III.C.2.a. Process Description
Background
Every five years, Virginia’s Title V Maternal and Child Health (MCH) Program conducts a statewide needs assessment of the health and well-being of women, children, youth, and families living in Virginia. The Virginia Department of Health (VDH) Office of Family Health Services (OFHS) houses the state Title V program and complementary MCH programs. The Title V MCH Block Grant requires states to prepare and submit a statewide Needs Assessment every five years that identifies population needs. Conducting this assessment is a best practice in public health. Virginia seeks to inform the selection of the state’s highest priority needs for Women, Pregnant Women, Infants, Children, Adolescents, Children and Youth with Special Health Care Needs (CYSHCN), and Men. The goals of Virginia’s 2021-2025 needs assessment were to:
- Complete a state-level assessment of key maternal and child health populations: woman, pregnant women and infants, men, children, adolescents, and children and youth with special health care needs.
- Complete an environmental scan of maternal and child health programs, services, policies, systems, and environmental changes identified as assets and needs.
- Develop informed and vetted priorities and recommendations for population health improvement in key maternal and child health populations.
Process Description and Oversight
Virginia’s MCH staff invested significant staff time, expertise and funding in order to design and implement a data-driven needs assessment process for the 2021-2025 Block Grant funding cycle. The team employed rigorous research methodology, skilled and knowledgeable staff, a leadership committee, and stakeholder engagement to identify priorities to drive the development of the five-year action plan. OFHS convened a cross-program steering committee (MCH Assessment Lead Team) that met monthly to conduct assessment of processes, data sources and indicators, and gap analysis. A summary of the needs assessment process and findings are presented and supporting documentation and tools are in the attachments. The following teams and people were integral to the design and implementation of the needs assessment process:
- Needs Assessment Project Team: OFHS staff within the Divisions of Population Health Data and Child and Family Health who organize, inform, and implement the process. This team included contractors hired to coordinate and implement the assessment.
- MCH Needs Assessment (MCHNA) Lead Team: MCH leadership who inform and make final decisions on process and priorities, including the OFHS Director, directors of the Divisions of Population Health Data and Child and Family Health, Title V Grant Coordinator, Lead MCH Epidemiologist, the VDH Population Health Trainer, and the VDH Population Health Surveys Supervisor.
- Advisory Team: MCH program managers, subject matter experts (SME), stakeholders and cross-agency partners who inform the process and priority selection, including collaboration with MIECHV needs assessment leadership and the VDH Office of Health Equity.
- Partners and people: Professional partners and community members who inform processes, implementation, and priorities; including local health districts and community-based organizations (CBO).
Planning for the needs assessment began in February 2018. Beginning in May 2018, the MCHNA Lead Team was convened under the guidance of the directors of the
Division of Population Health Data and Division of Child and Family Health. The MCHNA Lead Team was tasked to:
- Convene a project team of staff to implement the assessment.
- Identify lead-team structure.
- Develop work plans and timelines.
- Develop the overall approach to the assessment using the Block Grant guidance.
- Adopt guiding principles for the assessment.
- Adopt frameworks, principles, and tools from the MCH Needs Assessment Toolkit to guide data collection and needs assessment efforts.
- Perform key quantitative data collection methods and develop LiveStories boards for data products.
- Identify new and existing data sets and reports related to the MCH population to leverage assessment purposes.
- Work with the Early Childhood and MIECHV programs and partners to ensure alignment with needs assessments.
- Developed qualitative data collection methods and tools.
Guiding Frameworks
The needs assessment process was designed to align with the Block Grant’s life-course framework, the social-ecological model, and a grounded theory approach. Considerations were periodically assessed for inclusion and applying a health equity lens throughout the process. The life course approach assured alignment with the Title V population domains. The social-ecological model provided a lens to drive upstream thoughts, where the team considers potential priority issues and strategies through the complex interplay between individual, relationship, community, and societal factors. This further leads to the promotion of health equity, by reviewing data, considering priorities, and developing strategies with the social determinants of health at the forefront of thought and discussion. Grounded theory provides the systematic guidelines for gathering, synthesizing, analyzing, and conceptualizing qualitative data.
