To effectively plan for improving health, it is important to understand health is shaped by the social, economic, cultural, and environmental factors in which we live, and the available and accessible community resources. It is necessary to address the conditions that impact our health rather than only treating medical conditions after they occur. This section discusses the principal characteristics important to understanding the health status and needs of not only Florida’s population, but more specifically the Maternal and Child Health (MCH) and Children and Youth with Special Health Care Needs (CYSHCN) populations.

According to statewide population estimates conducted by the Florida Legislature, Office of Economic and Demographic Research, Florida has a total population of 22.0 million citizens in 2021, following only California and Texas as the third most populous state. Between 2011 and 2021, Florida’s population increased by 16.0 percent. The most recent demographic data for July 1, 2021, shows 77.3 percent of Florida’s population is white,16.9 percent black, and 5.8 percent other races, mixed race, or unknown. Of the total population by ethnicity, 26.4 percent are Hispanic. More than half of the state’s population (51.3 percent) is between the ages of 25-64 and 27.8 percent are between the ages of 0-24. Individuals 65 and older comprise 20.9 percent of the state’s population compared to just 16.5 percent in this age group nationally in 2019. A greater percentage of health care resources are expended on the elderly population in Florida compared to other states.

The mission of the Florida Department of Health (Department) is to protect, promote, and improve the health of all people in Florida through integrated state, county, and community efforts. The Department’s goal is to be the healthiest state in the nation. Our values are illustrated by the acronym ICARE:

• Innovation: We search for creative solutions and manage resources wisely.
• Collaboration: We use teamwork to achieve common goals and solve problems.
• Accountability: We perform with integrity and respect.
• Responsiveness: We achieve our mission by serving our customers and engaging our partners.
• Excellence: We promote quality outcomes through learning and continuous performance improvement.

Accomplishing our mission begins with fundamental plans of action. The Department’s State Health Improvement Plan (SHIP) establishes goals for the public health system, which includes state and local government agencies, health care providers, employers, community groups, universities and schools, nonprofit organizations, and advocacy groups. The Department uses a collaborative planning process to foster shared ownership and responsibility for the plan's implementation, with the goal of efficient and targeted collective action to improve the health of Floridians.

The Department is leading a diverse group of stakeholders to build Florida's SHIP for 2022-2026. This includes conducting a comprehensive state health assessment to identify the most important health issues. The SHIP Steering Committee is currently meeting to set five-year goals and objectives on the health issues and strategic opportunities identified in the assessment.

To keep projects on track, SHIP objectives will continue to have Priority Area Workgroups that meet quarterly. These workgroups are comprised of partners around the state who share updates on their projects that are impacting the SHIP goals. This time is also used to identify any barriers individuals may be experiencing and problem solving to overcome these barriers.

Additional Department plans include the Agency Strategic Plan, which provides a unified vision and framework for action. This plan positions the Department to operate as a sustainable integrated public health system and provide Florida’s residents and visitors with quality public health services. The Department is actively developing a new agency strategic plan for the coming five years. The Long- Range Program Plan provides the framework and justification for the agency budget. It is a goal-based plan with a five-year planning horizon and focuses on agency priorities in achieving the goals and objectives of the state.

In March 2022, the Department received re-accreditation as an integrated Department through the Public Health Accreditation Board (PHAB). This seal of accreditation signifies that the unified Department, including the state health office and all 67 county health departments (CHDs), has been rigorously examined and meets or exceeds national standards for public health performance management and continuous quality improvement. The Department was required to provide examples of quality improvement activities to demonstrate conformity with the PHAB standards and to maintain accreditation status.

The Title V MCH and CYSHCN directors, along with MCH and Children’s Medical Services (CMS) staff, utilize various methods to determine the importance, magnitude, value, and priority of competing factors that impact health services delivery. The five-year needs assessment and continual assessment during interim years provides valuable direction. Many of the Department’s priorities, policies, and services originate through legislative bills, statutory regulations, administrative rules, and directives from the State Surgeon General. Priorities for improving public health are addressed through a variety of plans that address collaboration with our partners as well as internal agency priorities. The Title V program receives input and advice from statewide partnerships, stakeholders, and other agencies and organizations.

Comprehensive community health assessment and health improvement planning are the foundations for improving and promoting healthier communities. CHDs use a common process for collecting, analyzing, and using data to educate and mobilize communities, develop priorities, gather resources, and plan and implement actions to improve public health.

At the state and local levels, three critical assessments provide the basis for action: community health status assessment, forces of change assessment, and local public health system assessment using the National Public Health Performance Standards Program. Assessment findings inform the selection of strategic community health priorities.

Goals, strategies, and measurable objectives are used to develop a community health improvement plan that includes implementation strategies and action plans. Two important, tangible products of these efforts are state and community health status profile reports and state and community health improvement plans, resulting in state and local documents reflecting each area's needs and priorities.

