Tennessee’s MCH/Title V Program

In the state of Tennessee, the Title V Maternal and Child Health (MCH) Services Block Grant to States is administered by the Tennessee Department of Health’s Division of Family Health and Wellness (FHW).  The division of roughly 150 staff members is led by a director with three deputy directors reporting to them.  Each of the deputies have between two and four administrators reporting to them.  The administrators have between two and five staff reporting to them.  These staff include program directors, epidemiologists, and administrative assistants.  For the two required positions for this grant the division director serves as one – MCH Director, and an administrator serves as the other – Children with Special Healthcare Needs (CSHCN) director.

FHW is organized into sections which focus on reproductive and women’s health, perinatal/infant/pediatric care, early childhood, injury prevention and detection, chronic disease and tobacco prevention, and supplemental nutrition (including WIC).  These sections implement programs that improve the health of women (including mothers), infants, children, adolescents, and their families, as well as those with special health care needs.  FHW programs include topics such as family planning, maternal mortality case review, newborn screening, breastfeeding support, infant mortality reduction initiatives, home visiting, pediatric mental health, Adverse Childhood Experience (ACE) reduction, tobacco use reduction, injury prevention, suicide prevention, and CSHCN.  Therefore, it is the most appropriate place to administer the MCH Block Grant.

Needs Assessment

At the beginning of each five-year grant cycle, a comprehensive needs assessment is used to identify priority needs of women, infants, children, adolescents, and their families; as well as determine the capacity of the health system to meet those needs.  During the years between the comprehensive needs assessments, an on-going needs assessment is conducted to identify any significant changes in needs and capacity.

FHW conducted the comprehensive needs assessment for the 2021-2025 cycle during 2019 and 2020 in conjunction with over 100 partners. Key components included:

• Quantitative analysis of key indicators
• Qualitative data collection and analysis; including focus groups, key informant interviews, and open-ended surveys
• Structured process for choosing priorities based on the data complied
• Capacity assessment of current and potential programming for each identified priority

As a part of the ongoing needs assessment, FHW hosts MCH partner meetings twice each year. These meetings are open to anyone, and effort is made to extend the invitation broadly. During the meetings, participants are asked to consider the progress made on performance measures during the past year, and then based on that evaluation make recommendations for the next year's action plan.

Needs and Priorities

States are required to identify at least one priority in each of the population health domains, except for the Cross-cutting/Systems Building domain which is optional.  There are a total of six domains: (1) Women’s and Maternal Health, (2) Perinatal and Infant Health, (3) Child Health, (4) Adolescent Health, (5) Children with Special Health Care Needs and (6) Cross-cutting/Systems Building.

As a result of the Needs Assessment, TDH identified priority needs for the MCH population for the 2021-2025 Block Grant cycle. These priorities include: (1) Increase family planning, (2) Decrease pregnancy-associated mortality, (3) Increase breastfeeding, (4) Decrease infant mortality, (5) Decrease overweight and obesity (among children), (6) Increase prevention and mitigation of Adverse Childhood Experiences (ACEs), (7) Decrease tobacco and e-cigarette use (among adolescents), (8) Increase medical homes and (9) Improve transition from pediatric to adult care.

Program Planning

The MCH/Title V Program is managed within the Tennessee Department of Health’s Division of Family Health and Wellness.  This division includes sections for:

• Reproductive and Women’s Health
• Perinatal, Infant, and Pediatric Care
• Early Childhood Initiatives
• Supplemental Nutrition (including WIC)
• Injury Prevention and Detection
• Chronic Disease Prevention and Health Promotion
• Children and Youth with Special Health Care Needs

The variety of content areas in FHW pairs well with the identified priorities. Therefore, each FHW section (including both program and epidemiology staff) leads a priority.  Teams are responsible for developing and reporting on the action plan and corresponding measures. This is done in conjunction with the MCH Partner Group, formerly referred to as the MCH Stakeholder Group. This group was formed during the 2015 needs assessment and has met twice a year since then. The group reviews the action plan, measurement progress, and suggests changes for the coming year. They also partner with the MCH/Title V Program to complete the activities outlined in the action plan and work towards the objective for each measure. This is all done under the guidance of the MCH Title V Director who oversees all aspects of program planning.

