The mission of the South Dakota (SD) Maternal and Child Health (MCH) Program is to improve the health and well-being of SD families and to assure access to preventive and primary health care services for mothers, infants, children, adolescents and young adults which also includes children and youth with special health care needs. The Office of Child and Family Services (OCFS) utilizes funds to enhance work in communities and tribal areas across the state. The expenditures complement the mission of the SD MCH program.

The OCFS is divided into three sections: Community Health Services, WIC, and MCH. These sections work collaboratively to utilize funding appropriately to support outreach to underserved populations through nurses and dietitians located in 74 community health offices across the state. SD has an MCH staff comprised of six program coordinators and the MCH Director that work with internal and external partners to implement the state action plans. The MCH program shares an epidemiologist with other OCFS programs.

For FFY 2021 expenditures, SD met federal Title V requirements that at least 30 percent of federal funds support CYSHCN activities. In addition, at least 30 percent of federal funding was used for preventive and primary care for child and adolescent activities. SD did not exceed the 10% administrative requirement. South Dakota’s maintenance of effort was fully met.

South Dakota Title V is the payer of last resort and MCH Block Grant funds were not used to reimburse a claim for a service that was otherwise covered under Medicaid. All services supported by the MCH Block Grant reflect services that were not covered or reimbursed through the Medicaid program or another provider.

Total Expenditures excluding Administrative Costs (Federal/General/Other) by Populations:

CYSHCN        $765,226

Pregnant Women/Infants     $1,113,232

Child/Adolescents      $1,086,745

All others        $54,690

Total Expenditures excluding Administrative Costs (Federal/General/Other) by Type of Service

Direct Services        $33,909

Enabling Services        $1,686,523

Public Health Services and Systems     $2,254,266

In broad terms, expenditures support personnel that facilitate MCH program efforts and provide services to the MCH population through Community Health’s nurses and dietitians. Additional outreach is provided through population-based strategies such as public education, data and surveillance, community outreach, epidemiology support, training, social media etc. across all MCH domains. Systems Development Initiative funding is also utilized to build and expand MCH data capacity to support Title V activities and contribute to data-driven decision making in MCH programs, including assessment, planning, implementation and evaluation.

Expenditures that are related to program management, including contract management, are implemented by MCH program staff within the OCFS. All MCH program activities include data analysis, evaluation, and continuous quality improvement activities to drive data driven decisions and program improvement.

Office of Child and Family Services 

OCFS expenses shared within contractual agreements include evaluation and epidemiology, consultation for the needs assessment, and media/communication support. Each contractual agreement includes detailed invoices to account for MCH spending.

An overview of the activities that are partially or fully funded with MCH dollars is below.

Women and Infants:      

• Modified case management of high-risk pregnant women not covered by Medicaid
• For Baby’s Sake website and Facebook page – promoting healthy moms and healthy babies
• Developing, implementing and evaluating local office maternal mortality prevention plans
• Postpartum home or office visits including assessment, education/counseling, anticipatory guidance, client need coordination, referral and follow-up
• Prenatal education/counseling for pregnant moms who are not high risk
• Ages and Stages Developmental Screening and related education, counseling, and anticipatory guidance for infant caregivers. Referrals as needed
• Ages and Stages Social and Emotional Screening and related education, counseling, anticipatory guidance for infant caregivers. Referrals as needed.
• Developing, implementing, and evaluating local office infant mortality prevention plans
• Quality Assurance activities
• Newborn home or office visits including assessments, education/counseling, anticipatory guidance, client need coordination, referral, and follow-up (mothers/infants not covered by Medicaid)
• Cribs for Kids safe sleep kit distribution/safe sleep education for parents/caregivers
• Child death review (previously infant death review)

Child and Adolescent:    

• Community-based and youth-driven activities to reduce suicide and injuries
• Well Visit promotion with Medicaid and 3rd party payers
• School-based health assessments/preventive health education including screening, education/counseling, referral, and follow-up
• Oral health assessments
• Nutrition/physical strategies to reduce overweight and obesity (i.e. healthy concessions, training for school personnel, height and weight data collection)
• Ages and Stages Developmental and Social/Emotional screenings for young children including education, counseling, anticipatory guidance and referrals when needed

Children and Youth with Special Health Care Needs

• Direct service reimbursement through the Health KiCC program
• Newborn screening identification, referral and follow-up
  • Support for families of children with chronic conditions, i.e. respite care; special needs car seats; resource and referral
  • Support genetic/specialty consultation in areas of the state where services are not available.
  • Care coordination and development with an emphasis on evaluation.

Budgeted versus expended:

During FY21, the OCFS has responded in a variety of ways to the COVID-19 pandemic. The form field notes on budget and expenditure differentials are due to the pandemic response of the OCFS and our contractual partners.

Significant variations of more than 10% in the expenditure data reported on Form 2 and are explained below:

The amount expended this year is significantly less than the amount budgeted. This is due to many staff responding to the COVID 19 pandemic and coding that time to COVID funding. In addition, many families opted to hold off on receiving services in our clinics due to the risk of infection, resulting in less staff time coding to MCH funds.

Significance of federal MCH Block Grant funding support:

Without the MCH Block Grant dollars, the SD DOH would be forced to make significant cuts to the services and education provided to SD families.

