Delaware is a small mid-Atlantic state located on the eastern seaboard of the United States. Geographically, the state's area encompasses only 1,982 square miles, ranking Delaware 49th in size among all states.

According to estimates from the U.S. Census Bureau, in 2018, the State of Delaware had about 967,171 residents, of which approximately 70% were White and 23% were Black. The Hispanic population is steadily increasing, from 8.7% in 2013 to 9.5% in 2018.  About 21.1% of Delawareans are children under the age of 18 and 5.7% were under the age of five.

Of Delaware's three counties, New Castle County, in the northern third of the state, is the largest in population with about 559,335 residents or about 58% of the state's total population. New Castle County has a large population of African-American residents (nearly 26%) and within the city of Wilmington, the state's largest concentration of African-American residents (about 58% of the city's population). New Castle County also has a large population of Hispanic residents, 10%. Kent County, home to the state’s capital of Dover, has an estimated 178,550 residents (66% White and 27% Black). For Sussex County, which includes very rural areas as well as coastal resort towns, the 2018 population was approximately 229,286 (83% White, 12% Black). Like New Castle, Sussex County also has a growing Hispanic population, estimated at 9.3% for 2018.

In 2018, statewide, it is estimated that there were about 179,749 women of childbearing age and 252,103 children and adolescents aged 0-21 years of age (Census).Preliminary data shows 10,615 births for 2018.  According to 2016-2017 combined years of data 23.1% or 46,973 (23.2% just for 207 with a sample of 101) have special healthcare needs.

Economic Indicators

In Delaware, from 2016-2018, it is estimated that 14.9% of children, aged 0-17, were living in poverty, with the highest rates among those children aged 0-5 (14.9%).  According to Kids Count in Delaware, 2019, from 2016-2018, 21.6% of Delaware's children lived in a household with underemployed parents (where no parent worked full-time, year round) compared to the U.S. percentage of 26.1%.  About 22% percent of children who live in single-parent households in Delaware lived in poverty, compared to 5.1% of children living in two-parent households. The median income of two-parent households in Delaware from 2016-2018 was $103,271, compared to $36,569 for single-parent households.

Of Delaware's children, 33.9% lived in a one-parent household in the 2016-2018 time. Almost half (46.7%) of births occurring in the five-year period 2013-2017 were to single mothers, with 70.5% of Black births, 61.5% of Hispanic births, and 34.9 of White births occurring among single mothers (Kids Count in Delaware, 2019). As of 2017, an average of 67,900 households per month received food assistance through Delaware's Supplemental Nutrition Assistance Program (SNAP).  (KIDS Count in Delaware, 2019).

Availability of Health Providers

Although Delaware is a relatively small state, disparities exist between its three counties with regard to healthcare access.  Access to health care services poses an issue for many uninsured, underserved and otherwise at-risk populations in Delaware.  A myriad of factors affect access to health care, including lack of health insurance, lack of providers, an overall mal-distribution of providers, etc. The Health Resources and Services Administration/Bureau of Health Workforce designated the following as Health Professional Shortages Areas (HPSAs).  Regardless of their location, Federally Qualified Health Centers (FQHCs) are also automatically designated as HPSAs.  In addition, many of the state correctional facilities are designated as HPSAs. 

New Castle County:

• 4 Primary Care HPSAs
• 1 Dental HPSA

Kent County in its entirety is a:

• Medically Underserved Population
• Primary Care HPSA
• Dental HPSA

Sussex County in its entirety is a:

• Medically Underserved Area
• Primary Care HPSA
• Dental HPSA
• Mental Health HPSA

Services for CYSHCN

In Delaware, Children and Youth with Special Health Care Needs (CYSCHN) are served by the Birth to Three Program for infants and toddlers aged 0-3 and by evidence based home visiting program services.  The mission of the Birth to Three Early Intervention System is to enhance the development of infants and toddlers with or at risk for disabilities or developmental delays, and to enhance the capacity of their families to meet the needs of their young children.  Child Development Watch (CDW) is the statewide early intervention program under the Birth to Three Early Intervention System.  The CDW program provides developmental assessments of children birth to 3 years of age and service coordination for developmental services and therapies.  CDW is a collaborative effort with staff from the Division of Public Health, the Department of Services for Children, Youth and Their Families, the Department of Education and the Alfred I. DuPont Hospital for Children (the only children’s hospital in Delaware) working together to provide early intervention to young children with special health care needs and their families. 

