II. A. Overview of the State

The Indiana State Department of Health (ISDH) is the second smallest of ten state agencies with approximately 900 employees and serves the population in a wide variety of ways including health promotion programming, public health preparedness, data collection and dissemination, food protection services, health facility licensing, and many other infrastructure building programs. The agency supports Indiana's economic prosperity by promoting, protecting and providing for the health of Hoosiers in their communities. To achieve this mission, ISDH has adopted principles that guide policy development and programs. These principles mandate that ISDH and its Commissions are to:

• Focus on data-driven policy to determine appropriate evidence-based programs and initiatives.
• Evaluate activities to ensure measurable results.
• Engage partners and include appropriate intra-agency programs in policy-making and programming.
• View essential partners to include local health departments, physicians, hospitals and other health care providers, other state agencies and officials, as well as local and federal agencies and officials, community leaders, businesses, health insurance companies, Medicaid, health and economic interest groups, and other groups outside the traditional public health model.
• Actively facilitate the integration of public health and health care activities to improve   Hoosiers' health.

In 2020, ISDH adopted a new mission and vision as listed below:

• Mission: To promote, protect, and improve the health and safety of all Hoosiers.
• Vision: Every Hoosier reaches their optimal health regardless of where they live, learn, work or play.

Lastly, ISDH also provides services that are guided by these Core Values:

• Health Equity: We place equity at the center of our work to ensure every Hoosier, regardless of individual characters historically linked to discrimination or exclusion, has access to social and physical supports needed to promote health from birth throughout end of life.
• Communication: We provide stakeholders and the public accurate and up-to-date scientific data and provide education and resources regarding utilization of evidence-informed practices in at timely manner.
• Innovation: We continue to learn, research evidence-informed practices, advance our services, and be open to new methods, ideas, and products that help build and expand upon the services we provide. 
• Integrity: We are honest, trustworthy, and transparent. We uphold our standards and do the right thing to achieve the best public health and safety outcomes.

The Maternal and Child Health (MCH) and Children’s Special Health Care Services (CSHCS) divisions both fall under the umbrella of the Health and Human Services (HHS) Commission at the Indiana State Department of Health. This Commission includes multiple divisions including: Fatality Review and Prevention; Trauma and Injury Prevention; the Division of Nutrition and Physical Activity; the Office of Chronic Disease, Rural Health and Chronic Disease; and the Office of Women’s Health. All these teams regularly collaborate to further our mission and vision for the state of Indiana.

MCH and CSHCS are responsible for the administration, coordination and surveillance efforts of Title V and other grants, consisting of programs that focus on promoting the health and well-being of mothers, children and adolescents, including children and youth with special health care needs, throughout the state of Indiana. MCH and CSHCS teams collaborate with internal and external partners, and stakeholders to determine the importance, magnitude, and value of competing factors that impact health services offered throughout the state while ensuring all Title V grants are effectively allocated and maintained in a manner that continually achieves the values and priorities outlined in the five year strategic plan.

In its efforts to make Indiana the healthiest state in the country, ISDH recognizes that key factors such as disease prevention, ensuring access to health care, and promoting personal responsibility of individual Hoosiers for their own health must be an integral part of the state's initiatives. ISDH works to collaborate effectively with its many partners in policy-making and program development. ISDH strives to develop an environment of respect--for those who serve Hoosiers in the public health field and the public it serves--by honoring diversity, equality of opportunity, cultural differences, and ethical behavior. ISDH values feedback and input from community members and works to engage local stakeholders. The State's Priority Health Initiatives include activities that support data driven efforts for both health conditions and health system initiatives. The state is emphasizing the integration of evidenced based health care policies and outcomes focused programming while continuing to highlight preparedness and effective responses to threats that cannot be prevented.

The MCH Epidemiology (Epi) team provides regular presentation updates to all ISDH staff regarding MCH Outcomes and Performance Measures along with Natality, Mortality and other reports, some of which can be found at http://www.in.gov/isdh/23506.htm. In addition, the Epi team is available to analyze ad hoc reports for ISDH staff as needed, which ensures the most recent and meaningful data is available to assist in program development and decision making.

The MCH and CSHCS teams work closely with the finance teams to review budget and expenditure reports quarterly to ensure all available resources are allocated and utilized in a manner consistent with MCH priorities and needs. The Program teams meet regularly with external stakeholders in order to understand the priorities, needs projects, and initiatives relevant to the MCH population domains. 

