Overview of the State

 

Title V in Louisiana serves as a foundational catalyst for high quality services and innovative approaches for protecting and promoting the health of women, children, and children and youth with special health care needs (CYSHCN) in the state. Led by the Louisiana Department of Health (LDH), Office of Public Health (OPH), Bureau of Family Health (BFH), Title V provides support for a sustained focus on MCH and CYSHCN populations in Louisiana. Anchored in the Essential Public Health Services, BFH provides:

 

●       Data to monitor health and well-being, guide programs, and inform public policy;

●       Policy and educational initiatives to improve access to and quality of medical, behavioral health and supportive services, and to improve community health;

●       Preventive and supportive services that are grounded in best practices and evidence to promote optimal health and well-being; and

●       Partnerships with families, communities, providers, government, and academia to advance common goals.

 

In past years, many changes in Louisiana have affected the health and well-being of women, children, and families in the state. Title V in Louisiana has continued to evolve, with a growing capacity to monitor population health and inform healthcare policy and practice. Readiness to inform the work of other systems is critical in this ever-changing environment. Described below are the most significant changes occurring in recent years in the healthcare system and in the state overall.

 

Understanding the Health Status and Needs of the MCH Population in Louisiana

 

The Place: Louisiana is the 31st largest state in the country, covering an area of 43,204 square miles along the Gulf of Mexico (Map 1). Louisiana consists of flat lowlands located on the coastal plain of the Gulf of Mexico and the Mississippi River’s alluvial plain. The economy is heavily dependent on its fertile soils and water to support farming and fishing industries. Louisiana also is one of the leading producers of natural gas and petroleum.

 

Of Louisiana’s 64 parishes (counties), 30 are considered rural per HRSA’s Office of Rural Health Policy.1 The largest urban centers include New Orleans and Baton Rouge. Hurricanes, oil spills, and vanishing wetlands–both natural and unnatural disasters–have threatened Louisiana’s well-being. Over the past 11 years, Louisiana residents have been impacted by hurricanes Katrina and Rita in August 2005, the British Petroleum oil spill in April 2010, severe flooding in August of 2016, tornados and flooding due to Hurricane Harvey in 2017, and persistent coastal erosion in the Louisiana wetlands. These disasters have significantly affected residents’ livelihood and have required robust emergency preparedness and response from state and local agencies.

 

The People: Louisiana’s population of about 4.6 million features a distinct multicultural and linguistic landscape. Today, the majority of the population in Louisiana identifies as White (62.4%), Black (32.2%), 5.0% identify as Hispanic/Latino, 1.7% Asian (majority Vietnamese), 1.9% two or more races, and 0.6% American Indian/Alaskan Native, with four federally recognized American Indian tribes and several state/local tribes.2,3

 

 

Challenges and Strengths:

There are many challenges and strengths present in Louisiana’s systems, politics, and communities that affect the health and wellbeing of the state’s maternal and child population. The Louisiana Title V Program identifies these challenges and strengths through the lens of the social determinants of health (SDOH): the conditions in which people are born, live, learn, work, and play. Specifically, social and community context, economic stability, education, neighborhood environments, and health and healthcare all pose various challenges and opportunities for health (see Figure 1).

 

 

Challenges:  Louisiana’s history of colonization, slavery, and legalized racism disempowered and oppressed portions of Louisiana’s population over multiple centuries. While conditions have vastly improved, as with the rest of the United States, these historical foundations still take a significant toll on communities in the state and are perpetuated, often unknowingly, through bias in institutions and systems. Throughout this discussion, persistent disparities by race are noted. These disparities should be interpreted in light of the conditions in which people are born and live--conditions largely affected by historical and institutional structures that create and sustain concentrated areas of disadvantage, particularly for communities of color.

 

 

Economic instability poses a major challenge to the attainment of health for Louisianans. In 2017, about one in five residents lived at or below the FPL, with 27.7% of all children (under age 18) living in poverty. The average household in Louisiana earned approximately $14,000 less than the national household income, and Black households made significantly less annually ($28,743) than White households in Louisiana ($57,109), according the American Community Survey 2017 5-year estimates.2 CYSHCN in Louisiana are also more likely to live in lower poverty levels than the rest of the nation (Table 2). Side effects of poverty, such as food insecurity are more common in CYSHCN and can further complicate their health. For parents and caregivers with CYSHCN, full-time employment takes time away from coordinating care for their children. Parents of CYSHCN are six times more likely to report cutting back hours or quitting their jobs than parents of non-CYSHCN.4 Additionally, out-of-pocket medical expenses for this population, even with insurance, are more extensive. Because of the lack of supports for these families, some caregivers may opt to make less money in order to qualify for public support systems.

