III.E.2.a. Title V Program Purpose and Design

Indiana’s Title V program is embedded in the work of both the Maternal and Child Health (MCH) Division and the Children’s Special Healthcare Services (CSHCS) Division. The team aims to support coordinated, comprehensive, and family-centered systems of care at a state, local and community level. The team has historically followed the Life Course Model, which has informed the structure of the MCH team and expertise. While the program is administered through the MCH and CSHCS divisions, the work could not be done without the extensive partnerships with both internal divisions at IDOH and subgrantees around the state. The block grant program truly serves as a convener, collaborator, and partner in addressing MCH issues both internally to the Department and externally with other state agencies and organizations.

Similar to other states, Indiana is a ‘home rule’ state, meaning that the Indiana Department of Health does not have direct oversight or control over the local health departments. While a handful of subgrants are with local health departments, most are with community-level organizations. The Title V program is working internally to cast a wider net of who is considered part of the ‘MCH workforce’ and invite them to participate in regular two-way communications with the State. MCH is committed to better understanding the needs of the MCH workforce, defined broadly here, especially as it relates to timely topics such as health equity. Leadership values creating ways to distribute dollars easier, data transparent and timely, and staff available for technical assistance for any organization, even tangentially aligned with MCH topics.

A large portion of Title V dollars are sub-granted to organizations around the state completing work at all levels of the MCH pyramid. With the completion of the 2020 needs assessment, IDOH has made significant adjustments to the Title V program in Indiana. MCH spent the latter part of 2020 redesigning the way in which funds are administered based on the results from the needs assessment and the priorities selected in the new state action plan. In Spring of 2021, MCH implemented those changes through a dramatically downsized Request for Proposal process and implemented a less burdensome application. Instead of funding legacy projects based on needs from five years ago or funding grantees for decade-long projects, the Department of Health aimed to cast a larger net, make the process less burdensome for those receiving funding, and ensure the work spans the life course over the next five years. In 2022, MCH has started to invest time and effort into relationship building with the new round of subrecipients.

• Staffing and professional development/capacity building: A large portion of the Title V budget is dedicated to staffing and contractor support across the Title V program within the agency. Each staff supports the efforts of the State Action Plan. In addition, the budget provides support for professional development and capacity building for staff.
• Subgrants: Another significant portion of the budget is for the subgrants through which Indiana completes much of its State Action Plan objectives. Traditionally, Title V supports upwards of 40 plus awardees across the IDOH program areas. MCH also reserves additional funds to address any emerging issues between grant cycles.
• IPQIC/Emerald Consulting: The Indiana Perinatal Quality Improvement Collaborative (IPQIC): was formed in 2012 and serves as an advisory body to ISDH. The vision of IPQIC is threefold: 1) all perinatal care providers and all hospitals have an important role to play in ensuring 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; and 3) through a collaborative effort, all women of childbearing age will receive risk-appropriate health care before, during and after pregnancy.
• Indiana Criminal Justice Institute (ICJI): Indiana’s state planning agency for criminal justice, juvenile justice, traffic safety and victim services. The institute develops long-range strategies for the effective administration of Indiana's criminal and juvenile justice systems and administers state and federal funds to carry out these strategies.
• Liv Pregnancy Mobile App: Hoosier women and families have relied on Liv for trustworthy, medically approved pregnancy and childcare information since the fall of 2017. Since that time, the Liv app has added users each month and can now boast 18,295 users. Social media advertising on Google Search, the App Store, and Facebook has been refreshed and is proving to be a magnet to attract users, averaging over 1000 clicks and 300 downloads per month.
• Labor of Love Conference: In Fall of 2022, the MCH division will host the 10th annual Labor of Love conference. This highly anticipated event generally draws well over 1500 attendees, including clinical providers, WIC, home visiting staff, and broad members of the MCH workforce. This year’s conference theme launches the “Year of the Mom” which will focus efforts and continued emphasis on maternal health.
• Internal Partnerships: The Title V program depends on partnerships within the Health and Human Services Commission to implement the State Action Plan. The budget supports staff and projects in the Division of Nutrition and Physical Activity, Fatality Review and Prevention Division, Division of Trauma and Injury Prevention, MCH, and Children’s Special Health Care Services.

