Maternal and Child Health Services Title V Block Grant – Overview

 

Public health in Ohio has undergone many changes since 1886 when the State Board of Health was established to help coordinate the fight against tuberculosis. In 1917, the Ohio Department of Health (ODH) was created by the Ohio General Assembly to control the spread of all infectious diseases.

 

Today, ODH is a cabinet-level agency, its Director reports to the Governor and serves as a member of the Executive Branch of Ohio’s government.  The Administration’s health and human services (HHS) cabinet agencies are tasked with goals to improve services to vulnerable Ohioans, reduce cost and increase efficiency.  

 

The ODH executive team helps the Director of Health formulate the agency’s strategic policy goals and objectives. The team is composed of Deputy Directors, Medical Director and the General Counsel.  These leaders, along with agency senior-level managers and supervisors, work in tandem to ensure the state health department is responsive to the needs of Ohio’s 11.5 million residents.

 

ODH’s mission is to protect and improve the health of all Ohioans by preventing disease, promoting good health and assuring access to quality care.  ODH fulfills its mission through collaborative relationships, including with Ohio’s 113 local health departments. ODH’s strategic agenda is informed by a State Health Assessment, and a State Health Improvement Plan to address key health issues identified in the assessment. Key health issues identified include infant mortality, prevention of infectious disease, and Ohioans’ access to primary care. ODH became an accredited health department by the Public Health Accreditation Board (PHAB) in 2015.

In 2015-2016, ODH developed a strategic plan that outlines the strategic issues, goals and objectives to move the agency forward and position it for continued success in the new healthcare environment. These strategic issues included aligning ODH’s work with the state health improvement plan, state health initiatives and priorities; ensuring effective decision-making processes to support the agency’s goals; developing the workforce to support ODH’s public health priorities; and ensuring that ODH’s data infrastructure supports data-driven decisions.

The state health assessment (SHA), released in August 2016, described the current status of health and well-being in Ohio and highlighted the state’s many opportunities to improve health outcomes, reduce disparities and control healthcare spending. The 2017-2019 state health improvement plan (SHIP) seizes upon those opportunities by laying out specific steps to achieve measurable improvements on key priorities including, maternal and child health, behavioral health and chronic disease.  Developed with input from many state and local-level stakeholders, the SHIP serves as a strategic menu of priorities, objectives and evidence-based strategies to be implemented by: State agencies; local health departments, hospitals and other community partners engaged in community health improvement planning; and sectors beyond health, including education, housing, employers/business, regional planning/transportation and criminal justice.  Ohio is currently in the process of updating the State Health Assessment and State Health Improvement Plan, which will be released in Fall of 2019.  The Title V Needs Assessment and Maternal, Infant and Early Childhood Needs Assessment update processes are intentionally aligning with new SHA and SHIP.

The Title V Maternal and Child Health Block Grant provides vital funding and infrastructure to the ODH by supporting the overall goals and strategies of public health and is an asset to improving maternal and child health outcomes.  The Bureau of Maternal, Child and Family Health (BMCFH) administers and houses the majority Title V MCH Block Grant programs and now includes Women, Infants and Children (WIC) and Children with Medical Handicaps (CMH).  The Interim Title V Director and Director of Children with Special Health Care Needs now reside within the BMCFH. 

The BMCFH is an organized effort to eliminate health disparities, improve birth outcomes and improve the health status of women, infants, children, youth and families in Ohio. Using evidenced-based and data driven practices, we support the delivery of direct services, linkages and referrals, population-based supports, education, monitoring and quality oversight, and policy and systems development. 

Ohio’s BMCFH priority needs include:

• Increase the prevalence of women receiving preconception care
• Reduce the rate of infant mortality and disparities statewide
• Increase comprehensive newborn screenings and improve Ohio’s newborn screening system
• Increase access to early infant care and wellness
• Increase the prevalence of children and youth receiving integrated physical, mental, and developmental services
• Reduce the rate of childhood obesity
• Reduce tobacco use rates
• Reduce the rate of maternal smoking and substance abuse by pregnant women
• Reduce barriers improve access, and increase the availability of health services for all populations

The Children with Medical Handicaps (CMH) program serving Children with Special Health Care Needs (CSHCN), including: a Diagnostic, Treatment, and Hospital Based Service Coordination Program, supporting Team Based Service Coordination for conditions such as Spina Bifida and Hemophilia; Community Based Service Coordination, supporting Public Health Nurses in the Local Health Departments who assist families in linking to local resources and helping families navigate the health care system. CMH utilizes vital committee/council structures to foster open dialogue, receive input and feedback regarding CSHCN needs across the state.  

