II.E.2.c. Women/Maternal Health: Annual Report (10/1/2020-9/30/2021)
 

 

State Priority Need:

Access to high-quality, family-centered, trusted care is available to all Hoosiers.

 

National Performance Measure (2020 - 2025):

NPM 1: Well-Woman Visit: Percent of women, ages 18 through 44, with a preventive medical visit in the past year

 

Evidence Based/Informed Strategy Measure (2020 - 2025): 

ESM 1.1: Number of Women who responded to PRAMS

ESM 1.2: The percent of women receiving postpartum follow-up health care services within the first four to six weeks after delivery.

ESM 1.3: Percentage of mothers enrolled in Home Visiting prenatally or within 30 days after delivery who received a postpartum visit with a healthcare provider within 8 weeks (56 days) of delivery

 

General Information:

 

To increase the percentage of women who have an annual well-visit, MCH must better understand how many women are getting into well-woman care and their reasons for either continuing regular medical visits or not obtaining consistent care. Based on this knowledge, MCH can plan and work toward eliminating barriers to accessing trusted care. A top need from the five-year needs assessment demonstrated the urgency for an easier transition from labor and birth to postpartum care. Survey participants noted that postpartum care is either insufficient or too long after delivery for many women which makes the transition back to well-woman care after delivery challenging, especially when much of the attention is focused on babies. IDOH will aim to assist women in navigating their healthcare with supportive programming and policies to ensure women have easy access to regular, trusted, and respected care before, during, and after pregnancy.

 

To better understand women’s experiences before, during, and after pregnancy, IDOH utilized data from the Pregnancy Risk Assessment Monitoring System (PRAMS). Indiana PRAMS has undergone quite a bit of change during the reporting period. In early 2021 the PRAMS Epidemiologist resigned, and a replacement was not hired until September. Going without a full-time PRAMS staff member for so many months was very taxing on the PRAMS project. Also, during this time period, MCH lost a long-time maternal health administrator who had previously been the PRAMS Principal Investigator, further impacting the PRAMS project. In addition, Indiana Vital Records transitioned to an entirely new database which halted PRAMS data collection for several months until the new database could be properly coded to meet all PRAMS protocols. These situations greatly affected PRAMS operations and response rates.

 

Despite the challenges, Indiana celebrated having four years of PRAMS data that can be used to drive programming and inform MCH initiatives. While Indiana has only met the CDC response rate threshold during one of those years (in 2018), the data is still weighted each year by the CDC and can still be utilized and shared with additional data caveat language. Understanding these limitations, PRAMS data shows that 89% of Hoosier women received a post-partum checkup when combining data from 2017 through 2020. Hispanic women reported the lowest percentage of women receiving a post-partum checkup (86%) and White women reported the highest percentage (92%). When looking at only 2020 PRAMS data, it is not surprising to see that the percentage of women who received a post-partum checkup decreased slightly to 88%, given the difficulties and added complications of COVID-19 restrictions and considerations for healthcare visits.

 

IDOH recognizes that PRAMS data is only a snapshot into postpartum care, and we are actively working to better collect information and data on these visits. Over the next year, we will explore the possibility of collecting data around postpartum visit frequency and insurance coverage in a partnership with the Indiana Hospital Association through outpatient data. This could also lead to more conversation around best practices for physicians, better postpartum visit coverage, and policy change that can be led by the Indiana Perinatal Quality Improvement Collaborative (IPQIC), which is Indiana’s PQC.

 

IDOH continued promoting adequate postpartum care among women and encouraged them to own their healthcare journey. Over the past year, IDOH has added numerous resources to the Liv Mobile Pregnancy App and released the CDC’s Hear Her® campaign to raise awareness among women to be advocates when it comes to trusted and respectful care. To ensure IDOH is able to meet women where they are, MCH will implement more group prenatal care options that will be operational in late 2022.

 

Lastly, we will increase the percentage of women who have an annual visit by tracking the percentage of mothers enrolled in home visiting who receive a postpartum visit with a healthcare provider within eight weeks of delivery. MCH will ensure that home visitors have access to training and education about postpartum care. Home visitors benefit from being knowledgeable about the benefits of postpartum care to share that information with mothers served. The home visiting programs ensure that staff are receiving training and education about postpartum care and how to define a postpartum visit. MCH is committed to increasing the home visiting program data through a Maternal, Infant, Early, and Childhood Home Visiting Program and My Healthy Baby. MCH is committed to maintaining and increasing the current home visiting service capacity to ensure that more clients have access to home visiting.

