Ongoing Needs Assessment Activities and Operationalization

The organizational pillars that guide the strategic vision of BFH also guide the Title V ongoing needs assessment activities. To align resources and efforts to improve health outcomes in the populations we serve, many ongoing needs assessment efforts now occur within the context of population surveillance initiatives and program activities led by the BFH Data to Action Team (DAT). Throughout the year, DAT epidemiologists continuously collect, link, analyze, and interpret data related to the health of women, children, and families. Programming within DAT includes the survey-based Pregnancy Risk Assessment Monitoring System, an active surveillance program for birth defects, passive surveillance of fatal and non-fatal injury (including sexual violence), and support for several mortality surveillance case review processes for infant, child, and maternal deaths. BFH operationalizes the data findings through data analytic briefs, presentations, reports, and factsheets illuminating public health issues and recommendations for proven and promising prevention interventions to improve the health of MCH populations. Detailed descriptions of DAT programmatic efforts can be found in the MCH Data Capacity section and throughout the Population Domain narratives.

In alignment with the BFH foundational pillar to identify, understand, and respond to complex challenges and opportunities, BFH epidemiologists also utilize their expertise and access to key MCH datasets to conduct targeted data research projects, many of which are in direct alignment with the Title V Priority Needs. In FFY 2021, BFH epidemiologists presented overviews of select research projects to Title V staff, leadership, and other key programs. Examples of research questions investigated by DAT staff over the past year include:

• How do Nulliparous, Term, Singleton, Vertex (NTSV) cesarean birth rates from birth certificate data compare to hospital reported data?
• Is there an association between severe maternal morbidity (SMM) and obstetric level of care?
• Is there any association between Physicians, OB/GYNs, and/or Certified Nurse Midwives per capita (at Parish Level) and the odds of experiencing an SMM event?
• Does providing the Louisiana Pregnancy-Associated Mortality Review (PAMR) committee with more information on characteristics of cases’ neighborhood and socio-demographic setting enable the committee to make more recommendations that incorporate social determinants of health?
• Is there an association between adequacy of postnatal care service utilization and adverse birth outcomes in Louisiana?
• What is the state of maternal and newborn health in Louisiana’s American Indian population?
• Is there a critical period for opioid exposure during pregnancy as it relates to adverse birth outcomes?
• Have child fatality victims involved with the child welfare system had previous interactions with the health system? What were those missed opportunities?
• What are the mechanisms behind traumatic brain injuries? How are they related to youth sports? Where are these occurring in Louisiana?
• Are there certain areas in the state where we see hot spots of sudden unexpected infant deaths (SUIDs)? Is there a better way to visualize this data and target resources appropriately?
• Has there been a change in the number of child deaths, emergency department visits, and crashes prior to and after the enactment of new child seat safety legislation?
• What is the effect of race on the disparities that are already seen in CYSHCN?
• Why are some hospital annual newborn screening (NBS) rates consistently less than 99%?
• How has COVID-19 impacted the timeliness of NBS repeat testing?

In addition to the ongoing population surveillance activities and epidemiologist-led analytical projects, several other ongoing needs assessment activities are underway:

Pediatric Subspecialty Provider Access Landscape Assessment.  In FFY 2021, BFH began conducting a targeted region-by-region needs assessment of pediatric specialty care access. The first part of the assessment focused on identifying what the health system and accessible patient care should look like in order to measure how BFH clinic practices and the system compare to national and industry standards. The next part of the assessment focused on measuring patient access to care by identifying the population need for pediatric sub-specialty services and how the parish health units and private providers were meeting the need. To capture the true accessibility of the subspecialty providers in each region, BFH worked with the regional Families Helping Families organizations to gather data directly from all specialty providers in each region. In FFY 2022, BFH will complete a second phase of the provider survey to collect data from the remaining providers as well as from those lost to follow-up.

Early Childhood Risk and Reach. Concurrent with and in coordination with the Title V Needs Assessment, BFH early childhood systems staff began a stakeholder-informed process to update the Early Childhood Risk and Reach in Louisiana report. The 2021 iteration of the report includes expanded and reorganized Risk and Reach sections compared to the 2016 report. The report uses state- and parish- level data to describe the risks and challenges that young children and families face across the five Social Determinants of Health domains: Economic Stability, Health Care Access and Quality, Social and Community Context, Education Access and Quality, and Neighborhood and Built Environment. The report also describes the reach of key publicly-funded programs that address these risks and challenges. Data on program reach are overlaid onto maps of overall risk, which helps to illustrate which parishes may require additional services and investments to support children’s health and well-being. The 2021 Early Childhood Risk and Reach in Louisiana report is expected to be released before the end of FFY 2021. A dashboard with interactive maps of the same data found in the report will also be published on the BFH Partners for Family Health website.

