III.C.2.a. Process Description - Florida - 2023
The Title V Maternal and Child Health (MCH) 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 Department of Health (Department), 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.
The Department staff bears statutory responsibility for the ongoing monitoring of the needs assessment; however, the Department 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 2021, Florida’s overall infant mortality rate was 5.9 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 2021 were not statistically significantly different than rates in 2011. The Department 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 Dashboard
The MCH Section is often tasked with responding to requests from Department 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 is updated monthly and quarterly and presented in tables containing results of statistical significance tests and data by county and state total. Aggregate data is displayed in tables and graphs. Having an automated process for these inquiries improves program efficiency. The dashboard has been completed.
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 the evaluation was to identify areas in the FIMR process that would benefit from statewide standardization, and improve the efficiency of infant mortality data collection, analysis, and dissemination. A key component of this evaluation was the input of FIMR team members on the efficiency of the FIMR process, which will be collected via an online survey. Results of the evaluation are currently being used to provide guidance for the statewide FIMR expansion.
Florida Maternal Mortality Review Committee (Florida MMRC)
The Department continues to gather and publish data on pregnancy-related deaths. Florida MMRC, 2019 Report was finalized and is available on the Department’s website at https://www.floridahealth.gov/statistics-and-data/PAMR/fl-maternal-mortality-review-committee-2019-update.pdf. The 2019 data update report provides an overview and comparisons of pregnancy-related death data and trends for Florida between the years 2009 and 2019.
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 Department 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 2019 Florida MMRC data was used to develop the Pregnancy-Related Deaths Due to Hemorrhage, 2010-2019, data brief. The brief presented an overview of pregnancy-related deaths due to hemorrhage in Florida during 2010-2019 and provided evidence-based recommendations intended to reduce the risk of maternal deaths due to hemorrhage. The brief was released in 2021 and was posted to the Department’s website at pregnancy-related-deaths-due-to-hemorrhage-2010-2019.pdf (floridahealth.gov) and was shared electronically with local and state partners.
The Florida MMRC is also featured on the Association of Maternal and Child Health Programs (AMCHP) Review to Action website at: https://www.reviewtoaction.org/, where Florida MMRC briefs and annual reports are available for viewing.
In 2021, the Department 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 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.
Maternal and Congenital Syphilis Analysis
The dramatic increase in congenital syphilis cases remain a concerning trend in Florida. In 2015, 17.7 infants per 100,000 births were diagnosed with congenital syphilis. By 2020, this rate reached 73.0 infants. Despite prenatal syphilis screening mandates, gaps in preconception and prenatal care persist. In June 2022, a Graduate Student Epidemiology Program (GSEP) intern began working on an analysis using PRAMS data to identify preconception factors associated with maternal syphilis diagnoses. Results from this analysis will help to identify where these gaps in care exist, as well as best strategies for diagnosing and treating syphilis prior to pregnancy.
Opioid Crisis
The opioid crisis continues to be a major issue in Florida. Due to the overwhelming issue of opioid addiction and overdose deaths, goals were added to Florida’s State Health Improvement Plan (SHIP) under the Behavioral Health Priority Area, which encompasses substance abuse. The Department, in partnership with the Florida Department of Children and Families (DCF) and other state agencies, established a priority area workgroup to collaborate on the goals and strategies of the priority area. To address the number of opioid overdose deaths among individuals with opioid use disorders, a campaign was implemented to increase access of naloxone to emergency departments, first responders, and law enforcement agencies, as well as to individuals at risk of witnessing or experiencing an opioid-related overdose. The Department has recently added a component encouraging distribution of naloxone kits in-hand prior to hospital discharge for pregnant and postpartum women with opioid use disorder. Working collaboratively with DCF, the Florida Society of Health System Pharmacists, and the Florida Hospital Association has enabled the Department to identify and eliminate barriers to distributing free kits at discharge. Eight hospitals are participating with maternity unit distribution with expansion to additional hospitals underway. The Department is also working to adapt our Health Management System (HMS) to incorporate components that will allow County Health Departments to screen patients as they check in and begin the brief intervention and referral process, if needed.
