I.E. Application/Annual Report Executive Summary

III.A.1. Program Overview

The Maternal and Child Health Division (MCH) and the Children’s Special Healthcare Services Division (CSHCS) are the two divisions at the Indiana Department of Health (IDOH) primarily responsible for meeting Indiana’s Title V priorities. Other important parts of the Title V team at IDOH include Nutrition and Physical Activity, Fatality Review and Prevention, and Trauma and Injury Prevention. A significant portion of Title V funding is granted to community-based organizations around the state to ensure all levels of the MCH pyramid and all state priorities are being addressed.

Major accomplishments/changes in the last year include:

1. A historic investment in public health for the State of Indiana with the passing of SB4 – increasing local public health funding from approximately seven million dollars per year to 225 million over the next two years.
2. IDOH received key federal grants to expand our investments in public health including: the Autism and Developmental Disabilities Monitoring grant, Newborn Screening Surveillance, Perinatal Quality Collaboratives, and Maternal Health Innovations. IDOH is also awaiting decisions on additional AIM funding, Maternal Mental Health and Substance Use, and Preventing ACEs.
3. The State of Indiana completed a salary analysis of all state employees, resulting in historic pay increases to match the talent and skill of the public health workforce which has allowed IDOH reduce turnover and to onboard new and talented staff members across the divisions.
4. MCH now has four innovation teams, encouraging staff to work outside of normal silos to tackle wicked public health challenges that impact Hoosiers. They incorporate staff in MCH and across the Title V program. Innovation teams launched after a 15-month Workforce Development Center cohort and have been up and running since January 2023.
5. All delivery hospitals have been certified through the Perinatal Levels of Care program, both obstetrical and neonatal. Many hospitals have now been reviewed twice.
6. Increase in state investment in Nurse Family Partership.
7. The MCH Moms Helpline recently rebranded to increase visibility and connect families to education and referrals. The Helpline completed 70,000 last year.
8. Celebrating one year of having the Indiana Youth Advisory Board in place – a joint effort between IDOH and the Division of Mental Health and Addiction.
9. MCH merged with The Office of Women’s Health – bringing a holistic and comprehensive approach to the health of women throughout the lifespan.
10. CSHCS and NBS partnered on a statewide, comprehensive RFA for sickle cell.  This resulted in several hospital and community partners creating one application to ensure that all Hoosiers with sickle cell or trait receive care in their communities, are informed about the disease, and that follow up care is occurring after screening.

The Title V leadership team spent the last two years building relationships with new Title V grantees. We continue to host regular all-grantee meetings, hold subsequent one-on-one quarterly meetings with our partners, deployed newly developed quarterly reports templates, and hosted an in-person all grantee meeting in October 2022. We repeated this process over the last year and will host grantees again in October 2023 for an in-person event.  MCH and CSHCS have started the 2025 needs assessment. The team hopes to dive deeper into populations we may have missed, or those we would like to hear more from this time. Indiana's State Action Plan remains relevant. Below, we have highlighted our current work for the year to come by population domain.

Women/Maternal Health 

Most notably in this is past year the statutorily required Office of Women’s Health (OWH) was integrated into the Maternal and Child Health Division. The mission of OWH has been to improve the health and well-being of women in ways not directly related to being a mother. Absorbing OWH has pushed the mandate of MCH into the realm of serving the whole person, and beyond the traditional 14-44 age range. MCH has now folded the Rape Prevention and Education (RPE) grant, the Sexual Assault Nurse Examiner (SANE) program, perimenopause programming, and other projects in our portfolio of work.

Another change this year will be the absorption of PRAMS administration into the division. Historically, Indiana has struggled to get weighted data; after many years of working with an external, out-of-state vendor, MCH made the decision to completely change, leveraging the mature and effective Moms Helpline to make the calls, and the State’s established logistics provider for survey mailing.

