Goals, Framework, and Methodology

Title V requires a comprehensive needs assessment every five years to identify the strengths and needs of the MCH population and to guide efforts to improve the health of the MCH population. Michigan’s goals for the 2020 needs assessment were to:

• Use multiple types of data to understand health outcomes, health behaviors, and health disparities, as well as underlying causes that drive inequity;
• Strengthen partnerships and strategies for achieving health equity;
• Engage diverse populations and system partners in describing and understanding the needs and strengths of the MCH population;
• Identify the state priority needs and performance measures that will be the focus of Title V for FY 2021-2025; and
• Identify opportunities to address needs beyond the scope of Title V.

The Public Health Planning Cycle (see Figure 1) from the Title V Guidance was adapted and used to organize the assessment process. Many methods and tools were adapted from the Mobilizing for Action Through Planning and Partnerships (MAPP) framework developed by the National Association of County and City Health Officials (NACCHO). Details on the MAPP assessments as well as findings across population domains are included in the needs assessment report, which is included as a Supporting Document.

Figure 1. Needs Assessment Process

MAPP is a health assessment and improvement planning framework commonly used by local health departments. It was selected to guide the needs assessment because it aligned well with Michigan’s goals. The MAPP process uses multiple types of data, engages diverse system partners, and emphasizes health equity. The framework is comprised of six phases and four assessments, as depicted in Figure 2.

Figure 2. MAPP Phases

Stakeholder Involvement

The needs assessment process was led by Michigan’s Title V MCH and CSCHN directors. Several groups were involved in different aspects of the process to comprehensively represent the Title V population domains, including many MCH stakeholders external to MDHHS and MCH leadership within MDHHS.

• Needs Assessment Planning Committee: Comprised of MDHHS Title V leadership, MDHHS epidemiologists, and MPHI consultants who were responsible for planning and implementation of the needs assessment. The group convened in May 2018 to begin the planning process and oversaw all logistics.
• Title V Steering Committee: Comprised of state MCH staff who oversee programs and initiatives that receive Title V funding and/or implement Title V state action plans. Members provided feedback and insight into the needs assessment process and used findings to inform state action plans.
• Needs Assessment Stakeholder Group: Included more than 70 MCH stakeholders from across Michigan, with over 50% representation outside of MDHHS. This group convened from February 2019 to February 2020 and participated in several needs assessment activities.
• Population Domain Workgroups: Three workgroups were convened to reflect the Title V population domains: women/maternal health and perinatal/infant health; child/adolescent health; and CSHCN. Participants at each workgroup included state and local MCH staff, MCH system partners, consumers and parent representatives, and partners with health equity expertise. The workgroups identified needs within each population domain based on the needs assessment findings and their experience within the MCH system.

Organizations and program areas that participated in the above groups are listed in a Supporting Document. Notably, the needs assessment was completed prior to the COVID-19 pandemic. The Title V program recognizes the significant impacts of COVID-19 on the MCH population and will assess emerging and shifting MCH needs over the next year.

Quantitative and Qualitative Methods and Data Sources

Identification of unmet needs was based on the four MAPP assessments, described below. The assessments collected a combination of qualitative and quantitative data to provide a holistic view of health and were tailored to focus on the MCH population.

Health Status Assessment

This assessment uses quantitative population level data to describe health status. The assessment began by identifying key MCH health indicators, including Title V National Performance Measures and National Outcome Measures and other measures tracked in each population domain.

Seventy health indicators were identified for maternal and infant health, of which 60 had adequate data for analysis. Eighty-two indicators were identified for child and adolescent health, of which 59 had adequate data for analysis. To identify indicators suggesting need, the following criteria were applied to each measure: a Black/White disparity of 10% or more; observed Black/White disparities worsening over time (minimum five years of data); statewide trend worsening over time (minimum five years of data); and Michigan performing two percentage points worse than the US overall in the most recent data year.

The analysis of CSHCN data relied heavily on the National Survey of Children’s Health (2016-2017 combined) and used the HRSA Maternal Child Health Bureau (MCHB) framework for understanding the prevalence and impact of special health care needs on children. Key indicators quantified the types and levels of severity of special health care needs for children in Michigan. Selected indicators were stratified by CYSHCN status and level of complexity, at both the state and national level. Analysis focused on understanding the CSHCN population as compared to all children and those without special health care needs. When possible, data were stratified by race and ethnicity.

System Assessment

This assessment explores the degree to which public health systems deliver essential services within existing capacity and available resources. Michigan focused on six of the 10 essential public health services: educate and empower; mobilize partnerships; develop policies; link to/provide health services; evaluate and improve; and inform and apply research. These services were prioritized to gather input from external partners to develop a well-rounded view of capacity. The National Public Health Performance Standards Program, which is designed to be inclusive of all public health services, was used to complete the assessment. The tool was significantly adapted for Michigan’s needs assessment to focus on MCH and health equity.

The system assessment was completed during a facilitated full-day meeting of the Stakeholder Group and involved a series of discussion questions to identify strengths and gaps in capacity in each essential service. After discussing specific aspects of an essential service, the group used confidential electronic voting to capture the degree to which the system was delivering the service.

Forces of Change Assessment

This assessment identifies forces outside the MCH system that could impact population health. Forces include trends, factors, and events that may influence health, both in the recent past and the foreseeable future. This assessment was completed by members of the Stakeholder Group who self-selected into one of four breakout groups: women, maternal and infant; child and adolescent; CSHCN; or cross-cutting. The assessment was completed during a half-day facilitated session in which each group identified forces that influence health. Forces that could create inequities were highlighted.