The Department has adopted the National Association of City and County Health Officials’ Protocol for Assessing Community Excellence in Environmental Health (PACE EH). For several years, the Bureau of Environmental Health has encouraged CHDs to work within their communities and address environmental health concerns.

Collectively, CHDs who have implemented PACE EH in communities have become a national model. These counties provide evidence that communities are able to identify environmental and urban planning concerns that affect health and wellbeing. All projects are designed to open the lines of communication between the CHDs and the affected communities. The Department’s Florida Healthy Babies program assists in supporting the efforts of PACE EH.

The Office of Minority Health and Health Equity (OMHHE), led by the Senior Health Equity Officer, serves as the Department’s coordinating office for consultative services and training in the areas of cultural and linguistic competency, partnership building, program development and implementation, and other related comprehensive efforts to address the health needs of minority and underrepresented populations. The OMHHE promotes the integration of culturally and linguistically appropriate services within health-related programs across the state to ensure the needs of the underserved communities are addressed.

The Florida’s Healthy Babies (FHB) program was established to address the black-white infant mortality gap in the state. The FHB program has expanded efforts since its inception. CHDs are encouraged to use their local data to inform projects and strategies that are implemented to address the six identified FHB priority areas within their communities. These priority areas include Infant Mortality, Maternal Mortality, Well Woman Care, Unplanned Pregnancy Prevention and Teen Pregnancy Prevention, Dental and Oral Health, and Access to Care. The Department allocates $3.7 million among the 67 CHDs to support these efforts. Workplans are completed each year and quarterly updates are submitted detailing the progress that has been made.

Per the 2020 Census, individuals in Florida identifying as only Native American comprise a total of 107,389. In addition, Native Americans experienced a 50.3 percent increase in identification as Native Americans (alone) over the 10-year (2010-2020) period. This is a greater increase than white or black (alone) over the same period. Florida shares borders with the reservations of two tribal governments, the Seminole Tribe and the Miccosukee Tribe. These governments have their own public safety and emergency services for reservation residents, but a substantial portion of their tribal citizens live outside the reservation boundaries. The Department established the American Indian Health Advisory Committee to provide guidance on issues impacting American Indian populations in Florida. The committee consists of representatives from tribes and stakeholders serving American Indian communities and staff from the Office of Minority Health and Health Equity. Florida is also home to many non-governmental tribal communities, whose members may be spread out geographically but who gather frequently to maintain their community's identity, culture, language, traditional knowledge, and traditional ways. These groups do not have government status either as a preference, or because their structure is not suited to political governance, or because they cannot provide documentation that they maintained a tribal government during the years that it was illegal to do so. A subset of this category would be American Indian Christian Churches, which brings members and descendants of various American Indian nations together around a shared faith practice that incorporates inter-tribal practices in their worship. Another subset of this category would be American Indian associations that organize cultural gatherings that are open to visitors. Yet another subset are American Indian associations concerned with activism in favor of American Indian causes.

Typically, Florida is a temporary home to well over 100 million tourists and visitors each year, which presents challenges to the state’s public health system. In the first quarter of 2022, Florida welcomed nearly 36 million tourists, up from 26 million during the first quarter months of 2021 according to VisitFlorida.org. This is a 27.8 percent increase. The 2022 estimate includes 34.1 million domestic visitors, 1.3 million overseas visitors and 0.6 million Canadian visitors. Migrant farm workers and unauthorized immigrants also have a significant impact on the state’s public health services and resources. According to the most recent data from the Migration Policy Institute, Florida was home to 772,000 unauthorized immigrants in 2019. California, Texas, and New York are the only states with greater numbers of unauthorized immigrants.

The diversity of Florida’s population creates unique challenges, as well as increased opportunities. This diversity makes Florida a more interesting place to live, work, and play. The Title V program, along with private and public health providers, contributes to meeting the challenges that come with the state’s diverse group of residents, immigrants, tourists, and visitors. The Department supports the culturally diverse MCH and CYSHCN population by tailoring services provided through the Title V program to meet the needs of different cultures. Educational materials are developed in English, Spanish, and Haitian Creole. The Department contracts with Language Line Services to provide telephonic interpretation services in over 180 languages, allowing a client to communicate with a health care provider through a conference or three-way calling system. Language Line Services also provides written translation services in over 100 languages and translates documents into multiple languages.

Florida’s total area is 58,560 square miles. Driving from Pensacola in the western panhandle of Florida to Key West at the southernmost point is nearly an 800-mile journey. The 1,200 miles of coastline become a target during hurricane season, and 2,276 miles of tidal shoreline are subject to concerns regarding water quality and fish and wildlife habitat degradation. With the threat of tropical depressions and hurricanes looming every summer, the Department takes emergency preparedness seriously for varying possible threats or disasters. Florida’s Public Health Preparedness effort is an excellent model of public-private cooperation. Well organized public-private partnerships benefit from the strengths and competencies of both systems.

