Oversight and Authority
The Virginia Department of Health (VDH) is the lead state entity providing core public health functions and essential services.
The VDH Strategic Plan establishes the agency’s mission to protect the health and promote the well-being of all people in Virginia, with a vision to become the healthiest state in the nation.
The VDH Plan for Well-Being lays out the foundation for giving everyone a chance to live a healthy life:
- Factoring health into policy decisions related to education, employment, housing, transportation, land use, economic development, and public safety;
- Investing in the health, education, and development of Virginia’s children;
- Promoting a culture of health through preventive actions; and
- Creating a connected system of health care.
The scope of the agency’s services includes ensuring food and water safety, disease and injury prevention and surveillance, emergency preparedness, health equity, and setting licensure and certification standards. As the leading public health agency in the state, the central office is located in Richmond, the state’s capital. The State Board of Health provides leadership in planning and policy development and supports VDH in implementing a coordinated, prevention-oriented program that promotes and protects the health of all Virginians. The agency is led by the State Health Commissioner, with additional oversight from deputy commissioners distributed across four main operating divisions: Public Health & Preparedness, Administration, Community Health Services, and Population Health.
VDH is responsible for the administration of programs carried out with allotments under Title V. The VDH Office of Family Health Services (OFHS) houses the state Title V program and complementary MCH programs under its flagship brand, VDHLiveWell. OFHS programs include the Women, Infants, and Children's Nutrition Program (WIC) in the Division of Community Nutrition; disease prevention and health promotion in the Division of Prevention and Health Promotion; protecting and improving the health of women, infants, children, adolescents, and their families in the Division of Child and Family Health; and providing scientific integrity and quality data analysis, reporting, and program evaluation related to these populations in the Division of Population Health Data.
Geography
The Commonwealth of Virginia encompasses 42,774 square miles (110,784 km2), including land and water areas, making it the thirty-fifth largest state by total area. The state is geographically located in the mid-Atlantic area of the United States, between the Atlantic Coast and the Appalachian Mountains. Washington D.C., the nation’s capital; Maryland to the north; the Atlantic Ocean to the east; North Carolina to the south; and Tennessee, West Virginia and Kentucky to the west. Land is distinctly divided by the Appalachian Mountains in the west, countryside, rolling hills, growing cities, and sandy beaches in the east where the Chesapeake Bay separates the contiguous portion of the Commonwealth from the two-county peninsula of Virginia's Eastern Shore. Many of Virginia's rivers flow into the Chesapeake Bay, including the Potomac, Rappahannock, York, and James.
Population Density & Urbanization
Virginia has 11 Metropolitan Statistical Areas, with Northern Virginia (Washington-Arlington-Alexandria), Hampton Roads (Virginia Beach-Norfolk-Newport News), and Richmond-Petersburg being the three most populous. The Commonwealth is divided into 133 localities (95 counties and 38 independent cities) with a population density of 206.7 people per square mile. The largest cities are Virginia Beach (450,435), Norfolk (244,703), Chesapeake (237,940), the state’s capital Richmond (227,032) and Newport News City (179,388). Norfolk forms the urban core of the Hampton Roads metropolitan area, which has a population over 1.6 million people and is the site of the world’s largest naval base, Naval Station Norfolk. The City of Alexandria has more people per square mile than any other jurisdiction in Virginia, according to 2016 population estimates. There are over 160,000 people living within the city, for a population density of 10,367 residents/square mile. In contrast, Highland County has the lowest density at 5.338 residents/square mile.
