Needs Assessment Update

Title V MCH utilizes national and state data to update the needs of Nevada’s MCH populations. Federal data sources include:

• National Vital Statistics System (NVSS)
• National Survey on Children’s Health (NSCH)
• Behavioral Risk Factor Surveillance System (BRFSS)
• American Community Survey (ACS)
• Youth Risk Behavioral Survey (YRBS)
• National Survey on Drug Use and Health (NSDUH)
• Pregnancy Risk Assessment Monitoring System (PRAMS)
• Early Hearing Detection and Intervention (EHDI)

State data sources include the Division of Health Care Financing and Policy Medicaid data, the Office of Analytics, the Office of Vital Records, hospital inpatient data, and the Nevada Report Card published by Nevada Department of Education (NDE) and the Nevada Rural and Frontier Data Book published by the University of Nevada, Reno, School of Medicine. Federally Available Data (FAD) and MIECHV federal data are also integrated into ongoing needs assessment activities.

The Title V MCH Program and State Systems Development Initiative (SSDI) managers met weekly to discuss the Title V Block Grant report and application. Discussions included updates to the 5-Year Needs Assessment and staff review of current priorities and performance measures and comparing them to the needs indicated by Needs Assessment and to state and federal data indicators.

The MCH Epidemiologist created a Power BI Data Dashboard which publicly displays Title V FAD at the following link https://dpbh.nv.gov/Programs/TitleV/MCAH-Data-and-Publications/. The dashboard includes Nevada trends, comparisons to national benchmarks, and breakouts by indicators such as race and ethnicity and urban-rural residence for all Title V MCH NPMs and NOMs. The dashboard is updated annually and is shared with partners to keep them engaged with MCH state performance.

The Nevada Critical Congenital Heart Disease (CCHD) Registry is maintained by the CYSHCN coordinator, and reports are published annually to monitor state performance. CCHD Report 2020

A survey is sent to statewide partners and is open to the public to assess the ongoing needs or changes in priorities from a community engagement perspective. CYSHCN partners serving families are engaged in this process. Feedback is also received through quarterly MCHAB meetings where updates on Title V MCH activities are widely shared and discussed in a public context. Ongoing performance monitoring and evaluating activities occurs in monthly check in calls and quarterly reports from each subawardee of Title V MCH funds. The results of this statewide public input survey are noted within each population domain.

Title V MCH Program staff worked with the University of Nevada, Las Vegas (UNLV), Nevada Institute for Children, Research, and Policy (NICRP) to assess current prenatal care systems in Nevada. This gaps analysis utilized data sources from federal and state government agencies as well as national organizations with data related to accessing prenatal care in tandem with parent interviews of pregnant persons or those who had been pregnant within the past 12 months.

COVID-19 impacted the state’s MCH population in many ways, and the overall changes in the health status and needs of the Nevada MCH population compared to the identified needs for the Title V MCH Block Grant are shown below:

Women/Maternal Health

• More than one (1) in six (6) women in Nevada (17.7%), ages 19-44 years, are uninsured (higher than the United States at 15%), according to the 2019 ACS.
• Across all MCH populations, a higher percentage of Hispanic women and children are uninsured compared to other race/ethnicity groups, according to the 2019 ACS.
• Single parents experience the highest poverty rates, at more than twice the rate of two-parent households, according to the 2019 ACS.
• Single parents of children younger than five (5) years are most likely to be economically marginalized.
• The percent of people in Nevada who receive prenatal care beginning in the first trimester has increased by 18.7% (from 65.9% to 78.2%) during the period of 2010 to 2020, according to NVSS data. College graduates and those with some college are more likely to receive prenatal care than high school graduates and those with less than high school education.
• In the public input survey, the top three most important health problems/health issues for women of reproductive age in the community where they live are: mental health (74%), domestic or intimate partner violence (29%), and illicit substance use (25%).
• In the public input survey, the top three most important health problems/health issues for pregnant and post-partum women in the community where they live are: mental health (64%), postnatal care (34%), and breastfeeding support (27%).

