II. A. Overview of the State

The Indiana State Department of Health (ISDH) is the second smallest of 10 state agencies with fewer than 800 employees, serving the population in a wide variety of ways, including providing environmental public health, food protection services, health facility licensing, public health preparedness, health promotion programs, statistical information, direct health services, and many other infrastructure building programs.

The Mission of the ISDH supports Indiana's economic prosperity and quality of life 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:
 

• 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.

ISDH’s Mission, Vision, and Strategic Priorities as listed below:

• Mission: To promote, protect, and improve the health and safety of all Hoosiers
• Vision: A healthier and safer Indiana
• ISDH Core Values:

• Integrity—We are honest, trustworthy, and transparent. We will do the right things to achieve the best public health outcomes.
  Innovation— We encourage innovation to continuously enhance our programs and services, engage our workforce, advance our mission, and keep pace with community needs, and to communicate and utilize scientific data and evidence-based practices to achieve optimal health.
  Collaboration—We will achieve optimal health for all Hoosiers when we work side by side with partners, communities, and individuals.
  Excellence—We will work every day to provide the best public health services to the citizens of Indiana through continuous quality improvement.
  Dedication—We are committed to solving public health issues by focusing on what we can do, not what we can’t.

Since 2014, reducing infant mortality has been a top priority of the agency with other top priorities including addressing the opioid epidemic, reducing adult obesity and reducing adult smoking.

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 Maternal Child Health (MCH) and Children’s Special Health Care Services (CSHCS) divisions reside within the Health and Human Services Commission of ISDH.  Both divisions 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.

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 (2018), Indiana had a population of over 6.6 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 23.8% of the population was under the age of 18, 6.3% under the age of 5, and 15.4% 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%, the White/non-Hispanic population is 85.4%, and the Black/non-Hispanic population is 9.7%. This contrasts highly with Indiana's largest county, Marion County, which has an African-American population of 28.6%, a Hispanic population of 10.5 % and a White/non-Hispanic population of 64.6%. 

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 2018, approximately 13.5% 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 2017 infant mortality rate for black non-Hispanic (15.3 per 1,000 live births) is about two and a half times that of the white non-Hispanic population (5.9 per 1,000 live births). The 2017 percentage of low birth weight infants for non-Hispanic black infants (13.5 %) is nearly double that of the non-Hispanic white infants (7.5 %). The percentage of mothers receiving early and adequate prenatal care decreased to 68.6% in 2017. While all continue to remain below the national goal of 77.9%, the discrepancy is considerably more evident among black women (55.2 %) than white women (71.4 %). The percent of non-Hispanic black mothers in 2017 who are breastfeeding at hospital discharge (72.5 %) is well below that of the non-Hispanic white mothers (83.2 %). 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.  Central to this concept is our utilization of Perinatal Periods of Risk (PPOR), engagement at the local community level, and addressing perinatal quality initiatives with the Indiana Perinatal Quality Improvement Collaborative (IPQIC).  Additionally, Indiana is very excited to begin receiving the Pregnancy Risk Assessment Monitoring System (PRAMS) results in the spring of 2019.  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.

ISDH promoted Presumptive Eligibility at the local level by collaborating with local minority health coalitions, neighborhood baby showers, faith based organizations, and WIC. ISDH worked with local Black Minority Health Coalitions to implement the Free Pregnancy Test Program in counties where black pregnant women have a lower entrance into early prenatal care than the state average.  Per community feedback, pregnancy tests are extremely inexpensive and, as such, ISDH no longer funds free pregnancy tests and instead allocates funding for care coordination aimed at engaging women in early prenatal care, particularly in the highest risk counties.

As part of the state infant mortality initiative, an FOA was released for local projects to impact infant mortality. MCH is funding three Early Start clinics in counties with high black perinatal disparity, such as Lake and Allen. Early Start clinics provide free pregnancy tests to county residents and initiates prenatal care at the time of a positive pregnancy test. A complete history and current risking occurs, as well as initial prenatal labs, exam, education, support, and enrollment into presumptive eligibility, pregnancy Medicaid, WIC, and other needed services. All women continue to receive prenatal care services through Early Start until they can get into care with a prenatal physician.
 

The IPQIC Perinatal Health Disparities committee was established to look at disparities in racial groups, geography, and other special populations. The committee established the following values to guide their work, and assigned subcommittees to move forward with efforts for each:

• Data used for the development of strategies, policies and laws should consistently reflect a complete picture of the impact of infant mortality in Indiana, regardless of gender, ethnicity, race, geography, religious-spiritual affiliation, sexual orientation or socio-economic status.
• Providers should always have the tools to be sensitive and responsive to the needs of every mother, caregiver, and baby in their care regardless of gender, ethnicity, race, geography, religious-spiritual affiliation, sexual orientation, or socio-economic status.
• Clients (mothers, caregivers, and babies) should, without exception, receive care during a pregnancy so that a healthy baby lives beyond the first year of life regardless of gender, ethnicity, race, geography, religious-spiritual affiliation, sexual orientation, or socio-economic status.

In 2016, the work of this sub-committee was recognized as too critical to be addressed by only a stand-alone sub-committee, and was instead integrated into the work of each of the other IPQIC sub-committees. Within this new framework, all IPQIC opportunities for improvement focus on addressing and eliminating health disparities for the citizens of Indiana. 

