The state of North Carolina (NC) covers 52,175 square miles including 48,710 in land, and 3,465 in water.  The 100 counties that comprise the state stretch from the eastern coastal plains bordering the Atlantic Ocean, continue through the densely populated piedmont area, and climb the Appalachian Mountains in the west. These diverse geographical features pose a number of challenges to the provision of health care and other social services.  In the sparsely populated western counties, there are vast areas of rugged terrain which make travel difficult especially during the winter months and contribute to the isolation of the rural inhabitants.  In the coastal plain counties, which cover almost a quarter of the state, swamp lands, sounds that bisect counties in half, and barrier islands that are often inundated during hurricane season, also complicate transportation problems and contribute to isolation and health care access problems. While urban centers have better health care provider to population ratios, access to affordable health care may still be a problem due to potential disparities because of race/ethnicity, long wait times for appointments or lack of insurance coverage (Healthy People 2020).  Moreover, because most local health departments (LHDs) have maintained their single-county autonomy, rural departments are often under-funded and have difficulties attracting sufficient staff and operating efficiently.  According to the NC Rural Center, 80 of the 100 NC counties are considered rural and have an average population density of 250 people per square mile or less.  There are 14 suburban counties and six urban counties (average population density that exceeds 750 people per square mile).

According to July 2018 population estimates from the US Census Bureau, NC is the ninth most populous state in the nation with an estimated population of 10,383,620 which is a 1.1% growth from the 2017 estimates (approximately 110,000 new residents).   This marked the third consecutive year that the state population has grown by more than 100,000 in a single year with 77% of total population growth due to net in-migration.  Most of these migrants moved to NC from other states. Trends noticed by Carolina Demography in the UNC Carolina Population Center suggest a shift in state growth patterns with population growth occurring more broadly across the state, but with counties with retirement destinations and suburban counties being the fastest growing.

Per the 2013-2017 American Community Survey (ACS), the age distribution of the female population of NC mirrors that of the nation.  Females in NC and in the US are also aging at approximately the same rate.  The median age in NC is 38.4 years; for women, it is 39.9 years.  The number of women in NC in their prime reproductive years (ages 15-44) compose 38.7% of the total female population.  The population projections for 2026 show that the proportion of women of childbearing age will comprise 38.1% of the total female population (NC State Data Center).

The number of births in NC peaked in 2007, with 130,866 births, and there was a steady decline to a total of 118,983 born in 2013, but a slight rise to 120,826 in 2015 and a slight decline in 2017 with 120,099 births.  Based on 2013-2017 ACS population estimates, children under five years make up 6.0% of NC’s population, while children under 18 years comprise 23%.  These percentages are almost exactly the same as those for the US (6.2% and 23% respectively).

2013-2017 ACS census population estimates indicate that more than one out of every three individuals in the state is a member of a minority group.  African Americans are the largest minority group at 21.2% of the population. The combined other minority groups – Latinos (9.1%), American Indian and Alaska Native (1.1%), Asian/Pacific Islanders (2.8%) and those reporting two or more races (2.1%) – represent a much smaller proportion of the total population, but their numbers have increased significantly over the past decade.  Data from the ACS show that NC’s Hispanic population was close to one million people in 2017, which is an increase of 116,404 new residents since 2012 for a growth rate of 13.8% in just five years.  The adult population grew faster than the child population over this period (UNC Carolina Population Center Carolina Demography’s blog Potential voters are fastest-growing segment of NC Hispanic population posted June 6, 2019).  See Figure 1 for a comparison of racial/ethnic distribution in NC and the US.

Figure 1

According to data from the ACS, poverty rates in NC have climbed or stayed steady from 2007 to 2014, from 14.3% in 2007 to 17.2% in 2014 and back down to 14.7% in 2017.  In 2017 more black (32%) or Hispanic (37%) children were living in poverty than white children (11%).  Poverty rates by race and ethnicity in NC are similar to national rates (Figure 2) in all categories except NC rates are higher for people of two or more races, those of Hispanic/Latino ethnicity, and those for White alone, not Hispanic or Latino. Based on ACS 2013-2017 data, the poverty rate for women was 17.5% as compared to 14.7% for men.  On average, in 2016, women in NC earned 81 cents for each dollar a man made, and this amount is even lower for women of color with Black women earning 62 cents, Native American women earning 62 cents, and Latino women earning 49 cents (Anderson and Williams-Baron, The Status of Women in North Carolina: Employment & Earnings, June 2018, Institute for Women’s Policy Research).