To address the complex needs of the population, agency priorities and goals of Title V, ODH uses a life course framework to improve health outcomes across the lifespan. The life course perspective recognizes the linkages between early life experiences and later experiences in adulthood and looks at health as an integrated continuum:

• Today’s experiences and exposures determine tomorrow’s health.
• Health outcomes are affected during critical or sensitive periods in our lives.
• Social determinates of health, including biological, behavioral, psychological, social, and environmental factors contribute to health outcomes.
• Populations within Ohio face significant barriers to achieving the best health possible these groups include Ohio’s poorest residents, persons with disabilities and racial and ethnic minority groups.

Ohio Demographic Information

 

In 2018, the population of Ohio was estimated at 11,689,442, a net increase of approximately 155,792 since 2010.  It is the seventh most populous state in the United States.  The capital of Ohio is Columbus which is Ohio’s most populous city with a population of 879,170 (2018) and the fifteen largest city in the United States.  It is located in Franklin County in Central Ohio. The most densely populated area of the state is the northeast corner which encompasses Cleveland, Akron, Youngstown, and Canton.  The least densely populated area of the state is the Appalachian region which follows the line of the Appalachian Mountains from Lake Erie to the Ohio River.

Population Distribution

According to U.S. Census Bureau, females 15-44 years comprise 37.1 percent of Ohio’s population.  Children and young adults through age 24 years accounted for 31.6 percent of the population.

The foreign-born (anyone who was not a U.S. citizen at birth) share of Ohio’s population rose from 3.0 percent in 2000, to 4.5 percent in 2017.  According to the American Immigration Council, 4.5 percent of Ohioans were native-born with at least one immigrant parent. The largest proportion of foreign-born residents come from Asia (42.7%) followed by Europe (20.2%), Latin America (20.1%), and Africa (13.4%).  One in six Ohioans working in the sciences is an immigrant.

Seventy-nine percent of foreign-born residents speak a language other than English. Of those, 35.0% speak English less than ‘very well’.  The most common languages spoken in Ohio other than English is Spanish.

Fourteen percent of Ohio’s population is Black or African American.  Hispanic or Latino (of any race) makes up about 4 percent of the population.  The percentage of the population that is Black is slightly larger than the US percentage.  However, the percentage Asian and Hispanic is substantially are lower than in the US population. Please refer to Table 2 for a breakdown of Ohio’s population by race.

Table 2: Ohio and US Population by Ethnicity and Selected Races, 2017

Race	Ohio (count)	Ohio (%)	US (%)
White	9,791,347	84.0	72.3
Black or African American	1,661,333	14.2	12.7
Asian	324,372	2.8	5.6
Two or more races	340,980	2.9	3.3
Ethnicity
Hispanic or Latino (all races)	436,762	3.7	18.1
Non-Hispanic or Latino	11,221,847	96.3	81.9

 

Birth Rates

Ohio’s crude birth rate has decreased in the past ten years from 12.9 to 11.7 per 1,000 persons in 2017.  (Figure 1). Hispanic births declined 18.8% from 2008 to 2017 (from 20.8 to 16.9 per 1,000), but remains higher than both non-Hispanic whites and non-Hispanic blacks.

 

 

Ohio’s teen birth rate (ages 15-19 years) has shown a steady decline (Figure 3). Teen births among Hispanics and non-Hispanic blacks are comparable and showed a similar decline in the past 10 years.

 

Ohio’s Disability Population

Each year, Cornell University publishes a disability status report to inform policy makers and the public on demographic and economic statistics on those with disabilities.  Information is summarized from the US Census Bureau’s American Community Survey. The 2017 report states that 14.1% of Ohioans have a disability. Percentages of disability type are presented in the chart.

