Form 1 Parts 1 & 2 Proposed Updated FY 2019_2021 MCH Block Gran

TITLE V MATERNAL AND CHILD HEALTH SERVICES BLOCK GRANT TO STATES PROGRAM

GUIDANCE AND FORMS FOR THE

TITLE V APPLICATION/ANNUAL REPORT

OMB NO: _________

EXPIRES: __________

U.S. Department of Health and Human Services

Health Resources and Services Administration

Maternal and Child Health Bureau

Division of State and Community Health

5600 Fishers Lane, Room 18N33

Rockville, MD 20857

(Phone 301-443-2204 FAX 301-443-9354)

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is XXXX-XXXX. Public reporting burden for this collection of information is estimated to average 143 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857.

TITLE V MATERNAL AND CHILD HEALTH (MCH) SERVICES BLOCK GRANT TO STATES PROGRAM APPLICATION/ANNUAL REPORT GUIDANCE

EIGHTH EDITION

The Title V Maternal and Child Health (MCH) Services Block Grant to States Program (hereafter referred to as the MCH Block Grant) is a formula grant under which funds are awarded to 59 states and jurisdictions upon their submission of an acceptable plan that addresses the health services needs within a state for the target population of mothers, infants and children, which includes children with special health care needs (CSHCN), and their families. For purposes of the MCH Block Grant program, children are defined as ages 1 through 21 years. As referenced in this Guidance, the population of CSHCN is inclusive of children and youth. Through the MCH Block Grant, each state and jurisdiction supports and promotes the development and coordination of systems of care for the MCH population, which are family-centered, community-based and culturally appropriate.

The Application/Annual Report is used by the 50 states and nine jurisdictions in applying for their MCH Block Grants under Title V of the Social Security Act and in preparing the required Annual Report. States/jurisdictions report annually on national and state outcome/performance measures, which document their progress towards the achievement of established performance targets, ensure accountability for the ongoing monitoring of health status in women and children and lend support to the delivery of an effective public health system for the nation’s MCH population. Complementary to the reporting of outcome and performance measure data is the narrative description of the state/jurisdiction’s Title V program activities.

The eighth edition of the Title V MCH Services Block Grant to States Program Guidance consists of two documents: 1) Instructions to the states on completing the required Application/Annual Report and Reporting Forms; and 2) Appendix of Supporting Documents, which includes background program information and other technical resources. As with previous editions, this Guidance adheres to the specific statutory requirements outlined in Sections 501-509 of the Title V legislation and honors the rights of states to determine their individual MCH program priorities, to develop tailored strategies for addressing their unique MCH population needs and to assume accountability in achieving measurable progress towards stated program goals.

This edition of the Title V MCH Services Block Grant to States Program Application/Annual Report Guidance provides continued emphasis on the use of evidence-based or -informed strategies and measures in the MCH Block Grant and retains the performance measure framework that was introduced in 2015. In recognition that each state and jurisdiction is unique, the updates to this edition of the Guidance allow states greater flexibility in selecting national and state performance measures that align with their identified MCH needs. Given that the MCH priorities largely shape Title V programming within an individual state, the proposed updates bring renewed focus to the role and use of State Performance Measures in addressing state-specific needs and working to improve MCH outcomes.

The updates to this edition also reflect a continued commitment to improving health care systems for the MCH population, particularly for CSHCN, and the leadership of families in being active partners engaged in Title V program planning and decision-making. Furthermore, the updates aim to reduce reporting burden and to streamline the Application/Annual Report narrative reporting. The updated instructions provided in this Guidance will assist states in preparing and submitting an Application/Annual Report for the remaining two interim years of the 2015 Needs Assessment reporting cycle. States will report on the findings of the 2020 Five-Year Needs Assessment in the third and final Application/Annual Report that will be submitted under this three-year Guidance. The submission of the 2020 Five-Year Needs Assessment will begin a new five-year reporting cycle.

This edition of the Title V MCH Services Block Grant to States Program Guidance is the sixth to be released since the introduction of a Web-based Application/Annual Report. The use of this online method for completing and submitting a yearly Application/Annual Report continues to be a requirement for the receipt of Federal MCH Block Grant funds. Since its development in 2002, the Title V Information System (TVIS) has contributed to numerous efficiencies in the Application/Annual Report submission process. Examples include the automatic calculations of ratios, rates, and percentages; capturing of past years’ narrative and data reporting; and assurance that the data presented in multiple tables are entered only once by the state.

Administered by the Health Resources and Services Administration’s (HRSA) Maternal and Child Health Bureau (MCHB), the TVIS consists of two components: 1) MCH Block Grant Application/Annual Report Data Entry (used by state/jurisdictional MCH Block Grantees to submit their financial, program, and performance data); and 2) TVIS Reports (a Web-based interface that allows public users to generate reports from Title V data).

Questions and comments regarding this edition of the Application/Annual Report Guidance may be addressed to:

Michele H. Lawler, M.S., R.D.

Director, Division of State and Community Health

Maternal and Child Health Bureau

Health Resources and Services Administration

5600 Fishers Lane, Room 18N33

Rockville, Maryland 20857

Telephone: (301) 443-2204

Fax: (301) 443-9354

mlawler@hrsa.gov

TABLE of CONTENTS

PART ONE: BACKGROUND AND ADMINISTRATIVE INFORMATION

1. Purpose of the Maternal and Child Health (MCH) Block Grant 1

2. Background and Brief History 2

3. Guiding Principles for the Development of the MCH Block Grant 2 Application/Annual Report Guidance

   1. Public Health Services Systems Model for MCH Populations 3

   2. Data Driven Programming and Performance Accountability 4

(National Performance Measure Framework)

3. Family Partnership 8

1. Legislative Requirements 9

   1. Who Can Apply for Funds 9

   2. Use of Allotment Funds 9

   3. Application for Block Grant Funds 10

   4. Annual Report 11

   5. Administration of Federal and State Programs 11

PART TWO: APPLICATION/ANNUAL REPORT INSTRUCTIONS 13

1. General Requirements 13

   1. Letter of Transmittal 13

   2. Face Sheet 13

   3. Assurances and Certifications 13

   4. Table of Contents 13

2. Logic Model 13

3. Components of the Application/Annual Report 15

   1. Executive Summary 16

   2. Overview of the State 17

   3. Needs Assessment 17

      1. Needs Assessment Update 18

      2. Five-Year Needs Assessment Summary 19

         1. Process Description 19

         2. Findings 20

1. MCH Population Health Status 21

2. Title V Program Capacity 21

3. Title V Program Partnerships, Collaboration, 23

and Coordination

3. Identifying Priority Needs and Linking to Performance 24

Measures

4. Financial Narrative 25

   1. Expenditures 26

   2. Budget 27

5. Five-Year State Action Plan 28

   1. Five-Year State Action Plan Table 28

   2. State Action Plan Narrative Overview 30

      1. State Title V Program Purpose and Design 30

      2. Supportive Administrative Systems and Processes 31

1. MCH Workforce Development 31

2. Family Partnership 31

3. States Systems Development Initiative and Other 32

MCH Data Capacity Efforts

4. Health Care Delivery System 33

1. State Action Plan Narrative by Domain 34

1. Public Input 36

2. Technical Assistance 36

PART THREE: REPORTING FORMS 37

PART ONE: BACKGROUND AND ADMINISTRATIVE INFORMATION

1. Purpose of the Maternal and Child Health (MCH) Block Grant

As defined in section 501(a)(1) of the Title V legislation, the purpose of the MCH Block Grant is to enable each state:

1. To provide and to assure mothers and children (in particular those with low income or with limited availability of health services) access to quality MCH services;

2. To reduce infant mortality and the incidence of preventable diseases and handicapping conditions among children, to reduce the need for inpatient and long-term care services, to increase the number of children (especially preschool children) appropriately immunized against disease and the number of low income children receiving health assessments and follow-up diagnostic and treatment services, and otherwise to promote the health of mothers and infants by providing prenatal, delivery, and postpartum care for low income, at-risk pregnant women, and to promote the health of children by providing preventive and primary care services for low income children;

3. To provide rehabilitation services for blind and disabled individuals under the age of 16 receiving benefits under title XVI, to the extent medical assistance for such services is not provided under title XIX; and

4. To provide and to promote family-centered, community-based, coordinated care (including care coordination services, as defined in subsection (b)(3)) for children with special health care needs (CSHCN) and to facilitate the development of community-based systems of services for such children and their families.

This legislative purpose is further affirmed through the Title V Vision and Mission statements, as shown below.

Vision of Title V

Title V envisions a nation where all mothers, infants, children aged 1 through 21 years, including CSHCN, and their families are healthy and thriving.

Mission of Title V

The Mission of Title V is to improve the health and well-being of the nation’s mothers, infants, children and youth, including children and youth with special health care needs, and their families.