Figure 2
 

The economy of NC is still recovering from the Great Recession as the state had only 5 percent more jobs in 2016 than during the 2007 peak.  Key findings from the NC Annual Economic Report released in June 2017 by the NC Department of Commerce’s Labor and Economic Division include that while the average annual unemployment rate fell by 0.7 percentage points to 5.1% in 2016, the state’s rate remains above the national rate of 4.9%.  NC’s average wage ($47,260 in 2016) has been consistently about 88% of the US average since 2000.  The median wage was only $33,920 for NC as compared to $37,045 for the US.  NC is projected to add more than 550,000 jobs by 2024 with 90% of those jobs being in Service-Providing industries.  Barriers to economic security and well-being remain for many people, however, particularly for communities of color and for rural communities.

The public health system in NC has a strong history with 84 autonomous LHDs serving all 100 counties ensuring access to maternal and child health services through Title V funding as well as other federal, state, and local funding.  During FY18, the NC Division of Public Health (NC DPH) submitted documentation to the Public Health Accreditation Board (PHAB) as part of the steps towards PHAB accreditation which highlighted some strengths and challenges that impact the health status of NC’s maternal and child health population.  Strengths included having a strong Division management team and strong relationships with local health directors and departments.  Identified challenges included an aging workforce and loss of historical knowledge when staff members leave, updating and implementing new information technology systems, the growing population of our state leading to greater disparities in health status between rural and urban areas, and the aging of our populations with an impact on demand for health services.  Work on the PHAB accreditation process was frozen for a one year period due to leadership changes within the NC DPH, but plans to continue the work in December 2019 are in process. Additionally, the changes in the governance of LHDs with many becoming consolidated Human Services agencies with someone who does not qualify to be a local health director as the agency head may impact how services are provided.  Also, LHDs are working hard to maintain local public health care management services under Medicaid Transformation, but it is too soon to know exactly the full impact of that transformation. The NC DPH has been providing input to NC Medicaid and working with the LHDs to maintain continuity for the Medicaid beneficiaries through the phased roll out of managed care services.

The Title V Program in NC is housed in the Women’s and Children’s Health Section (WCHS) in the NC DPH, with the Title V Director serving as Section Chief and the CYSHCN State Director serving as the Children & Youth (C&Y) Branch Head. Dr. Kelly Kimple, a pediatrician and preventive medicine physician, was named Title V Director in August 2016.  Marshall Tyson became the CYSHCN State Director in January 2017.  WCHS is responsible for overseeing the administration of the programs carried out with allotments under Title V and for other programs including Title X, early intervention, nutrition services (including the state WIC program), and immunization. In addition to the C&Y Branch, the WCHS includes four other branches: Women’s Health (WHB), Early Intervention, Immunization (IB), and Nutrition Services.

The mission of NC Department of Health and Human Services (NC DHHS), in collaboration with its partners, is to protect the health and safety of all North Carolinians and provide essential human services.  The Department’s vision is that all North Carolinians will enjoy optimal health and well-being. Governor Roy Cooper was sworn into office on January 1, 2017.  Prior to being elected Governor, Cooper served as the NC Attorney General from 2001 to 2017 and was previously a member of the NC House of Representatives (1987-1991) and NC Senate (1991-2001).  Governor Cooper appointed Dr. Mandy Cohen as Secretary of the NC DHHS on January 13, 2017.  Dr. Cohen is an internal medicine physician who served as the Chief Operating Officer and Chief of Staff at the Centers for Medicare and Medicaid Services (CMS) prior to coming to NC.  Among her top priorities are combating the opioid crisis, building a strong, efficient Medicaid program, and focusing on early childhood.  In October 2018, Danny Staley who had been the Director of the NC DPH since February 2015 resigned.  Beth Lovette, the Deputy Director was named Acting Division Director.  In June 2019, Secretary Cohen announced that effective July 22, Mark Benton, her current Deputy Secretary for Health Services would be the next leader of the DPH, assuming the title of Assistant Secretary for Public Health.  The Title V Director will be directly supervised by Assistant Secretary Benton. The previous State Health Director position in the NC DPH is now the Chief Medical Officer of NC DHHS, who coordinates efforts across DHHS, which reflects the Division’s and Department’s value of collaboration and teamwork. Dr. Betsey Tilson, a pediatrician and preventive medicine physician, was appointed to Chief Medical Officer and State Health Director in August 2017.

