Goals, Framework, and Methodology

The Ohio Department of Health (ODH) is the designated state agency responsible for the Title V Maternal and Child Health (MCH) programs. Within ODH, the Bureau of Maternal, Child, and Family Health (BMCFH) administers Title V programs to address preventive and primary care needs, which are family-centered, community-based and culturally appropriate for MCH populations. The overarching goal of the MCH Block Grant is to support and promote the development and coordination of systems of care for women of childbearing age, infants, and children, including children with special health care needs (CSHCN), adolescents, and families in Ohio.

In compliance with Title V legislation, every five years ODH is required to assess the needs of the MCH population, identify gaps in services, and ensure the state’s capacity to meet these needs. In alignment with state and national health objectives, the MCH needs assessment process serves as the driver in determining state Title V program priority needs and developing a five-year Action Plan to address them. Ohio’s needs assessment findings helped inform the selection of the state’s ten highest priority needs for its MCH and CSHCN populations.

In September 2018, the ODH entered into contract with the Health Policy Institute of Ohio to lead a large, multi-faceted needs assessment and state planning process to include the State Health Assessment (SHA), development of the State Health Improvement Plan (SHIP), the Title V Needs Assessment, and the Maternal, Infant, and Early Childhood Home Visiting Needs Assessment (MIECHV). Alignment of needs, increasing efficiency and capacity, and greater utilization of stakeholders were foundational to the joint needs assessment process. The project was managed through a SHA/SHIP Steering Committee and MCH/MIECHV Steering Committee working alongside ODH staff throughout the prioritization and decision-making process.

A strategic mixed-method approach was used to identify MCH needs. Multiple methods for obtaining stakeholder input included regional forums and an online survey, key informant interviews, feedback from the CMH Parent and Medical Advisory Committees, feedback from MCH/MIECHV Steering Committee, and feedback from ODH BMCFH staff. Priorities were discussed through the lens of health outcomes, social determinants of health, prevention and health behaviors, and healthcare system and accessibility. In addition, a review of data was conducted using data from the National Outcome Measures (NOMS), National Performance Measures (NPMS), and over 500 metrics compiled in the ODH online SHA.

Top priorities were identified through a crosswalk of stakeholder feedback and data analysis based upon Ohio’s performance in comparison to the United States. Prioritization criteria for the five population domains included the ability to track progress, potential for impact, nature of the problem, and alignment. Additional details for the MCH Needs Assessment are provided in the subsequent sections of the Process Description and the full MCH Needs Assessment Report, which is attached to the application in section V. Supporting Documents. The MCH Needs Assessment data were key to the finalization of priorities, selection of performance measures to drive improvement, and development of the Action Plan, with additional details on this process presented in III.C.2.c. Identifying Priority Needs and Linking to Performance Measures.

Qualitative Data and Stakeholder Involvement

The MCH Needs assessment process relied on five sources of qualitative data to include a wide representation of stakeholders.

Regional forums and online survey- HPIO facilitated five regional forums in October 2018 and conducted an online survey that was completed by forum attendees and other stakeholders. The purpose of the forums and online survey was to gather information on priorities and needs across the five MCH population domains, MCH strengths and challenges, and equity needs for addressing drivers of gaps in health outcomes to ensure all children and families achieve their full health potential. Overall, 692 stakeholders participated in either a regional forum or completed the online survey. Regional forum attendees and online survey respondents represented a variety of organizations, sectors, and perspectives, including MCH advocates, health care, public health, behavioral health, community residents, and consumer groups. Each regional forum began with a brief overview and summary report of Ohio’s performance on key maternal and child health indicators followed by two rounds of small group discussions. Regional forum attendees were seated in small groups with an assigned facilitator and asked to provide feedback on a series of questions. During the first round, discussion focused on community maternal and child health strengths, challenges, and equity, and participants were grouped by county type. During the second round, participants were asked to sit at a table representing one of the five MCH population health domains and participants completed a worksheet ranking a set of issues based on what they viewed as the biggest needs. The online survey was structured similarly to the worksheets completed by forum participants to rank issue and also asked respondents to identify the groups experiencing the worst health outcomes within the population domains. Regional forum attendees were invited to complete the online survey for population domains other than those for which they provided feedback at the regional forum. All of Ohio’s 88 counties were represented by online survey respondents.

Informant interviews- HPIO conducted 15 key informant interviews to assess the quality and capacity of early childhood home visiting in the state. Of the 15 organizations interviewed, 13 were home visiting providers or funders/payers of home visiting services, five were state agencies or commissions, one was a health plan and one was a statewide advocacy organization. Interviewees provided information on barriers and challenges faced by women and families in accessing home visiting services.

MCH-MIECHV Steering Committee- HPIO and ODH convened the Steering Committee to inform the identification of MCH priority needs and performance measures and provide input into the state’s MIECHV needs assessment. The Steering Committee included 35 maternal and child health and home visiting experts representing 27 organizations from around the state including representatives from the following state agencies, commissions, and advisory groups: Ohio Departments of Health, Medicaid, Developmental Disabilities, Mental Health and Addiction Services, Education, Job and Family Services, and Ohio Commission on Minority Health, Ohio Children’s Trust Fund, Governor’s Office of Children’s Initiatives, and Ohio Family 2 Family.

CMH MAC and PAC- ODH conducted focused conversations in December 2018 and May 2019 with members of the Children with Medical Handicaps Medical Advisory Council and Parent Advisory Committee to garner additional feedback on the needs of children and youth with special health care needs (CYSHCN). MAC and PAC inform ODH and other entities on policy, system, and program structures to support and improve physical, social, and emotional outcomes for CYSHCN and their families.

BMCFH Staff- HPIO gathered input from ODH BMCFH staff at two points during the needs assessment process. In January 2019 HPIO presented the preliminary findings from the regional forums and online survey and gathered feedback on the health priority needs that were identified and whether other priority needs that did not rise to the top should be explored further. In June 2019 HPIO presented the top ranked health priority needs based on stakeholder input and secondary data analysis and gathered feedback on identifying a final set of health priority needs and potential performance measures.