1. Background and Brief History

Since its original authorization in 1935, Title V of the Social Security Act has been amended several times to reflect an ongoing commitment to improving the health and well-being of our Nation's mothers, children and their families. Block-granted in 1981, with new accountability requirements added in 1989, Title V has remained a vitally important public health program for serving the MCH population. In 2015, an updated performance measure framework was introduced to reflect more clearly the contributions of Title V in improving health outcomes among the MCH population. A more complete history of Title V can be found in Appendix A of the Supporting Documents to the Title V MCH Block Grant Application/Annual Report Guidance.

The MCH Block Grant is a formula grant under which funds are awarded to 59 states and jurisdictions upon the submission of an acceptable plan that addresses the health services needs within a state for the target population of mothers, infants and children, including CSHCN. Through this process, each state and jurisdiction supports and promotes the development and coordination of systems of care for the MCH population.

Annual submission of an Application is required by law to entitle a state to receive MCH Block Grant funds (Section 505 of Title V of the Social Security Act). Per Section 506, a state is further required to submit an Annual Report on the expenditure of the previous year’s funds. In addition, Section 505(a) requires a state to conduct a comprehensive and statewide needs assessment every five years. The information and instructions for the preparation and submission of the Application/Annual Report and Five-Year Needs Assessment are contained in the Title V Maternal and Child Health Services Block Grant to States Program: Guidance and Forms for the Title V Application/Annual Report (hereafter referred to as the Application/Annual Report Guidance).

III. Guiding Principles for the Development of the MCH Block Grant Application/Annual Report Guidance

The development of the application/reporting structure for this edition of the Application/Annual Report Guidance incorporates key principles that are common to all state Title V programs. These principles are: 1) delivery of Title V services within a public health service model; 2) data-driven programming and performance accountability; and 3) partnerships with individuals/families/family-led organizations (hereafter referred to as family partnership). These principles have contributed to the MCH Block Grants’ success in operationalizing the legislative requirements and in delivering public health services and systems of care that address the needs of the MCH population.

1. Public Health Services Systems Model for MCH Populations

A 1988 Institute of Medicine (IOM) Report¹ defined the core functions of public health as assessment, policy development and assurance. In operationalizing the core public health functions and in ensuring that the unique needs of mothers and children were addressed, the MCH community worked with the Public Health Service and the IOM to identify ten (10) “Essential Public Health Services”² in 1994. Since that time, the 10 Essential Public Health Services have provided a framework for the delivery of MCH services, as reflected in Figure 1 below.

Figure 1.

A crosswalk of the 10 Essential Public Health Services with the purpose of the State MCH Block Grants, as defined in Section 501(a)(1) of Title V of the Social Security Act, yielded the following strategies for states to use in their program planning.

1. Mobilize partners, including families and individuals, at the federal, state and community levels in promoting shared vision for leveraging resources, integrating and improving MCH systems of care, promoting quality public health services and developing supportive policies;

2. Integrate systems of public health, health care and related community services to ensure access and coordination to assure maximum impact;

3. Conduct ongoing assessment of the changing health needs of the MCH population to drive priorities for achieving equity in access and positive health outcomes;

4. Educate the MCH workforce to build the capacity to ensure innovative, effective programs and services and efficient use of resources;

5. Inform and educate the public and families about the unique needs of the MCH population;

6. Promote applied research resulting in evidence-based policies and programs;

7. Promote rapid innovation and dissemination of effective practices through quality improvement and other emerging methods; and

8. Provide services to address unmet needs in healthcare and public health systems for the MCH population (i.e., gap-filling services for individuals).

B. Data Driven Programming and Performance Accountability (National Performance Measurement Framework)

National Outcome Measures

National Performance Measures

Evidence-based/Informed Strategy Measures

The MCH Block Grant utilizes a three-tiered national performance measurement framework (Figure 2), which includes National Outcome Measures (NOMs), National Performance Measures (NPMs) and state-initiated

Figure 2. Performance Measure Framework

Evidence-based or -informed Strategy

Measures (ESMs). The framework provides

flexibility to a state in identifying the best combination of measures to address the MCH priority needs that were identified based on the findings of the Five-Year Needs Assessment. This edition of the Application/Annual Report Guidance reduces the required minimum number of NPM selections by a state to five (5). It also allows increased flexibility for a state to select as many NPMs and State Performance Measures (SPMs) as necessary to address each of its priority needs. See Appendices B and C for detailed information about the NPM Framework, NOMs and NPMs.

The NPMs are a set of short-term and medium-term performance measures that utilize population-based, state-level data derived from national data sources and for which a state Title V program tracks prevalence rates and works towards demonstrated impact. They are intended to drive improved outcomes relative to one or more medium and long-term indicators of health status or access to quality health care (i.e., NOMs) for the MCH population. Thus, a state tracks the NOMs to monitor the impact of the NPMs.

ESMs are the final tier of the national performance measurement framework, and they are the structural or process measures through which a state can achieve intended impact on the NPMs. State-specific and actionable, the ESMs seek to track a state Title V program’s strategies/activities and to measure evidence-based or -informed practices that will impact individual, population-based NPMs. The ESMs are developed by the state, and they provide accountability for improving quality and performance related to the NPMs and to the MCH public health issues that they are designed to address. While not part of the NPM framework, a state will also develop SPMs to address its identified priority needs to the extent that they have not been fully addressed through the selected NPMs and ESMs.

Title V is responsible for promoting the health of all mothers and children, including CSHCN and their families. There are 15 NPMs, which address key MCH priority areas within five MCH population domains. These domains are: 1) Women/Maternal Health; 2) Perinatal/Infant Health; 3) Child Health; 4) CSHCN; and 5) Adolescent Health. The NPM framework also applies the life course theory, which identifies critical stages (i.e., beginning before a child is born and continuing throughout life) that can influence lifelong health and wellbeing.

A sixth domain addresses Cross-cutting and Systems Building needs. While there are currently no NPMs included in this last domain, a state may choose to develop one or more SPMs to address a priority need that is related to program capacity and/or systems-building (e.g., applies to all MCH population domains). A state is not required to identify a measure for this domain. If a SPM is developed, the state should define strategies for determining success. Examples of topics addressed by SPMs in this domain are:

1. Partnerships with individuals, families, and family-led organizations ;

2. Social determinants of health;

3. Workforce development; and

4. Enhanced data infrastructure

An overview of the NPMs, by MCH population health domain, is displayed in Table 1.

It should be noted that the five MCH population health domains reflected in the NPM framework are contained within the three legislatively-defined MCH populations [Section 505(a)(1)]. For example, the first two domains are included under “preventive and primary care services for pregnant women, mothers and infants up to age one,” which is the first of the three defined MCH populations. Child and adolescent health are included in the second defined MCH population, specifically “preventive and primary care services for children.” CSHCN is the third legislatively defined MCH population. This latter population is inclusive of children and youth with special health care needs.

Table 1: NPMs and Domains

NPM #		MCH Population Domains					Cross-cutting/ Systems Building Domain Optional
		Women/Maternal Health	Perinatal/ Infant Health	Child Health	Adolescent Health	Children with Special Health Care Needs
1	Well-woman visit						States have the option to develop a state performance measure (SPM) that is Cross-cutting/Systems Building. Examples of measure topic areas include but are not limited to: Family partnership activities that cross all population health domains; Social determinants of health; Workforce development; and Enhanced data infrastructure
2	Low-risk cesarean delivery
3	Risk-appropriate perinatal care
4	Breastfeeding++
5	Safe sleep
6	Developmental screening
7	Injury hospitalization*
8	Physical activity *
9	Bullying
10	Adolescent well-visit
11	Medical home*				
12	Transition*				
13	Preventive dental visit *++
14	Smoking *++
15	Adequate insurance *

* NPM with multiple domains (Note: States may choose to target children and adolescents without special health care needs, in addition to children and adolescents with special health care needs for NPM #11 and NPM #12.)

++ NPMs that are compound measures (i.e. have an “A” and “B” component to the measure)

The 15 NPMs remain the same as in the seventh edition of the MCH Block Grant Application/Annual Report Guidance, but they are now distributed within the five population health domains. As noted above, a state must choose a minimum of five (5) NPMs. At least one NPM must be selected for each of the five (5) MCH population domains, but a state may opt to select additional NPMs based on its identified priority needs. There is no maximum for the number of NPMs that a state can select. Thus, a state may continue to implement its current State Action Plan for the five-year reporting cycle with the eight (8) NPMs previously selected.