 

 

In addition to economic instability, low educational attainment is a challenge. Adults in the state are less likely to finish high school than their peers across the US, and 28% of students with disabilities drop out of high school, which is higher than the national average of 19% (Table 3). A report from the Louisiana Department of Education showed that public schools suspended 60,000 students in the 2015-2016 school year, and students of color and students with disabilities were more commonly suspended.5

 

 

Due to the challenges stated above, Louisianans have consistently poorer health outcomes compared to the rest of the nation. According to America’s Health Rankings 2018, Louisiana ranked 50th in the nation in overall health.6 For the maternal and child populations, low birth weight (LBW), preterm birth (PTB), infant mortality, maternal mortality, and CYSHCN status are significant challenges.

 

In 2016, Louisiana had the fourth highest infant mortality rate in the US: 503 babies born to Louisiana resident mothers died before their first birthday, an average of about 10 babies per week. Similar to nationwide data, Black infants in Louisiana die at twice the rate of White infants. Sudden Unexpected Infant Death (SUID) cases represent 19.6% of all infant deaths in the state, though many SUIDs are determined to be accidental suffocation and strangulation in bed (ASSB) upon further investigation.7

 

According to Louisiana’s latest Maternal Mortality Report, maternal mortality in Louisiana is increasing at a rate exceeding that of the United States. Within Louisiana, disparities by race are significant: black mothers are 4.1 times as likely to die as white mothers.8 Compared to the national average, Louisiana has a higher proportion of CYSHCN. Approximately 23% of children in Louisiana have special health care needs, and among CYSHCN, 69.5% have two or more health conditions.4

 

In recent years, opioid use and abuse has become a pressing issue. The rate of drug related deaths has increased in Louisiana from 13 per 100,000 deaths in 2014 to 18.9 per 100,000 deaths in 2018, according to America’s Health Rankings.6 Neonatal abstinence syndrome is also a growing concern, which will be further discussed in the State Action Plan section on Women’s/Maternal Health.

 

 

Strengths: While the challenges facing Louisiana are daunting, there are notable strengths and opportunities to improve health. According to the US Census Bureau, Louisiana is unique in that nearly four out of every five residents were born in-state.2 This stability lends itself to strong social supports. Additionally, systems changes for health insurance, criminal justice reform, and early education have already begun to show promising impacts for Louisianans.

 

Prior to Medicaid Expansion, Louisiana had one of the highest uninsured rates in the nation. In July of 2016, Medicaid was expanded to all adults under 138% of the FPL (children were not part of this expansion population because children in that income range are already eligible for public insurance coverage). With that change in health policy, Louisiana experienced one of the largest reductions in the uninsured rate for any state.9 With the expansion of Medicaid, more than 457,000 adult men and women have gained health care coverage under public insurance.10 With the inclusion of the expansion population, Medicaid is now responsible for approximately 1.5 million child and adult participants in Louisiana.11

 

To help cover uninsured children, the state offers Medicaid and the Louisiana Children’s Health Insurance Program (LaCHIP), which have been expanded over time to offer coverage to more children in lower income families, a group that historically face the highest uninsured rates. Louisiana has achieved and sustained high rates of coverage for children. Between 2009 and 2017, the percentage of uninsured children decreased from 7% to 3%.12 More than half of CYSHCN in Louisiana have public insurance which is higher than the national average, and a lower percentage of CYSHCN in Louisiana have no insurance as compared to the national average.4

 

 

Furthermore, Medicaid expansion has had a profound positive impact on Louisiana’s economy, as Medicaid is primarily responsible for funding safety-net hospitals and nursing homes. As a direct result of Medicaid expansion, more than 19,000 new jobs have been created and $178 million in new state and local revenues have been generated.13 Louisiana is expected to save $1 billion over the next decade due to Medicaid expansion.14

 

Louisiana's early care and education system has also undergone significant change to better serve the state's youngest learners. Child care licensing was unified with other early education programs under the Louisiana Department of Education in 2015 in an effort to create a cohesive early childhood system and improve school readiness. This system has continued to stabilize and mature, though access to childcare subsidies remains more limited than a decade ago.15

 

While Louisiana faces the heavy burden of incarceration (incarcerating almost twice the national average of people per 100,000), under Governor Edwards, the state has begun efforts to reform the criminal justice system. Since the reforms were passed in 2017, there has been a reported decrease in nonviolent prisoners (20%), first-time felony prisoners (18.2%), and drug-related incarcerations (47%).16

 

Systems of Care for Vulnerable and Underserved Populations

Financing and Integration of Services: In 2012, Louisiana Medicaid began transitioning from a fee-for-service system to Healthy Louisiana, a network of five managed care organizations (MCOs) to cover Medicaid services for children and adults. As of 2015, the state's MCOs are now responsible for both physical health and behavioral health benefits. Operating under the guidance of a contract spanning 2015-2018, the current MCOs offering full-risk plans through Healthy Louisiana include Aetna, Amerigroup, AmeriHealth, Louisiana Healthcare Connections, and United Healthcare.

