Needs Assessment Update

Summary

The District of Columbia (DC) Department of Health (DC Health) conducted the DC Title V Needs Assessment from February 2019 to March 2020 assessing the needs and strengths of its MCH population and infrastructure. The purpose of the Needs Assessment was to: 1) better understand the current health status of the District’s MCH populations; 2) ascertain current MCH needs through qualitative and quantitative methods; and 3) utilize the findings and Title V National Performance Measure System to identify top District priorities and determine allocation of resources and strategies that would improve the health and wellbeing of each of the District's five MCH population health domains -women, infants, children, including children with special health care needs, and adolescents. Using a mixed methods approach (qualitative/quantitative), the capacity, accessibility, and quality of delivery of services for DC’s MCH populations was assessed. DC Title V received ongoing stakeholder feedback through both formal and informal channels. The team engaged the MCH Advisory Council comprised of representatives from government agencies, consumers and health care, and community-based organizations at the beginning of the needs assessment. Council members participated in key informant interviews where they provided input on unmet needs, systematic factors impacting the District’s MCH population, and positive protective factors that strengthened their health. The team also conducted a community Discovery Survey to collect the public’s perspective on MCH topics, and a focus group with the Youth Advisory Council to solicit input and gain insight from middle and high school student representatives.

Partnerships and collaborations

The findings from the Needs Assessment highlight the importance of continuing collaborations and coordination with agencies that serve to improve outcomes within the MCH population. Title V team engages with both internal and external stakeholders representing the various MCH population domains through a variety of committees and working groups highlighted throughout this application. Title V, through its partnership with the Office of the State Superintendent (OSSE) Division of Early Learning (DEL), works to implement the Strong Start Early Intervention Program (Strong Start) - a statewide, comprehensive, coordinated, multidisciplinary system that provides early intervention therapeutic and other services for children ages0-5 with disabilities and developmental delays and their families. Title V additionally provides oversight of the HelpMe Grow (HMG) program. HMG provides services to District residents through a comprehensive and integrated system designed to address the need for early identification of children at risk for developmental and/or behavioral problems and to prenatal women. Title V funded the Office of Human Rights (OHR) to develop and complete a curriculum (El Camino Program) targeting bullying and help middle school students learn how to use technology and social media in a healthy and supportive way. DC Health’s Community Health Administration (CHA) actively participates with several District wide MCH collaborative groups, including the State Early Childhood Development and Coordinating Council, Child Fatality Review Committee (CFRC) and Infant Mortality Review subcommittee, Department of Health Care Finance Perinatal Quality Improvement Collaborative, the Thrive by Five Coordinating Council, DC Home Visitation Council, DC Food Policy Council, CSHCN Advisory Council, Maternal Mortality Review Committee and the D.C. Healthy Communities Collaborative, among others.

Changes in the Health Status and Needs of MCH Population

Key findings resulting from the needs assessment highlighted the following priority areas: well-woman visits, breastfeeding; reducing perinatal disparities; mental health including grief and trauma-informed care; implicit bias/discrimination; positive youth development; early childhood developmental screening; medical home identification/place-based care; and addressing social and economic needs. The findings point to persistent health disparities by race/ethnicity, immigration documentation status, and socio-economic status. Furthermore, these findings emphasize the need to address social determinants of health such as housing, education, violence, and discrimination/implicit bias which were among the top factors identified by community members as the biggest unmet needs of District women, children, and families. Factors identified through the Discovery Survey as positively influencing families to thrive within the District community were community support activities, access to public spaces, a safe environment, food access, social support, community-based services, public transportation, and quality education. As the unprecedented Covid-19 pandemic unfolded in 2020, during the 5-Year MCH Needs Assessment submission year, the impact of the public health emergency and potential to exacerbate already identified MCH issues was included in the Needs Assessment Summary.

Women/Maternal Health

Women comprise the majority of the District’s population (52.48%) with more than a quarter being of reproductive age (15 – 44). The racial demographic of women in the District shows that 47% identify as Black or African American, 40% as White and 11% as Hispanic. In 2020, the first year of the COIVD-19 pandemic, the top three leading causes of death among DC residents were heart disease, cancer, and COVID-19. Disparities in health for different age and racial/ethnic groups continue to exist despite high insurance rates (96.7%) for the maternal health population, which exceeds the national average (92.1%). Nearly 20% of women have income below the federal poverty level, with the highest concentration living in neighborhoods in Wards 7 (Twining, Stadium Armory) and Ward 8 (Douglass and St. Elizabeth’s), followed by some neighborhoods in Wards 2, 5, and 6. The District’s priorities for Women’s/Maternal Health include addressing: well-woman visits, prenatal care, mental health, social and economic needs, and implicit bias/discrimination. It is crucial to establish holistic form of care and a safe space to thrive.