Methodology
A mixed-methods approach for the needs assessment was implemented, with a priority to maximize the input of internal and external partners, and engagement of families and consumers in a meaningful way. Quantitative and qualitative data were collected to assess MCH health status, state and local capacity, partnerships and collaboration. The data collected informed the prioritization process leading to the selection of MCH priorities to guide implementation of strategies to address the most pressing issues among Virginia’s MCH population.
Stakeholder Engagement, Existing Efforts and Resources
In November 2018, the MCHNA Lead Team developed a partner survey to obtain stakeholder input in selecting priorities and areas of focus for qualitative assessment. The survey was distributed to over 382 statewide partners and received 287 responses.
The VDH Population Health Trainer is responsible for leading the coordination and planning of community health assessments and community health improvement plans (CHA/CHIP) with the 35 local health districts (LHD). As a member of the MCHNA Lead Team, the Population Health Trainer was able to help assure the systematic review of available reports to discern what was already known about the needs and strengths of the MCH population within Virginia. This also presented opportunity to use networks and existing alliances at the local level. The MCHNA Team gathered data and knowledge from entities with established relationships, partners were able to aid in facilitation and recruitment for qualitative methods, and the team was able to reach new partnerships.
The MCHNA Team had the unique opportunity to leverage and align key needs assessment activities with MIECHV. Virginia’s MIECHV program is housed within VDH OFHS, presenting prime opportunity to ensure combined efforts to gather the information and data required for both needs assessments. This opportunity ensured that programs avoided duplication of efforts, leveraged staff and fiscal resources, and aligned the data collected by each program. The Title V Grant Coordinator and the MCH Epidemiology Lead met periodically with Early Impact Virginia (EIV), a key Virginia MIECHV partner and facilitator of the state’s MIECHV Needs Assessment. Data, tools, and information were shares seamlessly and utilized by both programs, and plans were discussed to ensure gap-filling efforts.
Data Collection
Quantitative Data
Quantitative Data collection started in June of 2018 with data compiled at the state and local levels (where applicable) by population domains. Quantitative Data were obtained from a range of sources, including population-based surveys (PRAMS, BRFSS, YRBS, NSCH, NIS), vital statistics (birth, death, fetal death, induced terminations of pregnancy), American Community Survey and Census data, programmatic-level data, and data from cross-agency partners (DMAS, DOE, DSS) and CBOs (EIV), just to name a few. MCH-focused LiveStories dashboards were then created on a variety of health issues affecting the MCH population. These dashboards are organized by population domain, and are currently published for use. Updates for these dashboards are ongoing as these are meant to be living documents for broader use as part of ongoing assessment used by MCH stakeholders. The Virginia MCH LiveStories serve as a significant resource to inform stakeholders about the health status of the Virginia MCH population.
Qualitative Data
In February 2019, the team began qualitative assessment planning. The assessment was population-based and action-focused using a grounded theory approach. VDH hired three contract staff to support the management, coordination, and completion of the assessment recruitment, transcription, document formatting, and analysis. Three qualitative methods were used to collect data: key informant interviews (KIIs), focus groups (FGs), and open-ended questions in an online survey. Using the quantitative data to influence development, structured interview questions and protocols, focus group questions and guidelines, and open-ended survey questions were created for the population group between February and May 2019. Questions, protocols and guidelines were also validated with non-affiliated VDH staff for clarity in understanding and cultural appropriateness. Locations of assessments were selected utilizing the Virginia Health Opportunity Index. The health district with the lowest health opportunity per VDH region was selected, with the southwest split into two, due to its size. Through various partner providers and collaborators, we conducted interviews and focus groups at LHDs, health fairs, prayer breakfasts, a Virginia Premier Baby Shower, faith and community engagement day, and AfroFest. All qualitative data collection concluded in September 2019. There were 178 KIIs and 18 FGs conducted across five population domains. Gender distribution of KIIs was 91 females, 40 males, and 47 not recorded, and for FGs was 12 female, 2 male, 2 coed, and 2 not recorded. The distribution of KIIs and FGs by population had strong representation across the six population domains.