National Survey of Children's Health Oversample. During the 2020 Needs Assessment, BFH was unable to utilize statistically reliable data related to certain key population indicators, such as developmental screening and youth health transition, due to insufficient sample size of the NSCH. To ensure reliable data for ongoing needs assessment activities and enable more complex analyses and stratifications, BFH invested in a 20% oversample of the 2021 NSCH.

Health Status & Emerging Needs of the State’s MCH Population

The COVID-19 pandemic has exacerbated existing challenges described in the 2020 Needs Assessment and continues to present new challenges for the MCH and CYSHCN populations in Louisiana. While it may take years to fully understand the impacts of the pandemic, some short-term studies raise concerns that can potentially affect population health outcomes long-term.

Nationwide, there were significant drops in children and families accessing care. According to data from the Urban Institute’s April 2021 Health Reform Monitoring Survey, 19.4% of parents surveyed reported they had delayed or forgone care for their children under age 19 in the past year over concerns about exposure to coronavirus.1 These findings were particularly concerning because the data were collected at a time when case rates were well below peak levels and COVID-related restrictions were loosened across the country. Since then, the highly-transmissible delta variant of the virus has led to a fourth major surge in Louisiana, resulting in increased hospitalizations and the reintroduction of certain restrictions.

As the conditions surrounding the COVID-19 pandemic rapidly evolve, the ongoing uncertainty is likely to continue negatively impacting mental health among Louisiana families. National data suggest that both the pandemic and the isolation of quarantine have increased mental health issues. A Kaiser Family Foundation study found that 45% of adults in households with children under the age of 18 reported symptoms of anxiety and/or depressive disorder throughout the pandemic.2 A Canadian study of pregnant mothers also found substantially elevated anxiety and depression symptoms compared to similar pre-pandemic pregnancy cohorts. Higher symptoms of depression and anxiety were associated with more concern about threats of COVID-19 to the life of the mother and baby, as well as concerns about not getting the necessary prenatal care, relationship strain, and social isolation due to the COVID-19 pandemic.3 Furthermore, the COVID-19 pandemic may be increasing exposure to and amplifying the impact of some adverse childhood experiences (ACEs), which are associated with a wide array of negative health outcomes throughout life.4,5

BFH recognizes the need to consider the unfolding impacts of the COVID-19 pandemic on both the health of families and the data that inform public health action. For many population health indicators used in routine ongoing needs assessment activities, real-time data are not available and often have a several year delay between data collection and availability of validated datasets. Moving forward, BFH will continue to diversify the data sources and evidence utilized to inform programming while maintaining a commitment to the high quality and contextualized interpretation of data, 

Changes in Title V Program Capacity

In line with national trends,6 BFH has experienced significant staff turnover in recent months. As the Bureau works to fill vacancies and redevelop job descriptions to better align with current and anticipated organizational needs, programs have been forced to adjust project timelines and deliverables, redistribute available resources and efforts towards urgent and/or high-priority activities, and in some cases, shift strategic direction. Anticipated impacts to affected programs and state action plan strategies are discussed throughout the narrative.

Title V Partnerships and Collaborations

As illustrated in the 2020 Needs Assessment Summary, BFH has built an extensive network of partnerships and collaborations with other federal, state and local entities that serve the MCH population in Louisiana. In alignment with the organizational foundational pillar to build coordinated partnerships toward action, a focus for BFH has been to bolster existing partnerships to expand the scope and/or enhance the overall effectiveness of these collaborations. Notable examples of such efforts over the past year include:

• developing new contracts with ten regional Families-Helping-Families organizations to better serve more CYSHCN and their families across the state
• strengthening relationships with BFH-supported boards and commissions to increase effectiveness as levers of change
• coordinating partnerships between several BFH programs and birthing hospitals to reduce duplication, improve communication, and enhance impact of quality improvement efforts
• investing in a new staff position to develop new and deepen existing strategic partnerships in state- and local-level systems to prevent trauma and promote resilience regionally and statewide

These and other efforts are discussed further throughout the state action plan narratives.

Ongoing Needs Assessment Activities and Operationalization

The organizational pillars that guide the strategic vision of BFH also guide the Title V ongoing needs assessment activities. To align resources and efforts to improve health outcomes in the populations we serve, many ongoing needs assessment efforts now occur within the context of population surveillance initiatives and program activities led by the BFH Data to Action Team (DAT). Throughout the year, DAT epidemiologists continuously collect, link, analyze, and interpret data related to the health of women, children, and families. Programming within DAT includes the survey-based Pregnancy Risk Assessment Monitoring System, an active surveillance program for birth defects, passive surveillance of fatal and non-fatal injury (including sexual violence), and support for several mortality surveillance case review processes for infant, child, and maternal deaths. BFH operationalizes the data findings through data analytic briefs, presentations, reports, and factsheets illuminating public health issues and recommendations for proven and promising prevention interventions to improve the health of MCH populations. Detailed descriptions of DAT programmatic efforts can be found in the MCH Data Capacity section and throughout the Population Domain narratives.