Performance Reporting

The epidemiology staff for each priority team takes the lead on tracking and reporting on each measure. The MCH Block Grant coordinator facilitates the tracking and visualization of all measures among all priority teams. This enables everyone (MCH/Title V Director, MCH Block Grant coordinator, priority teams, and MCH Partner Group) to view the overall progress made among all priorities.

Assuring Comprehensive, Coordinated, Family-Centered Services

The MCH/Title V Program assures comprehensive and coordinated services in a number of ways. Core services such as WIC, family planning, breast and cervical cancer screening, preventive care for children (EPSDT and immunizations), health promotion, community outreach and the care coordination services of Community Health Access and Navigation in Tennessee (CHANT) and Children's Special Services (CSS) are offered in all county health departments. Rural health departments report to regional office and to the Community Health Services (CHS) division of the state health department. Metro health departments are independent and accountable to local governments but operate closely via contract with TDH. This organizational structure assures that MCH/Title V and other state and federal funds are administered comprehensively to all counties and that program fidelity is maintained via direct management or contract. Regular communication occurs with the Regional Leadership Team (metro and regional directors and CHS leadership), the Medical Leadership Team (metro and regional health officers), Nursing Leadership Team (metro and regional nursing leads), and the MCH regional directors to assure multi-directional transmission of key information and provide opportunities for sharing of ideas. Other core MCH/Title V services such as newborn screening provide services to the entire state but are centrally located at the state lab to assure excellent communication between the lab and the FHW clinical follow up team for lead, genetic disorders, hearing loss, and congenital heart disease.

The MCH/Title V Program continues to work with families to assure comprehensive coordinated family-centered services by providing education around the importance of receiving services in a patient-centered medical home, and how to partner with providers in the decision-making process. The program provides the “Partnering with your Provider Booklet” statewide for distribution at community events, as well as medical providers for distribution in their practices. Staff has also collaborated with the Bureau of TennCare, the state Medicaid agency, in their Primary Care Transformation Strategy “Patient-Centered Medical Home”. There are currently over 81 participating provider organizations in over 400 locations, covering over 37% of the TennCare population.

For the MCH/Title V CYSHCN program specifically, staff include a dedicated Family/Youth Engagement and Involvement Director whose primary responsibility is to work with Family Voices to ensure opportunities for family and youth training on patient centered medical homes, transition and policy/advocacy. Title V funds have also been used to expand the division contract with Family Voices to provide consultation and training for all programs within FHW. In addition, several programs continue to expand their own advisory and family groups to better inform programs and services. For example, the Perinatal Advisory Committee (PAC) and Genetics Advisory Committee have always been open meetings, and recently family representatives have been sought out to attend those meetings. Likewise, the family planning program has 13 required community and client advisory boards in each rural and metro region. Additional input from reproductive justice groups has also been sought to review program guidelines and messaging around contraception and neonatal abstinence syndrome. Furthermore, in the comprehensive redesign of the CSS, HUGS, and Community Outreach programs into the streamlined Community Health Access and Navigation in Tennessee (CHANT) program has incorporated family engagement in the design process to assure that the needs of children and families are being met appropriately.

Partnerships

The strength of MCH/Title V lies in its partnerships. In addition to the intentional engagement of families and customers listed above, TDH has pursued partnerships of all types using the collective impact framework. The descriptions below are not exhaustive and serve as examples of the myriad of partners valued by the agency and the division.