Mandatory MCO populations include the majority of Medicaid eligible population groups including children under 19 years of age, individuals and families receiving TANF, CHAMP-Child Program, Deemed Eligible Child Program, foster care children, youth aging out of foster care, former foster care children through the age of 26, Regular Medically Needy Program, LaCHIP Program, Blind/Disabled Children, eligible parents and caregiver relatives, pregnant women, LaMOMs, breast and cervical cancer program, aged, blind and disabled adults, Supplemental Security Income (SSI) Program, individuals diagnosed with tuberculosis and the new adults expansion population. Although there are populations excluded from managed care such as dual-eligible (those who receive both Medicare and Medicaid), waiver recipients, and individuals in long-term care, individuals receiving services through the 1915(c) Home and Community Based Waivers, such as Children’s Choice, are considered voluntary opt-in populations for MCO services and benefits. Furthermore, some dual-eligible are mandatorily enrolled in the MCOs for Specialized Behavioral Health Services, and non-emergency medical transportation.

The MCOs are required to cover all state plan services including the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) at or above the Medicaid published rate, unless the provider/MCO contract allows a different reimbursement rate. These plans also have flexibility to provide other services that will help meet their members' needs, incentivize additional network coverage, or provide cost savings to support care coordination at the provider level. Plans are required to report on certain quality measures, with plans offering incentives to both providers and members. Examples of various incentives for members include gift cards for preventative care such as wellness checks, STI screenings and prenatal and postnatal care. Extra benefits offered include dental care and hearing aids for adults, tobacco cessation and weight management.

 

In February 2019, the state Medicaid program released an RFP to re-bid MCO contracts. Four new MCO contracts will be awarded, and the contracts are expected to begin late July 2019. The new MCO contracts are rooted in the “Triple Aim” vision to build a Medicaid managed care delivery system that improves the health of populations (better health), enhances the experience of care for individuals (better care), and effectively manages Medicaid per capita care costs (lower costs). Guided by this vision, there is additional emphasis on value based purchasing contracts, with the aim of improving population health, patient centered medical homes and the quality of provider performance.

Health Services Infrastructure: Access to essential health services is a challenge, even in some of the more populous areas of the state. The US Health Resources and Services Administration (HRSA) as of December 2018, recognizes 141 primary care shortage areas and 129 mental health shortage areas in Louisiana.17 Despite these shortages, Healthy Louisiana MCOs are required to ensure network adequacy based on CMS guidelines and assist their members with making arrangements, including transportation upon request. As a result, telemedicine is a growing service line in Louisiana, especially in rural areas and as a solution to the behavioral health provider shortages. In addition, there is growing attention on provider consultation as a complement to other efforts to enhance the capacity of existing providers to appropriately identify and support individuals with behavioral health needs. BFH is exploring multiple ways to address these shortage areas, which are discussed throughout the State Action Plan narratives.

 

The network of existing healthcare resources in Louisiana consists of a variety of public and private entities and differs in rural versus urban areas. There are currently 260 different Federally Qualified Health Centers (FQHCs) in Louisiana, owned by 36 community health center organizations. In addition, Louisiana has 154 Rural Health Clinics which are dedicated to improving the health status of residents living in rural and underserved areas.

 

Changes in OPH Services: Louisiana's statewide network of OPH Parish Health Units (PHUs) once served as Louisiana’s main provider of primary care for low-income women, children and families. Over the past 15+years, however, care has been transitioned to private providers (such as FQHC’s) as Medicaid became more widely accepted. PHUs now primarily provide essential public health services, with a focus on high-quality family planning and STD services, WIC, CYSHCN safety-net specialty services and care coordination, and tuberculosis testing and treatment. While not currently supported by Title V, OPH is currently piloting a Community Health Worker model to support individuals who have needs identified through a screening based on a CMS SDOH tool. Funded in part through Title V federal and state allocations, 64 of the 70 PHUs provide reproductive health services, with programmatic oversight provided by the BFH Reproductive Health Program (RHP). PHUs in LDH Regions 2-9 (see Figure 2 below) provide a total of 20 specialty clinics for CYSHCN. After all CSHS clinics in Region 1 closed in 2010, CSHS established a Family Resource Center (FRC) at Children’s Hospital New Orleans (CHNOLA). FRC offers resource information to families of CYSHCN visiting outpatient clinics at CHNOLA and serves as a successful model for similar centers throughout the state.