Community Themes and Strengths Assessment

This assessment gathers the perspectives of community members, including thoughts, experiences, and opinions about their health and quality of life. It is designed to gain a deeper understanding of the strengths, assets, and barriers that exist in communities. Data for this assessment were collected through provider surveys, encounter surveys, focus groups, and listening sessions with both service providers and community members across Title V population domains. The provider survey was an online survey administered to participants (n=526) through the survey platform Qualtrics. The encounter survey was administered to recipients of MCH services (n=307) in one of two formats, an online survey or paper survey. Trained facilitators facilitated 18 focus groups and listening sessions to gather experiences and perspectives on health. Quantitative survey data were analyzed in SPSS and qualitative data were thematically analyzed to identify reoccurring strengths, barriers, and opportunities for improvement.

Identifying Priority Needs

After completion of the four MAPP assessments, data were analyzed to identify themes. Themes were identified when common topics or issues arose across each MAPP assessment. This filter supported narrowing themes, and ultimately priorities, to those most present in the data. The only exception to this process was related to the Community Themes and Strengths Assessment findings. If community data led to a theme that was less present in the other assessments, it was still included as a theme.

Three population domain workgroups representing a broad array of MCH stakeholders were convened in the fall of 2019 to review the findings of the MAPP assessments, review the themes, and identify priority needs. This process involved three full-day meetings. During the morning session, participants were guided through the assessment findings. In the afternoon, they participated in a facilitated session to explore each of the themes and draft priority need statements.

Following the population domain workgroups, over 50 priority need statements were reviewed to identify areas of commonality. Where the groups identified a similar need, a consolidated need statement was developed. Those needs that best aligned with Title V were identified and linked to a relevant NPM or SPM. The needs assessment findings were then used to inform state action plan development. Originally, an in-person workshop was planned with MCH staff to develop strategies, objectives, and ESMs. Due to the COVID-19 pandemic, the meeting was shifted to a webinar format during which guidance and resources for developing state action plans were provided. State action plans were developed with virtual technical assistance from Title V staff.

Michigan’s Title V priority needs for 2021-2025 were developed from themes that emerged across the four MAPP assessments. This section provides a high-level summary of major findings from each assessment, highlighting data that drove the selection of priority needs and performance measures.

Strengths and Needs

The Community Themes and Strengths Assessment revealed assets and needs across each population domain. The themes most closely related to Michigan’s Title V priority needs are summarized here.

Women, Maternal, & Infant Health

The provider survey, focus groups, and encounter survey all identified barriers in accessing healthcare, specialty providers, and mental healthcare for women and mothers. Provider survey and focus group participants shared that the cost of medical care limits access; families experience gaps in coverage; and coverage is too limited. Additionally, encounter survey and focus group participants identified gaps in the availability of high-quality care, including prenatal care, postnatal care, breastfeeding education and support, and family planning.

Provider burnout and a lack of birthing hospital access in rural areas was highlighted as a gap by both consumers and providers. The provider survey identified provider shortages in areas of the workforce critical to the health of women and mothers, including licensed medical social workers, community health workers, obstetricians, gynecologists, and medical assistants.

Women and mothers who participated in focus groups reported experiences of racism and implicit bias when seeking medical care. Focus group participants also reported feeling their race impacted the quality of care they received, particularly around family planning and birth spacing. This finding was echoed in responses to the provider survey, where providers suggested that frontline medical providers could benefit from training in implicit bias.

Focus group participants reported that more support for infant safe sleep and positive parenting practices would help families. Similarly, provider survey respondents suggested expanding supportive services such as home visiting, early childhood programs, and Great Start Collaboratives to support family planning, safe sleep, breastfeeding, and parenting. Focus group participants provided examples of restrictive workforce policies and practices that limit breastfeeding and stressed the need for supportive breastfeeding policies.

Child & Adolescent Health

Mistrust in the healthcare system was reported as a concern among focus group participants who noted gaps in access to accurate, trusted, linguistically appropriate, and culturally adapted messages about child health. Additionally, focus group participants reported that healthcare could be more accessible if it were integrated into settings where children live, learn, and play, such as school-based health centers. The provider survey also raised concerns about the availability of primary care for young children and limited access to preventive services.

Focus group and encounter survey participants reported environmental health concerns such as lead and PFAS contamination. They noted that socioeconomic status and race drive inequities in childhood exposure to lead contamination. Housing stock free of environmental contaminants was identified as a challenge, especially in lower-income neighborhoods. Focus group participants noted the need for greater investment in safe, livable communities and quality housing. This concern was echoed in the provider survey, and providers also noted that structural racism impacts exposure to unsafe living conditions.

Bullying, child abuse, domestic violence, and social/emotional abuse were all raised as concerns facing children and adolescents. Bullying in schools was highlighted as driving risky behaviors and mental health challenges among children and adolescents, especially those who identify as LGBTQ+. Focus group participants shared that schools need additional support to address the social and emotional needs of students, such as more counselors, social workers, and nurses.

Children with Special Health Care Needs

Insurance challenges and gaps in specialty providers were identified through focus groups and encounter surveys as challenges for families with CSHCN. Participants noted that access to available therapies, adaptive devices, and payment options that cover a variety of needs would help alleviate some of the stressors that result from caring for a child with special needs. Additionally, silos in communication across providers and provider turnover were reported as challenges that contribute to challenges in transition to adult care.

Multiple Population Domains

Mental and behavioral health was identified as an area of concern across population domains and through each data collection method. An overall lack of mental and behavioral health providers in Michigan, especially in rural areas, was reported as a challenge. Specifically, substance use disorder treatment and access to Community Mental Health centers were highlighted as challenges by focus group participants. Focus group participants also described how stigma surrounding mental health contributes to generational mental health issues and challenges.

