similar to the past four years. Data for the BMI-for-age in children will not be available for 2020 and 2021 because heights and weights data were not consistently collected and measured using a standardized method because of remote WIC services in agencies during the pandemic. Additional data from the 2020-21 NSCH show that 39.5% of children in NC between 9-35 months had received appropriate developmental screening which is about the same as the rate of 43% in the 2017-18 NSCH, but lower than the rate of 55.8% in the 2019-20 NSCH and higher than the national average of 34.8%. It should be noted that the percentage for NC should be interpreted with caution as the estimate has a 95% confidence interval width exceeding 20 percentage points and may not be reliable. While the percentage of children with ≥2ACEs decreased from the 2017-18 to 2020-21 NSCH, 19.2 % down to 17.8%, the decrease is likely not significant. The immunization coverage rate for the combined 7-series for infants from the 2017-19 National Immunization Survey (NIS) report was 80.1%, but this rate decreased to 75.9% per the 2018-20 NIS. There was a slight increase to 76.5% in the 2019-21 NIS, although with fairly wide confidence intervals this increase was not significant. NC rates did continue to be higher than the national 2019-21 NIS rate of 70.1%. NCDHHS will continue to track the impact of the COVID-19 pandemic on childhood immunization rates and work with partners on catch-up opportunities even as the IB has moved into the Epidemiology Section.

Adolescent Health

Per NSCH data, the percentage of adolescents (ages 12 through 17) with a preventive visit decreased from 2016-17 (81%) to 2020-21 (72.4%), and this decrease was probably due to the COVID-19 pandemic, particularly with School Health Centers being closed for much of SY20-21. Teen immunization rates from the 2021 NIS – Teen showed continued increase over 2019 reports for teens receiving the human papillomavirus series (60.4%), and the rates for teens receiving meningococcal conjugate vaccine (95.6%) and one or more doses of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (96.2%) remained about the same. According to 2020-21 NSCH data, 21% of parents in NC responded that their child (age 10 to 17) was obese with a BMI ≥95th percentile (BMI is based on parents' recollection of the selected child's height and weight). This is an increase from 13.5% in the 2017-18 survey. Children and youth whose parents reported that they had experienced two or more adverse childhood experiences or who were low-income (<200% of the federal poverty level) were more likely to be reported as being obese.

CYSHCN

Through the use of a five item, parent-reported screening tool, there were an estimated 22.1% of CYSHCN in NC per the 2020-21 NSCH, which is almost identical to the 2017-18 NSCH results of 21.2%. The 2020-21 NSCH shows that CYSHCN were in NC were less likely to be in very good or excellent health as children without special health care needs (69.7% for CYSHCN v. 94.5% for non-CYSHCN), and this difference appears to be statistically significant. CYSHCN in NC age 10-17 years were more likely to be obese (34.6%) than children and youth without special health care needs (15.7%) according to the same survey. The percentage of CYSHCN in NC receiving care in a medical home decreased from 41% in the 2017-18 NSCH to 36.3% in the 2019-20 NSCH, with the majority of CYSHCN not receiving care within a medical home.

Changes in NC’s Title V Program Capacity and MCH Systems of Care

During FY21 and FY22, the Title V Program Director continued to lead COVID-19 pandemic response efforts, particularly in the areas of nutrition and vaccine rollout, serving on multiple NCDHHS teams to ensure that vaccine was made available quickly to all eligible populations in an equitable manner. She worked with teams across NCDHHS to elevate MCH work, while continuing to monitor work on the Title V State Action Plan.

Two significant changes in the MCH systems of care in NC, the transformation to NC Medicaid Managed Care and the planned creation of the new NCDHHS Division of Child & Family Well-Being, are still early in implementation, and it is too soon to tell exactly what the impact of those changes will be on the delivery of MCH services.

NC Medicaid Managed Care was officially launched on July 1, 2021, after being originally legislated in 2015, with nearly 1.6 million Medicaid beneficiaries now receiving Medicaid services through NC Medicaid Managed Care health plans. NC Medicaid Managed Care establishes a payment structure that rewards better health outcomes, integrating physical and behavioral health, and investing in non-medical interventions aimed at reducing costs and improving the health of Medicaid beneficiaries. All beneficiaries moving to NC Medicaid Managed Care were enrolled in one of five health plans or the Eastern Band of Cherokee Indians Tribal option by either selection of a health plan during the open enrollment period which ran from March 15 to May 14, 2021, or through the auto-enrollment process. Under managed care, Medicaid providers enroll with one or more health plan networks. Some beneficiaries, including those people with significant behavioral health needs, intellectual/developmental disabilities, and traumatic brain injury, are not required to choose a health plan at this time, as the Behavioral Health and Intellectual/Developmental Disability Tailored Plan is now set to launch on October 1, 2023, after a couple of delayed launch dates. Other beneficiaries, such as those receiving Family Planning Medicaid or children in foster care or receiving Community Alternatives Program for Children (CAP/C) services will remain in traditional Medicaid, which is called NC Medicaid Direct.