Given the redistribution of the NPMs, states should note that the same measure selected in multiple domains (NPM #7, NPM #8, NPM #11, NPM #12, NPM #13, NPM #14 and NPM #15) will only count once toward the minimum of five (5) NPMs. For example, if a state selects NPM #14 in both the Women/Maternal Health Domain and the Child Health Domain, this measure would only count once towards the required minimum of five NPMs. The state would need to select another measure in either the Women/Maternal Health Domain or the Child Health Domain to satisfy the requirement of one NPM per population domain. If NPM #11 and/or NPM #12 are selected, the state must address children with special health care needs (i.e., CSHCN domain). States may choose to also reflect these measures in either the Child Health Domain or the Adolescent Health Domain. The four scenarios presented in Figure 3 provide further explanation regarding the available options to a state in the selection of NPMs to meet the minimum requirements.

Figure 3. Scenarios for Assuring Selection of NPMs Across Domains

Scenario 1: A state selects NPM #7 for both the Child Health Domain and the Adolescent Health Domain. In selecting a NPM for each of the five population domains, as required, the state can choose to count NPM #7 as the selected measure in either of the two domains. The state must then select a second NPM for the other domain.

Scenario 2: A state selects NPM #11 for the Child Health Domain, which is an optional target population. In selecting this measure, the state must also address the CSHCN Domain. The state may choose to count this measure in either the CSHCN Domain or the Child Health Domain. If selected as the NPM for the Child Health Domain, the state must select a second NPM from the CSHCN Domain.

Scenario 3: A state selects NPM #13.1 for the Women/Maternal Health Domain and NPM #13.2 for the Child Health Domain. While the measure targets different population groups, NPM #13 counts as only one measure. The state can choose to select this measure for either of the two domains. The state will need to select a different NPM for the second domain. A state can select NPM #13.1 without selecting NPM #13.2, or vice versa.

Scenario 4: A state selects NPM #15 for the Adolescent Health Domain and the CSHCN Domain. While the measure targets different population groups, NPM #15 counts as only one measure. The state may choose to count this measure as the selected NPM in either the Adolescent Health Domain or the CSHCN Domain. The state must choose a different NPM for the second domain.

C. Family Partnership

Building the capacity of women and children, including CSHCN, and their families to partner in decision-making with Title V programs at federal, state and community levels is a critical strategy in helping states to achieve the identified MCH priorities. Title V’s commitment to these partnerships are strong, as states expand and strengthen family engagement activities in all MCH population domains.

Traditionally, state Title V programs have engaged families in a variety of program activities. Specific examples include:

1. Contracting with Family-Led Organizations;

2. Paid Program Staff;

3. Advisory Committees/Task Forces;

4. Agency Decision-Making and Policy Development;

5. Program Outreach;

6. Training; and

7. Peer Support.

For purposes of the MCH Block Grant, family partnership is defined as, “patients, families, their representatives, and health professionals working in active partnership at various levels across the health care system – direct care, organizational design and governance, and policy making—to improve health and health care.³ This partnership is accomplished through the intentional practice of working with families for the ultimate goal of positive outcomes in all areas through the life course.”⁴ Relevant resources include, but are not limited to, the National Consensus Standards for Systems of Care for Children and Youth with Special Health Care Needs, authored by the Association of Maternal and Child Health Programs (AMCHP, 2014); a series of reports and case studies entitled, Sustaining and Diversifying Family Engagement in Title V MCH and CYSHCN Programs (AMCHP, 2016); and other resources that are available through Family Voices. 

This edition of the Application/Annual Report Guidance provides added emphasis on the need for a state to demonstrate the value of family partnerships in improving health outcomes across all sectors of the MCH population. In addition, a state should:

1. Assure families and individuals are key partners in health care decision-making at all levels in the system of services, especially those who are vulnerable and medically underserved;

2. Ensure the provision of training, both in orientation and ongoing professional development, for staff, family leaders, volunteers, contractors and subcontractors in the area of cultural and linguistic competence; and

3. Collaborate with community leaders/groups and families of every background in needs/assets assessments, program planning, service delivery and valuation/monitoring/quality improvement activities.

Appendix D includes additional information to assist a state in strengthening the family partnership and leadership within its Title V program.

IV. Legislative Requirements

The MCH Block Grant is authorized under Title V of the Social Security Act, which is the longest-standing public health legislation in American history. More than 80 years later, the law continues to support efforts to improve the health of the nation’s women and children. The law can be viewed at: http://www.ssa.gov/OPHome/ssact/title05/0500.htm. A general overview of the legislative requirements and the way in which these requirements are implemented by MCHB is set out below.

1. Who Can Apply for Funds [Section 505(a)]

The Application/Annual Report shall be developed by, or in consultation with, the state MCH agency and shall be made public within the state in such manner as to facilitate comment from any person (including any federal or other public agency) during its development and after its transmittal.

2. Use of Allotment Funds [Section 504]

The state may use its MCH Block Grant funds for the provision of health services and related activities (including planning, administration, education, and evaluation) consistent with its Application. In addition, the state may request supplemental funds from the MCHB to support identified technical assistance needs. Related to technical assistance, the state should plan for and allot funds for the MCH and CSHCN Directors to attend two required meetings each year in person. One of these meetings is the required MCH Block Grant Application/Annual Report review, which is held at a site designated annually by the Division of State and Community Health (DSCH) in HRSA’s MCHB. The other meeting is a MCH Technical Assistance Partners Meeting, which aims to: 1) update State MCH and CSHCN Directors on relevant legislation and MCHB initiatives; 2) convene leaders, disseminate best practices and share innovations in the field of MCH; and 3) provide opportunities for information exchange, networking, and collaboration among states and with MCHB. States should plan for this meeting to be held in Washington, DC.

The MCH Block Grant funds may not be used for cash payments to intended recipients of health services or for purchase of land, buildings, or major medical equipment. Other restrictions apply, as specified in Section 504(b).

3. Application for MCH Block Grant Funds [Section 505]

Each state is required to conduct a statewide Needs Assessment once every five years. A detailed overview of the MCH Five-Year comprehensive statewide Needs Assessment process is presented in Appendix E. The Needs Assessment findings will be integrated into that year’s Application/Annual Report as a Needs Assessment Summary. During the four interim years of the five-year reporting period, a state will submit an annual update of its ongoing needs assessment activities and findings in the appropriate section of the state Application/Annual Report. By law, the Application/Annual Report will contain information that is consistent with the health status goals and national health objectives regarding the need for:

1. Preventive and primary care services for all pregnant women, mothers, and infants up to age one;

2. Preventive and primary care services for children; and

3. Services for CSHCN [as specified in section 501(a)(1)(D) "family-centered, community-based, coordinated care (including care coordination services) for children with special health care needs (CSHCN) and to facilitate the development of community-based systems of services for such children and their families"].

The state will organize its reporting on the three legislatively defined MCH populations in the context of five population health domains: 1) Women/Maternal Health;

2) Perinatal/Infant Health; 3) Child Health; 4) Adolescent Health; and 5) CSHCN. Although the Application/Annual Report Guidance defines children as ages 1 year through 21 years, a separate Adolescent Health domain is included in the NPM framework due to their unique health needs. Adolescents often require different strategies than the strategies used to address the needs of the broader child health population.

Each year, at least thirty percent (30%) of federal Title V funds must be used for preventive and primary care services for children and at least thirty percent (30%) for services for CSHCN, as specified in Section 501(a)(1)(D). Such services include providing and promoting family-centered, community-based, coordinated care (including care coordination services) for CSHCN and facilitating the development of community-based systems of services for such children and their families. The thirty percent (30%) requirement may be waived as specified in Section 505(b)(1-2). A request for waiver must be included in the Application letter of transmittal. In addition, of the amount paid to a state under Section 503 from an allotment for a fiscal year under

Section 502(c), not more than ten percent (10%) may be used for administering the funds paid under this section.

The state must maintain the level of funds being provided solely by such state’s MCH programs at the level provided in fiscal year 1989. [Section 505(a)(4)].

Other requirements for allocation of funds, charging for services, maintenance of a toll-free hotline (and other appropriate methods) and coordination of services with other programs are found in Section 505.

4. Annual Report [Section 506]

An Annual Report must be submitted to the MCHB each year in order to evaluate and compare the performance of different states assisted under Title V and to assure the proper expenditure of funds. The Annual Report will include a description of program activities, a complete record of the purposes for which funds were spent, the extent to which the state has met its goals and performance objectives, as well as the national health objectives, and the extent to which funds were expended consistent with the state's Application. The Action Plan includes the Annual Report narrative on the state’s Title V program strategies and activities. States will utilize the Action Plan section of the Application/Annual Report to provide narrative discussion on the progress (by population health domain) achieved during the reporting year relative to the implementation of planned activities and gains in meeting the established performance measure targets. The standardized format of the Annual Report, as described, will allow for consistency in reporting and will facilitate the preparation of a report to Congress [Section 506(a)(3)].