The most populous county and largest jurisdiction in the Commonwealth is Fairfax County in Northern Virginia, with a climbing population of 1.14 million. Fairfax County has a major urban business and shopping center in Tysons Corner, Virginia's largest office market. Neighboring Prince William County (463,023) is Virginia's second most populous county, and is home to Marine Corps Base Quantico, the FBI Academy and Manassas National Battlefield Park. According to an article in the Washington Post, analysis of U.S. Census Bureau data has shown that Prince William County has leapfrogged Virginia Beach to become the second-most-populous jurisdiction in Virginia. Three out of four of the state's largest jurisdictions are now in Northern Virginia, which has accounted for 60 percent of the state's population growth. Loudoun County is the state's fastest-growing jurisdiction. Loudoun gained nearly 85,733 residents for 398,080, surpassing Chesterfield County, which gained 27,360 residents to become the state's fourth-most-populous jurisdiction. The four counties with the largest portions of population 35 and younger were Fairfax, Prince William, Loudoun, and Chesterfield according to 2017 census estimates. The four Virginia jurisdictions that have the smallest ratios of people 65 and older are Fairfax, Chesterfield, Henrico and Prince Williams. This population growth also has come with issues, most notably some of the worst traffic in the country and increasingly overcrowded schools.
Virginia is a place where state averages hide the contrasting stories of its subpopulations. There are approximately 1.2 million residents living within rural areas of the state, compared to over 7.2 million within urban areas. Virginia Department of Health has grouped the Commonwealth’s localities into 35 health districts and 5 health regions. The Northern region, composed of Alexandria, Arlington, Fairfax, Loudoun, and Prince William health districts, is densely populated and includes ten of the 30 highest income counties in the United States (USA Today, 2018). Conversely, the Southwest region, made up of Alleghany, Central Virginia, Cumberland Plateau, Lenowisco, Mount Rogers, New River, Pittsylvania/Danville, Roanoke City, and West Piedmont health districts, bordered by West Virginia, Kentucky and Tennessee, is rural with a rugged and mountainous terrain and is the least populous and least racial/ethnically diverse. Its terrain and vast geographic area pose many transportation barriers. The Central region is composed of Chesterfield, Crater, Chickahominy, Henrico, Piedmont, Richmond City, and Southside health districts. The Northwestern region is made up of Central Shenandoah, Lord Fairfax, Rappahannock, Rappahannock/Rapidan, and Thomas Jefferson health districts. These two regions have a mix of urban, suburban and rural areas. The urban areas are home to large state colleges/universities and are business districts. The suburban areas are more residential than industrial. The rural areas are agricultural. The Eastern region, composed of Chesapeake, Eastern Shore, Hampton, Norfolk City, Peninsula, Portsmouth, Three Rivers, Virginia Beach, Western Tidewater health districts, runs along the east coast (Chesapeake Bay and Atlantic Ocean) and includes the Eastern Shore, a peninsula separated from the mainland by the Chesapeake Bay. The Eastern Shore Health District is very sparsely populated and has a high level of poverty. The Eastern area has the largest concentration of military bases and facilities of any metropolitan area in the world. The coastal area has many bridges and tunnels that create transportation barriers to services. Individuals in the area also experience severe traffic congestion on a daily basis. Occasionally, hurricanes and tropical storms affect the area and can result in flooding and environmental health concerns.
Demographics
Virginia is the 12th most populous state in the U.S., with an estimated population of over 8.4 million people (PostCensus population estimates from NVSS).
Race/Ethnicity
Among people reporting one race alone, 69 percent identified as CAUCASIANS non-Hispanic White, 19.2 percent identified as non-Hispanic Black, and 6.2 percent identified as Asian (2012-2017 ACS). There were 9 percent of individuals that identified as Hispanic or Latino (of any race). According to the 2010 Census, Virginia ranks tenth in having the highest proportion of individuals who identified as Black or African-American (https://www.worldatlas.com/articles/us-states-with-the-largest-relative-african-american-populations.html). Within the population, 49.2% are male and 50.8% are female.
There were over 1.6 million women of childbearing age (15-44 years) in 2017, with race and ethnicity composition consisting of 58.4% non-Hispanic white, 21.4% non-Hispanic black, 0.3% non-Hispanic Native American or Alaska Native, 8.8% non-Hispanic Asian, and 10.95% Hispanic (any race) (PostCensus). The Virginia population, like that of the nation, is becoming more racially and ethnically diverse and 21.1% of the population are foreign-born (2012-2017 ACS).
