Geographic Description

 

South Carolina, also known as the Palmetto State, is a southeastern U.S. state known for its shoreline of subtropical beaches and marsh-like sea islands. South Carolina covers 30,109 square miles, with a 2017 estimated population of 5,024,369 people–with 745,781 (14.8%) living in rural SC (USDA-ERS).

 

In 2017, the five most populated counties in the state were Greenville (498,766), Richland (409,549), Charleston (396,484), Horry (322,342), and Spartanburg (301,463). Columbia, located in Richland County is the state capital. The state’s most populous cities are Columbia, Charleston, and North Charleston.

 

Data from the 2017 U.S. Census Bureau indicates that 63.8% of the state’s population is non-Hispanic white, 27.0% is non-Hispanic African-American, 1.5% is non-Hispanic Asian, 0.3% is non-Hispanic American Indian or Alaska Native, 0.1% is non-Hispanic Native Hawaiian or Other Pacific Islander, and 5.5% is of Hispanic or Latino origin. In the same report, 52.1% were women, 22.3% were under the age of 18 years, and 5.9% were under the age of 5.  

 

According to 2018 National Kid’s Count data, SC moved up one rank to 38th when measuring its efforts in child well-being, and SC ranks 43rd in health among all states in the America’s Health Rankings, produced by the United Health Foundation (2018).  

 

 

Organizational Overview

 

DHEC (www.dhec.sc.gov) is the state’s Title V agency and provides the ten essential services of public health as outlined by the National Public Health Performance Standards. Additionally, DHEC serves to fill gaps in the healthcare system, offering support services, resources, and financial assistance in areas such as immunizations, family planning, and care coordination for Children and Youth with Special Healthcare Needs (CYSHCN) to complement South Carolina’s healthcare systems.

 

DHEC is a centralized health department delivering Title V funding, programs, and services throughout its four Public Health Regions.

 

DHEC continues to champion its 2016 strategic plan through agency wide initiatives, strategies, and process improvements. Drawing from input across the agency, including significant input from MCH, the agency core values include the following: 1) Pursuing Excellence – The agency is steadfast in its commitment to the highest achievable standards of quality and professionalism in our pursuit of healthy people living in healthy communities; 2) Inspiring Innovation – The agency encourages and empowers its teams to find creative solutions to promote and protect the health of the public and the environment; 3) Promoting Teamwork – The agency fosters an inclusive and collaborative environment; valuing the diversity of thoughts, experience and expertise of every team member, stakeholders, and communities; and 4) Embracing Service – The agency embraces its responsibility to reliably serve its communities, customers, and staff in a respectful manner, relying upon clear and uncompromised commitments to integrity, trust, dependability, and responsiveness.

 

In addition to the above core values, the agency identified five strategic initiatives: 1) Education and Engagement; 2) Science in Action; 3) Leadership and Contribution; 4) Service and Accessibility; and 5) Operational Excellence.

 

The Title V program likewise continues to embrace the agency core values and strategic initiatives, and through the Title V Needs Assessment, has identified additional MCH-specific priorities. Priorities selected through the 2015 Needs Assessment are: 1) Improving health promotion, including preventive health visits and screenings; 2) Improving access to risk-appropriate care through evidence-based enhancements to the perinatal regionalization system; 3) Reducing the prevalence of preterm birth through evidence-based programs and clinical interventions; 4) Increasing implementation of safe sleep environment practices; 5) Improving breastfeeding support; 6) Increasing appropriate preventive health and developmental screenings and referrals to early intervention services; 7) Increasing physical fitness among children and adolescents; 8) Improving care coordination for CYSHCN; 9) Reducing smoking and exposure to tobacco use among maternal and child health populations; and 10) Reducing racial and ethnic disparities in social determinants of health, including insurance coverage and other barriers to medical care and employment.  The Title V program has initiated the 2020 Needs Assessment process and will use a similar process to examine recent data and set priorities to address gaps based on need and feasibility. This Needs Assessment incorporates a health equity framework ensuring that Title V activities are addressing outside factors that affect health.

