Geography, Demographics, and Economy
Michigan encompasses 56,804 square miles of land and is the only state made up of two peninsulas. Comprised of 83 counties, Michigan is the 10th most populous state and 11th largest state by total square mileage. Approximately 10 million people live in the state (2020 Census). Birth rates have decreased over the past 20 years, and the state saw a 0.18% decline in population from 2019 (U.S. Census Bureau). Most of Michigan’s population resides in the southern half of the Lower Peninsula, with approximately half of the population residing in Southeast Michigan. The state’s largest cities are Detroit, Grand Rapids and Warren. Over 1.8 million people live in rural areas. The median age of the population is 39.7 years. Out of the total population, approximately 21.5% are ages 0-17 and 78.5% are ages 18 and over. Michigan’s population is 78.7% Caucasian, 13.9% Black or African American, 2.9% Asian and Pacific Islander, 2.9% two or more races, 1.4% other races, and 0.5% Native American. Out of the total population, 4.9% identify as Hispanic or Latino.
Michigan’s economy saw improvements over the nine years leading up to 2020, but the COVID-19 pandemic had immediate impacts on the economy. While the seasonally adjusted unemployment rate decreased from 14.9% in June 2009 to 4.0% in January 2019, the unemployment rate spiked in April 2020 to 22.7% percent and varied throughout 2020 and 2021. The economic impact of COVID-19 has been significant but appears to be improving. Michigan’s unemployment rate was 5.5% in January 2022 in comparison to 3.6% in February 2020. The economic recovery has been uneven across the state, with the University of Michigan (February 2022) reporting that Detroit’s unemployment rate was 20%. According to the Carsey School of Public Policy (October 2021), Michigan recovered 74% of jobs lost during the pandemic. The Ford School of Public Policy reports that “As of spring 2021, 39% of Michigan local officials report their local economies have suffered significant (33%) or even crisis-level (6%) impacts over the past year of the pandemic. However, this is down sharply from the 86% of jurisdictions that reported the severe economic impacts at the beginning of the pandemic in 2020.”
According to the 2021 ALICE (Asset Limited, Income Constrained, Employed) report, 38% of households in Michigan struggled to afford the basic needs of housing, childcare, food, technology, health care and transportation. In Michigan, 58% of jobs were low wage jobs, paying less than $20 per hour; two-thirds of those jobs paid less than $15 per hour. According to the 2021 Kids Count, Michigan ranks 22nd in health, 24th in both economic and family wellbeing, and 41st in education for children. One in five children (19%) ages 0-17 live in poverty and certain areas of the state experience higher levels of poverty. Statewide, 50.5% of students are eligible for free or reduced-price lunches. Given this environment plus the impacts of COVID-19, family support programs such as WIC and childcare are critical safety net resources for families. The long-term effects of the COVID-19 pandemic on Michiganders’ physical, mental, and economic well-being will continue to be revealed over time.
Roles and Priorities of the State Health Agency
The Title V program is overseen by the Division of Maternal and Infant Health (DMIH), which is housed in the Bureau of Health and Wellness (BHW) in the Public Health Administration. DMIH includes Family Planning, the Maternal Infant Health Program, infant safe sleep, breastfeeding, the statewide Perinatal Quality Collaborative (PQC) and Early Hearing Detection and Intervention. DMIH works in partnership with the Children’s Special Health Care Services (CSHCS) Division and the Division of Child and Adolescent Health (DCAH) to administer Title V. CSHCS includes CSHCS Customer Support, Policy and Program Development, Quality and Program Services, and the Family Center for Children and Youth with Special Health Care Needs (Family Center). DCAH oversees school-based health centers, oral health for children, teen pregnancy prevention, the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program, and the Title V funding awarded to Michigan’s 45 local health departments. Title V works collaboratively with other programs in the Michigan Department of Health and Human Services (MDHHS) which includes public health; Medicaid; environmental health; emergency preparedness and response; communicable and chronic disease; food and cash assistance; migrant and refugee services; juvenile justice; child protective services; foster care; and adoption.
