III.C. Needs Assessment Update

 

Illinois Title V conducts ongoing additional needs assessment activities that were conducted to monitor ongoing changes to health status and public health systems in Illinois.

 

Women’s/Maternal and Perinatal/Infant Health
 

Obstetric Hospital Closures

 

Monitoring the changing availability of obstetric services throughout the state and potential impact on maternal and infant outcomes is a priority of Title V and the Illinois Perinatal Advisory Committee. Between January 2016 and January 2022, there were 22 obstetric hospitals closures in the state of Illinois (6 full facility closures, and 16 facilities that closed the obstetric unit). During this time, there were also three new hospitals that opened to provide obstetric services. This means that in a six-year period, there was a net loss of 19 obstetric hospitals in Illinois, reducing the number of birthing hospitals to 96. Of the 22 closures, 11 were in the Chicagoland area, four were in central Illinois, two were in southern Illinois, and five were in the St. Louis metropolitan area. Of the Cook County closures, four were within the city of Chicago, and all were in the southern half of Chicago. This area has a high proportion of Black residents, and these closures leave very few birthing facilities available to south side residents. (Only 3 of the remaining 16 birthing hospitals in Chicago are located in the southern half of the city, where one-third of Chicago residents live.) Of the deliveries in 2015 (prior to series of closures), 9% of births occurred in the 22 hospitals that would go on to close their obstetric (OB) services. Residents of Chicago, Black and Hispanic patients, and Medicaid patients had higher proportions of births in the hospitals that would go on to close during 2016-2021. Specifically, 27% of the births to residents of southwest and south Chicago occurred in the hospitals that would go on to close during 2016-2021. This phenomenon of hospital closures is not unique to Illinois, but most of the national attention has been focused on rural hospital closures. Illinois has also seen concentrated urban hospital closures in areas where Black and Hispanic patients live, which has implications for health equity in these urban areas. Further analyses of the differential impact of these closures will be completed in 2022-2023.

 

To better understand the issues affecting the perinatal hospital landscape, Title V partnered with the Illinois Hospital Association (IHA) to conduct a hospital survey to understand the factors affecting hospitals’ abilities to maintain OB care. Title V worked with the Perinatal Advisory Committee to develop the survey instrument and IHA implemented the survey and analyzed the data to maintain confidentiality for participating hospitals. The survey was sent to the chief medical officer of all Illinois hospitals with two branching survey instruments: one for hospitals that have closed their OB units within the last five years, and one for hospitals currently providing OB services. For hospitals that have recently closed OB services, the survey asked about the extent to which various factors contributed to the decision to close the unit. For hospitals still offering obstetric services, the survey asked about how concerning various factors are towards maintaining OB services.

 

A total of 118 Illinois hospitals responded to the survey, approximately 60% of all facilities in the state. This included 10 hospitals that had discontinued OB services within the past five years and 78 hospitals that were providing OB services at the time of the survey. About half of responding hospitals were in the Chicagoland area and half were outside the Chicagoland area. Among the hospitals that had closed OB services, the factors that were most frequently cited as contributing to the decision were: decreasing deliveries, Medicaid managed care reimbursement rates, physician staff requirements, inability to recruit/retain physicians providing obstetric services, nursing staff requirements, and inability to recruit/retain nurses. Some relevant comments in open-ended question included:

 

“The cost of keeping a unit open with low deliveries per year combined with the malpractice issues and maintaining RN competencies was just too much to surmount.”

“Challenges in recruiting OBs when physicians retired led to increased call for physicians and challenges in covering 24/7 coverage. The decrease in patient census and deliveries presented challenges with staffing safely, according to guidelines.”

“The main issue was the reimbursement rates and payor mix. The decreased amounts led to the lack of ability to upgrade units which ultimately became a deterrent for prospective patients.”