While the Community Themes and Strengths Assessment highlighted many needs across population domains, it also identified assets such as:

• Michigan’s caring and compassionate providers offer high-quality care with limited resources;
• Federally Qualified Health Centers, local health departments, and school-based health centers fill gaps in access to care;
• Community-based, culturally and linguistically appropriate organizations provide quality support services;
• A strong home visiting system that spans the state and provides numerous programming options to align with family needs;
• Michigan’s CSHCS program and its long-standing history of providing quality supports and helping families afford care; and
• Longstanding relationships, collaborative bodies, and MCH expertise at the state and local level.

Major Health Findings

The Health Status Assessment elevated strengths and areas of concern in each Title V population domain. Key findings related to Title V priority needs are highlighted below.

Women, Maternal, & Infant Health

Addressing disparities in infant and maternal mortality is one of Michigan’s top MCH priorities. Michigan has a large and persistent disparity between white and black women in maternal mortality, and the maternal mortality rate in Michigan overall has been increasing since 2012 to a high of 82/100,000 live births in 2016 (Michigan Maternal Mortality Surveillance, MDHHS, 2011-2016). Additionally, black infants are three times more likely to die before their first birthday as compared to white infants (14.6/1,000 as compared with 4.8/1,000 live births in 2017) (Vital Records & Health Statistics, MDHHS). Disparities also exist within other racial and ethnic groups.

The assessment highlighted factors driving maternal and infant health outcomes. Michigan has persistently lagged the US in women receiving prenatal care beginning in the first trimester (72.4% US compared to 64.0% MI in 2017), and black women in Michigan are 20% less likely to begin care in the first trimester (Vital Records & Health Statistics, MDHHS). Similarly, Michigan’s mothers undergo a low-risk cesarean delivery more frequently than the US (26.0% in the US compared to 28.7% in MI in 2017), and both the disparity and the rate for black mothers are increasing (Vital Records & Health Statistics, MDHHS, 2012-2017). Disparities in safe sleep are also striking; babies who are black are 20% less likely to be placed on their backs to sleep as compared to babies who are white (MI PRAMS, 2012-2017). Babies who are black are also 40% less likely than babies who are white to sleep alone, in a safe bed, on their backs (MI PRAMS, 2012-2017). Finally, while Michigan has seen a steady increase in breastfeeding initiation, disparities remain with 77.2% of black mothers initiating breastfeeding as compared to 90.1% of white mothers in 2017 (MI PRAMS, 2012-2017).

The assessment also highlighted improvements in the health of women, mothers, and infants. Since 2012, Michigan has observed a steady increase in women receiving a routine medical checkup in the past 12 months, from 62.9% in 2012 to 69.1% in 2017 (Behavioral Risk Factory Surveillance Survey). Smoking during pregnancy has also declined from 16.5% in 2012 to 11.3% in 2017 (MI PRAMS).

Child & Adolescent Health

One strategy to support child and adolescent health is through access to a medical home. The assessment found a disparity between white and black children, with 53.3% of white children having a medical home compared to 29.0% of black children in 2017-2018 (National Survey of Children’s Health, 2016-2018). Similarly, Michigan found disparities in access to preventive dental visits, with black children (71.5%) being less likely than white children (79.2%) to receive a preventive dental visit (NSCH, 2016-2018). Michigan also lags in vaccination rates. Children in Michigan ages 19-35 months have been less likely than children in the US to complete the seven-vaccine series every year from 2013 and 2017, and only 69.9% completed the series in 2017 (National Immunization Surveys). Children in Michigan’s large, urban centers have significantly higher rates of elevated blood lead levels among children under age six as compared with the state. For example, in 2016, 8.8% of children under six years old who received testing in Detroit had a blood lead level greater than or equal to 5 micrograms of lead per deciliter of blood, as compared with 3.6% in Michigan (Childhood Lead Poisoning Prevention Program, MDHHS). Finally, rates of bullying in Michigan have remained high with 29.6% of high school students reporting bullying in the past 12 months in 2017. Rates of bullying are higher among American Indian high school students, 43.6% of whom reported bullying in 2017 (Youth Risk Behavior Surveillance System, 2011-2017).

However, Michigan experienced improvements in continuous and adequate insurance for children. The percentage of children 0-17 without health insurance declined each year from 2012 to 2017; Michigan’s children were less likely to be without health insurance as compared to the US; and black children were less likely to be uninsured than white children (NSCH, 2016-2018). Additionally, Michigan observed a steady decline in its teen birth rate among females age 15-19, from 26.2/1,000 in 2012 to 15.8/1,000 in 2018 (Vital Records & Health Statistics, MDHHS, 2012-2018).

Children with Special Health Care Needs

The CSHCN data revealed unique needs among this population. The assessment raised concerns regarding adequacy and continuity of insurance coverage with 36.4% of CSHCN reporting that their insurance was inadequate or that they encountered a gap in coverage (NSCH, 2016-17). Additionally, 46.1% of CSHCN (as compared with 38.3% CSHCN in the US) experienced bullying (2016-17) (NSCH, 2016-17). Finally, only 16.0% of CSHCN had the support needed to transition to adult care, which was lower than the US average of 16.7% (NSCH, 2016-17).