 

As the state Title V agency, DHEC determines the importance, magnitude, value, and priority of competing factors that impact health services delivery in the state. In October 2018, DHEC, in partnership with the Alliance for a Healthier SC, released the first ever State Health Assessment (SHA) and State Health Improvement Plan (SHIP) documents. The SHA is a comprehensive compilation of health-related data, organized by several health topics. It will be used to inform health improvement plans at the state and community levels. It also serves as a resource for organizations that need access to health data. The Alliance is a multi-sector group of state and local leaders that convene quarterly to improve the health and wellbeing of South Carolinians. 

 

In addition to being an important part of public health activities in the future at the state and local levels, the SHA and SHIP are requirements for the agency’s public health accreditation application. DHEC began its journey toward public health accreditation several years earlier with a gap analysis. To date over 100 staff have been involved in reviewing documentation, identifying gaps, developing plans and procedures, and reviewing and approving activities related to improving processes, transparency, and the agency’s overall workforce. Capacity building and processes previously mentioned have been implemented to support this effort including: a DHEC strategic plan; the SHA and SHIP; an organizational performance management system; a continuous improvement plan; a workforce development plan; an emergency operations plan; and a DHEC branding strategy. The results of this accreditation will support central office and regional health clinics. DHEC plans to submit documentation for accreditation in late 2019.

 

Population Overview

 

Historically, health disparities have existed in SC in areas such as race, geography, and source of insurance. In recent years, DHEC has worked to identify and address the principal characteristics important to understanding the health status and needs of the state’s MCH population. The topics below describe some of the state’s demographics where barriers to equitable health have existed:

 

Education

From 2002-2017, the percentage of SC students who graduated from high school increased significantly from 77.3% to 86.5%. In 2017, SC’s educational attainment for adults over 25 was high school diploma/equivalent (29.4%), attended some college (20.8%), or had a bachelor’s degree (17.2%). As seen likewise with US trends, SC median income increased with education. 2017 individuals with a bachelor’s degree in SC had median earnings of $45,757, compared to $60,996 for the US. (2017 ACS, BLS)

 

Economy

According to the USDA Economic Research Service, the average per-capita income for SC residents in 2017 was $41,633, with rural areas having a per-capita income of $34,310. 2017 poverty rate was 22.3% in rural areas and 12.4% in urban areas, with a statewide poverty rate of 15.4%.

 

Foreign-Born versus Native-Born

In 2017 SC’s population (4,751,573) was comprised of 97.1% native citizens and 2.9% foreign-born citizens.  

 

Housing

In 2017, 25.1% of houses were constructed in the 2000s or later. The majority of SC housing was constructed between 1980-99 (36.3%), followed by homes build between 1950-79 (31.3%). Only 7.4% of SC houses were built prior to 1950. In SC 68.6% of homes were owner-occupied and 34.1% were renter-occupied.  For home renters, the median gross monthly rent was $836. 22.1% of owner-occupied homes with a mortgage had monthly owner costs as a percentage of household income over 35%.

 

Income

The median household income in SC rose from $42,018 in 2010 to $48,781 in 2017, although this still lags the national value of $57,652.

 

Language Spoken at Home

In 2017, the most common language spoken at home was English (93.1%). Of the 6.9% that spoke another language, Spanish (4.5%) was the most common.

 

Race/Ethnicity

Racial and ethnic disparities are greater in SC than in many other states. SC has a larger African-American minority population (27.9%) than the US average (13.4%). The state also has a growing Hispanic minority population (5.1%). There remain substantial, persistent racial disparities in many MCH outcomes in our state, in the southeastern region, and nationally. 

 

Poverty

23.0% of children live below the federal poverty level in SC, where 18.0% of the total population lives in poverty.

 

Urban/Rural

The 2010 Census recorded that 33.7% of SC’s population lived in rural areas and 66.3% lived in urban areas. Initiatives such as home visitation, community health workers, and telemedicine have been implemented to mitigate the impact of rurality. The MCH bureau within HDEC continue to focus on perinatal regionalization to assure risk-appropriate perinatal care across SC. 

 

Note: Unless otherwise noted, all information is from 2017 American Community Surveys of the US Census Bureau.