For example, a multitude of local, state, and national partnerships have emerged statewide regarding the opioid crisis and prevention of neonatal abstinence syndrome. In 2019, this resulted in the second consecutive year to year decline (26% from 2017) in cases reported to the NAS surveillance system since 2013. The NAS subcabinet met regularly from 2013-19 with representatives from TDH, Department of Mental Health and Substance Abuse (TDMHSA), Department of Education (DOE), Department of Children's Services (DCS), TennCare, Department of Human Services (DHS) and several others to review NAS surveillance data and research and to plan interventions together. TDH has partnered with the PAC, regional perinatal centers, rural hospitals, Tennessee Hospital Association and the Tennessee Initiative for Perinatal Quality Care (TIPQC) to share best practice and information regarding treatment of drug exposed mothers and infants. In addition, TDH has partnered with local drug coalitions, law enforcement, multiple state agencies and insurance companies to fund and promote medication take back sites in all 95 counties. The response to the opioid epidemic has been complex and growing, involving legislative action, law enforcement, regulation education, prevention messaging, and treatment.

Infant mortality reduction efforts have likewise relied extensively on partnerships. For example, DOE, DCS, EMS entities, the medical community, and the judicial system have been critical to maintaining the Child Fatality Review. Local review teams in all judicial districts serve on a volunteer basis and are essential to determining cause of death for infants and children. This data guides the priorities for the upcoming years, and the local review teams serve as bodies to dissemination information to local communities as well. Given the lack of improvement in the infant mortality rate in the state, the infant mortality strategic plan was revised during 2019 with the assistance of numerous partners including Tennessee Chapter of the American Academy of Pediatrics (TNAAP), TIPQC, the PAC, academic partners such as Vanderbilt University and Children's Hospital, the Children's Hospital Alliance of Tennessee, the Tennessee Breastfeeding Coalition, federally qualified health centers, MCH directors statewide, and community advocacy groups.

Obesity is likewise a complex problem requiring a multi-dimensional approach and many partnerships. DOE and the Office of Coordinated School health partner in both data collection and programming for schools across the state. Obesity has also been a priority for the Governor's Children's Cabinet and the state agencies represented. Recognizing the importance of the built environment and culture change for obesity prevention, TDH has partnered with the Department of Environment and Conservation to promote state parks via the Park Rx and rewards program, the promotion of youth activity clubs, and training state park restaurants to become Responsible Epicurean Agricultural Leadership (REAL) food certified. TDH also coordinates with Governor's Foundation for Health and Wellness to promote Healthier Community designation and Healthier Tennessee business initiatives. Academic partners such as Middle Tennessee State University, East Tennessee State University, and Vanderbilt have also been critical for data analysis and program implementation across the state for efforts in both obesity reduction and tobacco prevention. The Department of Human Services has been instrumental in training childcare facilities and assuring the inclusion of the seven Gold Sneaker policies regarding physical activity, nutrition, and tobacco were included in the star rating system for centers.

Leveraging of Federal and Non-Federal Funds

Aligning Title V funds within the Division of Family Health and Wellness allows for planning across programs to address population health priorities by leveraging both federal and state funds. This occurs for all priority areas. For example, reducing and mitigating the effect of ACEs is a priority area for Tennessee Title V since the most recent needs assessment, and activity around this topic has escalated dramatically over the last 5 years in all areas of the state. Title V state and federal funds have been used to support data collection and dissemination, workforce training of thousands of health department staff, and facilitation of multiple partnership meetings across the state. Assuring supportive infrastructure for families is essential to preventing ACEs, and FHW has an active role in this via WIC food security (federal), family planning (federal Title X, reimbursement, and state and federal MCH), investment in the built environment (state Project Diabetes and additional dedicated built environment funds). Positive youth development is promoted via federal rape prevention education funding, state and federal adolescent pregnancy prevention funding, and state funding for youth tobacco prevention councils in 64 counties. Specific programs in FHW also address social determinants of health, enhance parenting skills, and improve community linkages. These include state Healthy Start and federal MIECHV evidence-based home visiting programs and the care coordination program, Community Health Access and Navigation in Tennessee (CHANT). TDH also participates in several inter-agency and community partnerships targeting ACEs including the Children's Cabinet's "no wrong door" Single Team Single Plan approach to service coordination, the Three Branches Institute, the Young Child Wellness Council, and the Early Success Coalition via federally funded Project LAUNCH.