We sought inclusion and diversity within the population domains with certain lived experiences. KIIs and FGs with residents who speak Spanish (10), are within the refugee/immigrant community (8), have been incarcerated (3) or were in foster care (2), are women of color (2), identify as LGBTQ+ (1), and women who have experienced infertility (1).
The adolescent online survey launched, using the SurveyGizmo platform, in August 2019 and yielded 403 respondents (N=213 survey completions). Thorough reports regarding the needs assessment can be found in the appendices.
Prioritization Process
The MCHNA Team designed the prioritization process through researching best practice methods and commonly used criteria. The prioritization process was done in phases, each including quantitative and qualitative data, capacity/partnership information, and inclusion of the importance and feasibility of potential priority issues.
First, the team implemented the MCH Partner Survey to obtain partner input in selecting priorities, and an internal prioritization process among the VDH MCH programs to assess importance, feasibility and impact regarding resources and current efforts. Major re-occurring topics were assessed from each of these processes and used to guide qualitative methods to fill in gaps and further explore population needs. Here, context around potential priorities was gathered and information was organized by population groups.
The next phase of prioritization involved many discussions and the review and synthesis of large amounts of quantitative and qualitative data. Quantitative data were reviewed for notable disparities and differences among populations via the Virginia MCH LiveStories. This information was then compared with notable themes from quantitative data by population domain. This phase allowed the MCHNA Team to narrow focus on a list of priorities to present in a final prioritization template. During this phase, the MCHNA Team also considered the way in which priorities were defined. Historically, Virginia has defined priorities based on the key measures they address. The process of this needs assessment showed that there were key themes that resonated across populations, therefore potential priorities were inclusive of needs by domain and subpopulation through a cross-cutting approach.
In the final phase of prioritization, state program staff and key partners attended a multi-day virtual retreat. Initially, it was planned to have a series of in-person meetings by population group with key partners and stakeholders complete the prioritization template, but this was not feasible due to the COVID-19 pandemic. A prioritization template for each of the potential priority topics was created. The prioritization templates included key information such as Community & Political Will, Equity Lens, and Impact & Severity (template attached). MCH programs were also asked to work through potential program initiatives with the Government Alliance on Race and Equity (GARE) Racial Equity Toolkit. From this virtual retreat and final discussions among the team, ten priorities for the 2021-2025 Block Grant cycle were ultimately identified.
Capacity and Partnerships/Collaboration
MCH efforts in Virginia demonstrate a multidisciplinary partnership approach to health care by including traditional and nontraditional partners. This practice is reflected in our advisory committees (e.g. early hearing detection), strategic planning (e.g. VDH Population Health Plan), and ongoing MCH programs (e.g. CYSHCN). MCH partnerships include representatives from medicine, nursing, social work, public health, behavioral health, education, social services, academia, CBOs, and most importantly, families and individuals served by our programs. Program staff continue to conduct outreach to public and private primary care providers as well as public and private insurers. Input from each of these stakeholders informs the planning, implementation, and evaluation of MCH efforts. The MCH team also remains committed to increasing the level of engagement of insurance companies and the state Medicaid agency in strategic planning efforts. In addition, specialists and professionals from across the state and from academic medical centers, hospitals, and community-based services are engaged in VDH program development and oversight (i.e. universal newborn screening programs, CYSHCN programs).
The MCHNA Team took advantage of existing efforts and resources to assess state and local program capacity and state partnerships/collaboration. This needs assessment process allowed Virginia’s MCH programs to broaden its reach and gain new partners by promoting MCH needs assessment activities at state conferences such as the Virginia Neonatal Perinatal Collaborative (VNPC) Maternal Mortality Conference, and taking opportunities to hold listening sessions with key groups, such as the State Health Commissioner’s Advisory Council on Health Disparity and Health Equity.