 

 

Programmatic Overview

 

Selected MCH programs supported by Title V in SC are described below, organized by the HRSA framework of MCH population health domains:

 

Women/Maternal Health Domain Programs

 

Maternal Morbidity and Mortality Review (MMMR): In March 2016, the MMMR proviso was ratified into law. This review process allows SC to better understand the circumstances around maternal deaths, and to determine the leading causes of preventable maternal mortality in the state. This review committee makes systems-level recommendations aimed at reducing preventable maternal morbidity and mortality across the state. DHEC’s Title V program is responsible for organizing and convening the quarterly reviews as well as the analysis and reporting of the data.

 

Best Chance Network (BCN) Program: DHEC’s BCN provides free breast and cervical cancer screening for SC women who meet program eligibility requirements. The program goal is to reduce deaths from breast and cervical cancer by providing medically underserved women in SC access to breast and cervical screening and other BCN services.

 

Sexual Violence Services Program: The Sexual Violence Services Program (SVSP) funds rape crisis centers serving all 46 counties and the SC Coalition Against Domestic Violence and Sexual Assault. The SVSP provides funding for services for direct and secondary victims of sexual assault through the 15 sexual assault centers. It also provides funding for sexual violence prevention programs across the state. Additionally, the program is responsible for domestic violence training within DHEC.

 

Preventive Health and Family Planning (FP) Program in the Division of Women’s Health: The DHEC FP Program, or Preventive Health program, is a preventive services program that promotes positive birth outcomes, reduction of unintended pregnancies, and patient-centered health through clinical and educational services. The program provides access to contraceptive services, supplies, and information to all who want and need them. Preconception counseling and family planning are also available for women.

 

Perinatal/Infant Health Domain Programs

 

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC): South Carolina WIC (SC WIC) is a public health nutrition program under the Food and Nutrition Service of United States Department of Agriculture providing nutrition education, nutritious foods, breastfeeding support, and healthcare referrals to income-eligible women who are pregnant or postpartum, breastfeeding, infants, and children through five years old. The WIC program is housed within DHEC’s Bureau of Community Nutrition Services.

 

Perinatal Regionalization System (PRS): The SC PRS ensures that women and high-risk infants have access to an appropriate level of care through a well-established regional perinatal system. The PRS is widely supported across SC and has been in practice for over 30 years. DHEC’s MCH Bureau provides Title V funding to support this system and maintains an active role in monitoring the PRS across four perinatal regions.

 

Safe Sleep Work Group: Safe sleep practices have long been a priority to reduce infant mortality in the state. The previous Safe Sleep Coalition, under the leadership of Children’s Trust, has been reorganized as a work group with the Birth Outcomes Initiative. Staff from the MCH Bureau are actively involved members of this work group.

 

South Carolina Birth Outcomes Initiative (BOI): The BOI was launched in 2011 to decrease infant mortality and low birth weight births, two of the state’s most pressing public health problems. The goal of the BOI is to address these issues and reduce health care costs while improving the health outcomes of mothers and babies in the state. Some of the collaborative work by BOI includes policy changes to support the following: Early elective delivery reduction, Screening Brief Intervention and Referral to Treatment, Baby-Friendly USA certification, CenteringPregnancy, and the use of long-acting reversible contraceptives. The DHEC continues to be a strong supporter of BOI. DHEC’s Title V Director is an active member of the BOI Leadership team, and many of DHEC’s MCH staff are involved in BOI workgroups.

 

The Care Line: The Care Line now operates through Blue Cross and Blue Shield, PGBA. The Care Line is the state’s Title V statewide information and referral hotline that provides support to women and their families by making it easier to get the services they need. The Care Line provides referrals, assistance, and support to the residents of SC to empower them to access health care and social services. 

 

First Sound: First Sound is SC’s legislatively-mandated Early Hearing Detection and Intervention (EHDI) Program. SC delivery hospitals with 100 or more births per year screen each newborn baby for hearing difficulties, and the results are sent to DHEC. On average, 97.5 percent of newborns in SC are screened. Infants who do not pass the initial hearing screening in the hospital or who have certain risk factors are referred for rescreening.