Multiple Population Domains

The Health Status Assessment identified findings across population domains related to mental health. In 2017, 19.2% of Michigan women 18-44 reported more than 14 days of poor mental health in the past 30 days, as compared to 16.2% in the US. Moreover, 24.2% of black women reported poor mental health (BRFS). Similarly, the prevalence of postpartum depression for black women was reported to be almost twice that of white women in 2018 (23.6% compared to 13.6%) (MI PRAMS). Among adolescents, 37.3% reported feeling sad or hopeless for two weeks or more in 2017, a dramatic increase from the 26.0% who reported feeling sad or hopeless in 2011 (YRBS, 2011-2017). Michigan has also seen a disturbing upward trend in suicide mortality among adolescents from 6.5/100,000 in 2012 to 7.5/100,000 in 2016 (Vital Records & Health Statistics, MDHHS, 2013-2017). Finally, access to mental health care is problematic across all population groups, including CSHCN. Compared with a US average of 22.9%, 27.4% of CSCHN in Michigan sometimes or never had the insurance coverage they need for mental/behavioral care (2016-17) (NSCH, 2016-17).

MCH Efforts to Address Needs

The System Capacity Assessment identified strengths and weaknesses of the MCH system in Michigan. The Forces of Change Assessment identified opportunities and threats in the broader sociocultural and political context. Although the System Capacity Assessment was organized by Essential Services and not by population domain, this summary of key findings is organized by population domain for continuity.

Women, Maternal, & Infant Health

The System Assessment identified examples of services and strategies helping to meet the needs of this population. Michigan’s Regional Perinatal Quality Collaboratives are enhancing collaboration and supporting innovation; home visiting models are supporting families throughout pregnancy, birth, and the early years; safe sleep partners have developed and disseminated more culturally sensitive and responsive messaging for families; and policy and programs that support breastfeeding have grown steadily.

However, the System Assessment raised concerns regarding the shortage of OB/GYNs, nurse midwives, doulas and other specialty providers, especially in the state’s rural areas. These provider shortages limit supports available for women and mothers around breastfeeding, safe sleep, and family planning. The System Assessment also raised concern about the availability of birthing hospitals.

The Forces of Change Assessment noted factors beyond the MCH system that impact the health of women, mothers, and infants. The assessment highlighted the impact of the political climate on women’s health and raised concerns about access to family planning and unbiased reproductive care. The assessment also noted that existing policies and polarization create barriers to promoting optimal health and well-being for women and mothers. Medicaid work requirements, for example, were generating significant concerns about access to care. Finally, the assessment described how racism, discrimination, and biases in society have significant impacts on the health and well-being of women of color.

Child & Adolescent Health

The System Assessment identified examples of services that benefit children and adolescents. Home visiting and early childhood system building efforts have worked toward providing greater continuity and connection across services for young children. Additionally, while they are not available statewide, school-based health centers were noted as a key asset in Michigan’s public schools.

The System Assessment found gaps in the capacity of the MCH system to provide preventive services in the places where families live, learn, work, and play. This included primary care, dental care, developmental services, and mental health services. It also found gaps in the availability of home visiting beyond the first year; gaps in health and mental health care within school settings; and gaps in collaboration between different types of providers. The assessment noted that MCH services are often siloed, although examples of collaboration and coordination exist.

The Forces of Change Assessment indicated that the consistently rising cost of medical school was compounding the shortage of primary care providers. In addition, the assessment found that funding cuts to public education have led to a decrease in school nurses, threatening access to care. The assessment also raised concern about trauma and Adverse Childhood Experiences (ACEs) threatening the mental and physical health of children and adolescents. Finally, the assessment highlighted the complex and multifaceted impact of technology on child and adolescent health (which can be both positive and negative) and the need to address cyber bullying.

Children with Special Health Care Needs

The System Assessment noted several strengths of the CSHCN system in Michigan. Most prominently, the Family Center for CYSHCN was highlighted as a system strength. The Family Center provides support, information, and linkages to families of children with special health care needs and elevates the voices of parents within the system.

The System Assessment also highlighted the complexity of providing services and supports to CSHCN given that coordinating services for this population requires collaboration across multiple agencies and systems. Silos in communication and connectivity among partners present barriers to providing coordinated care and create barriers for families in accessing supports. The System Assessment also noted unique system gaps faced by this population and emphasized the potential for telemedicine and telehealth to mitigate some challenges.

The uncertainty of the health insurance system was reported as a challenge throughout the Forces of Change Assessment, specifically for individuals with pre-existing conditions. The supports that are provided through CSHCS, coordinated care and adequate transition services were identified as potential ways to support CSHCN and minimize the risk of losing adequate care.

Multiple Population Domains

Across all population domains, the System Assessment found that the MCH system has made progress toward improving its focus on equity. However, the assessment also found that more work is needed to address the root causes of inequity. The assessment highlighted the lack of diversity in the MCH workforce; the need to use data in more innovative ways to identify and address inequities; and the need for additional education for MCH providers on implicit bias. The System Assessment also noted the need for better linkages between healthcare services and community-based services to address social determinants of health and link families to needed services.

The System Assessment noted significant limitations on the provision of mental and behavioral healthcare and developmental services across all population domains. It found a systemic lack of consistent resources supporting access to these services, creating barriers to ensuring Michiganders have continued access to needed care.

Finally, the Forces of Change Assessment identified concerns about the rising cost of healthcare and other basic needs which may force families to make difficult choices between food or medicine, healthcare or rent. The assessment also highlighted the impact that a lack of a basic living wage can have on health, and the disproportionate increase in the cost of living versus access to jobs that pay a living wage.