The NC DPH is comprised of the Director's Office and nine other offices and sections: Administrative, Local, and Community Support; Chronic Disease and Injury; Epidemiology; Environmental Health; Human Resources; Oral Health; State Center for Health Statistics; State Laboratory; and WCHS.  NC DPH works collaboratively with 84 sub-state administrative units (single- and multi-county LHDs). The LHDs, which have local autonomy, have a longstanding commitment to the provision of multidisciplinary perinatal, child health, and family planning services, including prenatal care, care management, health education, nutrition counseling, psychosocial assessment and counseling, postpartum services, care coordination for children, well-child care, and primary care services for children. They are also instrumental in providing leadership for evidence-based programs county wide such as Nurse Family Partnership, Healthy Families America, Teen Pregnancy Prevention Initiatives (TPPI), Triple P, Reach Out and Read, and other programs dictated by the needs of the county.

There is a weekly Division Management Team (DMT) meeting for all the Section Chiefs within DPH.  This meeting is a time to co-plan and discuss issues of overlapping responsibilities and strategies for service improvement.  The WCHS Management Team (SMT), which consists of the WCHS Chief, the Operations Manager, and the five Branch Heads, meets weekly after the DMT meeting to further discuss any DMT agenda items and to assure internal communication and coordination occurs on a regular basis.  This provides the Section with a format to facilitate joint planning, to keep key staff informed of current activities and issues, and to plan short and long-term strategies for addressing current issues, while also providing the Title V Director with an overview of factors influencing maternal and child health services.  A similar process occurs within the Branches which are responsible for assessing and responding to the needs of their priority populations.

The WCHS oversees and administers an annual budget of over $619 million and employs 933 people. This is 48% of the DPH staff, along with 66% of the budget. The WCHS's broad scope promotes collaborative efforts while discouraging categorical approaches to the complex challenge of promoting maternal and child health. The Section is committed to ensuring that services provided to families are easily accessible, user-friendly, culturally appropriate, and free from systemic barriers that impede utilization. While many staff members work in the central office in Raleigh, there are a number of regional consultants who work from home and regional offices. The EIB has a network of 16 Children's Developmental Service Agencies (CDSAs) serving all 100 counties.

The Title V Block Grant fully funds 24 WCHS state-level employees, with many others funded in part per the cost allocation plan. These positions are primarily nurse consultants, public health genetic counselors, and public health program consultants within the WCHS, but also funds staff members in the SCHS, the Chronic Disease and Injury Section (CDIS), and the Oral Health Section. The funding that goes directly to LHDs is used to provide services for individuals without another payer source, as well as enabling services and population health education.

NC Title V leadership works diligently to maximize services for low income women and children by leveraging funds whenever possible, forming strong partnerships and interweaving funding from a variety of sources to support Title V performance measures, strengthen the integrity of the system of care and increase access for low income and disenfranchised individuals.  The primary populations served through Title V funding are women, children, and families seen in LHDs for direct and enabling services.  However, as part of the work of the WCHS, all infants born in NC are served through newborn screening efforts, all women of childbearing age are served through campaigns to promote preconception health, and these campaigns are becoming more inclusive of male partners and fathers.

According to data from the interactive NC Health Professions Data System (https://nchealthworkforce.unc.edu/) in 2018, for NC as a whole, there was an average of seven physicians with a primary care practice per 10,000 individuals.  However, 24 counties have relatively few primary care physicians (less than 3.5 per 10,000 people) and two counties did not have any primary care physicians.  NC also has an increasing shortage of health care professionals performing deliveries, and there have been six rural hospital closures since 2010 in NC.  NC has several children’s hospitals nationally ranked in pediatric specialties (i.e., NC Children’s Hospital at UNC; Duke Children’s Hospital and Health Center; and Levine Children’s Hospital), but access to these hospitals is often difficult for children not born in nearby cities and counties.

Prenatal care providers are available in most, but not all counties in NC. Birthing facilities across NC have varied capabilities to care for mothers and newborns with complex needs. The current geographic distribution of these facilities makes it challenging for some moms and newborns with complex conditions to access medical care and facilities that can meet their needs.  The NC Child Fatality Task Force supported legislation (House Bill 741) requiring a DHHS study of risk-appropriate neonatal and maternal care which is underway in partnership with the NC Institute of Medicine.  Mapping the geographic distribution and capabilities of prenatal care services is needed to determine the scope of this problem and to make recommendations on the best way to address it.  Designating facilities with specific “levels of care” per the most recent guidelines and policy statements issued by the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine helps ensure that women and infants receive care at a facility that aligns with their risk.  Title V funding is being used to implement the Perinatal/Neonatal Outreach Coordination project to assess the levels of care of birthing facilities in two regions of the state.