Health Status and Health Needs of Hoosiers

Demographics

The State of Indiana is located in the Great Lakes Region of the United States and the residents of Indiana are known as Hoosiers. Indiana is ranked 38th in land area, and is the smallest state in the continental U.S. west of the Appalachian Mountains. Indianapolis is the capitol of Indiana and ranks as the 3rd largest city in the Midwest.  According to the U.S. Census Bureau (2019), Indiana had a population of over 6.7 million, with the Indianapolis Metropolitan Area (defined as Marion County and its surrounding counties) as among the fastest growing metropolitan areas in the US, with the largest growth centering in the counties surrounding Marion County.  Approximately 23.4% of the population was under the age of 18, 6.3% under the age of 5, and 15.8% was over the age of 65. The population is 50.7% female and 49.3% male.

Indiana has limited cultural diversity outside of its metropolitan areas with over two-thirds of its counties reporting White/non-Hispanic populations of more than 85%. Indiana's overall Hispanic population is 7.1%, the White/non-Hispanic population is 85.1%, and the Black/non-Hispanic population is 9.8%. This contrasts highly with Indiana's largest county, Marion County, which has an African-American population of 28.9%, a Hispanic population of 10.6 % and a White/non-Hispanic population of 64.0%.  

Indiana's economy is considered to be one of the most business-friendly in the United States. This is due in part to its conservative business climate and low business taxes. Indiana is located within the U.S. corn and grain belts. The state has a feedlot-style system raising corn to fatten hogs and cattle. Along with corn, soybeans are also a major cash crop. Indiana's proximity to large urban centers, like Chicago and Indianapolis, supports dairying, egg production, and specialty horticulture. Other crops include melons, tomatoes, grapes, mint, popping corn, and tobacco in the southern counties.


Poverty

In 2019, approximately 13.1% of Indiana residents were living in poverty, with 978,043 Hoosiers below the poverty threshold, including 340,200 persons under the age of 18... In 2015, there were 1,655,043 Hoosier families living in poverty and 270,000 families with a female head of household were living in poverty. Additionally, there were 6,790 Hoosier families receiving Temporary Assistance for Needy Families (TANF), and 656,297 individuals received Food Stamps. According the Indiana Family and Social Services Administration, 414,983 school-aged children received free lunch, while 80,347 school-aged children received reduced-fee lunch in 2017. 


Low-income children are less likely to be covered by healthcare and thus are more likely to lack primary care and other necessary medical services. Because of these disparities, providing services to children from low-income households is of paramount concern for our nation and has led to national coverage programs for children. Healthcare-financing sources for low-income and disabled children include Medicaid and SCHIP funding and are administered in Indiana through Hoosier Healthwise, which includes a risk-based managed care (RBMC) program, Medicaid for aged, blind, disabled, and other special populations, and fee-for-service Medicaid programs. At the Governor's direction, Indiana is working diligently to improve the economic status of Hoosier children and their families.


Racial/Ethnic Disparity

Minority, racial, and ethnic populations in Indiana make up more than 20% of the population. Like the rest of the United States, Indiana is growing more culturally, racially, and ethnically diverse. This will continue to increase over the coming years, will enrich Indiana as a state, and help to expand its global perspective. However, while there are many positive outcomes due to this growth, there are also problems, such as inadequate health care delivery. The National Institutes of Health (NIH) states that "Health disparities are differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the US." Racial and ethnic minorities are facing a disproportionately greater burden of disease, injury, premature death, and disability.

Indiana's MCH and CSHCN programs are aware of racial and ethnic health disparities in Indiana and are working to impact the many contributing factors that influence an individual's health. These factors include, but are not limited to, the environment, cultural practices, poverty, trauma and toxic stress associated with past experiences, insurance status, and unemployment. Additionally, racial, and ethnic minorities also experience barriers to health including, access to care, access to culturally competent care, continual sources of health care coverage and limited access to health education.

Reducing health disparities among racial and ethnic groups in Indiana requires the cooperation of legislators, governments (both local and state), providers of health care, and the community. Improved data collection, better access to care, essential preventative care and community involvement are also necessary to improve current health status and conditions of all racial and ethnic minority groups.
 