Quantitative Data

To assess the health status of Ohio’s MCH population, HPIO took a comprehensive approach to analyzing secondary data reflecting the modifiable factors that influence health and grouped data findings into categories of health outcomes, community conditions, health behaviors, and access to care. The secondary data analysis identified notable findings based on one or more of the following factors: Ohio’s performance was better than the U.S. by 10% or more, Ohio’s data trend improved, Ohio’s performance was worse than the U.S. by 10% or more, Ohio’s data trend worsened, or Ohio experienced large disparities/inequities by race, ethnicity, income, geography, or other characteristic. HPIO analyzed data from the national outcome measures (NOMs) and national performance measures (NPMs) provided by the Health Resources Services Administration (HRSA) and metrics compiled by ODH in the Ohio Online State Health Assessment (SHA) and Summary Report. Data sources included health surveys (such as the Behavioral Risk Factor Surveillance System), Vital Statistics (birth and death records), healthcare system utilization data, and data from sectors beyond health (e.g. housing, transportation, education). A full list of metrics is available in appendix C of the MCH Needs Assessment report attached in section V. Supporting Documents.

The full report (available in section V. Supporting Documents) prepared by HPIO describes in detail the findings from the quantitative and qualitative analyses, including strengths and challenges for the MCH populations, health inequities and disparities, differences in stakeholder input by regions, and alignment between the identified MCH priority needs and priority areas in Ohio’s 2020-2022 State Health Improvement Plan (SHIP). A summary of overall MCH findings and summaries by population domain are presented below. MCH programs are included in the population summaries (only listed in one population despite serving multiple) and a full listing of programs (and all populations served) is available in the Program Map in section V. Supporting Documents. The resulting priorities are also listed and additional details on the process for selecting priorities and measures is available in section III.C.2.c. Identifying Priority Needs and Linking to Performance Measures.

The top three maternal and child health strengths identified by stakeholders in Ohio were strong collaboration and partnerships at the local level, prevention and public health programs and policies geared towards maternal and child health, and strong focus on prevention and social determinants of health. The top three challenges were identified as transportation, funding and capacity limitations, and lack of healthcare access. The sub-populations most-frequently identified as having the largest maternal and child health disparities for Ohio overall are low-income Ohioans, African American/Black Ohioans, residents of rural or Appalachian areas, and people with disabilities. Stakeholders identified the top drivers of gaps in health outcomes as poverty/income, educational attainment, transportation, and family stability. The most common response to needs for achieving health equity was coordination and collaboration among state- and local-level partners as well as improvements in educational attainment, employment opportunities, and healthcare provider access. Opportunities for systems change identified include improved data sharing and outcome tracking, improved coordination among state agencies, and identification of women and families most in need.

Women/Maternal Health

The rate of severe maternal morbidity per 10,000 delivery hospitalizations in Ohio was nearly 18% lower than the U.S. rate in 2015. However, the maternal morbidity rate for Hispanic, non-Hispanic Asian/Pacific Islander, and non-Hispanic Black women was higher than the rate for non-Hispanic white women (2.3, 1.8, and 1.7 times higher, respectively). Rates of early prenatal care have improved, however, African American and women without a high school diploma are less likely to receive prenatal care. The Ohio rate for well-woman visit has improved since 2015 and is slightly above the national rate, but room for improvement exists. Ohio’s teen birth rate has declined from 2014 to 2017 (25.2 to 20.8).

Mental health and addiction are serious issues facing Ohio’s maternal population. More Ohio women (16.2%) experience postpartum depression in 2015 compared to the U.S. (12.8%) and an increase of more than 20% occurred in Ohio from 2012 to 2015. Unintentional drug overdose deaths for the overall Ohio population increased through 2017 but promising decreases were seen from 2017 to 2018. Ohio’s rate of fetal alcohol exposure is nearly 20% lower than the U.S. rate. Ohio’s rate of women who smoked cigarettes during pregnancy decreased by 15.3% between 2014 and 2017 but remained two times higher than the rate for the overall U.S., and women covered by Medicaid had nearly twice the rate of Ohio overall.

MCH programs serving women/maternal health population include the Reproductive Health and Wellness Program, FASD Program, Perinatal Smoking Cessation Program, Pregnancy-Associated Mortality Review, and Sexual Assault and Domestic Violence Prevention Program. Across all populations, the MCH Oral Health program supports access to dental care and MCH supports the Primary Care Office to identify and support medically underserved communities and the State Office of Rural Health in supporting access for rural populations in Ohio. While not MCH funded, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and Home Visiting programs also serve Ohioans across the MCH populations.

Stakeholders identified the top five needs for women/maternal health across several categories:

• Health outcome needs: infant mortality and birth outcomes, mental health and suicide, drug use and dependency, unintended pregnancy and teen birth, and tobacco use.
• Social determinant of health needs: poverty, housing, transportation, employment and income, and Adverse Childhood Experiences (ACEs).
• Public health system, prevention, and health behavior needs: substance use/abuse, sexual and reproductive health, tobacco use, nutrition, and violence.
• Healthcare system and access needs: access to health care, access to mental health services, access to substance use/addiction treatment, insurance coverage and healthcare affordability, and home visiting and/or parent education.

The resulting MCH priorities: Decrease risk factors contributing to maternal morbidity; Increase mental health support for women of reproductive age; and Decrease risk factors associated with preterm births. To address the priority of maternal morbidity efforts must include improving the health outcomes for women before, during, and after pregnancy. The selected NPM 1 relates to leveraging women’s well visits as key opportunities for health intervention and referrals. The need to address mental health for both women of reproductive and pregnant and postpartum women is reflected in the selection of outcome and performance measures (SPM unmet mental health need among women of reproductive age). The risk factors associated with preterm birth include and extend beyond interventions for pregnant women. The selection of the SPM for smoking among reproductive age women aligns with the need to address smoking before women become pregnant to complement the existing efforts to identify and support pregnant women in quitting during pregnancy.