Perinatal/Infant Health

• Nevada’s rate of sleep-related sudden unexpected infant death (SUID) reached a high in 2018 of 142.9 deaths per 100,000 live births, a 53.5% increase from 2009. This rate decreased slightly to 136.9 in 2019. Rates disproportionately affect Black or African American infants with 251. White infants had a rate of 123.7, and Hispanic infants had the lowest rate at 62.9 according to NVSS 2017-2019 data.
• Nevada’s infant mortality rate has shown a slight decrease since 2009, decreasing from 5.8 deaths per 1,000 live births to a rate of 5.7 in 2019. Black infants and American Indian/Alaska Native have disproportionately higher rates, with 9.4 and 9.6, respectively. White and Hispanic infants had the lowest rates, at 5.2 and 5.1 respectively, according to NVSS 2017-2019 data.
• The Health Care Cost and Utilization Project-State Inpatient Database indicates the rate of infants born in Nevada with neonatal abstinence syndrome (NAS) has increased 263% from 2008 to 2019, from 1.6 per 1,000 birth hospitalizations to 5.8. Nevada has recently shown significant improvement; however, as the rate decreased 33% from a high of 8.6 in 2018 to 5.8 in 2019. The rate is highest amongst White infants (8.5), with the lowest rates among Hispanic infants (2.7) in 2019.
• In the public input survey, the top three most important health problems/health issues for newborns and infants in the community where they live are: child abuse and neglect (38%) maternal substance use during or after pregnancy (37%), and not receiving developmental screenings (33%).

Child Health

• According to the 2019-2020 NSCH, while insurance rates are generally high among children, access to consistent and adequate health insurance coverage is lower in Nevada (61.4%) compared to the United States (66.7%).
• The State of Nevada, Division of Child and Family Services 2017 Statewide Child Death Report indicates there is a racial and ethnic disparity among statewide child deaths of all causes, as Black or African American child deaths (ages 0 to 17 years) are disproportionately higher at 22.7 percent versus their population distribution in Nevada (10%).
• More children in Nevada (19%), compared to children nationwide (18.7%), have ever experienced two (2) or more Adverse Childhood Experiences (ACEs) according to the 2019 NSCH.
• In the public input survey, the top three most important health problems/health issues for young children (one to five years old) in the community where they live are: access to affordable childcare and/or pre-school (71%), poor eating habits (31%), and child abuse/neglect (29%).
• In the public input survey, the top three most important health problems/health issues for children (six to 11 years old) in the community where they live are: overuse of technology/excessive screen time (57%), mental health (38%), and physical activity (36%).

Adolescent Health

• Lesbian, Gay, and Bisexual (LGB) youth experience high levels of bullying and violence, homelessness, fear, and mental health issues compared to their heterosexual peers, according to the 2019 Nevada Youth Risk Behavior Survey (YRBS): Sexual Identity Special Report.
• Nevada ranks 31st among states for 2020 teen birth rate according to the NVSS. Nevada’s teen birth rate has decreased by 62% since 2009. Black or African American teens continue to experience the highest teen birth rates in Nevada, at 30.9 per 1,000 girls ages 15 to 19 years.
• Data from the NVSS shows the adolescent suicide rate in Nevada (15.1 per 100,000) is significantly higher than the national average (10.8 per 100,000) for 2018-2020. Nevada’s rate has increased by 132% since 2007.
• In the public input survey, the top three most important health problems/health issues for adolescents (12 to 21 years old) in the community where they live are: mental health (73%), lack of skills needed during adolescence and to transition into adulthood (56%), and excessive use/inappropriate use of social media (33%).

Children and Youth with Special Health Care Needs

• Access to a medical home occurs for only about one-third of Nevada’s children (35.2%), according to data from the 2019-2020 NSCH. This is significantly lower than the national average of 47.9%. Among CYSHCN, the Nevada percentage is slightly higher (38.4%), but lower than the United States average (42.2%).
• According to NSCH data, 2.6% of children in Nevada ages 3 through 17 were diagnosed with an autism spectrum disorder in 2019-2020, compared to 2.9% nationally.
• Data from the NSCH shows 40.2% of children in Nevada ages 3 through 17 with a mental or behavioral condition received treatment or counseling in 2019-2020, a 17% increase from 2016. This is below the national average of 52.3%.
• In the public input survey, the top three most important health problems/health issues for children and youth with special healthcare needs (birth to 21 years old) in the community where they live are: lack of adequate access to specialty medical care (60%), navigation of the system of care for CYSHCN (51%), and lack of skills needed during adolescence and to transition into adulthood (27%).