Age
The median age of Virginians is 38 years. There are over 1 million (1,187,867) Virginian’s age 65 and older, with more than half (56%) being female. Women of reproductive age 15-44 accounted for 19.9% (1,681,168) of the total population of Virginia. In 2017, there were 2,219,487 children and adolescents aged 1-21 years living in Virginia, representing 26.4% of the population. According to the 2016 National Survey of Children’s Health, 21.0% of Virginia children aged 0 to 17 (Pop. Est. 391,505 children) were identified as having special health care needs. There were more males (22%) estimated to have a special health care need than females (20%).
Educational Attainment
Educational attainment is a predictor of personal wealth and well-being and is directly related to social disparities. In Virginia, 4.5% of the population has less than a 9th grade education, 6.5% have a 9th to 12th grade education with no diploma, 24.3% are high school graduates or equivalent, 21.5% have a bachelor’s degree, and 16.1% have a graduate or professional degree. Thirty-six percent (37.6%) of Virginians have a bachelor's degree or higher compared with 30.9% for the U.S.
Economy/Income/Poverty
Virginia’s economy is diverse, including local and federal government, military, farming, business, manufacturing, tourism, and healthcare/medical. Virginia has 4.1 million civilian workers, and one-third of the jobs are in the service sector. The unemployment rate in Virginia was 3.5% as per ACS 2017, below the national rate of 4.1%. The median household income in Virginia is $68,766 compared to $57,652 in the U.S.
Compared to the U.S. population, a lower percentage of Virginians lived in households with incomes below the federal poverty level (10.6% vs. 13.4% for the U.S.) and also a lower percentage of children under age 18 lived in households with incomes below the federal poverty level (14.0% vs. 18.4% for the U.S.). However, wealth varies significantly across the state. The median household income has risen for families in Virginia from $71,600 in 2010 to $83,164 in 2017. However, the percentage of children living in high-poverty areas jumped, from 14% to 16% from 2010 to 2014 but then fell again back to 14% in 2016.
In 2017, 262,642 Virginia children under 18 years of age were living in poverty (VDH Poverty Data Dashboard). For the years 2016-2017, 21% of children with special health care needs lived in families with incomes less than 100% of the federal poverty level. This is in comparison to children without special health care needs, of which 15.7% are in families with incomes less than 100% of the federal poverty level.
Maternal & Child Population Overview
Virginia encompasses 42,774 square miles, divided into 95 counties and 38 independent cities. There are approximately 8,517,685 residents (Census Bureau, 2012-2018 ACS).
The diverse landscape includes countryside, rolling hills, and growing cities. The Appalachian Mountains frame the west, and the Chesapeake Bay separates the mainland from the Eastern Shore peninsula.
In 2017, infants were 1.2% (101,062) of the population (8,470,020). Women age 15-44 years accounted for 19.9% (1,681,168).3 There were 2,219,487 children and adolescents aged 1-21 years, representing 26.2% of the population. 3 According to the 2017 National Survey of Children’s Health4, 21.0% of Virginia children aged 0 to 17 (pop. est. 391,505 children) were identified as having special health care needs.
DOMAIN: Women’s/Maternal Health
NPM 13.1: Preventive Dental Visit During Pregnancy – Data from the Virginia Pregnancy Risk Assessment Monitoring System (VA PRAMS) showed that 52.2% of moms had a preventive dental visit during pregnancy (2017). Preventive dental care in pregnancy is recommended by the American College of Obstetricians and Gynecologists (ACOG) to improve lifelong oral hygiene habits and dietary behavior for women and their families.
SPM 4: Unintended Pregnancy – The proportion of women reporting using a Tier 1 contraceptive method was 31.04% (2017 VA PRAMS). Tier 1 family planning methods include long-acting reversible contraceptives (LARCs), e.g. implants or hormonal intrauterine devices (IUDs), and female or male sterilization. Births resulting from unintended or closely spaced pregnancies are associated with adverse MCH outcomes, such as delayed prenatal care, premature birth, and negative physical and mental health effects (2018 Guttmacher Institute). In Virginia, nearly 42% of pregnancies were described by women themselves as unintended, and 23% were mistimed (2017 VA PRAMS). In 2010, public spending for unplanned pregnancies in Virginia totaled an estimated $507 million (Power to Decide 2018).