Perinatal/Infant Health

Ohio’s 2016 infant mortality rate was 1.25 times greater than the U.S. rate. While Ohio has seen a decrease of 18.4% in infant mortality due to preterm birth and low birthweight babies, Ohio has worse outcomes than the U.S. across multiple infant mortality measures, including neonatal, post-neonatal, sleep-related, and pre-term related mortality. Non-Hispanic Black infants in Ohio had the highest mortality rate in 2018 (14 per 1,000), 2.6 times as high as the non-Hispanic white rate (5.3 per 1,000).

Ohio’s rate of infants born with neonatal abstinence syndrome (NAS) per 1,000 births was 76.5% higher than the U.S. rate and has increased in recent years. Further, Ohio infants covered by Medicaid experience NAS at nearly double the rate of Ohio overall.

Breastfeeding rates improved in Ohio between 2012 and 2015. The percent of infants ever breastfed increased by 13.9% (from 71.9% to 81.9%), and the percent of Ohio infants breastfed exclusively through six months increased by 63.4% (from 14.5% to 23.7%). Safe sleep rates also improved nearly 8% between 2012 and 2015, with the percent of infants places on their back to sleep increasing from 79.3% to 85.5%.

MCH programs serving the perinatal/infant health population include Title V Breastfeeding and Ohio First Steps for Healthy Babies, Infant Safe Sleep and Cribs for Kids©, Moms and Babies First, the Ohio Equity Institute, Newborn Screening for Critical Congenital Heart Disease, Comprehensive Genetics Services Program, Sickle Cell Services, Infant Hearing, Ohio Connections for Children with Special Needs (OCCSN) Birth Defects Surveillance Program, Sudden Infant Death Syndrome Program, and Fetal Infant Mortality Review. While not MCH funded, the Women, Infants, and Children (WIC) and Home Visiting programs also serve Ohioans across the MCH populations.

Stakeholders identified the top five needs for perinatal/infant health across several categories:

• Health outcome needs: infant mortality and birth outcomes, drug use and dependency, mental health and suicide, unintended pregnancy and teen birth, and violence.
• Social determinant of health needs: poverty, housing, transportation, ACEs, and family and social support/family functioning.
• Public health system, prevention, and health behavior needs: breastfeeding, safe sleep, violence, nutrition, and parent/caregiver tobacco use.
• Healthcare system and access needs: access to health care, home visiting and/or parent education, insurance coverage and healthcare affordability, care coordination, and access to social services.

The resulting MCH priority: Support healthy pregnancies and improve birth and infant outcomes. Addressing the disparity in birth and infant outcomes will be measured through the SOM created for the Black infant mortality rate. Improvements in infant outcomes will be measured through NPM 4 breastfeeding and NPM 5 safe sleep.

Child Health

Ohio’s children have similar overall health status when compared to the U.S., but a higher child mortality rate. In measures of access, Ohio children have a lower rate of uninsured, higher rate of medical home, and higher rate of receiving mental health treatment than the U.S. Ohio children also have a lower rate of tooth decay/cavities and decreasing rate of unmet dental care needs, but disparities for African American and Appalachian children persist. Ohio has similar rates for developmental screening but has not seen an improvement in this outcome. Compared to the U.S., Ohio has a lower rate of obesity among 2-4-year-olds, but a higher rate among ages 10-17, with lower income children experiencing disparities. Ohio performs similarly to the U.S. on several metrics related to nutrition and physical activity: fruit and vegetable consumption, access to exercise opportunities, and physical activity among children.

Ohio’s overall child asthma prevalence is lower than the U.S. and has improved in recent years, but African American and Hispanic children are 1.5 times more likely to have asthma than white children in Ohio. In 2016-2017, nearly a quarter of Ohio children (23%) lived in a home where someone smokes, which is 1.5 times the percent among U.S. children.

MCH programs serving the child health population include Early Childhood Health, School Hearing and Vision, Ohio Healthy Homes and Lead Poisoning Prevention Program, School Nursing, and Child Fatality Review. While not MCH funded, the Women, Infants, and Children (WIC) and Home Visiting programs also serve Ohioans across the MCH populations.

Stakeholders identified the top five needs for child health across several categories:

• Health outcome needs: mental health and suicide, drug use and dependency, child maltreatment, healthy weight status/obesity, and violence.
• Social determinant of health needs: poverty, family and social support/family functioning, ACEs, housing, and education/school readiness.
• Public health system, prevention, and health behavior needs: nutrition, violence, substance use/abuse, physical activity, and health literacy.
• Healthcare system and access needs: access to health care, access to mental health services, insurance coverage and healthcare affordability, access to dental care, and access to substance use/addiction treatment.

The resulting MCH priority: Improve nutrition, physical activity, and overall wellness of children. To address the priority of improving overall child health efforts must address a broad range of issues impacting children. Pediatric primary care visits represent a key opportunity for monitoring and addressing the comprehensive needs of children’s health. The selected NPM 6 relates to the critical role of developmental screening in monitoring and supporting child development.

Adolescent Health

Mental health and addiction issues are a challenge for Ohio. Adolescent and young adult suicide has increased by more than half from 2009 to 2018. The rate of adolescents with a major depressive episode in the past year has increased since 2011 and the percent of adolescents who bully others and who report being bullied is higher in Ohio than the U.S.