As required in Section 509(a)(5), the MCHB has made a substantial effort to not duplicate other federal data collection efforts. The MCHB will collect and provide national outcome and performance measure data, as well as Other State Data (OSD), for the individual states, as available. Limited data are available from the National Center for Health Statistics (NCHS) and other federal sources for Puerto Rico, Guam, the Republic of the Marshall Islands, Federated States of Micronesia, Republic of Palau, Commonwealth of the Northern Mariana Islands, American Samoa and Virgin Islands. In the absence of federally available performance measure data, states and these jurisdictions must report their own data.

5. Administration of Federal and State Programs [Section 509]

The MCHB in HRSA is the organizational unit responsible for the administration of

Title V. Within the Bureau, DSCH has responsibility for the day-to-day operation of the State MCH Block Grants. Applicants may obtain additional information regarding

administrative, technical and program issues concerning the Block Grant Application/Annual Report by contacting:

Division of State and Community Health

Maternal and Child Health Bureau

Health Resources and Services Administration

5600 Fishers Lane, Room 18N33

Rockville, Maryland 20857

Telephone: (301) 443-2204; Fax: (301) 443-9354

Within each state, the state health agency is responsible for the administration (or supervision of the administration) of programs carried out with Title V allotments.

PART TWO: APPLICATION/ANNUAL REPORT INSTRUCTIONS

1. General Requirements

1. Letter of Transmittal

An electronic letter of transmittal from the responsible state health agency official must be the first page of the MCH Block Grant Application/Annual Report. The letter must also contain the documentation for waiver of a 30 percent allotment, if the state is so requesting. The letter of transmittal is uploaded in TVIS as an image to Section I.A. of the Application/Annual Report.

2. Face Sheet

Each section of the Application Face Sheet (Standard Form 424) must be completed and submitted electronically along with the rest of the Application/Annual Report.

3. Assurances and Certifications

The appropriate Assurances and Certifications for the State MCH Block Grants, which include Application Form Standard Form (SF)-424B, Assurances for Non-Construction Programs and Certifications for debarment and suspension, drug free work place, lobbying, program fraud and tobacco smoke, are included in Appendix F. The state does not have to submit these forms as part of the Application/Annual Report, but they must be maintained on file in the state’s MCH program’s central office. TVIS provides capability for the state to certify that the required assurances/certifications are maintained on file and the state can provide them at HRSA’s request.

4. Table of Contents

The Table of Contents is automatically generated by TVIS, and conforms to the headings in the different Parts/Sections of this Guidance.

2. Logic Model

In follow-up to a legislatively required comprehensive Five-Year Needs Assessment, the state develops a five-year Title V program plan. Consistent with the block grant concept, the state has flexibility in the types of programs and activities that it implements to address the unique needs of their individual MCH populations. As depicted by the process flow diagram in Figure 4, a state’s priority needs should “drive” the development of a five-year program plan that is responsive to the needs identified and is performance driven.

Figure 4. MCH Block Grant Logic Model

SSTEP 1 STEP 1 Conduct a comprehensive Title V MCH program Five-year Needs Assessment		STEP 2 Review and summarize MCH Population Needs, Program Capacity, and Partnerships/ Collaborations		STEP 3 Identify (7-10) State Title V Program priority needs, which will guide the development of the state’s five-year Title V Action Plan		STEP 4 Develop program strategies to address the identified priority needs during the five-year reporting period		STEP 5 Identify areas of alignment between the state priorities/ strategies and the NOMs
STEP 6 Based on priorities and strategies, select five of the 15 NPMs (one per each of the five population domains) for programmatic focus		STEP 7 Establish SPMs to address each priority need that is not being addressed by one of the five selected NPMs		STEP 8 Review the selected NPMs and SPMs to ensure that every identified priority need is being addressed through one or more of the NPMS or SPMs		STEP 9 Develop one or more ESMs for each of the five selected NPMS		STEP 10 At the state’s discretion, consider the need to develop one or more SOMs
STEP 11 Establish five-year performance objectives for each selected NPM, SPM, and, SOM, if applicable		STEP 12 Report performance indicators for NPMs, ESMs, SPMs and SOMs in Annual Report/ Application		STEP 13 Analyze annual and multi-year performance trends		STEP 14 In interim year, Annual Reports/ Applications, reassess and update strategies and objectives for selected NPMs, SPMS, & SOMs, if applicable, to achieve desired outcomes		STEP 15 Conduct comprehensive Title V MCH program Five-year Needs Assessment

The state begins each five-year cycle by conducting a comprehensive Title V Five-Year Needs Assessment. This Needs Assessment includes a comprehensive review of MCH population needs, program capacity, and partnerships/collaborations that are critical components of a state’s system of care for addressing the needs of its MCH population. Based on the findings of the Five-Year Needs Assessment, the state identifies 7-10 Title V MCH priority needs. Using the State Action Plan Table as a working tool, the state develops strategies and overarching five-year objectives to address the identified priority needs. The state examines areas of potential alignment between its MCH priority needs and the Title V NOMs and NPMs, which informs the selection of at least one NPM in each of the five population health domains for programmatic focus over the five-year cycle. Priority needs not addressed by the selected NPMs will require the development of a targeted SPM. The state can chose to develop as many SPMs as needed to ensure that each priority need is addressed either by a SPM or by a NPM. While not required, the state may choose to also develop a SOM to complement the NOMs. For each NPM selected, the state is required to develop at least one ESM that further defines how the state plans to monitor and assess its annual progress in addressing the selected NPMs. In the four interim year Application/Annual Reports, the state reports on its ongoing needs assessment efforts, its success in implementing the five-year Title V program plan and its progress in achieving the established performance objectives for each selected NPM, SPM and ESM.

3. Components of the Application/Annual Report

By July 15 of each year, states and jurisdictions are required to submit an Application/Annual Report for the federal funds they receive through the MCH Block Grant. In addition, the state is required to conduct and report on a comprehensive, statewide Needs Assessment every five years. See Appendix G for Application/Annual Report Timeline. The findings of this Needs Assessment and the priority needs identified as a result of this process provide the basis for the development of a five-year Action Plan for the state Title V program. As new findings become available through the state’s ongoing/updating needs assessment efforts and the analyses of annual performance data, the state may refine its Action Plan in interim years (e.g., performance objectives) related to the state and national MCH priority areas. These changes may include the substitution of new or revised strategies, ESMs and/or SPMs for existing strategies and measures. States are encouraged not to change the selected NPMs during the five-year reporting cycle. If a state determines that a NPM needs to be changed, clear justification must be provided to the MCHB Project Officer.

The state’s narrative Application/Annual Report includes the following sections:

1. Executive Summary;

2. Descriptive Overview of the State;

3. Five-Year Needs Assessment Summary and Annual Needs Assessment Updates;

4. Financial Narrative;

5. State Action Plan Table and Narrative Discussion;

6. Public Input Process; and

7. Potential Areas of Needed Technical Assistance.

States should structure the narrative discussion of the Application/Annual Report to include the sections cited above. A detailed explanation of the specific discussion points that the state should include in each section is provided below.

1. Executive Summary

The Executive Summary describes the contents of the Application/Annual Report and gives the reader a concise, yet substantive, description of the state’s MCH program. Limited to no more than five pages in length or 15,000 characters, the Executive Summary should highlight the state’s Title V program efforts to address its identified MCH priority needs. The Executive Summary should also reflect on the state’s progress in improving its performance relative to the selected state and national performance measures. The points to be discussed are as follows:

1. A brief description of the state’s MCH population needs and the identified Title V priorities;

2. A high level overview of the working framework used by the state or jurisdiction in carrying out needs assessment, program planning and performance reporting;

3. The role of the state Title V program in supporting and assuring comprehensive, coordinated and family-centered services, including services for CSHCN; and

4. A description of the Title V program’s established partnerships and how federal and non-federal funds are being leveraged to deliver MCH services in the state.

The goal of the Executive Summary is to convey key descriptors about the state’s Title V program (i.e., needs assessment/priorities, goals, strategies, action plan and performance monitoring) to enable a reader to become acquainted with its MCH program without having to read the entire Application/Annual Report.

The Executive Summary also serves as the narrative portion of the TVIS State Snapshot. Publicly available, the document serves as a quick point of reference for policy makers, national MCH leadership associations and programs, local and state MCH stakeholders, state Title V programs, families, academia and other interested individuals. The State Snapshot incorporates information submitted in the MCH Block Grant Application/Annual Report into a format that the state can use in its Title V program outreach and health promotion efforts.

In addition, the Executive Summary concludes with two brief narrative sections that demonstrate the impact and value of the MCH Block Grant program in the state. In the first of the two sections, states should provide a description of how federal MCH Block Grant funds complement the overall MCH efforts supported by the state. The second section should highlight what the state considers a MCH success story, which illustrates the federal-state Title V partnership in action.

The Executive Summary is intended to be a standalone document. States can update the Executive Summary annually, but its overall content should reflect the five-year Title V program plan.

