The Pennsylvania Department of Health and the Bureau of Family Health (BFH) expend federal and state maternal and child health (MCH) funds in accordance with Title V and other federal and state guidelines with the goal of protecting and promoting the health and well-being of women, birthing people, children, and families. Title V FFY 21 expenditures, both federal and non-federal, aligned with Pennsylvania’s seven MCH priority needs identified during the 2020 Needs and Capacity Assessment process. Priority needs were addressed through the following strategies:

• Reduce or improve maternal morbidity and mortality, especially where there is inequity - Federal Title V funds were expended to implement evidence-based or evidence-informed home visiting programs, culturally relevant, community-based maternal care models, including doulas, and preconception, postpartum, and interconception care initiatives for women and birthing people. Federal Title V funds in partnership with other federal funds were expended on staff who reviewed the Maternal Mortality Review Committee findings to inform, develop, modify, and evaluate public health programs and policies in Pennsylvania. Other federal funding and federal Title V funding were used to support state-level program management and public health systems development.

• Reduce rates of infant mortality (all causes), especially where there is inequity - Federal Title V funds were expended to facilitate adoption of evidence-based strategies to support initiation and continuation of breastfeeding, provide and promote breastfeeding education, and develop collaborations, particularly with the Safe Sleep program. Federal Title V funds were expended to develop and implement a hospital-based model safe sleep program, implement a social marketing plan to increase awareness of safe sleep practices, and implement Sudden Unexpected Infant Death (SUID) prevention strategies, including safe sleep promotion, based upon the data reported in the SUID/Sudden Death in the Young (SDY) Case Registry. Federal Title V funds were also expended to support Perinatal Periods of Risk studies. Other federal funds were used to support participation in the SUID/SDY Case Registry.

• Improve mental health, behavioral health and developmental outcomes for children and youth with and without special health care needs -. Federal Title V funds were expended to expand the evidence-informed Health Resource Center (HRC) program and make available office visits and counseling/health education to youth as part of a reproductive health visit at a family planning provider. Federal Title V funds were expended to implement evidence-based strategies to address bullying, evidence-based or evidence-informed mentoring programs, SafeTeens/SafeTeens Answers!, and increase protective factors for LGBTQ-identified youth through evidence-based or evidence-informed behavioral health programs. Federal Title V funds were expended to provide training to professionals working in both the brain injury and substance use arenas. Other federal funds were expended in partnership with federal Title V funds to implement the Personal Responsibility Education Program and Abstinence Education Grant Program.

• Improve the percent of children and youth with special health care needs who receive care in a well-functioning system - Federal Title V funds were expended to inform quality improvement activities and implement identified strategies to improve newborn screening (NBS) data collection, reporting, and case management, including interagency coordination, utilize evidence-based or informed strategies to provide service coordination, implement the Autism Diagnostic Clinic, implement the BrainSTEPS program, support leadership development and training for children with special health care needs (CSCHN), implement targeted home visiting programs, offer resources and information to families of CSHCN, and develop collaborations between systems of care serving CSHCN. Additionally, Federal Title V funds were expended to review and analyze neonatal abstinence syndrome cases reported in the NBS case management system, to identify birth hospitals that are not making Early Intervention Referrals, and provide technical assistance to improve referral rates as well as to collaborate with the DHS’ Office of Children, Youth, and Families to help support enrollment of impacted infants into Plans of Safe Care. Federal Title V funds were expended on staff who used Child Death Review (CDR) findings to inform, develop, modify, and evaluate public health programs and policies in Pennsylvania. Federal Title V funds were expended on state-level program management and related systems development activities, such as collaborating with the Department of Human Services programs serving CSHCN. Non-federal funds were also expended to improve the NBS data system and follow-up services, provide direct, enabling, and public health services to CSHCN through specialty care grants, and provide school health services to children with and without special health care needs. Other federal funds were expended to provide direct and enabling services through the Traumatic Brain Injury program and implement newborn hearing screenings and interventions while federal Title V funds were used to support state-level program management of the Traumatic Brain Injury program, the newborn hearing screening program, and public health systems development.  

