Ongoing Needs Assessment Activities

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

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

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

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

1. Public-facing Dashboards: The population health data portal provides data on common indicators at the state, region, district and locality level. The MCH Dashboard is currently undergoing revisions to include updated data, visualizations, and racial/ethnicity disaggregation. The Health Behavior dashboard provides BRFSS profiles for health districts in Virginia. The Injury and Violence Dashboard provides hospitalization data by mechanism and intent at the state, region, district and locality levels. MCH staff also contribute to the Opioid Addiction dashboard, providing subject matter expertise on the Overdose Surveillance and Prevention Workgroup and data on substance misuse, hospitalizations and Neonatal Abstinence Syndrome (NAS).
2. Development of data briefs/fact sheets: The DPHD often develops data briefs and annual reports that are widely shared via presentations and access on the VDH website, including Virginia PRAMS and YRBS Annual Surveillance Data.
3. Performance Measure Update: The MCH epidemiology team provides an annual presentation to Title V staff and stakeholders on updates to performance measures and their related outcome measures, utilizing the Federally Available Data (FAD) Resource Document.

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

Plan for Well-Being (PfWB): Virginia Department of Health is currently implementing and in the process of updating a new state health assessment (SHA) and state health improvement planning (SHIP) set to begin in 2023, known as the Virginia Plan for Well-Being (PfWB). Additionally, all 35 health districts in the Commonwealth have completed or are engaged in the process of completing of a community health assessment (CHA) and a community health improvement plan (CHIP). The PfWB and CHIPs have a particular focus and emphasis on addressing the social determinants of health and the root causes of health inequities and disparities at the state and community level. Title V MCH staff are involved to provide insights, data, and expertise regarding MCH populations.

Operationalizing Five-Year Needs Assessment Process and Findings

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

• PEW Health Impact Project’s Calling All Sectors Initiative: The goal of this project is to create and support cross-sector, multiagency teams that will use evidence-based strategies to target social and economic drivers of health other than individuals’ behavior and access to medical care. VDH is partnering with the Virginia Hospital and Healthcare Association (VHHA) and the Virginia Neonatal Perinatal Collaborative (VNPC) to implement the Maternal Health Collaborative and connect hospital systems with community based organizations to create action around social determinants of health to decrease the disparity of certain health outcomes in black maternal populations.
• CityMatCH Alignment for Action Learning Collaborative: The purpose of this project is to better align state- and local-level MCH work. Virginia’s Title V leadership is providing consultation and partnering with the Blue Ridge Health District to assist in their plan of providing opportunities for anti-racism and implicit bias training for OB-GYN, Family Medicine and Pediatric providers as well as to facilitate maternal child health career paths for persons of color.

• Healthy Beginnings Learning & Practice cohort: As part of the Healthy Beginnings with Title V: Advancing Anti-Racism in Preterm Birth Prevention program, VDH MCH is partnered with the local organization Urban Baby Beginnings to identify and address racism in policy, data and funding structures at the state level that sustain inequities in perinatal health, including preterm birth, in Black, Latine/x, Indigenous, Asian, Pacific Islander, and other communities of color.
• National Maternal Child Health Workforce Development Center cohort:  VDH’s Title V staff is partnering with family based organizations to determine what a well-functioning, MCH system would like that is co-powered with families.  This cohort is an opportunity to ensure families equitably benefit from working together with local and state MCH leaders to develop and implement better policies, programs, and practices. The outcome is that family engagement and equitable collaboration become a core value across all MCH programs.

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

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

COVID-19 Health Disparities

To monitor the impact of COVID-19 on the MCH population, an internal-facing dashboard was created to display diagnosis among those noted as pregnant, and children and adolescents. As of May 26, 2022 total cases in pregnant women totaled 9,354, with 528 hospitalizations and 1,173 among those noted as healthcare workers. Among children and adolescents aged 0 to 19 years, there have been 373,825 cases, 1,781 hospitalizations, and 15,216 outbreak associated cases.

Maternal/Infant Morbidity and Mortality

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

In response to former Governor Ralph Northam’s goal of eliminating the racial disparity in maternal mortality by 2025, the Secretary of Health and Human Services released Virginia’s Maternal Health Strategic Plan in April 2021. The six focus areas include insurance coverage, healthcare environment, criminal justice and child welfare response, community-based services, contraception and data collection.  Recommendations specifically mention Title V Maternal Child Health block grant funding as a strategy in expanding access to community-led maternal health programs.

Maternal Health: Maternal mortality in Virginia due to direct and indirect obstetric causes has continued on an upward trend. Preliminary data in 2021 indicate a maternal mortality rate of 48.9 per 100,000 live births, nearly three times higher than the rate in 2020 (17.9 per 100,000 live births). Increases continue to be driven by rates among non-Hispanic Black birthing people. Late maternal deaths due to obstetric causes have also continued to increase, with preliminary data indicating a rate of 16.3 per 100,000 live births. This latter indicator provides insight into deaths occurring in the 4th Trimester and helps to inform efforts related to postpartum care.

Infant Health: In 2020, the top five most prevalent causes of infant mortality in Virginia included congenital malformations/chromosomal abnormalities, disorders related to short gestation and low birth weight, sudden infant death syndrome (SIDS), newborn affected by maternal complications of pregnancy, and unintentional injuries. 543 infants died before their first birthday in Virginia, making the overall infant mortality rate across all races 5.7 per 1,000 live births. This is a decline from an infant mortality rate of 5.9 in 2019. Since 2011, the overall infant mortality numbers have remained relatively constant, with a slight downward trend apparent in recent years. However, this rate varies by race and ethnicity. For example, the infant mortality rate among the non-Hispanic white population was 4.9, while the rate among non-Hispanic Black infants was 10.8, making the black/white infant mortality ratio to be 2.2.