2. Overview of the State

The intended purpose of this overview is to introduce a reader to the applicant state. Principal characteristics of the state, such as its demographics, geography, economy and health care environment, should be succinctly summarized to provide the reader with needed context for understanding the Title V program structure and approaches described in the Application/Annual Report.

Specifically, the State Overview should include a description of:

1. The state’s demographics, geography, economy and urbanization;

2. The state’s unique strengths and challenges that impact the health status of its MCH population (e.g., availability and access to health care services);

3. The defined roles, responsibilities and targeted interests of the state health agency and how they influence the delivery of Title V services;

4. Components of the state’s systems of care for meeting the needs of underserved and vulnerable populations, including CSHCN. This discussion may include, but is not limited to, the following descriptors:

   1. Population served;

   2. Health services infrastructure (e.g., number of children’s hospitals, pediatric specialists, accountable care organizational structure, etc.);

   3. Integration of services, such as physical, social and behavioral services; and

   4. Financing of services (e.g., managed care arrangements and Medicaid eligibility).

5. Specific state statutes and other regulations that have relevance to the MCH Block Grant authority and impact the state’s MCH and CSHCN programs.

An organizational chart should be included as an attachment.

3. Needs Assessment

The Title V legislation (Section 505(a)(1)) requires the state, as part of the Application, to prepare and transmit a comprehensive statewide Needs Assessment every five years that identifies (consistent with the health status goals and national health objectives) the need for:

1. Preventive and primary care services for pregnant women, mothers and infants up to age one;

2. Preventive and primary care services for children; and

3. Services for children with special health care needs.

Findings from the Five-Year Needs Assessment serve as the cornerstone for the development of a five-year Action Plan for the State MCH Block Grant. Figure 5 illustrates the three-year period covered by this Guidance (FY 2019 - FY 2021). As noted below, states will report on their next Five-Year Needs Assessment on July 15, 2020.

Figure 5. Schedule for Needs Assessment Narrative

2015 Five-Year Needs Assessment – Submitted July 15, 2015

FY 2019 Application: Interim Application Year Three — Provide Needs Assessment Update

FY 2020 Application: Interim Application Year Four — Provide Needs Assessment Update

2020 Five-Year Needs Assessment – Due July 15, 2020

FY 2021 Application: Application Year One — Provide Five-Year Needs Assessment Summary

1. Needs Assessment Update

The changing MCH population demographics, emerging health trends and shifting program capacity require that states routinely engage in selected steps of the Needs Assessment process. During any interim year when a state is not reporting on its Five-Year Needs Assessment, a state should reference and summarize the findings from its ongoing needs assessment activities in the Needs Assessment Update section of the Application/Annual Report. This update should include a discussion of the following items:

1. A brief description of the state’s ongoing needs assessment activities (e.g., MCH data collection and analyses, program evaluation, key informant interviews, customer satisfaction surveys, advisory councils, and other approaches for soliciting individual feedback and conducting ongoing performance monitoring and assessment) and the extent to which families, individuals and other stakeholders were engaged in the process;

2. Noted changes in the health status and needs of the state’s MCH population, as compared to the identified priority needs for the MCH Block Grant;

3. Noted changes in the state’s Title V program capacity or its MCH systems of care, particularly for CSHCN, and the impact of these changes on MCH services delivery;

4. The breadth of the state’s Title V partnerships and collaborations with other federal, tribal, state and local entities that serve the MCH population;

5. Efforts undertaken by the state to operationalize its Five-Year Needs Assessment process and findings; and

6. Changes in organizational structure and leadership.

The needs assessment update should include a dedicated section that describes emerging public health issues and the state’s capacity and resources to address them.

2. Five-Year Needs Assessment Summary

The mechanism for states to report on the legislatively required, comprehensive and statewide Five-Year Needs Assessment is the Needs Assessment Summary, which is submitted as part of the first year Application/Annual Report of a new five-year cycle. The state should present a concise summary of the Five-Year Needs Assessment process, methodology and findings, as described below. Given that the findings inform the development of the state MCH Block Grant’s five-year State Action Plan, the Needs Assessment Summary is retained in its original form as part of the four subsequent interim year Applications/Annual Reports. As it reflects a point-in-time, the state does not update the Five-Year Needs Assessment Summary in the interim years. Such updates are presented in the Needs Assessment Update section of the interim year Applications/Annual Reports. Each annual update, along with the original Five-Year Needs Assessment Summary, is prepopulated in each year’s Application/Annual Report across the five-year reporting cycle.

The Needs Assessment Summary is intended to emphasize only the key findings of the state’s Five-Year Needs Assessment. Given the scope and comprehensive nature of the Five-Year Needs Assessment, a state’s findings may exceed the required content for the Needs Assessment Summary. States may opt to develop a more detailed and complete Five-Year Needs Assessment document, which is tailored to meet their individual MCH program needs. If such a document is created by the state and made accessible on a public website, the state is encouraged to cite the URL for the website as part of its Application/Annual Report discussion. States may also choose to submit more detailed documentation on their Five-Year Needs Assessment findings as an attachment to this section.

1. Process Description

This description of the overall process/methodologies used by the state in conducting its Title V Five-Year Needs Assessment provides context for the interpretation of the reported findings and the priority needs subsequently identified. A report ⁵ prepared for MCHB on the needs assessment process cited four characteristics for states to consider in moving from a solely data-driven needs assessment effort to conducting a comprehensive assessment of its priority issues and stakeholder needs. These characteristics are:

1. A clear leadership structure for assembling data from both public and private sources;

2. Engagement of stakeholders for soliciting meaningful programmatic input;

3. A structured and inclusive priority-setting process; and

4. Collaborative program planning.

In describing the Five-Year Needs assessment process, states should provide a high-level summary that includes:

1. Goals, framework and methodology that guided the Needs Assessment process;

2. Level and extent of stakeholder involvement, including families, individuals and family-led organizations;

3. Quantitative and qualitative methods that were used to assess the strengths and needs of the MCH population in each of the five identified population health domains, MCH program capacity and supportive partnerships/collaborations ;

4. Data sources utilized to inform the Needs Assessment process; and

5. Interface between the collection of Needs Assessment data, the finalization of the state’s Title V priority needs and the development of the state’s Action Plan.

2. Findings

Findings derived from the comprehensive Five-Year Needs Assessment serve to inform the Title V program’s strategic planning, decision-making and resource allocation efforts. These findings also provide a benchmark against which states can compare and assess the progress that they have achieved during the five-year reporting period.

The Needs Assessment Summary should highlight the state’s noted MCH strengths/needs in three main areas:

1. MCH Population Health Status

2. Title V Program Capacity

3. Title V Program Partnerships, Collaboration and Coordination

1. MCH Population Health Status

The state should clearly describe the health status of the MCH population within each of the five population health domains (i.e., Women/ Maternal Health, Perinatal/Infant Health, Child Health, Adolescent Health, and CSHCN), based on the quantitative and qualitative analyses conducted. Specific discussion points should include:

1. A summary of the noted strengths and needs in the overall MCH population and in specific MCH sub-population groups;

2. A concise description of the state’s successes, challenges and gaps related to major morbidity, mortality, health risks or wellness for each of the five population health domains. At a minimum, the discussion should include the major health issues reflected in the state’s priority needs relative to the MCH population as a whole or specific sub-populations when stratified by age, income, geography, frontier/rural/urban status, or other relevant characteristics.

3. An analysis of current MCH Block Grant efforts in addressing the needs of its MCH population to determine areas of success and areas in which new or enhanced strategies/activities are needed.

ii. Title V Program Capacity

A state’s assessment of its Title V program capacity should examine current resources, staffing and organizational structure, state agency coordination and family partnerships. States should summarize the findings from their Five-Year Needs Assessment relative to each of these categories in the following sections.

1. Organizational Structure

In reporting on the organizational structure of the Title V program, the state should:

1. Describe the organizational structure and placement of the Governor, state health agency and the Title V MCH and CSHCN programs in the state government.

2. Clarify how the state health agency is "responsible for the administration (or supervision of the administration) of programs carried out with allotments” under Title V [Section 509(b)]. This description should include all of the programs that are funded by the federal-state MCH Block Grant.

2. Agency Capacity

In summarizing the state Title V program capacity, the state should describe the state Title V agency's capacity to promote and protect the health of all mothers and children, including CSHCN. Included in this description should be a discussion of the steps taken by the MCH and CSHCN programs to ensure a statewide system of services that reflect the components of comprehensive, community-based and family-centered care. The state should also describe the extent to which the Title V program collaborates with other state agencies, health services entities and private organizations to support health services delivery at the community level.

Specifically, the state’s summary on Title V program capacity should include the following:

1. A description of the state’s Title V capacity to provide and assure services within each of the five population health domains.