SOM 6: Maternal Mortality Disparity: Maternal Mortality Disparity Ratio – Maternal mortality is a sentinel indicator of health and health care quality worldwide. There are also significant racial disparities with Black women having rates of maternal mortality over two times as high as White women in Virginia. On June 5, 2019 Virginia's governor announced a goal to eliminate the racial disparity in the maternal mortality rate in Virginia by 2025. According to data from the Virginia Maternal Mortality Review Committee, the maternal mortality ratio (within 42 days of pregnancy) for Black women was 18.3 per 100,000 live births compared to White women at 4.5 in 2012. The state maternal mortality ratio was 6.8 during that same time.
Virginia PRAMS – This collaborative project with the Centers for Disease Control and Prevention (CDC) assesses maternal risk and behaviors before, during, and shortly after pregnancy. A steering committee, which includes Title V representatives, provides input and support. MCH programs use PRAMS data to inform planning and programming. Data for 2017 is available now.
DOMAIN: Perinatal/Infant Health
NPM 5: Safe Sleep – Sleep-related infant deaths, also called Sudden Unexpected Infant Deaths (SUID), are the leading cause of infant death after the first month of life and the third leading cause of infant death overall. In 2017, the SUID rate in Virginia was 99.3 per 100,000 live births (National Vital Statistics System, NVSS). The non-Hispanic Black SUID rate was 184.5 per 100,000, compared to 77.2 among non-Hispanic Whites and 85.2 among Hispanics. The American Academy of Pediatrics (AAP) has long recommended the back sleep position to reduce the risk of sleep-related SUIDs. Federally-available 2016 VA PRAMS data showed that 78.0% of infants were placed to sleep on their backs, 32.0% slept on separate approved sleep surfaces, and 44.6% of infants were placed to sleep without soft objects or loose bedding.
SOM 5: Infant Mortality Disparity: Infant Mortality Disparity Ratio – Infant mortality, or the death of a child within the first year of life, is a sentinel measure of population health that reflects the underlying well-being of mothers and families, as well as the broader community and social environment that cultivate health and access to health-promoting resources. A significant disparity exists in infant deaths between racial groups. In Virginia, Black women had an infant mortality rate in 2017 at 9.6, 2.2 times that for White women (4.4 per 1,000 live births). Goal 2.3 of the VDH Plan for Well-Being is to eliminate the racial disparity in Virginia’s infant mortality rates.
Neonatal Abstinence Syndrome – The Maternal and Infant Health Coordinator partners with the Virginia Neonatal Perinatal Collaborative (VNPC) to implement and promote hospital-based quality improvement activities. A comprehensive approach has been implemented that includes several levels of intervention, from surveillance to clinical practice improvements. The VNPC has introduced plans to implement the Vermont Oxford Network (VON) NAS Universal Training.
Newborn Screening – The Virginia Newborn Screening Program includes Early Hearing Detection and Intervention (EHDI), Dried Blood Spot Newborn Screening, education for Critical Congenital Heart Disease (CCHD) pulse oximetry screening, and the Virginia Congenital Anomalies Reporting and Education System (VaCARES) Birth Defects Surveillance. A Zika Birth Defects Surveillance Coordinator was hired in May 2017 with CDC funding support; this enhanced Virginia’s surveillance efforts and capacity to verify birth defects reported into VaCARES, respond to changing birth defects surveillance needs, and refer infants to CYSHCN programs.
DOMAIN: Child Health
NPM 7.1: Injury Hospitalization (ages 0-9 years) – Data from the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) showed the rate of hospitalization for non-fatal injury among children was 95.4 per 100,000 in 2016. Among age groups, the annual indicator was 203.1 for children less than one year of age, 106.3 among children ages 1-4, and 65.7 among children ages 5 -9. Reducing the burden of nonfatal injury can greatly improve the life course trajectory of infants and children, resulting in improved quality of life and cost savings.