The Title V program is administered by the Division of Maternal and Infant Health (DMIH) within MDHHS. The Division Director is the Title V MCH Director. The Division is located within the Bureau of Health and Wellness which includes the Divisions of Chronic Disease and Injury Control; Child and Adolescent Health (CAH); Women, Infants and Children (WIC); and Local Health Services. The Bureau of Health and Wellness is located within the Public Health Administration. Structurally, the Title V MCH Director reports to the Director of the Bureau of Health and Wellness, who currently reports to the Chief Deputy for Health. The Chief Deputy for Health is also the Chief Medical Executive and reports directly to the Governor.

The Title V CSHCN program is operated by the Children’s Special Health Care Services (CSHCS) Division. The Division Director is the Title V CSHCN Director. The CSHCS Division is located within the Bureau of Medicaid Care Management and Customer Service which is located within the Medical Services Administration (MSA). The Title V CSHCN Director reports to the Bureau Director, who reports to the MSA Director, who reports to the MDHHS Director.

In Michigan, Title V funding is used to support programs and services across several bureaus and administrations. A Title V leadership team (including DMIH, DCAH, and CSHCS directors) provides administrative oversight for Title V in coordination with program areas that receive Title V funding. Title V allotments currently support the following:

• Local Health Departments
• Medical Care and Treatment for CSHCN
• Family Planning Local Agreements
• Childhood Lead Poisoning Prevention Program
• Immunizations
• Dental Programs for Children
• Infant Safe Sleep
• Family Center for CYSHCN
• MCH special projects including maternal mortality surveillance, PRAMS, fetal alcohol spectrum disorder, and parent leadership

The mechanisms by which MDHHS administers Title V are described throughout the grant.

MDHHS has a longstanding history and capacity to promote and protect the health of the MCH population, including CSHCN. Most Title V programs are administered by the DMIH, DCAH, and CSHCS. Collectively, these three divisions provide services across the five HRSA population domains. They also work with MCH programs outside their divisions that receive Title V funding (e.g., Childhood Lead Poisoning Prevention Program, Immunizations, and maternal and infant mortality surveillance) to ensure a statewide system of services with comprehensive, community-based care. The divisions are responsible for assessing need; recommending policy; developing and promoting best practices and service models; engaging families and communities; and supporting the capacity within communities to provide high quality, accessible, culturally competent services. Priority is placed on prevention and health promotion activities to improve physical and behavioral health. A synopsis of key program areas is below.

Division of Maternal and Infant Health: DMIH focuses on improving the health, well-being, and quality of life for infants, pregnant women, and women of childbearing age and their families. Major programs include Title X Family Planning, the Maternal Infant Health Program, Infant Safe Sleep, Early Hearing Detection and Intervention (EHDI), Michigan Fetal Infant Mortality Review, Fetal Alcohol Spectrum Disorders, and Regional Perinatal Quality Collaboratives. DMIH provides a leadership role in state efforts to reduce maternal and infant mortality, including oversight of the Mother Infant Health and Equity Improvement Plan. The division provides technical assistance, infrastructure and epidemiologic support across maternal and infant health.

The Women and Maternal Health Section focuses on preconception, interconception, maternal and perinatal health for women. The section supports health planning and the delivery of equitable, quality contraceptive and reproductive health services. The Title X program supports local providers who provide health education and counseling, reproductive health assessments, contraceptive services, and referrals to the general population, including low-income women and men. The section is also involved in statewide breastfeeding and prenatal smoking cessation initiatives.

The Perinatal and Infant Health Section focuses on supporting a healthy perinatal period through positive pregnancy and infant health outcomes. The target populations are pregnant and postpartum women and newborns. The section administers the Maternal Infant Health Program (MIHP), Michigan’s statewide home visiting program for Medicaid beneficiaries. Certified local providers offer assessment, case management and support services to pregnant women and infants. The section is also responsible for infant health initiatives to reduce fetal and infant deaths; achieve infants safe sleep; promote screening and evidence-based treatment for chronic conditions in newborns; and increase the proportion of newborns that receive hearing screens, evaluations and services.

Division of Child and Adolescent Health (DCAH): DCAH works to improve the health and well-being of Michigan’s children, adolescents and young adults. The division is responsible for managing the Local Maternal Child Health (LMCH) program which provides consultation and monitoring to Michigan’s 45 local health departments (LHDs) that receive Title V funding. The Oral Health Unit is also located in DCAH.

The Child and Adolescent School Health Section oversees federal teen pregnancy prevention programs including the Personal Responsibility & Education Program (PREP), the State Abstinence Education Program, and Pregnancy Assistance Funds used to implement the Michigan Adolescent Pregnancy and Parenting Program. These programs work collaboratively with state and local partners including the Michigan Department of Education (MDE), faith-based and health organizations, schools, LHDs, parents, and early childhood partners. The section oversees Michigan’s Child and Adolescent Health Centers (CAHCs), funding 100 health centers and related programs in medically underserved, high-need communities. CAHCs provide primary care and behavioral health services, health education, Medicaid outreach and enrollment, and screening to K-12 students and young adults up to age 21. The section also oversees the state’s school nurse program and mental health in schools initiative; Michigan Model for Health, the state’s comprehensive school health education program; and Hearing & Vision Screening Program.

The Early Childhood Health Section administers programs and initiatives to improve child health outcomes and support the development of an integrated and comprehensive early childhood system, including program management for home visiting and early childhood initiatives. The section administers the MIECHV grant and state home visiting dollars with a focus on stakeholder engagement to build a more effective and robust system. The section oversees the Parent Leadership in State Government initiative and serves as a liaison between public health and Part C/Early On.