Commonly identified health needs for women included mental health, physical wellness (e.g., well-visits, annual check-ups), lack of sleep, and chronic physical conditions. Common barriers to health that women identified for themselves included needing to focus on other priorities (e.g., not having enough time or prioritizing other areas of life), not having enough money or income to meet their health needs, and healthcare not being affordable. To better address these health needs and barriers for women, IDOH will focus on (1) increasing access to high-quality, family-centered, trusted care; (2) reducing preventable women/maternal deaths; and (3) preventing substance use among pregnant women.

IDOH will continue its work with hospitals and birthing facilities to improve the access, availability, and care for all women and birthing persons through the Alliance for Innovation for Maternal Health (AIM) and Perinatal Levels of Care designations. It will expand its footprint with home visiting and offer CenteringPregnancy to sites around the state. The Maternal Mortality Review Committee will continue its work to review all maternal deaths and make recommendations to prevent these in the future. IDOH will continue to collaborate with the Indiana Perinatal Quality Improvement Collaborative (IPQIC), the Indiana Hospital Association (IHA), and other partners to provide education, tools, and technical support to facilities and providers to reduce maternal death, morbidity, and inequity.  In the upcoming year, IDOH will pilot a new tobacco cessation program for pregnant women and birthing persons to help them quit.

Perinatal/Infant Health

Women who were currently pregnant at the time of the survey and parents/caregivers of children less than a year old shared about their health and the health of their babies. The most selected needs for adults included pregnancy-related care (before, during, after), breastfeeding, mental health, and adequate sleep. For babies less than a year old, parents identified nutrition and physical development as top health needs. Common barriers to health for all perinatal/infant populations included not having access to affordable healthcare, not having access to affordable childcare, needing to focus on other priorities, and the baby not sleeping well on their own. Significant perinatal/infant needs shared in the Title V survey, such as mental health, will be addressed through cross-cutting performance measures.

For the perinatal/infant population, Indiana will continue to focus on reducing preventable infant deaths through risk-appropriate perinatal care and addressing infant mortality disparities. The MCH clinical team will work together to maintain a cohesive partnership with the 82-delivering hospitals throughout the state. We will also continue our close partnership with the Indiana Hospital Association and the PQC. In the upcoming year, MCH will be working more directly with local jurisdictions whose infant mortality rates and birth outcomes are disproportionately poor. The team has already had crucial conversations with local health departments and will continue to invest time and funding to reduce disparities in infant mortality rates. IDOH will also continue its work through IPQIC – building a new task force around Infant Well-Being, developmental screening, breastfeeding support, and safe sleep. Local Community Action Teams will also be key in uniting communities to prevent infant mortality and ensure all babies are thriving.

Child Health

For younger children (0-5 years), the greatest health needs included language development, sleep, and social/emotional development. For older children (6-12 years), the greatest health needs included mental health and oral health. Barriers to health experienced by children included not having access to affordable healthcare and not enough household income to provide for their health needs. For younger children, barriers also included not having access to affordable childcare and having other priorities. For older children, additional barriers included needing to focus on school responsibilities and not having activities to do outside of school. IDOH will work to address children’s mental and social/emotional health needs, specifically within the cross-cutting section. In addition, to support children’s development, IDOH will focus on (1) promoting physical activity and (2) reducing preventable child death.

IDOH will promote physical activity by continuing programming within schools and after school programs as well as well as investments in the built environment. IDOH will continue to provide support to the fatality review and community action teams dedicated to reducing preventable child deaths by helping local teams improve death scene investigations, conduct effective reviews, improving data collection, creating effective recommendations, and moving data to action. IDOH will continue to support local car seat programs, as well.

Adolescent Health

The most common adolescent health needs according to parents/caregivers included mental health and social/emotional development. Top barriers for adolescents included the amount of time spent on phone/computer/other electronics and having responsibilities related to school. In addition to parent feedback through the Title V Survey, adolescents themselves participated in the Title V focus groups. The most common health needs identified by adolescents included their physical health, trauma/violence (including bullying), and drug addiction/dependency. The most prominent health needs from the Title V survey, mental health and social/emotional development will be addressed through strategies in the cross-cutting section. IDOH will focus on adolescents’ physical health and care by (1) reducing preventable deaths, (2) promoting physical activity, (3) increasing access to high-quality care, and (4) promoting positive youth development.

