State Title V Program Purpose and Design

The Nevada Department of Health and Human Services (DHHS) oversees five Divisions, including Child and Family Services (DCFS), Health Care Financing and Policy (DHCFP/NV Medicaid), Aging and Disability Services (ADSD), Welfare and Supportive Services (DWSS), and Public and Behavioral Health (DPBH). The Nevada Title V MCH Program is part of the Maternal, Child and Adolescent Health (MCAH) Section of the Bureau of Child, Family, and Community Wellness within DPBH. The mission statement of DPBH, "It is the mission of the Division of Public and Behavioral Health to protect, promote and improve the physical and behavioral health of the people of Nevada, equitably and regardless of circumstances, so they can live their safest, longest, healthiest, and happiest life," is the guiding directive for all DPBH programs.

Title V Framework

Title V MCH has adopted the “10 Essential Public Health Services to Promote Maternal and Child Health” framework to guide programmatic decision making. This framework best encompasses Nevada’s approach to incorporating assessment, policy development, and assurance components into Title V programs. Examples generated from Title V MCH staff of how Nevada promote maternal and child health for each of the essential services are presented below:

Nevada is dedicated to improving Nevada families' health, emphasizing women, birthing people, infants, and children, including children and youth with special health care needs (CYSHCN). Title V funding from the Health Resources and Services Administration (HRSA) supports:

• Health education and prevention activities
• Increasing access to health care services
• Developing, and leveraging key partnerships and collaborations
• Planning and implementing program components reaching specific populations in collaboration with community-level partners, coalitions, non-profit organizations, and other state agencies

National Performance Measures (NPM), Evidence-Based or- Informed Strategy Measures (ESM), and State Performance Measures influence Nevada Title V MCH priorities. Nevada's Title V MCH 2020 Needs Assessment demonstrated the need to focus on the following priorities.

• Improve preconception and interconception health among individuals of childbearing age
• Reduce substance use during pregnancy
• Promote breastfeeding
• Promote Safe-Sleep
• Increase developmental screening
• Provide a Medical Home
• Improve care coordination among adolescents
• Increase transition care for adolescents and CYSHCN

Nevada Title V MCH Program staff meet weekly to discuss programmatic updates and address the needs of partners, collaborators, and subawardees. Nevada Title V MCH also remains flexible to adapt to the changing health outcomes for Nevadans. Emerging issues require Nevada Title V MCH staff to stay abreast of evolving MCH healthcare needs. Nevada Title V MCH currently address the following emerging issues:

Congenital Syphilis

In 2018, Nevada was the top ranked state for primary and secondary syphilis rates and ranked second for congenital syphilis (CS) rates. In 2019, Nevada remained the top ranked state for primary and secondary syphilis rates, while falling to fourth for CS rates. These rankings remained the same for 2020, but in 2021 Nevada fell to sixth for primary and secondary syphilis rates and ninth for CS. Although Nevada has dropped in the national raking, our rates have continued to increase. According to the CDC and presented in Figure 1, below, primary and secondary syphilis rates increased in Nevada, from 4.1 per 100,000 persons in 2012 to 29.9 per 100,000 persons in 2021. With this increase in syphilis cases follows a rise in CS. CS rates in Nevada have been rising since 2012, as illustrated in Figure 2, below. Nevada’s CS rates increased slightly by 1.8% from 2020 to 2021, and over the 10-year period from 2012-2021 increased 4,507%, from 2.9 to 133.6 per 100,000 persons (2.9, 5.7, 13.9, 22.0, 33.1, 57.9, 85.5, 114.7, 131.2, and 133.6).

MCAH staff are members of the CS Workgroup for Nevada and have been instrumental in CS prevention informational campaign development and resource distribution.

Figure 1. Rates of Primary and Secondary Syphilis in Nevada                  Figure 2. Rates of Congenital Syphilis in Nevada

Teen Suicide

Teen suicide is an emerging issue in Nevada. Data from National Vistal Statistics System (NVSS) shows the adolescent suicide rate for those ages 15-19 years per 100,000 adolescents in Nevada was 15.1 for the reporting period of 2019-21. Nevada’s 2019-21 teen suicide rate is higher than the U.S. rate of 10.6 suicides per 100,000 adolescents during the same reporting period. When stratifying adolescent suicide rates for those ages 15-19 years by urban/rural residence, the 2017-21 rate in Nevada was 25.1 in non-metro (rural) areas compared to 16.8 and 14.6 in small/medium and large metro areas, respectively.