 

Disability Type	Percent of Population
Visual	2.3
Hearing	3.8
Ambulatory	7.5
Cognitive	5.9
Self-Care	2.7
Independent Living	6.2
Any Disability	14.1

 

Children ages 4 years and under have a 0.7% prevalence rate of visual and/or hearing disability. The overall rate of disability for children ages 5 to 15 was 6.7 percent and 7.1 percent for older adolescents and young adults 16 to 20 years of age.  Cognitive disability was the highest prevalence among those 5 to 20 years of age.

Ohio’s Social and Economic Indicators

Hospitals

Ohio has six children’s hospitals serving children from all eighty-eight counties, all fifty states and many international countries.  According to Ohio’s Children’s Hospital Association, Ohio ranks 47th in the nation in costs per member per month for pediatric Medicaid expenditures and Ohio’s spending is 20% below the national average for Covered Families and Children population.  Ohio’s Children’s Hospitals created the first ever and largest repository of asthma patient information.  Additionally, their efforts to reduce infant mortality include:

• Working to predict, treat and prevent narcotic-dependent infants, which saved $13 million in costs for hospital stays with new protocols for treatment
• Preventing prematurity through the Ohio Perinatal Quality Collaborative
• Preventing child abuse through research on sentinel injuries
• Promoting safe sleep with the Ohio Chapter, American Academy of Pediatrics
• Researching new diagnosis and treatment protocols for pediatric pneumonia, the leading cause of death in children under age 5

Education

Approximately, 10% of Ohioans aged 25 and older have less than a high school diploma, 33.3% have only a high school diploma.  Please refer to Figure 4 for a breakdown of educational attainment in Ohio.

The percentage of women with a bachelor’s degree or higher (28.3%) is comparable to the percentage of men with a bachelor’s degree or higher (27.6%). However, there is a gender gap when we look at black women (18.2%) compared to black men (15.1%).

When examining educational attainment by race and ethnicity, Asian adults were more likely to have a bachelor’s degree or higher (62.0%) when compared with white, non-Hispanic (29.0%), Hispanic (18.5%) and black (16.8%) adults. 

The poverty rate for persons who have less than a high school diploma is 27.3% compared with 3.8% with a bachelor’s degree or higher.

According to the Ohio Department of Education, in school year 2017-2018 14.7% of students enrolled in public schools (K-12) had a disability.  Almost half (47.0%) of the students were economically disadvantaged.

Economic Overview

According to the Ohio Development Services Agency, Ohio’s Gross Domestic Product (GDP) for 2017 is initially estimated at $649.1 billion, up almost 4.0 percent from 2016, and growing for eight consecutive years.  Ohio is one of the nation’s leading sources for primary and fabricated metal products, as well as plastic, rubber and non-metallic mineral products, machinery, electrical equipment and appliances, and transportation equipment – especially motor vehicles and the associated parts, trailers, bodies and accessories.  Ohio has recently become a leading source for oil and natural gas – 5th ranked with 4.3 percent of national output; it also is a notable provider of related petroleum and coal products and pipeline services.

The median household income in Ohio is $54,021, a 3.22% growth from 2016.  Despite the growth, Ohio’s median annual income is still less than that of the United States which is $60,336.

The Ohio Department of Job and Family Services reported Ohio’s unemployment rate as 4.7 percent compared to 4.1 percent for the United States as of early 2019. The 88 counties ranged from a low of 2.9 percent in Mercer County to a high of 10.4 percent in Monroe County. Four the five counties with the highest rates (over 8.1) are considered Appalachian.

Poverty

Ohio’s Poverty Report published by the Ohio Development Services Agency states that 14 percent of Ohioans live in poverty, slightly higher than the national rate of 13.4 percent.  The latest American Community Survey data show 47 of Ohio’s 88 counties had poverty rates below the national average of 14.6 percent; 41 were above the average. Of the people living in Appalachian Ohio, a band of 32 counties stretching across the eastern and southern regions of the state, 17.2 percent were poor.

Regarding families and children and poverty, families with children had poverty rates ranging from 5.7 percent among married couples to 39.7 percent for those headed by a female single-parent; the corresponding poverty rates for families without children ranged from 2.9 percent to 10.4 percent.  Children ages 0 to 11 years and young adults ages 18 to 24 years had poverty rates exceeding 20 percent; other working-age adults had poverty rates between 10 and 15 percent.

