The Title V Program in North Carolina (NC) is housed in the Women’s and Children’s Health Section (WCHS) in the NC Division of Public Health (NC DPH), with the Title V Director serving as Section Chief and the CYSHCN State Director serving as the Children & Youth (C&Y) Branch Head. WCHS is responsible for overseeing the administration of the programs carried out with allotments under Title V and for other programs including Title X, Early Intervention (EI), nutrition services (including the state WIC program), and immunization. In addition to the C&Y Branch, the WCHS includes four other branches: Women’s Health (WHB), EI, Immunization (IB), and Nutrition Services.

During 2014, the WCHS embarked on two strategic planning processes focused on perinatal health and children and youth as part of the 2015 Needs Assessment, and these plans continue to inform the State Action Plan. Both of these processes reinforced the Section’s commitment to ensuring that pregnant women, mothers, infants, and children with and without special health care needs receive preventive and primary care services that are family-centered, community-based, and coordinated.  In 2015, the WCHS Management Team (SMT), which consists of the WCHS Chief, the Operations Manager, and the five Branch Heads, decided upon the following priority needs to be used in the State Action Plan as a result of the strategic planning and needs assessment process. As SMT considers each of these ten priority needs to be equally important, additional ranking of these needs did not occur. Even with the new guidance reducing the required minimum number of National Performance Measures (NPMs) to five, the SMT decided to maintain the current NPMs until the 2020 Needs Assessment.  In 2016, the State Performance Measures (SPMs) and Evidence-Based or –Informed Strategy Measures (ESMs) were added, and the ESMs are continually revised and updated as needed.

The WCHS conceives of needs assessment as a continuous process in which useful data, both quantitative and qualitative, relevant to the broad mission of the Section, DPH and DHHS are continuously being gathered and analyzed with an eye to adjusting the program priorities and activities as appropriate.  Most of the programs and initiatives provided by the WCHS require local community action teams or advisory councils comprised of community members who provide input throughout the course of the project regarding emerging and ongoing needs.  Often programs conduct focus groups and key informant interviews to gain more information from consumers, providers, and partners.  Working under its philosophy of continuous quality improvement, the WCHS is making progress on formalizing its process of both routinely reaching out to strategic partners and stakeholders and incorporating their feedback into the MCHBG application and needs assessment.  The Perinatal Health Strategic Planning Team, which meets every two months, provides opportunity for many stakeholders to provide input into the plan and specific action steps.  The Team presents annually to the NC Child Fatality Task Force.  The Data and Evaluation Subcommittee is working on a research action plan, and the Program Coordinator has recently released an updated environmental scan survey to stakeholders to help determine all the efforts being done around the strategies.  Work to operationalize the C&Y Branch Strategic Plan continues and includes the formation of three committees to review practices across all Branch programs related to communication, training, and quality assurance efforts.  The development of the CYSHCN strategic plan, which began with the work leading up to and during the October 2017 Summit, is ongoing.  Preparation for the 2020 MCH Block Grant Needs Assessment began in fall 2018, which will incorporate the feedback already gained from stakeholders and partners to identify potential priority needs.

The mission of NC Department of Health and Human Services (NC DHHS), in collaboration with its partners, is to protect the health and safety of all North Carolinians and provide essential human services.  The Department’s vision is that all North Carolinians will enjoy optimal health and well-being.  NC DPH, one of 30 divisions and offices that make up the NC DHHS, works to promote and contribute to the highest possible level of health for the people of NC.  NC DPH is comprised of the Director's Office and nine other offices and sections: Administrative, Local, and Community Support; Chronic Disease and Injury; Epidemiology; Environmental Health; Human Resources; Oral Health; State Center for Health Statistics; State Laboratory; and WCHS.  NC DPH works collaboratively with 84 sub-state administrative units (single- and multi-county LHDs). The LHDs, which have local autonomy, have a longstanding commitment to the provision of multidisciplinary perinatal, child health, and family planning services, including prenatal care, care management, health education, nutrition counseling, psychosocial assessment and counseling, postpartum services, care coordination for children, well child care, and primary care services for children. They are also instrumental in providing leadership for evidence-based programs county wide such as Nurse Family Partnership, Healthy Families America, Teen Pregnancy Prevention Initiatives (TPPI), Triple P, Reach Out and Read, and other programs dictated by the needs of the county.

There is a weekly Division Management Team (DMT) meeting for all the Section Chiefs within DPH.  This meeting is a time to co-plan and discuss issues of overlapping responsibilities and strategies for service improvement.  The SMT meets weekly after the DMT meeting to further discuss any DMT agenda items and to assure internal communication and coordination occurs on a regular basis.  This provides the Section with a format to facilitate joint planning, to keep key staff informed of current activities and issues, and to plan short and long-term strategies for addressing current issues, while also providing the Title V Director with an overview of factors influencing maternal and child health services.  A similar process occurs within the Branches which are responsible for assessing and responding to the needs of their target populations. In addition to these processes, the WCHS engages in ongoing collaborations within DPH and DHHS and with other agencies and organizations.

There are a number of emerging public health issues which impact WCHS and its priority populations.  Along with Medicaid transformation and building an innovative, whole-person system that promotes quality and value, the Secretary of the NC DHHS has made combating the opioid crisis and improving early childhood health and wellbeing, inclusive of infant mortality reduction, priorities for the department, requiring widespread collaboration within NC DHHS and with many external partners.