The Children and Youth with Special Health Care Needs Director (CYSHCN) sits in the Division of Public Health’s Maternal and Child Health Bureau in the Family Health Systems Section.  This position is essential as it functions to bolster and cultivate family and professional partnerships by working closely with families and family-led organizations.  Delaware’s Birth to Three system works in coordination with the CYSHCN Director through Family SHADE, a large network of partners that work to improve the system of care of services and develop family-centered care, which has become part of the culture for DPH in addressing the needs of families of young children with special needs. 

Context for Title V within the State

In Delaware, the executive branch of state government is headed by Governor John Carney. Within the executive branch, the Delaware Department of Health and Social Services (DHSS) is a cabinet-level agency, and is led by Secretary Kara Odom-Walker. The Delaware Department of Health and Social Services (DHSS) consists of 12 divisions and the Delaware Healthcare Commission, with an overarching mission to improve the quality of life for Delaware's citizens by promoting health and well-being, fostering self-sufficiency, and protecting vulnerable populations. The Delaware Division of Public Health (DPH), one of the largest divisions within DHSS, is the Title V agency responsible for planning, program development, administration and evaluation of maternal and child health (MCH) programs statewide. DPH is led by Karyl Rattay, MD, MS, FAAP, FACPM who serves as the Division Director.

Because our state does not have county or local health departments, DPH administers both state and local public health programs. Within DPH, the Family Health and Systems Management (FHSM) section has direct oversight of Title V, including the Children and Youth with Special Health Care Needs (CYSHCN) Program.

Authority and regulatory charges for the Division of Public Health come from Title 16 of the Delaware Administrative Code, which governs health and safety. Specific to Family Health, the code includes provisions for operation of a Birth Defect Surveillance and Registry Program and an Autism Surveillance and Registry Program, both of which are funded in part by Title V. The Delaware Healthy Mother and Infant Consortium (DHMIC) is also established in code, and is charged with coordinating efforts to prevent infant mortality and improve the health of women of childbearing age and infants in the State. As such, our Title V Program works closely with the DHMIC to align our priorities and strategies as much as possible. There are also provisions in Title 16 for school-based health centers and the Newborn Hearing and Screening Program, which are not funded by Title V, but work in close coordination with the program.

In May 2014, Governor Markell signed House Bill 214, requiring Down syndrome education material and information support be offered to health care professionals and parents.  Specifically, this bill requires that hospitals, physicians and other health professionals, who provide a prenatal or postnatal diagnosis of Down syndrome have access to resources and information that is up-to-date and evidence-based for distribution to parents and caregivers. 

The goal is for parents to receive timely and accurate information about Down syndrome to help them seek resources and have the best knowledge-base when caring for their child.  The Division of Public Health, in partnership with the Down Syndrome Association of Delaware, provides access to up-to-date information in two booklets available to health professionals online.  The first pamphlet entitled “Delivering a Down Syndrome Diagnosis” is for health professionals and contains additional websites and reference materials.  The second is a booklet to share with parents entitled “Understanding a Down Syndrome Diagnosis” available in English and Spanish.

The pamphlets are available free of charge by request from the website: www.Lettercase.org .  Additional information is available for Delaware health professionals and parents on the Down Syndrome Association of Delaware website:  www.dsadelaware.org . The Division of Public Health offers additional resources for health professionals and for parents at: www.DEThrives.com.