Public Assistance

According to the Ohio Department of Job and Family Services (ODJFS), about 1.5 million persons received benefits from Supplemental Nutritional Assistance Program (SNAP) during state fiscal year (SFY) 2018.  The average monthly benefit per person was $122.  The total expenditure was approximately $2.0 billion a 9% decrease from 2017. 

ODJFS also administers Ohio Works First (OWF) which is the financial assistance portion of Ohio’s Temporary Assistance to Needy Families (TANF) program.  OWF provided benefits to 99,510 individuals in SFY 2018.  OWF and the food assistance program have work requirements.  Many of the adult recipients were provided employment training programs.

Nearly 100 farmers markets throughout the state accepted the Ohio Direction Card in SFY 2018, making it easier for families to obtain fresh fruits and vegetables.  ODJFS sent notices to nearly 150,000 families living near farmers markets regarding acceptance of the Ohio Direction Card.

In January 2014, Ohio extended coverage to adults making less than 138 percent of the federal poverty level. According to the Ohio Medicaid Assessment Survey, Patterns and Trends in Health Insurance in Ohio, between 2008 and 2017, the percentage of working adults in Ohio with employer sponsored insurance dropped from 62.6% to 52.4%, with the largest decrease occurring between 2008 and 2010. This drop coincided with the recession in the United States.  The percentage of adults on Medicaid increased from 8.9% to 22.0% between 2008 and 2017, by which time 1,539,400 had Medicaid. The greatest increase was seen between 2012 and 2015 and coincided with Medicaid expansion in Ohio. The uninsured rate also dropped over time, from 17.5% in 2008 to 9.3% in 2017. In 2017, an estimated 648,000 adults were uninsured in Ohio. https://grc.osu.edu/sites/default/files/inline-files/Insurance_2017OMAS.pdf

In December 2018, the total enrollment for Medicaid and CHIP was 2,651,092 a 24% increase since the first Marketplace Enrollment Period and related changes from 2013. www.medicaid.gov

According to a report developed by Georgetown University Health Policy Institute and the American Academy of Pediatrics, the following percentages of children depend on Medicaid and Healthy Start (CHIP) for health care (http://ccf.georgetown.edu/2017/04/19/snapshot-source-2/) :

• 81% of Children living in or near poverty
• 44% of infants, toddlers, and pre-schoolers
• 47% of children with disabilities or other special health care needs
• 100% of children in foster care
• 52% of newborns

 

Managed Care

Ohio was an early adopter of managed care for its Medicaid program, with a voluntary program that began in the 1970s and a mandatory program initiated in the 1990s. The current managed care program was implemented in 2005, phasing in various mandatory and voluntary populations over time. As of 2018, the state’s Medicaid managed care model provides all acute, primary, specialty, and mental health and substance abuse services in the State Plan through five Managed Care Plans (MCPs). The five current MCPs include both local and national health plans and represent both the for-profit and non-profit sectors. Managed care has transformed Ohio’s Medicaid program from a payer of claims to a purchaser of value. MCPs have increased population wellness and outcomes for priority populations by working with providers to identify and close gaps in recommended care and improve overall quality.

Managed care’s focus on quality have identified “high-impact” populations to use a pay for value system while targeting specific metrics and outcomes.  The MCPs must meet targets to receive incentive payments.  The five populations include:

• Women, particularly those who are pregnant
• Individuals with chronic conditions such as cardiovascular disease and diabetes
• Individuals with primary behavioral health conditions
• Healthy children
• Healthy adults

MCPs design and implement strategies to improve performance in alignment with the ODM Quality Strategy. For example, MCPs identify the highest need and highest cost members and provide them with high-touch, person-centered care coordination to ensure timely access to appropriate, integrated care. The plans address Social Determinants of Health, such as nutrition, employment, and housing needs, recognizing the significant impact of these needs on health outcomes. MCPs also work with providers to ensure delivery of evidence-based care and to integrate physical and behavioral healthcare.  These improvement strategies are improving outcomes for the Title V population. https://oahp.org/wp-content/uploads/2019/02/OAHP-Value-Report-02252019.pdf

New Governor and Proposed Budget 2020-2021

Ohio’s newly elected Governor, Mike DeWine, has long history of public service and emphasis on protecting children and families.  Prior to serving as Governor, he was the Attorney General of Ohio and has previously been elected to serve as Greene County Prosecutor, Ohio State Senator, U.S. Congressman, Ohio Lt. Governor, U.S. Senator.