In 2022, the State of Florida created the Coordinated Opioid Recovery (CORE) program, in coordination with the Department, DCF, and AHCA, to implement a network of addiction care in up to 12 counties in Florida. CARE is the first of its kind in the United States and places Florida as a leader in sustainable addiction and opioid recovery. The program expands a state-supported cohesive coordinated system of addiction care for individuals suffering from substance use disorder. The network does not solely depend on emergency response for overdoses and substance use disorder. It ensures patients are also stabilized and treated for coexisting medical and mental health conditions. Patients will receive services based on their individual needs that can include dental care, primary care, psychiatric evaluation, maternal care, and social support services that can address career training, housing, or food insecurity. The goal of CARE is for stabilization and to receive medical assisted treatment that is specialized to sustain a clean pathway to success.
Prenatal Risk Screen
In accordance with 383.14(1)(a), Florida Statutes, the Department oversees a multilevel screening process that includes a risk assessment instrument to identify women at risk for a preterm birth or other high-risk condition. The obstetrician completes the risk assessment instrument and reports the results to the Office of Vital Statistics so that the woman may immediately be notified and referred to appropriate health, education, and social services. Currently, the prenatal screening process is paper-driven. Following completion, physical copies of the risk screenings are saved and picked up by County Health Department (CHD) staff monthly. The data is then entered by CHD staff into the Department’s Health Management System (HMS). Following entry in HMS, referrals are made to CONNECT, a community-based process to refer clients to maternal and child health services based on the client’s needs and desires. As a result of this paper-driven process, timely and critical referrals for additional screening, home visiting services, and other supports and services for pregnant women identified at-risk are delayed.
To eliminate delays in timely and critical referrals, the Department’s MCH Section is developing an electronic prenatal screening process that will ensure all women who consent to screening and services receive treatment/services in a timely and reasonable manner. Implementation of an electronic prenatal screening process will allow the Department’s MCH Section to address the statewide prenatal screening rates, easily identify delays and generate reports. The project plan for the upcoming year will incorporate standardizing the prenatal screening process, improving identification of pregnant women who are at-risk for adverse birth outcomes, and identifying health care providers who require technical assistance on their role in the risk screening process, the process to refer to CONNECT, and the benefits of home visiting services. The following accomplishments or outcomes are necessary for this project to be considered successful:
- Prenatal women can complete the electronic prenatal screen with ease and comfortability.
- Providers can access the prenatal screening details during the first prenatal visit or complete the prenatal screen during the first prenatal visit for prenatal women who did not complete the screen prior to visit.
- There is a reduction in the timeframe from identification of at-risk to referrals/treatment.
- Increase in the statewide prenatal screening rates.
Healthy Start
In accordance with 383.216(2)(a)2, Florida Statutes, Healthy Start Coalitions develop a plan that is used to determine outcome performance objectives, jointly with the Department. Additionally, in accordance with 383.216(3)(f), Florida Statutes, supervision of Healthy Start Coalitions is the responsibility of the Department. The Department evaluates provider performance based on the established outcome measures. The Department’s MCH Section continues to adopt, implement, and integrate evidence-based practices into the Healthy Start program to address issues that affect the health of women and infants. To improve these efforts, and to enhance data collection practices that increase the effectiveness of services provided statewide, the MCH Section is working in collaboration with procured consultants (ISF, Inc.) to complete an assessment of provider outcome performance objectives.
Father Engagement
During the 2022 Florida legislative session, House Bill 7065 (Child Welfare) was passed. This legislation amended Section 383.011, Florida Statutes, to expand services provided by Florida’s Healthy Start program to include father engagement activities. This will be accomplished through individualized home visiting services, provided to fathers, that strengthen family and child well-being.
The Department, in collaboration with Healthy Start Coalitions, identified an evidence-based curriculum offered by the National Fatherhood Initiative® for father engagement activities in Florida’s Healthy Start Program. Curriculum topics include:
- Discipline: Morals and Values; Rewards and Punishment
- What it Means to Be a Man: Today’s Man; Body Image
- Children’s Growth: Goals and Self-Worth; Nature or Nurture?