In alignment with the BFH foundational pillar to identify, understand, and respond to complex challenges and opportunities, BFH epidemiologists also utilize their expertise and access to key MCH datasets to conduct targeted data research projects, many of which are in direct alignment with the Title V Priority Needs. Examples of research questions investigated by DAT staff over the past year include:

• Are there fluctuations in ED visits for suicide ideation or attempt across age groups overtime (using syndromic surveillance/ESSENCE data)?
• What are the differences in manner of suicide or weapon for different age groups? Are there differences across regions?
• What are the circumstances associated with suicides among youth ages 10-19? Has there been a decrease in suicides and suicide-related attempts using firearms?
• Have there been a reduction in suicide rates/suicide-related outcomes in youth ages 10 -19 following the implementation of the comprehensive suicide program in 2021 – 2022?
• What is the state of maternal and newborn health in Louisiana’s American Indian population?
• Is there a critical period for opioid exposure during pregnancy as it relates to adverse birth outcomes?

In addition to the ongoing population surveillance activities and epidemiologist-led analytical projects, several other ongoing needs assessment activities are underway:

Pediatric Subspecialty Provider Access Landscape Assessment: In FFY 2021, BFH began conducting a targeted region-by-region needs assessment of pediatric specialty care access. The first part of the assessment focused on identifying what the health system and accessible patient care should look like in order to measure how BFH clinic practices and the system compare to national and industry standards. The next part of the assessment focused on measuring patient access to care by identifying the population need for pediatric sub-specialty services and how the parish health units and private providers were meeting the need. To capture the true accessibility of the subspecialty providers in each region, BFH worked with the regional Families Helping Families organizations to gather data directly from all specialty providers in each region. In FFY 2022, BFH completed a second phase of the provider survey to collect data from the remaining providers as well as from those lost to follow-up. The data collected during both phases of the survey are being analyzed, and findings will be synthesized and presented to inform programmatic direction. A third phase of the landscape assessment, which will likely incorporate geospatial analysis to identify underserved areas, is currently being designed. 

Early Childhood Risk and Reach: Concurrent with and in coordination with the Title V Needs Assessment, BFH early childhood systems staff began a stakeholder-informed process to update the Early Childhood Risk and Reach in Louisiana report. The 2021 iteration of the report includes expanded and reorganized Risk and Reach sections compared to the 2016 report. The report uses state- and parish- level data to describe the risks and challenges that young children and families face across the five Social Determinants of Health domains: Economic Stability, Health Care Access and Quality, Social and Community Context, Education Access and Quality, and Neighborhood and Built Environment. The report also describes the reach of key publicly-funded programs that address these risks and challenges. Data on program reach are overlaid onto maps of overall risk, which helps to illustrate which parishes may require additional services and investments to support children’s health and well-being. The 2021 Early Childhood Risk and Reach in Louisiana report was released during FFY 2021. A dashboard with interactive maps of the data found in the report was also published on the BFH Partners for Family Health website.

National Survey of Children's Health Oversample: During the 2020 Needs Assessment, BFH was unable to utilize statistically reliable data related to certain key population indicators, such as developmental screening and youth health transition, due to insufficient sample size of the NSCH. To ensure reliable data for ongoing needs assessment activities and enable more complex analyses and stratifications, BFH invested in a 20% oversample of the 2021 NSCH. In FFY 2023, Title V will be investing in a significantly larger oversample of the 2023 NSCH to ensure reliable disaggregated data by race and CYSHCN status for all NPMs.

Health Status & Emerging Needs of the State’s MCH Population

While COVID remains a public health concern in Louisiana, hospitalizations and deaths due to COVID-19 have dropped steadily over the last 12 months, with occasional virus variants causing temporary increases in these rates. Of mounting concern are the mental health issues that are exacerbated or precipitated by the stress of the pandemic and other environmental stressors such as Hurricane Ida. Suicide across all age groups has significantly declined since 2019 (-8.6%), but suicide attempts remain a concern for younger populations.1 Pre-pandemic survey data indicate that nearly 17% of Louisiana teens attempted suicide at least once in the preceding 12 months.2 Nearly one third (29%) of injury deaths age 10-14 are due to suicide.3 Mental health disorders also impact women and mothers. More than 16% of Louisiana mothers report frequent symptoms of postpartum depression. Nearly 14% of pregnant women were depressed prior to their pregnancy.4