According to Ohio’s Youth Tobacco Survey, e-cigarettes/vaping products were the most commonly used tobacco products by high school students in 2017 and U.S. data indicates that e-cigarette use among U.S. high school students increased from 11.7% in 2017 to 20.8% in 2018. The percent of adolescents, ages 12-17, perceiving great risk in consuming five or more drinks of an alcoholic beverage once or twice a week improved by 13.5%, increasing from 37% in 2013-2014 to 42% in 2016-2017. For young adults, ages 18-25, drug overdose deaths have more than doubled from 138 deaths in 2007 to 319 deaths in 2018. However, there was a promising decline of 28.8% in the overdose death rate for young adults between 2017 and 2018.

Ohio’s rates of adolescent well-visits compare with the national rates, and improvements have been observed with nearly 80% of adolescents obtaining a well-visit, but disparities persist. While the overall rate by well-visits among Medicaid enrollees are lower, between July 2015 and June 2018, the rate improved 4% (42.6% to 44.3%).

MCH programs that serve the adolescent health population include Adolescent Health, School Nursing, Reproductive Health and Wellness Program, Sexual Assault Domestic Violence Prevention Program, and Youth Risk Behavior Survey/Youth Tobacco Survey.

Stakeholders identified the top five needs for adolescent health across several categories:

• Health outcome needs: mental health and suicide, drug use and dependency, violence, healthy weight status/obesity, and tobacco use.
• Social determinant of health needs: poverty, ACEs, family and social support/family functioning, housing, and education.
• Public health system, prevention and health behavior: substance use/abuse, alcohol use, tobacco use, sexual and reproductive health, and nutrition.
• Healthcare system and access needs: access to mental health services, access to health care, access to substance use/addiction treatment, insurance coverage and healthcare affordability, and access to social services.

The resulting MCH priorities: Increase developmental approaches and improve systems to reduce adolescent and young adult suicide rate; Increase protective factors and improve systems to reduce risk factors associated with the prevalence of adolescent substance use. The selected NPM 10 aligns with the priorities as adolescent preventive medical visits provide key opportunities for screening, education, and referral on numerous topics including mental health and substance use.

Children with Special Health Care Needs

Overall Ohio has a higher proportion of children with special health care needs (CSHCN) compared to the U.S. (21.9 vs. 18.8). In Ohio, CSHCN have a similar rate of receiving care in a well-functioning system and a higher rate of receiving care in a medical home compared to the U.S. CSHCN have many of the same challenges faced by children without special healthcare needs in Ohio, including mental health and addiction. However, disparities exist. Children with special health care needs are 2.5 times more likely than children without special health care needs to be bullied. Challenges related to accessing healthcare also emerged from the data. For example, stakeholders highlighted the need for greater care coordination and increased access to services for children with autism, spectrum disorders, developmental disabilities, and learning disabilities. Adolescents, ages 12-17, with and without special health care needs, were also more than 17% less likely than U.S. peers to receive the services necessary to transition to the adult healthcare system in 2016-2017.

MCH programs serving the CSHCN population include the Children with Medical Handicaps Program (CMH) which includes the Title V supported Diagnostic Program, Treatment Program, Metabolic Formula, and Hearing Aid Assistance Claims Processing and programs with other state funds include Hospital-based Service Coordination, Adults Cystic Fibrosis, Adult Hemophilia Insurance Premium Payment, and Payor of Last Resort. The newborn screening and newborn screening follow-up programs listed in the perinatal/infant section and programs listed in the child section also serve CSHCN.

Members of the CMH Parent Advisory Committee (PAC) and Medical Advisory Council (MAC) were asked to reflect on strengths, challenges, and opportunities to improve health and health care outcomes for CSHCN and their families. The following opportunities and challenges were identified. Challenges: health systems discharge pediatric patients with medical complexity from the hospital to a home that is not equipped to address their needs; additional medical and emotional support services are needed for patients and caregivers; CSHCN and their families face barriers with primary payers who question and deny prescribed treatments/pharmaceuticals. Opportunities: Increase and improve services that promote and support transition to adulthood healthcare throughout adolescence; increase screenings for mental health needs of parents/caregivers of CSHCN and provide resources and connections to care; improve inclusion opportunities for CYSHCN within education and in settings that promote physical activity (e.g., state and local parks); increase and improve workforce development for those who provide physical and mental health services to CYSHCN to improve comprehensive and quality care; and educate primary payers on the rationale for why certain/unique services/goods need to be covered for this specialized population.

Stakeholders identified the top five needs for CSHCN health across several categories:

• Health outcome needs: mental health and suicide, child maltreatment, drug use and dependency, child maltreatment, infant mortality and birth outcomes, and violence.
• Social determinant of health needs: family and social support/family functioning, poverty, ACEs, housing, and transportation.
• Public health system, prevention and health behavior: health literacy, violence, substance use/abuse, nutrition, and tobacco use.
• Healthcare system and access needs: insurance coverage and healthcare affordability, access to health care, access to mental health services, care coordination, and services for children with autism, spectrum disorders, developmental disabilities and learning disabilities.

Resulting MCH priority: Increase prevalence of children with special health care needs receiving integrated physical, behavioral, developmental, and mental health services. The selection of the NPM relates to the need to address transitions to adult care.

Cross-Cutting

An estimated 50% of modifiable factors that influence health are attributed to community conditions/social determinants of health, or the factors within the social, economic, and physical environments in which families live. Community conditions, such as housing, transportation, education, and unemployment, lay the foundation for good health outcomes and are critical to ensure all mothers infants, children, and families in Ohio have the opportunity to lead healthy lives. Drivers in gaps in outcomes include poverty, racism, discrimination, trauma, violence, and toxic stress. Ohio has made some notable improvements in child poverty and unemployment; however, Ohio has many opportunities to improve outcomes across community conditions, particularly for exposure to violence and trauma, lead risk, and transportation.

The percent of Ohio fourth-graders proficient in reading is higher in Ohio than in the U.S., but disparities persist for children from low-income, Black, and Hispanic families. Ohio has experienced positive trends in recent years for income, employment, and poverty but performs worse than the U.S. for unemployment and median household income and in 2016 Black children were more than three times as likely to live in poverty than white children in Ohio. Ohio performs better than the U.S. on access to federal housing assistance and the number of people experiencing homelessness per capita. The percent of children in Ohio identified with elevated blood lead levels is below the U.S. rate, but lead exposure risk in many Ohio cities is extremely high.