Current Priorities of the Division of Public Health

DPH is embarking on the Public Health 3.0 approach. Public Health 3.0 refers to a new era of enhanced and broadened public health practice that goes beyond traditional public health department functions and programs. Cross-sectoral collaboration is inherent to the Public Health 3.0 vision. We are collaborating across multiple sectors and leveraging data and resources to address policies as well as social, environmental, and economic conditions that affect health and health equity. We spent the better part of eight months re­ searching and analyzing our existing goals, strategies, and data; examined current national and local public health challenges; and considered future public health challenges. As a result, we have identified four strategic priorities, of which our new strategic plan is based: Promote Healthy Lifestyles; Improve Population Health and Reduce Health Care Costs; Achieve Health Equity; Reduce Substance Use Disorder and Overdose Deaths. The DPH is doubling its efforts to work collaboratively alongside Delaware state agencies and external stakeholders to address the immediate and long-term health consequences of substance use disorder and violence in communities. To tackle these complicated issues, DPH sees its role as providing prevention expertise, as well as technical assistance related to evidence­ based population health practices.

DPH staff will actively implement this strategic plan by improving our services, participating in robust workforce development activities, and practicing the LeadQuest 10 Principles of Personal Leadership.

Public Health has a unique lens. Our guiding principles call upon us to engage in population-based activities to strengthen community-based public health. Research continues to tell us that while 95 percent of our health care dollars are spent on acute care, these dollars account for only 10 percent of improvements to our health status. For sustainable results, our future efforts must include collaborating with communities to improve their ability to identify the most important determinants of health, to develop strategies to address them, and to implement those strategies. This strategic plan is evidence of our commitment to working strategically with our partners to achieve our vision of healthy people in healthy communities.

The process to revamp the Division of Public Health (DPH) strategic plan for the period 2019 to 2023 began in August 2017. At that time, the DPH Strategic Leadership Group agreed to form a Strategic Plan Action Committee to begin the process of updating the organizational strategic plan. The Strategic Plan Action Committee consisted of these leadership team volunteers including the Title V Director.

The DPH strategic planning process called for a much larger group to review and provide input to the plan.

This larger group included the full DPH Leadership Team, DPH employees, and DHSS leadership. Once the Strategic Plan Action Committee drafted the plan, the full DPH leader­ ship team was given the opportunity to review and provide input.  The plan was then updated and the final draft was provided to DHSS leadership and DPH employees for review and input. Final updates were made and the DPH Division Director formally adopted the DPH 2019-2023 Strategic Plan on January 1, 2019.

During the strategic planning process, the Strategic Plan Action Committee reviewed and used many resources to inform our organizational strategic plan. Those included the State Health Assessment, The Delaware State Health Improvement Plan, Priorities of Governor John Carney and DHSS, national organization public health reports, public health journal reports, and other health entity strategic plans. Another activity that the Strategic Plan Action Committee undertook was to identify and analyze organizational strengths; weaknesses, opportunities, and threats (SWOT) during the strategic planning process.

The State Health Assessment (SHA) is an examination of the health of our population. Data gathering for a needs assessment to develop this document began in 2016. The data, pulled from a variety of sources including focus groups, were used to identify local and statewide trends for the identification and prioritization of strategies. The ultimate goal of the SHA is to develop strategies to address critical health needs and identify challenges and assets in the state in a comprehensive way. All results were compiled and analyzed collectively to paint a collective picture of Delaware’s health. This comprehensive process yielded the following four top-level priority areas of focus: chronic disease; maternal and child health; substance use/misuse; and mental health

The plan is posted at http://www.dhss.delaware.gov/dhss/dph/files/shna.pdf.

Simultaneously, the Division is engaged in maintaining its accreditation status by the Public Health Accreditation Board (PHAB).  The Division of Public Health achieved this prestigious designation as an accredited health department in 2016.  This is an ongoing effort to maintain our designation over the next five years, which will need to be monitored.  Reports are submitted annually to demonstrate that we continue to meet the PHAB standards. 