The MDHHS vision to “Deliver health and opportunity to all Michiganders, reducing intergenerational poverty and promoting health equity” is supported by 11 goals:
- Public health investment
- Racial equity
- Address food and nutrition, housing, and other social determinants of health
- Improve the behavioral health service system for children and families
- Improve maternal-infant health and reduce outcome disparities
- Reduce lead exposure for children
- Reduce child maltreatment and improve rate of permanency
- Implement the Families First Preservation Services Act state plan
- Expand and simplify safety net access
- Reduce opioid and drug-related deaths
- Manage to outcomes and invest in evidence-based solutions
Michigan’s MCH programs align with several of these goals. The 2020-2023 Mother Infant Health & Equity Improvement Plan (MIHEIP) focuses on the mother-infant dyad and provides a framework for expanding partnerships and strategies to enhance local and state efforts to address the root causes of adverse outcomes—social determinants of health and drivers of health inequity. A Year Two Update was released in September 2021 to recognize stakeholder success and update indicator data. Annual updates will highlight progress on achieving the vision of “Zero preventable deaths, Zero health disparities.”
The MIHEIP was developed collaboratively by MDHHS and stakeholders, and efforts to implement the MIHEIP are also informed by input garnered from the Mother Infant Health and Equity Collaborative (MIHEC), Regional Perinatal Quality Collaboratives (RPQCs), Michigan families, MCH stakeholders, health care providers and community leaders. Implementation of the MIHEIP includes alignment of programs within MDHHS; quality improvement efforts within RPQCs; and external implementation through community partners and health providers. Further alignment and action occur through Maternal Infant Health (MIH) Action Committees which are aligned with MIHEIP priorities to impact systems through policy and practice change. Each Action Committee is co-chaired by content experts.
Improving maternal and infant health outcomes is a priority of Governor Whitmer. In 2020, Gov. Whitmer released the Healthy Moms, Healthy Babies initiative to address health disparities and ensure all women have access to high-quality health care. The FY 2021 and FY 2022 state budgets allocated funds to support and expand the initiative through increased access to evidence-based home visiting programs and continuous Medicaid coverage to beneficiaries for 12 months postpartum. The FY 2022 budget also supported the largest increase in childcare funding in Michigan’s history plus initiatives to support health equity, such as screening for health-related social needs.
Michigan is expanding home visiting to better support families that historically have a higher risk of child welfare involvement and family separation. The first expansion is under the Families First Prevention Services Act (FFPSA). The Children’s Services and Public Health Administrations are partnering to implement evidence-based home visiting (EBHV) expansion in seven high-risk counties. The second expansion is through new funding in FY 2022 to support families with infants who have been exposed prenatally to substances, by expanding EBHV in 10 communities with high numbers of infants impacted by substance misuse. The project is piloting Peer Navigators within the healthcare system to break down barriers of shame, stigma, and fear. Peer navigators will connect families to resources, including EBHV, and will provide support 12 weeks postpartum.
Additionally, the Home Visiting Advisory, which launched in 2019, is charged with building an integrated home visiting system for Michigan’s families. Michigan’s evidence-based home visiting system includes the Maternal Infant Health Program (MIHP), Nurse-Family Partnership, Healthy Families America, Early Head Start-Home Based, Parents as Teachers, and Family Spirit. The Advisory is intended to have an active role in system development through discussions about centralized access, professional development, and equity. Title V leadership participates in the Advisory.
Early childhood partnerships and systems building are also critical to supporting children and their families. The Office of Great Start (OGS) within the Michigan Department of Education (MDE) leads the integration of the state’s healthy development and early learning investments for prenatal to age 8. MDHHS collaborates with OGS to support the development of early childhood systems that meet the needs of children and families. The Great Start Operations Team (GSOT) convenes state agencies and partners to provide strategic direction for early childhood integration and coordination. Several MDHHS program areas, including Title V and home visiting, serve on the GSOT. The GSOT work is grounded in Michigan’s four early childhood outcomes which include “children born healthy” and “children healthy, thriving, and developmentally on track from birth to third grade.”
Michigan was awarded an Early Childhood Comprehensive Systems (ECCS) Grant in 2021. The five-year project is intended to foster the development and integration of maternal and early childhood systems of care that are equitable, sustainable, comprehensive, and inclusive of the health system. The grant will explore integration into the Early Childhood Advisory and how to support health integration across sectors at the local level. The ECCS Advisory Committee is housed within the MIHEIP structure, meeting perinatal health professionals where they are already working.
Advancing equity is a priority both within MDHHS and the State of Michigan. At the state level, several initiatives implemented in 2020 continue to address implicit bias, racism, and racial disparities:
- Gov. Whitmer’s Executive Directive 2019-09 established Equity and Inclusion Officers within each state department. The 2021 Strategic Plan includes goals to build Diversity, Equity, and Inclusion (DEI) infrastructure and leadership and measure DEI efforts across state departments.