In Indiana, the black non-Hispanic population has consistently more severe health outcomes than the white non-Hispanic population. The 2018 infant mortality rate for black non-Hispanic (13.0 per 1,000 live births) is over two times that of the white non-Hispanic population (6.0 per 1,000 live births). The 2018 percentage of low birth weight infants for non-Hispanic black infants (13.5 %) is nearly double that of the non-Hispanic white infants (7 %). The percentage of mothers receiving early and adequate prenatal care decreased to 68.1% in 2018. While all continue to remain below the national goal of 77.9%, the discrepancy is considerably more evident among black women (54.2 %) than white women (72.8 %). The percent of non-Hispanic black mothers in 2018 who are breastfeeding at hospital discharge (71.9 %) is well below that of the non-Hispanic white mothers (83.1 %). This information has helped to guide the development of the newly revised State Performance Measures and will be used to determine the judicious allocation of scarce Title V resources.

By systematically reviewing data, we intend to address disparities through the implementation of programs specific to the needs of the population. MCH will also work to promote internal policies and procedures that are anti-racist.  To achieve this, MCH is integrating strategies and objectives in its strategic plan and state action plan that will ensure new and existing initiatives are measured using objective anti-racism tools.   Additionally, Indiana is very excited to begin receiving the Pregnancy Risk Assessment Monitoring System (PRAMS) results in the Fall of 2020 The results, stratified by race, will assist us to understand maternal attitudes, behaviors, and expectations immediately before, during and in the months after delivery.  With a close alignment of quality data and program planning, addressing disparities will be a constant focus. Indiana’s newly linked birth and death records for infant loss will allow MCH epidemiologists and program team to paint a clearer picture of babies’ birth and death.

Geography

In Indiana, 70% of the population lives in a metropolitan area, while 30% reside in a rural area. According to the Indiana Rural Health Association, rural communities have higher rates of chronic illness and disability and poorer overall health status than urban communities. Rural residents also tend to be older and poorer than urban residents. Eighteen percent of rural residents are over 65 compared to 15% of urban residents and more rural residents live below the poverty level compared to urban residents. Chronic conditions such as heart disease and diabetes are more prevalent in rural areas. Injury-related deaths are 40% higher in rural communities than in urban communities. Cancer rates are higher in rural areas. People living in rural areas are less likely to use preventive screening services, exercise regularly, or wear safety belts. These disparities among rural and urban Hoosiers may be due to a number of factors, including:

Transportation--Many individuals lack access to medical care and treatment because appropriate transportation is too expensive, limited by weather factors, not available in a specific geographic area, or because the patient is too sick to use the options that are available.


Lack of Providers— Indiana is still facing a severe shortage of providers. As of today, 67 Indiana counties have a Medically Underserved Area or Population Designation. Sixty-four counties have primary care designations. Eighty-three counties have mental health designations and 54 counties have dental health designations. We also have 27 Federally Qualified Health Centers, 8 Federally Qualified Health Center Look a Likes, and 8 Rural Health Clinic that are Auto-HPSA designations (only for facilities). 

Lack of Services-- Several counties in Indiana, such as Pike and Crawford counties in southwest Indiana, do not have a hospital, and a number of areas in Indiana have limited or no trauma services. As of March 2018, only 67% of the land area and 89% of the total population are within a 45-minute drive to a trauma center. In south central Indiana, several counties lack hospitals and, as such, require extensive travel to Indianapolis or Evansville for elevated trauma care services.

Limited Services--Rural residents are more likely to report that their provider does not have office hours at night or on weekends.


Insurance-- In comparison to other states, the health insured status of Hoosiers is below average.  In 2019, 9.7% of Indiana adults, aged 18 to 64, lacked health insurance. Additionally, 7.5% of Indiana children under the age of 18 lacked health insurance coverage.

Urbanization

Within Indiana, metropolitan areas experienced population gains, while other areas experienced population declines. The fastest growth was in the Indianapolis metropolitan area. Urbanization can have negative impacts disproportionately suffered by the poor and minorities (Urban Institute and Kaiser Commission on Medicaid and the Uninsured). Urbanization is associated with changes in diet and exercise that increase the prevalence of obesity with increased risks of Type II diabetes and cardiovascular disease; vulnerability to sexual abuse and exploitation; and separation from social support networks. Many of these conditions affect the most vulnerable segment of the population - women, children, and the elderly.

