The Maternal and Child Health Block Grant Needs Assessment is the guiding document for the MCH and CYSHCN programs. Partners and users of the needs assessment include county health departments, health districts, health planning organizations, health and social service organizations, federally qualified health centers, partner agencies, social service agencies, academic institutions, and numerous other organizations. Within the FDOH, it is used for improvement planning; agency strategic planning; workforce assessment planning; informing, educating and empowering residents about maternal and child health issues; and identifying research and innovation opportunities.
FDOH staff bears statutory responsibility for the ongoing monitoring of the needs assessment; however, the FDOH is only one part of the MCH and CYSHCN system. Efficient collaboration and coordination with other agencies, non-governmental organizations, institutions, and informal associations play an essential role in the needs assessment process.
Continual monitoring identifies priority health and quality of life issues and provides a focus for the organizations and entities that contribute to the MCH and CYSHCN system. Assessing strengths and weaknesses identifies the important health issues that are emerging or in need of potential new direction and may also identify additional health issues as perceived by residents and consumers. Lastly, continual monitoring and assessment determine forces that impact the way the MCH and CYSHCN system operates, including areas such as legislation, funding and funding shifts, and technology or other impending changes that may affect state residents, visitors, tourists or the system itself. These changes may provide opportunities for improvement and efficiency.
In 2020, Florida’s overall infant mortality rate was 5.8 per 1,000 live births. The Healthy People 2030 target is 5.0 infant deaths per 1,000 live births. When the data are separated by race/ethnicity, the rate was 4.2 for White infants, 4.7 for Hispanic infants, and 10.7 for Black infants in the state. Statewide rates in 2020 were not statistically significantly different than rates in 2011. The FDOH is working to lower these rates through a variety of methods, including improving preconception health care and behaviors, safe infant sleep practices, breastfeeding practices, and smoking cessation rates among pregnant women, as well as strengthening relationships with community members and organizations.
MCH Indicators Dashboard
The MCH Section is often tasked with responding to requests from FDOH leadership and State Legislators for the most up-to-date quarterly data on fetal and infant mortality, birth rate, C-sections, and preterm births. A dashboard for each of these indicators will be updated monthly and quarterly and presented in tables containing results of statistical significance tests and data by county and state total. Aggregate data will be displayed in tables and graphs. Having an automated process for these inquiries would improve program efficiency.
Fetal and Infant Mortality Review (FIMR) Surveillance System Evaluation
An evaluation of the FIMR program began in July 2021. FIMR projects in the state of Florida are implemented by local Healthy Start Coalitions, and their individual practices and policies can vary between coalitions. The main goal of this evaluation is to identify areas in the FIMR process that would benefit from state-wide standardization, and improve the efficiency of infant mortality data collection, analysis, and dissemination. A key component of this evaluation is the input of FIMR team members on the efficiency of the FIMR process, which will be collected via an online survey. FIMR projects are comprised of two interdisciplinary teams: (1) the Case Review Team (CRT) and (2) the Community Action Team (CAT). The CRT, which consists of physicians, social workers, nurses, midwives, coroners, and mental health workers, ultimately drafts recommendations for community improvements based on case summaries. The CAT, which works to implement the recommendations of the CRT within the community via community education, program development, and existing program evaluation, is comprised of government representatives, health and human service organizations, and passionate community members.
Florida Maternal Mortality Review Committee (Florida MMRC)
The FDOH continues to gather and publish data on pregnancy-related deaths. Florida MMRC, formerly known as the Pregnancy-Associated Mortality Review (PAMR), 2018 Report was finalized and is available on FDOH’s website. The 2018 data update report provides an overview and comparisons of pregnancy-related death data and trends for Florida between the years 2008 and 2018.
