I.E. Application/Annual Report Executive Summary

III.A.1.Program Overview

Indiana’s Title V program is committed to evolving and improving the state’s approach to improve the health and well-being of mothers, children, children with special healthcare needs,  adolescents, fathers, and families.  We listened closely to communities during our needs assessment and believe that their barriers and health concerns are reflected in the priorities as well as the National and State Performance Measures identified in our state action plan. Our cross-cutting measures reflect the values of giving data back to communities; examining programs, policies, and services through an equity lens increasing family and youth voices into our work; and continuing to partner and expand our mental health services statewide. We remain excited about the future as we are constantly evolving our Title V work.

The Maternal and Child Health Division (MCH)  and the Children’s Special Healthcare Services Division (CSHCS) work together at the Indiana Department of Health. To assist in the work, MCH and CSHCS partner closely with other divisions in the commission including: the Division of Nutrition and Physical Activity, Office of Women’s Health, Fatality Review and Prevention, and the Division of Trauma and Injury Prevention. A significant portion of Title V funding is granted to community organizations around the state to ensure all levels of the MCH Pyramid of Services are being addressed.

Major accomplishments/changes in the last few years include:

1. Onboarded new leadership within the CSHCS Division.
2. Completed the promulgation process of Indiana’s Levels of Care rules. As of August 2021, all but two level III and IV hospitals have completed certification, half of the level IIs have been designated, the majority of Level I applications have been received.
3. Launched a new community engagement and systems building section within the MCH division. Help Me Grow and the Indiana Mom’s Helpline combined to form a comprehensive information, resource, and referral system that connect families to resources in communities.
4. My Healthy Baby, initiated in 2019 in which the State invested dollars to create a system to refer women enrolled in Medicaid to home visiting services in their community expanded to 23 counties. My Healthy Baby doubles down on Indiana’s efforts to use home visiting as a way to improve health outcomes for infants and families.
5. Indiana Alliance for Innovation on Maternal Health (AIM) recently launched its second bundle: hypertension and continues to prepare for its third bundle on substance use disorder.
6. Reworked the way in which Title V subgrants dollars to community organizations in an effort to attract new applicants. This application included a question regarding health equity.
7. Title V staff continue to serve in a newly formed agency Health Equity Council.
8. Many Title V program staff were deployed to assist with COVID-19 response efforts, and most staff were shifted to virtual work.
9. Implemented an innovative payment model for place-based care coordination in collaboration with Indiana Medicaid.
10. Modernized the CSHCS care coordination data collection and tracking of referrals processes through the development of a program-specific Care Coordination Module.
11. Embarked on a partnership with the Indiana Sickle Cell coalition in an effort to pull and match data on sickle cell patients.
12. Indiana completed the School Health Profiles Survey with weighted data in 2020 and the Youth Risk Behavior Survey in the winter semester of 2021. Although we will not officially hear from the CDC until Fall, MCH achieved an overall 70% overall response rate.

The MCH director as now been in place for two years; however, the CSHCS division has recently hired a new director, Kristi Linson. Ms. Linson has been with IDOH since 2018 and helped conduct the 2020 needs assessment. She shares the values of the MCH staff and is committed to taking a critical eye to the programs and services traditionally funded by Title V and make a concerted effort to listen to the MCH population and partners in order to inform the state’s next action plan.

The Title V leadership team spent late 2020 into early 2021 sharing the results of our latest Needs Assessment and State Action Plan with a wide array of stakeholders. The results have been posted on the Department of Health’s website and have been used in grant applications, presentations, reports, and more. MCH and CHSCS are planning the next iteration of the Needs Assessment and hope to start by continuing to collect qualitative data to inform our primary and secondary data collection. While Indiana feels proud about the 2020 Needs Assessment process, we will deliberately seek out ways to gather even wider and more diverse voices in our 2025 plan development.