Ohio performs similar to the U.S. for child abuse and neglect, incarceration, and intimate partner violence. Ohio had fewer violent crimes per capita than the U.S., but a higher incidence of children exposed to adverse childhood experiences (ACEs). Black, non-Hispanic children and children with low incomes were much more likely to be exposed to two or more ACEs as compared to peers.

Families in Ohio experience various transportation challenges with lower proportion of active commuting, lower transit accessibility in three cities, and more Black households without access to a vehicle than white households. The percent of households that are food insecure in Ohio decreased by 20% from 18% in 2011 to 15% in 2016 but remains above the U.S. rate of 13% in 2016. Food insecurity differed markedly by county, with a high of 20% in one Appalachian county.

Stakeholders noted the top social determinant of health needs across all populations as poverty, housing, adverse childhood experiences, employment and income, and transportation. When asked what needs to happen to achieve health equity, the most common response from stakeholders was coordination and collaboration among both state- and local-level partners. This was followed by improvements in educational attainment, employment opportunities, and healthcare provider access.

Resulting MCH priorities: Prevent and mitigate the effects of adverse childhood experiences; Improve healthy equity by addressing community and social conditions and reducing environmental hazards that impact infant and child health outcomes. These priorities will be addressed within each population domain and also from a systems-level.

ODH is a cabinet-level agency that reports to the Governor's Office. As a cabinet-level agency, the ODH Interim Director Lance Himes reports to the Governor's Office. ODH is organized by Offices/Bureaus that ultimately report to the Chief of Staff. ODH is organized according to our core public health responsibilities:

• Eliminate health disparities, improve birth outcomes, and improve the health status of women, infants, children, youth, and families in Ohio – Bureau of Maternal, Child, & Family Health
• Prevent and control the spread of infectious diseases – Bureau of Infectious Diseases
• Provide direction, support and coordination in preventing, preparing for and responding to events that threaten the public’s health – Office of Health Preparedness
• Build strong communities to enable Ohioans of all ages and abilities live disease and injury-free – Bureau of Health Improvement and Wellness
• Address health inequities and disparities, and support access to comprehensive, integrated healthcare for all to achieve the best possible outcomes – Office of Performance and Innovation
• Assess and monitor environmental factors that potentially impact public health including air, water, soil, food, and physical and social features of our surroundings – Bureau of Environmental Health and Radiation Protection
• Assure quality in health care facilities, health care services, and environmental health through smart regulation to protect the health and safety of Ohioans – Office of Health Assurance and Licensing

Additionally, there are several Offices and Bureaus within the agency that assist with internal and external operations, including the Bureau of Vital Statistics, Bureau of Public Health Laboratory, Office of the Medical Director, Office of Management Information Systems, Office of Human Resources, Office of Financial Affairs, Office of Government Relations, Office of Communications, and the Office of General Counsel.

A total of 1,241 employees work for ODH. The majority of ODH employees work in the ODH central office located in Columbus, Ohio and approximately 200 work in the field at district or remote locations across Ohio. ODH is the designated state agency for implementation of the Title V Maternal and Child Health Block Grant (MCH BG) in Ohio. The Bureau of Maternal, Child, and Family Health (BMCFH) is responsible for MCH programs at the state/local level. The BMCFH is designed to improve the health status of women, infants, children, adolescents, and CSHCN in Ohio by identifying needs and implementing programs and services to address those identified needs. The BMCFH capacity to address the five population health domain needs is accomplished by engaging in a multidisciplinary, collaborative approach to health improvement in coordination with internal and external stakeholders.

Programs administered and housed within the BMCFH supported by Title V funding include: Children with Medical Handicaps (CMH) Program, Title X Reproductive Health and Wellness, Gestational Diabetes Collaborative, Perinatal Quality Improvement programs, Infant Mortality, Ohio Equity in Birth Outcomes Institute (OEI), Group Prenatal Care Initiatives, Fetal Alcohol Spectrum Disorders Program, MCH smoking cessation, Infant Safe Sleep, MP Subsidy program (Adolescent Resiliency, Pregnancy and Postpartum Peer Behavioral Health, and Pre/Inter-conception care), Breastfeeding, Genetics Services and Sickle Cell Services related to newborn bloodspot screening for 36 metabolic, endocrine, and genetic conditions, Newborn Screening for Critical Congenital Heart Disease, Ohio’s Birth Defects Surveillance System, the Universal Newborn Hearing Screening (UNHS), the Infant Hearing Program, Children’s Hearing and Vision, Early Childhood Comprehensive Systems (ECCS) program, School Nursing, Adolescent Health, Oral Health, Help Me Grow (HMG) Home Visiting Moms and Babies First (MB) Ohio’s Black Infant Vitality Program, and MCH data and surveillance including Child Fatality Review (CFR), Fetal Infant Mortality Review (FIMR), Ohio Study of Associated Risks of Stillbirth (SOARS), Ohio Pregnancy Assessment Survey (OPAS), Pregnancy Associated Mortality Review (PAMR), Sudden Infant Death Syndrome (SIDS) Program, and the Youth Risk Behavior Surveillance System (YRBS).

BMCFH also houses the Asthma, Save Our Sight (SOS) children’s vision programs, non-Title V Home Visiting including Maternal Infant and Early Childhood Home Visiting (MIECHV), Infant Vitality Community Intensive, Sexual Risk Avoidance Education, Choose Life, and the Supplemental Nutrition Program for Women, Infants, and Children (WIC) and WIC Farmers’ Market Nutrition (WIC FMNP) programs.