As mental health disorders rise, so too do substance abuse issues. A Substance Use Disorder (SUD) can negatively impact entire families - even members of the family who do not abuse substances. According to the most recent PAMR, in 17% of pregnancy-associated deaths, the mother or someone in their immediate family had a SUD that influenced the death.4 Substance abuse can also result in violence against oneself or others. Domestic violence, homicide, and suicide are all areas of concern in Louisiana. Neonatal Opioid Withdrawal Syndrome (NOWS) is a growing concern in Louisiana as well, with incidences rising nationally and in the state over the last decade. Some areas of the state saw the incidences of NOWS double between 2013 and 2018.5

The BFH has taken considerable strides in reducing injury across all Title V populations, but injury-related deaths and hospitalizations are still higher than national averages. Half of all child deaths in Louisiana are due to injury and most of these are considered preventable. The majority of child injury deaths are due to motor vehicle crashes, drowning, and homicide. Nearly one in ten of these injury deaths were due to suicide in children age 0-10.3 Motor vehicle crashes contributed to 17% of maternal deaths in 2018.6 There is significant overlap in all of these areas of concern: mental health impacts substance use, and substance use and mental health impact injury and violence prevention. This overlap of issues emphasizes the key role that Title V can play in aligning efforts and partners for coordinated action.

Changes in Title V Program Capacity

BFH has experienced significant staff turnover over the past year and half. As the Bureau works to fill vacancies and redevelop job descriptions to better align with current and anticipated organizational needs, programs have been forced to adjust project timelines and deliverables, redistribute available resources and efforts towards urgent and/or high-priority activities, and in some cases, shift strategic direction. Several vacancies have been difficult to fill, causing some significant delays in various projects and deliverables. Impacts to affected programs and state action plan strategies are discussed throughout the narrative.

In general, the Covid-19 pandemic has taken a major toll on the workforce across the state. For more than two years, BFH staff have experienced personal and professional losses and have been living and operating in a near-constant state of uncertainty. Like many other parts of the country, Louisiana experienced a resurgence in Covid-19 cases during late summer 2021. State offices, which had started to re-open, closed again, causing another disruption in forward momentum. In April 2022, state offices reopened, and employees were ordered to resume working in physical office locations. LDH revised its telework policy to incorporate a more flexible hybrid work schedule, and most BFH employees have opted-in to the new hybrid option. The transition “back to the office” resulted in another disruption in momentum, but after several months, staff are beginning to settle into the new routine.

While hurricanes have been and will continue to be an annual threat in Louisiana, the Louisiana Title V program experienced a significant disruption when Hurricane Ida struck southern Louisiana on August 26, 2021. Ida, a Category 4 storm, was the second-most damaging and intense hurricane to make landfall Louisiana. Many BFH staff and partners experienced significant damages to their homes, businesses, and community. Most state offices were closed until September 16, 2021 and in some areas, well beyond that date. Central offices where the business and finance operations are housed for the Office of Public Health, were closed for the majority of this time, as well as two of BFH’s major employment contractors, causing significant delays in the approval of contract amendments and hiring for positions across the bureau.

Title V Partnerships and Collaborations

As illustrated in the 2020 Needs Assessment Summary, BFH has built an extensive network of partnerships and collaborations with other federal, state and local entities that serve the MCH population in Louisiana. In alignment with the organizational foundational pillar to build coordinated partnerships toward action, a focus for BFH has been to bolster existing partnerships to expand the scope and/or enhance the overall effectiveness of these collaborations. Notable examples of such efforts over the past year include:

• developing new contracts with ten regional Families-Helping-Families organizations to better serve more CYSHCN and their families across the state
• strengthening relationships with BFH-supported boards and commissions to increase effectiveness as levers of change
• coordinating partnerships between several BFH programs and birthing hospitals to reduce duplication, improve communication, and enhance impact of quality improvement efforts
• investing in a new staff position to develop new and deepen existing strategic partnerships in state- and local-level systems to prevent trauma and promote resilience regionally and statewide

These and other efforts are discussed further throughout the state action plan narratives.

Ongoing Needs Assessment Activities and Operationalization

The organizational pillars that guide the strategic vision of Bureau of Family Health (BFH) also guide the Title V ongoing needs assessment activities. To align resources and efforts to improve health outcomes in the populations we serve, many ongoing needs assessment efforts now occur within the context of population surveillance initiatives and program activities led by the BFH Data to Action Team (DAT). Throughout the year, DAT epidemiologists continuously collect, link, analyze, and interpret data related to the health of women, children, and families. Programming within DAT includes the survey-based Pregnancy Risk Assessment Monitoring System, an active surveillance program for birth defects, passive surveillance of fatal and non-fatal injury (including sexual violence), and support for several mortality surveillance case review processes for infant, child, and maternal deaths. BFH operationalizes the data findings through data analytic briefs, presentations, reports, and factsheets illuminating public health issues and recommendations for proven and promising prevention interventions to improve the health of Maternal Child Health (MCH) populations. Detailed descriptions of DAT programmatic efforts can be found in the MCH Data Capacity section and throughout the Population Domain narratives.