 

 

 

 

 

 

 

 

 

Figure 2. Louisiana Department of Health Administrative Regions

 

As reflected in the Title V state action plan, OPH clinics are integral to Louisiana's approach in addressing the NPMs. In addition, since much care is now accessed in community settings, BFH is also engaging with the larger system of healthcare providers and insurers to improve access to and quality of care.

 

State Health Agency Priorities and Influence on Title V Service Delivery

There are several significant priorities within LDH, OPH, and OPH BFH that affect Title V programming:

●       Medicaid MCO contracts: In February 2019, the state Medicaid program released an RFP to re-bid MCO contracts. The redevelopment of the contracts represented a time-sensitive opportunity to advocate for changes to strengthen the system of care for children and families, and Title V staff actively contributed feedback and recommendations throughout the RFP development process. LDH received six proposals and plans to award contracts by September 2019. BFH is currently reviewing the RFP to identify new requirements and opportunities.

●       OPH PHU clinical “footprint”:  OPH is continuing to reassess its role as service provider and what services are considered essential for the agency to provide. The OPH PHUs are currently the largest statewide network for reproductive health services and, while much reduced from a decade ago, the PHUs continue to provide some clinical services for CYSHCN with particular conditions. The Title V program is contributing to this agency priority by evaluating the availability and capacity of community providers.  Any plan to transition services to community providers will likely need to include provider level capacity building and policy level changes to ensure meaningful network adequacy.

●       Maternal mortality: Both nationally and at the state level, addressing worsening maternal health outcomes is a priority. During the 2018 Regular Legislative Session in Louisiana, the Healthy Moms, Healthy Babies Advisory Council (Act 497) was established to review causes of and solutions to maternal mortality and morbidity, particularly focusing on the disparities by race with a community and equity lens. The Louisiana Title V Program is tasked with coordinating this council.

●       Prematurity: Reducing the incidence of premature birth in Louisiana continues to be a major goal for LDH, especially in Medicaid. The Title V program participates in Medicaid’s performance improvement project on prematurity reduction. This includes continuous quality improvement to reduce preterm birth via interventions such as birth spacing, progesterone prophylaxis, case management and policy changes. In addition, the Title V program partners with the state chapter of the March of Dimes on their various efforts to reduce prematurity.

●       Opioid strategies: It is likely that there will continue to be funding opportunities related to prevention and treatment of substance use disorders, and continued attention on the prevention and management of neonatal abstinence syndrome. To date, the Title V program has been participating in agency wide calls around surveillance and other agency response efforts. However, it is anticipated that there will be growing attention and a need for coordination of efforts across the agency.

Louisiana State Statutes and Regulations

Louisiana Revised Statutes

LA Rev Stat 40:1071-5 - (CSHS Enabling legislation): Designates OPH to cooperate with Title V of the Social Security Act; receive and expend federal funds for services to extend and improve services for children with special health care needs.

LA Rev Stat §40:31.3 - (ASHP Enabling legislation): The Office of Public Health, Department of Health and Hospitals [currently Louisiana Department of Health], shall establish an adolescent school health initiative.

 

LA Rev Stat 40:2018 (Perinatal Commission Enabling Legislation) - Establishes the Commission on Perinatal Care and Prevention of Infant Mortality. 

 

LA Rev Stat 40:2019 - (Child Death Review Enabling Legislation) - Establishes a child death review panel, protocols, criteria for reporting and investigations for the unexpected deaths of children below the age of fifteen and the ability to suggest recommendations within the agencies presented on the state panel.

 

LA Rev Stat 40:1081.1-7 (Newborn Screening and Sickle Cell Programs Enabling Legislation) - Authorizes LDH to screen for and establish programs designed to reduce mortality and morbidity from sickle cell disease and other genetic conditions.

 

LA Rev Stat 40:1285.1-.5 (Lead Screening Program Enabling Legislation) - Establishes a program for the prevention, screening, diagnosis, and treatment of lead poisoning in the Office of Public Health; Mandatory reporting of lead poisoning cases required; comprehensive records

 

LA Rev Stat 46:2263-4 (Newborn Hearing Screening Enabling Legislation) - Establishes within OPH a program to provide for the early identification and follow-up of infants susceptible to a hearing disability, of deaf or hard of hearing infants, and of infants who have a risk factor for developing progressive hearing loss; establishes an advisory council.