WCHS partners with NC Medicaid and Community Care of North Carolina (CCNC) to provide pregnancy care management services (OBCM) and the Care Coordination for Children (CC4C) program, a population management program for children ages 0 to 5 years who meet certain criteria (children with special health care needs or those exposed to severe stress in early childhood).  With Medicaid Transformation, these programs will continue with some modifications.

The WCHS supports services and programs for underserved and vulnerable populations using state appropriations, grant funding, Title V, Medicaid Federal Financial Participation, and other receipts.  The WCHS provides Title V funding to LHDs through DPH’s Consolidated Agreement which is a contract between the LHD and DPH that outlines requirements of DPH and the LHD including funding stipulations, personnel policies, disbursement of funds, etc.  State, federal, or special project funds cannot be used to reduce locally appropriated funds.  The Consolidated Agreement is revised and renewed annually.  Program specific requirements for each state funded activity are provided in Agreement Addendum (AA) which are also revised annually.  The AA provides a scope of work and deliverables which provide guidelines for the provision of services and outcomes.  LHDs bill Medicaid and private insurance companies and have a sliding fee scale for uninsured patients.  LHDs are free to allocate portions of the Title V funds to provide OBCM and CC4C services or other support services to patients who are ineligible for Medicaid.  WCHS also administers a limited amount of state appropriations for these services.

Services and resources for CYSHCN are included within all programs and initiatives under the C&Y Branch. This intra-agency approach is inclusive, helping to ensure that all programs that serve young children, youth, and their families also provide for the subset of CYSHCN. There is no longer a discreet, separate agency/office or program for CYSHCN in NC as exists in most other states.  The WCHS does not reimburse for services directly but supports the provision of services to children and youth who are not enrolled in Medicaid or Health Choice by contracting with LHDs and major medical facilities.  In addition, C&Y Branch staff are supported by Title V to provide training and technical assistance to providers.  To the greatest extent possible, services are offered within family-centered, community-based systems of care.

In 2015, the C&Y Branch began a process of developing a strategic plan for the years 2015-2020.  Five broad strategies were developed, each with multiple objectives for the Branch. Under the five broad inclusive strategies for all children, these five specific objectives addressed CYSHCN:

• increase the percent of CYSHCN that have an identified medical home;
• assure the purposeful integration of services for CYSHCN among all children’s services;
• increase the capacity of health professionals to improve quality care for people with disabilities and CYSHCN;
• increase the number of CYSHCN that have access to patient and family centered care; and
• increase coordinated annual training opportunities for families and parents of CYSHCN.

In 2017, it was determined that a more specific strategic plan needed to be developed for CYSHCN.  The Standards for Systems of Care for CYSHCN was selected as the framework for the strategic plan, and a Summit was held in October 2017 that included all C&Y Branch staff as well as parents of CYSHCN and other internal and external partners.  Over 100 participants contributed to a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis of the WCHS’s current system of care for CYSHCN.  In preparation for the Summit, surveys went to state staff, key informants (providers) and to parents across the state.  Survey respondents included 49 state staff members and 136 parents.  In addition, 41 key informant surveys were returned representing 24 counties and providers from education, health, and private services.  The parent surveys came from 51 counties plus one military base, and 11.8% of respondents were Spanish speaking.  The strategic plan includes one-year and five-year strategies that have been reviewed by C&Y Staff and family partners. Initial strategies included the development of a CYSHCN website, strengthening the emphasis on transition at all levels, increasing family engagement, and increasing knowledge of system of care for CYSHCN.

The nine-member Commission on CYSHCN, appointed by the Governor, is charged with monitoring and evaluating the availability and provision of health services for CSHCN in NC and to monitor and evaluate the services for special needs children through NC Health Choice. The Commission makes recommendations for modifications or additions to the rules necessary to improve services to these children and make service delivery more efficient and effective.  The C&Y Branch provides staffing support for the Commission.

Implementation of the 2015-2020 Perinatal Health Strategic Plan (PHSP) continues.  A PHSP program consultant was hired in April 2018.  Bi-monthly PHSP Team meetings are held along with three work groups (Data and Evaluation, Community and Consumer Engagement, and Communications) who meet as needed to move forward the work of the PHSP.