 

Newborn Screening (NBS) Program: The SC NBS Program is a legally-mandated newborn screening program. The test panel includes over 60 core and secondary metabolic and genetic conditions that are recommended by HRSA’s Advisory Committee on Heritable Disorders in Newborns and Children (ACHDNC), the American College of Medical Genetics (ACMG), and the March of Dimes to identify infants born with these conditions.

 

Text4baby: Text4baby is a free mobile information service designed to promote maternal and infant health. The service provides pregnant women and new moms with information to help them care for their health and give their babies the best possible start in life. The messages also connect women to resources and national hotlines as well as critical alerts to moms, fathers, friends, and families through the child's first birthday. The DHEC MCH Bureau serves as the coordination center for overseeing and monitoring Text4baby. 

 

Postpartum Newborn Home Visits (PPNBHV) Program: The PPNBHV program serves families with newborn infants, focusing resources on mothers and infants with priority medical needs or diagnoses. The family receiving services voluntarily receives the visit and, in most instances, a single visit is provided within one to two weeks from the time that the mother and infant are discharged from the hospital. Services include an assessment of the home environment of the mother and infant, observation of feeding and bonding, a complete physical assessment of the infant, and a limited, but more strategic, physical assessment of the mother. Title V provides funding for visits to high-risk mothers and infants who are not Medicaid-eligible.

 

South Carolina Birth Defects Surveillance Program (SCBDP): In 2004, the SC Birth Defects Act (Title 44-44-10) mandated the creation of a statewide birth defects surveillance system. The resulting SCBDP, housed within DHEC, collects active surveillance data of birth defects recommended by the National Birth Defects Prevention Network (NBDPN) for children up to two years old. In recent years, the scope of the program has expanded from surveillance to prevention, research, and referrals as allowed by the legislation. 

 

Nurse Family Partnership (NFP): Nurse-Family Partnership pairs qualified vulnerable first-time parents with specially trained nurses. During home visits from early pregnancy through the child’s second birthday, the nurses support first-time moms to have healthy pregnancies, become knowledgeable and responsible parents, and give their babies the best possible start in life. DHEC is one of the NFP partners, providing nurse home visits from four locations, one in each of the Public Health Regions. 

 

Children’s Health Domain Programs

 

Child Well-Being Coalition (CWBC): The Child Well-Being Coalition is a new initiative established by the MCH Bureau and strategic partners as a result of the 2015 Title V Needs Assessment. It is based on the successful model of BOI, described above for the Perinatal/Infant Health Domain. The group is being established to address key issues in children’s health, such as access to care and referrals, early child care, education and environments, special health care needs and chronic disease, and early clinical screening and intervention. Title V funds a contract with the coalition’s backbone agency, Children’s Trust, to employ a full-time coalition program manager. 

 

State Child Fatality Advisory Committee (SCFAC): The State Child Fatality Advisory Committee (SCFAC; https://scfac-sc.org/) was enacted in 1993. The SCFAC is mandated by SC Code 63-11-1950 to identify patterns in child fatalities that will guide educational and programmatic efforts by agencies, communities and individuals to decrease the number of preventable child deaths. DHEC’s MCH Bureau serves as the coordinating agency for the committee. 

 

The South Carolina Muscular Dystrophy Surveillance, Tracking, and Research Network (MD STARnet): The MD STARnet is a CDC-sponsored collaborative effort between DHEC and the University of SC to: 1) Maintain a dynamic surveillance system for muscular dystrophy that capitalizes on the strengths of the medical record and administrative data available in SC; and 2) Develop and manage a data system that allows for ongoing analyses of health care utilization, costs, and community participation of people with these conditions.

 

State School Nurse Program: The State School Nurse Program (SNP) is a collaborative relationship that exists between the SC Department of Education (DOE) and DHEC. This dual partnership supports and funds the state’s School Nurse Consultant (SNC) position. Title V funds 50% of this position, and the other 50% is supported with DOE state funds.  The SNC provides statewide leadership and expertise in using evidence-based practice standards for delivery of school nursing services. The SNC serves every public school district, public charter school, and other local education agencies (Kindergarten through grade 12), the students, school personnel, parents/family, and community. The SNC also provides a linkage to healthcare agencies and providers of care.

