See Forms 2, 3a, and 3b

The Oklahoma State Department of Health (OSDH) MCH value for parts A, B, and C is determined through the OSDH time and effort reporting system in which all state and local staff code their daily time to program activities. Non-personnel expenses are made as direct charges to the appropriate program budgets. State funds include state and county appropriations for local health departments. Other contributions include in-kind monies. Program income includes fee revenues from Medicaid. The OSDH is audited each year by the state auditor's office following the federal guidelines applicable to the MCH Title V Block Grant. All appropriate fiscal records are maintained to ensure audit compliance. It should be noted that the required breakdown of expenditures by types of services and individuals served, along with specific funding sources has necessitated some of these numbers to be estimated through the agency’s current budgeting system. All should be moved from estimates to actual expenditure numbers once the agency’s new financial system is in place.

The Oklahoma Department of Human Services (OKDHS) CSHCN value is determined through the Random Moment Time Study (RMTS) and based on employees’ responses specifically related to the CSHCN Program. All Adult and Family Services staff that work multi-funded programs are sampled in the RMTS. RMTS sampling is a federally approved technique for estimating the actual distribution of worker time to various activities when numerous federal funding sources exist. The percentage of employees’ responses to CSHCN-related tasks compared to responses to all other federal and/or state programs in the RMTS constitutes the value of costs directly charged quarterly to the CSHCN Program. Payroll, benefits, travel, etc., for RMTS participants are allocated proportionately based on RMTS responses.

The Oklahoma Title V Program continually looks for opportunities to realign funding for core enabling services and public health services and systems, while assuring critical gap-filling direct health care services are maintained. Expansion of Medicaid coverage up to 138% federal poverty level for Oklahomans between the ages of 19-64 begins July 1, 2021. Enrollment for this expanded coverage begins June 1st. These efforts will not only assist the MCH population in accessing necessary services and care, but will also assist the Title V Program in further accomplishing critical realignments. These realignments will benefit Oklahoma by providing needed data and evaluation for policy and services decisions, quality improvement activities, training for health care providers, public education, and improved coordination among health and human services agencies.

Form 2 indicates Title V federal, state and local dollars remained fairly level when comparing 2019 to 2020 numbers, which was an accomplishment in itself considering the many historical challenges faced in 2020. While there were difficulties with staffing, due to the flexibility of Title V to utilize funds for COVID-19 dire needs in the MCH population, staffing and funding issues did not reach the severity they may have otherwise. Additionally, moving to gap-filling prenatal care and child health services in local county health departments and mobile units was delayed due to COVID-19 urgencies with hotline, testing, vaccination pods, etc. However, if things continue to improve as they have in recent weeks, these services should be able to begin by early summer 2021 in four pilot districts.

Form 3a documents expenditures by the MCH types of individuals served. For FFY 2020, total funding for children 1-21 increased by approximately 10% and funding for infants/infant mortality reduction program increased by 42%. At the same time, funding for pregnant women and CSHCN decreased by 24% and 15% respectively. This shift in funds in these areas was due in large part to enhanced efforts in regard to our infant mortality reduction initiative: Preparing for a Lifetime: It’s Everyone’s Responsibility. The infant mortality funding increase nicely complimented additional funds from the SMHIP grant that MCH utilized for pregnant women through innovative maternal health initiatives such as: a special clinic for pregnant women with substance use disorder, tribal maternal-fetal medicine services, High Risk OB Project ECHO, and implementation of a new maternal safety bundle for Oklahoma Mothers and Newborns affected by Opioids, to name a few. Additionally, enhancements to grow the teen pregnancy prevention and positive youth development programs, health education, and epidemiology/analytical services in all districts in the state over the next year should assist in data-driven decisions and better outcomes for children with and without special health care needs.

Form 3b documents shifts that occurred within the categories of direct health care services, enabling services, and public health services and systems. Direct health care service expenditures utilized mostly for mental health treatment services for children with special health care needs remained flat from 2019 to 2020. Enabling services expenditures decreased by approximately 17% and public health systems and services increased by 9% in 2019. The shift to more population-based systemic services to address pandemic immediate and resulting needs, along with working with hospitals and partners in relation to best practices implementation in the areas of maternity, infant mortality reduction, and child health to address the need of the Oklahoma MCH population were demonstrated in 2020 expenditures.

With these changes, it should be noted that the Oklahoma Title V Program is very thoughtful in its process of looking at the priority needs of the MCH population and realigning funds and resources to meet those needs. As opportunities present with changes in national, Medicaid and state policies; state and county Title V staff; and Title V contractual services; the Title V Program will assure that the funds available are used for appropriate and quality services to optimize health outcomes for mothers, infants, children, and their families in Oklahoma. The Oklahoma Title V program is grateful to the HRSA Maternal and Child Health Bureau for the flexibility and support to adapt funding and services to the needs of our MCH population, as was particularly necessary and evident in the pandemic year of 2020.