- Showing and Handling Feelings: Holding Feelings Inside; Grief and Loss
- Getting Involved: Ways to be involved; Helping my children do well in school
- Men’s Health: Stress and Anger; Physical Health
- Working with Mom and Co-Parenting: Parenting Differences; Walking a Mile in Her Shoes; I’m Okay, She’s Okay
- Communication: Ways to Communicate; Talking with Children
- Dads and Work: Work and family; Balancing work and family
- The Father’s Role: The Ideal Father; What kind of father am I? and Benefits of Marriage.
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. The Department 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, the Department 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. The SEM perspective was applied, a framework for improving health that considers individual, interpersonal, organizational, community, and policy levels of influence to identify patterns of effectiveness across the SEM. The Department summarized 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.
Children and Youth with Special Health Care Needs
Annual Regional needs assessments add to the comprehensive five year needs assessment process to inform integrated community and state strategic planning 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 continue to validate the established priority needs of access to patient centered medical homes (PCMH), and access to behavioral/mental health treatment. In addition, a theme of increased ER and hospitalization rates for asthma was identified across many of the regions.
An estimated 4.2 million children and adolescents under the age of 17 reside in Florida. The National Survey of Children’s Health for 2019-2020, indicates that approximately 54 percent of children and adolescents (ages 3-17 years) diagnosed with a behavioral/mental health condition do not receive the needed treatment or counseling. The afore-mentioned data is representative of children previously reported as screened and diagnosed, and was prior to the nation’s pandemic, COVID-19. 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. 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.
The American Association of Child and Adolescent Psychiatry workforce map from 2018, shows 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 1 child and adolescent psychiatrists per 10,000 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 was 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 primary care. In response, CMS established and continues to build out 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 and evidenced based practices, academic medical university or health system partners, also known as Behavioral Health Hubs (BHHS), work as a pediatric mental health care access team partnering 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 was awarded HRSA’s 2021 Pediatric Mental Health Care Access (PMHCA) grant funding opportunity. The additional funding will be used 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. This year’s activities focused on finding the needed partners and planning. Planning included quality improvement activities from the previous BHH work including alignment with HRSA’s updated quality performance measures to maximize collective impact across the established and new BHHs. Funding from the PMHCA grant was also used to set up family focus groups in these underserved areas, to address health equity needs for this project. The focus groups were planned and hosted though collaborative engagement with family focused, community partners. The focus groups captured families’ lived experience with equitable access to their behavioral health systems as well as recommendations for improvement. Family voice will be used to develop action strategies that can be implemented by new BHHs and community partners, with bi-directionals sharing of best practices with established BHHs.
The statewide FPBHC is led by the CMS leadership team (Florida’s Title V CYSHCN Director) and Specialty Program’s Bureau Chief/Title V CYSCHN Block Grant Administrator 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), Florida Chapter of American Academy of Pediatrics and champions from the BHH’s. As a statewide network, FPBHC is responsible for organizing statewide communication and meetings, ensuring continuous quality improvement efforts and coordinating with state and community partners, especially through the assemblance of a workgroup that helps to address replication of best practices and sustainability.
As previously stated, the annual regional needs assessment process for CYSHCN, also identified asthma emergency room and hospitalization rates as a troubling trend. Leveraging the partnership with the Department’s Bureau of Chronic Disease Prevention and Novartis Pharmaceuticals led to the formation of the Asthma Coalition Workgroup. The aim of the asthma workgroup is to reduce emergency department visits, prevent costly impact and improve the continuum of care, across systems, in the achievement of asthma control for pediatric clients ages 5-18 that are diagnosed with asthma. As a result, additional educational materials were developed and are being distributed, 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, we completed our third year of implementation with our strengthening system-building initiative with the launch of Florida’s Statewide Networks for Access and Quality (SNAQs). These SNAQs are condition-specific programs (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 led to 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. This work was highlighted during a workshop presentation at this year’s annual Association of Maternal Child Health Partners (AMCHP) conference. Family engagement and partnership was a primary theme for last year’s LAN and will continue this year with a focus on implementation and sustainability. 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. An example of this is seen with the Pulmonary team members reaching out to the schools to provide education. For the upcoming LAN year, learning and activities specific to workforce wellness, and brining awareness to burnout as part of quality improvement, are in development. The SNAQs (and other groups mentioned) have started to recognize population health approaches and identify integration opportunities, prompted their thinking and working on ways to better collaborate and communicate with primary care, specialty care, school systems, and other community and public health partners. In order to develop evidenced-based and efficient health systems, CMS staff, the RNAQs, SNAQs and the other groups are analyzing data and working together to identify evidence-based or informed strategies in improving their delivery of care and the way children receive it.