The findings, goals, and strategies that are part of both the Delaware SHIP and DPH’s strategic plan will be intentionally factored in to the Title V needs assessment process, with the goal of leveraging the results of these comprehensive planning efforts. We believe the input gathered from professional MCH stakeholders, families, and community members through surveys, focus groups, and interviews will reinforce the priorities of healthy lifestyles; population health and reducing health care costs; achieve health equity; substance use disorder and overdose deaths

Health Equity

In Delaware, there is increased attention being directed to address health disparities, and with good reason.  Here are just a few examples of the disparities that exist within our state:

• Infant Mortality.The annual infant mortality rate for 2017 was 6.6 per 1,000 as compared to 5.8 for the U.S. The five-year infant mortality rate was 7.3 (12.1 for non-Hispanic blacks and 4.5 for non-Hispanic whites).
• Breastfeeding. In 2016-2017, the percent of Black infants who were ever breastfed was 67.8%, compared with 84.6% of White infants. 
• Teen Births. The five-year average teen birth rate in the U.S. and in Delaware declined. The five year average in Delaware for the 2000-2004 teen birth rate was 43.2 and for 2013-2017 teen birth rate it was 20.3 (~53% decline).  Delaware’s non- Hispanic black five-year average teen birth rate was 76.9 in 2000-2004 and 30.8 in 2013-2017 (~60% decline) as compared to non-Hispanic white five-year teen birth rate 27.1 in 2000-2004 and 13.0 in 2013-2017 (~52% decline). The disparity ratio in the teen birth rates was 2.4 times for Black teens to White teens.  Despite the racial disparities, Delaware made great strides in five-year average rates among white and black teen birth rates through several population based health interventions.
• Overall Health.  Overall, in 2016-2017, 90.3% of Delawareans reported to be in excellent/very good health (Hispanic, 87.4%; White, 93.4%; Black, 86.3%; Other, 89.1%) as compared with 89.8% (Hispanic, 85.3%; White, 93.2%; Black, 84.2%; Other 90.1%) in the U.S.  There was a similar disparity for income level for families who reported to be in excellent/very good health.  In Delaware for FPL below 100%, it was 85.6%; FPL 100-199% 88.4%; FPL 200-399% 90.2%; and 400%> 94.6% as compared with 80.6%, 87.4%, 92.2%, 95.7% respectively.
• Smoking. For 2016-2017, compared to Black (20%) and Hispanics (12%), a slightly higher percentage of White (23%) mothers stated they had smoked in the 3 months before pregnancy.  When asked whether they smoked in the last 3 months of their pregnancy, the percentage responding “Yes”, was 10 for Black, 3% for Hispanic, and 11% for White women. (DE PRAMS 2016-2017)
• Medical Home. In 2016-2017, 56.0% of white children with special health care needs had a medical home (U.S. 48.3%) as compared with 48.2% of black children (U.S. 38.7%) and 49.9% of other children (U.S. 44.5%). Due to small sample size, Hispanic data was not available for Delaware but the estimate for the U.S. was 34.8%.  (2016/17 National Survey of Children with Special Health Care Needs).

It is clear from these examples that disparities exist across racial and ethnic groups, across ages, and across geographical boundaries.  We know that many of these inequities are a result of the social determinants of health. Focus groups conducted for our needs assessment confirmed that our population experiences challenges with access to transportation to medical visits, access to healthy foods, and safe places to be active. There are language barriers and issues of cultural competency that prevent our Spanish-speaking citizens from being able to benefit from the programs and services that are available. And access to specialists and quality care is often limited by the county in which one lives.

There is momentum building to address health disparities in our state. The Delaware Division of Public Health has established health equity as a strategic priority for the entire division.  Every person deserves equal access to safe communities that foster opportunities to achieve optimal health and well-being.  The Delaware Healthy Mothers and Infants Consortium continues to emphasize health equity and the social determinants of health, through highlighting the topic on Annual MCH Summit agendas, bestowing health equity awards to individuals and organizations to recognize efforts, and launching an online Health Equity Action Center (http://healthequityde.com/).  

