NC Title V Program 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 and families. 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 Title V Program, 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 intentionally becoming more inclusive of male partners and fathers.
Along the MCH continuum with these initiatives, implementation of the Perinatal Health Strategic Plan (PHSP) continues. The 2022-2026 PHSP was released in August 2022 after embedding the Maternal Health Strategic Plan and Task Force into the broader structure of the PHSP. Bi-monthly Perinatal Health Strategic Plan Collective meetings are held as well as routine meetings of the Collective Leadership Team which is composed of the chairs of the five work groups: Communications; Data and Evaluation; Maternal Health; Village to Village (focused on community and consumer engagement); and Policy. These work groups meet as needed to move forward the work of the PHSP.
In collaboration with LHDs, the Reproductive Health Branch coordinates the provision of a wide range of preventive care and planning services, critical to reproductive and sexual health. This service is available to all regardless of religion, race, color, national origin, disability, age, sex, number of pregnancies, marital status, or income on a sliding fee scale. The family planning clinics are supported in part with funding from Title V, Title X, other local and state funds. Programs offer a broad range of acceptable and effective family planning methods and services, including infertility services, and services for adolescents.
The reproductive health services include but are not limited to a broad range of medically approved contraceptive methods, pregnancy testing and counseling, assistance to achieve pregnancy, basic infertility services, sexually transmitted infection services, and other preconception health services, including reproductive life planning. Every effort is made to ensure that families with incomes at or below 100% of the federal poverty level are given priority in receiving family planning services. Clients with incomes between 100% and 250% are also given priority but are charged according to a sliding fee scale.
The Maternal Health Branch oversees the provision of Title V funding to LHD to deliver low and limited high-risk prenatal care services for women in our state. A team of WICWS nurse consultants along with a nutritionist and licensed clinical social worker provide ongoing training, technical assistance, and monitoring to the LHD prenatal clinics. Services may also include health behavior intervention, skilled nursing home visits, and postnatal assessment and follow-up care. Title V also collaborates with the Division of Mental Health, Developmental Disabilities, and Substance Use Services to fund a Perinatal Substance Use Specialist position.
Care Management for High-Risk Pregnancies (CMHRP) services are also provided by most LHDs. It is an outcome-focused program, with an emphasis on improving birth outcomes through reducing the rate of preterm and low birthweight births and monitors the pregnant Medicaid population and prenatal service delivery system using data. CMHRP applies systems and information to improve care and assist members in becoming engaged in a collaborative process designed to manage medical, social, and behavioral health conditions more effectively. Meeting the varied and complex needs of members requires a holistic, person-centered approach that addresses both physical and behavioral health. A holistic approach must also consider the social determinants of health - "conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks" (Office of Disease Prevention and Health Promotion, 2016). The more complex the needs, the more comprehensive the approach should be for assisting the member with a care plan that addresses the whole person and collaborates with other systems that impact the member’s well-being.
The Care Management for at Risk Children (CMARC) Program is also operated by most LHDs in the state. This program provides care management services for children with special health care needs from birth to five years old, focusing on improving health outcomes and supporting families. The CMARC program works closely with LHDs providing child health services. Services address both physical and behavioral health needs from birth through childhood, inclusive of adolescent health.
LHDs are also responsible for implementing the Reducing Infant Mortality in Communities (RIMC) Program. It provides services to pregnant women and women of reproductive age utilizing five different evidence-based strategies that are proven to help reduce infant mortality rates: breastfeeding support services, Centering Pregnancy, doula services, infant safe sleep services, and preconception and interconception health services. The program is currently being implemented within eight local health departments, serving eleven counties in the state. Each program implements two evidence-based strategies and works with community partner organizations to provide services to individuals within the counties they serve.
In addition to LHDs, Title V works with other members of the healthcare systems. Ongoing collaborations include the NC Association of Community Health Centers. Along with LHDs, they serve as safety net providers in many communities. Title V collaborates with the NC Healthcare/Hospital Association with the implementation of several MCH efforts, including Levels of Care and Maternal Mortality Reviews. We also provide training and educational materials when requested.
In FY25, the WICWS received a second five-year HRSA State Maternal Health Innovation (MHI) grant which provides funding to assist states in collaborating with maternal health experts and maximizing resources to implement specific actions that address disparities in maternal health and improve maternal health outcomes, including the prevention and reduction of maternal morbidity and severe maternal morbidity. One stipulation of this funding was to create a Maternal Health Task Force (MHTF), which was done through partnership with the NCIOM, with this Task Force continuing to promote adoption of some of the PSOC Task Force recommendations while creating its own set of recommendations. A decision was made in March 2022 to merge the work of the MHTF into the PHSP Collective to avoid duplication of efforts. The NCIOM will continue to play a vital role in promoting the recommendations identified by the MHTF.