 

My Healthy Baby is a collaboration between the Indiana Department of Health, the Indiana Family and Social Services Administration (FSSA) and the Indiana Department of Child Services (DCS). This initiative is building a network of services and support to wrap our arms around moms and babies to create healthier outcomes for both. It was established by House Enrolled Act 1007, which was signed into law by Gov. Eric Holcomb in 2019. My Healthy Baby connects pregnant women on Medicaid to home visiting providers in their own community. A family support provider offers free, personalized guidance and support to the woman during her pregnancy and for at least the first 12 months after her baby’s birth. My Healthy Baby referred women to perinatal home visiting programs and offered many areas of support including positive parenting, child development, maternal and child health resources, access to social supports, and family economic self-sufficiency. My Healthy Baby referred 2,738 clients to home visiting programs during the 12-month period from July 1, 2020, through June 30, 2021.

 

MCH continued to partner with state agencies in the coordination of home visiting services within other systems. Specifically, MCH invests in Nurse-Family Partnership (NFP), with state and federal funding, including the Maternal Infant and Early Childhood Home Visiting (MIECHV) Program. The overall vision of Indiana’s investment in home visiting is to improve health and developmental outcomes for children and families. Nurse Family Partnership is an evidence-based community health program with years of evidence showing significant improvements in the health and lives of first times mom and their children. The NFP model engages women early in pregnancy aiming to improve pregnancy outcomes through engagement in preventive health practices, improve child health and development, and improve families’ economic self-sufficiency. Implementation of NFP began in 2011 and has expanded to reach 42 of the 92 counties in Indiana. Across four active implementing agencies, Indiana has a total funded NFP capacity of approximately 2,000 families. From 10/1/2020-9/30/2021, a total of 1,993 families were served in the NFP program. In FY21 Title V directly supported the NFP Lake County implementation which served a total 240 clients with a total 2,272 completed home visits by a team of 8 full time nurse home visitors. 

 

MCH home visiting continued to increase the percentage of women who had an annual visit within 30 days after delivery. The 10/1/2020 - 9/30/2021 data is representative of two local implementing agencies receiving MIECHV funding that tracks the percentage of mothers enrolled in home visiting who receive a postpartum visit with a healthcare provider within eight weeks of delivery. In FY21, 212 women were enrolled in home visiting prenatally (or within 30 days after delivery) and remained enrolled for at least eight weeks. Of those women, 124 received a postpartum visit with a healthcare provider within eight weeks of delivery. This represents 58.5% of eligible women receiving this service, which is an increase from the previous two years of reporting on this measure. NFP serves mothers and infants for two years postpartum and will continue to advocate and be an essential proponent for getting women into essential postpartum care.

 

Throughout the pandemic, it was essential that pregnant women had adequate access to health insurance. It was even more critical that they were covered during the postpartum period. During the ongoing federal public health emergency, no coverage in Indiana was discontinued, which means new mothers could stay on Medicaid beyond the 60-day postpartum limit. This order stood as long as the public health emergency declaration was in place. Fortunately, IDOH and state legislatures worked throughout the pandemic to expand postpartum Medicaid coverage. Hoosier mothers will be able to stay on Medicaid for up to 12 months after giving birth under a new coverage expansion starting in April 2022.

 

For women transitioning from menstruation to menopause, IDOH’s Office of Women’s Health partnered with the Indiana University National Center of Excellence in Women’s Health (IUNCoE). The education project was intended to ease the transition with less anxiety and discomfort and prepare women for the next phase of their life as they manage the shift through perimenopause, menopause, and post-menopause. The project had two main goals: (1) to provide menopause education to 300 physicians, medical students, and healthcare professionals and (2) provide education to 700 women on the symptoms and management of menopause.

 

The first goal was completed through IUNCoE's prestigious Merritt Lectureship with the American College of Obstetrics and Gynecology (ACOG). Four hundred and forty physicians and 349 medical students were provided education on the challenges in recognizing and sufficiently managing menopausal symptoms. In addition, the IU National Center of Excellence in Women’s Health presented a poster on menopause education and the “#AFTER” brochure at American Medical Women’s Association’s 107th Annual Meeting. The conference was attended by 279 physicians and 349 medical students. For the second project goal, 519 women received menopause education or access to information regarding the symptoms and management of menopausal symptoms. The women were provided education through the 10th annual Women of INfluence Symposium which featured two physicians speaking on menopause-related topics. In addition to the symposium, a one-day clinic was hosted to provide health education to underserved women in Marion County. 