Additional identified needs led to partnership development to help improve the system of care for CYSHCN, including Got Transition® provided outreach and technical assistance to CMS and its vendor for the CMS Health plan, for the planning of a value-based purchasing (VPB) pilot specific to transition.
A Dental/Orthodontia workgroup has been developed to help to address CYSHCN, access to services. This led to the inclusion of this need for Florida's upcoming 2022–2026 State Health Improvement Plan (SHIP).
The Department is operationalizing a health equity framework into all program and policy work, including the needs assessment process. 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 Title V MCH 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, the Department 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:
- Joseph Ladapo, MD, PhD, was named State Surgeon General for the Florida Department of Health.
- Weesam Khoury is now serving as Acting Deputy Chief of Staff.
- Kenneth A. Scheppke, MD, FAEMS, was named Deputy Secretary for Health.
- Melissa Jordan, MS, MPH, was named Assistant Deputy Secretary for Health.
- Shay Chapman, BSN, MBA, was named Division Director for Community Health Promotion in March 2021. Prior to her new role, Shay served as the Bureau Chief for Family Health Services.
- Anna Simmons, MSW, was named Bureau Chief for Family Health Services. Prior to her new role, Anna served as the Maternal and Child Health Section Administrator.
- Kelly Rogers was named Section Administrator for the Maternal and Child Health Section.
The Title V Maternal and Child Health (MCH) 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 Department of Health (Department), 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.
The Department staff bears statutory responsibility for the ongoing monitoring of the needs assessment; however, the Department 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 2021, Florida’s overall infant mortality rate was 5.9 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 2021 were not statistically significantly different than rates in 2011. The Department 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 Dashboard
The MCH Section is often tasked with responding to requests from Department 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 is updated monthly and quarterly and presented in tables containing results of statistical significance tests and data by county and state total. Aggregate data is displayed in tables and graphs. Having an automated process for these inquiries improves program efficiency. The dashboard has been completed.
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 the evaluation was to identify areas in the FIMR process that would benefit from statewide standardization, and improve the efficiency of infant mortality data collection, analysis, and dissemination. A key component of this evaluation was the input of FIMR team members on the efficiency of the FIMR process, which will be collected via an online survey. Results of the evaluation are currently being used to provide guidance for the statewide FIMR expansion.
Florida Maternal Mortality Review Committee (Florida MMRC)
The Department continues to gather and publish data on pregnancy-related deaths. Florida MMRC, 2019 Report was finalized and is available on the Department’s website at https://www.floridahealth.gov/statistics-and-data/PAMR/fl-maternal-mortality-review-committee-2019-update.pdf. The 2019 data update report provides an overview and comparisons of pregnancy-related death data and trends for Florida between the years 2009 and 2019.
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 Department 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 2019 Florida MMRC data was used to develop the Pregnancy-Related Deaths Due to Hemorrhage, 2010-2019, data brief. The brief presented an overview of pregnancy-related deaths due to hemorrhage in Florida during 2010-2019 and provided evidence-based recommendations intended to reduce the risk of maternal deaths due to hemorrhage. The brief was released in 2021 and was posted to the Department’s website at pregnancy-related-deaths-due-to-hemorrhage-2010-2019.pdf (floridahealth.gov) and was shared electronically with local and state partners.
