ASSOCIATION OF MATER N AL & CHILD HEALTH PROGRAM S July 2 014 AMCHP Case Study Coordinating Efforts across the Title V MCH Services Block Grant and the Title X Family Planning Program Introduction improving smoking cessation and optimal birth spacing. This case study shares examples from five states – Systems integration has been identified as an essential Alaska, Iowa, West Virginia, Wisconsin, and Virginia – of element for achieving the Triple Aim of health reform, collaboration between Title V and Title X-funded which is a useful framework developed by the Institute programs. The purpose of this case study is to assist for Healthcare Improvement for optimizing health system Title V agencies in considering opportunities for aligning performance. It includes the following dimensions: resources and coordinating efforts toward shared improving patient experience of care, improving the outcomes. health of populations, and reducing the per capita cost of health care. The Affordable Care Act (ACA) is rapidly changing the health care landscape in states; while it Historical Relationship between Title V and should greatly improve women’s access to family Title X in States planning and preventive health services, some details remain unclear, including the impact for the low-income The Office of Population Affairs in the U.S. Department population and women who will continue to be of Health and Human Services awards Title X grants uninsured. directly to a network of community-based clinics, public and private non-profit institutions, and state agencies in Title X of the Public Health Service Act, enacted in 1970, addition to administering other grants and cooperative authorizes and funds the Title X Family Planning agreements. The five state agencies that participated in Program, the only federal grant program dedicated this case study have different funding relationships with solely to providing individuals with comprehensive family the Title X program: in Alaska, both the Department of planning and related preventive health services, with a Health and Social Services (DHHS) and the Municipality special emphasis on the low-income and uninsured of Anchorage DHHS Reproductive Health Clinic are population. Title X sets the standards and guidelines for grantees of the Title X program; in Iowa, the Department the provision of publicly funded family planning services of Public Health and the Family Planning Council of Iowa in the United States and supports key components of are Title X grantees; in Virginia, both the Department of clinic operations. Title V of the Social Security Act, Health and Planned Parenthood of the Blue Ridge are enacted in 1935, established the only federal program Title X grantees; in West Virginia, the Department of that focuses solely on improving the health of all mothers Health and Human Resources is the sole grantee for and children. Known as the Title V Maternal and Child Title X and delivers services to individuals via their sub- Health (MCH) Services Block Grant, the program is a recipients and contracted service sites; and in federal-state partnership that encompasses a wide array Wisconsin, Planned Parenthood of Wisconsin is the sole of direct services to individuals and population-based grantee, with no Title X funds passing through the health programs that serve everyone in a community. Despite department. different histories and legislative origins, the Title V and Title X programs share common goals to improve Despite the differences in funding structure, the Title V outcomes in reproductive, maternal, and infant health. agencies shared a number of similarities with Title X These goals include preventing HIV/STIs, reducing teen agencies with regard to how today, Title V funding pregnancy, increasing access to preventive health, enables coordination, continuum of care in MCH including contraceptive counseling and services, and services, and ‘gap filling’ in access to family planning and preventive health services in their respective states. Alaska used Title V funds to provide supplemental support to Title X personnel, continuing education to 1 Title X grant staff, and clinical services contracts for Four of the five state agencies that participated in this lab processing of Pap smears and other key case study are both Title V and Title X grantees. These activities. agencies share that the flexibility of the Title V program As one of two Title X grantees in the state, the Iowa allows them to use available funding to fill gaps when Department of Public Health leverages its Title V Title X funds run short, allowing for the majority of Title funds to coordinate training and align internal policy X dollars to go to direct service providers. According to oversight activities with the Family Planning Council the Guttmacher Institute, only 1.2 percent of public of Iowa, the other Title X grantee. expenditures for family planning client services come West Virginia describes the Title V program as the from the Title V MCH Services Block Grant.1 Despite ‘foundation’ that knits together a continuum of care Title V comprising a small proportion of family planning for MCH services that include the Title X program, dollars, it is critical for the functioning of the program. and enables coordination across similar efforts. Components of Successful Collaborations Role of Performance Measures Of the states that participated in this case study, four out Participating agencies overall agreed that performance of the five Title V agencies also are Title X grantees. measures play a critical role in the evaluation of efforts These programs expressed a number of benefits to co- under both grant programs. While the Title X location that enable successful collaborations, including performance measures are described as a ‘subset’ of supervision across programs, shared decision making at the Title V performance measures with regard to the leadership level, and frequent dialogue and reproductive health and unintended pregnancy exchange of ideas. However, for many states, co- prevention, and focus on clinical family planning service location of programmatic activities is not feasible. delivery, states described performance measures as an Regardless, all participating agencies offered a number opportunity to focus on preconception and of strategies that can be employed in coordinating efforts interconception care while working toward common across Title V and Title X programs: goals. Needs assessment: Alaska, Iowa, Virginia, and Iowa acknowledged that performance measures for West Virginia described the Title V needs low birth weight and preterm birth are related to assessment and similar activities as an opportunity maternal health, including interpregnancy intervals to share information and resources for program and the role of family planning in preconception planning purposes, support reproductive health health. In this respect, key activities such as goals and objectives between programs, and reproductive life planning are steps toward both effectively link programs through the life course improved maternal and infant health outcomes. Iowa approach. describes the Title V and Title X goals as, Sharing information at joint meetings: Iowa, “interwoven, though not connected on paper.” Virginia, West Virginia and Wisconsin identified In Virginia, reporting on the Title X performance regional meetings, statewide networks or measures led to the inclusion of preconception and committees, and yearly planning sessions as interconception health into the recent Title V agency opportunities to learn about various programs and Infant Mortality Strategic Plan. foster integration of program goals to better serve the MCH population. Further, Title V agencies also discussed the role of Training: Both Iowa and Wisconsin identified quality indicators and benchmarks in promoting quality training as an opportunity for successful and the cost effectiveness of care. Wisconsin collaboration. In Wisconsin, the MCH Women’s emphasized that measuring performance and outcomes Health-Family Planning Training Program is a joint can establish the credibility of these programs in setting collaboration for program and personnel training and quality standards and as an integral component of the continuing education that has helped to support an health care landscape. In Virginia, program and district integrated statewide approach to training MCH staff have ready access to a dashboard displaying professionals. benchmark data to see areas of opportunity and to initiate communication. 2 Sustainability Examples of Specific Impacts Between FY 2010 and FY 2013, the Title X family In reflecting on the results of partnerships between Title planning program experienced $39.2 million in funding V and Title X efforts, participating agencies shared a reductions– a total of 12.3%.1 The final FY 2014 number of specific impacts for the promotion of access Omnibus package included a modest $8.2 million to women’s health services for specific populations or for increase, not replacing the cuts that had already taken specific services: place. The Title V MCH Block Grant also has seen declines: since FY 2003, funding for the Title V MCH In Alaska, Title X funds are adequate to support two Block Grant has decreased by $91 million, with FY 2013 clinical service sites; however, in other parts of the appropriations totaling $639 million.2 Sequestration state with a high need for family planning services further cut the Title V MCH Block Grant down to its and methods but