2. An expanded discussion on the state’s capacity for serving CSHCN, which includes the Title V program’s ability to provide rehabilitation services for blind and disabled individuals under the age of 16 receiving benefits under Title XVI (the Supplemental Security Income Program), to the extent that medical assistance for such services is not provided under Title XIX (Medicaid). If applicable, states may describe their capacity to serve CSHCN and their families by referencing the National Consensus Standards for Systems of Care for Children and Youth with Special Health Care Needs as a guiding framework (AMCHP, 2014)⁶.

3. MCH Workforce Capacity

State Title V program efforts to implement the core public health functions (assessment, policy development and assurance) and to achieve increased accountability through ongoing performance measurement and monitoring require an adequately sized and skilled workforce. In reporting on their Title V program capacity, states should describe the strengths and needs of their MCH and CSHCN workforce. Specifically, states should include in their MCH workforce summary the following information:

1. Number, location and full-time equivalents of state and local staff who work on behalf of the state Title V programs;

2. Names and qualifications (briefly described) of senior level management employees who serve in lead MCH-related positions and program staff who contribute to the state’s planning, evaluation, and data analysis capabilities;

3. Number of parent and family members, including CSHCN and their families, who are on the state’s Title V program staff and a brief description of their roles (e.g., paid consultant or volunteer); and

4. Additional MCH workforce information, such as the tenure of the state MCH workforce and projected shifts in the MCH and CSHCN workforce over the five-year reporting period, that aligns workforce capacity with the achievement of Title V program goals.

3. Title V Program Partnerships, Collaboration, and Coordination

Title V programs partner with a range of federal, state and local entities to further supplement state agency capacity in meeting the needs of its MCH population. In summarizing these partnerships as well as the engagement of stakeholders in programmatic decisions, the state should describe relevant organizational relationships that serve to expand the capacity and reach of a state Title V program in meeting the needs of its MCH population, including CSHCN. The state should reference formal and informal collaboration processes and partnerships with the public and private sector and with state and local levels of government. In addition, the state should describe the process for involving stakeholders and their contributions to the Title V program.

In summarizing the strengths and weaknesses of its partnership building and collaboration efforts, the state should describe its partnerships and relationships with such programs as:

1. Other MCHB investments (e.g., State System Development Initiative (SSDI) Grants, Family-to-Family Health Information Centers; MCHB investments related to newborn and early childhood screenings, epilepsy, genetics, and blood disorders, Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Grants, Healthy Start Grants, Early Childhood Systems of Care (ECCS) Grants, MCH Training programs and other MCHB efforts relating to injury prevention, autism, developmental disabilities, adolescent health, workforce development, oral health, bullying and emergency medical services for children);

2. Other Federal investments (e.g., ACF, CDC and USDA-funded programs, such as immunizations, infant and child death reviews and WIC);

3. Other HRSA programs (e.g., community health centers and HIV/AIDS/AIDS programs and Area Health Education Centers);

4. State and local MCH programs (e.g., local health departments and urban MCH programs );

5. Other programs within the State Department of Health (e.g., chronic disease, prevention and health promotion, immunization, vital records and health statistics, injury prevention, behavioral and mental health and substance abuse);

6. Other governmental agencies (e.g., Medicaid, CHIP, Education, Social Services/Child Welfare, Social Security Administration, Corrections and Vocational Rehabilitation Services);

7. Tribes, Tribal Organizations and Urban Indian Organizations;

8. Public health and health professional educational programs and universities; and

9. Other state and local public and private organizations that serve the state’s MCH population.

c. Identifying Priority Needs and Linking to Performance Measures

Consistent with Figure 4 on page 14, findings from the Five-Year Needs Assessment should drive the state’s identification of its seven to ten highest MCH priority needs for the five-year reporting cycle. The selected priorities may address the defined MCH population groups and/or cross-cutting/ systems building areas, and they should reflect the unique needs of the state. In addition, the identified priority needs should address areas in which a state believes that targeted interventions can result in needed improvements to its health care delivery systems. Once identified, the priority needs inform the selection of a minimum of five NPMs, one in each of the MCH population health domains, and the development of SPMs. Collectively, the NPMs and SPMs should address the state’s identified priority needs.

States list their seven to ten priority needs on Form 9 of the Application/Annual Report. The TVIS will record up to 10 priority needs, but a state can include additional priorities in a field note, if desired. For each of the listed priority needs on Form 9, states should indicate if the need is new for this reporting cycle or if it is being revised or continued from the previous reporting cycle.

The narrative discussion supplements the listing of the final priority needs by providing a rationale for how the priority needs were determined and how they link with the selected national and state performance measures. Specifically, this discussion should include:

1. Methodologies used to rank the broad set of identified needs and the state’s process for selecting its final seven to ten priorities;

2. Emerging issues or other frequently cited needs that were not included in the final list of priority needs and a rationale for why they were not selected;

3. Factors that contributed to changes in the state’s priority needs since the previous five-year reporting cycle; and

4. Relationship between the priority need and the selected national and/or state performance measures in driving improvement.

4. Financial Narrative

The development and implementation of a workable State Action Plan requires careful analysis and utilization of available funding and resources. Building on the assessment of state MCH population needs and Title V program needs, the state should present a budget plan for the Application year that aligns its proposed Title V program activities with the identified MCH needs. In addition, the state should report and reflect on its MCH Block Grant expenditures for the Annual Report year. This reflection should include a comparison of planned, budgeted activities with actual expenditures for that fiscal year and link the allocation of financial resources with outcomes achieved relative to the State’s Title V program plan. Together, the budget and expenditure narrative reporting demonstrate how federal MCH Block Grant funds complement non-federal Title V funds in enabling a state to address its unique MCH priority needs. The state should also describe the contribution of federal MCH Block Grant funds towards supporting essential MCH programs/services and the capacity of the state to adequately address its MCH population needs in the absence of this federal funding.

The combined Expenditure and Budget narrative sections should demonstrate accountability in the state’s use of its federal and state MCH Block Grant funds to meet the program’s legislative intent, i.e., “to improve the health of all mothers and children” (Section 501(a)). States should reflect on whether the Title V program efforts and outcomes discussed in the State Action Plan and other sections of the Application/Annual Report could have been achieved without federal MCH Block Grant funding support.

States should maintain expenditure and budget documentation for the MCH Block Grant, consistent with the requirements in Section 505(a) and Section 506(a). Per Section 506(b)(1), each state is required to conduct an audit of its expenditures every two years.

1. Expenditures

In describing its MCH Block Grant expenditures, states should reflect on the federal and non-federal monies that have been obligated and spent. This discussion is intended to provide the reader with an understanding of how the supported programs and services link with the state’s MCH priority needs and meet the requirements of Title V legislation.

The expenditure narrative should demonstrate the Federal/State partnership and how federal support complements the state’s total MCH investment, as reflected on Form 2, Lines 3-6 (i.e., reported State, Local, Other, and Program Income expenditures). States should monitor expenditures regularly to ensure compliance with legislative financial requirements. The state should document and explain how the reported expenditures comply with the 30%-30%-10% requirements, as specified in Section 504(d) and Section 505(a)(3). Significant variations of more than 10% in the expenditure data reported on Form 2 and Form 3, as compared to the state’s planned budget for that same fiscal year, should be explained in the narrative discussion. In addition, states should reflect on the number/percent of the MCH population who are served by Title V, as reported on Form 5, and provide a description of the state’s efforts to expand its reach. Challenges faced by the state should be noted and addressed.

It is recognized that funds for the reporting year may be not be fully expended at the time of submission. Given that the state is required to submit a Federal Financial Report (FFR) with the final financial data within 3 months of the expiration of funds, the most recent expenditure data should be reported at the time of submission. The state may wish to utilize the form or field notes on Forms 2 and Form 3 to explain any discrepancies in its submitted financial data and work with its MCHB Project Officers in reporting final expenditures.

States report the federal and non-federal MCH Block Grant expenditures separately on the budget/expenditure forms. This breakdown should be further examined as part of the narrative discussion.

With respect to Medicaid, Title V should be the payer of last resort and MCH Block Grant funds cannot be used to reimburse a claim for a service that is otherwise covered under Medicaid. Additionally, service providers receiving MCH Block Grant funds are strongly encouraged to seek payment from other public and private insurance providers when applicable. The state should describe how services supported by the MCH Block Grant reflect services that were not covered or reimbursed through the Medicaid program or another provider.

2. Budget

In its budget narrative, a state should present a plan that describes how federal and non-federal Title V funds will be used to address the state’s priority needs, improve performance related to the targeted MCH outcomes and expand its systems of care for both the MCH and CSHCN populations. The budget narrative should also demonstrate and assure the state’s commitment to complying with the legislative financial requirements (e.g., 30%-30%-10% requirements) and program regulations.