- Gov. Whitmer’s Executive Directive in July 2020 requires implicit bias training for 26 licensed health professional classifications to address racial disparities. Requirements are effective as of June 2022.
- In August 2020, Gov. Whitmer issued an executive directive recognizing racism as a public health crisis. All state employees were required to complete an implicit bias training. Effective November 2021, State of Michigan new hires must complete implicit bias training within 90 days of start date.
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Gov. Whitmer signed an Executive Order in April 2020 creating the Michigan Coronavirus Task Force on Racial Disparities. The Task Force investigated causes of COVID-19 racial disparities and recommended actions to address the disparities, including transparency in data reporting; remove barriers to physical/mental health care; reduce the impact of medical bias in testing and treatment; mitigate factors that contribute to increased exposure; and develop systems to support long-term economic recovery and physical/mental health care.
- MDHHS collaborated with the Task Force to establish 22 Neighborhood Testing Sites in 15 communities. A data-driven approach used the CDC’s Social Vulnerability Index and mortality data for six comorbid conditions associated with increased risk of adverse COVID-19 outcomes. MDHHS partnered with churches and colleges to establish neighborhood testing sites. To date, over 300,000 tests have been collected.
- The Task Force initiated MDHHS funding to Wayne State University/Wayne Health, Genesee Health Systems, and three health departments to serve rural and urban communities at the highest risk of infection. During the last quarter of 2021, six mobile health units administered 44,950 COVID-19 tests, 19,045 COVID-19 vaccinations, and 438 flu vaccinations. Approximately 3,075 residents were assisted with wrap-around services addressing determinants of health; 5,649 residents received services for hypertension and diabetes, primary care referrals, needle exchanges, blood pressure screenings, food and housing, mental health, or sexual health services.
At the departmental level, MDHHS is working to assess and change policies and programs to address DEI.
- The MDHHS DEI Plan details the Department’s “commitment to eliminating systematic inequities and promoting diversity, equity and inclusion.” A DEI Council was created to promote and foster a culture that values DEI throughout MDHHS and the diverse communities it serves.
- In October 2020, MDHHS created the Race, Equity, Diversity, and Inclusion (REDI) Office to address racial, health, social and wealth disparities.
- The MDHHS Office of Equity and Minority Health (OEMH) is part of REDI and delivers an annual report to the state legislature on health disparities and departmental progress. The 2020 Report focused on COVID-19, including MDHHS actions to respond to the pandemic within communities of color and lessons learned for addressing racial and ethnic inequities. The OEMH also provides training and technical assistance to the MDHHS workforce on unconscious bias, systemic racism, cultural competency, health equity, and community engagement.
- The DEI Council and REDI/OEMH created a Countering Bias in the Interview training that is required for all MDHHS interview panelists.
- Starting in 2021, all MDHHS position postings require a Valuing Diversity and Inclusion competency in the posting questions as well as DEI questions in the interview. A DEI objective is also required for annual performance management plans.
- “Introduction to Health Equity” and “Systemic Racism” trainings are required for all MDHHS staff. Introduction to Health Equity describes health equity and health disparities; factors that contribute to inequities; the impact of health inequities; and how MDHHS can help to achieve health equity for all Michiganders. The Systemic Racism training identifies how state or national systems may produce or perpetuate inequitable outcomes. The training is open to MDHHS employees, contractors, and the public.
- MDHHS and the Michigan Department of Civil Rights developed a two-day in-person workshop “Inside Our Mind: Hidden Biases.” MDHHS is currently developing a computer-based implicit bias training.
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In the Executive Directive announcing racism as a public health crisis, the Governor announced the piloting of an Equity Impact Assessment (EIA) process in MDHHS, with potential rollout to other state departments. The EIA process can be used to inform decisions when developing budgets, programs, procedures, and policies. OEMH is leading the pilot in three MDHHS administrations:
- Policy: Provide Medicaid coverage for doulas.
- Practice: Eliminate obstacles for individuals with visual disabilities who apply for Economic Stability Administration programs.
- Procedure: Training to Community Mental Health agencies on screening and trauma-focused Cognitive Behavioral Therapy.
- In response to Gov. Whitmer’s Executive Directive on State/Tribal Government Relations, MDHHS issued a training on working with Michigan’s Tribal Governments in 2022. The training is mandatory for MDHHS employees and is intended to increase understanding of the history of Michigan’s 12 tribal nations and ways to support tribal relations to address disparities and improve health outcomes.
- The MDHHS Office of Policy and Planning is developing a social determinants of health strategy to align, collaborate, and create innovative solutions to support health equity.