Over the years, the Florida MMRC has produced four Urgent Maternal Mortality Messages (UMMM) aimed at providers. These UMMMs have been on hemorrhage-placental disorders, peripartum cardiomyopathy, maternal early warning systems for hospitals, and most recently opioid use during pregnancy. These messages were distributed to providers through Florida perinatal professional associations such as the District XII American College of Obstetricians and Gynecologists; Association of Women’s Health, Obstetric and Neonatal Nurses, Association of Certified Nurse Midwives; and the Florida Perinatal Quality Collaborative. The work of the Florida MMRC drives the FDOH priority that all of Florida’s mothers and infants receive high-quality, evidence-based perinatal care to help ensure the best health outcomes possible.
The Florida MMRC continues to use the Maternal Mortality Review Information Application (MMRIA) data system developed by the CDC. The MMRIA data system is designed to empower the maternal mortality review community to create action through a common data language and bring standardization to the maternal mortality review process across the nation. MMRIA is designed to support standardized case abstraction; case narrative development; documentation of committee deliberations on pregnancy relatedness, preventability and contributing factors; and routine analyses.
The Florida MMRC is also featured on the Association of Maternal and Child Health Programs (AMCHP) Review to Action website at: www.reviewtoaction.org, where Florida MMRC briefs and annual reports are available for viewing.
Children and Youth with Special Health Care Needs
In 2018, Children’s Medical Services (CMS) was facing a challenge to transform from a direct-care service model to a public health assurance model. During our 2018 and 2019 projects, Children’s Medical Services worked with the MCH Workforce Development center to strengthen the skills of our team, focusing on change management, systems-thinking, and appreciative inquiry. These skills were put to the test using various tools including the 5 Rs, logic model, and system support mapping in order to develop the framework for Florida’s Regional Networks for Access and Quality (RNAQs). Three year follow up demonstrates that CMS has strengthened skills and abilities of teams and the number of Title V CYSHCN staff reporting that they could apply the skills they learned from the MCH workforce skill development training increased by 46 percentage points. CMS launched an additional 9 professional development opportunities, aligned with the public health core competencies in July 1, 2021 and developed a mentorship program, in which the pilot launch is anticipated in October 2021. As a result of the progress made, CMS was able to address this priority need and discontinue this previous state performance measure.
Annual Regional needs assessments inform strategic planning at both the community and state level for the CYSHCN program. As Florida’s regions are very diverse, this process helps ensure sensitivity and early identification with emerging themes or needs as well as alignment with the current priorities. Results from the annual assessment process continued to support the priority needs of access to patient centered medical homes (PCMH), and access to behavioral/mental health treatment.
An estimated 4.2 million children and adolescents under the age of 17 reside in Florida. The National Survey of Children’s Health for 2018-2019, indicates that approximately 47 percent of children and adolescents (ages 3-17 years) diagnosed with a behavioral/mental health condition do not receive the needed treatment. The afore-mentioned data is representative of children previously reported as screened and diagnosed, and was prior to the nation’s pandemic, COVID-19. Many children have yet to be screened for mental health disorders and may need care that has yet to be determined. Conclusions can be drawn that untreated behavioral and mental health conditions are pervasive across the state. Children are not receiving adequate services due to child and adolescent psychiatrist shortages, the maldistribution of providers, lack of behavioral health screenings, cultural barriers, stigma, and cost. As a result of COVID-19, evidence supports that depression and anxiety rates in children have doubled; further exacerbating the need for access to behavioral/mental health treatment.
The American Association of Child and Adolescent Psychiatry workforce map shows that there is a severe overall shortage of practicing child and adolescent psychiatrists in Florida, with only 412 practicing child and adolescent psychiatrists. This averages to 10 child and adolescent psychiatrists per 100,000 children. The child and adolescent psychiatrist shortage is not projected to improve significantly as the current workforce ages and not enough providers replace retirees. Long-standing evidence proposes behavioral health integration as key to combating mental health provider shortages.
Collective and intersectoral approaches occur across state and local organizations; however, there is no designated statewide network in place to communicate, learn, and participate in a quality improvement collaborative specific to behavioral health integration for children and adolescents. In response, CMS in in the early implementation stages with the establishment of a statewide network entitled the “Florida Pediatric Behavioral Health Collaborative” (FPBHC).