 

Among the hospitals with current OB services, the following factors were cited as potential concerns to maintaining OB services by more than half of responding hospitals: Medicaid managed care reimbursement rates, inability to recruit/retain nurses, TORT reform, private insurance reimbursement rates, nursing staff requirements, inability to recruit/retain other staff (e.g., respiratory therapists), decreasing deliveries, and inability to recruit/retain physicians providing OB services. The factors with the highest reports of “a major concern” were inability to recruit/retain nurses (38.7%) and Medicaid managed care reimbursement rates (33.3%). Some relevant comments in open-ended question included:

 

“The ability to recruit and retain pediatricians, OBGYN, nursing staff is a great concern in our area.”

“Insurance reimbursement and medical liability are always a concern that should be continuously monitored.”

“Insurance reimbursements do not cover the cost for providing the in hospital and out of hospital care. There needs to be more done to help rural hospitals cover those costs.”

“Recruiting nursing staff and having a delivery volume large enough to maintain skills and competencies. Difficulty finding pediatric coverage for emergencies.”

 

These findings overall demonstrate two main types of factors that are affecting OB services in Illinois: insufficient reimbursement rates/volume of deliveries to support maintenance of OB unit, and difficulties maintaining required staffing levels for both physicians and nurses. Illinois will continue to consider how to address the financial and workforce challenges faced by the state’s hospitals. These findings have been shared at the Illinois Maternal Health Summit, and to state workgroups, such as the Perinatal Advisory Committee and Illinois Maternal Health Task Force. These findings are contributing to discussions about policy solutions to stabilize hospital OB services in Illinois.

 

Maternal Mortality

 

Illinois released the second Illinois Maternal Morbidity and Mortality Report in April 2021 found here: https://dph.illinois.gov/content/dam/soi/en/web/idph/files/maternalmorbiditymortalityreport0421.pdf.

This report is the most extensive report Illinois has released on maternal health. It includes analyses of chronic disease during pregnancy, severe maternal morbidity, pregnancy-associated deaths, pregnancy-related deaths, and violent pregnancy-associated deaths, in addition to a detailed list of critical factors and recommendations prioritized by actor.

 

The report found that the leading cause of pregnancy-related death was mental health conditions, including substance use disorders and that 83% of the pregnancy-related deaths were potentially preventable. The report highlighted the inequities in maternal mortality that Black women were about three times as likely to die from a pregnancy-related condition as White women and were more likely to die from pregnancy-related medical conditions while White women were more likely to die from pregnancy-related mental health conditions. The recommendations and critical factors identified in the report have been used to create priorities and strategies to address poor maternal health outcomes in Illinois. This release of the report served as a driver for ongoing initiatives to improve maternal health as well as a place to highlight gaps that need to be filled in the maternal health landscape.

 

Impact of COVID-19 on Maternal and Infant Health

 

The Title V epidemiology team continued to monitor the impact of the COVID-19 pandemic on MCH services and outcomes in Illinois during 2021. This included considering both direct COVID-19 effects (e.g., impact on maternal or infant morbidity and mortality due to COVID-19 infection) and indirect effects caused by the circumstances of the pandemic (e.g., changes in health service utilization and mental health/substance use). Through participation in the Centers for Disease Control and Prevention’s (CDC) Surveillance of Emerging Threats to Mothers and Newborns (SET-NET) surveillance system for COVID-19, more than 13,000 pregnant persons with confirmed positive specimens for SARS-CoV-2 have been identified for the first year of the pandemic (specimens March 2020-March 2021). Of all live births for the first year of the pandemic, 5.6% had confirmed maternal prenatal SARS-CoV-2 infection. The groups of birthing persons with the highest prevalence of maternal prenatal SARS-CoV-2 infection were: Hispanic, younger than 25 years old, Medicaid recipients, and residents of Chicago. Data has been linked from the state’s infectious disease reporting system (INEDSS) with birth and fetal death certificates and have sampled a subset of cases for medical chart abstraction to obtain more details information about the maternal and birth outcomes for confirmed COVID-19 cases during pregnancy. Data will be analyzed during 2022 to understand the effects of COVID-19 during pregnancy on maternal and birth outcomes.