II.C.2.b Findings
III.C.2.b.i MCH Population Health Status
Population Needs
According to America’s Health Rankings, Virginia is an overall healthy state when compared to the rest of the country, ranking 15th according to the 2019 report. According to the 2020 State Data Profiles on Kids Well-Being, Virginia ranks 14th overall. However, health inequities across MCH populations are prevalent and persistent within the state, particularly across geography and among the state’s lower-income and minority populations. During the needs assessment process, a few cross-cutting issues emerged that deserved the attention of Virginia’s MCH programs, including:
- Mental health
- Health disparities and inequities
- Health care infrastructure and networking
- Community and family voice and supports
The information in the sections below provide a comprehensive overview of general findings and themes regarding the health status of Virginia’s MCH population. A majority of the data collected and synthesized throughout the needs assessment process can be viewed in the Virginia MCH LiveStories and the attached Qualitative Assessment of Maternal and Child Health in Virginia Report located in the appendices.
General Findings and Themes from Quantitative Data Collection
Major re-occurring topics observed from the synthesis of quantitative data included social determinates of health (SDOH), behavioral and mental health, and health access. These topics are reflected among MCH population domains within the Virginia MCH LiveStories.Once on the Virginia MCH LiveStories landing page, viewers can choose a population domain and a topic to explore.
Population |
Key Themes within Quantitative Data - LiveStories |
Women of Reproductive Age
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Pregnant Women and Infants
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Children
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Adolescents
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Children & Youth with Special Health Care Needs (CYSHCN) |
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Men
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General Findings and Themes from Qualitative Data Collection
Key themes were developed using a grounded theory approach to a population-based needs assessment of maternal and child health in Virginia. Collecting codes of similar content into concepts and categories led to a theoretical understanding of the needs and gaps to be addressed by population domain. These findings are induced through an active role of the Virginians who shared their lives and stories so we can fully understand and know socially-shared meaning that forms maternal and child health-related risk and protective factors and actions for implementation.
Women of Reproductive Age
Reproductive health needs for Virginia’s women include pregnancy prevention and family planning, preventive screenings, disease testing, and barriers related to infertility, abortions, and sterilization. Women report the need for more awareness and promotion in situations of intimate partner violence or domestic violence. Women see that resolving food deserts and improving healthy eating is essential to manage chronic disease. Mental health is a primary need, and common complaints relate to finding a mental health provider, long wait times to schedule an appointment, large gaps between appointments, and long-distance travel to see providers or access services. Lack of transportation, living in a rural area, being a woman of color, economic and insurance discrimination, and language and cultural barriers are health disparities experienced by women of reproductive age. Women of reproductive age believe that by having adequate resources and educational opportunities in their communities, they can live healthier lives.
Pregnant Women and Mothers of Young Children
Childcare is unachievable for some families because it is too expensive or hard to find. Parenting needs include affirmation and reassurance that they are doing the right thing. Support system and service needs include financial stress and issues, access to and navigation within housing and transportation, lack of community, essential supplies for infants like diapers, breastfeeding, and mental health counseling. Pregnant women want their entire medical and mental health needs met. Infant and child health is very important to expectant and new mothers. Health Insurance for children is necessary to have.
Adolescents
Health issues that impact youth include mental health and substance abuse, nutrition and food security, vaping and smoking, physical fitness and recreation, chronic diseases like obesity and cancer, community and social issues, and discrimination of the LGBTQ+ population. Services and investments to improve adolescent health should focus on mental health services in schools, healthy eating and recreation opportunities, teen-centered medical and dental care, and equitable investments in Internet access and social cohesion. Methods for addressing physical and mental trauma in youth should center on finding the right care, having someone to talk to and outlets for relaxation, and acknowledging a sense of persistent desperation. Barriers to appropriate mental health care relate to lack of responsive and cooperative mental health services, stigma and parental denial, lack of understanding within the school and community, and feeling trapped in their situations. Reproductive and sexual health care education provided by public schools is inadequate and fails to include LGBTQ education, among other limited topics, so information is gained from Planned Parenthood, family, the Internet, peers, and social media. Recommendations for improving adolescent health comprises expanding the mental health system and services, offering comprehensive sexual health education, addressing substance use, and including youth in planning.