CMS is organized into seven geographic regions to address the large size and extreme variation in population density and available resources of our state. Employing national guidelines, academic medical university partners, also known as Behavioral Health Hubs (BHHS), partner locally with primary care practices and community mental health networks, with the goal of providing consultation and technical assistance in building the primary care providers capacity and skills to better identify and treat common behavioral health conditions in children. Starting with five regional academic medical university partners, child and adolescent psychiatrists provide regional training and consultation to primary care providers via telehealth and other modalities, thus building capacity in the primary care provider workforce. Each BHH works with community mental health experts, primary care providers, community partners and families and youth to collaborate in addressing the specific needs of their region based on local resources. BHHs have the autonomy to tailor integrated behavioral models based on their areas and readiness of local providers.
In response to the increased need for access to mental/behavioral health services, CMS applied to HRSA’s 2021 Pediatric Mental Health Care Access grant funding opportunity. The goal is to build two additional regional Behavioral Health Hubs (BHH), in needed underserved areas, to join Florida’s existing five BHHs and further fortify the FPBHC statewide network with representation in all of CMS’s seven geographic areas.
The statewide FPBHC is led by the CMS leadership team (Florida’s Title V CYSHCN Director and Bureau Chief/Director of Clinical Operations) and include representatives from state government agencies and organizations such as the Agency for Health Care Administration (AHCA), Medicaid program, Department of Children and Family’s Substance Abuse and Mental Health (DCF-SAMH) program, Florida Chapter of the National Alliance on Mental Illness (NAMI), and champions from the five existing BHH. As a statewide network, FPBHC will be responsible for organizing statewide communication and meetings, ensuring continuous quality improvement efforts and coordinating with state and community partners, especially through the technical assistance workgroup that operates like as Statewide Advisory Council.
The annual regional needs assessment process for CYSHCN, also identified asthma ER and hospitalization rates as a troubling trend. Leveraging the partnership with the FDOH’s Bureau of Chronic Disease Prevention led to the formation of a workgroup. As a result additional educational materials are in development, home visiting programs were utilized with expansion being planned, and a clinical pilot in a tertiary care center is underway.
Engaging with the two RNAQs has been an opportunity to work with one long standing partner in a new way, as well as establish new relationships with a complex clinic we had not previously worked with. The two teams are now currently collaborating through information sharing and developing a joint quality improvement project. In addition to the established RNAQs, a direct result of our teams’ strengthening system-building capabilities has resulted in the launch of Florida’s Statewide Networks for Access and Quality (SNAQs). These SNAQs are condition-specific teams (e.g. Hematology/Oncology, Endocrine, HIV) that work locally to strengthen their local systems of care (using the National Standards for Systems of Care for Children and Youth with Special Health Care Needs) as well as work together on joint quality improvement projects through a Learning and Action Network (LAN) orchestrated by the National Institute for Children’s Health Quality (NICHQ).
Family engagement and partnership, as part of health equity, continues to be a need including our SNAQ partners. Strategic planning includes the development of a how to or road map guide, with outlined steps and resources for systems to utilize in their implementation of family voice at all system levels. Family engagement and partnership will be a primary theme for this year’s LAN. To provide partnerships across sectors to optimize maternal and child health populations, especially in the LAN environment, teams are looking at ways to work with people outside of the traditional health care system, mainly education right now.
The SNAQs (and other groups mentioned) have started to embrace population health approaches and better integration, and are thinking about and working on ways to better collaborate and communicate with PCPs with the goal of integrating primary care, specialty care, and public health. In order to develop evidenced-based and efficient health systems, CMS staff, the RNAQs, SNAQs and the other groups are all analyzing the data and working together to identify evidence-based or informed strategies in improving the care they deliver and the way children receive it.