CSHCS Division: The CSHCS Division focuses on identifying and addressing the health needs of CSHCN to help them achieve optimal health and an improved quality of life. CSHCS partners with families, community providers and other state agencies to ensure access to quality services. Within Medicaid Health Plans (MHPs), eligible Medicaid enrollees (e.g., SSI, Blind and Disabled, Healthy Michigan Plan, etc.) who have qualifying diagnoses and meet criteria of severity and chronicity are also enrolled into CSHCS. These CSHCS/Medicaid dual enrollees are guaranteed access to primary care providers and a network of subspecialists and receive care coordination services through the MHP. Care coordination, case management, outreach and advocacy for blind and disabled individuals under the age of 16 receiving SSI are provided through CSHCS programs at local health departments.

The CSHCS Division includes five work areas. The Customer Support Section (CSS) processes medical eligibility determinations made by the Office of Medical Affairs (OMA), program applications for clients with qualifying diagnoses, and providers approved by OMA. CSS also conducts financial assessments; implements payment agreements; and issues and renews client program coverage. The Policy and Program Development Section (PPD) develops program policies; oversees implementation of program development plans; and develops and promotes transition strategies. PPD is responsible for administering the Insurance Premium Payment Benefit Assistance Program and provides oversight for care coordination through specialty clinics. Staff also help LHDs and families navigate complex billing issues. The Quality and Program Services Section (QPS) ensures program quality and improvement planning, monitors customer satisfaction, conducts LHD trainings, and assists LHDs in supporting clients (e.g., transportation and care coordination). The Children with Special Needs (CSN) Fund provides services and equipment to CSHCN not available through any other resource, including state or federal programs. The CSN Fund is available for Michigan residents under 21 who are eligible for CSHCS enrollment.

The Family Center for CYSHCN shapes CSHCS policies and programs by bringing a family perspective and helps families navigate the systems of care for CSHCN. Parent Consultants within the Family Center help to identify family needs; provide referral to resources; and connect parents to educational and emotional supports. Parent Consultants also promote the CSHCS program and provide trainings to help parents become advocates. Through its Parent-to-Parent Support Network, the Family Center provides emotional support and information to families. The statewide Family Leadership Network provides community-based perspectives on programs and policies and informs families of resources and services. The Family Phone Line provides another avenue of support and is available to any family that has a child with special needs.

Michigan has many MCH leaders who provide strategic leadership and oversight to MDHHS programs and initiatives. Title V senior level leadership and program staff include:

• Dawn Shanafelt, MPA, BSN, RN, Director, Division of Maternal and Infant Health has 23 years of clinical and administrative public health experience at local and state levels. Ms. Shanafelt has served as the Title V MCH director since 2019. She administers Michigan’s maternal and infant health programs including Title X Family Planning, the Maternal Infant Health Program, and statewide initiatives to reduce maternal and infant mortality.
• Lonnie Barnett, MPH, Director, CSHCS Division has over 25 years of state and local public health experience in health administration, health planning, systems development, workforce development, and data-informed program development. Mr. Barnett has worked for MDHHS since 1998 and previously served as the Manager for the Health Planning and Access to Care Section. He has served as the Title V CSHCN Director since 2011.

• Carrie Tarry, MPH, Director, Division of Child and Adolescent Health has 20 years of state-level experience working in child health, adolescent and school health, and teen pregnancy prevention programs. She also oversees the MIECHV home visiting initiative and oral health programs and administers Title V funding to 45 local health departments.
• Sarah Davis, MPA, Departmental Specialist, Division of Maternal and Infant Health has 13 years of state-level experience in health and human services program coordination and grant management. She has served as the Title V block grant coordinator since 2015 and serves on state-level MCH committees and advisory boards.
• Theresa Christner, MA, CSHCS Policy and Program Development Section Manager, has more than 30 years of public health experience at the local and state level. She provides oversight to staff responsible for policy, healthcare transition services, specialty clinics, insurance premium payment benefit and billing assistance.
• Chris Fussman, MCH Epidemiology Section Manager has 12 years of state level experience with epidemiologic analysis and interpretation to inform and guide MCH program leaders and policy makers about population health.
• Lindsay Townes, MPH, Adolescent School Health Epidemiologist, has nearly a decade of experience in academic and government epidemiology. Ms. Townes provides epidemiological and data support to the Title V program, including comprehensive needs assessment activities and annual reporting.
• Trudy Esch, MS, BSN, RN, Nurse Consultant, Division of Child and Adolescent Health has worked for 37 years as a nurse, with 20 years in academia and 10 years of state level experience. She oversees contract monitoring for Title V local MCH services funded through 45 local health departments.

Additional managers and staff across MCH program areas provide oversight and administration of services funded by Title V. These include managers and staff in the Childhood Lead Poisoning Prevention Program; the reproductive health unit; the infant health unit; the infant safe sleep program; the oral health unit; the adolescent and school health unit; and the Division of Immunization. Representatives from each Title V program area serve on the Title V steering committee to ensure a coordinated approach to Title V activities.

Title V funding currently supports five state-level positions that provide administrative support to the Title V block grant. Two positions provide oversight of the local MCH program; two positions provide epidemiological support; and one position provides coordination of all block grant activities. These positions are based in MDHHS central office in Lansing, Michigan. Only one LMCH position is supported in full by the Title V block grant; the remaining four positions are supported through blended funding (e.g., state general funds) as most positions have responsibilities in addition to Title V.