The North Carolina Maternal Mental Health: Making Access to Treatment, Evaluation, Resources and Screening Better (NC MATTERS) program aims to decrease barriers to screening and treating for maternal mental health and substance use disorders (MMH/SUD) by increasing the capacity of the health care professionals (e.g., obstetricians, pediatricians, family physicians, midwives, home visitors, psychiatrists) who need enhanced training and support to meet the needs of their patients. Housed within the WICWS, Maternal Health Branch (MHB), NC MATTERS contracts with the University of North Carolina at Chapel Hill (UNC) and Duke University to achieve the goals and objectives of making access to screenings, treatment, evaluation and resources for depression and related behavioral health disorders more accessible and advantageous in North Carolina.
NC MATTERS provides access to education and training, including screening and treatment support for health care professionals. These core program components are delivered through:
- A clinical psychiatric access line staffed by perinatal mental health specialists to answer patient-specific treatment questions
- Referral and resource coordination services
- Telepsychiatry assessments to perinatal patients at no cost
- Publications and toolkits as detailed guides in managing perinatal behavioral health conditions
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Training and technical assistance such as:
- The Maternal Mental Health Fellowship, a cohort-based learning opportunity for selected providers to increase their knowledge, skills, and capacity to address MMH/SUD within their scope of practice
- The Patient-Centered Outcomes Research Institute (PCORI) Pathways Project to implement recommended perinatal mental health guidelines into obstetric settings
- A Stakeholders Network consisting of professionals who serve as advisors in NC MATTERS program implementation and MMH/SUD care recommendations
- Outreach and engagement including practice touchpoints and participation in conferences, events, and community activities
NC Psychiatry Access Line (NC-PAL) is a free telephone consultation and education program to help health care providers address the behavioral health needs of pediatric and perinatal patients. Behavioral Health Consultants can respond to questions about behavioral health and local resources and can connect providers to on-call psychiatrists to assist with diagnostic clarification and medication management questions. Funding for this project expanded significantly through the blending of funds from multiple sources. Prior to 2021, NC-PAL was primarily funded through HRSA grants and the program’s focus was on the development of the call center. In 2021-2022, NCDHHS more than doubled the investment in this program by dedicating more funding through Mental Health Block Grant and Medicaid. In 2023, HRSA awarded NCDHHS with a new 3-year grant. Mental Health Block Grant and Medicaid funds continue to support the program. With the increased funding, NC-PAL has been able to expand offerings to include the following supports:
- Participation in daily clinical staffing calls with DHHS staff, county DSS staff, and pre-paid health plan staff to focus on children in Emergency Departments or DSS offices awaiting medically recommended behavioral health services. They provide recommendations on services, needs assessments, and medication reviews.
- Development of pilot program with four county DSS offices, working with social services staff to support better permanency planning for children with significant behavioral health needs.
- Implementation of a school training and consultation program, supporting schools with needs related to complex behavioral health challenges.
- Implementation of a pilot program for early intervention programs, providing consultation and support to local CDSAs.
- Implementation of a training initiative for psychiatrists and other practitioners to support behavioral health needs of children in their practices and local communities.
Rapid Response Team (RRT) was established in late 2020 in response to the growing number of children in DSS offices and in Emergency Departments without access to necessary behavioral treatments. The RRT process was established in state statute in 2021. RRT is a cross departmental initiative coordinated and administered by the WCHS Child Behavioral Health Unit. The cross departmental team accepts referrals from local partners for children in DSS custody awaiting necessary treatment placements. Meetings are held daily to staff the referrals with local DSS and Medicaid Pre-paid Health Plans. RRT provides the local team with support and suggestions aimed at identifying needed treatment options and also works to alleviate any state system barriers impacting access to care. In 2023, RRT facilitated calls with local DSSs and MCOs for 208 children to plan and troubleshoot challenges with access to care.
High Fidelity Wraparound (HFW) services assist families when youth experience mental health or behavioral challenges. HFW professionals partner with youth and families to identify their specific priorities and goals, assemble a team that gives them the support they want and need, and develop a process that empowers them to achieve their unique vision for the future. HFW is evidence-based and nationally standardized. In July 2021, less than a third of all counties in NC had HFW services available to their residents. By June 2022, 66% of counties had HFW services available to families in their area. By the end of calendar year 2023 HFW services were available in 76% of NC counties and services will be expanded to the remaining counties over the next year. In 2023, NC received a three-year Substance Abuse Mental Health Administration grant to support the continued expansion of this service and to support System of Care expansion in the state. The grant will provide start-up funds to expand HFW services, improve identification of children for HFW, and increase training and support for local System of Care Collaboratives.