In alignment with the BFH foundational pillar to identify, understand, and respond to complex challenges and opportunities, BFH epidemiologists also utilize their expertise and access to key MCH datasets to conduct targeted data research projects, many of which are in direct alignment with the Title V Priority Needs. Examples of research questions investigated by DAT staff over the past year include:

• Is there variation in contraceptive method use by insurance status and geographic setting (urban/rural) among people with a live birth in 2018 using data from 20 jurisdictions?
• What are the trends in contraceptive method use from 2015 to 2018 overall and within subgroups in 20 jurisdictions?
• Is there an association between children ages 0-3 in Louisiana that received developmental screening and those that received special services to meet their developmental needs from 2020-2021?
• Among infants who died, what were the most common risk factors mothers experienced?
• What are the circumstances associated with suicides among youth ages 10-19? Has there been a decrease in suicides and suicide-related attempts using firearms?
• Has there been a reduction in suicide rates/suicide-related outcomes in youth ages 10 -19 following the implementation of the comprehensive suicide program in 2022 – 2023?
• Has syndromic surveillance increased partner awareness of suicide data or suicide occurrences in their areas?

In addition to the ongoing population surveillance activities and epidemiologist-led analytical projects, several other ongoing needs assessment activities are underway:

Pediatric Subspecialty Provider Access Landscape Assessment: In FFY2021, BFH began conducting a targeted region-by-region needs assessment of pediatric specialty care access. The first part of the assessment focused on identifying what the health system and accessible patient care should look like in order to measure how BFH clinic practices and the system compare to national and industry standards. The next part of the assessment focused on measuring patient access to care by identifying the population need for pediatric sub-specialty services and how the parish health units and private providers were meeting the need. To capture the true accessibility of the subspecialty providers in each region, BFH worked with the regional Families Helping Families organizations to gather data directly from all specialty providers in each region. In FFY2022, BFH completed a second phase of the provider survey to collect data from the remaining providers as well as from those lost to follow-up. The data collected during both phases of the survey were merged and analyzed. BFH compared the unified data with the utilization of services in its own Parish Health Units (PHUs) and financial data for calendar years 2021 and 2022. Additionally, geospatial analysis was performed to map the provider locations and compare the area of access of each provider to the locations of Children’s Special Health Services (CSHS) patients of corresponding specialty need. Both Medicaid and non-Medicaid patients and providers were included in the analysis to identify areas with gaps in access that may benefit from additional CSHS providers. The findings contributed to BFH leadership’s understanding of the current services distribution and underserved areas that would benefit from service expansion. Further analysis could help inform operational and policy changes to improve the sustainability of the services and the overall efficiency of resources used.

Early Childhood Risk and Reach: Concurrent with and in coordination with the Title V Needs Assessment, BFH early childhood systems staff began a stakeholder-informed process to update the Early Childhood Risk and Reach in Louisiana report. The 2021 iteration of the report includes expanded and reorganized Risk and Reach sections compared to the 2016 report. The report uses state- and parish- level data to describe the risks and challenges that young children and families face across the five Social Determinants of Health domains: Economic Stability, Health Care Access and Quality, Social and Community Context, Education Access and Quality, and Neighborhood and Built Environment. The report also describes the reach of key publicly-funded programs that address these risks and challenges. Data on program reach are overlaid onto maps of overall risk, which helps to illustrate which parishes may require additional services and investments to support children’s health and well-being. The 2021 Early Childhood Risk and Reach in Louisiana report was released during FFY2021. A dashboard with interactive maps of the data found in the report was also published on the BFH Partners for Family Health website.

National Survey of Children's Health Oversample: During the 2020 Needs Assessment, BFH was unable to produce statistically reliable data related to certain key population indicators, such as developmental screening and youth health transition, due to insufficient sample size obtained through the standard collection of Louisiana’s National Survey of Children’s Health (NSCH). To ensure reliable data for ongoing needs assessment activities and enable more complex analyses and stratifications, BFH invested in a 20% oversample of the 2021 NSCH to ensure reliable Louisiana state-wide data for all NPMs. In FFY 2023, Title V has invested in a significantly larger oversample of the 2023 NSCH to ensure reliable data disaggregated by race and, separately, Children and Youth with Special Health Care Needs (CYSHCN) status for all National Performance Measures, thereby improving Louisiana’s ability to monitor health through an equity lens and inclusion of special populations.

Health Status and Emerging Needs of the State’s MCH Population

While COVID remains a public health concern in Louisiana, hospitalizations and deaths due to COVID-19 remain relatively low, with less than 10 hospital admissions per 100,000 being reported each week since late February 20231. Of mounting concerns are mental health issues and substance use disorders that are exacerbated or precipitated by the residual stress of the pandemic along with other environmental and social stressors, such as lack of affordable housing and high rates of poverty.