Preventative Care Utilization: In 2020, the DC Behavioral Risk Factor Surveillance System (BRFSS) revealed that 79.2% of women ages 21-65 had a pap test in the past 3 years, a decrease compared to 81.3 % in 2018. There is a difference across race /ethnicity in utilization of care: 18.2% of Black women, 19.9% of white women, and 25.6% Hispanic Latino women have reported to have a pap test in the past three years. There are also clear disparities among wards among adult females who did not have a pap test within the past three years. Early initiation into prenatal care can reduce the risk of preterm births, low-birthweight babies, and overall improve birth outcomes. In the District 85% of non-Hispanic white mothers, 81% of non-Hispanic Asian/Pacific Islanders mothers, nearly 70% of Hispanic mothers (67.8%), but only a little more than half of non-Hispanic black mothers (55.2%) initiated prenatal care during their first trimester.

Chronic Disease Burden: In the 2020 9BRFSS report, 29.1% of women in the District reported being obese. There are also clear racial disparities in adults who were classified as obese across the District: Black or African American residents reported being more likely to be obese (39.6%) compared to 20.8% for Hispanic and 11.5% for White residents. Wards 8 and 7 had the highest percentage of adult residents who were obese 49.1% and 40.5% respectively.

Substance Abuse: CDC data for 2020 revealed that 5.5% of pregnant women reported smoking at anytime during pregnancy. According to 2020 BFRSS data, higher rates of tobacco use were reported among non-Hispanic Black (19.3% currently smoke) compared to non-Hispanic White (6.1%). Wards 7 and 8 had the highest percentage of adult residents who reported being current smokers. BRFSS also reported a slight decrease in the number of women in the District who binge drink in 2020 (20.8%) compared to in 2019 (22%), however it is significantly higher than the national average (16%). Wards 2 and had the highest percentage of adult residents who reported being binge drinkers.

Perinatal and Infant Health

Infant Mortality Rate (IMR): The DC IMR decreased from 9.9 per 1,000 live births in 2009 to 6.9 per 1,000 live births in 2018 yet continues to exceed the DC Health People 2020 Target of 6.0 per 1,000 live births. The 2018 non-Hispanic Black: non-Hispanic white disparity ratio of 36.1 indicates that the infant mortality among infants of non-Hispanic black mothers is 36 times higher than that of non-Hispanic white mothers.

Preterm Births: The percentage of preterm births among all DC resident live births has increased from 9.7% in 2014 to 10.1% in 2018. During 2017-2018, there were differences in the percentage of preterm live births by demographic characteristics. The percentage of preterm live births among non-Hispanic Black mothers (13.6%) was significantly higher than the percentage of preterm live births among non-Hispanic white (6.5%), Hispanic (9.5%) and non-Hispanic Asian/ Pacific Islander (6.1%) mothers. The percentage of preterm births differed by ward. Across the eight wards, the highest percentage of preterm births was in Ward 7 (15.1%), which was significantly higher than the percentage of preterm births in all other wards except Ward 8 (13.8%) (Figure 9).

Breastfeeding: The 2020 Breastfeeding Report Card reports that 88.0% of infants in DC were initially breastfed. Duration of breastfeeding reduced as the age of the infant increased, with 64.7% of women breastfeeding at six months, and 39.3% at 12 months. From 2011- 2015, about 96% of White infants in DC were breastfed at birth, versus 65% of Black infants.

Child Health

Developmental Delays: A significant portion of infants and toddlers in DC live in low-income households (21.4% live less than 100% Federal Poverty Line (FPL) and 16.5% live 100-200% of FPL), a known risk for developmental delays. To ensure children have early and appropriate access to services, the American Academy of Pediatrics recommends that all children aged 9, 18, and 30 months receive a developmental and behavioral screening during their well-child visit. However only approximately 32.2% of children in the District between9 – 35monthswere reported to have received a developmental screening using a parent-completed screening tool. Given that multiple points of access can serve as the opportunity to screen children for developmental delays (e.g. DC Early Intervention Program/Strong Start led by OSSE for children 0-3 and the DC Early Intervention Program led by DCPS for children 3 years and older), the developmental screening rate may be underreported. DC Health Title V team along with its partners continue to work on promoting efforts to create and implement use of a centralized database (i.e. Ages and Stages Questionnaire (ASQ) Hub) for developmental screening to reduce the duplication of services and connect families to timely and appropriate services should continue.