The Florida MMRC is also featured on the Association of Maternal and Child Health Programs (AMCHP) Review to Action website at: https://www.reviewtoaction.org/, where Florida MMRC briefs and annual reports are available for viewing.
In 2021, the Department 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 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.
Maternal and Congenital Syphilis Analysis
The dramatic increase in congenital syphilis cases remain a concerning trend in Florida. In 2015, 17.7 infants per 100,000 births were diagnosed with congenital syphilis. By 2020, this rate reached 73.0 infants. Despite prenatal syphilis screening mandates, gaps in preconception and prenatal care persist. In June 2022, a Graduate Student Epidemiology Program (GSEP) intern began working on an analysis using PRAMS data to identify preconception factors associated with maternal syphilis diagnoses. Results from this analysis will help to identify where these gaps in care exist, as well as best strategies for diagnosing and treating syphilis prior to pregnancy.
Opioid Crisis
The opioid crisis continues to be a major issue in Florida. Due to the overwhelming issue of opioid addiction and overdose deaths, goals were added to Florida’s State Health Improvement Plan (SHIP) under the Behavioral Health Priority Area, which encompasses substance abuse. The Department, in partnership with the Florida Department of Children and Families (DCF) and other state agencies, established a priority area workgroup to collaborate on the goals and strategies of the priority area. To address the number of opioid overdose deaths among individuals with opioid use disorders, a campaign was implemented to increase access of naloxone to emergency departments, first responders, and law enforcement agencies, as well as to individuals at risk of witnessing or experiencing an opioid-related overdose. The Department has recently added a component encouraging distribution of naloxone kits in-hand prior to hospital discharge for pregnant and postpartum women with opioid use disorder. Working collaboratively with DCF, the Florida Society of Health System Pharmacists, and the Florida Hospital Association has enabled the Department to identify and eliminate barriers to distributing free kits at discharge. Eight hospitals are participating with maternity unit distribution with expansion to additional hospitals underway. The Department is also working to adapt our Health Management System (HMS) to incorporate components that will allow County Health Departments to screen patients as they check in and begin the brief intervention and referral process, if needed.
In 2022, the State of Florida created the Coordinated Opioid Recovery (CORE) program, in coordination with the Department, DCF, and AHCA, to implement a network of addiction care in up to 12 counties in Florida. CARE is the first of its kind in the United States and places Florida as a leader in sustainable addiction and opioid recovery. The program expands a state-supported cohesive coordinated system of addiction care for individuals suffering from substance use disorder. The network does not solely depend on emergency response for overdoses and substance use disorder. It ensures patients are also stabilized and treated for coexisting medical and mental health conditions. Patients will receive services based on their individual needs that can include dental care, primary care, psychiatric evaluation, maternal care, and social support services that can address career training, housing, or food insecurity. The goal of CARE is for stabilization and to receive medical assisted treatment that is specialized to sustain a clean pathway to success.
Prenatal Risk Screen
In accordance with 383.14(1)(a), Florida Statutes, the Department oversees a multilevel screening process that includes a risk assessment instrument to identify women at risk for a preterm birth or other high-risk condition. The obstetrician completes the risk assessment instrument and reports the results to the Office of Vital Statistics so that the woman may immediately be notified and referred to appropriate health, education, and social services. Currently, the prenatal screening process is paper-driven. Following completion, physical copies of the risk screenings are saved and picked up by County Health Department (CHD) staff monthly. The data is then entered by CHD staff into the Department’s Health Management System (HMS). Following entry in HMS, referrals are made to CONNECT, a community-based process to refer clients to maternal and child health services based on the client’s needs and desires. As a result of this paper-driven process, timely and critical referrals for additional screening, home visiting services, and other supports and services for pregnant women identified at-risk are delayed.
To eliminate delays in timely and critical referrals, the Department’s MCH Section is developing an electronic prenatal screening process that will ensure all women who consent to screening and services receive treatment/services in a timely and reasonable manner. Implementation of an electronic prenatal screening process will allow the Department’s MCH Section to address the statewide prenatal screening rates, easily identify delays and generate reports. The project plan for the upcoming year will incorporate standardizing the prenatal screening process, improving identification of pregnant women who are at-risk for adverse birth outcomes, and identifying health care providers who require technical assistance on their role in the risk screening process, the process to refer to CONNECT, and the benefits of home visiting services. The following accomplishments or outcomes are necessary for this project to be considered successful:
- Prenatal women can complete the electronic prenatal screen with ease and comfortability.