Additional needs assessment findings has led to other recent or emerging partnership development to help improve the system of care for CYSHCN, including:
- Got Transition is working with Children’s Medical Services and its vendor for the CMS Health Plan on a transition pilot
- A Dental/Orthodontia workgroup has been developed to help to address CYSHCN, access to services.
- A Pediatric Palliative Care Coalition to increase awareness of and access to palliative care in Florida
- Bullying prevention for CYSHCN
Emerging Public Health Issues
COVID-19 Pandemic
During earlier months of the COVID-19 pandemic, many places worldwide, including multiple U.S. states, began implementing stay-at-home orders and other policies to mitigate the spread of SARS-CoV-2. During this time, some investigators observed declines in preterm birth, yet others reported no change. Recognizing patterns in preterm birth rates within the United States during the pandemic may enhance understanding of the preterm birth etiology and guide programmatic strategies to reduce its incidence. We collaborated with 11 other states to examine preterm birth rates during the COVID-19 pandemic in 2020 compared with 2017–2019. We will conduct a more comprehensive analysis specific to Florida to examine rates of different birth outcome variables by various demographic, social, and clinical factors.
Furthermore, soon we will analyze Florida data from the Pregnancy Risk Assessment Monitoring System (PRAMS) COVID Supplement to gain a better understanding of how the COVID-19 pandemic has affect our maternal and child health population. The Florida PRAMS is a surveillance system of maternal behaviors and experiences before, during, and shortly after pregnancy. PRAMS survey responses can help improve resources, health care, and program services available to women and children across Florida. Supplemental questionnaires are added to the survey to address emerging topics, most recently COVID-19 infection. We will analyze this data to examine COVID-19-related delays in prenatal care and lack of social support, such as not being able to receive help with the baby and not having a partner or family member to accompany the mother to prenatal care visits or breastfeeding classes. Results will help identify potential strategies to improve the pregnancy experience and quality of health care and programs.
Out-of-Hospital Births
The popularity of out-of-hospital births in Florida has steadily grown for the past two decades, from a low of 0.87% of live births in 2001 to 1.77% in 2019. Provisional data indicates that in 2020, 2.04% of live births occurred out-of-hospital, a significant increase compared to the prior year. In August 2021, an in-depth surveillance report of planned out-of-hospital births in Florida began, examining maternal demographics, risk factors, and birth outcomes of these pregnancies. The goal of this report is to evaluate the changing landscape of women’s healthcare, and improve access to quality healthcare before, during, and after pregnancy.
Opioid Crisis
Maternal Mortality
In 2021, the FDOH received an award notification from the Centers for Disease Control and Prevention (CDC) regarding the Preventing Maternal Deaths: Support Maternal Mortality Review Committees grant, to support agencies that coordinate and manage a maternal mortality review committee. The FDOH applied for the funding opportunity to strengthen the current Florida MMRC process. The grant will allow the Florida MMRC to enhance the current comprehensive case identification and review of pregnancy-related deaths and expand the ability to thoroughly review pregnancy-associated deaths, such as substance abuse and suicide cases. A pregnancy-associated death is a death to a woman from any cause, while she is pregnant or within one year of termination of the pregnancy, regardless of duration and site of the pregnancy. Pregnancy-related deaths are a subset of pregnancy-associated deaths. The Florida MMRC will also work with state and local partners to explore ways to address racial disparities in maternal deaths, create effective and actionable recommendations for care improvement, and convert those recommendations into actions.
Development of a State Health Improvement Plan Objective on Father/Partner Engagement
For Florida's upcoming 2022–2026 State Health Improvement Plan (SHIP), the state has been working to add a MCH objective focused on father or partner engagement during the perinatal period. Florida’s SHIP stems from collaborative work of a diverse group of statewide partners to create a blueprint for action, under the leadership of the State Surgeon General. The SHIP sets goals for Florida's public health system, including state and local government agencies, health care providers, employers, community groups, universities and schools, non-profit organizations, and advocacy groups. We conducted a literature review and summarized interventions that sought to improve partner involvement during pregnancy. Results from this review will guide Florida on selecting an appropriate evidence-based objective for the 2022–2026 SHIP cycle.