 

Lead Screening Program: Through the Bureaus of Maternal and Child Health, the Bureau of Health Improvement and Equity (BHIE), and Environmental Affairs, DHEC provides educational materials for healthcare professionals and families, conducts surveillance of blood lead testing, conducts case consultation for children up to 16 years of age with elevated blood lead levels (EBLLs), and provides environmental assessments for children with qualifying elevated blood lead levels. Title V funds some of the educational materials and portions of the salaries of staff providing program oversight. The long-established working relationship between Title V and SC DHHS expedited changes in the Medicaid Enhanced Services Provider Manual and agreements for Medicaid funding of increased numbers of environmental assessments when the intervention threshold changed to a single EBLL of 10 mcg/dl in 2017. 

 

Adolescent Health Domain Programs

 

“The Point” DHEC Clinics: The FP program within DHEC provides confidential reproductive health care services, counseling and education by caring professionals in teen-friendly clinics, called, “The Point”. Some of the many services provided in “The Point” sites are: Birth control methods (including emergency contraception); A year's supply of birth control; Pregnancy testing; Sexually Transmitted Infection (STI) screening; Abstinence education; Training on resisting coercion; and Encouraging family involvement.

 

Abstinence Education Program: A part of the MCH Bureau, the Abstinence Education Program, receives federal and state funding to support abstinence-until-marriage education in order to prevent teenage pregnancy and sexually transmitted infections. Partial funding for program oversight is provided by Title V. DHEC works with sub-grantees to implement the program in areas across the state.

 

State Adolescent Health Program: The State Adolescent Health Program in the Division of Women’s Health at DHEC provides leadership and advocacy for adolescent health and development for youth 10-24 years old. The program focuses on supporting healthy and safe lifestyles, improving access and utilization of health care, and increasing school success. The program actively works to prevent teen pregnancy and sexually transmitted diseases through the Personal Responsibility Education Program, and works with internal and external partners with injury, violence, suicide, and substance abuse prevention program.

 

Children and Youth with Special Healthcare Needs Domain Programs

 

CYSHCN Program: The SC CYSHCN Program has served over 4900 children and their families in FY 2017. Title V funding allows the program to provide care coordination, financial assistance, select premium assistance, information, referrals to appropriate care, transition planning, a residential summer camp, and parent resource partners for children and young adults with special health care needs and their families. The CYSHCN program is working toward building a robust family-centered care coordination system. SC has successfully transitioned from clinic-based model to a systems of care model.

 

Crosscutting/Life Course Domain Programs

 

Division of Oral Health (DOH): Many of the activities and programs led by DHEC’s DOH support the oral health of MCH’s target population: pregnant women, infants, children and individuals with special needs. The DOH receives funding from the CDC to maintain the infrastructure that supports a state dental disease prevention program and from DOH to support oral health integration activities for pregnant women and infants through a Perinatal Infant Oral Health Quality Improvement (PIOHQI) Expansion grant.

 

The Division of Nutrition, Physical Activity, and Obesity (DNPAO): The aim of the DNPAO program area in DHEC's new Bureau of Community Nutrition Services is to improve access to healthier foods and beverages and opportunities for daily physical activity through policy, systems, and environmental approaches reaching South Carolinians where they live, learn, work, and play. To address child and adolescent health, the division has three full-time employees (School Health Coordinator, SC FitnessGram Coordinator, and Healthy Eating/Active Living Special Projects Coordinator) who work to improve school environments across the state, including incorporation of physical activity before, during, and after school.

 

MCH Epidemiology: The MCH Epidemiology team provides ongoing data collection, analysis, summarization, presentation, program assessment and evaluation, and research interpretation to programs across the MCH Bureau and to external partners. A team of MCH epidemiologists are housed in DHEC’s Bureau of Health Improvement and Equity, within both the Population Health Data and Surveillance Divisions. Other MCH analysts are housed in the Biostatistics Unit of the Vital Records Division. Title V funding supports several of these positions; and the State Systems Development Initiative (SSDI) grant provides supplemental support for the administration of the Pregnancy Risk Assessment Monitoring System (PRAMS), the Behavioral Risk Factor Surveillance System (BRFSS), and the SC Child Health Assessment Survey (CHAS), three population-based data collection systems that provide quality data on maternal and child health indicators used to drive programmatic planning and evaluation.