Accountability:

MCH block grant activities performed by MCH program and field staff are accounted for by a daily time study. The time study includes funding codes that reflect the population being served (i.e., child/adolescent, pregnant women, mothers and infants, and CYSHCN). Function codes determine if the service was direct, enabling, or public health services and systems (e.g., developmental screening, travel to provide services, training, networking, quality assurance, or modified case management).

The DOH Division of Finance provides hard-copy grant reports monthly to the MCH Director. More detailed reports are available on a shared drive where end users can utilize a pivot table to bring into focus the expenses by detail to track expenses on a regular basis. Contracts are monitored and invoices approved by MCH staff to assure program activities are accounted for. If a contract is determined to be a subrecipient contract the Division of Finance assists with monitoring and compliance. A monitoring guide is available to DOH staff to ensure a monitoring plan and methods for proper oversight of subrecipient entities is in place. The guide also includes tools and suggestions that could be included in the monitoring process.

Securing and monitoring of match is the primary responsibility of the MCH Director. Finance staff refresh expenditure data monthly and publish to program managers as well as an annual report to our federal HRSA partners.

Opportunities:

The infrastructure of an electronic health record platform is now operational and is being

utilized by the community health offices. The platform has been expanded to include a comprehensive billing platform for services provided in field offices such as immunizations, fluoride varnish application, developmental screening and maternal depression screening in the last quarter of FY21. The expanded platform will also provide data that will inform strategy development and program improvement measures.

In FY21 the OCFS finalized a plan, utilizing data and recommendations gathered during a detailed service assessment looking at expenses, revenue and return of investment of services provided in counties across the state. The final plan will include tools to monitor outcomes and financial measures around service delivery.

Challenges:

South Dakota law prohibits deficit spending, so the Governor and state legislature control the spending of general funds that in turn affect dollars that are available for MCH block grant match.

MCH block grant funds have historically been used to address priorities outlined in the needs assessment and strategic action plans for the MCH population. The comprehensive needs assessment process assists the DOH in setting priorities for resource allocation. The amount of funding allocated to MCH services is determined as part of the state budget process that includes development of the budget by DOH; interim approval by the Bureau of Finance and Management (BFM) and Governor's Office; and final approval by the State Legislature.

The budget outlines areas for which Title V funds will be allocated. Development of the budget complies with the "30-30" requirement for primary and preventive care and special health care needs for children and adolescents and is consistent with the requirements to limit administrative costs to no more than ten percent. The DOH maintains the overall level of funds for MCH at the level established in FFY 1989 and monitors funding allocations quarterly to ensure compliance. Most years the DOH spends more than the federal allocation but it is difficult to reflect this due to the overlapping periods of obligation under the previous fiscal year and the spending of funds in the current fiscal year. In FY21 MCH spending was greatly affected by the COVID 19 pandemic and the availability of COVID funding.  The DOH continues to align funding resources to support the MCH priority areas and selected measures.

Appropriation of general funds for MCH state match is at the discretion of the Legislature, Governor's Office, and DOH. State match funding sources are state funds (including general funds appropriated by the Legislature), local match, program income, and other sources. The level of funds utilized from each match source varies from year to year based on availability of funds and the state's allocation process. Increasing inflationary costs have depleted revenue reserves within the DOH and the state as a whole requiring shift in match fund sources.

Budget development is subject to rules and requirements set by BFM dictating both the process and content of the budget, including availability of funds and limitations on authorization levels. SD continues to refine the budget development and expenditure process to meet both state and federal rules and requirements. The DOH continues to move toward accounting programs that more easily reflect population group and pyramid level reporting requirements.

In addition to state general funds, MCH federal funds are also supported by matching funds from partners and other income from fees collected on birth certificates and services provided in local Community Health Offices. Federal funds from Family Planning, PREP, Sexual Risk Avoidance Education (SRAE),  Home Visiting (MIECHV), Pregnancy Risk Assessment Monitoring System (PRAMS), State Systems Development Initiative (SSDI), Universal Newborn Hearing, and WIC complement MCH federal and non-federal funds and enable the state to address its priority needs and provide a greater reach to all populations served by MCH. 

Proposed budget for FY2023 reflects:

• A shift to a more sustainable revenue-based model through review of the operations and implementation of services in local communities. This is reflected by an increase in program income being utilized to support efforts for the MCH populations. 
• Ongoing efforts for federal spending to be maintained within one federal year’s allocation.  The COVID pandemic response as well as the influx of additional COVID funds has made spending the federal year’s allocation challenging, as staff shift their time and focus to response efforts, however, the MCH program is committed to enhancing services and programs through new initiatives, as well as supporting our partners that serve the MCH population.   As a part of the Office of Child and Family Services needs assessment process, a review of the service delivery structure will also assist in meeting the federal funding allocation.

A large portion of our funding supports workforce infrastructure and capacity to deliver services.  Without the Title V Block Grant dollars, services to our MCH population would need to be provided at a reduced capacity, either reaching fewer people or conducting fewer program activities.  In addition, our capacity to communicate and work with our existing MCH partners would be greatly affected.  Although our state is able to leverage funding from other sources, the loss of MCH funding would result in a change of priorities to meet program requirements.  

For the FY23 budgeted amounts, our agency used FY19 expended amounts when creating the budgeted amounts. The expenses for FY20 and FY21 were not typical due to COVID response and the availability of COVID funding.  We felt budgeting based on those FY20 and FY21 expenses would not provide the most accurate budgeted amount.  We based our budgets more on the percentage of the federal allocation.