The WCHS oversees and administers an annual budget of over $619 million and employs 933 people. This is 48% of the DPH staff, along with 66% of the budget. The WCHS's broad scope promotes collaborative efforts while discouraging categorical approaches to the complex challenge of promoting maternal and child health. The Section is committed to ensuring that services provided to families are easily accessible, user-friendly, culturally appropriate, and free from systemic barriers that impede utilization. While many staff members work in the central office in Raleigh, there are a number of regional consultants who work from home and regional offices. The EIB has a network of 16 Children's Developmental Service Agencies (CDSAs) serving all 100 counties.

The Title V Block Grant fully funds 24 WCHS state-level employees, with many others funded in part per the cost allocation plan. These positions are primarily nurse consultants, public health genetic counselors, and public health program consultants within the WCHS, but also includes staff members in the SCHS, the Chronic Disease and Injury Section (CDIS), and the Oral Health Section. The funding that goes directly to LHDs is used to provide services for individuals without another payer source, in addition to other enabling services and population health education.

NC Title V leadership works diligently to maximize services for low income women and children by leveraging funds whenever possible, forming strong partnerships and interweaving funding from a variety of sources to support Title V performance measures, strengthen the integrity of the system of care and increase access for low income and disenfranchised individuals.  The primary populations served through Title V funding are women, children, and families seen in LHDs for direct and enabling services.  However, as part of the work of the WCHS, all infants born in NC are served through newborn screening efforts, all women of childbearing age are served through campaigns to promote preconception health, and these campaigns are becoming more inclusive of male partners and fathers.

Prenatal care providers are available in most, but not all counties in NC. Birthing facilities across NC have varied capabilities to care for mothers and newborns with complex needs. The current geographic distribution of these facilities makes it challenging for some moms and newborns with complex conditions to access medical care and facilities that can meet their needs.

Services and resources for CYSHCN are included within all programs and initiatives under the C&Y Branch. This intra-agency approach is inclusive, helping to ensure that all programs that serve young children, youth, and their families also provide for the subset of CYSHCN. There is no longer a discreet, separate agency/office or program for CYSHCN in NC as exists in most other states.  The WCHS does not reimburse for services directly but supports the provision of services to children and youth who are not enrolled in Medicaid or Health Choice (NC Child Health Insurance Program) by contracting with LHDs and major medical facilities.  In addition, C&Y Branch staff are supported by Title V to provide training and technical assistance to providers.  To the greatest extent possible, services are offered within family-centered, community-based systems of care.

The mission of the WCHS, to assure, promote and protect the health and development of families with emphasis on women, infants, children, and youth, aligns well with the goals of Title V.  The WCHS works closely with local, state, and national partners to promote the wellbeing of women, children and families and serves as a critical collaborator and convener. From reproductive life planning and preconception health to perinatal and infant health to child/adolescent health including those with special health care needs, WCHS emphasizes a life course approach to achieving health and health equity in all populations.  The Title V Program values evidence-based and evidence-informed strategies in promoting health, while following guidelines around best practice.  Given the importance of cross-sector work, WCHS leverages the expertise and experience of its many partners and leaders in the state.

WCHS partners with NC Medicaid and Community Care of NC (CCNC) to provide Pregnancy Care Management Services (OBCM) and the Care Coordination for Children (CC4C) program, a population management program for children ages 0 to 5 years who meet certain criteria (children with special health care needs or those exposed to severe stress in early childhood).  With Medicaid Transformation, these programs will continue with some modifications and the WCHS has been focused on training, support and leading the programs through the transition.

The WCHS supports services and programs for underserved and vulnerable populations using state appropriations, grant funding, Title V, Medicaid Federal Financial Participation, and other receipts.  The WCHS provides Title V funding to LHDs through DPH’s Consolidated Agreement which is a contract between the LHD and DPH that outlines requirements of DPH and the LHD including funding stipulations, personnel policies, disbursement of funds, etc.  State, federal, or special project funds cannot be used to reduce locally appropriated funds.  The Consolidated Agreement is revised and renewed annually.  Program specific requirements for each state funded activity are provided in Agreement Addendum (AA) which are also revised annually.  The AA provides a scope of work and deliverables which provide guidelines for the provision of services and outcomes.  LHDs bill Medicaid and private insurance companies and have a sliding fee scale for uninsured patients.  LHDs are free to allocate portions of the Title V funds to provide OBCM and CC4C services or other support services to patients who are ineligible for Medicaid.  WCHS also administers a limited amount of state appropriations for these services.

WCHS also collaborates on a number of activities with several professional organizations in the state including but not limited to: NC Medical Society; North Carolina Pediatric Society (NCPS); NC Obstetrical and Gynecological Society; Midwives of North Carolina; NC Friends of Midwives; and the NC Academy of Family Physicians. WCHS partners with the NC Institute of Medicine, the NC Hospital Association, and the NC Area Health Education Centers.  The WCHS works closely with the NC Partnership for Children, Prevent Child Abuse NC, the NC Chapter of the March of Dimes (MOD), SHIFT (Sexual Health Initiatives For Teens) NC, NC Child, Community Care of North Carolina (CCNC), and other organizations.

There are many accredited schools of public health and medicine in NC, and WCHS maintains close working relationships with many of them, particularly the UNC-Chapel Hill Gillings School of Global Public Health, but also with the Department of Public Health at East Carolina University and the Departments of Public Health Education at NC Central University and UNC-Greensboro.