Programs with close working relationships and Title V funding outside of the BMCFH include Ohio Healthy Homes and Lead Poisoning Prevention Program, Primary Care Office, State Office of Rural Health, Violence and Injury Prevention, and Sexual Assault and Domestic Violence Prevention. The Title V program also has plans to strengthen programmatic relationships with the Tobacco Use Prevention and Cessation Program and Immunization Program.

The BMCFH engaged in a process to map all programs within the bureau and program characteristics including MCH population(s) served, service level, funding sources, types of partner organizations, inclusion of health equity activities, and if the program is required by Ohio statute. Key partner programs receiving Title V funds outside of the bureau were also included to represent the full scope of the MCH BG funds. The program map details the number of programs serving each of the populations and the breadth of partnerships with external organizations. Additional information on partnerships is available in section b.iii. Title V Program Partnerships, Collaboration, and Coordination. The Program Map is available in section V. Supporting Documents. The program map is also an important planning tool to prioritize during COVID-19 operations including monitoring workforce capacity presented in the next section.

The Children with Medical Handicaps (CMH) program serves CSHCN and administers a diagnostic, treatment, and hospital based service coordination program, supporting team based service coordination for conditions such as spina bifida and hemophilia; and community based service coordination, supporting public health nurses in local health departments who assist families in linking to local resources and helping families navigate the health care system. CMH utilizes vital committee/council structures to foster open dialogue, receive input and feedback regarding CSHCN needs across the state. One of these committees is the Medical Advisory Council (MAC), whose members are appointed by the Director of Health, and represents various geographic areas of Ohio, medical disciplines, and treatment facilities involved in the treatment of children with medically handicapping conditions. CMH also convenes the Parent Advisory Committee (PAC) composed of parents from around the state who meet regularly to advise CMH. The mission of the PAC is to assure that family-centered care is an essential component in the development and delivery of programs and services for CSHCN.

James Duffee, MD, MPH, FAAP, has spent his life advocating for the needs of Ohio’s most disadvantaged children and serves as the chair of the CMH MAC. Dr. Duffee has also been contracted to act an as advisor during the COVID-19 response.

BMCFH also utilizes the medical expertise of two highly skilled physicians who serve as subject matter experts in addressing issues directly impacting MCH populations. Mary Kate Francis, MD serves as the Assistant Medical Director and the current Interim Medical Director. Dr. Francis oversees medical issues with the goal of developing and implementing public health policies to improve the health of all Ohioans. Her work places a strong focus on efforts to decrease Ohio’s infant mortality rate, improve maternal health outcomes, and collaborate with health care providers. Dr. Francis began her career in the public sector as a licensed social worker and spent many years working in the areas of child welfare and mental health.

In addition, Cynthia Shellhaas, MD, MPH provides medical consultation to BMCFH programs serving reproductive age and pregnant women, children, and families and guides ODH’s work in fetal, child, and pregnancy fatality and mortality reviews. Dr. Shellhaas is a licensed OB/GYN specializing in maternal-fetal medicine (high risk obstetrics) and holds a full-time faculty position in the Ohio State University's department of OB/GYN.

The BMCFH has 221 positions in the ODH organizational chart and as of August 2020 employs 179 individuals. Many BMCFH staff are supported by multiple funding sources. Across all bureaus, currently 147 staff receive Title V funding for a total of 89.9 FTEs funded by the MCH BG. Across ODH, 249 staff are immediately eligible for retirement and an additional 158 are eligible within the next five years. Among the 179 BMCFH staff, 58 are eligible for retirement immediately and an additional 13 are eligible within the next five years. During the COVID-19 outbreak, nearly 50 BMCFH staff have contributed to the state’s response. Specifically, BMCFH staff have been assigned full-time or volunteered part-time for Ohio’s COVID-19 call centers, participated on state workgroups to develop guidance for sectors operating safely, participated in the Minority Health Strike Force, led the data team responsible for creating the Ohio Public Health Advisory System, and provided support for the state’s population study of coronavirus infection. Staff not involved in the COVID-19 response have assumed additional duties to continue non-COVID-19 operations. In addition, as of March 2020, Governor DeWine ordered an immediate hiring freeze for all agencies, boards, and commissions under the control of the governor and a freeze on new contract services for the state of Ohio. With over forty vacant positions and the additional COVID-19 responsibilities, BMCFH leadership are utilizing the program map to ensure programs have adequate support to continue operations. ODH and BMCFH maintain resources for recruiting, training, and retaining a qualified workforce. Plans for addressing workforce capacity are in section III.E.2.b.i MCH Workforce Development.

Lance Himes serves as interim director of the agency. He has more than 15 years of public health experience and has previously served as director, interim director, chief of staff, and general counsel for ODH.

William McHugh serves as Assistant Director, over administrative support areas including fiscal, IT, and HR as well as the Bureaus of Vital Statistics and Public Health Laboratory. He has more than 20 years of previous experience at ODH.

Joanne Pearsol serves as the Deputy Director of the new Office of Performance and Innovation where she develops statewide policies and strategic plans to carry out the mission of public health in Ohio in coordination with local health departments, public health providers, as well as community action agencies. She oversees public health accreditation activities as well as leads the agency’s quality improvement efforts.

Dyane Gogan Turner, MPH, RD/LD, IBLCLC, serves as the Title V Director and Chief of the Bureau of Maternal, Child, and Family Health. She has more than 24 years of public health experience working with the Supplemental Nutrition Program for Women, Infants, and Children (WIC), Child and Adult Food Care Program, and Title V Maternal and Child Health programs.

Anna Starr serves as the Assistant Chief for the Bureau of Maternal, Child, and Family Health and has previously served as Interim Chief as well as section administrator for Child and Specialty Health. Anna has over 34 years of experience in maternal and child health.

Patrick Londergan and is the Director of Children and Youth with Special Health Care Needs. Patrick has over 20 years of experience in the Children with Medical Handicaps Program, serving as the administrator of the program for 15 years.