Title V MCH will continue to be an active participant in the Healthy Tomorrows Grant with the Nevada Primary Care Association. The Healthy Tomorrows project is focused on creating adolescent-friendly spaces in Federally Qualified Health Centers to increase repeat visits and a develop a patient-centered medical home for Nevada’s adolescents. Title V MCH Program funding also helped support the Nevada Office of Suicide Prevention (OSP) with teen suicide prevention and systems-building projects, such as Youth Mental Health First Aid and Project Advancing Wellness and Resiliency in Education (AWARE), via funding for the OSP Manager and the crisis call line. Title V MCH staff also participate on the HRSA Mental Health Evaluation Committee and attend Statewide Children’s Mental Health Consortia meetings. The MCH Director participated in Association of State and Territorial Health Officials (ASTHO)’s Suicide, Overdose, and Adverse Childhood Experiences Prevention Capacity Assessment Tool (SPACECAT) initiative with Substance Abuse Prevention and Treatment Agency (SAPTA), OSP, and Center for the Application of Abuse Technologies (CASAT) partners to focus on ACES and suicide efforts. The AHW Coordinator and MCH Manager participate on a multi-department mental health focused workgroup. MCAH staff participated in Leadership Exchange for Adolescent Health Promotion (LEAHP) activities focused on social and emotional learning and comprehensive reproductive health information.

Substance Use During Pregnancy and Substance Exposed Infants

Close monitoring of substance use during pregnancy and substance exposed infants will continue to be a priority for DPBH and Nevada’s Title V MCH Program. According to data from NVSS, the percent of women who smoked during pregnancy was 3.3% in 2021; a decrease from 5.4% in 2010, or a change of 39%. NVSS data also reflects a modest decline in the use of substances during pregnancy, as the percentage of women who reported smoking, alcohol use, and/or drug use decreased from 5.5% in 2016 to 5.3% in 2019. MCAH will continue to work on state efforts regarding CARA and the Infant Plan of Safe Care including education, training, OMNI/Perinatal Health Initiative work group participation, and increasing awareness.

Nevada PRAMS applied for and received supplemental opioid funding to add 13 additional questions around opioid use to the survey. Opioid supplemental questions were included in the survey for 2018, 2019, and 2020.  These questions make inquiries about substance use before, during, and after pregnancy and provide self-reported data in addition to vital statistics and hospital inpatient data to inform Title V MCH efforts/activities. In July 2022, the Nevada PRAMS Steering Committee voted to permanently add a question about drug use. Starting in birth year 2023, the question will be a permanent part of the survey. Other questions related to opioid and drug use were added to the survey for birth year 2023 as well. To enhance other substance use prevention efforts, PRAMS data was presented to both the OMNI and Promoting Innovation in State/Territorial Maternal and Child Health Policymaking (PRISM) learning communities.

Title V MCH Program staff are core members of the Nevada Perinatal Health Initiative NAS-related efforts in Nevada and also participated in the AMCHP PRISM efforts. MCH funds supported Infant Plan of Care material translation and distribution.

Maternal Mortality Review Committee and Alliance for Innovation on Maternal Health Efforts

The Nevada Maternal Mortality Review Committee was established per Nevada Revised Statutes (NRS) 442.764 in 2019, convening for the first time in 2020. The committee reviews all pregnancy-associated deaths in Nevada (encompassing all deaths of Nevadans while pregnant or within one year of the end of pregnancy, due to any cause) and develops recommendations to prevent future deaths. NRS 442.767 states that the Department of Health and Human Services shall compile and publish a biennial report on or before December 31 of each even-numbered year consisting of data, a summary of disparities, plans for corrective action, and policy and legislative recommendations concerning maternal mortality and severe maternal morbidity in this State.

The Maternal Mortality Review Committee (MMRC) creates recommendations based on their review of deaths that occur during or within a year of pregnancy in Nevada and their case-based recommendations and relevant statewide maternal mortality (MM) and severe maternal morbidity (SMM) data are provided to the Advisory Committee of the Office of Minority Health and Equity which was added as a collaborator in 2021 as amended by Nevada Revised Statutes 442.767 and which contributes recommendations. Themes and priorities are highlighted below. These recommendations include making improvements to mental health care, Medicaid coverage, transportation access, law enforcement processes, increasing maternal health education, childcare access, and access to certain clinical services. The following were identified as priority recommendations by the MMRC; the Advisory Committee of the Office of Minority Health and Equity recommendations highlighted the importance of transportation and primary care access, as well as the importance of the psychiatry rotation during residency MMRC recommendation:

• State of Nevada agencies and programs such as the Department of Health and Human Services, Division of Public and Behavioral Health, and Behavioral Health and Wellness Program, as well as groups such as the Perinatal Health Initiative, should develop a focused campaign and dedicate funding for methamphetamine use in pregnancy reduction.
• State of Nevada agencies and programs should mandate priority access to mental health and medication assisted substance use treatment for pregnant persons by July 1, 2025.
• Division of Child and Family Services, Department of Education, Nevada Part C and Early Intervention Services programs should develop and implement early childhood intervention and trauma therapy for impacted children by July 1, 2024.
• State Medicaid (Division of Health Care Financing and Policy) should receive funding from the State such as a legislative appropriation to expand postpartum coverage in Nevada to 12 months to allow access to behavioral health care and medical care by July 1, 2024.
• Medicaid policy and reimbursement changes for behavioral health care treatment should be allowed and incentivized to encourage it to be performed within medical offices with equal Medicaid reimbursement for medical and behavioral health services by the end of 2024.
• Institutions and hospitals should standardize response and reporting of abnormal perinatal vital signs and severe pain to include not only pain treatment but prompt evaluation of the cause of acute pain and presence of protocols to do so be part of licensing and certification processes for Health Care Quality and Compliance, Division of Public and Behavioral Health by July 1, 2024.
• State of Nevada agencies and programs such as Nevada State Medicaid should improve availability and use of perinatal case coordinators and improve patient communication, with Nevada State Medicaid to receive funding, including but not limited to legislative appropriations to expand existing programs or create new ones to improve perinatal health outcomes by December 31, 2024.
• Education by state medical professional associations by July 1, 2024, to prevent failure to recognize the impact of obesity as a risk factor for poor perinatal outcomes.

Nevada Title V and MMRC staff are working to implement these recommendation as well as other recommendations coming from the MMRC.

Selected MM and SMM Prevention Efforts in Nevada are highlighted below:

• Establishment of a Nevada MMRC and efforts to establish a PQC
• Alliance for Innovation in Maternal Health (AIM) patient safety bundle on hypertension in pregnancy implementation. Nevada AIM launched the hypertension bundle in Fall 2022 and out of the 18 birthing facilities in Nevada, the following are Nevada AIM-participants:
  • Henderson Hospital
  • Humboldt General Hospital
  • Renown Regional Medical Center
  • South Lyon Medical Center (Not a birthing facility, but participating in AIM)
  • Summerlin Hospital
  • Banner Churchill Hospital
  • Centennial Hills Hospital
  • Spring Valley
  • Sunrise Hospital
  • Dignity Health St. Rose San Martin Hospital
• Pregnancy Risk Assessment Monitoring System data collection and surveillance
• University of Nevada, Las Vegas, School of Nursing, Perinatal Regionalization Program
• Hear Her Campaign and maternal warning signs education efforts statewide

Reporting produced by the MMRC support staff is included in Nevada’s Title V MCH Block Grant reporting. Health equity in birth outcomes and maternal domain population health maximization are key areas of topical intersect in priorities of the MMRC, MCAH Section, SSDI Program, AIM, ERASE MM, and Title V MCH Program. SSDI funds help support MMRC administrative support staff.

The Title V MCH Program is in discussions with the NRHP to launch Advanced Life Support in Obstetrics (ALSO), American College of Obstetricians and Gynecologists (ACOG) efforts to reduce rural maternal mortality by working with critical access hospitals.

MMRC support staff presented to groups on data from the biennial report and created products specific to disparities in maternal mortality, mental health, and SUD.

Early Childhood Continuum

Strengthening the early childhood education continuum to include public health is an emerging issue the Nevada Title V MCH Program will help address. The Title V MCH Program will continue and expand efforts to achieve the goal of NPM 6: To increase the percent of children, ages 9 to 35 months, who received a developmental screening using a parent completed screening tool. According to data from National Survey of Children’s Health, Nevada has experienced a significant decrease in the percent of children screened, from 22.3% during 2019-20 to 21.6% during 2020-21. Systems-level interventions are needed to address all components of child development. Title V MCH Program staff will continue to work with the Early Childhood Advisory Council, Pritzker initiatives, Children’s Advocacy Alliance/Pritzker, Early Childhood Comprehensive System, Nevada Early Intervention Services, and NHV to engage diverse partners and leverage existing efforts to address the early childhood continuum. The MCH Director and NHV staff have been core participants in Pritzker efforts in Nevada also related to strengthening the early care continuum.