Cross-Cutting

• Language and insurance status (i.e., uninsured or Medicaid) are shared risk factors across MCH population groups regarding access to services and are reported to be a common reason why people report experiencing unequal treatment in receiving services.
• Substance use was a concern among adolescents, pregnant, and one-year postpartum people.
• Alcohol and marijuana were the most reported substances used during pregnancy among Nevada birthing people, with marijuana surpassing alcohol use in 2015 (5.3 and 5.0, respectively, per 1,000 live births) and sharply increasing in 2018 (13.7 and 4.2, respectively) according to the 2019 Nevada Substance Abuse Prevention Treatment Agency (SAPTA) Epidemiologic profile.

Access to Services

Access to services is a significant barrier to health and wellbeing, with community members reporting lack of providers, needed services offered by a local provider, and physical access to providers as key barriers. Community members, MCH professionals, and service providers identified the same set of resources needing improvement (or those services not available, accessible, affordable, and/or high quality) in their community to benefit MCH population groups: mental health services, childcare options, housing, health care options, and jobs with livable wages.

The barriers are particularly prevalent in rural and frontier communities. Only 5.3% of health care and social assistance employees in Nevada live in rural and frontier counties (despite 9.5% of Nevada’s population living in these areas). Overall, more than two-thirds of Nevada’s population live in a federally designated primary medical care health professional shortage area (HPSA). The proportion of populations who reside in dental and mental health care HPSAs is even larger with almost 100% of the population in all rural and frontier counties living in a mental health HPSA.

Protective factors for adverse health outcomes for MCH population groups are less prevalent in Nevada. For example:

• Nevada ranks 28th nationwide for percent of children who live in a home where the family demonstrates qualities of resilience during difficult times, using data from the 2019 NSCH.
• Using ACS data, one (1) in ten (10) youth (ages 16 to 19 years) are disconnected in Nevada (defined by neither working nor in school), putting them at greater risk of increased violent behavior, smoking, alcohol consumption and marijuana use, and emotional and cognitive deficits than their peers who are working and/or in school.
• The percent of parents who report feeling their child definitely lived in a safe neighborhood was lower in Nevada (46.7%) compared to parents across the United States (63.9%), according to the 2019 NSCH. The percent reporting their child is definitely safe at school was also lower (52.9% vs 70.1%).
• 2019 KidsCount data shows more children in Nevada ages three (3) to four (4) years are not enrolled in school (62%), including preschool or pre-kindergarten, than in the United States (52% not enrolled); this is most prevalent among children who are low-income (70%) and children who are Hispanic (72%).

Funding for public health is an indicator of the resources available to improve population health. Nevada is identified as the least healthy state when considering the amount of public health funding available relative to other states, including both state dollars dedicated to public health and federal dollars directed to states by the CDC and HRSA. Per-capita public health funding is $72 in Nevada, lower than the United States per-capita average of $116, according to Trust for America’s Health.

The Nevada Title V MCH Program will continue collaborations with public and private partners to improve the health of the Nevada MCH populations in areas of need identified by state data, FAD, and Needs Assessment feedback. The 5-Year Needs Assessment and state and federal data informed the state priorities, objectives, and strategies for the State Action Plan.

Noted Changes to Title V Program Capacity

Nevada Maternal, Child and Adolescent Health (MCAH) Section has experienced changes in the MCH Program Unit. The CYSHCN Coordinator position was vacant from December of 2020 and filled in February of 2022 by Cassius Adams. The position was formerly a contract position, but the most recent legislative session approved the request to make the position a state line employee. During the position vacancy in the reporting period, other staff members maintained the program and the CYSHCN Director continued to address all CYSHCN constituent calls and ensured all activities of the CYSHCN Coordinator were maintained. The MCH Epidemiologist updated the Medical Home Portal and CCHD database. The CYSHCN Director embedded CYSHCN populations in the HRSA funded AMCHP Telehealth grant received by MCAH to help support access to care. Sickle cell focused immunization supports and materials, sexual assault prevention among children with developmental and intellectual disabilities, and access to accessible parks statewide all came from novel CYSHCN-focused partnerships.