Similar to the narrative description that the state provided for its expenditures, the budget narrative should demonstrate the federal-state partnership and how federal MCH Block Grant support will be utilized to complement the state’s planned total match (i.e., State, Local, Other, and Program Income funds) for the Application year. The budget narrative should highlight the State’s MCH/CSHCN program and align with the identified MCH/CSHCN priorities. This discussion should clearly articulate how federal and non-federal MCH Block Grant funds will support the activities that are described in the State Action Plan for the upcoming budget period.

While the final federal MCH Block Grant allocation is not yet known, states should use the allocation for the current fiscal year as a basis for determining budget estimates for federal and non-federal MCH Block Grant funds in the Application year. In the budget narrative discussion, the state should describe sources of other federal MCH dollars (as noted on Form 2, Line 9), state matching funds and other state funds used by the agency in its Title V programming. This discussion should include how MCH Block Grant funds support essential services, as defined by the Title V MCH Services Block Grant Pyramid (Figure 1), for the three legislatively defined populations. The narrative discussion should provide an explanation of how the planned funding will support the budget estimates for individuals served and types of services provided, as reported on Form 3a and Form 3b.

Significant variations in the budgeted amounts reported by a state on Form 2 and Form 3, as compared to previous years’ reporting, should be explained. Any budget notes provided on Form 2, Form 3a, and Form 3b should be further clarified in the narrative discussion.

The state should describe how the it plans to meet and monitor the required match requirements, which includes a $3 match in non-federal funds for every $4 of federal MCH Block Grant funds expended [Section 503(a)] and the maintenance of effort from 1989 [Section 505(a)(4)]. Any continuation funding for special projects [Section 505(a)(5)(C)(i)]; or special consolidated projects as defined in Section 501(b)(1) and the nondiscrimination provisions in Section 505(a)(5)(B) should also be briefly described.

States are reminded that “any amount payable to a state under this title from allotments for a fiscal year, which remains unobligated at the end of such year, shall remain available to such state for obligation during the next fiscal year. No payment may be made to a state under this title from allotments for a fiscal year for expenditures made after the following fiscal year” [Section 503(b)]. While states apply annually for MCH Block Grant funding, a state has two years in which to expend the federal MCH Block Grant allocation awarded in any fiscal year.

5. Five-Year State Action Plan

States shall develop a five-year State Action Plan in follow-up to the Five-year Needs Assessment. This Action Plan serves as the Application/Annual Report narrative discussion for the state on their planned activities for the Application year and the activities that were implemented in the Annual Report year. Activities should be discussed relative to the pertinent domain, state priority need, Title V program goal, evidence-based or -informed strategies and national and state-specific performance and outcome measures. Building on its needs assessment, financial planning and performance reporting, the state’s five-year action planning begins with the completion of the State Action Plan Table.

1. Five-Year State Action Plan Table

Based on the logic model presented in Figure 4, the State Action Plan Table (Figure 6) is intended to serve as a planning tool for states to use in identifying key strategies, objectives and relevant performance measures to align with the selected priority needs. Organized by the five MCH population health domains (i.e., women/maternal health, perinatal/infant health, child health, CSHCN and adolescent health) and the sixth cross-cutting and systems building domain, the State Action Plan Table should include the following components.

1. Priority Needs – Title V legislation directs states to conduct a state-wide MCH Needs Assessment every 5 years to identify the need for preventive and primary care services for pregnant women, mothers, infants, children, and CSHCN. From this assessment, states select seven to ten priorities for focused programmatic efforts over the five-year reporting cycle.

2. Strategies – Strategies are the general approaches taken to achieve the objectives; activities are specific actions to implement the strategies. Program activities for implementing the identified strategies will be discussed and updated annually as part of the State Action Plan narrative.

3. Objectives – An objective is a statement of intention with which actual achievement and results can be measured and compared. SMART objectives are Specific, Measurable, Achievable, Relevant and Time-phased.

4. Performance Measures – For purposes of the MCH Block Grant, performance measures include both national and state-specific measures (i.e., NPMs, ESMs, SOMs, and SPMs). States select performance measures that align with their identified strategies, and to the NOMs and SOMs.

States should update the Five-year State Action Plan Table as needed for each year’s Application/Annual Report.

Figure 6. Five-Year State Action Plan Table

Priority Needs	Strategies	Objectives	National and State Performance Measures	Evidence–Based or –Informed Strategy Measures	National and State Outcome Measures
	Women’s/Maternal Health
	Perinatal/Infant Health
	Child Health
	CSHCN
	Adolescent Health
	Cross-cutting/Systems Building

2. State Action Plan Narrative Overview

1. State Title V Program Purpose and Design

Each state Title V program is unique in its organizational and fiscal structure; operating statutes and regulations; available resources; targeted MCH needs; established performance goals; and portfolio of supported programs and services. States should provide a “big picture” overview of their Title V program to give context to the activities and approaches that are described in the State Action Plan. Noted discussion points should include:

1. The Title V program’s partnership and leadership roles in accomplishing the MCH Block Grant’s goals and mission;

2. The Title V program’s framework (e.g., life course model) and strategic approach to addressing the identified MCH priorities while considering program successes, ongoing challenges and emerging issues;

3. The purpose and commitment of the Title V program in providing a foundation for family and community health across the state and in assuring access to the delivery of quality health care services for mothers, infants and children, including CSHCN.

Given the uniqueness of each state, the Title V program has flexibility in writing a narrative description that best conveys the elements it considers to be the most critical in giving context to the Title V program. This description should respond to the question, “What does a reader need to know about the Title V program to understand the activities and approaches that are described in the State Action Plan?” Most relevant to this discussion is the Title V program’s demonstrated leadership in such areas as:

1. Serving as a convener, collaborator and partner in addressing MCH issues;

2. Supporting coordinated, comprehensive and family-centered systems of care at state and local levels, which may include the implementation of AMCHPs’ National Consensus Standards for Systems of Care for Children and Youth with Special Health Care Needs;

3. Developing and utilizing innovative and evidence-based or -informed approaches to address cross-cutting issues that impact the health status of specific MCH populations and sub-populations, such as social determinants of health; and

4. Implementing the core public health functions of assessment, assurance and policy development through program efforts that are supported by the MCH Block Grant.

2. Supportive Administrative Systems and Processes

In developing the Action Plan, the state should describe other administrative factors (e.g., personnel, family partnerships, MCH program capacity and integrated health care delivery partnerships) that influence the Title V program’s ability to meet its planning goals and objectives.

1. MCH Workforce Development

Successful implementation of the five-year State Action Plan requires a workforce that is adequate in size, effectively trained and properly supported. The state should describe its Title V program workforce plan and the strategies in place for advancing a common agenda and future MCH workforce vision (e.g., types of personnel and skill sets needed). Specific activities to meet the following three workforce goals, along with other state-identified goals, should be discussed.

1. Recruitment and retention of a qualified Title V program staff;

2. Training and growth opportunities for Title V program staff and family leaders; and

3. Innovations in staffing structures and workforce financing.

2. Family Partnership

As discussed on page 8 family partnership is defined in the MCH Block Grant as: “the intentional practice of working with families for the ultimate goal of positive outcomes in all areas through the life course. Family engagement reflects a belief in the value of the family leadership at all levels from an individual, community and policy level.”

The state should provide an overarching discussion of its organizational capacity and vision for partnering with families and individuals in all aspects of their Title V Action Plan development and implementation in all population domains. Descriptions of partnership activities may include, but are not limited to, the following areas:

1. Advisory Committees;

2. Strategic and Program Planning;

3. Quality Improvement;

4. Workforce Development and Training;

5. Block Grant Development and Review;

6. Materials Development; and

7. Program Outreach and Awareness

Training activities that serve to strengthen and advance family partnership in the Title V program, both in orientation and ongoing professional development, which are conducted for staff, family leaders, volunteers, contractors and subcontractors should be discussed. In addition, the state should describe the contributions of family and community leaders to such Title V program processes as assessment of needs/assets, program planning, MCH and CSHCN services delivery and evaluation/monitoring/quality improvement activities. Participating members should reflect the MCH community that is being served.

Specific details on the roles and responsibilities of families, individuals and family-led organizations at the direct care, organizational and governance, and policymaking levels, should be presented in each of the MCH domain-specific discussions in the State Action Plan. The state should highlight the outcomes and impacts of their family partnerships on Title V program policies and activities in the overarching discussion. Specific impacts of family partnership on each of the five MCH populations and on the Title V program’s cross-cutting and systems building activities should be included in the appropriate MCH domain narrative discussion.

3. States Systems Development Initiative and Other MCH Data Capacity Efforts

States who receive SSDI funding should discuss how this grant funding supports MCH data collection and reporting in the MCH Block Grant. In addition, each state should discuss its progress in achieving direct, annual access to timely, electronic MCH health data and how these data have served to inform and support Title V programming, assessment and monitoring.