 

 

State Priority Need:

Reduce preventable deaths in the MCH population with a focus on reduction and elimination of inequities in mortality rates.

 

State Performance Measure (2020 - 2025):

SPM 2: Reduce maternal mortality rates and disparities by promoting best practices in clinical care.

 

General Information:

 

The Indiana MMRC was formalized in July 2018 following passage of IC 16-50, which required the multi-disciplinary review of pregnancy-associated deaths in Indiana and secured protections for the confidentiality of the process. The MMRC was developed with guidance from the Centers for Disease Control and Prevention (CDC) Division of Reproductive Health’s Building US Capacity to Review and Prevent Maternal Deaths Program and is modeled after other well-established MMRCs in the United States. IDOH’s Division of Fatality Review and Prevention (FRP) coordinates the MMRC and related activities.

 

The Indiana MMRC includes representation from a broad range of physicians and nurses from multiple specialties (Obstetrics and Gynecology, Cardiology, Pulmonary Medicine, Anesthesiology, Pathology, Maternal-Fetal Medicine, Public Health), along with social workers, coroners, health advocates, and other allied health professionals. These volunteers conduct extensive reviews of pregnancy-associated deaths to identify opportunities for prevention. As the goal of the review is to identify systems-level changes and not assign individual blame, the names of patients, medical providers, and involved institutions are not disclosed during the process.

 

In 2019, FRP was awarded funding through a CDC project entitled ‘Enhancing Reviews and Surveillance to Eliminate Maternal Mortality,’ known as ERASE MM. This grant and the associated technical assistance have allowed for the expansion of efforts already underway to systematically identify and collect relevant information pertaining to pregnancy-associated deaths, review findings, and make data-driven recommendations for prevention.

 

The Indiana MMRC is currently continuing its work to identify and review all deaths of women within one year of pregnancy and childbirth. Deaths occurring in 2020 will be completely identified and reviewed by late spring 2022. FRP has been concurrently identifying and gathering records for deaths that occurred in 2021 and 2022 to facilitate the beginning of those cohorts’ reviews immediately following the completion of 2020 deaths. The third annual MMRC report will be completed and released in summer of 2022.

 

The second annual MMRC report identified that the pregnancy-associated mortality rate decreased slightly from 2018 to 2019, while the pregnancy-related mortality rate increased. More than half of the pregnancy-associated deaths (56.7%) occurred six weeks or more post-partum, and 60% of the deaths determined to be pregnancy-related occurred either during pregnancy or within the first week post-partum. These findings suggest that women are most at risk of a pregnancy complication or other condition aggravated by pregnancy died either during pregnancy or in the first week following childbirth. However, their risk of dying from other causes, including injury or other medical conditions, is highest six or more weeks after childbirth.

 

The race-specific ratios were different between 2018 to 2019, with 2018 data showing approximately 20% higher mortality ratio among Black, non-Hispanic women compared to White, non-Hispanic women, with a slightly higher mortality ratio for White, non-Hispanic women in 2019. This difference was likely due to unstable ratios because of the small numbers in one-year data. The report also identified another disparity with Black, non-Hispanic women, who experienced 88.9 pregnancy-associated deaths per 100,000 live births, compared to 83.5 for White, non-Hispanic women. As the MMRC collects more data through continual review of all maternal deaths, it can also continue to make more targeted, evidence-based recommendations for preventing similar deaths and reducing maternal mortality in Indiana.

 

FRP continues to evaluate the membership of the MMRC and expand the types of records and information that can be accessed to understand each woman’s history and each touchpoint or type of service/care she received prior to her death. This process has become more refined with experience over the first two years of the program. The MMRC has been working to incorporate more records into the review process that provide a full picture of both medical and social events that could have impacted outcomes. For example, FRP has engaged FSSA, Medicaid, and the Division of Mental Health and Addiction to obtain vital information for enhanced reviews. The addition of mental health resources has allowed MMRC to evaluate the mental health challenges, and access to Department of Child Services (DCS) records has allowed for a better understanding of prior circumstances that may have affected outcomes. Recommendations can then be made that affect mortality at multiple life stages. FRP continues to work on engaging DCS, WIC, local jails, the Department of Correction, substance use treatment providers, and more.