Maintenance of effort from 1989:

For 1989 the OSDH administered 77.5 percent of the MCH Title V Block Grant funds and the OKDHS administered 22.5 percent of the funds. Even with this split, 1/3 of the available dollars were spent on CSHCN activities. The amount of the award for 1989 was $5,980,100. The OSDH share was $4,634,578 and the OKDHS received $1,345,522.

The OSDH expenditure reports indicate that a total of $4,634,578 of MCH Title V Block funds was expended during the grant period October 1, 1988 through September 30, 1989. For that period, a total $4,109,415 of the OSDH and county health department resources were expended for Block Grant activities. The amount of state/local expenditures exceeded the required match of $3,475,932 by an amount of $633,483.

Special consolidated projects:

MCH Title V Block Grant funds continue to be used to carry out safe sleep activities and the CSHCN Supplemental Security Income-Disabled Children’s Program (SSI-DCP). Safe sleep activities include public education and technical assistance along with resource provision (e.g. cribs, sleep sacks) at the community level. The Public Health Social Work Coordinator in MCH is responsible for coordination of Safe Sleep and sudden infant death syndrome (SIDS) related activities. The CSHCN SSI-DCP uses funds to provide formula, durable medical equipment, supplies and services that would otherwise not be available to children with special health care needs.

State matching funds:

In 2009, the OSDH made a policy decision to provide cost sharing in grant applications based on the requirements in each specific grant. For the MCH Title V Block Grant, cost sharing is based on the three state dollars for each four federal dollars as well as the requirement to meet the maintenance of effort set in 1989.

Federal 30/30 requirement:

For FFY 2021, 33% of the federal Title V Block Grant funds are designated for programs for preventative and primary care services for children, 30% for services for children with special health care needs, and 10% for administrative costs.

State provides a reasonable portion of funds to deliver services:

The OSDH uses MCH funds towards programs of priority for state and local needs. Assistance is provided to state and local agencies to: 1) identify specific MCH areas of need; 2) plan strategies to address identified needs; and 3) provide services to impact needs. Allocation of resources to local communities will continue to be based on factors such as: the identified need and scope of the particular health problem; community interest in developing service(s)/implementing evidenced-based practice(s) to eliminate the problem, including the extent and ability to which local resources are made available; ability to recruit the specialized staff which are often needed to carry out the proposed service; the cost effectiveness of the service to be provided; coordination with existing resources to assure non-duplication of services; and periodic evaluation to determine if resources have impacted the problem.

The OKDHS administers the CSHCN Program through Adult and Family Services (AFS). AFS also administers the SSI-DCP for SSI recipients under age 18. Other components of the CSHCN Program include a project that supports neonates and their families; support of the Sooner SUCCESS toll-free information and referral system for CYSHCN; a project that provides sickle cell services; respite care services for medically fragile children; medical, psychological and psychiatric services to the CSHCN population in the custody of the OKDHS; a project that is establishing an integrated community-based system of services for children with special health care needs in several communities in the state; funding for a statewide mentorship program for families of children with special needs; and, funding of a parent advocate on a team that provides multi-disciplinary services to children in the autism clinic. Coordination continues between the AFS and the Oklahoma Health Care Authority (OHCA) to assure services are not duplicated and policies and procedures are in compliance with federal and state mandates. The AFS continues to utilize Title V funding to assure the development of community-based systems of services for children with special health care needs and their families.

Other federal programs or state funds within MCH to meet needs and objectives:

The State Systems Development Initiative (SSDI), a grant funded by the Maternal and Child Health Bureau (MCHB), supports activities to link maternal, infant, and child health data (including birth and death certificates) with Medicaid eligibility and claims data. This compliments and strengthens MCH’s activities to link relevant program services to existing MCH databases including the Pregnancy Risk Assessment Monitoring System (PRAMS) and The Oklahoma Toddler Survey (TOTS) surveillance systems. These linkages enable the state to generalize the results to Oklahoma’s population of pregnant women (or new mothers) and young children.

The Pregnancy Assistance Fund (PAF), a grant funded by the Office of Adolescent Health, is a competitive grant program that funds states and tribal entities, including Oklahoma, so they can provide a seamless network of support services to expectant and parenting teens, women, fathers, and their families, with the goal of improving the health, educational, social, and economic outcomes of this special population. The Pregnancy Assistance Fund ended in December 2020.

The Pregnancy Risk Assessment Monitoring System (PRAMS), funded by the Centers for Disease Control and Prevention (CDC) and MCH, provides population-based data on maternal and infant health issues. This information is used to educate health care providers on maternal and infant health issues; recommend health care interventions; monitor health outcomes; and provide support for state policy and services changes.

The State Maternal Health Innovation Program is funded by HRSA to meet the needs of Oklahoma women and reduce maternal mortality and morbidity utilizing a multi-pronged approach. Through the OSDH MCH Service, the Oklahoma Maternal Health Task Force, and well-established partnerships throughout the state, the following are areas of focus for impacting and improving maternal health in Oklahoma: addressing racial disparities and implicit bias; increasing access to prenatal and postpartum care; addressing maternal morbidity through education and healthcare; addressing substance abuse and misuse in pregnant and postpartum women; increasing awareness and access to treatment for maternal mood disorders; and, increasing access to telehealth services for high risk obstetric, substance use/abuse services and maternal mood disorders in rural Oklahoma.

