Program Overview

Nebraska Title V Overview

The Title V Maternal Child Health (MCH) Block Grant is administered within the Nebraska Department of Health and Human Services (NDHHS).  Leadership of the Title V program is shared between the Division of Public Health (DPH) and the Division of Children and Family Services (DCFS).  Core leadership, or the Title V Team, is comprised of seven DHHS staff representing both Divisions.  This operational approach extends the reach of Title V activities, expands the amount of available state support, and increases the range and diversity of staff expertise available to the program. 

Assessing Needs of the Maternal-Child Population in Nebraska

Nebraska’s Title V is built on a strong framework of data collection and analysis; collaborative planning; implementation of strategies; and evaluation of process, outcomes, and impact as reflected in the five-year Needs Assessment.  This robust process applies a deliberate methodology to determine the 10 priorities which govern activities for the next five years and is highly inclusive – intentionally bringing in stakeholders and family/consumer voices at various stages throughout the overall process. 

The 2020 Needs Assessment determined the following priorities (in alphabetical order):

• Access to Preventative Oral Health Services
• Access to and Utilization of Mental and Behavioral Health Care across the Lifespan
• Behavioral Health in School for Children and Youth with Special Health Care Needs
• Cardiovascular Disease among Women aged 18 through 44 years
• Child Abuse and Neglect
• Infant Safe Sleep
• Motor Vehicle Crashes among Youth aged 10 through 19 years
• Premature Birth
• Sexually Transmitted Disease Prevention
• Suicide Prevention

Women/Maternal Health

Cardiovascular Disease

Like national trends, cardiovascular disease including diabetes, obesity, and hypertension continues to burden Nebraska women, particularly those of African American, American Indian, or Hispanic descent.  Addressing this disease is difficult due to the multifactorial nature of the issue, containing medical, behavioral, and socio-economic root causes.  Title V supports a systems approach that focuses on ensuring access to health care, culturally and linguistically appropriate services, and available wrap around services such as case navigation and community health worker involvement for women.

Perinatal/Infant Health

Infant Safe Sleep

While data from the Nebraska Pregnancy Risk Assessment Monitoring System (PRAMS) indicates that Nebraska parents routinely place infants in the supine position for sleep and the incidence of SIDS has decreased, the number of infants dying from accidental suffocation and strangulation in bed (ASSB) has steadily increased.  PRAMS data shows that significant racial and ethnic differences exist in numbers and percentages of infants who routinely share their sleep surface with others, the highest rates among African American, Asian, and American Indian mothers. 

Title V work includes promoting the protective practice of infants sharing a bedroom with a parent, but close to the parents’ bed, on a separate surface designed especially for infants; promoting initiation of and sustained breastfeeding; and providing culturally and linguistically appropriate education for new parents and birthing hospital staff.

Premature Birth

In Nebraska, approximately 2,600 babies are born prematurely (earlier than 37 weeks gestation) every year, which in 2018 was 10% of all births. This was higher than both the Healthy People 2020 and March of Dimes 2020 goals.  Additionally, significant demographic disparities exist between racial/ethnic, income, and educational attainment groups.  Babies born prematurely are at high risk for mortality and morbidity, and when compared to full-term babies, they are at significant risk for cerebral palsy, chronic lung disease, hearing loss, and intellectual disabilities.  Title V will partner with stakeholders to implement screening women for social determinants of health, offering appropriate information and tools for clinicians, and encouraging women to become healthy before becoming pregnant.

Child Health

Child Abuse and Neglect

According to the NDHHS, 2,369 Nebraska children experienced substantiated abuse and/or neglect during 2020.  Poverty is often associated with a greater risk of child maltreatment, and data indicates that neglect is the primary reason most children enter foster care.  Additionally, approximately 45% of children who enter out-of- home care are ages 0-5 and in significant numbers do so because of parental substance use.  This provides a compelling case for providing family supports prenatally and during early childhood, as well as to identify and serve families dealing with substance use.  Title V seeks to leverage the strong existing partnership with the Division of Children and Family Services to expand Home Visiting services across Nebraska, particularly in the Child Welfare Protocol within the Healthy Families America model, as well as to implement system changes around screening for and serving families with infants born exposed to substances.