- Providers can access the prenatal screening details during the first prenatal visit or complete the prenatal screen during the first prenatal visit for prenatal women who did not complete the screen prior to visit.
- There is a reduction in the timeframe from identification of at-risk to referrals/treatment.
- Increase in the statewide prenatal screening rates.
Healthy Start
In accordance with 383.216(2)(a)2, Florida Statutes, Healthy Start Coalitions develop a plan that is used to determine outcome performance objectives, jointly with the Department. Additionally, in accordance with 383.216(3)(f), Florida Statutes, supervision of Healthy Start Coalitions is the responsibility of the Department. The Department evaluates provider performance based on the established outcome measures. The Department’s MCH Section continues to adopt, implement, and integrate evidence-based practices into the Healthy Start program to address issues that affect the health of women and infants. To improve these efforts, and to enhance data collection practices that increase the effectiveness of services provided statewide, the MCH Section is working in collaboration with procured consultants (ISF, Inc.) to complete an assessment of provider outcome performance objectives.
Father Engagement
During the 2022 Florida legislative session, House Bill 7065 (Child Welfare) was passed. This legislation amended Section 383.011, Florida Statutes, to expand services provided by Florida’s Healthy Start program to include father engagement activities. This will be accomplished through individualized home visiting services, provided to fathers, that strengthen family and child well-being.
The Department, in collaboration with Healthy Start Coalitions, identified an evidence-based curriculum offered by the National Fatherhood Initiative® for father engagement activities in Florida’s Healthy Start Program. Curriculum topics include:
- Discipline: Morals and Values; Rewards and Punishment
- What it Means to Be a Man: Today’s Man; Body Image
- Children’s Growth: Goals and Self-Worth; Nature or Nurture?
- Showing and Handling Feelings: Holding Feelings Inside; Grief and Loss
- Getting Involved: Ways to be involved; Helping my children do well in school
- Men’s Health: Stress and Anger; Physical Health
- Working with Mom and Co-Parenting: Parenting Differences; Walking a Mile in Her Shoes; I’m Okay, She’s Okay
- Communication: Ways to Communicate; Talking with Children
- Dads and Work: Work and family; Balancing work and family
- The Father’s Role: The Ideal Father; What kind of father am I? and Benefits of Marriage.
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. The Department 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, the Department 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. The SEM perspective was applied, a framework for improving health that considers individual, interpersonal, organizational, community, and policy levels of influence to identify patterns of effectiveness across the SEM. The Department summarized 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.
Children and Youth with Special Health Care Needs
Annual Regional needs assessments add to the comprehensive five year needs assessment process to inform integrated community and state strategic planning 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 continue to validate the established priority needs of access to patient centered medical homes (PCMH), and access to behavioral/mental health treatment. In addition, a theme of increased ER and hospitalization rates for asthma was identified across many of the regions.
An estimated 4.2 million children and adolescents under the age of 17 reside in Florida. The National Survey of Children’s Health for 2019-2020, indicates that approximately 54 percent of children and adolescents (ages 3-17 years) diagnosed with a behavioral/mental health condition do not receive the needed treatment or counseling. The afore-mentioned data is representative of children previously reported as screened and diagnosed, and was prior to the nation’s pandemic, COVID-19. 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. 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.