According to data from the interactive NC Health Professions Data System, in 2024, for NC as a whole, there was an average of 7.74 physicians with a primary care practice per 10,000 individuals. However, 33 counties have relatively few primary care physicians (less than 4 per 10,000 people) and one county did not have any primary care physicians. NC also has an increasing shortage of health care professionals performing deliveries, and there have been eight rural hospital closures since 2010 in NC. Also in 2022, there was an average of 1.58 physicians whose specialty was general pediatrics per 10,000 population, but nineteen counties did not have any pediatricians. NC has several children’s hospitals nationally ranked in pediatric specialties, but access to these hospitals is often difficult for children not born in nearby cities and counties.
The Positive Parenting Program (Triple P) System in NC consists of the NC State Partnership for Strategy and Governance (PSG), the NC Triple P Support System (which consists of Triple P America, The Impact Center at UNC FPG, and Positive Childhood Alliance), the Triple P Design Team (The Impact Center and Triple P America), and the lead implementing agencies (LIAs). This system practices model flexibilities designed to maximize LIA and practitioner service delivery. The PSG (leadership level) practices flexibility with regards to deliverables, especially relative to the “Scale-Up Plan.” LIAs makes efforts to work towards their developed goals and objectives based on community need and infrastructure to determine scaling counties (those with Triple P online and levels two to four) and supporting counties (non-scaling) to allow for flexibility. The current operating principle is that the Scale-Up Plan, which emanated from the Strategic Plan, is a “living” document, and allows for the flexibility of editing and revising at any time that it is a reasonable expectation to do so. The NC Triple P Support System worked with each LIA to assess the training and support needs of local practitioners to deliver Triple P as part of their work.
The WCHS supports the Triple P System in NC through Title V and the NC Division of Social Services (DSS) funding by employing a State Triple P Coordinator, funding the LIAs for infrastructure and training support, and providing a part-time data specialist to work in coordination with the WCHS Data Manager to support statewide data collection and reporting and using data for local CQI projects.
In addition, the WCHS partners with the NC DSS to support Incredible Years and Strengthening Families cohorts in local communities and integrate those evidence-based family strengthening programs with Triple P as those initiatives are very compatible and integrate well with Triple P. The WCHS receives funds from DSS to provide additional funding for the LIAs and provide a co-chair for the PSG with the State Triple P Coordinator serving as the other co-chair. DSS utilizes the Triple P evidence-based program in their menu of approved family strengthening programs, that can be supported by local DSS funds.
The Triple P State Learning Collaborative, consisting of all the coordinators at the LIAs, continues to provide a learning environment in which coordinators meet to learn, share, and plan to implement best practices, offer collective problem solving and efficiencies, determine sustainability needs, and encourage model fidelity based on the Triple P Implementation Framework. The Collaborative members are an incredibly effective group of Triple P partners/coordinators who consistently provide perspectives for quality assurance and improvement for the operationalization of the Triple P Program.
With the addition of state appropriations transferred from DSS to the DCFW under an annual agreement, Triple P coverage has been expanded to all 100 counties in NC, which includes Triple P Online that is available statewide at no cost to families. In addition, hybrid support continued to be offered to families. Hybrid support refers to the active engagement of a practitioner in aiding a caregiver's comprehension of the Triple P Online modules' content and lessons. This involves the practitioner regularly checking in with the caregiver, providing answers and clarification for module concepts, assessing the caregiver's understanding of the learning goals, and encouraging the completion of all modules.
The partnership between DCFW, DSS and The Duke Endowment has continued to support the implementation of Triple P to ensure consistent delivery and availability of model implementation in all regions, a process referred to as the “Practitioner Round-Up” continues to be implemented that required all LIA Coordinators to seek out and follow up with all trained practitioners to assess their current status relative to delivery of the model at their agency. This process is in place to ensure that investments made in practitioner training at the local level are being sustained with full access to Triple P services as needed. The Practitioner Round-Up survey has been transformed into the Practitioner Impact and Needs Evaluation (PINE) report since the “Round-Up survey process proved to be a challenge in some cases with practitioners moving outside the service delivery region and/or having changed agencies or careers, thus no longer providing services. The hope for the PINE report is to streamline data collection processes for LIAs and practitioners informed by regular input from LIA data team leads during weekly data team meetings in addition to data requests from funders.
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