Access to Preventive Oral Health Services

The NDHHS Office of Oral Health and Dentistry (OOHD) reports in 2015-2016 that 63.9% of 3rd grade children had decay experience, 32% of 3rd grade children had untreated caries, and 15% of children ages 1-17 reported active oral health problems; all are higher than the U.S. averages.  Further, hospital emergency room dental visits have doubled over 10 years, with 16% being for children ages 0-17.  Access to care is one root cause to this problem, since more than half of Nebraska is considered a state designated general dentist shortage area, and.a significant percentage of Nebraska’s population lives in rural locations, including approximately 125,000 children aged 1- 9 years.  As a result, many low-income children and youth eligible for Medicaid benefits do not receive mandated preventive dental services.  In partnership with the OOHD, Title V work includes providing culturally and linguistically appropriate education and dental health supplies to new parents and engaging in surveillance of young children’s oral health. 

Children and Youth with Special Health Care Needs

Behavioral Health in School

Students with disabilities are more than twice as likely to receive an out-of-school suspension as students without disabilities, and those receiving special education supports have a disproportionate rate of school-related arrests.  These practices lead to higher incarceration rates which are positively associated with academic failure, high school dropout, and involvement with the juvenile justice system, grade retention, and illegal substance abuse.  Title V will utilize existing relationships with partners serving CYSHCN and school staff to increase screening and referrals for mental/behavioral health issues, to explore training that is trauma-informed and designed to de-escalate, and to ensure that families are aware of their rights, available resources, and educational opportunities.

Adolescent Health

Motor Vehicle Crashes

Motor Vehicle Crashes are the leading cause of unintentional injury related death for Nebraska youth aged 10-19 years.  In 2017, teen drivers aged 19 and younger were involved in 21% of all reported crashes but only represented 7.3% of all licensed drivers.  Also in 2017, 72.7% of teen traffic fatalities were not wearing seat belts, and the Nebraska Youth Risk Behavioral Survey (YRBS) reported that nearly half of students reported texting or emailing while driving in the past 30 days.  Continuing a strong partnership with the NDHHS Injury Prevention program, Title V will support the Teens in the Driver’s Seat program and engage in surveillance of youth driving behaviors and needs across the state.

STD Prevention

According to the Centers for Disease Control and Prevention (CDC), young people aged 15 to 24 years acquire approximately half of all new Sexually Transmitted Diseases (STD) while making up only about one quarter of the sexually active population.  Chlamydia and gonorrhea are the most prevalent STD for this age group, both nationally and in Nebraska. In 2018, the reported rate of gonorrhea infections per 100,000 Nebraska youth aged 15 to 19 years was 137.3 and 788.9 for chlamydia. Significant disparities exist in chlamydia and gonorrhea infections by race and ethnicity.  Title V work supports other programs focused on reducing STD rates in NE youth by providing culturally and linguistically appropriate educational materials and distributing funds to local organizations.

Suicide Prevention

Suicide has been, and continues to be, a top cause of death in the state for young people. Nebraska Vital Records show that in 2017, the rate of youth (aged 10-19 years) deaths due to suicide was 11.4 per 100,000 compared to the national suicide rate of 7.2 per 100,000. Further, the number of deaths due to suicide for youth has been steadily increasing since 2009 according to NE Vital Statistics data.  Title V will collaborate with state and local partners focused on suicide prevention and seek to expand that collaboration to include school staff with the goal of describing how state training requirements are being met and what gaps exist.