The American Association of Child and Adolescent Psychiatry workforce map from 2018, shows 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 1 child and adolescent psychiatrists per 10,000 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 was 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 primary care. In response, CMS established and continues to build out 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 and evidenced based practices, academic medical university or health system partners, also known as Behavioral Health Hubs (BHHS), work as a pediatric mental health care access team partnering 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 was awarded HRSA’s 2021 Pediatric Mental Health Care Access (PMHCA) grant funding opportunity. The additional funding will be used 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. This year’s activities focused on finding the needed partners and planning. Planning included quality improvement activities from the previous BHH work including alignment with HRSA’s updated quality performance measures to maximize collective impact across the established and new BHHs. Funding from the PMHCA grant was also used to set up family focus groups in these underserved areas, to address health equity needs for this project. The focus groups were planned and hosted though collaborative engagement with family focused, community partners. The focus groups captured families’ lived experience with equitable access to their behavioral health systems as well as recommendations for improvement. Family voice will be used to develop action strategies that can be implemented by new BHHs and community partners, with bi-directionals sharing of best practices with established BHHs.
The statewide FPBHC is led by the CMS leadership team (Florida’s Title V CYSHCN Director) and Specialty Program’s Bureau Chief/Title V CYSCHN Block Grant Administrator 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), Florida Chapter of American Academy of Pediatrics and champions from the BHH’s. As a statewide network, FPBHC is responsible for organizing statewide communication and meetings, ensuring continuous quality improvement efforts and coordinating with state and community partners, especially through the assemblance of a workgroup that helps to address replication of best practices and sustainability.
As previously stated, the annual regional needs assessment process for CYSHCN, also identified asthma emergency room and hospitalization rates as a troubling trend. Leveraging the partnership with the Department’s Bureau of Chronic Disease Prevention and Novartis Pharmaceuticals led to the formation of the Asthma Coalition Workgroup. The aim of the asthma workgroup is to reduce emergency department visits, prevent costly impact and improve the continuum of care, across systems, in the achievement of asthma control for pediatric clients ages 5-18 that are diagnosed with asthma. As a result, additional educational materials were developed and are being distributed, 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, we completed our third year of implementation with our strengthening system-building initiative with the launch of Florida’s Statewide Networks for Access and Quality (SNAQs). These SNAQs are condition-specific programs (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 led to 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. This work was highlighted during a workshop presentation at this year’s annual Association of Maternal Child Health Partners (AMCHP) conference. Family engagement and partnership was a primary theme for last year’s LAN and will continue this year with a focus on implementation and sustainability. 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. An example of this is seen with the Pulmonary team members reaching out to the schools to provide education. For the upcoming LAN year, learning and activities specific to workforce wellness, and brining awareness to burnout as part of quality improvement, are in development. The SNAQs (and other groups mentioned) have started to recognize population health approaches and identify integration opportunities, prompted their thinking and working on ways to better collaborate and communicate with primary care, specialty care, school systems, and other community and public health partners. In order to develop evidenced-based and efficient health systems, CMS staff, the RNAQs, SNAQs and the other groups are analyzing data and working together to identify evidence-based or informed strategies in improving their delivery of care and the way children receive it.
Additional identified needs led to partnership development to help improve the system of care for CYSHCN, including Got Transition® provided outreach and technical assistance to CMS and its vendor for the CMS Health plan, for the planning of a value-based purchasing (VPB) pilot specific to transition.
A Dental/Orthodontia workgroup has been developed to help to address CYSHCN, access to services. This led to the inclusion of this need for Florida's upcoming 2022–2026 State Health Improvement Plan (SHIP).
The Department is operationalizing a health equity framework into all program and policy work, including the needs assessment process. 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 Title V MCH 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, the Department 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:
- Joseph Ladapo, MD, PhD, was named State Surgeon General for the Florida Department of Health.
- Weesam Khoury is now serving as Acting Deputy Chief of Staff.
- Kenneth A. Scheppke, MD, FAEMS, was named Deputy Secretary for Health.
- Melissa Jordan, MS, MPH, was named Assistant Deputy Secretary for Health.
- Shay Chapman, BSN, MBA, was named Division Director for Community Health Promotion in March 2021. Prior to her new role, Shay served as the Bureau Chief for Family Health Services.
- Anna Simmons, MSW, was named Bureau Chief for Family Health Services. Prior to her new role, Anna served as the Maternal and Child Health Section Administrator.
- Kelly Rogers was named Section Administrator for the Maternal and Child Health Section.
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