The CSHCS program continues to work to support coordinated, comprehensive, and family-centered systems of care at the state and local levels. Currently, Title V provides funding for all staff in the CSHCS program, which provides supplemental medical coverage to help families of children who have serious, chronic medical conditions, from birth to 21 years of age who meet the program's financial and medical criteria pay for treatment related to their child's condition. Within the CSHCS division, there are five sections that ensure that the program is operating effectively and efficiently.

• Eligibility: Eligibility receives new applications, as well as re-evaluating current participants. They ensure that the participant is medically and financially eligible for the program. They also ensure that the participant has applied for Medicaid. 
• Prior Authorization: All services, except pharmacy, lab and X-ray, must be approved by either a prior authorization (PA) or by a linkage of the provider to the participant for services related to the participant’s eligible medical condition. PA confirms medical necessity and the relationship of the service to an eligible medical diagnosis.
• Provider Relations/Claims: Claims and Provider Relations team processes claims for providers of CSHCS and enrolls new providers and updates their provider records when needed. The team handle calls from providers needing status of claims or any questions they may have concerning their provider agreements, adjustments, check registry and pharmacy. The team is responsible for shredding and filing and work with AOS concerning payments.
• Care Coordination: Care Coordination is available state-wide for families with children and youth with special health care needs, regardless of if they are on the supplemental healthcare program. Care Coordinators are social service professionals who work with the child's family, doctors, and other service providers to identify needs and the resources available to meet social and health related needs. For individuals on the program, care coordination ensures that families are notified when it’s time for their re-evaluation and discuss any updates in services.  In addition, our care coordinators ensure they understand they are connected to the system of care coordination to ensure they are not duplicating services.
• Integrated Community Services: This team improves access to quality, comprehensive, coordinated community-based systems of services for children and youth with and without special health care needs (CYSHCN) that are family-centered and culturally competent. This work is achieved through Title V funding which includes partners internally and externally.  External partners include:
  • Indiana Family to Family: State-wide parent-to-parent organizations. 
  • Foster Success: Ensures that youth transitioning out of foster care are educated, housed, financially stable, employed, and connected to support system by age 26.
  • Riley Care Coordination Project: a place-based care coordination project that demonstrates a value-based payment model.
  • CYACC: Ensures that transition age youth are empowered to transition to adult health care providers. In addition, the clinic trains future providers about transition.
  • Indiana Youth Services Association (IYSA): IYSA has been able to hire an Adverse Childhood Experiences Director who coordinates trainings, best practices, and data collection statewide.
  • Safe Transportation for All Children (STAC): The Safe Transportation of All Children (STAC) curriculum to assist caregivers, child passenger safety technicians and health care providers in ensuring that children with special health care needs travel in appropriate travel restraints, properly positioned, and secured in the vehicles in which they ride. 

The Title V program is passionate about leading the state and region in MCH issues, and all staff is encouraged to serve on related committees, boards and groups at all levels of implementation. A significant portion of the budget is dedicated to workforce development and capacity building for staff and partners through professional development and conferences. Staff routinely participate in national collaborative networks, planning committees, and trainings. Indiana is home to the Past President of AMCHP Board of Directors, Shirley Payne. Eden Bezy serves as the Region V Director, representing Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin. Her responsibilities include convening delegates from the five states for regular meetings via phone calls and annual in-person meetings. Ms. Bezy works with state staff to identify and share trends, issues, and news which she then relays to the board and AMCHP staff, including any emerging best practices, evidence-based practices, government policies, and opportunities to advance the health and well-being of the MCH population.

The core Title V program cannot complete the deliverables of the State Action Plan on its own. The team depends on the vast network of internal partners, partnerships and formal MOUs with other state agencies, funded subgrantees, clinical partners, and others to accomplish the variety of work needed to improve the health and well-being of Hoosier families. Key partners of Indiana’s Title V program are included below:

In addition, we rely on other state government agencies to further our reach in the MCH population including: the Family and Social Services Administration (FSSA), which contains the Division of Mental Health and Addiction, Office of Childhood and Out of School Learning, Medicaid, First Steps, Department Family Resources; the Indiana Department of Education; the Commission on Improving the Status of Children; and the Council for People for Disabilities.