 

We are currently working to incorporate informant interviews and interviews with family or loved ones into our process. The goal of these interviews is to understand the women’s perceived experiences and well-being during pregnancy or in the time leading up to death. Official records do not tell the whole story, and these interviews provide valuable insight into how a woman felt and what she may have experienced during this time. Indiana MMRC has maintained a contract with the Grassroots Maternal Child Health Leadership Training Project, which trains and mentors women to help their neighborhoods improve pregnancy and infant outcomes. These women work to make change at the community, organizational, and policy levels, while meeting the needs of women, infants, and families in their neighborhoods by linking them to services. These community leaders and FRP nurse consultants have received appropriate training for conducting family interviews and will ultimately embed these qualitative data into the pregnancy-associated death case presentations. This critical addition to the case narratives has helped the Indiana MMRC better understand the experiences of women who died, as well as the perceptions of their families, friends, and communities who endured the loss of a pregnant or recently pregnant woman. By hearing stories directly from those closest to the women who died, recommendations generated by the committee can be informed by the individual circumstances leading to pregnancy-associated deaths. MMR program staff continue to send notifications to families of the deceased and has conducted five interviews this year.

 

SOFR

The FRP Suicide and Overdose Fatality Review (SOFR) Program began in 2018 as a pilot program in three counties. Since then, the program has expanded to 20 functioning teams, with six more in formation. The local expertise of the SOFR team membership has been a critical addition to the MMRC work because there is a high burden of suicide and overdose death among maternal mortalities in Indiana. MMRC members have been identified through SOFR teams. In addition, coordinated case identification and a records sharing process has been established. As additional SOFR teams are created and prevention efforts are recommended through the MMRC, the joint efforts of both programs will be critical for information dissemination and guidance for evidence-based best practices.

 

AIM

IDOH continued working with the American College of Obstetricians and Gynecologists (ACOG) to reduce maternal mortality and morbidity through evidence-based patient safety bundles under the Alliance for Innovation on Maternal Health (AIM). To date, IDOH has successfully implemented the Obstetric Hemorrhage bundle and the Reduction in Severe Hypertension bundles. Both bundles have high rates of enrollment, with over 90% of Indiana delivering facilities participating. Indiana will continue to implement new AIM bundles following the release of the Annual MMRC report based on recommendations and needs from the emerging data. Over the past 12 months, MCH has given extra attention to hospitals that are currently not enrolled in AIM in order to increase enrollment to 100% and to better monitor goals and outcomes of each facility while encouraging continuous quality improvement. The MCH nurse surveyor team has continuously worked with these facilities to enroll.

 

Levels of Care:

In September 2019, IDOH promogulated the Perinatal Level of Care (PLoC) rules which designates both neonatal and maternal units in a delivery facility. By September of 2021, IDOH has received 100% birthing facilities PLoC applications, and in the years since, MCH survey team has traveled the state surveying and designating all delivery facilities. The Team has seen marked improvement in the quality of care delivered when comparing gap analysis results from 2015 to the results of facilities’ surveys. 

In this reporting period, a significant portion of the State’s Level II/II delivery facilities were surveyed and designated. In partnership with the Indiana Perinatal Quality Improvement Collaborative, MCH’s Clinical Team worked through considerable challenges and problem solving to help facilities navigate through the designation process. Not only were hospitals dealing with considerable barriers due to COVID pandemic, staffing shortages on the units as well as on transport teams made it difficult for many facilities. Clinical team worked with each facility individually to understand their unique challenges and strengths. The team used tools such as remote chart reviews, flexible scheduling, and the increasing use of tele-health to evolve MCH’s survey process.

 

Justice-Involved Moms and Babies

In September 2020, IDOH partnered with IU Richard M. Fairbanks School of Public Health to support Grassroots Efforts to Improve Indiana’s MCH Outcomes. The funding supported the creation and development of Mothers on the Rise (MOTR), which aims to create a system to serve mother/baby pairs transitioning from the Leath Nursery Unit at the Indiana Women’s Prison to their home community. Mothers on the Rise worked with each mom/baby dyad to provide education, help create a resume and think about job placement upon release, provide clothing, hygiene supplies, and infant care supplies, connect them with food banks, link them to necessary mental health services, prenatal services, or women’s health care, and provide assistance with the BMV or legal help. MOTR paired each dyad released from the women’s prison to a community navigator who supports the mom and baby in attending well child visits and securing social services like Section 8 housing. MOTR experienced great success in preventing two mother/baby pairs from homelessness through assisting in the establishment of secure housing. This small pilot project will continue to expand into the next year.