Kirstan Duckett, MPH, CHES, serves as the Title V Maternal Child Health Block Grant Coordinator and previously served as the Birth Defects Surveillance System Coordinator within the BMCFH.

Reena Oza-Frank has extensive training and expertise as a Maternal and Child Health epidemiologist. She manages the Data and Surveillance section for the Bureau. Dr. Oza-Frank leads the State System Development Initiative (SSDI) and Ohio Pregnancy Assessment Survey (OPAS).

Maurice Heriot was hired as the BMCFH Financial Program Manager in March 2018. Prior to this position, Maurice served as fiscal liaison for MCH within the Office of Financial Affairs.

Two parent consultants joined the BMCFH in 2020 with the goal of improving integration of family perspective within programs. Kimberly Mathews is the parent of a child with special health care needs and has extensive background leading CYSHCN patient and family advisory boards and community organizations. Kimberly previously served as the chair for CMH Parent Advisory Committee. Melissa James is also the parent of a child with special health care needs and has extensive background in nonprofits and community organizations. Melissa leads the Pediatric Cancer Work Group for Ohio's Cancer Plan. Both consultants will work throughout the bureau programs and assist with engaging parent perspectives in our work, materials, and activities. In addition, they will lead specific projects around transition for CSHCN, working to improve diversity in the Parent Advisory Committee, and speaking directly with parents in Ohio to provide assistance and mentoring.

The Ohio Title V Program has strong collaborative relationships with other state agencies, local health departments, local public health agencies, academic programs, and professional associations to improve the health of MCH and CSHCN populations. The program also utilizes vital committee and council structures to foster open dialogue and receive input and feedback in regard to implementing effective public health interventions to support and improve outcomes for the MCH population and needs across the state. These structures support the implementation of the Title V 5-Year Action Plan, ODH’s Strategic Plan, and State Health Improvement Plan.

Executive Level State Collaboration starts with the Governor’s Office of Children’s Initiatives and its Cross Agency Leadership Team, Department of Administrative Services (DAS), and Office of Budget Management (OBM) working with the Governor’s Health and Human Services Cabinet Departments of: Job and Family Services (ODJFS), Rehabilitation Services Commission (RSC), Aging (ODA), Mental Health and Addiction Services (OhioMHAS), Developmental Disabilities (DODD), and Medicaid (ODM), with connections to the Departments of: Education (ODE), Rehabilitation and Corrections (ODRC), Youth Services (ODYS), Agriculture (AGR), Veterans Services (DVS), Insurance (ODI), and Taxation (ODT) working together to streamline health and human service operations and governance and coordinate priorities across agency boundaries.

Within Title V programs, collaborative efforts by Ohio’s state, local, and community-based service systems for individuals and families is vitally important. These systems work together on achieving shared policy and programmatic goals to ensure that all of Ohio’s women, infants, children with and without special health care needs, youth and adolescents, and families receive the services they need to promote their health and wellness. These partnerships are critical because no single system has the resources or capacity to meet this goal alone. Where applicable, the Title V program has established inter-agency agreements between ODH and its sister agencies to establish administrative and financial accountability for shared programs. In addition, there are data sharing and research project agreements between ODH and agencies with a mutual interest. These agreements foster the exchange of information for making data-driven decisions regarding MCH policies and practice. Where appropriate and when possible, Title V programs include families of CSHCN and consumers of MCH services on its committees and councils.

A few examples of Ohio’s Title V Programs collaborative efforts include:

• The Governor’s Early Childhood Advisory Council (ECAC) provides input and guidance to the Governor’s Office of Children’s Initiatives and early childhood programs. ECAC membership includes a diverse array of stakeholders from early childhood programs, schools, health, social services, unions, philanthropy, and other groups. Ohio's governance and administrative structures have the authority and responsibility to oversee, implement and coordinate state-funded or state-administered early childhood programs and services for children and their families. Title V staff also represent ODH on the Ohio Child Care Advisory Council responsible for advising and assisting JFS on the administration and development of statewide child care policies and procedures.
• ODH and ODM works together on the coordination of services by the Ohio Medicaid Managed Care Programs.
• At the state, regional, and local levels, the Ohio Medicaid Assessment Survey (OMAS) delivers health and healthcare data and gives insight into the health status of Ohio’s Medicaid, Medicaid-eligible, and non-Medicaid populations. OMAS provides necessary data to measure the impact of healthcare reform over time, especially issues relevant to the efficient administration of the Ohio Medicaid program.
• DODD and ODH have an interagency agreement regarding the implementation of the Help Me Grow Early Intervention and Central Coordination services and sharing of data and referrals with other MCFH programs such as birth defects, infant hearing, and children with medical handicaps.
• The CMH program collaborates closely with Ohio Association of Children’s Hospitals (OACH) as they are a key partner/advocate for health care issues for all children, especially CSHCN. OACH is a key member of the MAC Advisory Council. The Ohio Chapter of American Academy of Pediatrics (OH-AAP) co-chairs the Children with Disabilities Subcommittee with the CMH Medical Advisory Council. This subcommittee is made up of members from the private sector and several state agencies and deals with social/educational issues of CSHCN in addition to medical issues. OH-AAP also participates in many of the Title V Action Groups supporting the implementation of the 5-Year Strategic Plan.
• Title V staff co-lead the Infant Safe Sleep subcommittee of the Ohio Injury Prevention Partnership’s Child Injury Action Group (OIPP, CIAG). The Office of Health Improvement and Wellness leads the OIPP, a statewide partnership that brings stakeholders and experts together to create and implement action plans to address injury priorities, promote policy and system’s change, and improve statewide data collection.
• OhioMHAS, ODE, ODJFS, ODYS, DODD and ODH participate in an Interagency Council for Youth to support the unique needs of youth and young adults with co-occurring disorders. Policy and system improvements are made to the Deputy Directors of the Governor’s Cabinet, when appropriate.
• Title V staff represent ODH on committees with ODE and ODM for school-based health concerns including the Whole Child and Student Wellness and Success committees, the Board of Directors for the Ohio Association of School Nurses, and OH-AAP’s Home and School Health Committee.
• The Fetal Alcohol Spectrum Disorder (FASD) Steering Committee led by OhioMHAS and ODH coordinate efforts to prevent FASD and improve screening and treatment.
• Title V staff also lead or represent ODH on a number of committees to prevent violence including Ohio Sexual Assault and Intimate Violence State Planning Group, Sexual Assault Advisory Board of Central Ohio, Ohio Injury Prevention Partnership, ODE’s Anti-Harassment, Intimidation, and Bullying Committee, Interagency Victim Assistance Coordinating Council, and Family Violence Prevention Council.
• ODH staff participate in SNAP-ED, a statewide collaborative group made up of state agencies and USDA funded nutrition education programs serving similar populations with the goal of information and resource sharing.
• Title V staff participate in a statewide breastfeeding workgroup comprised of breastfeeding experts across the state. The group shares information and resources and identifies strategies and initiatives to improve breastfeeding initiation and duration rates, particularly among African American and Appalachian women.

