Iowa’s Title V program continues to evaluate programs and processes, and strives to include family input into all activities, including the assessment of needs and priorities. Iowa’s Title V Family Delegate was a core member of the Needs Assessment team. The Title V plans and Needs Assessment process are presented for feedback from the Maternal, Child, and Adolescent Health Advisory Council (MCAH Advisory Council) which includes multiple youth and family representatives. Additionally, the DCCH Family and Professional Partnership Program Manager provides regular feedback to ensure that the strategic plans for the Family Partnership program and the Title V CYSHCN program are aligned with the needs articulated by Iowa families. The Family Advisory Council (FAC) provides review of the block grant initiatives and members of DCCH and FAC leadership have strengthened the role of family advisors in advising all DCCH programs, including the Title V Block Grant.

Collaborative Service Areas (CSAs)

IDPH funds many different activities carried out by local public health, hospitals and community action programs. Several of these areas – WIC, Maternal, Child and Adolescent Health, I-Smile, Title X, and 1st Five – are the focus of an effort to improve health outcomes and enhance program collaboration when providing services.

Currently, in some areas of the state multiple WIC agencies serve a single MCAH agency and vice-versa. There have been inconsistencies leading to service issues for program participants. Having multiple service providers/agencies also the competition/switching counties between service areas and programs can negatively impact families who struggle to navigate ongoing changes.

All of the included programs within the new CSA structure have strong desires to improve health outcomes and have identified that in order to meet the needs of clients the programs must pool resources to achieve the goals.

Title V emphasizes the need for evidence based strategies to address performance measures. WIC emphasizes funding creativity and partnerships. Therefore, the collaboration between these programs, along with the others listed above, will continue to strengthen the evidence based programming as well as utilizing creativity to achieve the overall goals of the programs.

This was a data-driven process that considered which populations were served by area. Data for the past several years includes:

• Population information
• Program utilization information
  • WIC
  • Title V Maternal Health
  • Title V Child and Adolescent Health
  • I-Smile
  • 1st Five
• Medicaid enrollment
• Medicaid births
• Primary care practices

General considerations for all CSAs:

• Goal to keep 0-5 year old population estimate at 7,000 or greater
• No more than 12 counties per CSA to assure the ability to reach all counties each month
• Although some regions follow the service areas of Community Action Programs (CAP), it is not the intention of the Department that the CAP serve as the WIC or MCAH/I-Smile/1st Five Contractors. It was recognized that CAP counties work together on health and social services so could easily work together for these programs as well.
• Funding must be adequate to effectively serve the CSA population.
• Most service areas will have competition when applying to be a contractor.
• Maps reviewed to develop the CSA map – Iowa’s Public Transit System; Early Childhood Iowa; Mental Health and Disability Service (MHDS) Regions; Iowa Community Action Agencies; Iowa Department of Human Services; IDPH Preparedness Program Service Areas

Maternal Health Strategic Plan

The previous reporting year the Maternal Health Program undertook a strategic planning process utilizing a Learning Survey and focus group methodologies. The 2021 Maternal Health Strategic Plan has now been released. The plan identifies strategic priorities to lead the state’s maternal health efforts. Developed through engagement with community, clinical, and provider perspectives, and in alignment with national public health goals, our strategic priorities will guide IDPH efforts. Current IDPH and partner activities supporting the strategic priorities have been identified and captured in a supplementary report. IDPH and Title V intend for this document to guide the work of Maternal Health programs to ensure resources are maximized, information sharing remains ongoing, and that we work collectively towards meeting the maternal health needs of all people living in Iowa.

Iowa’s goals in pursuing the identified strategic priorities and general recommendations are to improve the state’s number of healthy deliveries and births, along with ensuring that every person has access to the care they need during pregnancy.

Balancing the feedback from the information-gathering process captured through surveys reaching wide audiences, focus groups to refine the themes, and assessing existing plans and strategies, IDPH and partners have determined the following strategic priorities:

Elevate Focus on Maternal Mental Health (MMH)

The World Health Organization (WHO) defines maternal mental health as “a state of well-being in which a mother realizes her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her community.” Mental health conditions are the most common complication of childbirth impacting 1 in 5 individuals during pregnancy and the year following pregnancy. Untreated maternal mental health conditions can have negative and long-term impact on pregnant and postpartum women and her infant.  Mental health conditions are a leading and preventable cause of maternal mortality. Despite these negative consequences, depression and anxiety largely goes undiagnosed and untreated during pregnancy and postpartum periods. The state’s shortage of all mental health provider types (psychiatrists, psychologists, social workers, and marriage and family therapists), contributes to the lack of access for maternal mental health supports.

General Recommendations to Improve Maternal Mental Health:

1. Empower healthcare providers and birthing hospitals to:
   1. Assure all pregnant and postpartum women are screened for depression and, when appropriate, referred to treatment. 
   2. Embrace the necessity of recognition and treatment of mental health concerns and assure individuals receive counsel on ongoing care, follow-up and care coordination. 