Parents of CYSHCN
Health insurance for health care services is an asset and a frustration. Care coordination involves knowledge of the services, where they exist, and how to access them. Community-based resources promote inclusive recreation and acceptance in social settings. Dental care is a long-standing issue for children with special health care needs. Therapies and support services are challenging to access but effective when secured. Afterschool, summer, and respite (temporary relief) care are inconsistent across localities and expected level of support is lacking.
Men
Men’s health is described by diseases and conditions that range from chronic diseases to social health influences that perpetuate poor health behaviors. Mental health issues are common among men, including those that lead to diagnosis and substance abuse based on reasons associated with social factors and cultural issues. Services relate to general health care, resolving issues with health care, and needed specialty care access.
MCH Providers and Systems
Many gaps and unmet needs exist among the current maternal and child health (MCH) providers and systems in which they function, from the individual to policy levels. Focusing MCH interventions on the individual patient is a common approach but too narrow to be effective. Relationships within families are known sources of influences to improved health but providers and systems do not readily provide support at this level. MCH providers describe system gaps related to capacity, coordination and availability of services, including specialists, itinerant care, medical homes, mental health, dental health, and hemophilia care. Community-level health influence is based on the relationships between organizations and the connection with social determinants and factors such as transportation, housing, food security, childcare, and employment. National, state, local laws and regulations governs health care access, including Medicaid expansion. MCH providers demonstrate implicit bias in their practice and systems of healthcare have chronically oppressed and disenfranchised people of color, immigrants and non-native English speakers, persons of low socioeconomic status, incarcerated persons, people with disabilities, and those who identify as LGBTQ+. Many MCH providers in Virginia offer education, advocacy, health promotion, chronic disease management, preventive screenings, case management and care coordination, developmental evaluations, leadership and systems development, and general health care. Resolving the gaps may include more transparency on health care costs, culturally-responsive services, supporting the family unit in care settings, integration of medical-mental-dental care, employ telemedicine and satellite clinics, and move MCHBG funds to greatest needs in locality.
Summary of Key Population Health Findings
On the surface, Virginia seems to be an overall healthy state, with high rankings compared to other states in the country, and consistent metrics that rank positively when compared to the U.S. However, intentional disaggregation and focus on special population groups throughout the needs assessment process revealed disparities. While there are strengths in the MCH population groups, there are also needs. Virginians experience disparities in overall mental and physical health, and struggle with navigating essential medical, reproductive, mental, and dental health services. Health disparities caused by racism, health insurance bias and discrimination, language and culture responsiveness, and regional funding inequities further expand the health gap. Access to key social and community supports such as childcare, employment opportunities, transportation, and general financial well-being arose as an issue across population domains. There is wide opportunity to address these issues by creating a culture of health, normalizing health-seeking behaviors, and full engagement of key stakeholders in all population domains for policy and program influence.
III.C.2.b.ii. Title V Program Capacity
III.C.2.b.ii.a. Organizational Structure
Since the VDH is within the Executive branch of Virginia’s Government, the issues impacting MCH populations have a direct linkage to the Governor and subsequently Secretary of Health and Human services for Virginia. The Governor’s Administration is supportive of women’s health, children and youth and has initiated several efforts to expand state capacity to improve the health and well-being within these groups.
Organizational Structure
The Health and Human Services Secretariat oversees the state health and human services agencies (e.g., VDH, Department of Medical Assistance Services, Department of Behavioral health and Developmental Services and Department of Social Services).
The Code of Virginia authorizes the VDH to prepare and submit the Title V plan.
The Commissioner of Health is authorized to administer the plan and expend the funds.
The grant is administered within the Office of Family Health Services.
The Title V Director manages the state programs, provides strategic direction and ensures coordination with other state and federal MCH programs. She reports to the Director of the Division of Child & Family Health is responsible for strategic and fiscal guidance and day-to-day operations (e.g. overseeing grant activities, liaising with program managers, monitoring grant expenditures) and prepares and submits the Title V grant.
The Director of Children and Youth with Special Healthcare Needs program also reports to the Director of the Division of Child & Family Health and provides oversight and management of the Child Development Centers, Care Coordination for Children Centers and Bleeding disorders programs in Virginia.