Title V Program Partnerships, Collaboration and Coordination

The Title V MCH Program collaborates with a network of partners, collaborators, and agencies to support a systems-based model of delivering public health and enabling services to Nevada’s MCH populations. Partnerships include the local Family to Family Health Information Center – Family Navigation Network, state agencies, Local Health Authorities (LHAs), the Nevada System of Higher Education (NSHE), non-profit organizations, MCH Coalitions, community partners, and advocacy groups.

DHHS formed an Office of Analytics under the Director’s Office to consolidate data capacity and facilitate cross training and data analytics support. Title V MCH continues to fund a MCH Biostatistician and Health Resource Analyst (HRA) and MCAH has two HRA positions located in the Office of Analytics working with Early Hearing Detection (EHDI) and Nevada Home Visiting data (NHV/MIECHV). These positions are crucial in increasing MCH data support and analytics capacity, accessing primary data and generating analyses and reports on behalf of MCAH and Title V MCH, in addition to the work of the MCH Epidemiologist and SSDI Manager. Title V MCH continues to integrate with SSDI; MCAH created a PRAMS, SSDI, MCH Epidemiology organizational unit to foster cross-training and data supports. The MCAH Section Manager and Office of Analytics Manager meet regularly with staff in relation to MCAH data needs.

SSDI enhances Nevada Title V MCH data capacity to allow for informed decision making and resource allocation supporting effective, efficient, and quality programming. The MCH Program plans to improve evaluation activities around NPMs. MCAH PRAMS, MMRC and AIM efforts support enhanced surveillance capabilities benefitting the MCH Program.

Other programs who partner to promote Title V MCH priorities in Nevada include: the Office of Analytics, Nevada Home Visiting, EHDI, TPP, Nevada Governor's Council on Developmental Disabilities, Individuals with Disabilities Education Act (IDEA) Part C Office, Nevada Early Intervention Services (NEIS), the Nevada Office of Minority Health and Equity (NOMHE), Primary Care Office (PCO), Oral Health, Community Health Services, Account for Family Planning, Office of Vital Records, Aging and Disability Services Division (ADSD), PCO, OSP, Office of Public Health Investigations and Epidemiology (OPHIE), SAPTA, the Division of Child and Family Services (DCFS), Chronic Disease Prevention and Health Promotion (CDPHP), Women, Infants, and Children (WIC) and the Immunization Program (IZ).

The Children’s Health Insurance Program (CHIP) provides coverage to low- and moderate-income children. Nevada Medicaid is administered through the Division of Health Care Financing and Policy (DHCFP), with enrollment administered by the Division of Welfare and Supportive Services (DWSS) for Nevada Check Up, Nevada’s Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) Program and Medicaid. Both Fee for Service (FFS) and Managed Care Organizations (MCOs) operate in the state. Rural areas are served by FFS providers and the urban areas of Clark and Washoe counties are served by contracted MCO providers. Tribal members can choose FFS or MCOs in urban or rural areas.

DHHS and DBPH partner with 27 Tribes across Nevada through a Tribal Consultation Process Agreement to strengthen ties with Tribal Governments. The Regional Emergency Medical Services Authority (REMSA), a Title V MCH partner, is funded by MCH to distribute car seats and provides safe sleep education and injury prevention information as part of the MCH injury prevention pilot developed with key staff at participating Tribal Nations.

Title V MCH partners with WIC, MCH statewide coalitions, breastfeeding coalitions, community-based programs, LHAs, the public, and private partners to increase breastfeeding rates by improved access to breastfeeding supports for new mothers. Breastfeeding campaigns and an MCH-administered website increase awareness, promote breastfeeding services, and normalize breastfeeding in public locations in partnership with WIC staff.

Title V MCH funds the Nevada Institute for Children’s Research and Policy (NICRP) to conduct an annual health survey of children entering kindergarten, in partnership with all school districts.

Other state and local public and private organizations funded by MCH include Children’s Cabinet, Washoe County Health District Fetal Infant Mortality Review (FIMR), University of Utah Medical Home Portal, Nevada 211, REMSA, Immunize Nevada, Nevada Broadcasters Association, Urban Lotus, and Statewide MCH Coalitions. Information and materials disseminated by these partners are required to be culturally appropriate. Internal translation support is provided by MCAH staff members. Children’s Cabinet TACSEI provides technical assistance and facilitates parent involvement in social emotional Pyramid Model activities.