• Reduce rates of child mortality and injury, especially where there is inequity - Federal Title V funds were expended to provide comprehensive home assessments to identify potential home health and safety hazards as well as home safety interventions to address the leading causes of child injury and death, on staff who used CDR findings to inform, develop, modify, and evaluate public health programs and policies in Pennsylvania, to improve safety in youth sports including providing trainings on the ConcussionWise™ curriculum, and to utilize the Coaching Boys into Men curriculum to promote violence prevention. Other federal funds were expended to enhance childhood blood lead level surveillance and implement lead poisoning prevention activities. Federal Title V was expended to support state-level management of these programs as well as related public health services and system activities, such as CDR and collaborating with the Pennsylvania Department of Health’s injury prevention program.

• Strengthen Title V staff’s capacity for data-driven and evidence-based decision making and program development - Federal Title V funds were expended on staff who reviewed program activities and goals to determine programmatic needs, conducted analysis, interpreted results, developed actionable reports, developed program strategies based on actionable findings, and used PA Pregnancy Risk Assessment Monitoring System (PRAMS), the National Survey for Children’s Health (NSCH), CDR findings, and the Maternal Mortality Review Committee to inform, develop, modify, and evaluate public health programs and policies in Pennsylvania. Other federal funds, supplemented with federal Title V funds, were expended to collect, analyze, and report PA PRAMS and SUID/SDY data as well as to improve the state’s ability to identify, collect, and use relevant data to inform decision-making and evaluate population and programmatic needs. Federal Title V and other federal funds were expended to assess program performance related to targeted MCH outcomes so improvements can be made as needed.

• Support and effect change at the organizational and system level by supporting and promoting policies, programs and actions that advance health equity, address the social, environmental and economic determinants of health and deconstruct institutionalized systems of oppression - Federal Title V funds were expended to improve and expand reproductive health and family planning services and to support staff training in and implementation of health equity principles. Federal Title V funds were expended to support state-level management of these programs as well as related public health systems and MCH workforce development activities.

Form 2 (MCH Budget/Expenditure Details), Form 3a (Budget and Expenditure Details by Types of Individuals Served), and Form 3b (Budget and Expenditure Details by Types of Services) were completed in accordance with the guidance. All direct service expenditures reported on Form 3b reflect services that were not covered or reimbursed through another provider. These Title V funded direct services include pharmacy and physician/office charges for pregnant women, infants, children, and CSHCN. Title V is the payor of last resort for all direct services. The state match funded direct services include pharmacy, laboratory and physician/office charges for pregnant women, infants, and CSHCN.

Federal Title V, state, and other federal funds were expended in FFY21 to support MCH programming throughout the state, improving the health of women, birthing people, children, and families. The program outcomes discussed in the State Action Plan and other sections of the Application/Annual Report could not have been achieved without federal Title V funding.

In FFY21, $23,954,647 federal Title V dollars were expended, $11,087,519 (46% of the total Title V federal expenditures) on preventive and primary care for children, $7,215,266 (30% of the Total Title V federal expenditures) on CSHCN, and $2,395,464 (10% of the total Title V federal expenditures) on Title V administrative costs. Pennsylvania bases maintenance of effort match funds on all non-federal funds that serve MCH populations. In FFY21, $49,045,442 state dollars targeting MCH populations were expended, surpassing the state’s maintenance of effort amount from 1989, $20,065,575. Total state and federal Title V expenditures for FFY21 were $73,000,089. Additionally, the BFH expended $3,241,422 in other federal funds implementing MCH programming. State MCH grand total expended for FFY21 was $76,241,511. State funds that contributed to the maintenance of effort amount included state appropriations for school health services and MCH Services as well as appropriations for special conditions impacting MCH populations such as sickle cell, cystic fibrosis, hemophilia, Cooley’s Anemia, Tourette Syndrome epilepsy, and NBS. State funded expenditures supported direct, enabling, and public health services and systems targeting infants and children with and without special health care needs.