The proposed 2020-2021 budget has significant investments in children and families:

• Investing new, targeted funding to support student wellness and success in schools.
• Investing $22 million to make more of Ohio’s homes lead-safe for children and families.
• Investing an additional $50 million in evidence-based home visiting programs to give children the best possible start in life.
• Nearly doubling the state’s investment in children services agencies.

Funding for Ohio’s Help Me Grow home visiting program, through the Ohio Department of Health, is more than doubled in the proposed budget, from $20 million per year to more than $40 million in 2020 and to nearly $50 million in 2021. The Governor also created an advisory council on home visitation which proposed recommendations, many of which are reflected in programming supported by the increased funding.  Also included in the proposed budget is a plan to increase Ohio’s legal age to buy products containing nicotine from 18 to 21.  Medicaid expansion continues to be supported in the 2020-2021 budget which will enable hundreds of thousands of Ohioans to have continued access to health coverage.

Emerging Issues and Efforts to Improve Population Health Outcomes

Continuing the fight against Opiate Abuse - Ohio continues to be at the center of the opioid epidemic.  Newly elected Governor DeWine released “Recovery Ohio Plan” to guide future law enforcement, community outreach and education efforts to combat the crisis.  The Plan has goals that focus on legislation to declare a public health emergency, creating a data sharing infrastructure for law enforcement, double substance abuse treatment capacity, expand the addiction workforce, implement a media prevention campaign, and expand early intervention programs for families and children in foster care.

The Ohio Perinatal Quality Collaborative is working in collaboration with the Ohio Department of Mental Health and Addiction Services (OHMAS), the Ohio Department of Medicaid (ODM), and the Ohio Department of Health (ODH) efforts to optimize the maternity medical home and improve outcomes for pregnant women with OUD and their infants.  Building upon the Maternal Opiate Medical Supports (MOMS) program, the MOMS Plus program aims to support maternity care providers in the care of pregnant women with OUD, working closely with those who provide medication assisted treatment (MAT) and behavioral health (BH) therapy in addition to various support organizations.

Targeted Resources to Reduce Infant Mortality - ODH released an Infant Mortality Report in late 2018, reporting the number of Ohio infants who died before their first birthday declined to 982 in 2017 from 1,024 in 2016. It was only the second time since the state began keeping records in 1939 that Ohio had fewer than 1,000 infant deaths in a year, with the first time occurring in 2014. At the same time, the disparity in birth outcomes continued in 2017, with black infants dying at three times the rate as white infants. Nine Ohio counties and metropolitan areas accounted for close to two-thirds of all infant deaths, and 90 percent of black infant deaths, in Ohio in 2017: Butler Co., Cleveland/Cuyahoga Co., Columbus/Franklin Co., Cincinnati/Hamilton Co., Toledo/Lucas Co., Youngstown/Mahoning Co., Dayton/Montgomery Co., Canton/Stark Co., and Akron/Summit Co. Four counties saw fewer black infant deaths in 2017 – Butler, Franklin, Stark and Summit. 

In all nine communities, local groups are pursuing evidence-based strategies and promising practices to reduce infant mortality and address racial disparities in birth outcomes supported by state and federal funding. A new strategy that began in October 2018 involves the use of “neighborhood navigators” to identify pregnant women in their community who may be at risk for a poor birth outcome and connect them with needed healthcare, social and other services in order to have a healthy pregnancy and deliver a healthy baby. The following initiatives are continuing in addition to the navigators: Centering Pregnancy, smoking cessation, safe sleep, breastfeeding, family planning/LARC, progesterone, fatherhood, peer advocates, health education curriculum, evidenced-based home visiting, Pathways Community HUB, and community engagement.