Money Management/Nevada 211 provides information and referral via www.nv211.org, a toll-free phone number, text support, as well as hosting the Title V MCH toll free line, supporting the MHP resource sections, and educating people on the priority status of pregnant persons at SAPTA funded treatment centers. Urban Lotus provides trauma-informed yoga to disproportionately affected youth. REMSA, in addition to distributing car seats, provides safe sleep media outreach, and distributes Infant Safe Sleep Survival Kits to families experiencing disadvantage statewide via partners.

Immunize Nevada supports training/workforce development, including the statewide Nevada Health Conference with trainings to build topical MCH knowledge. Nevada Broadcasters Association is funded to promote Safe Sleep, PRAMS, and Sober Moms Healthy Babies PSAs. DP Video is funded to promote transition to adult health care and Medical Home Portal social media campaigns. The Statewide MCH Coalition is funded to support website maintenance, communication, maternal mental health and other MCH trainings, promote Go Before You Show campaign, and plan conferences for meeting community needs of diverse populations and focusing on specific MCH NPMs.

Efforts to Operationalize the Five-Year Needs Assessment

Efforts to operationalize the Nevada 5-Year Needs Assessment include the addition of NPM 5 and NPM 12. NPM 5 includes three parts: A) Percent of infants placed to sleep on their backs B) Percent of infants placed to sleep on a separate approved sleep surface C) Percent of infants placed to sleep without soft objects or loose bedding. PRAMS data is used for ESM 5.1 to monitor safe sleep efforts. The needs assessment and FAD indicated safe sleep as a priority. Title V MCH efforts to increase the percentages of infants placed in a safe sleep environment include the Cribs for Kids Program through the Regional Emergency Medical Services Authority (REMSA), statewide PSAs on radio and television, all coalitions and funded partners being required to promote safe sleep as a condition of funding, active participation in social media awareness of safe sleep in partnership with DCFS on DHHS platforms, FIMR support and MCH staff service in reviews and data to action efforts, joint efforts with the Executive Committee of the Statewide Child Fatality Review, and social media efforts with partners on safe sleep.

NPM 12, Percent of adolescents with and without special health care needs, ages 12 through 17, who received services to prepare for the transition to adult health care, was added due to the needs assessment. Efforts to increase the percentages include partnering with the Nevada Center for Excellence in Disabilities (NCED) for transition activities.

Ongoing activities with partners supported NPMs being retained due to the most recent needs assessment. Special attention to areas of disconnect between provider rankings and those of the public and CBOs is an area of particular interest with the 5-year needs assessment results. Promoting use of the needs assessment by partners and to help secure other funding has helped inform numerous grant applications. The needs assessment was made publicly available and shared with numerous partners statewide as a resource.

Nevada implemented several innovative projects to build childhood resiliency and reduce suicide rates. State agencies, including the Department of Health and Human Services (DHHS), Division of Public and Behavioral Health (DPBH), Division of Child and Family Services (DCFS), and Nevada Department of Education (NDE) have taken leadership roles in ensuring Nevada’s children are equipped with necessary skills. Furthermore, school districts have bolstered messaging in their local communities, informing schoolchildren and their families how to access resources for assistance.

Organizational Structure

DPBH is led by Administrator Lisa Sherych and organized into four (4) branches: Administrative Services; Clinical Services; Community Services; and Regulatory and Planning Services. Within Community Services, led by Deputy Administrator Julia Peek, MHA, CPM, is the Bureau of Child, Family, and Community Wellness (CFCW), led by Bureau Chief Kyle Devine, MSW and Deputy Bureau Chief Vickie Ives, MA. The MCAH Section is led by Tami Conn, and the MCH Director and CYSHCN Director is Vickie Ives, MA. The MCAH mission is to improve the health and wellbeing of Nevada's pregnant persons, women of childbearing age, infants, children, and youth, including CYSHCN, and their families to protect and advance health, safety, and quality of life through the development of partnerships, education, health promotion, and disease and injury prevention. MCAH staff understand active engagement of families, caregivers, and communities are integral to positively impacting the health of MCH populations.

Title V MCH staff collaborate with other sections and programs within DPBH, other state agencies within DHHS, NDE, ADSD, DHCFP, DCFS, and the Department of Taxation.