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-- Many individuals living in rural areas do not have appropriate medical care in their county of residence.  As of December 2017, 65 of the 92 Indiana counties have a primary care health professional shortage. There is a mental health professional shortage in 76 counties and 21 counties have a shortage of dental health professionals. Additionally, 64 of the 92 counties in Indiana have a Medically Underserved Area designation.

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 July 2016, only 57% of the land area and 81% 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 2017, 12.74% 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), 18 of Indiana’s 92 counties are without a single provider participating in Presumptive Eligibility. Furthermore, although the remaining 69   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. To do this, MCH has been collaborating with the ISDH Office of Minority Health, the Indiana Minority Health Coalition (IMHC), and local minority health coalitions throughout the state. In 2015, ISDH created the Indiana Perinatal Quality Improvement Collaborative (IPQIC) Health Disparities sub-committee.  In 2016, the critical work of this sub-committee was recognized as too important to be addressed in a stand-alone sub-committee and was thus integrated into the work of each of the other IPQIC sub-committees. Within this new framework, all IPQIC opportunities for improvement focus on addressing and eliminating health disparities for the citizens of Indiana. 

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.


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 2018, 31 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

The ISDH, in partnership with the Indiana Perinatal Quality Improvement Collaborative (IPQIC), has been working to develop regulations and a process for designating perinatal levels of care in compliance with national recommendations. The vision of IPQIC is threefold:  (1) All perinatal care providers and all hospitals have an important role to play in assuring all babies born in Indiana have the best start in life; (2) all babies in Indiana will be born when the time is right for both the mother and baby; (3) and through a collaborative effort, all women of childbearing age will receive risk appropriate health care before, during and after pregnancy. There are over 100 active members of IPQIC working on a wide range of projects through five core committees including: Education, Quality Improvement, Perinatal Systems Integration, Perinatal Substance Use, and Finance, each with multiple ad hoc workgroups.

 The Indiana Perinatal Standards were approved in the 2018 Indiana legislative session providing ISDH with the authority to establish a program to certify perinatal levels of care designations for every delivering hospital and birthing center in the state.  The related rules were revised in 2018 to ensure continued compliance with evidence-based practice guidelines and recommendations from national organizations such as American Congress of Obstetricians and Gynecologists (ACOG), the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), and American Academy of Pediatrics (AAP).

The gap analysis for levels of care readiness was completed in May 2017 and centered on the Indiana Perinatal Hospital Standards, which define risk appropriate care.

ISDH began the promulgation of Article 39 Indiana Perinatal Hospital Services in 2018 and is nearing the final phases of approval with the goal of implementing the levels of care survey process in late 2019. Upon implementation, all delivering hospitals and birthing centers will complete an initial survey followed by a three year cycle of resurveying to ensure risk appropriate care is maintained throughout the state.

While it is unrealistic to expect that 100% of very low birth weight babies would be born in level III nurseries, Indiana remains significantly below the Healthy People 2020 goal of 83.7%, and as such continues to focus on increasing the percentage.

In 2014, the 118th Indiana General Assembly passed Senate Bill 408 which added IC 16-19-16, requiring ISDH to establish a task force charged with developing clinical definitions, uniform process of identification, estimated time and resources needed, identification of appropriate data reporting options available, and identification of payment methods for Neonatal Abstinence Syndrome (NAS). With the completion of the report to the General Assembly, ISDH and task force efforts turned to an additional request in Senate Bill 408 to establish one or more pilot programs with volunteer hospitals to implement appropriate and effective models for NAS identification, data collection and reporting. The goal of the pilot is to establish the prevalence of NAS in Indiana and to test the process used for potential expansion to all Indiana delivering hospitals. The initial pilot began in January 2016 and included four hospitals utilizing an established protocol. When the pregnant woman arrives at the hospital for delivery, hospital personnel will conduct a standardized and validated verbal screening on all women. Medical staff will request that any woman with a positive screening result at any point during her pregnancy consent to a urine toxicology screening. Babies whose mothers had a positive verbal screen or positive toxicology screening results, and babies whose mothers did not consent to the toxicology screen will be screened using urine, cord or meconium, depending upon the results of the maternal screening. In 2018, 30 hospitals participated in this pilot. Of the 39,278 births in these hospitals, the cords of 7,241 babies (18.4%) were tested for substance exposure. Of the cords tested, 2,658 (36.7%) tested positive. The types of drugs being utilized varies geographically. Because we are not conducting universal screening of all Indiana babies, we believe pilot results are an underrepresentation of true prevalence. Future actions for this task force include expanding the established protocols statewide, and pursuing legislation to mandate universal drug screening of pregnant women

Obstetric Deserts and Reduced Access to Resources 

Many individuals living in rural areas do not have appropriate medical care in their county of residence, and in urban areas, growing populations and demand are exceeding the number of providers available for both mental and primary care providers. As of December 2017, 64% of Indiana counties have a primary care health professional shortage, and there is a mental health professional shortage in 80% counties. In Indiana, between 2013 and 2018, eight of Indiana’s birthing hospitals closed their obstetrics services, creating more obstetric deserts across the state. In Indiana, 33 of 92 counties do not have a hospital with labor and delivery services or simply do not have a hospital. They were all mostly located in less metropolitan areas of the state. With the closing of these services, OB-GYN providers also relocated from the area to hospitals that continued to provide delivering services. Because of this gap in accessible risk-appropriate care, programs to address maternal health are needed to reduce maternal deaths and morbidity in the rural parts of Indiana.