Cross-Cutting

Access to and Utilization of Behavioral Health Care

Unmet mental health and behavioral health needs significantly impact the MCH population.  One in five Nebraskans are reported to experience mental illness; a significant number of others also experience behavioral health concerns.  The prevalence of mental health disorders among persons with Intellectual or Developmental Disorders range from 15% to 41% depending on the diagnosis.  Title V work in this area leans heavily on partnerships with the Division of Behavioral Health and the Pediatric Mental Health Care Access project.  The focus is to ensure access to care through Medicaid expansion, to increase screening and referral services, and to offer training and resources specific to mental/behavioral health services for Community Health Workers.

Emerging Needs

Maternal and child health is never static and identifying priorities/needs once every five years does not limit the focus of Title V – significant attention is paid to emerging needs and the flexibility required to quickly pivot and address those needs when necessary.  Lingering effects of the COVID pandemic remain and continue to be felt most strongly by vulnerable populations.  Mental/behavioral health continues to be a major concern across the lifespan – affecting children, youth, and women alike. Challenges within the Public Health workforce have risen, after many professionals left the field after experiencing burnout, recruitment issues delayed the onboarding of new staff, and now training and integrating new public health professionals. Recently, syphilis has emerged as a significant issue in Nebraska, where cases have risen 300% since 2017 and any case of congenital syphilis is a serious concern. The State Epidemiologist has taken the lead on the response, Title V has collaborated by providing data, and working with the STD program.

The framework to address the needs of the maternal and child population in Nebraska mentioned above is broad and inclusive.  Title V staff have significant expertise and partnering with other NDHHS programs enhances the options to address Nebraska’s priorities.  In addition to those mentioned earlier, partners such as the Office of Health Disparities and Health Equity, Medicaid and Long-Term Care, and the Office of Rural Health bring significant subject matter expertise. 

Equally important to this work are several external partnerships.  These partners bring not only expertise, but their own networks of participants, partners, and contacts who are vital to informing and performing Title V work.  Partners include the NE Perinatal Quality Improvement Collaborative (NPQIC), the University of Nebraska system (Munroe-Meyer Institute, College of Public Health, and Public Policy Center), public schools and school staff, Local and Tribal Health Departments, and the Nebraska Children and Families Foundation, among others.  Partnerships such as these amplify the work of Title V in priority areas involving MCH populations and their professional health providers, ultimately benefitting Nebraska MCH, regardless of whether it is an informal relationship or formal in nature through an executed agreement.  Additionally, these affiliations mean opportunities for involvement including participating in the five year Needs Assessment, serving on the Title V Steering Committee, and providing feedback on various initiatives. 

Comprehensive and Family-centered Care

Nebraska Title V also works to develop approaches promoting comprehensive and family-centered services across the state.  These approaches include making space for family members or consumers on Advisory Committees, planning work, and evaluation efforts; compensating non-professionals for their time serving on Title V priorities; and funding work to stabilize and increase partnerships with Community Health Workers, Parent Resource Coordinators, or other community level roles within a system of health.  Many of these approaches began within the population of children/youth with special health care needs and are expanding to serve all other domains within MCH.

Program Evaluation

Evaluation is an important part of any program, ensuring that funds are spent effectively in ways that truly reach intended goals.  Title V incorporates evaluation in several ways, beginning at the strategy level and extending to an overall review of the work as a whole.  As strategies are drafted, implementation teams are encouraged to build evaluation into their activities and review the evidence base for any activity, often using the MCH Evidence data base.  Evaluation can be based on easily quantifiable metrics or more qualitative metrics and often are described throughout the action plan narrative as our Results Based Accountability (RBA) measures.  Additionally, Title V seeks to describe overall performance to such stakeholders as our Steering Committee members, by looking at high level performance measures that can indicate success at the priority level over a longer period.

Through a framework of assessment, inclusive planning, and regular evaluation Nebraska Title V seeks to promote systems change that will directly benefit families, and ultimately improve the health of the maternal and child population in Nebraska.