Recognizing the importance of social determinants of health, a place-based, community approach has been established as a key component.  In the past year, a request for proposal was posted to solicit proposals for a backbone organization to manage what we are calling the Healthy Women Healthy Babies (HWHB)Zones project.  This is main focus of the Delaware Healthy Mother and Infant Consortium’s efforts as it aims to reduce the infant mortality rate. 

Health Management Association (HMA) won the bid.  They proposed a five-year plan with that includes developing a mini-grant process to fund local community-based organizations or entities.Over the course of five years, HMA will provide technical support and training to ensure interventions implemented within the targeted zones are as impactful as possible.  They are proposing to create learning collaboratives of mini-grant awardees and community health workers that will meet in person on a quarterly basis. During these learning collaboratives, grantees will have the opportunity to learn from each other, network with community health workers, learn best practices, understand and learn to leverage existing programs on resiliency and self-sufficiency and do continuous quality improvement based on collected data. HMA will, based on available funding, be able to provide mini-grant awards to the same organizations over the course of five years, allowing organizations to demonstrate outcomes, while also providing opportunities for new grantees to apply for funding following the first year of the project.  As part of the selection process, HMA will ensure mini-grant awardees have the capacity to collect data and track measures. Our lead evaluator will work closely with each awardee to support them in developing infrastructure to collect shared data metrics, as well as monitor their impacts, engaging in continuous quality improvement efforts as opportunities for improvement are identified through evaluation processes.

Health Care Reform Efforts in Delaware

Health care spending per capita in Delaware is higher than the national average. Historically, health care spending has outpaced inflation and the state’s economic growth. Health care costs consume 25% (or approximately 1 billion in FY 2017) of Delaware’s budget. Medicaid cost per capita and the growth in per capita spending have been above the national average. These challenges are not unique to Delaware – affordability is of equal concern to private employer sponsors of Commercial health insurance, as well as some consumer segments who have seen increases in deductibles, copays, and coinsurance.  Delaware’s demographics and the percentage of our citizens with chronic conditions are key drivers of both spending and poor health outcomes. Delaware’s population is older and is aging faster than the national average – we will be the tenth oldest state by 2025. We are also sicker than the average state, with higher rates of chronic disease, in part driven by social determinants including poverty, food scarcity, and violence. In the most recent publication of America’s Health Rankings, Delaware ranked 31st, exceeding the national average in cancer deaths per capita, cardiovascular deaths per capita, diabetes per capita, infant mortality, and premature death. The hospital landscape is more concentrated in Delaware than in most other markets, with just six acute care hospital systems across the state, with most populations relying on a single hospital for their care. Our hospital systems vary widely in both scale as well as operational efficiency. Primary care and some other physician specialties remain fragmented. Other physician specialties are concentrated. Behavioral health care is in short supply in some parts of the state. Increased demand for health care, as well as inefficiencies in the supply of health care, in combination lead to 25% greater historical spend per capita than the U.S. as a whole, which itself has among the highest cost health care systems in the world. While we spend more on care, our investments have not led to better health or outcomes for Delawareans. We spend more than average, not to get better access or higher quality care, but simply to address the challenges of an older and sicker population.

After receiving federal grant monies through the Centers for Medicare and Medicaid’s State Innovation Model (SIM) project, Delaware has made a significant investment in transitioning to value-based payment models. Value based payment models enable collaboration between providers and health systems in addition to allowing a greater focus on keeping people healthy through improving primary care. This is vastly different from the traditional Fee for Service model that aligns payment for services with volume, regardless of patient outcomes and whether the overall population of the state is getting healthier. The State has supported these changes from a policy perspective by setting the expectation for Medicaid Managed Care Organizations (MCOs) and State Employee/Retiree Third-party administrators to offer and promote the adoption of value-based models. Currently, nearly 40% of primary care practices have participated in primary care practice transformation funded by the federal grant. Delaware recently became the first state in the country to achieve universal participation of our adult acute care hospitals in the Medicare Shared Savings Program. Some of these hospital systems as well as other physicians-led Accountable Care Organizations have recently begun to expand their participation into the Commercial segment as well. Overall, 30% of Delawareans are attributed to providers participating in value-based payment models. Despite this progress, many primary care providers in smaller practices have not yet chosen to participate in value-based models, and even for larger health systems the change to value based payments can be expensive requiring retraining of providers, paying for services not reimbursed under the Fee for Service model, and making investments in health IT or other infrastructure to support value. In Delaware, we may already be seeing the limitations of a purely voluntary adoption model for payment reform.