Development of a Safe Infant Sleep & Breastfeeding Event Planning Toolkit for African American Sororities and Fraternities
African American infants are at a higher risk of dying than other racial and ethnic groups in the United States. Two ways to prevent infant deaths are practicing safe infant sleep and breastfeeding. To increase safe infant sleep and breastfeeding, community events can be used as tools to inform African American communities by trusted individuals. African American Greek Organizations or Fraternities and Sororities, as trusted community members, can play an important role in decreasing infant sleep practices that are not safe and increasing breastfeeding initiation and duration in areas of Florida that need the most help. By using this toolkit, African American Greek Organizations can join in the ongoing effort to save babies from dying of preventable causes and help eliminate racial disparities. We will meet with representatives of these organizations again to obtain feedback on our drafted toolkit.
Literature Review: Long-Acting Reversible Contraception (LARC) Interventions Across the Social Ecological Model (SEM)
With support from two students from the Title V Internship Program, we conducted a literature review of interventions that sought to increase use of LARC methods, namely intrauterine devices and implants. LARC methods safely prevent unintended pregnancies and short interpregnancy intervals, which increase the risk of adverse birth outcomes. We applied the SEM perspective, a framework for improving health that considers individual, interpersonal, organizational, community, and policy levels of influence to identify patterns of effectiveness across the SEM. We summarize findings from interventions that sought to increase LARC use and map interventions to SEM levels. In addition to sharing findings with key MCH partners in the state, we will submit a paper for publication.
Medicaid Data Analysis on Postpartum Contraceptive Use
With support from the Graduate Student Epidemiology Program, funded by the Health Resources and Services Administration, we analyzed Medicaid data provided by Florida’s Agency for Health Care Administration to examine postpartum contraceptive use among Women on Medicaid from 2016 through 2020. We examined patterns of effective contraception, including LARC use, among postpartum women with Medicaid insurance in two age groups (15-20 and 21-44) at 3 and 60 days postpartum after linking eligibility, claims, and encounter Medicaid data. We also explored the patterns of postpartum contraception use by age group, race/ethnicity, poverty status, refugee status, delivery type, and Medicaid type.
Index of Concentration at the Extremes (ICE) and Preterm Birth Analysis
In collaboration with experts from federal and academic institutions, we are examining ICE as a risk factor of preterm birth subtypes. ICE is a promising measure of spatial polarization that can simultaneously capture extremes of privilege and deprivation as well as economic and racial/ethnic segregation. Identifying differences between spontaneous and medically-indicated preterm birth or live births <34 or 34-36 weeks gestation may guide Florida public health and clinical interventions on how to strategically focus resources on groups most affected by racial and economic disparities.
The FDOH is operationalizing a health equity framework into all program and policy work beginning with the needs assessment process and findings, and culminating into the State Health Improvement Plan (SHIP) and Agency Strategic Plan. The framework includes:
- Improving the accessibility of the health system through outreach, location, physical design, opening hours, and other policies.
- Improving the patient-centeredness of the system by providing culturally competent care, interpretation services, and assisting patients and families who face social and economic barriers to care.
- Partnering with other sectors to improve population health.
The block grant outlines innovations and opportunities for operationalizing each of these aspects of health equity to advance on and improve our needs assessment findings. Furthermore, in partnership with members of our SHIP MCH Workgroup, we established a formal process for assessing MCH programs and policies from a health equity perspective.
Following are some changes since last year’s application in the Department’s leadership positions that provides oversight to Title V:
Shay Chapman, BSN, MBA was named Deputy Division Director for Community Health Promotion in March 2021. Prior to her new role, Shay served as the Bureau Chief for Family Health Services.
Cassandra Pasley, BSN, JD was appointed as Chief of Staff. Prior to her appointment, she served as the Division Director for Medical Quality Assurance.
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