 

Provisional vital records were used to look at monthly time trends in a wide variety of MCH indicators to understand how the circumstances of the pandemic may have affected health care utilization, health behaviors, and health outcomes. The monthly rates of various outcomes during 2020 and 2021 were compared to the average of what was observed during 2017-2019. There were not statistically significant changes for any of the following indicators during the pandemic: preterm birth, risk-appropriate care, neonatal intensive care unit admission, breastfeeding in delivery hospital, neonatal hospital transport, maternal hospital transport, low-risk cesarean rate, or receiving no prenatal care. There were three indicators, however, that did demonstrate statistically significant changes that correlated with the pandemic time period: planned home births, adequate prenatal care utilization, and pregnancy-associated mortality.

 

Home births are relatively rare in Illinois (less than 1% of all live births), and planned home births usually account for about three-quarters of the state’s total home births. There was a modest, but statistically significant, increase in planned home births starting in April 2020 that persisted throughout most of 2021. The planned home birth rate increased from a baseline average of 0.4% of all live births to 0.6% of all live births in April 2020 and beyond. This translates to approximately 15-20 “extra” planned home births per month than were seen pre-pandemic. In contrast, there was not any difference in the rate of unplanned home births in 2020-2021 compared to 2017-2019. The increase in planned home births could be due to fear of COVID-19 exposure at the hospital, or changes to hospital policies that made in-hospital births less desirable (e.g., limiting visitors or birth support persons).

 

Among live births, the rates of adequate prenatal care utilization were significantly lower for infants born during July 2020-January 2021 compared to baseline rates. Of all live births in January 2019-March 2020, about 77.5% received at least adequate prenatal care. However, during July 2020-January 2021, this decreased to 74.6%, with rates returning to baseline levels in February 2021 and beyond. Upon examination of these data, it appeared that the reason for the decrease in “adequate” prenatal care was due to an overall decrease in the number of prenatal visits for persons giving birth during this time, not due to more people having delaying entry into prenatal care. Given that many outpatient provider offices were closed for non-urgent visits during the first few months of the pandemic and the fact that it took some time for offices to figure out how to set up telehealth appointments, it makes sense that women delivering during July 2020-January 2021 may have received fewer than the expected number of prenatal care visits, especially during the early stages of their pregnancy. For births in February 2021 and beyond, the levels of adequate prenatal care returned to the pre-pandemic levels, perhaps reflecting that provider offices had mostly returned to normal operations by that time.

 

Finally, there is a statistically significant excess of about 21 pregnancy-associated deaths during 2020 compared to the average for the last three years (108 deaths in 2020, compared to an average of 87 per year in 2017-2019). On a month-by-month basis, the higher than average numbers of pregnancy-associated deaths occurred during May, June, October, and November 2020. Deaths from COVID-19 (n=7) and drug overdose (“excess” n = 10) account for most of the excess pregnancy-associated deaths during 2020. Twelve pregnancy-associated deaths related to SARS-CoV-2 infection have been identified through death certificates so far: seven during 2020 and five during 2021. Various racial groups have been affected and nearly all of the women who died from COVID-19 resided in the Chicago area, which had higher infection rates during the earlier stages of the pandemic. Among COVID-19-related pregnancy-associated deaths, the age range of the women who died was 18-38 years. Illinois will begin a review of the 2020 deaths during 2022 to identify contributing factors and opportunities to prevent future deaths.

 

Child and Adolescent Health

 

Ambulatory sensitive asthma hospitalizations

 

During FY21, the Title V Program conducted an analysis on ambulatory care sensitive asthma hospitalizations among children. Working in conjunction with the IDPH Asthma Program, Title V epidemiologists analyzed hospital discharge data for the period 2016-2019 and identified pediatric asthma hospitalizations that met the Agency for Healthcare Research and Quality prevention quality indicator definition. Title V staff reached out to neighboring states and received data on Illinois residents hospitalized in out-of-state facilities, addressing a bias in underreporting of hospitalizations in border communities. Hospitalizations rates were analyzed by child age, race/ethnicity, and primary payer to identify socioeconomic disparities in burden. The analysis demonstrated that young children, children with Medicaid insurance, and children of color had substantially higher rates of ambulatory sensitive asthma hospitalizations than older children, children with private insurance, and non-Hispanic White children.