Federal funds are received from the CDC to support ongoing administration of the Youth Risk Behavior Survey (YRBS). This survey provides Oklahoma with information on risk-taking behaviors of high school youth that is utilized to educate providers and public on current issues and recommended interventions.

Targeted state and general revenue funds are received to support key MCH activities such as: gap-filling maternity and child health clinical services; outreach to vulnerable and disparate populations; infant mortality reduction program activities including preconception and interconception care and education; preterm birth initiatives using evidence-based practices to reduce premature births; support of mothers and health care providers with breastfeeding information, education, and a statewide 24 hour 7 day per week breastfeeding hotline and texting services, Fetal and Infant Mortality Review (FIMR) projects; Maternal Mortality Review (MMR); adolescent pregnancy prevention and positive youth development efforts; childhood injury prevention; school health to include funding of school nurses in priority areas of the state; Oklahoma’s Center for Poison and Drug Information; health education in public schools; Oklahoma Perinatal Quality Improvement Collaborative; birthing hospital safe sleep programs; Period of Purple Crying; Every Mother Counts maternal morbidity reduction program and related initiatives; and, data matching and analysis. Medicaid administrative match funds are received to support FIMR and data matching and analysis. The OSDH/MCH continued to receive funds this year for state- and community-based infant mortality reduction activities from the Governor and Legislature for key prevention and priority activities.

State funds, county funds, Medicaid revenue, fees, and Title X federal funds support the provision of family planning services through county health departments and contract clinic sites. These funds are also used to provide a variety of educational programs targeted at decreasing unintended pregnancies; postponing sexual activity in teens; preventing sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS); and, increasing knowledge of human sexuality.

The Oklahoma State Department of Health was designated as the state agency to receive funding from the Administration on Children, Youth, and Families (ACYF), Family and Youth Services Bureau (FYSB) to continue a Personal Responsibility Education Program (PREP). Funds are used to implement projects in the two large metropolitan areas of Oklahoma City and Tulsa through contractual agreements with the two independent city-county health departments. These projects focus on educating adolescents on both sexual risk avoidance and contraception to prevent pregnancy and STDs, including HIV/AIDS, and adulthood preparation (e.g., healthy relationships, adolescent development, financial literacy, parent-child communication, educational and career success, healthy life skills).

Budget Documentation:

Overall budget preparation and monitoring are provided through administrative support under the direction of the OSDH Chief Financial Officer. Agency budgeting, grants, and contract acquisition staff meets routinely with program areas. The MCH Director is responsible for overall program budget oversight and, along with each individual Division Administrative Program Manager, is responsible for compliance with program standards and federal and state requirements.

The OSDH receives an annual independent audit of program and financial activities. The state's Office of the State Auditor and Inspector conducts this annual statewide single audit. The OSDH maintains an internal audit staff that reviews county health departments and subcontractors for compliance with contract fiscal matters relating to OSDH support. Additionally, MCH performs onsite program reviews with county health departments and contractors to assure programmatic compliance for both Title V and Title X.

The comptroller for the Adult and Family Services prepares and oversees the budget for the CSHCN Program. The CSHCN Director is responsible for compliance with federal and state requirements. CSHCN program staff monitors the budget and meet regularly to insure financial awareness within each budgeted area. CSHCN performs yearly onsite reviews with each contracted entity to insure program compliance. Each contractor also undergoes an independent audit. The state’s Office of the State Auditor and Inspector conducts an annual audit of the CSHCN Program to assure compliance and accountability.

The Title V Grant application documents a proposed budget on Forms 2, 3a, and 3b, inclusive of Title V federal funds, state dollar match, local dollars, and anticipated income to be received from Medicaid. This budget is the base for services at the beginning of the grant period. As the year passes, the OSDH may make available more state and local funded resources (e.g., staff, supplies, travel) as available for provision of MCH services as an agency priority. This results in increased funding reported as expended on Forms 2, 3a, and 3b, compared to budget requirements. It is understood each year that these additional state and local funded resources are fluid and may be redirected at any time by the Commissioner of Health based on state and/or agency priorities, or in the event of a state health event, emergency or disaster needing to be addressed. An example of this is the recent COVID-19 pandemic, as all funds and resources possible needed to be diverted to these response efforts. The OSDH appreciates Title V’s understanding and willingness to utilize Title V funds and personnel to meet the health needs of Oklahoma’s moms, babies, children and families in the state during this critical time period.

Federal MCH block grant funds complement non-federal Title V funds in supporting essential MCH programs and services to meet Oklahoma’s maternal and child health population needs. Both federal and non-federal Title V MCH Block Grant funds are vital to the state’s capacity to address these needs.