After two years of decline, suicide rates increased nationally in 20212.  Deaths due to suicide among individuals 5-14 years of age in Louisiana are suppressed in the National Vital Statistics System due to small counts. Louisiana’s child death review indicated that nearly one in three (29%) injury-related deaths were due to suicide among children age 10-14 years3. As mental health issues rise, so too do substance use disorders. A Substance Use Disorder (SUD) can negatively impact entire families - including members of the family who do not abuse substances. According to the most recent Louisiana Pregnancy-Associated Mortality Review (PAMR) report, in nearly 1 in 4 pregnancy-associated deaths, the mother or someone in their immediate family had a SUD that influenced the death4. Substance abuse can also result in violence against oneself or others. Domestic violence, homicide, and suicide are all areas of concern in Louisiana. Neonatal Opioid Withdrawal Syndrome (NOWS) is a concern in Louisiana as well, with incidences rising nationally and in the state over the last decade. Some areas of the state saw the incidences of NOWS double between 2013 and 20185.

The BFH has taken considerable strides in reducing injury across all Title V populations, but injury-related deaths and hospitalizations are still higher than national averages. Half of all child deaths in Louisiana are due to injury and most of these are considered preventable. Two-thirds of child injury-related deaths are due to motor vehicle crashes, homicide, and drowning. These three causes of death accounted for an average of 66 deaths per year among children aged 1-14 years. Unintentional overdose and motor vehicle crashes contributed to 15% and 13% of maternal deaths from 2017-2019, respectively, accounting for 50 deaths in the three-year period6. There is significant overlap in all of these areas of concern: mental health impacts substance use, and substance use and mental health impact injury and violence. This overlap of issues emphasizes the key role that Title V can play in aligning efforts and partners for coordinated action and prevention.

Changes in Title V Program Capacity

Like many health departments and organizations, the changes and opportunities prompted by the pandemic have contributed to a particularly notable cycle of personnel changes over the past year and half. As a result, the Bureau has been in a period of reassessing needed roles and redeveloping positions and contracts to better align with current and anticipated organizational needs. While challenging, this period of change is also timely. It has been five years since the Bureau’s comprehensive strategic planning process that realigned work across the organization around core strategies rather than solely “programs” and services. Some of the newer areas of work, discussed throughout the narrative, are now ready for expansion.

During this period, the Bureau has had to adjust some project timelines and deliverables, redistribute available resources and efforts towards urgent and/or high-priority activities, and in some cases, shift strategic direction.  Over the last several months, BFH has been able to hire new people in some of the more challenging vacancies to fill (epidemiology) and begin hiring new leadership positions. By the start of FFY2024, BFH expects to have filled all major leadership positions.

Title V Partnerships and Collaborations

As illustrated in the 2020 Needs Assessment Summary, BFH has developed an extensive network of partnerships and collaborations with other federal, state and local entities that serve the MCH population in Louisiana. In alignment with the organization’s foundational pillar to build coordinated partnerships toward action, a focus for BFH has been to strengthen existing partnerships to expand the scope and/or enhance the overall effectiveness of these collaborations. Notable examples of such efforts over the past year include:

• continued contracts with ten regional Families-Helping-Families organizations to better serve more CYSHCN and their families across the state
• strengthening relationships with BFH-supported boards and commissions to increase effectiveness as ”agents” of change
• coordinating partnerships between several BFH programs and birthing hospitals to reduce duplication, improve communication, and enhance impact of quality improvement efforts
• investing in a new staff position to develop new and deepen existing strategic partnerships in state- and local-level systems to prevent trauma and promote resilience regionally and statewide

These and other efforts are discussed further throughout the state action plan narratives.

Process Description for Needs Assessment Update

The organizational pillars that guide the strategic vision of Bureau of Family Health (BFH) also guide the Title V ongoing needs assessment activities. To align resources and efforts to improve health outcomes in the populations we serve, many ongoing needs assessment efforts now occur within the context of population surveillance initiatives and program activities led by the BFH Data to Action Team (DAT). Throughout the year, DAT epidemiologists continuously collect, link, analyze, and interpret data related to the health of women, children, and families. Programming within DAT includes the survey-based Pregnancy Risk Assessment Monitoring System, an active surveillance program for birth defects, passive surveillance of fatal and non-fatal injury (including sexual violence), and support for several mortality surveillance case review processes for infant, child, and maternal deaths. BFH operationalizes the data findings through data analytic briefs, presentations, reports, and factsheets illuminating public health issues and recommendations for proven and promising prevention interventions to improve the health of Maternal and Child Health (MCH) populations. Detailed descriptions of DAT programmatic efforts can be found in the MCH Data Capacity section and throughout the Population Domain narratives.