MCH and CSHCS are responsible for additional state and federal funding that also address intervention points across the lifespan and at all levels in the MCH pyramid. While Title V-funded programs generally work in the infrastructure and population health sections of the pyramid, much of the supplemental funding provides support for enabling services, and in some cases direct services. Indiana is fortunate to have a variety of other state and federal funds supporting the work benefitting the MCH population across the state.

SafetyPIN (state, perinatal, maternal): In 2014 the Indiana state legislature earmarked $5.5 million per year intended to fund innovative, local programs that work to reduce infant mortality. SafetyPIN legislation requires grantees to demonstrate a reduction in the infant mortality rate within a defined region within two years in order to qualify for the next two years of the award. Special focus in the legislation includes tobacco cessation in pregnant people, home visiting, substance use disorder, and care coordination. The MCH Division uses this fund to provide subgrants to community organizations and hospital systems across the state. Recently, awards have been given to support home visiting and care coordination programs aimed at increasing care to pregnant patients and their families. These programs consist mainly of ‘home grown’ or non-evidenced-based programs designed and implemented by local hospital systems.

MIECHV (federal, crosscutting): The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program supports the delivery of coordinated and comprehensive high-quality and voluntary early childhood home visiting services to eligible families. Indiana’s MIECHV vision is to improve health and development outcomes for children and families who are at risk through achievement of the following goals: 1) Provide appropriate home visiting services to women, their infants and families who are low-income and high-risk; 2) Develop a system of statewide coordinated home visiting services that provide appropriate, targeted, and unduplicated services and locally coordinated referrals; 3) Coordinate necessary services outside of home visiting programs to address needs of participants. MIECHV funds provide Indiana resources to continue home visiting and improve outcomes for at-risk families through Healthy Families Indiana (HFI) and Nurse-Family Partnership (NFP). Indiana has 1,296 MIECHV-funded families enrolled in home visiting. Clients are often characterized by risk factors including mental illness, substance abuse, low educational attainment, history of interpersonal violence, single parenting, and limited access to health care. Home visiting will address high-risk, low-income families in need of services through education, intervention, and referrals to support services.

NFP State Funds (state, crosscutting): Beginning in 2018, the Indiana legislature allocated a state fund of $5M per fiscal year to support the expansion of NFP in Indiana.  NFP services are available in 42 counties through four local implementing agencies with state, federal, and private funds. This equates to approximately 88 nurses with the maximum capacity to service approximately 2,100 clients at a single point in time. The NFP state funds support 975 of those clients. As a MIECHV recipient, funds must supplement, and not supplant, funds from other sources for early childhood home visitation programs or initiatives to meet the Maintenance of Effort (MOE) requirement. In Indiana, the NFP state fund is considered applicable under the MOE requirement for MIECHV. Home visiting remains a priority in Indiana’s efforts to reduce infant mortality. Additionally, IDOH is committed to complementing all Title V programs with the seamless integration of available home visiting services.

Perinatal Navigation/My Healthy Baby (state—perinatal, child, & maternal): In the 2019 state budget, Indiana’s legislature allocated $3.3 million to build a referral system that aims to connect women who are pregnant to local home visiting providers. This includes MIECHV, NFP, Safety PIN and other funded home visiting programs through the state. My Healthy Baby (MHB), formerly known as OB Navigator, is a collaboration between the Indiana State Department of Health (ISDH), the Indiana Family and Social Services Administration (FSSA) and the Indiana Department of Child Services (DCS). Through this partnership, MCH and FSSA have entered a series of MOUs that provide the contact information for individuals who have recently applied for presumptive eligibility, applied for Medicaid, changed their Medicaid status to pregnant, or their medical records indicate a positive pregnancy test.  As of July 31, 2021, My Healthy Baby has been implemented in 71 counties and plans to expand to 7 more by the end of the calendar year.