 

Health Equity: Although health equity is an important part of activities conducted in all bureaus of the public health area, the Bureau of Health Improvement and Equity (BHIE) has the responsibility of being a resource of other areas of the agency, including the MCH Bureau, and to provide technical assistance for bureau activities that may include a component health equity. The Office of Multicultural Health within BHIE focuses specially on building the capacity for the provision of more equitable programs internally and externally. The Office works with staff and partners to identify, communicate, and develop strategies to achieve health equity and reduce disparities. The Office of Multicultural Health plays a key role in the development of the South Carolina Health Equity Action Plan based on the State Health Assessment and State Health Improvement Plan data and recommendations. This office also serves as the lead for the Agency’s Cultural Competency Advisory Committee.

 

Division of Tobacco Prevention and Control:  Tobacco Cessation is one of four priority program goal areas for the DHEC Division of Tobacco Prevention and Control, a division within the DHEC Bureau of Chronic Disease and Injury Prevention. The Tobacco Division has maintained a long-standing and supportive partnership with the MCH Bureau to advance the goals and objectives within the MCH Title V Block Grant that address tobacco use among this vulnerable population.

 

Immunizations Division: The Immunizations Division at DHEC plays an important role in protecting the MCH population in SC, pursuant to statutory authority, allowing DHEC to have general direction and supervision of vaccination, screening, and immunization in this state. The Federal Vaccines for Children Program in SC is administered by the DHEC Division of Immunization and covers vaccines for children 18 years old and younger. The Immunization Division works closely with the MCH Bureau and common key stakeholder groups.

 

MEGA Contract: The MEGA administrative work is included in the contract between SC DHHS and DHEC for the provision of cost-based services. There is a 50-50 Medicaid match to draw down funds for performing deliverables specified in the contract. MEGA provides a mechanism to address health care system issues including adequate number of providers, appropriate use of services, access to care/insurance, and referral/service follow-up concerns.

 

The Division of Injury Prevention (DIVP) monitors health status to: identify community health problems; develop plans supportive of individual and community health improvement efforts; research for new insights and innovative solutions to health problems; link people to needed personal health services; assure a competent workforce; inform, educate and empower people; and, mobilize state, regional and county-level partners to better identify and address health problems.

 

 

State Statutes and Other Regulations Relevant to Title V

 

Several bills have been introduced and passed this year that could have an impact on Maternal and Child Health:

 

Dylan’s Law, effective May 2019, adds three disorders to South Carolina’s newborn screening panel. The Department will begin testing for Krabbe disease, Pompe disease, and Hurler syndrome upon securing funding for implementation. Additionally, Dylan’s Law established a Newborn Screening Advisory Committee to review additional disorders for inclusion on the newborn screening panel.

 

In May 2019, Senate Bill 21 was signed into law amending the existing statute establishing the Maternal Morbidity and Mortality Review Committee. The statutory amendments grant the committee much needed access to necessary data from death, birth, and fetal death certificates.

 

House Bill 3420, effective April 2019, requires retail tobacco establishments to post signage prohibiting entrance by persons under 18 years of age, and further requires signage with the number to DHEC’s Tobacco Quitline.

 

Amendments to Regulation 61-120, SC’s Immunization Registry, effective May 2019, establish the creation of an electronic Patient Portal, a new feature of the registry allowing parents to access their child’s immunization record.

 

Legislation was introduced to establish an “Advisory Council on Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS) and Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS).” This legislation, if passed, would require the council to issue an annual report to the state legislature with recommendations concerning the most current practice guidelines for diagnosis and treatment of PANS/PANDAS, increasing clinical awareness, outreach to educators and parents, and the development of a network of volunteer experts on the diagnosis and treatment of PANS/PANDAS.