As part of the BFH's core strategy to address complex challenges and opportunities, epidemiologists use their skills and MCH data access to carry out specific data research projects. Many of these projects directly align with the Title V Priority Needs. Some of the research questions investigated by DAT staff in the past year include:

• Is there an association between children aged 0-3 in Louisiana who have undergone developmental screening and those who have received EarlySteps referrals and services to address their developmental needs?
• What factors contribute to the higher excess mortality among non-Hispanic Black infants in Greater New Orleans in 2022?
• What are the circumstances associated with suicides among youth ages 10-19? Has there been a decrease in suicides and suicide-related attempts using firearms?
• Has there been a reduction in suicide rates/suicide-related outcomes in youth ages 10-19 following the implementation of the comprehensive suicide program in 2022 – 2023?
• Has syndromic surveillance increased partner awareness of suicide data or suicide occurrences in their areas?
• What are the characteristics of the domestic abuse fatalities in Louisiana in 2022?

In addition to the ongoing population surveillance activities and epidemiologist-led analytical projects, several other ongoing needs assessment activities are underway:

Pediatric Subspecialty Provider Access Landscape Assessment

In FFY2021, BFH began conducting a targeted region-by-region needs assessment of pediatric specialty care access. The first part of the assessment focused on identifying what the health system and accessible patient care should look like in order to measure how BFH clinic practices and the system compare to national and industry standards. The next part of the assessment focused on measuring patient access to care by identifying the population's need for pediatric sub-specialty services and how the parish health units and private providers met the need. To capture the true accessibility of the subspecialty providers in each region, BFH worked with the regional Families Helping Families organizations to gather data directly from all specialty providers in each region. In FFY2022, BFH completed a second phase of the provider survey to collect data from the remaining providers and those lost to follow-up. The data collected during both phases of the survey were merged and analyzed. BFH compared the unified data with the utilization of services in its own Parish Health Units (PHUs) and financial data for calendar years 2021 and 2022. Additionally, geospatial analysis was performed to map the provider locations and compare the area of access of each provider to the locations of Children’s Special Health Services (CSHS) patients of corresponding specialty needs. Both Medicaid and non-Medicaid patients and providers were included in the analysis to identify areas with gaps in access that may benefit from additional CSHS providers. The findings contributed to BFH leadership’s understanding of the current services distribution and underserved areas that would benefit from service expansion. Further analysis could help inform operational and policy changes to improve the sustainability of the services and the overall efficiency of resources used.

National Survey of Children's Health Oversample

During the 2020 Needs Assessment, BFH encountered challenges obtaining statistically reliable data on key population indicators such as developmental screening and youth health transition due to small sample sizes from the standard collection of Louisiana's National Survey of Children's Health (NSCH). Stratification of data to explore disparities between subpopulations (i.e., race, rural/urban, etc.) was also not possible due to the standard survey sample size. To address this issue, BFH has invested in Title V funding to increase the number of households surveyed in 2021, 2023, and 2024.  The data from the 2023 oversample will be available in October 2025 and will be utilized to support identification of priority needs for the 2026-2030 Title V strategic period.  Data from the 2024 oversample will be available in October 2025 and will set the baseline values from which the Bureau’s 2026-2030 objectives will be measured. This investment will allow us to gather reliable data disaggregated by race and Children and Youth with Special Health Care Needs (CYSHCN) status for all National Performance Measures. By doing so, we will strengthen Louisiana's ability to monitor health through an equity lens and ensure the inclusion of special populations.

MCH Population Health and Wellbeing

Louisianans consistently experiences poorer health outcomes compared to the rest of the nation. According to America’s Health Rankings 2023, Louisiana ranked 50th in the nation for the second consecutive year in overall health.

Maternal Health

The state’s maternal mortality rate is also among the highest in the US. Significant racial disparities show that Black women are almost twice as likely to die from pregnancy- associated causes as White women. This disparity was even greater for pregnancy-related deaths.1 The 2020 Needs Assessment identified violence as a significant contributor to poor maternal health outcomes in Louisiana. According to the Violence Policy Center 2020 study, When Men Murder Women, Louisiana ranked 5th in the United States for women murdered by men, with a homicide rate of 2.18 per 100,000 females killed by males in single victim/single offender incidents.2 For homicides in which the victim-to-offender relationship could be identified, 98% of female victims (39 out of 40) were murdered by someone they knew. Of the victims who knew their offenders, 56% (22 victims) were wives, common-law wives, ex-wives, or girlfriends of the offenders.  From 2017-2019, homicide was the second leading cause of pregnancy-associated deaths in Louisiana.3

According to both the 2017-2019 and 2020 Pregnancy-Associated Mortality Review (PAMR) Report, substance use is a leading contributor to pregnancy-associated mortality.  In 2020, Substance Use Disorder (SUD) contributed to almost half (44%) of maternal mortality cases.3 High rates of substance use are correlated with high rates of mental health issues. According to the 2021 Pregnancy Risk Assessment Monitoring System (PRAMS) Report, over 14% of individuals surveyed reported experiencing depression during pregnancy. 12.1% reported frequent symptoms of postpartum depression.4 Even if violence, substance use or mental health issues are only present prior to conception, traumatic experiences can still have negative implications for a woman and her future children.