Emerging Public Health Issues

COVID-19

The Nevada Health Response Center, Nevada DPBH, and the CDC are closely monitoring the outbreak of the respiratory illness caused by the 2019 novel coronavirus (COVID-19). DPBH Technical Bulletins and DHHS efforts inform the state COVID-19 information hub at https://nvhealthresponse.nv.gov/ and MCH is posting MCH resources on the program website. The latest Nevada COVID-19 statistics and response efforts are also located at the website and kept updated through the efforts of the DHHS Office of Analytics and DPBH OPHIE office. LHAs, including Southern Nevada Health District (SNHD), Washoe County Health District (WCHD), and Carson City Health and Human Services (CCHHS) are key responders monitoring and providing information related to COVID-19. Clear masks were provided by MCH to schools statewide to support those who are living with deafness or hard of hearing and the Nevada Telehealth Project was done in response to COVID-19 related needs, as were numerous CARES related funding enabled projects in the MCAH Section.

Congenital Syphilis

In 2018, Nevada was the top ranked state for primary and secondary syphilis rates and ranked second for congenital syphilis (CS) rates. In 2019, Nevada remained the top ranked state for primary and secondary syphilis rates, while falling to fourth for CS rates. In 2020, these rankings remained the same. According to the CDC, Nevada’s primary and secondary syphilis rates have been increasing since 2012, from 4.1 to 26.6 per 100,000 persons in 2019. In 2020, the rate decreased slightly to 24.9 per 100,000. With this increase of syphilis cases comes a rise in congenital syphilis. According to CDC, CS rates in Nevada have been rising since 2012, from 2.9 to 131.2 per 100,000 in 2020, a 4424% increase. MCAH staff are key members of the CS Workgroup for Nevada and have been instrumental in CS prevention informational campaign development and resource distribution including specialized training and resources for all home visiting LIAs.

Substance Use During Pregnancy and Substance Exposed Infants

Close monitoring of substance use during pregnancy and substance exposed infants is a continuing priority for DPBH and Nevada’s Title V MCH Program. According to NVSS, the percent of women who smoked during pregnancy was 3.6% in 2020; a decrease from 5.4% in 2010, or a change of 33.3%. NVSS data also reflects a modest decline in the use of substances during pregnancy, as the percentage of women who reported smoking, alcohol use, and/or drug use decreased from 5.5% in 2016 to 5.3% in 2019. MCAH will continue to work on state efforts regarding CARA and the Infant Plan of Safe Care including education, training, OMNI/Perinatal Health Initiative work group participation, and increasing awareness. Nevada PRAMS staff make inquiries about substance use before, during, and after pregnancy and provide self-reported data in addition to vital statistics and hospital inpatient data to inform Title V MCH efforts/activities. To enhance other substance use prevention efforts, PRAMS data was presented to both the OMNI and Promoting Innovation in State/Territorial Maternal and Child Health Policymaking (PRISM) learning communities.

Title V MCH Program staff are core members of the Nevada ASTHO OMNI NAS-related efforts in Nevada and participate in the AMCHP PRISM efforts. MCH funds will support Infant Plan of Care material translation and distribution and the MCH Director will present on CARA referral pathways at a Project ECHO webinar in August 2021 and co-presented at the Nevada Health Conference in March 2021 on Infant Plans of Care.

Maternal Mortality Review Committee (MMRC) and Alliance for Innovation on Maternal Health (AIM) Efforts

Reporting produced by MMRC support staff is included in Nevada’s Title V MCH Block Grant reporting, and health equity in birth outcomes and maternal domain population health maximization are key areas of topical intersect in priorities of the MMRC, MCAH Section, SSDI Program, and Title V MCH Program. SSDI funds help support a part-time RN Case Abstractor. Nevada’s MMRC Applied for the Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) grant in 2019 and was approved but not funded. In July 2021, the program was notified the prior application was now funded and funding began September 2021. This funding allows for the addition of one full-time RN case abstractor.

The Title V MCH Program is in discussion with the Nevada Rural Hospital Partnership to launch Advanced Life Support in Obstetrics (ALSO), American College of Obstetricians and Gynecologists (ACOG) efforts to reduce rural maternal mortality by working with critical access hospitals. Nevada is an Alliance for Innovation on Maternal Health (AIM) State, which will help staff support activities reducing preventable maternal mortality and severe maternal morbidity, beginning with the hypertension patient safety bundle. The Nevada AIM Kick-off was June 24, 2021, with bundle implementation planned for fall 2022.