 

Working with the department’s social epidemiologist, hospitalization rates were mapped by county for the whole state. Cook County and the St. Louis metropolitan area had the highest rates of hospitalization and were mapped by census tract, with childhood poverty. This demonstrated the strong relationship between childhood poverty and ambulatory sensitive asthma hospitalizations.

 

Youth suicide

 

Youth suicide and suicidal behavior remain top priorities for the Title V program. During FY21, Title V completed an analysis of suicidal behavior and mortality, led by the program’s CSTE Applied Epidemiology Fellow. This report included trends in suicidal behavior among Illinois adolescents, including suicidal ideation and attempt, from the Youth Risk Behavior Survey. Data from 2017-2019 were analyzed and the report included many risk factors for adolescent suicide, including violence victimization, physical activity, and substance use.

 

In addition to data on risk factors and behaviors, data on adolescent suicide mortality from 2010-2020 were analyzed and included in the report. Deaths were analyzed by youth age, sex, race/ethnicity, and urbanicity. The report demonstrated that suicide death is either steady or increasing in every group studied. Of particular importance, suicide deaths are increasing significantly among female, urban, and youth of color, groups traditionally considered to be lower risk for death from suicide.

This report was shared with many stakeholders and partners. The program used the report to author a public-facing infographic that was shared widely.

 

Children and Youth with Special Health Care Needs

 

During spring 2021, two separate focus groups were conducted for caregivers of children with medical complexity to learn more about the supports and challenges caregivers have. This information was used to validate a policy analysis project. The policy analysis was shared with Medicaid in June 2021. The timing of this worked well as in the summer of 2021 states were notified of an opportunity for increased Federal Medical Assistance Percentage (FMAP) for initiatives to improve, to enhance, or to expand care provided through Home and Community Based Waivers as part of the American Rescue Act. The main recommendation of the policy analysis was to expand consumer direction for individuals receiving in-home shift-based nursing care enabling families to consider unlicensed care as they preferred. Medicaid agreed for this expanded consumer direction to be an FMAP initiative in Illinois for the Medically Fragile Technology Dependent Waiver population and also agreed to include the population of individuals under the age of 21 who receive in-home shift-based nursing care as an Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit of Medicaid. Federal CMS approval for Illinois’ proposed FMAP initiatives came in the fall of 2021. UIC-DSCC is currently partnering with Medicaid to implement this caregiver expansion. The findings and lessons learned through the focus group discussions was written into a manuscript that has been accepted for publication by Home Healthcare Now and will be published in summer 2022.

 

Changes in Title V Capacity/Structure

 

During FY21, Illinois hired two new full-time epidemiologists to support the Title V program: one for maternal and infant health and one for child and adolescent health. This brings the total number of state MCH epidemiologist positions to three full-time equivalents (FTE) (up from 1 FTE) and the addition of these permanent state positions is key for developing sustainable epidemiologic capacity in support of the Title V program. By increasing the intern epidemiology capacity, Title V has been able to increase its ongoing needs assessment activities and will be well positioned for the next five-year Title V needs assessment. More information about the MCH Epidemiology workforce is available in section III.E.2.b.iii.a.

 

Emerging Public Health Issues and Future Needs Assessment Activities

 

Emerging Issues in Maternal and Infant Health

 

During 2022, there are plans to continue work to assess the needs of Illinois’ birthing persons and infants, and to understand the capacity of the regionalized perinatal system. Data is being collected from birthing hospitals to understand volumes of neonatal surgeries performed and the volumes of neonatal patients transported out due to surgical needs. These data will be used both for regulation of birthing hospitals under the current system, as well as inform the revisions to the perinatal code with respect to neonatal surgery. A new project order is planned with the UIC School of Public Health for assistance with economic analyses related to the perinatal system. These analyses will focus on assessing the availability of maternal care and potential barriers to accessing maternal care, including local geographic provider shortages and the configuration of Illinois regional perinatal networks. This work will contribute to a deeper understanding of maternity care shortage areas and how maternal and infant outcomes may be affected by such shortages.