Health Services:  According to the 2020 National Survey of Children‘s Health, 15.3% of the children in the District had no preventative care visit, of which Black and Latinx children made up approximately 21.2% and 17.2% respectively, compared to 2%White children. It is noted that White and Latinx data yielded small sample sizes.

Obesity:  Between 2019-2020, about 14.2% of DC children between 10-17 years of age were considered obese, which is lower than the national rate (16.2%). However, this rate is an incredible increase from 2018-2019 (12.5%).

Oral Health:  Between 2019-2020, 81.3% of children ages 1 – 17 of age had one or more preventative dental care visit in the past 12 months. Efforts must ensure that resources are equitably distributed to allow access to affordable dental care, in particular, for those who are Medicaid-eligible and under 2 years old.

Children with Special Health Care Needs

There is a shortage in the availability of data illustrating the needs and challenges of CSHCN in the District. However, access to rich qualitative data from partners in the field have allowed for an assessment of this population. Approximately 20% of DC families reported their child has a special health care need, and therefore, is vital to provide support for this population. Based on report from the 2019-2020 National Survey of Children's Health, 63.8% of children with special health care needs, ages 0 through 17 do not have a medical home. The District’s priorities for the CSHCN population include: Medical Home and Transition.

Care Coordination:  The District of Columbia has a first-of-its kind health system - Health Care System (HSC). This is a nonprofit health care organization committed to serving people with complex health care needs and eliminating barriers to health services by providing the resources of a health plan, a pediatric specialty hospital, home health agency, rehabilitative therapy centers and parent foundation assistance. The District offers a Medicaid health plan for CSHCN through Health Services for Children with Special Needs, Inc. (HSCSN). HSCSN serves children and young adults up to age 26 who live in Washington, D.C. and receive SSI. A care manager helps ensure an individual or their child gets the care or services prescribed by a physician. A healthcare system professional stated that additional work is required to increase quality of services throughout the entire continuum of care. This includes helping CSHCN integrate back into their communities and allowing CSHCN to practice skills learned in speech therapy, developmental therapy, etc. to engage in social interactions, participate in physical activity, and live more independent lives. Despite the District’s improvements in expanding access to care, CSHCN continue to face challenges accessing supportive services within the community.

Medication for Emotional and Mental Health: CSHCN may be an increased risk of experiencing adverse childhood experiences (ACEs), which include witnessing violence towards a parent/guardian, experiencing violence themselves, living with someone who suffered from poor mental health, and more. Approximately 35.8% of CSHCN in DC were reported to have two or more ACEs, almost double the rate of children with no special health care needs (17.2%), which are both more than the national average (34.1% and 14.3%, respectively). CSHCN are also at an increased risk for experiencing bullying with 35.1% of CSHCN between ages 12-17 reporting a higher rate of experiencing bullying compared to 18.3% of children without a SHCN.

Adolescent Health

Sexual Health: In 2019, 44% of high school students in the District reported ever having sex, with 7.9% of youth engaging before age 13, a decrease from 2017(45.6% and 8.9% respectively). Approximately one-quarter of currently sexually active students (20.8%) reported not using any method to prevent pregnancy and 72.4% of the students reported that they had not been tested for a sexually transmitted disease. Teen birth rates have decreased steadily over the years with the current rate at 19.3 in 2020, a decrease from the rate in 2019 at 21.0 per 1,000females ages 15 to 19. However, the DC birth rates for mothers aged 15-19 years is still higher than the national

Obesity and Nutrition: The 2019 YRBS reported 17.1% of high school respondents were obese and 17.6% were overweight. 28.4% of District high school students do not engage in recommended physical activity, with the female rates (32.4%) higher than the males (24%).DC was ranked 4th in the country for households with children experiencing food hardship (23.3%) by the Food Research and Action Center between 2016-2017.

Unintentional Injuries and Violence: About 20% of high school students reported riding in a car with a driver who had been drinking in 2019.Over a quarter of high school students (28.7%) were in a physical fight, with 14.1%reporting to be in a physical fight on school property.9.4% of the students were threatened or injured with weapons as a gun, knife, or club, one or more times on school property and nearly 16% of high school students have reported carrying a weapon.10% of students experienced physical dating violence and almost fifteen percent of high school students attempted suicide at least once. In 2013, DC ranked 13th (8.9 per 100,000) among states for rate of firearm deaths, decreasing to 26th (13.1 per 100,000) by 2017.