Within Title V, the 2020 five-year needs assessment identified three key “pillars” that were important to all MCH populations: achieving equitable health outcomes, engaging families and communities, and delivering culturally and linguistically appropriate health education. Strategies related to these pillars are included in the state action plans.
Strengths and Challenges that Impact the MCH Population
The Title V needs assessment, which was completed prior to the COVID-19 pandemic, identified several strengths and challenges that impact the MCH population. These are discussed in detail in the FY 2021 application. Strengths include longstanding relationships with local public health, a robust home visiting network, commitment to addressing health disparities and pursuing equity, health campaigns that leverage technology and community voice, recognition of the impact of social determinants on health, resources and services to meet basic needs, and elevation of family voices to serve CSHCN.
Challenges facing Michigan’s MCH system and families include the impact of poverty coupled with system limitations to address poverty as a driver of health disparities; gaps in capacity and access to services for basic needs like transportation, childcare, and healthcare; inconsistent distribution of culturally or linguistically relevant health information; gaps in respite care for caregivers of CSHCN; barriers to accessing behavioral health services; and racism and other drivers of health inequity.
Over the past two years, the most significant public health challenge has been the COVID-19 pandemic. In 2022, the Title V program conducted a second assessment to gauge the pandemic’s ongoing impact on the MCH population. Findings are included in the Needs Assessment Update. Findings from the 2021 assessment are included in the previous application. The NPM/SPM annual reports and state action plans also include information about the impact of the pandemic on programs and service delivery.
Michigan’s first presumptive positive COVID-19 case was reported on March 10, 2020. Gov. Whitmer declared a state of emergency on the same day. Comprehensive information on the state’s COVID-19 response is available on the Coronavirus website. As of March 7, 2022, Michigan reported 2,062,354 confirmed cases and 32,134 COVID-19 deaths. Cumulative data including trends, demographics, and testing information is available on the State’s COVID-19 Data Dashboard. The pandemic has disproportionately affected certain populations in Michigan. Cases per million are 156,079 for Black/African American in comparison to 142,788 for White. Deaths per million by race are also highest for Black/African American (4,104 per million) and American Indian/Alaska Native (3,841 per million) compared to 2,888 per million for White. While total cases by age group are currently highest among 20-29 years, total deaths by age group are highest among 80+ years. Research by Lichtenberg and Tarraf (2021) indicates that the COVID-19 pandemic has had a negative impact on Michiganders’ mental health, especially for people of color[1].
The State of Michigan utilized Executive Orders and MDHHS Orders (e.g., related to mask wearing and social distancing) to mitigate and contain the spread of COVID-19 and to prevent overwhelming the state’s healthcare systems. The Protect Michigan Commission was created by executive order in December 2020 to serve in an advisory capacity to the Governor and MDHHS and to provide leadership to elevate the COVID-19 vaccine. Throughout the pandemic, local health departments have been critical partners in education, mitigation, and vaccination efforts. Since the first COVID-19 vaccinations were administered in Michigan on December 14, 2020, vaccination has been the key strategy to prevent the spread of COVID-19. According to the COVID-19 Vaccination Dashboard, 6,174,354 residents have initiated vaccination (i.e., one or more doses of any vaccine) as of March 8, 2022, which is 65.5% of eligible residents (i.e., 5 years of age and older); 60.0% (5,655,530) have completed vaccination. Eleven counties have vaccination initiation rates of 70% or above. In January 2021, MDHHS launched a media campaign to inform Michiganders about the safe and effective COVID-19 vaccines and to address vaccine hesitancy. The campaign included a “My Why” series of TV and radio ads (see an example here). Significant effort took place in Summer 2021 to prepare for COVID-19 vaccinations for children, which were authorized in November 2021. To prepare for the anticipated long-term presence of COVID-19, in February 2022 MDHHS adopted a new Readiness (pre-surge) – Response (surge) – Recovery (post-surge) cycle. The cycle will allow the state to prepare and respond to surges in COVID-19 and adapt public health recommendations accordingly.
Activities to address COVID-19 and to support vaccination efforts among the MCH population include the following:
- Michigan’s public schools, teachers, and students continued to feel the burden of the pandemic in 2021. Efforts to bring resources to schools included establishing onsite COVID-19 testing; launching the School Backpack Program in high-risk communities to send home tests for families; and embedding Health Resource Advocates and School Liaisons to support testing, contact tracing, and other mitigation strategies.