Mental Health, Substance Use, Injury and Violence

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

Substance Use: In 2020, almost five Virginians died by drug overdose approximately every day. Virginia has seen a 32% increase in the number of drug overdose deaths from 2016-2020; approximately eight out of 10 drug overdose deaths each year (2016-2020) involved opioids. However, it is also important to note that drug overdose deaths involving psychostimulants or cocaine also saw marked increases from 2016 to 2020, at 450% and 80%, respectively. There were also an average of over 7,800 nonfatal drug overdose hospitalizations among Virginians each year from 2016-2020; in 2020 alone, nonfatal drug overdose hospitalizations cost an average of over $35,000 and a length of stay of over four days per hospitalization, with a total cost of over $267 million.

Maternal opioid use is also a public health issue, as this can lead to withdrawal symptoms and opioid dependency of the newborn, known as neonatal abstinence syndrome (NAS). In 2020, there were 7.7 maternal opioid related diagnoses (MOD) per 1,000 delivery hospitalizations and 5.8 NAS cases in Virginia per 1,000 birth hospitalizations. Higher MOD and NAS rates were seen in the Southwest health region and among the non-Hispanic White population.

VDH’s Injury and Violence Prevention Program (IVPP) has leveraged Title V funding to expand Project Echo®: Neonatal Abstinence Syndrome (NAS) prevention labs equipping providers with the skills to provide case management and harm reduction services to women at risk for, or with a history of, substance misuse, abuse, and addiction during childbearing age; all with the goal for prevention of NAS. IVPP also leads Project Patience Version 2.0, an initiative advancing statewide delivery of prenatal and postpartum education on child maltreatment and infant injury prevention to newborn and infant parents and caregivers prior to their maternity hospital discharge to home or setting after birth and/or as they access community level settings, inclusive of service receipt from libraries and health departments. Priority populations include mothers of NAS infants and pregnant women at risk for or with a history of addiction.

The Code of Virginia § 32.1-73.12 directs VDH to serve as the lead agency for the development, coordination, and implementation of a plan for services for substance-exposed infants (SEI) in the Commonwealth. The Plan for Services for Substance Exposed Infants (see Supporting Document 2) was approved by the Commissioner of Health in FY21.  In FY23, under the direction of the Maternal Infant Consultant, coordination and implementation of the plan will begin.

Self harm: On average from 2016-2020, suicide was the 10th leading cause of death in Virginia. Suicide dropped to the 11th leading cause of death in Virginia in 2020, solely due to COVID-19 rising to the top three causes of death statewide. The average number of deaths by suicide in Virginia from 2011-2020 was 1,115 deaths each year, with an increase of 8% from 2011 to 2020. In 2020, deaths by suicide among Virginians resulted in 33,388 years of potential life lost. Self-harm is also a public health issue, as self-harm and suicidal ideation remains a significant risk factor for suicide death. There were an average of 2,964 nonfatal self-harm hospitalizations each year in Virginia from 2016-2020, costing an average of over $34,000 and a length of stay of almost four days per hospitalization, with a total cost of over $525 million.

IVPP staff supporting ongoing suicide prevention efforts partnered with the Department of Education (DOE) to develop school guidance on suicide prevention including detailed planning of resources related to prevention, intervention, and postvention in schools. Additionally, staff worked to connect and expand individuals working in the suicide prevention field, identifying additional partners to participate in the Suicide Prevention Interagency Advisory Group (SPIAG). SPIAG serves as the primary mechanism for connecting and disseminating best practice suicide prevention information and data.

Finally, staff have begun working on the Virginia Suicide Prevention Plan across the Lifespan, which has resulted in a number of partnerships and identified areas for additional growth. These steps have positioned staff working on suicide prevention funded projects to achieve the activities outlined below for the October 2021 – September 2022 grant year.  IVPP will continue its work to ensure a comprehensive suicide prevention program statewide by increasing the number of gatekeepers serving disparate populations and (state plan). 

Mental health assessment and coordination of support services are a priority of Title V supported programs. In close collaboration with other state agencies and organizations, they help to address the mental health needs of women, children, adolescents and families through screening and education. These include, but not limited to, home visiting, Resource Mothers, adolescent family life programs and CYSHCN child development centers work. Local health districts also have the opportunity to focus on mental health in their MCH work plans, which are currently in development for FY22. In addition, the MCH Epidemiologist Lead and IVPP Senior Epidemiologist have been selected for the 20/20 Mom Governmental Maternal Mental Health Fellows Program, representing the Virginia Department of Health. This 12-months-long learning collaborative brings fellows from agencies across the nation in order to assist localities in closing gaps in maternal mental health using a multi-agency approach.

The Virginia Mental Health Access Program (VMAP) focuses on the connection of pediatricians to local/regional child psychiatrists to advise them on mental health concerns of young children with the goal of reduced wait time for mental health assessment and treatment of young children.  Due to the lack of resources and low number of child psychiatrists in Virginia, this program strives to minimize barriers to treatment and provide support to local pediatricians who see children with mental health issues.  This initiative is led by the Virginia Department of Behavioral Health and Developmental Service (DBHDS) and VDH provides consultation and funding that focuses on the educational components of the program.

Title V Program Capacity

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

Leadership

Since the Department of Health is within the Executive Branch of Virginia’s Government, the issues impacting MCH populations have a direct linkage to the Governor and subsequently Secretary of Health and Human services for Virginia. Executive Branch leadership has strategic focus on women’s health, children and youth, and has initiated several efforts to expand state capacity to improve the health and well-being of MCH populations and families (e.g. Maternal Health Strategic Plan).

Organizational Structure

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

Agency Capacity

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

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

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

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

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

Title V Partnerships and Collaborations

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