To effectively plan for improving health, it is important to understand health is shaped by the social, economic, and environmental conditions 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 MCH and CYSHCN population.

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 April 1, 2021, shows 77.2 percent of Florida’s population is white,17.0 percent black, and 5.8 percent other races, mixed race, or unknown. Of the total population by ethnicity, 26.7 percent are Hispanic and 73.3 percent non-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 15.2 percent in this age group nationally in July 1, 2016. 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 (FDOH) is to protect, promote, and improve the health of all people in Florida through integrated state, county, and community efforts. The FDOH’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 FDOH’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 FDOH 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 FDOH 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 priorities based 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 plans include the Agency Strategic Plan, which provides a unified vision and framework for action. This plan positions the FDOH to operate as a sustainable integrated public health system and provide Florida’s residents and visitors with quality public health services. The FDOH 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 2020, the FDOH received re-accreditation as an integrated Department of Health through the Public Health Accreditation Board (PHAB). This seal of accreditation signifies that the unified FDOH, including the state health office and all 67 county health departments, has been rigorously examined and meets or exceeds national standards for public health performance management and continuous quality improvement. The FDOH 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 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 FDOH’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. County health departments 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 FDOH has also 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 county health departments to work with their communities and address environmental health concerns. Collectively, county health departments who have implemented PACE EH in communities have become a national model, and provided evidence that communities can identify environment and urban planning issues as environmental health issues and address the social determinants of health. All projects are designed to open the lines of communication between the county health departments and affected communities. The PACE EH initiative is also supported through the FDOH’s Florida Healthy Babies program.

Children and youth with special health care needs is the primary focus of the Office of Children’s Medical Services Managed Care Plan and Specialty Programs (CMS). Florida has 4.2 million children, of whom approximately 770,000 are CYSHCN. Children with medical complexity, a subset of CYSHCN, number approximately 42,000 children; despite their small numbers, they account for a third of health care spending, 40 percent of deaths, and 25 percent of hospital days. Florida has 18 pediatric children’s hospitals statewide to serve the acute, chronic, and complex needs of children. Despite this large number of hospitals, there is remarkable geographic variation in 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 includes 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) Collaboratively partner with the CMS Plan a managed care plan specifically designed for CYSHCN. CMS partners with the 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 1:1 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 is being developed and readiness assessments will be used to stage providers for the most appropriate PCMH activity. 

1. CMS partners with the 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 1:1 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 is in development and readiness assessments will be used to stage providers for the most appropriate PCMH activity.  

2. Florida has an estimated 400,000 children and youth with one or more mental health conditions, and only about half receive treatment.  With the goal to build capacity of primary care providers to identify and treat common pediatric behavioral or mental health conditions (e.g. ADHD, anxiety, depression), CMS partnered with five university system partners across the state to develop pediatric mental health care access teams.  The aim is to increasing access through telehealth consultations services, while providing skill-building training and technical assistance so that primary care providers can learn to integrate behavioral health services in their practice. These regional partners, along with additional state and system stakeholders, come together to form Florida’s Pediatric Mental Health Collaborative, a statewide network that looks at pediatric  mental health system gaps and needs, including quality improvement and sustainability issues.

3. An informed strategy for community systems approaches is the integration of multisector service systems that work together on community needs, including social determinates of health. CMS’s infrastructure is built on six regional programs that provide the evidenced based practice of public health detailing, providing outreach, education and technical assistance to community partners and health care providers.  These regional teams link community and state resources, create a pipeline of providers for PCMH practice transformation and Behavioral Health integration,  ensuring that local health planning includes CYSHCN.  As such they complete an annual regional assessments, so that state CYSHCN priorities and strategies are informed by regional variation and emerging needs are addressed early.  An additional strategy for integrated community system building, includes CMS’s regional network for access and quality model.   CMS partnered with two community systems to pilot this model, results will inform future community infrastructure building for CYSHCN.

4. CMS  has  59 vendors statewide to ensure that CYSHCN have access to high-quality health care.  A subset of this includes tertiary care systems, that serve seven specific conditions (Behavioral Health, Chronic Kidney, Craniofacial, Endocrine, Hematology- Oncology, HIV/AIDS and Pulmonary). The focus of these contracts has  shifted away from direct care services, and individual institutional approaches to building an integrated system of care, forming statewide networks for access and quality (SNAQ).  A collaborative learning approach includes 32 quality improvement teams, across the state from their various institutional programs, that come together to work on common quality improvement projects through peer to peer learning and technical assistance with the National Institute for Children’s Health Quality (NICHQ).

5. CMS administers a Medicaid Managed Care plan and CHIP option for clinically eligible CYSHCN, known as the CMS Plan operated by contracted vendor. Effective February 1, 2019 CMS implemented its new health care delivery system model which was conceived with comprehensive stakeholder input at the family, provider, and community levels; as well as state and national experts. Over 91,000 of Florida’s CYSHCN are currently enrolled in the CMS Health Plan, receiving direct care services for their medical, behavioral, and developmental needs. The CMS Health Plan provides increased payments to high-performing providers and enhanced care coordination services to families. To address social determinates of health, the CMS Plan offers families “in lieu of” services and enhanced benefits, such as over-the-counter stipends, home and grocery allowances, non-medical transportation and caregiver behavioral health services. The CMS Plan is a valuable partner for the Title V CYSHCN program, and bi-directional communication help inform each other 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 measures in the CMS Plan; this innovative approach promises to help ensure that health care services are aimed at addressing critical child and family needs. In addition, Title V and the CMS plan are working on a pilot model to look at value based payment models for transitioning youth to adult health care services.

The Office of Minority Health and Health Equity (OMHHE), led by the Senior Health Equity Officer, serves as the FDOH’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 state’s racial and ethnic minority communities are addressed, as well as the needs of people who are lesbian, bisexual, gay, transgendered (LGBT).