All pregnant women enrolled in managed care through pre-paid health plans (PHPs) will continue to receive a coordinated set of high-quality maternity services through the Pregnancy Medical Program (PMP), which will be administered as a partnership between PHPs and local perinatal service providers. Birthing people will continue to be screened using a standardized screening tool to identify and refer those at risk for an adverse birth outcome to the Care Management for High-Risk Pregnant Women (CMHRP) program, a more intense set of care management services coordinated and provided mostly by LHDs. In addition, the Care Management for At-Risk Children (CMARC) program which serves children ages zero-to-five, will continue as PHPs will contract with LHDs for the provision of local care management services at least for the first four years now with a recent extension.

Medicaid postpartum health coverage had been extended in North Carolina from 60 days to 12 months as of November 2021 as the extension was approved in the state budget based on a provision of the American Rescue Plan Act of 2021.  Effective April 1, 2022, the new benefit provides 12 months of continuous postpartum coverage to eligible NC Medicaid beneficiaries, giving them access to full Medicaid benefits instead of the maternity-focused benefits previously included in the Medicaid for Pregnant Women program. This extended coverage is currently authorized through March 2027.

In April 2021, the Secretary of NCDHHS announced the following five major changes to the Department’s organizational structure which stemmed from lessons learned during the COVID-19 pandemic:

1. Creation of a new leadership position of a Chief Health Equity Officer who will lead cross department work on equity and manage an expanded Office of Health Equity (formerly the Office of Minority Health and Health Disparities) and the Office of Rural Health to help embed equity in every aspect of the Department’s work.
2. Alignment of NCDHHS divisions and programs to focus on whole-person health with the Chief Deputy Secretary for Opportunity and Well-Being (managing programs and policies that promote the economic and social well-being of families, children, individuals, and communities across North Carolina) and the Chief Deputy Secretary for Health (managing programs and policies that foster the whole-person health of North Carolinians).
3. Establishment of a new Division of Child and Family Well-Being to elevate and coordinate the critical work of supporting children and families in North Carolina.
4. Establishment of an Office of Emergency, Preparedness, Response, and Recovery to bring together teams from across NCDHHS to prepare for, respond to, and recover from disasters and health emergencies affecting North Carolina, strengthening the Department’s partnership with the Division of Emergency Management at the Department of Public Safety.
5. Creation of the Deputy Secretary for Operational Excellence to better integrate accountability, performance management, and quality improvement in all aspects of how we do business and the Deputy Secretary for Policy, Strategy, and External Engagement positions to promote transparent communication with and authentic engagement of stakeholders.

The change that has impacted the NC Title V Program most directly was the establishment of the DCFW. The DCFW will bring together complementary programs from within NCDHHS that primarily serve children and youth to improve outcomes for children and their families. The programs include:

• Nutrition programs for children, families, and seniors, including WIC, CACFP, FNS/SNAP, and the special metabolic formula program
• Health-related programs and services for children that enable them to be healthy in their schools and communities, such as school health promotion, home visiting services, and children and youth with special health care needs programs
• School and community mental health services for children and youth, including supporting children with complex needs, coordination with schools, and systems of care work to meet needs of families who are involved in multiple child service agencies
• Early Intervention/ Infant-Toddler Program, which providers supports and services to young children with developmental delays or established conditions

The Nutrition Services Branch (WIC, CACFP), the Early Intervention Branch, and the Children and Youth Branch were all moved into the new DCFW. No positions were lost, but job roles and responsibilities may change as a result of the reorganization. NCDHHS understands the critical importance of Title V being administered by the state’s health agency and strong collaborations and structures to maintain a coordinated, life course approach to maternal and child health.

With the additional changes to the structure of DPH made in June 2022 putting the CDIS under the supervision of the NC Title V Director/Senior Medical Director for Health Promotion, collaborations already in place regarding life course, substance use, and injury and violence prevention will be strengthened. In June 2023, the Oral Health Section was also moved under the supervision of the NC Title V Director, which will further enhance collaboration across these programs.

Title V Partnerships and Collaborations with Other Federal, Tribal, State, and Local Entities that Serve the MCH Population

The broad-reaching partnerships and collaborations of NC’s Title V program described in other sections of this application have continued in the past year and will continue moving forward. Work by the Title V Director and staff members to help promote COVID-19 prevention efforts and testing have been immense and have strengthened relationships both with other state agencies and non-governmental partners. As mentioned above, the transformation to NC Medicaid Managed Care and the creation of the new DCFW will also strengthen existing partnerships and create opportunities for new collaborations.