Environmental contaminants, although not restricted to urban settings, can alter the reproductive process, and increase the risk of miscarriage, birth defects, fetal growth, and perinatal death. Particularly in cities, motor vehicles are a primary source of air pollution and studies in Indiana are associating pesticides in water with poor birth outcomes. Children are especially susceptible to disease in an urban environment. Not only can they suffer from overcrowding, poor hygiene, excessive noise, and a lack of space for recreation and study, they also suffer from stress and violence that such environments create.

Private Sector Title V Service Delivery Challenges

The three private sector challenges in providing Title V services are (1) lack of providers who accept Medicaid reimbursement, (2) lack of cultural competency, and (3) location of services.


Medicaid Providers -- Indiana has a risk-based managed care system for all MCH populations on Medicaid. Providers in some counties have refused to participate in Medicaid reimbursement for pregnancy and infant care until the infants are on the Children’s Health Insurance Program (CHIP). These counties tend to have poorer pregnancy outcomes. Over the past few years, a serious challenge has been not only the number of physicians who do not accept Medicaid reimbursement, but also a flawed Medicaid enrollment system.  This has left many eligible women and infants without insurance coverage throughout the pregnancy and the baby’s critical first few months of age.

In an effort to overcome enrollment challenges for pregnant women, Indiana Medicaid began Presumptive Eligibility (PE) on July 1, 2009. Even so, there are areas of the state where providers are less likely to accept Medicaid reimbursement. Per Indiana Medicaid’s directory website (http://www.indianamedicaid.com/ihcp/ProviderServices/ProviderSearch.aspx), 9 of Indiana’s 92 counties are without a single provider participating in Presumptive Eligibility. Furthermore, although the remaining 83 counties have PE qualified providers, MCH has found that by comparing the MOMS Helpline extensive database records and speaking with individual callers, certain providers that are listed as accepting PE actually do not and some no longer have OB/GYN departments. The ISDH is partnering with providers across the state to clarify the intent of PE is to bridge the gap until Medicaid is in place and that they will be paid for services rendered.

Lack of Cultural Competency

Lack of cultural competency has played a role in driving black-to-white perinatal disparities higher. To address these disparities, MCH is utilizing a life course perspective to impact change. For Indiana to make a difference in disparities, ISDH and MCH must address needs at the neighborhood and community levels to ensure medically accurate and culturally competent health education and resources are widely available, not only to minority populations, but also to ensure healthcare and other service providers are well-equipped to meet the unique and diverse needs of the children and families they serve.

In addition to the disparities that exist between the white and black populations, Indiana also has other minority groups of concern, such as the growing Hispanic, Burmese, and Amish populations. An increasing Hispanic population is facing barriers to care from lack of insurance, scarcity of interpreters, and educational materials and forms that are not often translated into Spanish. Hispanic centers around the state do not have the capacity to assist all Hispanic families in need. Outside of Burma, Indiana has the largest Burmese population in the world. While there are services in place to help this population, they may not yet be adequate to ensure the Burmese have consistent access to culturally appropriate healthcare services.

ISDH and the MCH division have also made a commitment to becoming a leader in addressing health disparities and outcomes. ISDH has instituted health equity policies and is focusing on determining the root causes of these disparities. To help with this, a team from MCH and Office of Minority Health (OMH) divisions attended a 2.5 day workshop through Crossroads Anti-racism Training and Organizing Institute, titled “Understanding and Analyzing Systemic Racism” in April 2019. From this training, root causes of the systemic power imbalance that leads to the health disparities across Indiana were discussed in a common language and understanding. ISDH provided this training to 45 employees in November 2019 and will host an additional three in 2020. The agency aims to deepen this work and has created a Health Equity Policy. The inaugural Health Equity Council is currently creating a strategic plan as well - including policy and hiring procedure changes, strategies around grant language re-training, and continued anti-racism training opportunities including for grantees and external partners.