Expenditures of Title V funds complied with the legislative requirement that a minimum of 30% of funds are allocated for the support of preventive and primary services for children, a minimum of 30% of funds are allocated for services for children with special health care needs, and a maximum of 10% of funds are allocated as administrative costs. There were no significant variations of more than 10% in the FFY21 Title V expenditure data reported on Form 2 as compared to the planned budget for FFY21, though less was expended in other federal grants due to delays in program implementation, grants ending, and decreased funding availability. However, there were significant variations of more than 10% in the FFY21 Title V expenditure data reported on Forms 3a and 3b. Several factors led to the significant variations. First, the Department of Health prioritized addressing maternal mortality in its strategic plan and, simultaneously, the Title V 2020 Needs and Capacity Assessment process resulted in a new Title V priority focused on reducing maternal mortality. As a result, new enabling and public health services and systems initiatives were begun in the pregnant women domain; however, delays in program implementation contributed to decreased expenditures. Second, an increased birth rate in 2021, along with new programming targeted at addressing infant mortality, increased in Title V and state match related expenditures for infants. Third, the addition of programs serving all Title V population domains, including postpartum people and families, as well as the addition of legislative additions targeting CSHCN and their families led to an increase in expenditures in the all others population domain for both Title V and the state match in 2021. Finally, conscious efforts to move MCH programming down the pyramid led to a significant variation in direct service expenditures for both federal Title V and state match funded programs. The result of these efforts led to a significant increase in enabling services expenditures for 2021.

Expenditures are monitored on a monthly basis to ensure compliance with legislative financial requirements. Federally and state funded Title V programs served an estimated 2.6 million individuals from the MCH population. Title V served 91% of pregnant women, 99% of infants, 33% of children, and 51% of CSHCN in FFY21. The COVID-19 pandemic continued to impact service numbers especially in reduced school health screenings. Over time, Pennsylvania has increased its capacity to serve a greater proportion of the MCH population by shifting reimbursable direct service expenditures to the appropriate payors and utilizing federal and state Title V funds for population health programs, such as school health services and NBS.

Title V FFY 2023 budget estimates, both federal and non-federal, align with Pennsylvania’s seven MCH priority needs resulting from the 2020 Needs and Capacity Assessment, as identified on Form 9. Priority needs will be addressed through the following strategies:

• Reduce or improve maternal morbidity and mortality, especially where there is inequity - Federal Title V funds are budgeted to implement evidence-based or -informed home visiting programs, Centering Pregnancy programs, community-based, culturally relevant maternal care models, and innovative interconception and early postpartum care initiatives for women as well as to promote maternal behavioral health screenings and referral to services. Federal Title V funding is budgeted to support state-level management of these programs as well as related public health services and systems activities, such as participating on the Maternal Mortality Review Committee (MMRC) and collaborating with the Pennsylvania Department of Human Services (DHS) programs serving people who are pregnant or postpartum.

• Reduce rates of infant mortality (all causes), especially where there is inequity - Federal Title V funds are budgeted to facilitate adoption of evidence-based strategies to support initiation and continuation of breastfeeding. Federal Title V funds are also budgeted to implement a hospital-based model safe sleep program and Sudden Unexplained Infant Death (SUID) prevention strategies, including safe sleep promotion, based upon the data reported in the SUID/Sudden Death in the Young (SDY) Case Registry. Federal funds are budgeted to support Perinatal Periods of Risk studies. Other federal funds are budgeted to support participation in the SUID/SDY Case Registry. Federal Title V funding is budgeted to support state-level management of these programs as well as related public health services and systems activities, such as Child Death Review (CDR) and collaboration with the Pennsylvania Department of Human Services programs serving infants and people caring for infants.