2. Implement system wide changes to support universal screening for depression, anxiety and substance use, as well as access to consultation and treatment for all pregnant and postpartum individuals.

3. Increase access to mental health providers and treatment for depression and other mental health issues.
4. Identify opportunities for the development of a statewide resource for health care providers and professionals caring for pregnant and postpartum individuals struggling with mental health or substance abuse to easily link to mental health and addiction medicine experts for consultation and referral when needed. (Identified by the IMQCC Mental Health and Substance Use Disorder Subcommittee; and a 2021 Maternal Mortality Review Committee Recommendation)

Advance Workplace Policies

Workplaces benefit from addressing the needs of their employees, including the needs of pregnant and parenting people.  Having a workplace that supports access to prenatal and postpartum care, including accommodations within the workplace to support pregnant and parenting people’s physical and emotional needs during the perinatal period, and complying with medical recommendations, helps support successful pregnancies as well as healthy moms and babies. 

General Recommendations to Advance Workplace Policies to Support Maternal Health

1. Normalize breastfeeding practices and ensure appropriate, dedicated space and time is provided while at work.

2. Review of current family leave policies to provide consideration for modern family structures, time to adjust to new life norms, and to recover mentally and physically from the birthing experience.

3. Expand insurance coverage (Medicaid and private insurance) for pregnancy related services such as lactation services, doula services, and extending postpartum Medicaid coverage for 12 months.

4. Support findings and recommendations of the Breastfeeding State Plan that is currently being developed (Anticipated Completion Date of September 2022).

Improve Health Before, During & After Pregnancy

A healthy pregnancy begins before conception.  Chronic illness can create complications in every phase of reproduction, can be exacerbated as a result of pregnancy and often contribute to maternal morbidity and mortality.  Birth outcomes are improved with increased attention to the health of individuals of reproductive age before, during, and after pregnancy. 

General Recommendations to Improve Health Before, During, and After Pregnancy (IH)

1. Elevate the focus on social determinants of health including screening and treatment for domestic violence and substance abuse, offering transportation support to maternal health care appointments, and improving neighborhoods and communities to increase safety, physical activity, and access to healthy food.

2. Encourage broader education about and use of family planning resources to support the full spectrum of maternal health needs.

3. Include chronic disease prevention and management in maternal health care, linking management of health complications to their impact on pregnancy. Common chronic diseases in women of reproductive age include obesity, diabetes, hypertension, and cardiac disease.   

4. Explore solutions to strengthen postpartum follow-up, including referrals to support programs and services.

To view the full Maternal Health Strategic Plan and supplementary documents follow this link.

Children and Youth with Special Health Care Needs

Ongoing needs assessment activities:

DCCH assesses needs through the framework of the National Standards for Systems of Care for CYSHCN. DCCH staff are also working to align on-going needs assessment activities with the new Blueprint for Change from MCHB. The National Survey of Children’s Health is an ongoing source of population-based, family-reported data for Iowa’s Title V CYSHCN program. Other needs assessment activities include the annual Youth Services Survey for Families, sent to a sample of families who receive direct and enabling services through DCCH, a survey of members of the Family Navigator Network, a survey for members of the Family Advisory Council, and a review of ongoing activities of partner organizations such as the Developmental Disabilities Council, and internal programs such as the Regional Autism Assistance Program.

Changes in health status and need

The top priority needs for Iowa’s Title V program were identified in the 2020 needs assessment as:

• Infusing Health Equity in the Title V System
• Access to care for the MCH population
• Maternal, Child, and Adolescent Health systems coordination
• Dental Delivery Structure
• Safe and Healthy Environments
• Access to community-based services and supports, pediatric specialty providers, and coordination of care
• Access to support for making necessary transitions to adulthood
• Support for parenting CYSHCN with mental health or complex health needs.

Covid-19 exacerbated the need to address all of these priority areas, especially access and parent support. Iowa’s Title V program including CYSHCN continued to provide support in all of these areas, including expanded access to in-home telehealth direct services and supports for families. For a large portion of 2020 and 2021, many Title V local and state program staff provided this care while working from home, or in reduced density work environments.

DCCH collects information from the Family Navigator Network about changes in issues and needs from families they are working with. The Family Advisory Council also provides information about the needs of families of CYSHCN. Family Navigators indicated that over the past year, families struggled to access respite providers, in-home nursing care, and specific therapies such as Applied Behavioral Analysis and occupational therapy. Family Navigators observed that issues with childhood anxiety became more prevalent since the start of the Covid-19 pandemic, and that mental health issues seem to be at a crisis point, but access to mental health services is still challenging in Iowa because there is a shortage of providers. The survey of the Family Advisory Council indicated that there is a need for more child care, increasing opportunities for youth to learn social skills, and that the Consumer Choice Option for waiver services that allows enrollees to directly hire their own employees and services is helpful. 