Infant Health

Louisiana has the fifth highest infant mortality rate in the country5. Similar to nationwide trends, Black infants in Louisiana die at twice the rate of White infants. According to the 2019-2021 state Child Death Review (CDR) report, 41% of infant deaths are due to conditions originating in the perinatal period6. These conditions are closely related to maternal health before conception. Maternal health is also closely linked to low birth weight and premature birth7, both of which are risk factors for the second most common category of infant death in Louisiana, Sudden Unexpected Infant Death (SUID). Many of these deaths are sleep-related. While behaviors like co-sleeping expose infants to a heightened risk of SUID, social factors may influence a caregiver’s decision to co-sleep with their baby8.

Child Health

The 2020-2021 National Survey of Children’s Health (NSCH) indicates that Louisiana's developmental screening rates remain significantly below the national average (LA 24.2%/US 34.8%).9 Between 2018-2020, the Louisiana mortality rate for children aged 0-14 was 22.6 per 100,000, compared to 16.2 nationally. Half of these deaths were due to injury and are largely considered preventable. The majority of child injury deaths in Louisiana are due to motor vehicle crashes, drowning, and homicide. Nearly one in ten of these injury deaths were due to suicide.10 Non-fatal injuries can have life-long consequences for a child, and injury-related hospitalizations are a leading cause of child hospitalizations in Louisiana. Louisiana’s Adverse Childhood Experiences (ACE) rate is one of the highest in the nation. Nearly 19% of Louisiana children age 0-17 have experienced two or more ACEs, compared to 14% nationally.11

Adolescent Health

Adverse experiences in childhood can impact the mental and physical well-being of individuals throughout the life course. Louisiana’s Adverse Childhood Experiences (ACE) rate is one of the highest in the nation. Nearly 20% of Louisiana children age 0 -17 have experienced two or more ACEs, compared to 14.8% nationally.12 Suicide is another concern for children and young adults. According to the American Foundation for Suicide Prevention, suicide was the 3rd leading cause of death for Louisianans aged 10-24 and the 4th leading cause of death for 25-34 in 2021.13 Multiple risk factors related to suicidal thoughts and behaviors are on the rise across the state. Depression rates of Louisiana adolescents age 18-24 are increasing steadily.14 Environmental stressors including community and domestic violence, hurricanes and other natural disasters, and the ongoing stresses associated with the COVID-19 pandemic all contribute to this increase in mental health issues.

CYSHCN Health

Louisiana has one of the highest percentages of children and youth with special healthcare needs (CYSHCN) in the country, with over 24% of children ages 1-17 having a special health care need. The national Medical Home healthcare delivery model was specifically designed to meet the needs of CYSHCN and has become the recommended standard of care for all children. Screening, resource linkage, transition support, and timely access to comprehensive, coordinated care in a medical home are critical to ensure that CYSHCN minimize their disabilities and maximize their independence. 26.4% of CYSHCN in Louisiana do not receive effective care coordination, with only 39.3% of CYSHCN receiving ongoing, comprehensive care within a medical home.15

In addition to having complex healthcare needs, CYSHCN are more likely to experience social adversity.  2021-2022 data from the National Survey of Children’s Health shows that CYSHCN report experiencing bullying more frequently than children without special healthcare needs, report being less physically active than children without special healthcare needs, and more frequently report experiencing food insufficiency than children without special healthcare needs.15    

Other Cross-Cutting Health Concerns

Drug and opioid abuse are growing areas of alarm. From 2019 to 2021, opioid-involved deaths increased by 134%, from 588 to 1378.16 According to the National Alliance on Mental Illness (NAMI), 715,000 adults in Louisiana have a mental health condition and 179,000 adults have a serious mental illness.17 In February 2023, 39.1% of adults in Louisiana reported symptoms of anxiety and/or depression, compared to 32.3% of adults nationally.18 As mental health issues rise, substance use disorders also increase, negatively impacting entire families, including members who do not abuse substances. Suicide is another concern for children and young adults. After two years of increase, the national suicide rates slightly decreased in 2023. According to the American Foundation for Suicide Prevention, suicide is the 3rd leading cause of death for Louisianans aged 10-24 and 25-34.19 Mothers are also at risk for mental health issues. There is a significant overlap in these areas of concern: mental health affects substance use, which in turn impacts injury and violence. This overlap underscores the crucial role that Title V can play in coordinating efforts and partners for action and prevention.