Efforts to Operationalize the Five-Year Needs Assessment Process

As stated earlier, the NC Title V Program conceives of needs assessment as a continuous process. Given that, the biggest effort to operationalize the Five-Year Needs Assessment process over the past year has been to align Title V Program staff members around the State Action Plan to better understand how the state priority needs, strategies, objectives, and performance and outcome measures are aligned with the work that they are doing. The DCFW/WCHS and WICWS Chiefs and their staff members spent time during FY23 making minor revisions to the State Action Plan to better reflect the work of their staff members and the Title V partners. In developing the population narratives, relevant portions of the State Action Plan are shared with program staff for input on the annual report and annual plan. While work on the COVID-19 pandemic shifted some priorities, the NC Title V Program’s mission to support and promote the health and well-being of NC individuals including mothers, infants, children, youth, and their families to reduce inequities and improve outcomes continued to drive the work of staff members.

Changes in Organization Structure and Leadership

Other than the changes that came with the Title V Director’s expanded role and creation of the DCFW which have been described earlier, there was only one major leadership change in FY22. In March 2022, Dr. Anne Odusanya assumed the role of Assistant Director for the DCFW/WCHS and serves as the NC CYSHCN Director. Before taking this position, she was the CYSCHN Director/Unit Supervisor for Title V at the Wisconsin Department of Health Services. She received her DrPH from Georgia Southern University in Community Health Behavior and Education.

Emerging Public Health Issues

In addition to the ongoing COVID-19 pandemic and Medicaid Transformation, there continue to be a number of emerging public health issues which impact the NC Title V Program and its priority populations. One is the continued opioid crisis which seems to have become even more exacerbated during the COVID-19 pandemic as the rate of overdose deaths rose from 22.4 deaths per 100,000 residents in 2019 to 38.5 deaths per 100,000 residents in 2021. This burden of overdose has disproportionately worsened in some historically marginalized communities. The percentage of children who are in foster care due to parental substance use in NC has risen from 42.5% in 2018 to 45.7% in 2021. In addition to substance use, the stress related to the COVID-19 pandemic, job loss, social isolation, school closures, lack of usual supports, among other situations have highlighted the worsening mental health crisis among children and adults that will have to be addressed with COVID-19 recover and long-term. NCDHHS is working to offer services further upstream to build resiliency, invest in coordinated systems of care that make mental health services easy to access when and where they are needed and reduce the stigma around accessing these services.

While health inequity due to systemic racism and structural disadvantage is not an emerging public health issue but a longstanding one, the COVID-19 pandemic has exposed the disproportionate impact of crisis in a profound way, not only on physical health outcomes, but on access to mental health support, food security, and employment, among others. In May 2022, NCDHHS published Governmental Public Health: Workforce and Infrastructure Improvement in Action which provides a high-level overview of efforts to reform the public health architecture in NC in the following three areas: Systems Capacity & Strong and Inclusive Workforce; State-Local Efficiency and Effectiveness; and Data Modernization & Transparency. Other initiatives included in this work are the NC Institute of Medicaid Task Force on the Future of Public Health, NC Association of Local Health Directors ongoing initiatives, and North Carolina’s participation in the cross-state 21st Century Learning Collaborative on public health system change. In addition, the new DPH Director plans to focus on the following three goals:

1. Supporting the recruitment, development, retention, and diversity of our public health workforce
2. Building a durable statewide infrastructure that supports foundational public health capabilities – particularly community partnership development, advancing health equity, and data infrastructure
3. Earning trust by listening and lifting up the voices of our public health experts and combatting misinformation

The health insurance coverage gap coupled with insufficient access to affordable care disproportionately impacts Historically Marginalized Populations who have also experienced worse outcomes than others with the COVID-19 pandemic. Expanding Medicaid has been a key priority of NCDHHS for the past several years as an unprecedented opportunity to increase access to health care across the state, particularly in rural communities. Governor Cooper signed House Bill 76, Access to Healthcare Options into law on March 27, 2023, which will expand Medicaid and is expected to provide health coverage to over 600,000 people. While we are still waiting on the state budget to pass which is needed to become effective and determine the specific dates for eligibility rules, Medicaid Expansion is a powerful tool to improve the health and well-being of North Carolinians and their families. 

On March 14, 2023, Governor Cooper announced the creation of a statewide Office of Violence Prevention which will be located in the NC Department of Public Safety. The Office will focus on reducing violence and firearm misuse by coordinating efforts across the state, including those by the NC Title V Program and along with other NC DPH partners, particularly those in the Chronic Disease and Injury Section.