Approximately $105,000 of Title V funding helps to support the programmatic work of the Family Center for CYSHCN and its staff, which are paid positions:

• Candida Bush, Director, is a Certified Family Life Educator through the National Council on Family Relations.  She is a parent of two young adults with special health care needs and has worked over 25 years to support, empower, and increase access to services for CSHCN.
• Lisa Huckleberry, Megan Mezel, Aleisha Leavitt, Ayanna Eggleston, Kate Jones (Parent Consultants) are parents of children with special health care needs or chronic health conditions. They have 40 years of combined experience advocating, educating, supporting, and providing direct care to individuals with special health care needs and their families. Parent consultants encourage, engage, and help to empower families to know the value and impact of their voice and their story.
• Dawn Adkins, Program Assistant, is a parent of two adult children with chronic health issues and continues to advocate for their health and the health of others.
• Christina Davis and Brenda Blair (Family Phone Line Representatives) are parents of children with special health care needs or chronic health conditions. They have 17 years of combined experience supporting and advocating for those with special health care needs.

The Title V needs assessment identified MCH workforce capacity and gaps. A provider survey was sent to individuals across the state who provide services to children and families to assess unmet needs impacting the MCH population. In total, 526 responses were captured. The top two survey respondents were Registered Nurses (n=90, 26.9%) and licensed childcare providers (n=65, 19.4%). The provider survey and other needs assessment data revealed that Michigan faces gaps in provider availability, including:

• A systemic lack of mental and behavioral health providers equipped to provide treatment specific to substance use disorders
• A shortage in medical and dental providers for CSHCN
• A statewide shortage of medical and dental providers that accept Medicaid
• A shortage of providers with open caseloads accepting new patients
• A limited numbers of obstetricians and birthing hospitals in rural areas

These findings related to gaps in provider availability align with other studies. A September 2019 Kaiser Family Foundation (KFF) report concluded that Michigan required an additional 529 primary care providers to ensure Michiganders have access to primary care and that only 42% of Michiganders’ primary care needs are met. Similarly, an Altarum report identified a critical shortage of behavioral health providers in Michigan. Of the 1.76 million Michiganders experiencing a mental illness, about 62% receive treatment. Additionally, only 20% of Michiganders with a substance use disorder receive treatment.

MCH provider shortages in Michigan align with similar shortages across the US. The March of Dimes report Nowhere to Go: Maternity Care Deserts Across the US (2018) revealed an uneven distribution of MCH providers (OB/GYN, certified nurse-midwives, and family physicians) across the US, which contributes to access inequities in certain communities and rural areas. Almost half of US counties lack a single OB/GYN, and more than 20 million women lived in counties without an OB provider. The US also faces a critical shortage of Registered Nurses. According to the 2018 National Sample Survey of Registered Nurses (HRSA), 83% of licensed nurses were currently employed and 47.5% were over the age of 50. Michigan also faces an aging nursing workforce. Additionally, according to the 2019 Michigan Annual Nurse Survey 12.4% of Michigan nurses who provide direct patient care and 27% of nurses who do not provide direct patient care plan to leave the workforce in the next five years.

Equally problematic is the shortage of pediatric subspecialists, pediatric surgical specialists, child and adolescent psychiatrists, and advanced practice professionals. The Children’s Hospital Association Survey (2017) reports that nationwide, these shortages exacerbate burdens on families who experience long wait times for appointments and often must travel great distances to obtain care.

The needs assessment also found strengths and gaps in the degree to which the MCH workforce feels well prepared for their roles. When asked on the provider survey whether they agreed with the statement “My workforce has access to high-quality training specific to their role” 52% of respondents strongly agreed, 27% agreed, and 18% disagreed. Additionally, the needs assessment found:

• Longstanding MCH staff and leaders at the local and state level bring expertise and wisdom to the MCH system
• Michigan’s MCH system is collaborative and provides opportunities for statewide learning
• Providers need additional training and resources on cultural competency
• Providers need additional training and resources to assess and address patients’ basic needs

These findings can inform future efforts to strengthen Michigan’s MCH and public health workforce in partnership with MDHHS, local partners, and colleges and universities.

The Title V needs assessment utilized and built upon a wide range of partnerships and collaboration. Long-standing relationships between MDHHS and public and private organizations, service providers, and advocacy organizations were identified as a strength in the needs assessment. These relationships allow for collaborative and coordinated work which strengthens the ability to meet MCH population needs. For example, MDHHS provides Title V funding to local health departments to address MCH needs through local program implementation. MDE is also a close partner in programs supporting early childhood, school health, and child and adolescent health. MDE and MDHHS have a long history of integrated funding for early childhood, Child and Adolescent Health Centers, Hearing and Vision school-based screenings, and shared state-level positions.

Key Title V and MCH partnerships include the following: Children’s Special Health Care Services Advisory Committee; Children’s Trust Fund; Early Childhood Investment Corporation; Early Hearing Detection and Intervention (EHDI) Advisory Committee; Family Leadership Network; Family to Family Health Information Center; Great Start Operations Team; Health Disparities Reduction and Minority Health Section; Infant Safe Sleep State Advisory Team; Michigan Alliance for Families; Michigan Association for Local Public Health; Michigan Association of Health Plans; Michigan Breastfeeding Network; Michigan Council for Maternal and Child Health; Michigan Family Voices; Michigan Health and Hospital Association; Michigan Maternal Mortality Surveillance Committee; Michigan Primary Care Association; Michigan Oral Health Coalition; Regional Perinatal Quality Collaboratives; School-Community Health Alliance of Michigan.

Provider organizations such as the Michigan chapters of the American College of Obstetrics and Gynecology, American Academy of Pediatrics and Society of Adolescent Medicine enhance health advocacy efforts and offer education and training. Several Michigan universities partner in program evaluation and in pilot projects to expand services, including projects in telemedicine and telepsychiatry. Tribal, youth-serving, faith-based, community-based and other non-profit organizations are often recipients of grant funds for service delivery and create linkages to service recipients, allowing MDHHS to uplift the consumer voice through consumer representation on advisory boards, councils and task forces.