Please see Section III.E.2.b.ii. Family Partnership for additional information on established family and consumer partnerships including: Ohio Family and Children First Councils, CMH Medical Advisory Council, CMH Parent Advisory Committee, Ohio Developmental Disabilities Council, Ohio’s Interagency Workgroup on Autism, Early Childhood Advisory Council, Early Intervention Advisory Council, CMH Collaboration to Serve Ohio’s Children with Special Health Care Needs, Family-to-Family Health Information Centers, Adolescent Health Partnership, and Ohio Collaborative to Prevent Infant Mortality.

Ohio’s population health assessment and planning efforts were conducted through a joint process including the State Health Assessment (SHA), State Health Improvement Plan (SHIP), Title V MCH Needs Assessment, and MIECHV Needs Assessment. MCH priority needs were first identified by MCH/MCHIEV regional forum and online survey participants. These priorities were then revised and narrowed to a list of ten priority needs based on feedback from members of the MCH/MIECHV Steering Committee, feedback from BMCFH staff, and the results of the secondary data analysis. MCH/MIECHV Steering Committee members and BMCFH staff were asked to consider the following prioritization criteria when providing feedback on the MCH priority needs:

• Ability to track progress: measurable indicators are available to assess and report progress in a meaningful way on an annual basis at the state level
• Potential for impact: availability of evidence-based strategies, co-benefits, feasibility to address at the state level by ODH, and the ability to improve outcomes
• Nature of the problem: magnitude, severity, disparities, U.S. comparison, and trends (based on secondary data analysis)
• Alignment: with Ohio’s 2020-2022 SHIP and other state agency plans and initiatives

From this process, the following 10 MCH priority needs were identified:

• Decrease risk factors contributing to maternal morbidity
• Increase mental health support for women of reproductive age
• Decrease risk factors associated with preterm births
• Support healthy pregnancies and improve birth and infant outcomes
• Improve nutrition, physical activity, and overall wellness of children
• Increase developmental approaches and improve systems to reduce adolescent and young adult suicide rate
• Increase protective factors and improve systems to reduce risk factors associated with the prevalence of adolescent substance use
• Increase prevalence of children with special health care needs receiving integrated physical, behavioral, developmental, and mental health services
• Prevent and mitigate the effects of adverse childhood experiences
• Improve healthy equity by addressing community and social conditions and reduce environmental hazards that impact infant and child health outcomes

After identification of the MCH priority needs, a set of prioritization criteria was used by HPIO to propose national and state outcome and performance measures that aligned with the identified MCH priority needs and could be tracked in the State Action Plan.

• Health priority need alignments: measure aligns with a top MCH priority need
• SHIP alignment: measure aligns with a health outcome or health factor metric in the 2020-2022 SHIP
• NOM and NPM alignment: measure is identified as a NOM or NPM
• Evidence linkage: NPMs selected have an evidence linkage to a NOM
• Population domain alignment: minimum of five NPMs selected, one per MCH population domain

The BMCFH Title V program uses an Action Group structure to manage its MCH Priorities and implement strategies within the 5-Year Action Plan. Following completion of HPIO’s final report with proposed outcome and performance measures, the Action Group teams began meeting in February 2020 on a bi-weekly to monthly basis through summer 2020. Stakeholders from BMCFH and programs and subject matter experts were invited to these meetings to utilize the results of the needs assessment to inform the development of Action Plan. In April 2020 the National MCH Workforce Development Center led the Action Groups through remote training and planning workshops on Results Based Accountability (RBA). Action Groups completed a pre-workshop webinar on utilizing the RBA framework for advancing performance and measurement in addressing needs. During the workshops, tools including the Turn the Curve and Performance Quadrant report were used to help the teams identify data trends, identify root causes and partners, align performance measures, select evidence-based strategies, design evidence-based strategy measures, and identify the potential impact on the NOMs, NPMs, and SOMs. In June of 2020 Action Groups shared the Action Plan framework with sister state agencies in a meeting to ensure the measurements aligned with other state agencies’ goals. Due to limited resources and staff capacity because of the state’s response to the COVID-19 pandemic, the Action Groups plan to continue to expand stakeholder involvement in the groups and refinement in measures during the first year of 2021-2025 implementation. Additional discussion of the measures and alignment with the priorities are available by population domain within Section III.E.2.c. State Action Plan Narrative by Domain.

Since the conclusion of the needs assessment process an emerging issue has been the COVID-19 pandemic. While not on the list of priorities, responding to and protecting maternal, child, and family populations from the outbreak has been prioritized throughout ODH and other state agencies. As mentioned in the MCH workforce capacity section, BMCFH staff are active in the response and BMCFH leadership utilize the Program Map to plan and adjust to ensure all of the MCH priority needs are addressed.