When hurricanes approach, the Department operates and staffs Special Needs Shelters (SpNS) to allow people with special or complicated medical needs, their family members, and aides to safely shelter from the storms, with nurses on hand to assist with their needs. At-risk or vulnerable populations include those groups whose needs may not be fully integrated into planning for disaster response. These populations include persons with physical, cognitive, or developmental disabilities. Included in this group are persons with limited English proficiency, the geographically or culturally isolated, medically, or chemically dependent, homeless, frail elderly, children, and pregnant women. Meeting the needs of vulnerable populations during or following a disaster is a key component of public health and medical preparedness planning. FDOH staff collaborate with the CHDs in planning for disasters, staffing the SpNS around the state, and assisting in recovery efforts.

The basic statutory authority for MCH is section 383.011, Florida Statutes, Administration of Maternal and Child Health Programs. The statute authorizes the Department to administer and provide MCH programs, including prenatal care programs, the Women, Infants and Children (WIC) program, and the Child Care Food Program. This statute also designates the Department to be the agency that receives the federal MCH and Preventive Health Services Block Grant funds.

Section 383.216, Florida Statutes, authorizes prenatal and infant coalitions for establishing partnerships among the private sector, the public sector, state government, local government, community alliances, and MCH providers and advocates, for coordinated community-based prenatal and infant health care. Chapter 64F-2, Florida Administrative Code, establishes rules governing coalition responsibilities and operations. Chapter 64F-3, FAC, establishes rules governing Healthy Start care coordination and services.

Section 383.014, Florida Statutes, authorizes screening and identification of all pregnant women entering prenatal care and all infants born in Florida, for conditions associated with poor pregnancy outcomes and increased risk of infant mortality and morbidity. This statute also governs screening for metabolic disorders and other hereditary and congenital disorders.

Chapter 64C-7, Florida Administrative Code, establishes rules governing prenatal and infant screening for risk factors associated with poor outcomes, and rules related to metabolic, hereditary, and congenital disorders.

The statutory authority for CYSHCN and their families is Chapter 391, Florida Statutes, known as the Children's Medical Services Act. Section 391.016, Florida Statutes, establishes the Children’s Medical Services Program, and defines two primary functions: provide to children and youth with special health care needs a family-centered, comprehensive, and coordinated statewide managed system of care that links community-based health care with multidisciplinary, regional, and tertiary pediatric specialty care; and provide essential preventive, evaluative, and early intervention services for children at-risk for or having special health care needs, to prevent or reduce long-term disabilities. Section 391.026(13), Florida Statutes, is specific to the authorization of administration of the CYSHCN program in accordance with the Title V of the Social Security Act. 

CYSHCN, from birth through 21 years of age, is the responsibility of the Office of Children’s Medical Services Managed Care Plan and Specialty Programs (CMS). With Florida having over 5.2 million children and youth from birth through 21 years of age, and a population estimate of 18.6% being CYSHCN, that equates to a population focus of almost 1 million. When looking at the subset of children and youth, birth through 17 years of age, Florida has over 4.2 million children, of whom approximately 796,500 are CYSHCN. Children with medical complexity (CMC), a 1-2% subset of CYSHCN, represents approximately 42,000 to 84,000 children. Despite their small numbers, CMC account for a third of health care spending, 40 percent of deaths, and 25 percent of hospital days. Florida has 18 children’s hospitals statewide to serve the acute, chronic, and complex needs of children. Despite this large number of hospitals, there is a lack of access to specialty care.

To ensure that all CYSHCN receive care in a well-functioning system, CMS engages in a wide variety of activities which include five main leverage opportunities: (1) Transform pediatric practices into patient-centered medical homes; (2) Build behavioral health integration capacity with pediatric primary care providers; (3) Address community integrated system building in Florida’s diverse regions; (4) Improve access and quality through contracts with specialty networks that have condition-specific expertise; and (5) Partner with the CMS Plan a managed care plan specifically designed for CYSHCN.

In transforming pediatric practices into patient-centered medical homes, CMS partners with Florida’s only designated National Committee for Quality Assurance (NCQA) Partner in Quality, the University of Central Florida’s Health Advancing Resources to Change Health Care (UCF HealthARCH). Annually UCF provides technical assistance to support pediatric practices in their Patient Centered Medical Home (PCMH) practice transformation, and continued assistance for renewal requirements. To expand to a population health approach, a learning action network was developed, and readiness assessments have been used to stage providers for the most appropriate PCMH activity.