• Improve mental health, behavioral health and developmental outcomes for children and youth with and without special health care needs - Federal Title V funds are budgeted to expand the evidence-informed Health Resource Center program, increase protective factors for LGBTQ-identified youth through evidence-based or evidence-informed behavioral health programs, implement Olweus Bullying Prevention Program for community youth organizations, support youth mentoring, implement SafeTeens/SafeTeens Answers!, promote awareness of the correlation between substance use and brain injury, and implement CDR recommendations to address trauma. Other federal funds are budgeted to provide services through the Personal Responsibility Education Program and Abstinence Education Grant Programs while federal Title V funding is budgeted to support state-level management of these programs as well as related public health systems development activities.

• Improve the percent of children and youth with special health care needs who receive care in a well-functioning system - Federal Title V funds are budgeted to review and analyze data from the Newborn Screening (NBS) system to inform quality improvement activities to improve data collection and reporting and develop strategies to address identified weaknesses in NBS data collection, reporting, and follow-up. Federal Title V funds are also used to ensure families are partners in decision making and are satisfied with the services received, CSHCN receive coordinated, ongoing, comprehensive care within the medical system, CSHCN are screened early and continuously for special health care needs, community-based services are organized so families can use them easily, and youth with special health care needs receive services to make appropriate transitions. Additionally, Federal Title V funds are used to review and analyze neonatal abstinence syndrome cases reported in the NBS case management system to identify birth hospitals that are not making Early Intervention Referrals and provide technical assistance to improve referral rates as well as to collaborate with the DHS’ Office of Children, Youth, and Families to help support enrollment of impacted infants into Plans of Safe Care. State and other federal funds are also budgeted to improve the NBS case management system, implement newborn hearing screenings and interventions, provide direct, enabling, and public health services to CSHCN through specialty care grants, provide school health services to children with and without special health care needs, and implement the service component of the Traumatic Brain Injury program while federal Title V funds are budgeted for state-level program management and related systems development activities, such as collaboration with DHS programs serving CSHCN.

• Reduce rates of child mortality and injury, especially where there is inequity - Title V funds are budgeted to reduce sports-related head injuries, increase adolescent males understanding of healthy relationships through evidence-based or -informed programs, provide comprehensive home assessments to identify potential home health and safety hazards as well as home safety interventions to address the leading causes of child injury and death. Other federal funds are budgeted to enhance childhood blood lead level surveillance and implement lead poisoning prevention activities. Federal Title V funding is budgeted to support state-level management of these programs as well as related public health services and systems activities, such as CDR and collaborating with the Pennsylvania Department of Health’s injury prevention program.

• Strengthen Title V staff’s capacity for data-driven and evidence-based decision making and program development - Federal Title V funds are budgeted to review program activities and goals to determine programmatic needs, conduct analysis, interpret results, develop actionable reports, develop program strategies based on actionable findings, and use PA PRAMS, National Survey for Children’s Health (NSCH), CDR, and the MMRC findings to inform, develop, modify and evaluate public health programs and policies in Pennsylvania. Title V and other federal funds are budgeted to collect, analyze, and report PA PRAMS, SUID/SDY, and NSCH data as well as to improve the state’s ability to identify, collect, and use relevant data to inform decision-making and evaluate population and programmatic needs. Federal Title V and other federal funds will be used to assess program performance related to targeted MCH outcomes so improvements can be made as needed.

• Support and effect change at the organizational and system level by supporting and promoting policies, programs and actions that advance health equity, address the social, environmental and economic determinants of health and deconstruct institutionalized systems of oppression - Federal Title V funding is budgeted to support reproductive health and family planning for adolescents with the intent of addressing determinants influencing disparities in unintended teen pregnancy rates. Federal Title V funding is also budgeted to increase staff understanding of health equity principles and to support state-level management of these programs as well as related public health systems and MCH workforce development activities.