In 2018, the Indiana State Department of Health (ISDH) adopted a formal, agency-wide health equity policy, this policy was later revised in July 2020. The policy statement is below:

Eliminating Health Disparities: According to Healthy People 2020, “There are many dimensions of disparities that exist in the United States, particularly in health. A health disparity is a health difference that is closely linked with social, economic, or environmental disadvantage.” It is incumbent upon ISDH to assess health issues facing the community, identify health disparities, and support and enable meaningful access to essential health services for all Hoosiers in a manner that: is culturally and linguistically appropriate; advances health equity; supports continuous quality improvement; eliminates health disparities; and addresses incidents of high morbidity and mortality, to include that among underserved and overlooked populations.

Addressing Health Inequities and Anti-racism: Health inequities are systemic differences in the health status of different population groups. These inequities often have considerable social and economic costs both to individuals and societies. We will continually engage in the active process to identify, address, and dismantle the structures, policies, and norms that perpetuate race-based and other advantages so that optimal health outcomes are achieved for all.

Health in All Policies: Health in All Policies is a collaborative approach to improving the health of all people by incorporating health considerations into decision-making across sectors and policy areas. The goal of Health in All Policies is to ensure that all decision-makers are informed about the health, equity, and sustainability consequences of various policy options during the policy development process. For example, Health in All Policies builds on successful inter-sectoral collaboration, such as efforts to implement water fluoridation, reduce lead exposure, restrict tobacco use in workplaces and public spaces, improve sanitation and drinking water quality, reduce domestic violence and drunk driving, and require the use of seatbelts and child car seats. Ultimately the Health in All Policies approach seeks to institutionalize considerations of health, equity, and sustainability as a standard part of decision-making processes across a broad array of sectors.

Examining Social Determinants of Health:  Social determinants of health are conditions in the environment in which people are born, live, learn, work, play, worship and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Healthy People 2020 has developed a “place–based” organizing framework, reflecting five (5) key areas of social determinants of health: economic stability; education; social and community context; health and health care; and neighborhood and built environment. Objectives and resources are identified for each of the five (5) areas. The goal is to enhance quality of life and influence population health outcomes. ISDH will better serve Hoosiers by identifying and exploring the impact of social determinants of health and take a Health in All Policies approach to address key drivers of health outcomes and health inequities.

Location of Services

All Indiana county health departments are autonomous. This has led to stark differences among local health department offerings, and therefore a lack of consistent accessible services for all Title V populations. The majority of Indiana's primary care physicians are located within 5 counties and 16 counties are without a hospital. As of 2019, 33 of the 92 Indiana counties do not have a hospital with delivery services or obstetric providers. The only two specialty children's hospitals are located in Marion County (Indianapolis). Families in many parts of the state must travel long distances to receive specialty care during pregnancy and for their children. MCH will address systems of care and collaboration among hospitals so that facilities providing various levels of perinatal services can be more evenly distributed over the next five years.

 

Current and Emerging Issues

In March of 2020, Indiana confirmed its first diagnosis of the novel Coronavirus. MCH and its colleagues pivoted quickly to ensure there were no gaps in services for women and children. As the number of cases grew, MCH worked closely with ISDH’s Office of Public Affairs to author and disseminate guidance pertaining to topics such as: breastfeeding, labor and delivery, home visiting, vision and hearing screening in schools, and others. MCH and ISDH also worked closely with the Indiana Hospital Association to co-host weekly web-calls with hospital staff and executives in order to ensure clinicians across the state heard the most-up-to-date information and were able to ask questions and connect in real-time.

Programmatically, MCH has worked with subgrantees to ensure they have the needed resources to continue to deliver services to the women and families they serve. Many subgrantees are seeing participants virtually through telehealth and have implemented programmatic changes to meet those needs.  For example, home visitors see their clients over the phone or video call when available and appropriate. Maternal tobacco cessation programs are reviewing results over the phone and mailing incentives to participants.

Many personnel in both the CSHCN and MCH division were deployed and continue to serve in the COVID response including Shirley Payne, CSHCN director, Kate Schedel, Title V Programs director, and Sarah Briley, Maternal Health administrator. Along with these leaders, frontline staff across the divisions and the agency were diverted from daily duties.

As in many program areas, COVID-19 has exposed MCH’s lack of telehealth infrastructure. Some rural parts of the state lack broadband internet, and many families lack the resources to access telehealth. For providers, anecdotally, MCH has heard that it has increased the time it takes to see a patient, however they are seeing positive patient engagement. MCH and CSHCN will work to create guidance for providers and families around using telehealth.