- The Division of Maternal and Infant Health hired a Nurse Consultant in 2021 to focus on immunization efforts in the Maternal Infant Health Program (MIHP). The Consultant will work with a marketing firm to develop and launch a communication campaign to increase awareness of immunizations (tentative launch Summer 2022). A vaccine education toolkit is being developed for MIHP agencies that will include resources to communicate with families about vaccines during pregnancy and vaccines for infants. A required training module for MIHP agencies will focus on vaccine communication, using a motivational interviewing approach. A session in Summer 2022 will focus on state immunization rates, navigating vaccine hesitancy, and mitigating disparities in vaccination. Vaccine information is being integrated into newsletters, web-based vaccine resources for families and MIHP agencies, and programmatic expectations such as agency protocols for immunization assessments.
- To reduce COVID-19 vaccine disparity rates, the Division of Child & Adolescent Health, Division of Immunization, Detroit Public Schools Community District, and the Governor’s Office partnered to stand up vaccination clinics in all Detroit Public Schools. The project focused on schools without a school-based health center and utilized existing district School Nurses to administer vaccines during the school day. The intention is that holding clinics during the school day will remove barriers to access and will increase parents’ support of vaccination. Nurses also have a trusted relationship with parents and students that will be leveraged as vaccine hesitancy continues to be a challenge.
- Child and Adolescent Health Centers (CAHCs) provide school-based or school-linked comprehensive primary care and preventive health services and mental health services in an atmosphere friendly to children and adolescents ages 5-21. CAHCs are poised to help students and families keep vaccination status up to date and can provide any needed vaccines to youth. CAHCs directly supported influenza and COVID-19 vaccination efforts during the pandemic. At the end of 2020, CAHCs delivered 4,251 influenza vaccines through 322 special events. In FY 2021 these sites delivered 24,399 COVID-19 vaccines to youth and are continuing to deliver COVID-19 vaccines as a part of routine care in FY 2022.
- The CSHCS Vaccine Initiative addresses vaccination gaps in CYSHCN and their families. Funding is provided to LHDs to improve access to COVID-19 vaccines; expand vaccination education, messaging, and partnerships; and improve understanding of barriers to vaccination.
Components of the State’s Systems of Care
Health Services Infrastructure and Financing
Michigan’s health care infrastructure includes 176 hospitals, including 37 critical access hospitals that serve rural areas (Michigan Health & Hospital Association). The state has 80 birthing hospitals and 21 Neonatal Intensive Care Units. Michigan also has six children’s hospitals (Children’s Hospital Association). The health care system includes 39 Federally Qualified Health Centers (FQHCs) and three FQHC look-alikes with over 250 delivery sites (Michigan Primary Care Association); 122 school-based/school-linked health centers (MDHHS); 33 Family Planning agencies providing services at 92 clinic sites (MDHHS); and 195 rural health clinics (Michigan Center for Rural Health). The public health infrastructure to protect and promote community health is supported by 45 local health departments (LHDs) that serve all 83 counties and the City of Detroit. MDHHS works closely with LHDs to provide comprehensive public health services. This decentralized structure allows for local efforts to remain connected to the state for support, funding, and other resources.
After the implementation of Medicaid expansion in 2014, coverage expansions under the Affordable Care Act (ACA) provided Michigan consumers with two new options: Healthy Michigan Plan (HMP) and Health Insurance Marketplace (Marketplace). In January 2014, eligible individuals above 133% of the federal poverty level (FPL) could enroll in private health insurance coverage through the Marketplace. In April 2014, Michigan expanded HMP to cover residents who were at or below 133% of the FPL and who were not previously eligible for traditional Medicaid. According to the HMP website, the plan provides health care coverage to Michigan residents who:
- Are age 19-64 years.
- Have income at or below 133% of the FPL.
- Do not qualify for or are not enrolled in Medicare.
- Do not qualify for or are not enrolled in other Medicaid programs.
- Are not pregnant at the time of application.
As of January 24, 2022, 979,004 beneficiaries are enrolled in HMP (HMP County Enrollment Report) which is a significant increase from March 23, 2020 (674,853 beneficiaries). Under the Families First Coronavirus Response Act of 2020 the Medicaid program will keep Medicaid eligibility cases open until the end of the COVID-19 Public Health Emergency.