 

Furthermore, IDPH was selected to participate in the Association of State and Territorial Health Officers (ASTHO) Data Roadmap for Racial Equity Advancement in Maternal and Child Health (DREAM) learning community (March 2022-February 2023). The aim of this learning community is to build programmatic and epidemiologic workforce capacity and inform data strategies promoting racial equity in maternal and child health across the lifespan. The interdisciplinary IDPH team will pilot the use of the Racial Equity Data Road Map to assess the Regionalized Perinatal Health Care Program in the Chicago metropolitan area, which includes 50 obstetric hospitals. These hospitals deliver 67% of total births to Illinois residents, 71% of births to Black Illinois residents, and 87% of births to Hispanic Illinois residents. By examining the data in a new way, Title V program needs, and policy changes may be identified that are necessary to support health equity. The benefits of this learning collaborative will go beyond the perinatal programs. Participation will build capacity among the IDPH team to apply a health equity framework to its total portfolio of programs and initiatives across the state.

 

To inform the revisions to the administrative code for the regionalized perinatal hospital system, Illinois Title V plans to implement the Levels of Care Assessment Tool (LOCATe) for the second time later in late 2022. LOCATe is a tool developed by CDC that surveys hospitals about personnel, resources, and policies, and assigns expected levels of maternal and neonatal levels of care, based on guidance from the American College of Obstetrics and Gynecology/ Society for Maternal-Fetal Medicine and the American Academy of Pediatrics. Illinois previously implemented LOCATe during 2015-2016 and the data from that assessment were critical in leading the state to decide to revise the perinatal hospital code. The updated version of the assessment will be edited to include additional survey questions specific relevant policy and systems issues in Illinois. The findings from this assessment will be shared with the state Perinatal Advisory Committee, levels of care workgroups, and other relevant stakeholders involved in the regionalized perinatal system.

 

The Illinois MMRCs are currently reviewing deaths that occurred during 2020. In these reviews, the MMRCs will consider the contributing role of infection with the SARS-CoV-2 virus and the indirect effects of the broader COVID-19 pandemic. For maternal deaths where COVID-19 played a role, additional experts with specialized skills and knowledge of critical care and respiratory disease will participate in the reviews. For all deaths occurring during 2020 and 2021, it is even more important to discuss the social determinants of health that impacted each woman’s death – such as access to care, finances, employment, and social support – and how these factors were affected by the societal changes brought on by the pandemic. Illinois has been participating in a CDC workgroup to establish best practices for abstracting and assessing the impact of these factors during the COVID-19 pandemic.

 

Since June 2020, the Illinois MMRC’s have participated as one of two states piloting the use of a “community vital signs dashboard” during case review. These dashboards, which were developed by Emory University in partnership with CDC, provide various community-level indicators to describe the social/community context of a woman’s neighborhood and county. These dashboards have increased conversation around social determinants of health and community-level factors contributing to the death. The data included in the dashboards also allow for analysis of the indicators and their contribution to pregnancy-associated and pregnancy-related deaths. Incorporating social-contextual determinants of health into Illinois’ aggregate reporting of maternal deaths is important for improving maternal death reviews and helping the MMRCs move beyond identification of only provider and hospital factors and recommendations. In the coming year, Title V epidemiology staff will develop a plan for incorporating community-level data into the aggregate analyses for pregnancy-associated and pregnancy-related deaths. We will also develop visualizations and strategies for incorporating these findings into the next state Maternal Morbidity and Mortality Report.

 

Emerging Issues in Child and Adolescent Health

 

Title V remains dedicated to the mental health of children and adolescents. The COVID-19 pandemic has been challenging for young people and there have been national published reports of an increase in emergency department and inpatient care for mental health conditions among children and adolescents. During FY23, the Title V Program will conduct an analysis on children and youth in Illinois who seek care for mental and behavioral health conditions in hospital emergency departments and inpatient units. The analyses will examine hospital encounters by patient age, race, sex, and region of the state. The role of accessibility of outpatient care will be examined and racial/ethnic and social disparities will be identified. A final report will be distributed to partners working in pediatric mental and behavioral health care and shared with stakeholder groups.