TPP: (federal – adolescent): In 2020, IDOH was awarded a teen pregnancy prevention grant through the Office of Population Affairs for the first time. This collaborative agreement supports positive youth development and the Think, Act, Grow (TAG) Essentials to encourage optimal health in teens 13 to 19 years of age. This is an additional 1.4 million dollars per year to reach youth in areas with high rates of teen pregnancy and/or sexually transmitted infections through multiple leverage points: in and out of schools, through community-based events, and through clinical providers.

SRAE: (federal – adolescent): MCH continues to implement Sexual Risk Avoidance Education through the Family and Youth Services Bureau. Indiana uses its 1.2 million dollars to reach over 15,000 youth per year with positive youth development curricula. Partners implementing this grant reach over half of the counties across the state of Indiana.

YRBS/School Health Profiles: (federal – children/adolescent): Indiana continues to work with the CDC on conducting the YRBS and PROFILES every two years. The surveys are either completed by high school students (YRBS) or essential school staff at middle schools and high schools (PROFILES). Data from this survey is critical to drive programming needed in this age group.

PRAMS: (federal – maternal) MCH conducts the Pregnancy Risk Assessment Monitoring Survey to further understand the experience of Hoosiers before, during, and after pregnancy. This is one of the only sources of data related to giving birth and furthers the reach of Title V programming and the work of IPQIC based on the results of the survey each year.

AIM/ACOG: (federal – maternal) IDOH MCH is partnered with ACOG to implement the Alliance for Innovation in Maternal Health patient safety bundles at delivering hospitals around the state. ACOG provides technical assistance and some financial support to ensure Indiana’s hospitals are providing safe healthcare for every woman. Indiana is working with ACOG through 2023.

ERASE MMR: (federal – maternal) IDOH FRP were awarded ERASE MM by the CDC. This grant and the associated technical assistance have allowed IDOH to systematically identify and collect relevant information pertaining to pregnancy-associated deaths, review the findings, and make data-driven recommendations. Resulting MMRC data is reported data through the web-based Maternal Mortality Review Information Application (MMRIA) system, and ongoing data quality measures are utilized to ensure accuracy and timeliness. Records for review are currently obtained from state public health data systems, the Indiana Hospital Association (IHA), and via hospitals and health systems (required by IC 16-50).

Preventing Maternal Deaths Due to Violence (federal- maternal): Funding from The Office of Women’s Health is allowing additional staff to join Indiana’s Maternal Mortality Review Committee and investigate maternal deaths due to violence even further. The MCH team is working on upstream prevention through a community learning webinar series (known as an ECHO project) and will be implementing CenteringPregnancy and CenteringParenting to further support pregnant persons throughout the duration of pregnancy and as they become new parents. 

OTHER (state—lifespan): MCH is allocated a number of smaller state funds, totaling approximately $500,000, to help supplement the work of targeted projects within the division. For example, MCH has a state budget line to reduce the burden of tobacco and substance use in women of child-bearing age. Additionally, MCH and Fatality Review and Prevention Division share a state fund to support fatality reviews. These dollars traditionally supported the Fatality Review and Prevention Director; however, this fund was expanded in the 2021 state budget year, and the MCH and FRP division look forward to working together on planning for the use of this additional investment. Finally, the general MCH state fund, or ‘MCH supplement’, is available to help support ad hoc division needs as identified by the State Action Plan and the Needs Assessment. MCH has yet to determine how the dollars will be spent for this fiscal year.

Children’s Special Health Care Services state fund: Indiana Children's Special Health Care Services provides supplemental medical coverage to help families of children who have serious, chronic medical conditions, age birth to 21 years of age, who meet the program's financial and medical criteria, pay for treatment related to their child's condition. Indiana allocates 14.95 million per fiscal year.  CSHCS division has dedicated funds that serve individuals with sickle cell disease and 0-5 children with visual impairments.

GNBS & IBDPR (state—infant and children's): MCH has dedicated state funds for newborn screening and the birth defects and problems registry. The newborn screening fund supports GNBS staff, six care coordination programs after newborn screening, metabolic formula expenses, and educational efforts. Funds from the birth defects and problems registry fund support staff and the folic acid campaign.