Substance Abuse: In 2019, 13% of high school students used electronic vapor products which was an increase from the 10.9% in 2017. 29.2% of students reported current marijuana use. High school students in 2019 reported lower rates of “current alcohol use” and “lifetime cocaine use” (20.2% and 5.8%, respectively) than in 2017 (20.5%and 7.4%, respectively). However, higher rates of initiation of alcohol use (17.8%) was reported compared to 16.1%in 2017.

Emerging Issues – Maternal Health

Covid-19 Vaccination Rates

From December 2020 to September 2021, the District of Columbia administered 833,567 doses of the COVID-19 vaccine to DC residents. Those administrations include the first dose, second dose, booster shots, and all eligible shots available to the public. From December 2020 to date, DC has overall administered 1,664,743 COVID-19 vaccine doses within the District, including residents and non-residents. No Shots, No School is a public health guidance requiring families with students attending DC public, charter, private and parochial schools to update their immunizations, including the COVID-19 vaccine if eligible, before the start of the next school year. Children without updated immunization will not be able to attend school and their absences will be counted as unexcused. The guidance is a coordinated efforted sponsored by the Deputy Mayor of Education and consists of public health partners, i.e. DC Health, and the DC education cluster, including the Office of the State Superintendent of Education (OSSE), DC Public Schools (DCPS), charter Local Education Agencies (LEAs), and Child and Family Services Agency (CFSA). DC Health establishes the District’s public health guidance and policies, provides expanded access to immunizations for District residents, and oversees outreach and communication campaigns.

The American Rescue Plan Act of 2021 (ARP) brought direct relief to the nation in response to devastating effects of the COVID-19 pandemic. The ARP establishes a new state option to extend Medicaid coverage for pregnant women for one year following the baby’s birth. The postpartum period is an important, but often neglected element of maternity care. New mothers may be dealing with a host of medical conditions, such as complications from childbirth, pain, depression, or anxiety, all while caring for a newborn. While Medicaid pays for nearly half of all births and must cover pregnant women through 60 days postpartum, after that period, states can and have made very different choices regarding whether eligibility for Medicaid coverage is continued. ARP’s new state option to extend continuous coverage for one-year postpartum enables states to take a major step towards improving health outcomes for postpartum women and their babies by mitigating coverage loss, providing comprehensive coverage in the postpartum period to address maternal mortality and morbidity, and advancing health equity. The District of Columbia Council and Congress proposed several changes to maternal health services that affect Department of Health Care Finance (DHCF) health insurance programs that will include:

1. Adding in doula services as a covered benefit of DHCF health insurance programs, to be authorized for Medicaid coverage through a State Plan Amendment (SPA)
2. Extending the length of eligibility postpartum from 60 days to 365 days
3. Requiring coverage of Non-Emergency Transportation to and from maternal appointments through the Alliance program

As the stark disparities in maternal and birthing outcomes plague our nation, evidence-based initiatives are required to set the stage for real change.

Changes in Program Capacity or MCH Systems of Care/Organizational Structure

Organizational Structure

The District of Columbia is governed by the Mayor who has the sole authority and responsibility for the daily administration of the District government. Within the Office of the Mayor there are four Deputy Mayors, representing various public sectors. The Deputy Mayor for Health and Human Services serves as a liaison between the Executive Office of the Mayor and health and human service cluster, which includes the Department of Health (DC Health). There are six administrations in DC Health, including the Community Health Administration (CHA). CHA is responsible for administering the Title V grant.

Within CHA, the Deputy Director for Strategy, Programs and Policy Family Health Bureau Chief was serves as the Title V MCH State Director.  The Division Chief of the Perinatal and Infant Health Division (formerly the Title V Program Manager) collaborates with the Title V MCH State Director to provide oversight of Title V program activities and MCH collaboration throughout the Community Health Administration.  The Title V MCH director is responsible for the strategic direction of the program while the Program Manager (vacant) oversees the programmatic activities for Title V grantees. The Grants and Budget Monitoring Unit within the Office of the Deputy Director for Operations provides grant support through fiscal monitoring of contracts and grant awards. All bureaus within CHA: Nutrition and Physical Fitness Bureau, Family Health Bureau, Cancer and Chronic Disease Prevention Bureau, and Health Care Access, collaborate to facilitate Title V MCH programming to DC residents.