NPM 11: Medical home (ages 0-11 years) – The National Survey of Children's Health (NSCH) in 2017 showed that 62.7% of children age 0-5 years and 57.8% of children age 6-11 years had a medical home. Research indicates that children with a stable and continuous source of health care are more likely to receive appropriate preventive care, are less likely to be hospitalized for preventable conditions, and are more likely to be diagnosed early for chronic or disabling conditions.
NPM 13.2: Preventive Dental Visit (ages 1-11 years) – The NSCH showed that 67.3% of children age 1-5 years and 93.3% of children age 6-11 years had a preventive dental visit in 2017. Insufficient access to oral health care and effective preventive services affects children’s health, education, and ability to prosper. The American Academy of Pediatric Dentistry (AAPD) recommends preventive dental care for all children after the eruption of the first tooth or by age 12 months.
DOMAIN: Adolescent Health
NPM 7.2: Injury Hospitalization (ages 10-19 years) – The HCUP-SID showed the rate of hospitalization for non-fatal injury among adolescents was 196.3 per 100,000 in 2016. The annual indicator was 100.5 among age 10-14 years and 288.8 among age 15-19 years.
NPM 11: Medical Home (ages 12-17 years) – The NSCH in 2017 showed that 56.8% of adolescents age 12-17 years had a medical home. Research indicates that children with a stable and continuous source of health care are more likely to receive appropriate preventive care, are less likely to be hospitalized for preventable conditions, and are more likely to be diagnosed early for chronic or disabling conditions.
NPM 12: Transition (ages 12-17 years) – The 2017 NSCH showed only 9.6% of adolescents age 12-17 years received services necessary to make transitions to adult health care. Health care transition focuses on building independent health care skills – including self-advocacy, preparing for the adult model of care, and transferring to new providers. The goal of transition is to optimize health and assist youth in reaching their full potential.
NPM 13.2: Preventive Dental Visit (ages 12-17 years) – The NSCH showed that 90.1% of children age 12-17 years had a preventive dental visit in 2016. Insufficient access to oral health care and effective preventive services affects children’s health, education, and ability to prosper.
DOMAIN: Children with Special Health Care Needs
NPM 11: Medical Home (CYSHCN ages 0-17 years) – The 2017 NSCH showed that 45.7% of CYSHCN had a medical home.
NPM 12: Transition (CYSHCN ages 12-17 years) – The 2017 NSCH showed that 36.8% of CYSHCN age 12-17 years received services necessary to make transitions to adult health care (Combined 2016_2017 = 28.1%). While it is important for all youth to receive support in connecting to programs and services needed for adult care, CYSHCN may face additional challenges when making this transition.
DOMAIN: Cross-Cutting/Systems
SPM 6 - Cross-Cutting (Family Engagement): Implement and develop report on survey of families served by the VDH Care Connection for Children program – The CYSHCN Program developed a survey for families served by its regional CCC centers. The statewide survey is conducted every 3-5 years to assess family satisfaction with services and identify possible areas for program improvements.
SPM 7 - Cross-Cutting (Early and Continuous Screening): Percent of infants with confirmed newborn screening disorders who are enrolled in supportive services no later than 6 months of age – Early identification of developmental disorders is critical. The newborn screening and birth defects surveillance program has developed strategies to ensure timely referral of newborns and infants into Early Intervention (EI) services. In 2017, 57% of Virginia infants with confirmed hearing loss were enrolled in EI services by six months of age.
SPM8 - Cross-Cutting (Youth Engagement): Develop and sustain the Virginia Department of Health Youth Advisor Program – The VDH Adolescent Health Program is currently developing a youth advisor program. VDH will amplify youth voice across adolescent-serving initiatives by hiring two Youth Advisors to be based at VDH’s Richmond Central Office and by funding regional youth advisory councils.