 

State Priority Need:

Reduce preventable deaths in the MCH population with a focus on reduction and elimination of inequities in mortality rates.

 

State Performance Measure (2020 - 2025):

SPM 1: Prevent the use of substances, including alcohol, tobacco, and other drugs among youth and pregnant women.

 

General Information:

 

The statewide needs assessment survey showed substance use as the second highest need (behind mental health) for communities across the state. Inevitably, women who use substances may become pregnant, and MCH is committed to ensuring they have access to optimal healthcare throughout and after their pregnancy. As MCH improves the ability to screen and identify women using substances during pregnancy, we hope to grow in our capacity to provide further treatment and care for all families.  

 

MCH continued to increase the number of delivering hospitals that participated in the Perinatal Substance Use (PSU) Collaborative with the Indiana Perinatal Quality Improvement Collaborative (IPQIC). MCH surveillance efforts grew from collecting data from 41 hospitals in 2019 to 69 hospitals in September 2021. Increasing the number of hospitals that participated in the PSU Collaborative helped to provide more comprehensive data and a more accurate snapshot of substance positivity and neonatal abstinence syndrome (NAS) in Indiana.

 

Utilizing the PSU Collaborative hospital data and comparing changes from Quarter 3 2020 to Quarter 3 2021, there was a decrease in the rate of positivity of opiates (108.9 to 78.4) per 1,000 cords tested. Within the same timeframe, there was also a decrease in the rate of NAS diagnoses per 1,000 positive cords from 206.6 to 163.7. While these decreases were welcomed news, we did see an increase in cannabinoid rates (197.4 to 238.4) during the same time period. Any utilization of PSU Collaborative data should be noted with several data limitations, including that any changes in the data could be a result of changing hospital participation and increased consistency in NAS diagnosis and reporting. Therefore, trend analyses using PSU Collaborative data is limited.

 

In 2019, Indiana’s legislature passed HEA 1007. This bill required that all women receive a validated verbal screening for substance use as part of their prenatal care and if the screen is positive that she is referred to treatment. MCH will work with IPQIC and relevant professional organizations to ensure these screens are happening and ensure there is an available provider in her community to provide care. Additionally, MCH is partnered with the Office of Medicaid Policy and Planning (OMPP) to about expanding Medicaid coverage for 12 months after delivery for women enrolled in treatment for substance use disorder. This was made effective in April 2022. Providers will also be provided opportunities for training on substance use during pregnancy through traditional conference-style training events as well as the availability of collaborative style training events through the ECHO model.

 

In late 2020 and again in early 2021, MCH enhanced data collection by adding supplemental questions to report on into the REDCap database for PSU Hospitals. This opportunity for additional data collection aided MCH in understanding the implementation of HEA 1007. This additional data collection showed that 98% of participating PSU Hospitals conducted a verbal screen on every woman at presentation for delivery. We also learned that 92% of participating hospitals will test the baby’s umbilical cord if a pregnant person refuses the verbal screen and/or toxicology test. These additional data points helped MCH to ascertain the level of screening happening in Indiana in order to ensure pregnant persons are being screened so that they can be connected to treatment if needed.

 

MCH utilized the platform of the PSU Collaborative to educate hospitals on the importance and continued need for them to report NAS and perinatal substance use codes to the Indiana Birth Defects and Problems Registry (IBDPR), which is housed in MCH. Utilizing the PSU Collaborative to strengthen IBDPR reporting will aid in collecting more comprehensive substance use data since the IBDPR also contains demographic and medical record data. This continues to be a goal for future PSU Collaborative work so that substance use can be more accurately surveilled and prevention efforts can be data driven.

 

In early 2020, IPQIC added a subcommittee specifically tasked to explore how public health and clinical providers can work together to examine how to measure, prevent, and mitigate Fetal Alcohol Spectrum Disorder (FASD). During the year, the committee examined strategies to measure the impact of FASD by screening for ETOH on the cord blood tests. Additionally, MCH sought to understand how to work with providers to better report alcohol exposure to the IBDPR. The IBDPR program provided education regarding the ICD-10-CM codes for alcohol exposure and fetal alcohol syndrome. The committee was also tasked with providing recommendations on appropriate interventions in the clinical setting at the prevention (maternal health) level, and screening for children during grade schools. MCH also sought population health interventions and prevention strategies that could be deployed within the structure of the Title V program.