Form 2 (MCH Budget/Expenditure Details), Form 3a (Budget and Expenditure Details by Types of Individuals Served), and Form 3b (Budget and Expenditure Details by Types of Services) have been completed in accordance with the guidance. Pennsylvania is requesting a federal funding amount for FFY 2023 that is level with the FFY 2021 award.

Pennsylvania's proposed budget for FFY 2023 is in full compliance with the federally mandated threshold requirements. Of Pennsylvania's proposed federal grant award for 2023, $10,368,088 (43.3% of the total grant award) is designated for the support of preventive and primary services for children, and $8,544,331 (35.6% of total grant award) is designated for the support of services for children with special health care needs. Administrative costs are budgeted at $2,395,464, which is 10% of the grant award. Administrative Costs include all personnel and operating costs that are not directly or indirectly incurred for the provision of direct, enabling, or public health services and systems. Beginning in FFY 2018, Pennsylvania adjusted the reporting methodology for funding designated to preventive and primary care for children to reflect the population served, rather than the outcome of the service. In previous years, services provided to pregnant women were included in the calculation because the goal of these services was to improve perinatal and infant health outcomes. Services provided to pregnant women are no longer designated as preventive and primary services for children.

Pennsylvania bases maintenance of effort match funds on all non-federal funds that serve MCH populations. Pennsylvania’s maintenance of effort amount from 1989 is $20,065,575. State funds that contribute to the maintenance of effort amount include state appropriations for school health services and MCH services as well as appropriations for special conditions impacting MCH populations such as Sickle Cell, Cystic Fibrosis, Hemophilia, Cooley’s Anemia, Tourette Syndrome, Services for Children with Special Needs, Epilepsy, and NBS. Total state funds contributed to MCH services in 2023 are $53,009,500. This exceeds the required $3 match in non-federal funds for every $4 of federal Title V Block Grant funds expended. The federal-state Title V Block Grant partnership subtotal for 2023 is $76,964,147. Federal Title V and state funds will be monitored on a monthly basis to ensure the match requirements are met for FFY 23.

The BFH is the recipient of several other federally funded projects that impact the MCH population, including: State Sexual Risk Avoidance Education Grant and Personal Responsibility Education Program from the Administration for Children and Families; PRAMS, SUID/SDY Case Registry, Preventing Maternal Deaths, and Childhood Lead Poisoning Prevention Program from the Centers for Disease Control and Prevention; State Systems Development Initiative, and Universal Newborn Hearing Screening and Intervention from HRSA; Traumatic Brain Injury from the Administration for Community Living; and Lead-based Paint Hazard Control from the Department of Housing and Urban Development. The total funding from all other federal projects for 2023 is $8,127,554. State MCH budget grand total for 2023 is $85,091,701.

Budgeted amounts outlined on Form 3b reflect Pennsylvania’s intent to spend the majority of its anticipated FFY21 MCH funding from federal Title V, state, and other federal sources on enabling services and public health services and systems. The budgeted amounts for direct services reported on Form 3b are estimates of the cost of direct services not covered or reimbursed through another payor. These Title V funded direct services include pharmacy, laboratory, and physician/office charges for pregnant women, infants, children, and CSHCN. Title V is the payer of last resort for all direct services. The state funded direct services include pharmacy, laboratory, and physician/office charges for infants and CSHCN. As evidenced by the variety of programming listed within the State Action Plan, Pennsylvania has allocated funding to directly and indirectly support the public health essential functions for the three legislatively defined populations, preventive and primary care services for all pregnant women and birthing people, mothers, and infants up to age one, preventive and primary care services for children, and services for CSHCN. The allocation of funding for enabling services and public health services and systems outlined on Form 3b demonstrates Pennsylvania’s continued commitment to expanding systems of care for both MCH and CSHCN populations.