While the public health system at the local level in NC is not state administered, there are general statutes in place for assuring that a wide array of maternal and child health programs and services are available and accessible to NC residents. State statutes relevant to Title V program authority are established for several programs administered by WCHS. These statutes, found in Article 5 – Maternal and Child Health and Women’s Health of GS 130A: Public Health, include (not an exhaustive list):

• GS130A-4.1. This statute requires the NC DHHS to ensure that LHDs do not reduce county appropriations for local maternal and child health services because they have received State appropriations and requires that income earned by LHDs for maternal and child health programs that are supported in whole or in part from State or federal funds received from NC DHHS must be used to further the objectives of the program that generated the income.

• GS130A-33.60. This statute establishes the Maternal Mortality Review Committee.  The purpose of the committee is to reduce maternal mortality in this State by conducting multidisciplinary maternal death reviews and developing recommendations for the prevention of future maternal deaths to be disseminated to policy makers, health care providers, health care facilities, and the general public.  The duties of the committee are cited as well as guidelines for the use of the information shared and the protections provided to committee members and their activities.

• GS130A-124. This statute requires NC DHHS to establish and administer the statewide maternal and child health program for the delivery of preventive, diagnostic, therapeutic and habilitative health services to women of childbearing years, children and other persons who require these services. The statute also establishes how refunds received by the Children's Special Health Services Program will be administered.

• GS130A-125. This statute requires NC DHHS to establish and administer a Newborn Screening Program which shall include, but not be limited to, the following: 1) development and distribution of educational materials regarding the availability and benefits of newborn screening, 2) provision of laboratory testing, 3) development of follow-up protocols to assure early treatment for identified children, and provision of genetic counseling and support services for the families of identified children, 4) provision of necessary dietary treatment products or medications for identified children as indicated and when not otherwise available, 5) for each newborn, provision of screening in each ear for the presence of permanent hearing loss, and 6) for each newborn, provision of pulse oximetry screening to detect congenital heart defects.

• GS130A-127. This statute requires NC DHHS to establish and administer a perinatal health care program. The program may include, but shall not be limited to, the following: 1) prenatal health care services including education and identification of high-risk pregnancies, 2) prenatal, delivery and newborn health care provided at hospitals participating at levels of complexity, and 3) regionalized perinatal health care including a plan for effective communication, consultation, referral and transportation links among hospitals, health departments, physicians, schools and other relevant community resources for mothers and infants at high risk for mortality and morbidity.

• GS130A-129-131.2 These statutes require NC DHHS to establish and administer a Sickle Cell Program. They require that LHD provide sickle cell syndrome testing and counseling at no cost to persons requesting these services and that results of these tests will be shared among the LHD, the State Laboratory, and Sickle Cell Program contracting agencies which have been requested to provide sickle cell services to that person. In addition, these statutes establish the Governor’s Council on Sickle Cell Syndrome, describing its role and the appointments, compensation, and term limits of the council members.

• GS130A-131.8-9 These statutes establish rules regarding the reporting, examination, and testing of blood lead levels in children. Statutes 131.9A-9G include requirements regarding the following aspects of lead poisoning hazards: 1) investigation, 2) notification, 3) abatement and remediation, 4) compliance with maintenance standard, 5) certificate of evidence of compliance, 6) discrimination in financing, 7) resident responsibilities, and 8) application fees for certificates of compliance.

• GS130A-131.15A. This statute requires NC DHHS to establish and administer Teen Pregnancy Prevention Initiatives. The statute describes the management and funding cycle of the program, with the Commission for Public Health adopting rules necessary to implement the initiatives.

• GS130A-131.16-17. These statutes establish the Birth Defects Monitoring Program within the State Center for Health Statistics. The program is required to compile, tabulate, and publish information related to the incidence and prevention of birth defects. The statutes require physicians and licensed medical facilities to permit program staff to review medical records that pertain to a diagnosed or suspected birth defect, including the records of the mother.

• GS130A-152-157. These statutes establish how immunizations are to be administered, immunization requirements for schools, child care facilities, and colleges/universities, and when and how medical and religious exemptions may be granted.

• GS130A-371-374. These statutes establish the State Center for Health Statistics within NC DHHS and authorize the Center to 1) collect, maintain, and analyze health data, and 2) undertake and support research, demonstrations and evaluations respecting new or improved methods for obtaining data. Requirements for data security are also found in the statutes.

• GS130A-422-434. These statutes establish the Childhood Vaccine-Related Injury Compensation Program, explain the Program requirements, and establish the Child Vaccine Injury Compensation Fund.

• GS130A-440-443. These statutes require health assessments for every child in this State enrolling in the public schools for the first time and establish guidelines for how the assessment is to be conducted and reported. Guidelines for religious exemptions are also included.