The benefit design of the Healthy Michigan Plan ensures beneficiary access to quality health care, encourages utilization of high-value services, and promotes adoption of healthy behaviors. HMP benefits include preventive/wellness services, chronic disease management, prenatal care, oral health, and family planning services. Most HMP beneficiaries are required to pay some level of cost-sharing via monthly contributions and co-pays based on income. Some populations are excluded from cost sharing, such as individuals enrolled in CSHCS, under 21 years of age, pregnant people, and those with no income. A Health Risk Assessment provides beneficiaries the opportunity to earn incentives for engaging with the health care system. HMP enrollees who complete a health risk assessment and agree to maintain or address healthy behaviors, as attested by their primary care provider, may be eligible for cost-sharing reductions.
The ACA also provided significant funds through HRSA to expand access to primary care by increasing the number of Community Health Centers in Michigan. The number of FQHCs grew as additional centers were funded and look-alike sites were approved. According to the Michigan Primary Care Association, Michigan’s Health Centers are health care homes to more than 615,000 Michiganders.
ACA consumer protections improved access to private insurance for CSHCN by eliminating preexisting condition exclusions and discrimination based on health status, the two most frequent enrollment barriers for families. The ACA also expanded access to parent employer coverage for adults 19-26 years of age. CSHCS/Healthy Michigan enrollment for December 2021 was 1,625 (MDHHS Health Services Data Warehouse, 3/8/2022). LHDs, Family Resource Centers and designated state staff work with families and community partners to help families understand and access private and publicly funded resources to meet needs.
CSHCN often require and use more health care services than other children. Specialty care and extensive, on-going, or long-term treatments and services may be required to maintain or improve health status. Financing these costs can pose significant challenges and burdens for families even with access to private insurance. Family health care costs can include deductibles, cost sharing and premium payments. Private insurance may not include any covered benefit for a specific, medically necessary service. In other cases, only a limited benefit may be available. Although ACA eliminated annual and lifetime dollar limits, other annual limits exist, and benefits may be exhausted for the current contract year even though needs continue. CSHCS helps to limit costs to families and continues to be a significant resource for achieving appropriate and equitable health and specialist care. Steady CSHCS enrollment following ACA’s implementation reflects the value of CSHCS to families even when private insurance is available.
Integration of Services
MDHHS recognizes the importance of integrating physical health and behavioral health services to improve health and address individual or family needs. The COVID-19 pandemic highlighted the critical nature of behavioral health services and gaps in current systems. In March 2022, MDHHS announced a behavioral health restructuring to ensure that services are supported across community-based, residential, and school locations. The restructuring is described in the Cross-Cutting/Systems Building state action plan. MDHHS initiatives to better address behavioral and mental health needs include the following:
- The Michigan Warmline is a statewide, anonymous warmline for any Michigander experiencing a mental health or substance use condition. The warmline is staffed by certified peer support specialists and recovery coaches and is available seven days a week from 10am-2am. In 2021, MDHHS piloted the Michigan Crisis and Access Line (MiCAL) in the Upper Peninsula and Oakland County. MiCAL is staffed 24/7 and provides crisis and warmline services, informational resources, and coordination with local systems of care such as Community Mental Health Services Programs and Prepaid Inpatient Health Plans. It is anticipated that MiCAL will be rolled out statewide over the next two years.
- The Expanding, Enhancing Emotional Health (E3) model helps to address the need for mental health services for children and youth. E3 is a designated model through the Child & Adolescent Health Center (CAHC) Program. E3 programs provide on-site comprehensive mental health services from mild to moderate severity of need by a full-time licensed Mental Health Professional. Services include assessments, brief intervention, ongoing therapy, referrals, and follow-up. E3 sites are open year-round and provide telehealth when school is not in session. Services are designed for children and adolescents 5-21 years of age when access to behavioral health resources are limited or inaccessible in the community. Currently, 93 E3 sites operate across Michigan in 43 counties. An RFP process in FY 2022 will enable further expansion.
- The CAHC Program (Michigan’s School-Based Health Centers) is utilizing $4.25 million in MI Kids Now funding to expand mental health services for youth throughout the state. These funds will allow for expansion of mental health staffing from 0.5 FTE to 1 FTE per CAHC site.
- In 2021, Michigan continued to roll out expanded coverage for nursing and mental health services for general education students through a CMS approved Medicaid waiver. The Caring 4 Students (C4S) expansion allows schools that provide mental health and nursing services to general education students to receive Medicaid reimbursement. All 56 Intermediate School Districts participate in C4S. In 2021, over 385,000 students were served.
- In August 2020, MDHHS was approved for a two-year CMS Certified Community Behavioral Health Clinic (CCBHC) Demonstration. CCBHC demonstration sites provide nine core behavioral health services, including formal care coordination with primary and other care providers, and must meet standards for service provision, staffing, quality and financial reporting, and governance.