SOURCES:
- VDH Division of Health Statistics,2017
http://www.vdh.virginia.gov/HealthStats/documents/pdf/2017/birth_1-1.pdf
- MCH Indicators tableau dashboard https://dataviz.vdh.virginia.gov/#/views/MCHIndicatorsDashboard/Sheet1?:iid=3
- NCHS Vintage population https://dataviz.vdh.virginia.gov/authoringNewWorkbook/NCHS_Vintage_Population#1
- National children health survey, 2017
- Annie E. Casey Foundation, 2017 KIDS COUNT Profile, Virginia
- National Survey of Children’s Health NCHS, 2017
Primary Care Access and Health Insurance Coverage
Based on the 2012-2017 ACS data, 90.1% of Virginians have health insurance of some kind and 94.9 percent of those under age 19 have health insurance. Among the uninsured population, 15.8% are young adults age 26 to 35. Others that are uninsured include 7.7% of the White non-Hispanic population compared to 10.7% of non-Hispanic African Americans, and 22.6% of those with less than a high school education.
In 2018, the Bureau of Labor Statistics reported 4,990 family and general practitioners in Virginia, and 730 obstetricians/ gynecologists. There were 500 pediatricians, 2,990 dentists with 60 of those being specialists, and 100 Oral and Maxillofacial Surgeons in the state. There are needs recognized across the state that can be unique to different areas of the state, such as transportation barriers and availability of providers. There were 111 counties/cities in Virginia designated as Primary Care Health Professional Shortage Areas (HPSAs), 92 in Dental Care, and 83 in Mental Health (HRSA Data Warehouse). Among children that received or needed specialist care but had a problem getting it, 23.8% were CSHCN compared to 16.7% of non-CSHCN.
State Statutes and Other Regulations
The state plan for the Virginia CYSHCN Program is found in the Virginia Administrative Code (VAC). The plan closely mirrors some of the recommendations of AMCHP and the Maternal and Child Health Bureau. In the plan, the Virginia CYSHCN Program is defined along with the program scope and content. The CYSHCN unit includes four programs: Care Connection for Children, Child Development Services Program, Sickle Cell Program, and Bleeding Disorders Program. In addition, the CYSHCN Program connects with newborn screening services in the VAC and has responsibilities in support of newborns confirmed to have certain conditions as described on the newborn screening panel.
Virginia House Bill 1467 requires the Board of Health to adopt regulations to include NAS on the list of diseases that shall be reported by physicians and directors of medical care facilities. Virginia medical facilities began reporting clinical diagnoses of NAS in an electronic case reporting system on November 27, 2017. Information captured includes severity of NAS signs, supportive elements for diagnosis, and source of exposure.
Virginia House Bill 1157 provides that the Department of Health shall serve as the lead agency with responsibility for the development, coordination, and implementation of a plan for services for substance-exposed infants in the Commonwealth. It details that plans shall (i) support a trauma-informed approach to identification and treatment of substance-exposed infants and their caregivers and (ii) include (a) options for improving screening and identification of substance-using pregnant women, (b) use of multidisciplinary approaches to intervention and service delivery during the prenatal period and following the birth of the substance-exposed child, and (c) referral among providers serving substance-exposed infants and their families and caregivers.
Virginia House Bill 2546 establishes the Maternal Mortality Review Team (MMRT) to develop and implement procedures to ensure that maternal deaths occurring in the Commonwealth are analyzed in a systematic way. The bill requires the MMRT to (i) develop and revise as necessary operating procedures for maternal death reviews, including identification of cases to be reviewed and procedures for coordinating among the agencies and professionals involved; (ii) improve the identification of, and data collection and record keeping related to, causes of maternal deaths; (iii) recommend components of programs to increase awareness and prevention of, and education about, maternal deaths; and (iv) recommend training to improve the review of maternal deaths.
Children’s Cabinet: In June 2018 Virginia Governor Ralph Northam issued Executive Order No. 11 reestablishing the Children’s Cabinet (Press Release). The First Lady is leading the effort to improve quality of and access to early childhood education programs across Virginia, support the early childhood education workforce, and ensure that Virginia makes the most of early childhood education resources. The Children’s Cabinet prioritizes issues including early childhood development and school readiness, nutrition and food security, and systems of care and safety for school-aged youth.
Source: Annie E. Casey Foundation, 2018 KIDS COUNT Profile, Virginia
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