Mental Health and Suicide Among Youth - Suicide deaths for Ohio’s children and young adults have increased dramatically from 2007 to 2017. Suicide deaths have increased more than two-fold for ages 8 to 17 (35 deaths to 80 deaths) and by nearly 1.5 times for ages 18-25 (155 to 225 deaths) from 2007 to 2017. The youngest suicide victim from 2007 to 2017 was age 8. In 2017, suicide was the second leading cause of death for Ohio children age 1-17, surpassing homicides and cancer (ODH Vital Statistics).  Ohio’s schools are increasing efforts to improve mental health and wellness in adolescents by focusing on whole child initiatives such as engagement, safety, access to care, and school climate.

*Except where otherwise indicated, the data for this summary was obtained from the 2017 American Community Survey 5-year estimates available at www.census.gov.

Key State MCH Statutes

• In March 2019, Governor Mike DeWine released recommendations from the Governor’s Advisory Committee on Home Visitation about how to increase the state’s investment in proven home visitation programs and announced a new pilot program to expand home visiting programs.  The advisory committee created 20 recommendations aimed at tripling the number of families served through evidence-based home visiting.  The recommendations include:
  • Make race and ethnicity foundational elements of the state’s infant mortality efforts.
  • Expand and streamline eligibility requirements so more at-risk families can be served.
  • Create a central point of intake for all home visiting programs.
  • Create a central data warehouse for all home visiting programs.
  • Promote collaboration among healthcare payers, children’s hospitals, birthing hospitals, and other community-based providers.
  • Leverage the Medicaid program to reimburse for eligible services in a more cost-effective manner.
  • Align the Department of Medicaid infant mortality reduction funds to complement the Help Me Grow program.
  • Increase the frequency of the Ohio Department of Health incentive payments.

To implement these recommendations, Governor DeWine proposed an additional $50 million over the biennium into evidence-based home visiting programs, bringing the total state funding for home visiting to $90 million over two years.

 

• The Ohio Department of Medicaid requires supported enhanced care management for women in high-risk neighborhoods and engages leaders in those neighborhoods to connect women to care (ORC 5167.17);  maintained current Medicaid eligibility levels for pregnant women (ORC 5163.06); covered additional services in home visitation for pregnant women and newborns, including cognitive behavioral therapy and depression screenings (ORC 5167.16); required the Health Director to identify and report on performance of programs to reduce infant mortality (ORC 3701.95); improved the administration of Progesterone for at-risk mothers (ORC 289.20); required additional disease screenings for newborns (ORC 3701.501); provided funding for evidence-based tobacco cessation programs for pregnant women in areas with high infant mortality rates (ORC 289.20, 289.33, 3794.07);  and conducted safe infant and child fatality reviews (ORC 121.22, 2151.421, 3701.70).

 

• Senate Bill 332 (SB 332) was passed in 2017 based on recommendations of the Infant Mortality Commission and public testimony. Key initiatives include requirements for state agencies to publish timely data; provide training; ban the sale of crib bumper guards; requires the creation of a comprehensive tobacco plan; increases access to long-acting, reversible contraception (LARC); and created a Home Visiting Consortium and task force to examine the impacts of the social determinants of health on infant mortality.   Effective July 1, 2018 new rules for implementing evidenced-based home visiting, the new data collection system and reporting went into effect. The Central Coordination system functions as a coordinated, community-based single point of entry with access to local services that promote family-centered programs for expectant parents, newborns, infants, toddlers, including those with disabilities and their families in collaboration and cooperation with other state and local agencies. Activities conducted through the Early Childhood Central Intake shall specifically provide centralized intake and referral services for all home visiting programs operating in the state of Ohio, including early childhood focused Community Health Worker Initiatives, as well as Part C Early Intervention services facilitated by the Department of Developmental Disabilities. This new model is in its second year and is being successfully implemented in partnership with Bright Beginnings based in Northeast, Ohio.

 

• ORC 3701.67 established an infant safe sleep screening procedure for hospitals and birthing centers. Hospitals are required to screen new parents and caregivers prior to the infants discharge home to determine if the infant has a safe sleep environment at their residence. If the infant is determined not to have a safe sleep environment, the hospital may do any of the four following activities: obtain a safe crib with its own resources; collaborate with or obtain assistance from persons or government entities that are able to procure a safe crib or provide money to purchase a safe crib; refer the parent, guardian, or other person to a person or government entity described above to obtain a safe crib free of charge from that source.