Delaware is moving forward with global health care benchmarks.  Governor Carney established heath care spending and quality benchmarks in Executive Order 25, issued on November 20, 2018. The full implementation manual contains the technical and operational steps that the Delaware Health Care Commission (DHCC) and the Delaware Economic and Financial Advisory Council (OEFAC) Health Care Spending Benchmark Subcommittee (DEF AC Subcommittee) will need to take to implement Executive Order 25. The full manual contains the methodologies for setting the health care spending and quality benchmarks, and the methodologies for calculating performance against the benchmarks. It also contains the technical specifications for data reporting and collection. This Executive Summary contains the highest-level articulation of a very detailed process.  The most recent manual can be found at https://dhss.delaware.gov/dhcc/global.html .

The Health Care Commission (HCC) will continue to support the Department of Health and Social Services in their efforts to construct and launch a health care benchmark plan for the state focused on total cost of expenditures in the state (Choosehealthde.com). Health care costs consume 30% of Delaware’s budget.  The benchmark plan is essentially a target for health care spending growth. By increasing transparency and the dialogue about total health care spending, we can identify opportunities for cost and quality improvement. Benchmark reporting will be at the system level and may look at large organizations, such as accountable care organizations, but not at small, individual practices. New models for payment will be developed in collaboration with Delaware payers, providers, and consumers. The HCC and its vendors will also continue to focus on transparency and quality efforts through payment reforms on many fronts—linking with DHIN and the practice transformation efforts under SIM.

Behavioral health integration is also a very important aspect of Delaware’s practice transformation work. Founded on the plan developed in year three of the SIMs work, the HCC plans to work with practices across the state to improve their capacity to address behavioral health needs alongside primary care.  In November 2018, the Delaware Health Care Commission awarded the first value-based payment reform mini-grant to Christiana Care Health System to test a new reimbursement model that will also improve the coordination of patient care.  Christiana Care Health System’s CareLink Behavioral Health Medical Home Pilot was awarded $62,168 to test a reimbursement model to foster behavioral health integration within primary care practices focusing on a subset of AmeriHealth Medicaid members with chronic behavioral health conditions as a primary diagnosis.

The HCC will also continue to support other practice transformation activities, and seek ways to support provider engagement in Delaware’s Health Information Network (DHIN).  Behavioral health is also a core priority of our maternal and child health work, mitigating adverse childhood experiences (ACES), NPM decrease rates of bullying by promotion social and emotional wellness, as well as supporting adolescent health through the 32 school based health centers that we monitor, whereby mental health visits make up 40% of all visits.

Legislation was also introduced this year and passed both the House and Senate, Senate Bill 227, and now is ready for the Governor’s signature.  The bill will 1) require the Health Care Commission to collaborate with the Primary Care Reform Collaborative to develop annual recommendations to strengthen the primary care system in Delaware 2) Require all health insurance providers to participate in the Delaware Health Care Claims Database. 3. Require individual, group, and State employee insurance plans to reimburse primary care physicians, certified nurse practitioners, physician assistants, and other front-line practitioners for chronic care management and primary care at no less than the physician Medicare rate for the next 3 years. The scope of the Primary Care Reform Collaborative long-term recommendations would include payment reform, value based care, workforce and recruitment, directing resources to support and expand primary care access, increasing integrated care (including for women and behavioral health), and evaluating system-wide investments into primary care using claims data.