 

In partnership with the Family and Social Services Administration (FSSA) and the Department of Child Services (DCS), MCH and IPQIC will develop protocols for delivery hospitals to develop plans of safe care for all mother/baby dyads discharged from the hospital. Currently, plans of safe care are completed for some families involved in child services; however, it is the goal that all families are connected to needed resources, regardless of circumstance.

 

FRP coordinated with MCH, IPQIC, local health departments, and local FIMR teams to assist in increasing the quantity and quality of direct services for infants with perinatal substance exposure and mothers with substance use disorder through grant work funded by the Department of Justice’s Office for Victims of Crime (OVC). Anticipated work will include assessment of current practices and policies in birthing hospitals relating to language and stigma and plans of safe care, training opportunities, as needed, on best practices of care of infants, and encouragement of connectivity and referral practices between pre-natal care providers, hospitals, and mental health services.

 

MCH will continue to support evidence-based programs to help pregnant women quit smoking. Previously, Title V supported many sites implementing the Baby and Me Tobacco Free (BMTF) program. However, due to the collected data not showing intended outcomes, IDOH closed out the BMTF programming on 09/30/2021. IDOH did commit to support sites beyond the 9/30 deadline for anyone still enrolled in the program. Out of 16 locations, only three have asked for continued support for after the deadline. The maternal health programs staff are working alongside the Tobacco Prevention and Cessation team to explore how pregnant people can receive tobacco cessation care and treatment through additional services or programming in the year to come.

 

Members of the Title V program, including the MCH Director, Clinical Director, and members of FRP are participating with partners at the Division of Mental Health and Addiction on a PRISM project through ASTHO. The Promoting Innovation in State & Territorial MCH Policymaking (PRISM) Learning Community has provided regular technical assistance and capacity building over the past twelve-months to support and advance policy implementation within states and territories to equitably address substance misuse and addiction and mental health disorders in women, children, and families within the context of the COVID-19 pandemic. The Indiana team ebbed and flowed as staff turnover, specifically in the maternal health space, taxed the time and resources of MCH and FRP staff. Indiana was able to use the technical assistance time to meet more closely with our partners in the Family and Social Services Administration to learn more about their Plans of Safe Care initiatives and the Indiana Pregnancy Promise Program. 

 

In 2019, Indiana was awarded a Centers for Medicare and Medicaid (CMS) grant to address opioid use disorder in pregnant patients. The Indiana Pregnancy Promise Program is a free, voluntary program for pregnant Medicaid members who use opioids or have used opioids in the past. The program ensures individuals’ privacy and confidentiality. The Pregnancy Promise Program connects individuals to prenatal and postpartum care, other physical and mental health care, and treatment for opioid use disorder. The Pregnancy Promise Program provides support during the prenatal period and for 12 months after the end of pregnancy. Through these supports and relationships, the Pregnancy Promise Program provides hope to parents and babies and sets a strong foundation for their future. The project director the program serves on IPQIC and the MMRC. The MCH Director serves on the board for the Pregnancy Promise program. In this reporting year, the program continued to build partnerships and infrastructure to refer pregnant people to resources across Indiana. They have successfully leveraged the Managed Care Entities (MCEs) and the Indiana 211 system to connect pregnant people to services. Pregnancy Promise began enrollment on 7/1/2021 and by 9/30/2021 there were exactly 100 enrollees across the state. Sixty-four of those enrollees were pregnant and 36 were in the postpartum period. IDOH and FSSA anticipates a lot of growth as it moves into the next year.

 

The MCH Director continued to work with NACCHO and CityMatCH on the Alignment for Action Learning Collaborative with Bartholomew County. This partnership seeks to examine how state and local health departments can more collaboratively learn and work together to align strategies for population health improvement. Specifically, the state is learning from Bartholomew County how they implemented a FIMR program that essentially eliminated safe sleep related deaths in their community. The Title V program will take those learnings and spread and sustain to other counties with similar projects. Additionally, Bartholomew County is working to build prevention and intervention strategies related to substance use disorder in pregnant people. These learnings are especially important as Bartholomew County is considered ex-urban and rural. Its population is similar to many other counties within the state where these strategies may be replicated. The Title V program is grateful for the opportunity to forge new and strengthen existing partnerships as a result of this opportunity.