- MDHHS was awarded the Promoting Integration of Primary and Behavioral Health Care (PIPBHC) Grant in FY 2019. PIPBHC is a five-year grant to promote integration and collaboration in clinical practice between primary and behavioral health care, and to support improvement of integrated care models for primary and behavioral health care to improve the overall wellness of adults with serious mental illness (SMI) or children with serious emotional disturbance (SED). Grantees promote integrated care for screening, diagnosis, prevention, and treatment of mental and substance use disorders and co-occurring physical health conditions and chronic diseases.
- The Michigan Child Collaborative Care (MC3) was expanded to all 83 Michigan counties (through HRSA funding) to increase access to mental health treatment for underserved children, adolescents and high-risk perinatal women. The expansion is significant given the shortages of specialty providers, especially in rural areas. MC3 provides psychiatry support to primary care providers who have patients with behavioral health concerns. Behavioral Health Consultants are linked with or embedded in pediatric primary care practices to assess and link children to appropriate mental health services. Patients are linked to evidence-based interventions if specialty services are not available. MC3 also provides behavioral health education for primary care providers, including cultural sensitivity. MC3 is administered collaboratively by MDHHS, the University of Michigan, and Michigan State University.
- MC3 for MOMs was launched in FY 2021 to engage and enroll Michigan’s perinatal providers and their patients in targeted areas. The initiative is intended to improve perinatal providers’ knowledge of and comfort with perinatal behavioral health screening and treatment (e.g., mood and anxiety disorders, substance/opioid use disorders). Universal psychiatric screening is important since up to 25% of perinatal women experience depression and anxiety. Behavioral Health Consultants are being trained in interventions to address behavioral health issues that impact the perinatal period. A perinatal resource and referral list will also be developed to help ensure that pregnant and postpartum people are referred to home visiting programs, have access to basic needs, and are enrolled in other relevant services.
- Michigan supports over 30 Children’s Multi-Disciplinary Specialty (CMDS) Clinics in seven tertiary care and teaching hospitals. The clinics offer a highly coordinated, interdisciplinary approach to the management of specified complex medical diagnoses, which include teams that consist of a specialist/pediatrician, nurse, social worker, and dietician. Families receive a comprehensive, patient-centered Plan of Care (POC). The POC includes an assessment and ongoing treatment plan which is monitored and updated. Patients also receive health education, transition, and referral services.
- CSHCS continues to work with Behavioral Health partners to identify challenges accessing services experienced by populations served by the mental/behavioral health, intellectual/developmental disabilities, and physical health systems. Work includes cross-sector education, tools to assist families, and addressing systemic access issues.
Title V and Medicaid
Michigan’s Title V and Title XIX programs are both housed within MDHHS and share the common goal to improve the overall health and well-being of the MCH population through implementation of affordable health care delivery systems, expanded coverage, and strategies to address social determinants of health and reduce health disparities. Areas of collaboration include maternal and infant care, perinatal care, child and adolescent health, developmental screening and referral, home visitation, oral health, and CSHCS. Key partnerships are discussed in the Title V–Title XIX section of this application.
In January 2022, 2,192,260 Medicaid beneficiaries were enrolled in the Medicaid Health Plans (MHPs) and 682,936 beneficiaries were enrolled in fee for service. Medicaid uses a population health management framework to build a Medicaid managed care delivery system that maximizes the health status of beneficiaries, improves beneficiary experience, and lowers cost. Medicaid contracts with nine Medicaid Health Plans (MHPs) to achieve these goals through evidence- and value-based care delivery models; health information technology; strategies to prevent chronic disease; and coordination of care that includes assessing social determinants of health such as transportation, housing, and food access. The Managed Care Plan Division (MCPD) requires MHPs to annually report the Healthcare Effectiveness Data and Information Set (HEDIS) and uses a Pay for Performance Incentive Program with access, process, and outcome metrics for all managed care populations, including women and children. Each MHP’s governing body must either have a minimum of 1/3 representation of Medicaid enrollees or the plan must establish a consumer advisory council that reports to the governing body. The council must include at least one Medicaid enrollee, one family member or legal guardian of an enrollee, and one consumer advocate. MHPs must actively recruit CSHCS beneficiary parents/guardians to participate in non-compensated governing bodies or consumer advisory councils.