States should also highlight other MCH epidemiological and data enhancement activities that support Title V needs assessment and performance measure reporting.

Launched in 1993, the purpose of the State Systems Development Initiative (SSDI) is to develop, enhance, and expand state and jurisdictional Title V MCH data capacity for responding to the needs assessment activities and performance measure reporting requirements in the MCH Block Grant. Such enhanced MCH data capacity is intended to enable states and jurisdictional Title V programs to engage in informed decision-making and resource allocation that supports effective, efficient and quality programming for women, infants, children, including CSHCN, and their families. SSDI complements the MCH Block Grant by improving the availability, timeliness, and quality of MCH data in the 59 states and jurisdictions. Utilization of these data is central to state and jurisdictional reporting on their Title V program assessment, planning, implementation, and evaluation efforts, along with related investments, in the yearly MCH Block Grant Application/Annual Report.

Collection and reporting of timely and comprehensive MCH Block Grant data is determined in part by the state’s ability to link data from multiple sources (e.g., vital records, child health surveys, newborn screening, Medicaid claims, immunization and birth defects registries, hospital discharges and the Special Supplemental Nutrition Program for Women, Infants and Children (WIC)) and across programs.

3. Health Care Delivery System

Organizational relationships and the leveraging of federal and state program resources contribute to the services delivery capacity of a state Title V program. States should provide a description of their collaborative work with other federal, state and non-governmental partners, and how this work complements Title V program efforts to provide a system’s approach to ensure access to quality health care and needed services for the MCH population.

Within a state, the Title V program and Title XIX Medicaid program share a common goal in working to improve the overall health of the MCH population through affordable health care delivery systems and expanded coverage. Partnership and collaboration between these two programs allow for the effective leveraging of federal and state resources, which yields administrative efficiencies to help ensure that women and children are provided needed preventive services, health examinations, treatments and follow-up care. Section 509(a)(2) of Title V of the Social Security Act cites the need to promote “coordination at the Federal level of activities authorized under this title [Title V] and under title XIX….” Also, Section 1902(a)(11) of Title XIX requires State Medicaid agencies to enter into Inter-Agency Agreements (IAAs) with state Title V agencies. This provision further clarifies that Medicaid funds are to be used to reimburse expenditures made by the Title V agency for Medicaid-covered services to Medicaid recipients, as appropriate, (i.e., that Medicaid should be the first payer.)

The state should provide a detailed description of the existing relationship between the Title V program and the Medicaid program, which builds on the noted areas of coordination and collaboration in the IAA/Memorandum of Understanding (MOU). A copy of the most recently signed IAA/MOU is a required attachment for this Application/Annual Report.

The state’s narrative discussion should address areas of defined coordination between the two programs and the benefits that have been realized. At a minimum, the discussion should address Title V program impacts in the following areas:

1. Program outreach and enrollment;

2. Health care financing (e.g., the percent of services delivered by managed care organizations (MCO), primary care case management (PCCM) and fee for service, if applicable);

3. Waivers or state plan amendments that influence health care delivery for the MCH population, particularly CSHCN; and

4. Joint policy level decision making on issues related to MCH services delivery and coverage, particularly for CSHCN.

In working to strengthen their Title V – Title XIX IAAs, states may wish to consider the strategies developed by the National Academy of State Health Policy (NASHP) under funding support provided by the HRSA/MCHB.⁷

3. State Action Plan Narrative by Domain

Supplemental to the overarching State Action Plan narrative discussion is the state’s detailed reporting, by MCH domain, on its specific Title V program activities for the Annual Report year and for the Application year. The order of the narrative reporting is organized to allow states to discuss their strategies, achievements and performance trends, relevant to the specific MCH domain, in the Annual Report year prior to presenting the planned activities and performance objectives for the Application year. The six MCH domains are:

Five MCH Population Domains

1. Women/Maternal Health

2. Perinatal/Infant Health

3. Child Health

4. Adolescent Health

5. CSHCN

Optional Domain

6. Cross-cutting/Systems Building

The state should include a discussion of the selected NPM and related ESM(s), along with any SPMs and/or SOMs, in each of the five MCH population domains. While there is not an associated NPM in the Cross-cutting/Systems Building domain, the state should report on any state-initiated activities or established SPMs/SOMs that fall within this domain. This discussion will likely build on the high-level presentation in the State Action Plan Narrative Overview and include more detailed descriptions of such Title V program efforts as strengthening family partnerships, addressing social determinants of health, expanding MCH data capacity and enhancing public health surveillance/reporting systems.

The domain-specific State Action Plan narrative discussion should focus on the alignment of the strategies, objectives and performance measures for a corresponding priority need, as outlined in the State Action Plan Table. This discussion should primarily include strategies and activities for which the Title V program has a leadership role in administering the activity. Critical partnerships with other MCHB-supported programs (e.g., MIECHV, MCH Training Programs, Healthy Start programs and Collaborative Improvement and Innovation Networks (CoIINs)) should be highlighted, along with family partnerships, in the relevant MCH domain narrative discussions.

For the Annual Report year, the state should:

1. Provide an analysis that gives context to the state of this population domain;

2. Summarize programmatic efforts and the use of evidence-based or -informed approaches to address each of the identified priority needs;

3. Re-assess the alignment of the selected NPMs, ESMs, SPMs and SOMs, if applicable, with its related priority need:,

4. Analyze the state’s progress in achieving its established performance measure targets along with other programmatic impacts;

5. Note challenges and emerging issues that have resulted in changes to the State Action Plan; and

6. Assess the overall effectiveness of the implemented program strategies and approaches in addressing the identified MCH population needs and in promoting continuous quality program improvement.

For the Application year, the state should:

1. Describe the planned activities for the Application year, with ongoing emphasis on their relevance to the identified priority needs;

2. Align planned activities with the priority needs that were identified based on the Five-Year Needs Assessment and the annual needs assessment updates;

3. Assess if new priorities have emerged that take precedence over the established priority needs;

4. Assess the relevance of the current ESM(s) for a selected NPM and determine if a new ESM needs to be established;

5. Assess if changes are needed in the established SPMs and SOMs, if applicable; and

6. Discuss updates to the Five-year Action Plan Table that reflect new or revised priority needs, evidence-based or -informed strategies or performance measures for driving improved performance.

MCH strategies and activities that reflect ongoing efforts and support the overall system of care for the MCH population but do not directly align with a State’s identified priority needs should be discussed in the relevant MCH domain. For example, state Title V program support for newborn screening should be described in the perinatal/infant health section regardless if there is an identified priority need.

6. Public Input [Section 505a]

In its Application/Annual Report, the state should describe its process for making the Application/Annual Report available to the public for comment during its development and after its transmittal. This discussion should include efforts by the state to solicit public comments during the development of the Application/Annual Report. The number and nature of the comments received and how they were addressed in the final Application/Annual Report should be noted for each year. The state should clearly identify specific activities for engaging families and other stakeholders prior to, during and after the Application process. Such activities may include:

1. Public Hearings;

2. Advisory Council Review;

3. Web Posting;

4. Social Media;

5. Public Notices;

6. Other Use of Media; and

7. Outreach to Specific Stakeholders (e.g., MCH Training Grantees)

6. Technical Assistance

States should consider potential areas of needed technical assistance as they work to implement their five-year Action Plan. In accordance with the responsibilities specified in Section 509 of the Title V legislation, the MCHB makes available to states and jurisdictions needed technical support and resources, as determined by a state. To receive MCHB-supported technical assistance, the state may complete and submit a Technical Assistance Request Form. This form is available upon request from the MCHB Project Officer.

1 Institute of Medicine. (1988). The Future of Public Health. Washington, D.C.: National Academy Press..

2 Public Health in America. (1994), Washington, DC: US Public Health Service. Essential Public Health Services Working Group of the Core Public Health Functions Steering Committee.

3 Carman K., Dardess, P., Maurer, M., Sofaer, S., Adams, K., Bechtcl, C., Sweeney, J. “Patient and Family Engagement: A framework for understanding the elements and developing interventions and policies.” Health Affairs. 2013; 32:223-231. 

4 Ibid 

5 Gabor, V., Noonan, G., Anthony, J. and Gordon, E. “Review of the Title V 5-Year Needs Assessment Process in the States and Jurisdictions.” Final Report, Health Systems Research, Inc. (Altarum), December 15, 2006.

6 http://www.amchp.org/AboutTitleV/Resources/Documents/Standards%20Charts%20FINAL.pdf

7 Wirth, B. and Van Landeghem, K. “Strengthening the Title V-Medicaid Partnership: Strategies to Support the Development of Robust Interagency Agreements between Title V and Medicaid.” April 2017.

http://nashp.org/wp-content/uploads/2017/04/Strengthening-the-Title-V-Updated.pdf.