 

LA Rev. Stat. 46.2351-2356 (Louisiana Commission for the Deaf Enabling Legislation) -  Establishes the Louisiana Commission for the Deaf within the Louisiana Department of Health; defined duties; permits LDH hiring of executive officer of the commission; permits receipt of money from any source

 

LA Rev. Stat. 40; 31.41-48 - (LBDMN Enabling Legislation): Establishes a system to collect, analyze, and disseminate data regarding birth defects and to provide information to families regarding services available and prevention programs.

 

LA Rev Stat 46:447.1 (Reproductive Health Program Enabling Legislation)- Establishment of a family planning program to provide family planning education and contraceptives for public assistance recipients.

 

LA Rev Stat 46:973 - Allows the Office of Public Health to provide a special program of preventive, health, and medical care and health education services for adolescents that concentrates on adolescent pregnancy and pregnancy prevention.

 

LA Rev Stat 46:974 - Asks that OPH maintain a statewide toll free number to advise pregnant women on available resources

 

LA Rev Stat 40:1061.17 - Pertains to Abortion Alternatives/Woman’s Right To Know

 

LA Rev Stat 13:5713 - Instructs the coroner to report SIDS to the Director of the Parish Health Unit within 48 hours.

 

LA Rev Stat 40:1086.1-4 - Defines Shaken Baby Syndrome and Sudden Unexpected Infant Death Prevention a major public health priorities for the state and authorizes LDH to conduct public awareness activities.

 

LA Rev Stat 17:407.40 - Assigns OPH to provide information and resources to the state Department of Education for such training and for other areas of training required for employees of early learning centers in promoting the health, safety, and welfare of children.

 

LA Rev Stat 17:407.23 - Louisiana Early Childhood Education Act (Act 3, 2012) - Establishes the Early Childhood Care and Education Network; Board of Ed must coordinate with the DCFS and LDH to align the standards for the licensing of child care facilities, including the requirements for participation in the Louisiana Quality Start Child Care Rating System, with the standards established for early childhood education programs.

 

LA Rev Stat 40:1075.4 - Emergency Medical Services for Children Program (1995) -

Establishes an Emergency Medical Services for Children Program and shall include a full-time coordinator, education programs for EMS personnel, guidelines for referring, guidelines, inter-hospital transfer system for critically ill or injured children and pediatric rehabilitation units. 

 

The Healthy Moms, Healthy Babies Act (Act 497, 2018) -

Creates within the Louisiana Department of Health the Healthy Moms, Healthy Babies Advisory Council for the purpose of working with existing state entities to address racial and ethnic disparities in maternal health outcomes and incorporate a community-engaged, equity-focused lens on maternal death and morbidity.

 

Language Equality and Acquisition for Deaf Kids (LEAD K) Task Force (Act 455, 2018) -

Establishes the Language Equality and Acquisition for Deaf Kids (LEAD-K) Task
to develop a resource for parents to monitor and track deaf or hard of hearing children's language acquisition and developmental stages and to develop a framework for assessing children who are deaf or hard of hearing for the purpose of ensuring they have the opportunity to achieve kindergarten readiness in an equitable manner.

 

Early Childhood Care and Education Commission (Act 693) -

Establishes the Early Childhood Care and Education Commission charged with establishing pilot programs in high-performing community early childhood care and education networks that will further efforts to improve kindergarten readiness.

 

Louisiana Administrative Code (Regulations):
LAC Title 48, Public Health-General, Book 2 of 2; Part V; Subpart 17. Children’s Special Health Services Chapters 49 - 59

 

LAC Title 48, Public Health-General, Book 2 of 2; Part V; Subpart 55. Birth Defects Surveillance System Chapter 161-163

 

LAC Title 48, Public Health-General, Book 2 of 2; Part V; Subpart 19. Genetic Diseases Services Chapter 63 Neonatal Screening; 6303.

 

LAC Title 48, Public Health-General, Book 2 of 2; Part V; Subpart 18. Disability Prevention Program Chapter 70. Lead Poisoning Prevention Program; 7001-7009

 

LAC Title 48, Public Health-General, Book 2 of 2; Part I; Subpart 13. Family Planning Chapter 35-37
 

LAC Title 51, Sanitary Code, Part XXI Day Care Centers and Residential Facilities, Chapter 3, Child Day Care Centers, #9
 

DOE Child Care Development Fund Bulletin 137 – Early Learning Site Licensing Regulations requires three hours of training by a child health care consultant on infectious diseases, health, safety, and/or food service preparation.

 

Louisiana Children’s Code:
LA Chil Code 609. Mandatory and permitted reporting