Lastly, the Title V program regularly partners with other federal investments (including the State System Development Initiative, Newborn Screening, MIECHV, Healthy Start, Medicaid, and WIC) and state programs (including chronic disease and injury control, substance abuse prevention, behavioral health, vital records, and epidemiology). Many of these partnerships and collaborative initiatives are described throughout this application.

The findings from Michigan’s needs assessment drove identification of seven state priority needs which were used to select seven NPMs and six SPMs. The alignment between NPMs/SPMs, state priority needs, and population domains is illustrated in the NPM/SPM chart included as a Supporting Document. The needs assessment also identified three “pillars” that apply across Michigan’s state action plans.

The process of selecting state priority needs included two phases. First, the 50+ priority need statements developed by the population domain workgroups were reviewed to identify commonalities. Similar statements were consolidated, resulting in a list of 35 priority needs. Second, the priority need statements were reviewed to determine if they were within or outside the scope of Title V. As a result of this process, priority needs were sorted into five categories:

1. Title V State Priority Needs
2. Title V Pillars
3. Needs Assessment Gaps
4. MCH Priorities
5. Priorities to Elevate beyond MCH

Priority needs in the first category were selected as Michigan’s Title V state priority needs for the next five-year cycle. They aligned with the purpose of Title V and could be linked to performance measures and/or used to develop SPMs. The Title V priority needs for 2021-2025 are:

1. Develop a proactive and responsive healthcare system that equitably meets the needs of all populations, eliminating barriers related to race, culture, language, sexual orientation, and gender identity.
2. Improve access to high-quality community health and prevention services in the places where women, children, and families live, learn, work, and play.
3. Ensure children with special health care needs have access to continuous health coverage, all benefits they are eligible to receive, and relevant care where they learn and live. 
4. Expand access to developmental, behavioral, and mental health services through routine screening, strong referral networks, well-informed providers, and integrated service delivery systems.
5. Improve oral health awareness and create an oral health delivery system that provides access through multiple systems.
6. Create and enhance support systems that empower families, protect and strengthen family relationships, promote care for self and children, and connect families to their communities.
7. Create safe and healthy schools and communities that promote human thriving, including physical and mental health supports that address the needs of the whole person.

The needs categorized as Title V pillars aligned with the purpose of Title V and were used to inform NPM and SPM state action plans. They reflected broad and overarching drivers of health outcomes and system effectiveness. The Title V pillars are:

1. Build capacity to achieve equitable health outcomes by understanding and addressing the role of implicit bias and macro-level forces (such as racism, gender discrimination, and environmental degradation) on the health of women, infants, children, adolescents, and children with special health care needs.
2. Intentionally and routinely find opportunities to seek the knowledge and expertise of communities and families in all levels of decision-making to build trust and create policies and programs that align with family and community needs.
3. Deliver culturally, linguistically, and age-appropriate health education that reflects customer feedback, effectively uses technology, and reaches multiple audiences.

Needs in other categories will be carried forward in various ways. Three needs suggested gaps in the needs assessment and will be used to inform future assessment activities. Ten needs were identified that aligned with the work of broader MCH programs and partners. These priorities highlighted needs related to addressing social determinants of health, strengthening advocacy, diverse representation in the workforce, and respite care. These priorities can be considered through MCH programs beyond Title V and/or addressed through partnerships.

Lastly, ten needs were identified that are broader than Title V and the MCH system. These priorities included creating systems for whole person care, improving rural health care, addressing payment barriers and administrative and funding silos, abolishing racism and other forms of oppression, and creating equitable distribution of income. These findings will be shared with leadership in the Public Health Administration and with other system partners. For example, Michigan is currently conducting its State Health Assessment and these priorities will be elevated as part of that process.

Michigan developed its state priority needs in 2015 and 2020 through a comprehensive group process. In each cycle, dozens of MCH partners reviewed data and developed priority need statements independent of priorities that emerged from the prior assessment. Given this process, it is highly unlikely that the specific statements developed from one iteration of the needs assessment to the next would be the same. As such, Form 9 indicates all state priority needs as “new.” However, commonalities and differences emerged between the two cycles, as illustrated in Table 1.

Table 1: Alignment between FY 2016-2020 and FY 2021-2025 Priority Needs

In both cycles, the needs assessments suggested gaps in access to healthcare, including physical, mental, behavioral, developmental, and oral health care. They also highlighted the need to expand or enhance key components of the service system for families, including preventive services, early intervention, and services for children with special needs. Both sets of priority needs also highlighted the need to partner with schools and communities to foster safety and wellbeing.

Compared to the 2015 needs assessment, the 2020 needs assessment resulted in priority needs more focused on equity and social determinants of health. It also focused more explicitly on integrated, whole-person care, as well as delivering care and services where people live, learn, work, and play. Finally, this needs assessment more explicitly focused on family partnership in defining need, shaping services, and driving improvement.

NPMs and SPMs were assessed and selected based on three main criteria: conceptual alignment between the measure and the priority need statement; the capacity of the Title V program to impact the measure (e.g., whether activities, funding, and/or leadership related to the measure are within the scope of Title V); and current performance based on population health data. Title V leadership determined whether state or local Title V resources were allocated toward the measure, and MCH epidemiologists examined each NPM and potential SPM to identify disparities, trends, and Michigan’s performance related to the US. Once NPMs and SPMs were selected they were vetted with the Title V Steering Committee and presented to the Needs Assessment Stakeholder Group.