 

Emerging Issues for Children and Youth with Special Health Care Needs

 

During summer 2022, UIC-DSCC will host two Title V interns to conduct assessments of how social determinants of health affect families of children and youth with special health care needs. They will use various existing data sources, such as the National Survey of Children’s Health and data from PowerBI reports, as well as collecting data through interviews with key informants. UIC-DSCC then plans to evaluate if certain care coordination interventions or other resource provisions can lead to improvements in care.

 

Changes in Title V Measurement

 

Each year, the MCH epidemiology team reviews Illinois’ selected NPM, SOM, SPM, and ESM to ensure alignment with the current MCH action plan. There are several goals in this annual review:

1. Ensure that selected measures match the overall priority areas of the Title V program,
2. Ensure that all strategies in the action plan are related to at least one of the NPM or SPM,
3. Consider revisions to any state-developed measures (SOM, SPM, and ESM) that might improve measurement, definitions, or clarity, and
4. Consider new or evolving strategies in the state’s MCH action plan that would be good candidates for development of an ESM.

 

While most years this results in no changes to the Title V measures used by Illinois Title V, there are several changes that are being made this year.

 

First, Illinois Title V has opted to add the selection of an additional NPM in the perinatal/infant health domain: Safe Sleep (NPM #5) because the Illinois Title V program recognizes our need to address Sudden Unexpected Infant Deaths (SUID) as a leading contributor to racial inequities in infant mortality. During 2020, compared to white infants, black infants were 2.7 times as likely to die during the first year of life, but 3.8 times as likely to die from Sudden Unexpected Infant Death (SUID). A perinatal periods of risk analysis in the state’s infant mortality data report published in December 2020 showed that focusing on reducing SUID among Black infants could promote equity in infant mortality. Therefore, the Illinois Title V program will fund new infant safe sleep strategies in the coming years and adding NPM #5 enables us to track this topic over time. An ESM related to NPM #5 will be developed next year once the strategies for the MCH action plan have been finalized.

 

Secondly, based on feedback provided by the MCH Evidence Center at Georgetown University, the MCH epidemiology team critically reviewed all existing ESMs to identify ways to improve existing measures and consider new measures. Discussions included review of:

• Strategies in the Illinois MCH action plan,
• Evidence-based strategies related to each NPM (from MCHBest website)
• Available data sources or potential new data collection mechanisms,
• Timeline on which we would expect to see reasonable changes

 

After careful consideration, Illinois has opted to add three new ESMs to our measurement framework for this year:

 

• ESM 4.2 = percent of Illinois birthing hospitals that are Baby-Friendly.
  • Rationale: ESM 4.1 measures reach of Baby-Friendly hospitals into the birthing population but is more an outcome of the breastfeeding systems support work. The new ESM 4.2 will provide a more direct measure of an output of work to support improved breastfeeding practices in hospitals.

 

• ESM 13.1.2 = Number of WIC staff trained on oral health
  • Rationale: We recognized that our existing oral health ESMs were measures of mid- to long-term change. We wanted to develop a process measure to directly describe an activity/output of our state strategies. After reviewing our Oral Health Section’s detail report on activities and the evidence around various strategies, we decided to capture WIC staff trained on oral health issues.

 

• ESM 13.2.2 = Number of school-based health centers providing dental services onsite.
  • Rationale: We recognized that our existing oral health ESMs were measures of mid- to long-term change. We wanted to develop a process measure to directly describe an activity/output of our state strategies. After reviewing our Oral Health Section’s detail report on activities and the evidence around various strategies, we decided to capture the number of school-based health centers providing dental services onsite.

 

Next year, we will finalize the development of ESM 5.1 related to the new safe sleep strategies, as well as re-review the relevance of all state-selected measures.