The FDOH established a Health Equity Program Council to focus on the issue of health equity. The council is comprised of county health department officers and leaders in the state health office. The council guides county health department and state health office efforts by monitoring emerging research and expanding and implementing evidence- based practices statewide.

The first project of the Health Equity Program Council was Florida’s Healthy Babies Initiative, the FDOH’s direct response to focus on the black-white infant mortality gap. Annually, the FDOH invests $1.5 million in Title V funding. Funding was initially provided to the county health departments to conduct an enhanced data analysis on infant mortality, including an environmental scan of existing pertinent programs, and to host a community action-planning meeting to examine disparities in infant deaths, the role of social determinants of health, and to propose local action. The program has evolved since then.  County health departments are encouraged to use their data to inform projects and strategies that are implemented to address infant mortality in their communities. Workplans are completed each year and quarterly updates are submitted detailing the progress that has been made.

Encouraging physical activity and healthier food choices has a positive impact on birth outcomes and child health. Women who are healthier before and during pregnancy lessen the risk of maternal and infant morbidity and mortality. Several factors determine what people eat, but access to healthy food and beverages has a major influence. Finding healthy food is not always convenient. Studies have found that people buy food that is readily available. Today, it is often the case that communities with the highest rates of obesity are also places where residents have few opportunities to conveniently purchase nutritious, affordable food.  The FDOH has a SNAP Education grant that helps teach people to shop for and cook healthy meals.  This happens at the CHD level.

The rate of pregnant women diagnosed with opioid use disorder (OUD) during labor and delivery in the U.S. more than quadrupled from 1999 to 2014, according to a 2018 analysis by the Centers for Disease Control and Prevention (CDC). In Florida, the rate increased from 0.5 per 1,000 delivery hospitalizations in 1999 to 6.6 in 2014.  The FDOH has several initiatives to address this.

To identify Neonatal Abstinence Syndrome (NAS) cases, the FDOH currently uses a passive case ascertainment methodology that relies on linked administrative datasets and diagnostic codes indicative of NAS. First, birth certificate records from the Bureau of Vital Statistics are linked to the infant’s birth hospitalization record, which is provided as part of quarterly submission of inpatient hospital discharge data by hospitals to the Agency for Health Care Administration (AHCA). Each discharge record includes International Classification of Diseases, Clinical Modification (ICD) diagnosis codes documented during the hospital encounter. The prevalence rates of NAS in Florida have increased from 2.8 to 67.3 per 10,000 live births from 1998-2015. After 2015, the prevalence of NAS decreased to 56.3 per 10,000 live births in 2019. This prevalence rate equates to an average of 1,400 cases of NAS per year in Florida since 2011. (most recent data available).  Over the last two years the statewide trend in NAS rates has decreased, from a rate of 67.2 per 10,000 live births in 2017 to the current rate of 56.3 per 10,000 live births in 2019.

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 FDOH 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 bring 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.

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.

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. Due to the COVID-19 pandemic, the number of visitors dropped from 131.4 million in 2019 to 79.4 million in 2020. However, in the first six months of 2021, Florida welcomed nearly 59 million tourists, up from 39.9 million during the first six months of 2020. This is a 47.9 percent increase. The 2021 estimate, includes 57.2 million domestic visitors, 1.7 million overseas visitors and 0.1 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, Florida was home to 732,000 unauthorized immigrants in 2018. California and Texas are the only states with greater numbers of unauthorized immigrants.

The racial, ethnic, and cultural 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 FDOH supports the culturally diverse MCH 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 FDOH 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.

The health of the economy plays a major role in the health status of the state’s MCH population. The economy in Florida has been recovering since the onset of COVID19.  The average annual wage of $50,020 in Florida currently stands at 88.8 percent of the national average in May 2020. Florida’s economy is heavily reliant upon the service-related industry, where minimum wage jobs with little or no benefits are more the norm than the exception. In November, 2020 voters approved a minimum wage increase to $15.00 an hour. This increase will scale up over the next six years.  While this is a move in the right direction, until this increase is fully realized, many individuals and families continue to struggle to meet their basic needs. Groups disproportionately affected are female-headed households and people who are Black, Hispanic, living with a disability, and unskilled recent immigrants. According to the latest final numbers from the U.S. Bureau of Labor Statistics, Florida’s unemployment rate was 5.0 percent in June 2021, this is lower than the national employment rate of 5.9 percent. However, prior to the COVID-19 pandemic, Florida had historically low unemployment rates Florida had a four-year adjusted cohort graduation rate for public high schools of 86.9 percent in 2018-19. In comparison, the corresponding national rate was 85.8 percent during the 2018-19 school year. Florida’s standard diploma is a rigorous credential for which standards and testing requirements have periodically increased. As states have different criteria for awarding a standard diploma, comparing rates among states is problematic.

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 FDOH takes emergency preparedness seriously for all sorts of possible threats or disasters. Most recently this includes preparation and response as a result of the COVID-19 pandemic. 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 FDOH 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 county health departments 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, F.S. Administration of Maternal and Child Health Programs. The statute authorizes the FDOH 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 FDOH to be the agency that receives the federal MCH and Preventive Health Services Block Grant funds.

Section 383.216, F.S., 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, F.S. 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 (FAC), establishes rules governing prenatal and infant screening for risk factors associated with poor outcomes, and rules related to metabolic, hereditary, and congenital disorders.

The basic statutory authority for CYSHCN and their families is Chapter 391, F.S., known as the Children's Medical Services Act. Section 391.016, F.S., 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), F.S., is specific to the administration of the CYSHCN program in accordance with the Title V of the Social Security Act.