After a year of examining our efforts, the Title V program in Indiana reasserts our commitment to the following:

1. Reduce Preventable Deaths in the MCH population with a focus on reduction and elimination of inequities in mortality rates.
2. Reduce Health Disparities and Inequities in internal programs, policies, and practices to improve maternal and child health.
3. Prevent Substance Use including alcohol, tobacco and other drugs among pregnant women and youth.
4. Strengthen Mental, Social, and Emotional Wellbeing through partnerships and programs that build capacity and reduce stigma.
5. Promote Physical Activity through policy improvements and changes to the built environment.
6. Engage Families and Youth with diverse life experiences to inform and improve MCH services.
7. Access to high-quality, family-centered, trusted care is available to all Hoosiers.
8. Ensure Frequent Surveillance, Assessment and Evaluation of data drives funding, programming, and system change.

The Title V Leadership Team continues to reviews all available data and aligned the most frequent and highly rated needs with Title V’s National Performance Measures. Leadership Team re-evaluated, and then confirmed State Performance Measures to capture additional nuances of Indiana’s health needs. The Action Plan that has been used as part of this Title V grant application remains relevant and urgent. Below, we have highlighted the findings from the needs assessment and our current work for the year to come by population domain:

Women/Maternal Health 

Through the Title V Survey, over 4,000 women 18 and older shared about their health. The most commonly identified health needs for women included mental health, physical wellness (e.g., well-visits, annual check-ups), 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. Top strengths/resources for women included support from family, friends, and the community, and support from doctors (including primary care, OB/GYN, and specialists). To better address these health needs and barriers for women, ISDH 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.

Perinatal/Infant Health

Through the Title V Survey, 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 (breastmilk, formula, solids) and physical development (tummy time, crawling) as top health needs. Common barriers to health for all three 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 his/her own. Top strengths/resources included support from family, friends, and the community, and support from doctors (including primary care, OB/GYN, and specialists). 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 focus on reducing preventable infant deaths through risk-appropriate perinatal care and addressing infant mortality disparities.

Child Health

Through the Title V Survey, parents/caregivers of children were asked about the health of their children 0-5 years old and 6-12 years old. 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 dental 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. Similar to other populations, top strengths/resources included support from family, friends, and the community, and support from doctors. ISDH 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, ISDH will focus on (1) promoting physical activity and (2) reducing preventable child death.

Adolescent Health

Through the Title V Survey, parents/caregivers shared about the health of their adolescents (13-21 years old). The most common adolescent health needs included mental health and social/emotional development. Top barriers for adolescents included the amount of time spent on a phone, computer, or other electronics and having responsibilities related to school (e.g., homework, testing, grades). Top strengths/resources included support from family, friends, and the community, support from doctors, and support from teachers/school staff. In addition to parent feedback through the Title V Survey, adolescents themselves participated in the Title V focus groups. Three adolescent-only focus groups were held with a total of 28 adolescent participants. Through these conversations, 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. Additionally, ISDH will focus on adolescent’s 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.

Children and Youth with Special Health Care Needs 

Based on community feedback through the Title V Survey, a variety of specific health needs and challenges were identified for children with special healthcare needs (CSHCN). This included needs around 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 (e.g., Individualized Education Plan), and their older children faced barriers related to school responsibilities (e.g., homework, tests) and (over) use of electronic devices. Overall, parents identified family, friends, and community members as the top resource that has been an area of strength for their child. In addition, doctors, teachers, school staff, and government programming were also valuable resources for CSHCN. To better address the health needs and barriers of CSHCN, it is important to provide families with a well-functioning health system, including medical homes, transition services, and developmental screening.

Cross-Cutting/Systems Building

Common themes across all population groups include need to access trusted care with providers that listen and who reflect the population they serve. Stigma around substance use and mental health continues to prevent Hoosiers from seeking care, and social determinants of health are preventing families from achieving optimal health and well-being. It also became clear that in some cases, MCH lacks the partnership in communities to help address these complicated issues. In other cases, MCH is unaware of what current organizations and partners are currently doing in these spaces. MCH has intentionally sought partners and intentionally made connections over the past year to address these blind spots.

In this new five-year cycle Indiana will lean into the charge as a collaborator and convener, especially as it relates to our new 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 ISDH. MCH will also more deliberately use the voices of families and consumers in building our portfolio of work. Department of Health staff will work to ‘give the data back’ to communities and request feedback on how we are doing. A new State Performance Measure on data analyzation and evaluation will drive staff to measure and evaluate and share data back with community partners. Lastly, MCH will take a concerted and deliberate approach in addressing racism and health inequities pervasive in MCH outcomes data.

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 towards health equity.