IDOH will promote physical activity by continuing programming during and after school. Funding will be provided for built environment improvements. IDOH will continue to support fatality review and community action teams dedicated to reducing preventable adolescent deaths.  A special pediatric suicide fatality review committee and the Youth Risk Behavior Survey data will drive policy recommendations. IDOH continues to expand the Adolescent Champion Model to more primary care clinics across the state. In addition, the team will continue to hear from the youth voices through the Indiana Youth Advisory Board (IYAB) and integrate them into our processes. They have presented and spoken at national conference and statewide summits on mental health in the past year, helped write and submit a grant application, and will continue to build goals for the next year this summer.

Also of note, in the past year, IDOH has increased partnerships with other state agencies that serve adolescents and young adults. MCH partnered with the Division of Mental Health and Addiction not only for the IYAB, but also to create a new state youth suicide action plan that will go into place in 2024. They invited IDOH to join a Black Youth Suicide Policy Summit to reduce disparities in youth suicide attempts. MCH has also partnered with the Department of Corrections as they seek to overhaul their Youth Justice Initiatives. The Youth Justice Oversight Committee (YJOC) completed the Final Report and submitted it to the General Assembly and Commission on Improving the Status of Children (CISC) at the end of June 2023. Lastly, the team continues to be involved with the Commission on Improving the Status of Children and its work on reducing sexual victimization, homelessness, and more that impact Indiana youth and young adults.

Children and Youth with Special Health Care Needs 

Health needs and challenges identified for children with special healthcare needs (CSHCN) included mental health, social/emotional development, cognitive development, language development, and physical development. Common barriers to health that parents identified for their child included long provider waitlists, a lack of coordination among providers, and not having specialized providers in their local area. Parents also shared that they did not have enough income to meet their health needs, they experienced challenges accessing educational resources and their older children faced barriers related to school responsibilities and use of electronic devices.

During the past year, CYSHCN staff have attended cross-agency meetings including multi- generational, early childhood, and transition. We continue to serve on the following boards: First Steps (Part C), Indiana Governor's Council for People with Disabilities, and the Department of Education Special Education. The CSHCS director has a leadership role on the advisory board for the state care coordination expansion project, which will expand to 26 practices over the next three years for complex medical needs. CYSCHN and Newborn Screening are collaborating with the Early Evaluation Hubs across the state. The Neurodevelopmental Behavioral System of Care is a statewide effort in Indiana to improve early detection and intervention for children ages 1-4 years old with autism or developmental delay.  

The CYSCHN division has a strong partnership with Indiana Family to Family that involves collaboration on daily operations for the supplemental coverage program. The collaboration has strengthened information sharing, community empowerment, and health equity across all Title V and state-funded activities. CSHCS staff is promoting how to best utilize supplemental coverage via presentations in Federally Qualified Health Centers, health fairs, Part C statewide meetings, and other conferences.  The program is transitioning to an online system to make the application process easier for caregivers.

Cross-Cutting/Systems Building

As we continue at the mid-point of this five-year cycle, Indiana will lean into the charge as a collaborator and convener, especially as it relates to the cross-cutting measures related to mental health, substance use, and social and emotional health. The groundwork for this has been laid over the past many years; however, special emphasis will be placed on maternal depression, adolescent suicide prevention, child abuse and neglect, and other work not traditionally in the purview of IDOH.  Department of Health staff will work to ‘give the data back’ to communities and request feedback on how we are doing.

MCH will take a concerted and deliberate approach to addressing racism and health inequities pervasive in MCH outcomes data. This includes our MCH Health Equity Innovation team, our newly hired Maternal Health Equity Specialist as a part of our Maternal Health Innovations grant, our continued equitable grant making process, our prevention and upstream work through the Preventing Maternal Deaths Due to Violence, and our work in youth suicide and teen pregnancy prevention.  Indiana’s Title V program will continue to do things differently. We will listen carefully to our community, engage with and develop new partnerships, evaluate the work, and fund programming and services with a critical eye toward health equity.