Florida has over 500,000 children and youth, ages 3 through 17, with one or more mental health conditions, and less than half (45.4%) receive treatment. To build behavioral health integration capacity of primary care providers specifically to improve identification and treatment of common pediatric behavioral or mental health conditions (e.g., ADHD, anxiety, depression), CMS partnered with five universities and two health care systems across the state to develop pediatric mental health care access teams. The aim is to increase access through telehealth consultations services, while providing skill-building training and technical assistance so primary care providers can learn to integrate behavioral health services in their routine practice care. These regional teams, known as Behavioral Health Hubs (BHHs), along with additional state and system stakeholders, come together to form Florida’s Pediatric Mental Health Collaborative, a statewide network that examines pediatric mental health system gaps and needs, including quality improvement and sustainability issues.

Based on the recommendations from the Public Health 3.0 framework, an informed strategy includes the engagement of multiple sectors and community partners to generate collective impact including broad social, economic, cultural, and environmental factors. CMS’ infrastructure is built on a public health workforce (field and program specialists) that provide the evidenced based practice of public health detailing, outreach, education and technical assistance to health care providers, community, state, and national partners. This public health workforce drives initiatives, links community and state resources, creates a pipeline of providers for PCMH practice transformation and behavioral health integration, and ensure that local health planning includes CYSHCN. As such they complete an annual regional assessment so that state CYSHCN priorities and strategies are informed by community variation and emerging needs are addressed early. An additional strategy for integrated community system building includes CMS’ Regional Network for Access and Quality (RNAQ) model. CMS partnered with two community systems to pilot this model. Results from their needs assessment inform community infrastructure building for CYSHCN. This was illustrated when one of the RNAQ’s noted a troubling trend with an increase in their county’s teen suicide rate, exceeding the state rate. Their follow up activity included conducting a specialized training in the assessment and management of youth with depression or suicide risk with over 330 primary care providers participating in this virtual training. CMS also utilizes its regional BHH partners in this framework to help form a vibrant, structured, cross-sector statewide partnership. For example, the five regional BHH’s completed over 267 pediatric mental health consultations, with the RNAQ completing 55 in an area not served by a regional BHH. 

CMS has 46 contracted vendors statewide to ensure that CYSHCN have access to high-quality health care. A subset of vendors includes tertiary care systems that serve seven specific conditions, e.g., behavioral health, chronic kidney, craniofacial, endocrine, hematology-oncology, HIV/AIDS, and pulmonary. The focus of these contracts has shifted from direct care services and individual institutional approaches to building an integrated system of care and forming Statewide Networks for Access and Quality (SNAQ). A collaborative learning approach includes 32 quality improvement teams across the state that collaborate on common quality improvement projects through peer-to-peer learning and technical assistance with the National Institute for Children’s Health Quality (NICHQ). Key tenets of family partnership, community integration, transition, and workforce wellbeing are woven into the learning, dialogue, and application to quality improvement work. Last year over 150 plan, do, study, act (PDSA) cycles were completed.

CMS administers a Medicaid managed care plan and CHIP option for clinically eligible CYSHCN, known as the CMS Plan. Since February 1, 2019, CMS has successfully implemented its new health care delivery system model which was conceived with comprehensive stakeholder input at the family, provider, community, state, and national levels. An annual average of more than 90,000 of Florida’s CYSHCN are currently enrolled in the CMS Plan, receiving direct care services for their medical, behavioral, and developmental needs. The CMS Plan offers enhanced care coordination services to families and value-based payments to high-performing providers. Last year 98% of members reported satisfaction with their Care Manager, and 97% reported being satisfied with services from the community. To address social determinants of health, the CMS Plan offers families “in lieu of” services and enhanced benefits, such as over-the-counter stipends, housing assistance, non-medical transportation, and caregiver behavioral health services. For example, last year over-the counter stipends were provided 203,146 times, with grocery assistance being provided 48,571 times.

The CMS Plan and Title V CYSHCN program partnership features bi-directional communication of needs, trends, and leverage opportunities to improve the service delivery system for CYSHCN in Florida. For example, a Title V initiative to review quality measures led to the inclusion of quality of life (QOL) measures in the CMS Plan. This innovative approach can help ensure that health care services are aimed at addressing critical child and family needs. A QOL data sample indicated that out of 2,225 members who previously scored fair or poor for general health responses, 60% of those members increase their response to good, very good or excellent upon reassessment. In addition, Title V, the CMS Plan, and national partner, Got Transition® are collaborating on a pilot study of value-based payment opportunities for transitioning youth to adult health care services. This pilot program spans 12-months and incorporates the coordinated exchange of medical information, a plan of care, a joint telehealth visit with member/family, pediatric and adult care provider, and facilitated integration into adult care. Providers will receive an enhanced fee-for-service payment with reimbursement at 100% of the Medicare fee schedule for both pediatric and adult providers.  Members will receive a direct-to-consumer payment incentive which will consist of a $25 Visa Prepaid card for attending each scheduled appointment within the first 6 months after the member transitions to an adult care provider.