A Shared Business Services team submits fiscal reports.
Funded teams are described in the State Title V Program Purpose and Design section o this submission. See attached organizational chart for details on how funded programs are organized within the Department of Health.
III.C.2.b.ii.b. Agency Capacity
Title V funds are used to improve the health of women, pregnant women, infants, children and adolescents in Virginia. An emphasis is placed on reaching populations with fewer resources, programs and services and those communities most greatly impacted by infant mortality, maternal mortality and the opioid crisis.
Virginia’s MCH program, including the CYSHCN program, prioritize quality improvement and sustainability of the statewide coordinated comprehensive system of care that reflects a family-driven, data-informed, community-based approach to care. This comprehensive complex system of care is composed of state agencies, regional partners (the Child Development Centers or CDCs, Care Coordination of Children Centers or CCCs, Health Systems), local partners (e.g., local providers, faith community, businesses, schools etc.) and families.
The CYSHCN program includes a network composed of five CDCs and six CCCs. The CDCs provide a range of health and developmental screenings for children 0-21 years of age and referral to treatment. The CCCs provide comprehensive care coordination and wrap-around services to children 0-21 years of age and their families, with an emphasis on providing high quality, cost-efficient comprehensive care.
The VDH infrastructure includes 35 health districts. Each district received an allotment of the federal Title V funds to address the needs of MCH populations in the local communities.
The Title V team is composed of staff representing a multi-disciplinary approach to MCH. The skills represented include public health practice, research and service in the areas of data collection and analysis, program development, implementation and evaluation, stakeholder engagement, policy development, community mobilization, clinical services, and care coordination.
III.C.2.b.ii.c. MCH Workforce Capacity
There are three federally-defined positions on our state Title V team:
- Carla Hegwood, MPH, is the state’s Maternal and Child Health (“MCH”) Director and Title V Project Director.
- Marcus Allen, MPH, is the state’s Children and Youth with Special Health Care Needs (CYSHCN) Director.
- Dana Yarbrough is the state Title V Family Delegate.
Our leadership team also includes the state MCH epidemiologist, Meagan Robinson, DrPH and the Director of the Division of Child & Family Health, Jennifer Macdonald, BN, RN, MPH. We’re joined by a team of 15 state program managers, approximately 70 state-level staff and contractors, and over 110 local health district staff.
Since the VDH is within the Executive branch of Virginia’s Government, the issues affecting MCH populations have a direct linkage to the Governor and subsequently Secretary of Health and Human services for Virginia, which very supportive of women’s health, children and youth and have initiated several efforts to expand state capacity to improve the health and well-being within these groups.
The 2021-2025 MCH Needs Assessment included a robust qualitative analysis of the MCH workforce, to include key informant interviews with MCH providers. A detailed summary is provided in the attached contractor’s report.
III.C.2.b.iii. Title V Program Partnerships, Collaboration, and Coordination
Title V Partnerships
Virginia Title V has prioritized increasing diversity and inclusiveness of local partners as well as an emphasis on authentic inclusion of families. Virginia’s partnerships are described in the Appendices.
III.C.2.c. Identifying Priority Needs and Linking to Performance Measures
Priority Need Selection
Virginia used specific and complex criteria (see ‘Prioritization Process’) to organize, analyze, and prioritize MCH issues. Phase I prioritization with VDH MCH programs assessed the importance, feasibility and impact regarding resources and efforts (template in appendices). Phase II-IV assessed Community & Political Will, Equity Lens, and Impact & Severity. Due to the cross-cutting nature of the needs assessment findings, the MCHNA was able to cover more broadly the recurring priorities.
Priority Needs and Performance Measures
Goals for each priority statement were identified and specific objectives and strategies to address each goal were stated in the action plan. The Virginia Title V is carrying forward priority needs from the previous cycle, either in its entirety or through revisions in language to capture reach. The following table depicts the linkage of Virginia’s MCH priorities, performance measures, and population domains.
Emerging Issues and Other Needs
Primary emerging needs are related to the COVID-19 pandemic and Health Equity. See technical assistance section for details.
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