To help achieve integrated care, MHPs are required to work with MDHHS to develop initiatives to better align services with Community Mental Health Services Programs/Prepaid Inpatient Health Plans (PIHPs) to support behavioral health integration. Medicaid incentivizes performance by MHPs and PIHPs on shared metrics and shared populations. The MHPs must also provide or arrange for the provision of community health worker (CHW) or peer-support specialist services to enrollees who have significant behavioral health issues and complex physical co-morbidities. CHWs serve as a key resource for services and information needed for enrollees to have healthier, more stable lives. CHW services include conducting home visits; participating in office visits; arranging for social services; and helping enrollees with self-management skills.
The DMIH and Michigan Medicaid jointly manage several programs for the Medicaid-eligible MCH population. One of the largest collaborations is the Maternal Infant Health Program (MIHP), Michigan’s largest population-based home visiting program available to all Medicaid-eligible pregnant people and infants up to age one. Effective January 1, 2017, MIHP services provided to beneficiaries enrolled in an MHP are administered by the MHPs. In FY 2021, MIHP provided services to 11,564 adults and 14,991 infants.
Another area of coordination is for CSHCN. In March 2022, CSHCS program data indicate that 26,553 CSHCS beneficiaries were dually enrolled in an MHP. MHPs are responsible for the medical care and treatment of CSHCS members while community-based services beyond medical care and treatment are provided through the LHD’s CSHCS office. MHPs are responsible for coordinating and collaborating with LHDs and the Children’s Multidisciplinary Specialty Clinics to make a range of essential health care and support services available to enrollees. MHPs are also responsible for the coordination and continuity of care for enrollees who require integration of medical, behavioral health and/or substance abuse services.
Information Systems
MI Bridges is another key component of the MDHHS service platform to better meet consumer needs through technology. MI Bridges is an online site managed by MDHHS that enables users to apply for benefits (including healthcare coverage, food and cash assistance, childcare, and state emergency relief) and to find resources such as transportation, food, and utilities assistance. MI Bridges users can review and access their benefits information; renew benefits; and share beneficiary information with a specialist. In the fall of 2020, new functionality was built in MI Bridges to include home visiting. Families in need of home visiting can receive a custom list of models that are available in their community and, if the parent chooses, they can self-refer to a specific model. This new feature launched in December 2020 and averages over 300 referrals each week.
MDHHS also uses multiple health information systems to support the care and services provided to the MCH population. The Michigan Care Improvement Registry (MCIR) allows for the identification of children who are not up to date on Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) well child visits according to the American Academy of Pediatrics Bright Futures Recommendations for Preventive Pediatric Health Care periodicity schedule. All MHPs have access to MCIR, and it is an approved data source for Medicaid Healthcare Effectiveness Data and Information Set (HEDIS) immunization and lead testing data. MIHP providers also have access to MCIR to facilitate referral and access to appropriate preventive services.
State Statutes Relevant to Title V (Effective September 29, 2021)
The Michigan Public Health Code, Public Act 368 of 1978, governs public health in Michigan. The law indicates that the state health department shall “continually and diligently endeavor to prevent disease, prolong life, and promote the public health through organized programs” (MCL 333.2221). Furthermore, it shall “promote an adequate and appropriate system of local health services throughout the state and shall endeavor to develop and establish arrangements and procedures for the effective coordination and integration of all public health services including effective cooperation between public and nonpublic entities to provide a unified system of statewide health care” (MCL 333.2224).
In FY 2022, state funding for MCH and CSHCS programs was appropriated through Public Act 87 Enrolled Senate Bill 82 Health and Human Services of 2021. CSHCS is mandated by the Michigan Public Health Code, Public Act 368 of 1978, in cooperation with the federal government under Title V of the Social Security Act and the annual MDHHS Appropriations Act. State general funds for MCH programs are itemized in Sec. 116, Family Health Services, of Public Act 87 of 2021, and CSHCS is addressed in Sec. 117. Additional MCH details are provided in Sec. 1301-1305, 1307-1317, 1320-1321, 1342, 1343, 1347, 1348. The sections identify how funding shall be used; MDHHS and contractor requirements; and requirements for evidence-based programs to reduce infant mortality; pregnancy and parenting support services; prenatal care education; rural home visiting; Healthy Start; fetal alcohol syndrome services; oral health initiatives; Michigan Model for Health™; and immunization policy and practices.
Requirements in the FY 2022 Health and Human Services budget for CSHCS included criteria in Sec. 1360 for MDHHS to provide services; Sec. 1361 authorizes that some appropriated funding be used to develop and expand telemedicine capabilities and to support chronic complex care management.
[1] Slootmaker, E. (2021). Michigan grapples with COVID-19's disproportionate impact on people of color's mental health. Second Wave Michigan.
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