Since FY23 involves an election year for mayor and representatives for DC Council, staff, grantees, and the DC community are prepared for the results in November 2022 and for any changes to the District-wide public health strategy, if necessary. Furthermore, the Director of DC Health is transitioning into another opportunity after serving in this role for seven years. The Mayor has appointed an interim Director, Dr. Sharon Lewis, Senior Deputy Director of the Health Regulations and Licensing Administration, to fill the Director’s position until filled. Please see [APPENDIX] for the organizational chart.

Agency Capacity

DC Health's capacity to promote and protect the health of the District’s maternal and child population is evidenced in its policies, programs, grants and collaborations with government, health systems and community-based organizations. The Community Health Administration (CHA) of the District of Columbia Department of Health promotes healthy behaviors and healthy environments to improve health outcomes and reduce disparities in the leading causes of mortality and morbidity in the District. CHA focuses on nutrition and physical fitness promotion; cancer and chronic disease prevention and control; access to quality health care services, particularly medical and dental homes; and the health of families across the lifespan and is organized into four respective bureaus: Nutrition and Physical Fitness Bureau, Cancer and Chronic Disease Prevention Bureau, Health Care Access Bureau and the Family Health Bureau (see Supporting Document #1 for Office & Bureau descriptions). Each bureau addresses at least one of the six population health domains. CHA’s approach targets the behavioral, clinical, and social determinants of health through evidence-based programs, policy, and systems change.

MCH Workforce Capacity

The District of Columbia Title V staff includes 37 full time equivalent staff. Senior level management include Robin Diggs Perdue, Deputy Director for Programs & Policy and DC Title V State Director; Jasmine Bihm, DrPH, MPH, Perinatal & Infant Health Division Chief and interim Title V Program Manager; Kafui Doe, EdD, MPH, Child, Adolescent & School Health Division Chief; and Omotunde Sowole-West, MPH, Early Childhood Health Division Chief.

DC Health experienced rapid staff turnover and realignment of organizational structure due to the COVID-19 pandemic. In response to the pandemic, CHA leveraged key individuals to fulfill major projects and deadlines while senior leadership coordinated the Covid response. The program filled a missing key analytic function in hiring and Epidemiologist, Larissa Pardo (formerly Patricia Lloyd, PhD, ScM) in FY 21. Jasmine Bihm, DrPH, MPH, subsequently joined the Title V team in FY19 as Program Manager then transitioned into the role of Perinatal & Infant Health Division Chief in FY 21. She currently provides oversight of the DC Healthy Start Program due to the vacancy of the Healthy Start Program Manager role. She also assists in executive oversight of the Family Health Bureau due a vacancy in the role of Family Health Bureau Chief (this position also serves as the CSHCN State Director in which Ms. Robin Diggs Perdue is currently serving in the interim).  Simileoluwa Ekundayo was hired in FY21 as the Title V Data Analyst and Lawryn Fowler was hired in FY22 as a Public Health Analyst that supports Title V programming.  Other Title V staff are embedded throughout CHA Bureaus, and work on a variety of MCH programs. Jasmine Davis, Public Health Advisor serves as the State Family or Youth Health Leader focusing on CSHCN. The MCH workforce has strong medical, public health, program planning and evaluation capabilities and a core cohort of staff with several years of MCH experience. CHA anticipates expanding the MCH workforce capacity by supporting the MCH leadership development of mid-level managers for retention and transition into senior level roles.

Title V Program Partnerships, Collaborations, and Coordination

The DC Title V program partners with other District agencies to implement important MCH work. Title V, through its partnership with the Office of the State Superintendent (OSSE) Division of Early Learning (DEL), works to implement the Strong Start Early Intervention Program (Strong Start) - a statewide, comprehensive, coordinated, multidisciplinary system that provides early intervention therapeutic and other services for infants and toddlers with disabilities and developmental delays and their families. Title V and OSSE DEL provide staff oversight of the Help Me Grow (HMG) program. CHA actively participates with several District wide MCH collaborative groups, including the State Early Childhood Development and Coordinating Council, Child Fatality Review Committee (CFRC) and Infant Mortality Review subcommittee, Department of Health Care Finance Perinatal Quality Improvement Collaborative, the Thrive by Five Coordinating Council, DC Home Visitation Council, DC Food Policy Council, CSHCN Advisory Council, Maternal Mortality Review Committee and the D.C. Healthy Communities Collaborative, among others.

Identifying Priority Needs and Linking to Performance Measures

DC Health has worked in partnership with communities, families, stakeholders, and public health professionals to better understand the needs of women, children, and families living in Washington, D.C. We’re continuing to focus on the nine priority areas and 11 NPMs from the previous report in addition to revised SPMs.