A family survey is part of the annual process for this 5-year Title V cycle for DCCH programs. The Youth Services Survey for Families is a questionnaire that includes 26 questions with a 5-level Likert-type response scale ranging from ‘Strongly Agree’ to Strongly Disagree.’ Respondents are also given the option ‘Does not apply.’ The items in the questionnaire are grouped into 6 domains that pertain to the direct and enabling services provided through DCCH: Access, Participation in Treatment, Cultural Sensitivity, Satisfaction, Outcomes, and Social Connectedness. Domains contain between 2 and 6 questions, which are combined into a mean domain score. Additional questions cover basic demographic information: Gender, age-category, and race/ethnicity. Additionally, there are 3 open-ended questions, asking 1) What has been the most helpful thing about the services you and your child received as a result of DCCH services? 2) What would improve services for families who need support? and 3) Any other comments? The survey is administered annually in the spring. The table below shows the results from 2021 and 2022. A review of the data showed that although scores were high overall, there were increasing challenges for families who receive services from DCCH between 2021 and 2022.  DCCH is currently working with staff to gain an understanding of this finding and look for opportunities to strengthen our partnerships with families.

Changes in capacity and MCH systems of care

Essential services for MCH priority populations were enhanced in several ways during the 2022 Iowa legislative session.  For people with disabilities, including CYSHCN, more funding is now available for direct support staff wages, to reduce the length of Home and Community Based Services waiver waiting lists, increase vocational rehabilitation services, and ensure that special education for children disabilities in private schools are provided.

Breadth of Partnerships with other entities that serve the MCH population

Iowa’s Title V program works extensively with organizations such as the Iowa Departments of Management, Education, and Humans Services. Coordination of services and ensuring Iowa’s most vulnerable families are receiving the needed services to succeed has been a cornerstone of these collaborations. The MCH program, including CYSHCN, has strong linkages within IDPH Bureaus of Immunizations, Oral and Health Delivery Systems, Chronic Disease Prevention and Management, as well as Vital Records & Health Statistics, and Substance Abuse Prevention and Treatment programs. IDPH’s Office of Disability, Injury & Violence Prevention supports state and local efforts to improve services for victims of domestic and sexual violence. IDPH and DCCH appreciate many public-private partnerships with organizations such as Delta Dental of Iowa Foundation, the Iowa AAP, ChildServe, Blank Children’s Hospital, the Iowa Primary Care Association, the National Alliance on Mental Illness Iowa Chapter, Child and Family Policy Center, ASK Resource (Family Voices affiliate), the Autism Society of Iowa, Blank Children’s Hospital, and a number of other health care providers and systems.  Opportunities range from funding for school-based dental sealant programs, participation on health advisory councils, and evaluating program data.

The CYSHCN section of Title V also works with the Iowa Developmental Disabilities Council (DD Council) and is co-located and meets regularly with the University Center for Development and Disability (UCEDD), and the Iowa Leadership Education in Neurodevelopmental and Related Disabilities Project (LEND) programs. The Iowa Title V CYSHCN program has active collaborations within the University of Iowa Stead Family Children’s Hospital and Department of Pediatrics, including the Division of Developmental Pediatrics and the Division of General Pediatrics. Other University of Iowa programs that Title V actively collaborates with include the Carver College of Medicine Departments of Psychiatry, Family Medicine, and the College of Public Health.

Operationalizing the 2020 Needs Assessment

BFH is currently in the process of reviewing and rewarding the FY2023 Title V Request for Proposals (RFPs) The Title V Block Grant State Action Plans directly affect and dictate the development of requirements and activities outlined in the funding opportunity. Staff continue to use and update the 2020 Needs Assessment to ensure the needs of Iowa’s population are continuing to be met and continue to reduce barriers faced by families.

In order to further operationalize the Needs Assessment state Title V staff are continuing to utilize the findings to inform and programmatic changes including but not limited to the Maternal Health Strategic Plan and the CSAs discussed previously.

DCCH updated the strategic plan in 2021 with a focus on alignment between the needs of CYSHCN and families and the work that is carried out by DCCH. Title V Priority areas are used as a basis to direct efforts within DCCH as well as to advocate with other organizations with shared goals.

Changes in organizational leadership

Iowa’s Title V MCH program is housed in the Division of Health Promotion and Chronic Disease Prevention, the Division Director, Nalo Johnson, PhD resigned from the position. The Division Director role is currently vacant and will not be filled based on the merger and restructuring of the Iowa Department of Public Health.  Sarah Reisetter, J.D., Deputy Director of IDPH is serving as the executive leadership of the Division.

Over the past year, DCCH’s medical director, Dr. Jessie Marks, left her position within DCCH. Currently, the DCCH Director, Dr. Tom Scholz has integrated the duties of the medical director position into his role.