• Maternal and Child Health Block Grant - Title V
• Traumatic Brain Injury
• Universal Newborn Hearing Screening and Early Intervention
• Emergency Medical Services for Children
• Healthy Start
• Family-to-Family Health Information Centers

MATERNAL AND CHILD HEALTH CARE BLOCK GRANT -TITLE V

Notes:
^a Long term measure with 2008 established as out-year target date.
^b Vital statistics compiled by the National Center for Health Statistics, Centers for Disease Control and Prevention (CDC) 2007. Deaths: Preliminary Data for 2005, Health E-Stats, September 12, 2007.
^c The target for FY 2008 was changed from 6.5/1000 to 6.8/1000 to reflect the complexity of the infant mortality problem.
^d Indicator: Hospitalizations per 1000 deliveries due to illness and complications resulting from pregnancy. Actual data reported for FY 2004 and 2005 are based on the average rates for the two most common illnesses in pregnancy (i.e., diabetes and pregnancy-induced hypertension). The targets for FY 2006 and 2007 were developed based on earlier data which included three conditions of pregnancy (i.e., diabetes, pregnancy-induced hypertension and anemia.) These targets are not appropriate for the data as it is currently collected. This difference in data collection is due to changes in the revised 2003 Certificate of Live Birth.

INTRODUCTION

Since its inception, the Title V Maternal and Child Health (MCH) Block Grant program has provided a foundation for ensuring the health of the Nation's mothers, infants, children, adolescents, including children and adolescents with special health needs, and families. The MCH Block Grant supports a wide variety of services that address the Title V legislative requirements and the strategic goals outlined by HHS, HRSA and MCHB. Consistent with other HRSA programs, State Title V programs use their appropriated MCH Block Grant funds to address three overarching goals: 1) improving access to health care; 2) eliminating health disparities; and 3) improving the quality of health care. Progress in meeting these goals is assessed through the examination of the annual performance measure and indicator data that is reported by States. While each measure addresses a different aspect of health care delivery specific to pregnant and breastfeeding women, infants, children and adolescents, the measures collectively provide a snapshot into the health, safety and well-being of the Nation's MCH population. The Program utilizes these findings to identify emerging public health needs and critical issues relative to MCH. A strategy used in efforts to improve performance is to provide needed technical assistance to States in areas identified in their needs assessment plans and in their annual applications. Another strategy is to identify and promote promising practices that can be used by State MCH programs to improve MCH outcomes. The program also supports States in their efforts to do outreach to increase participation in Medicaid and SCHIP.

DISCUSSION OF RESULTS AND TARGETS

Long-Term Objective: Expand the capacity of the health care safety net.

10.1. Decrease the number of uninsured children.
(Baseline - 2000: 8.4 million; Target - 2008: 8 million)

Long-Term Objective: Promote outreach efforts to reach populations most affected by health disparities.

10.IV.B.1 Decrease the ratio of the black infant mortality rate to the white infant mortality rate.

While there has been progress in reducing infant mortality rates for both racial groups, the proportional discrepancy between Blacks and Whites has remained largely unchanged. Preliminary data indicate that the Black/White Infant Mortality Ratio declined slightly in
FY 05 to 2.38 to 1. The target of 2.1 to 1 was not met; however, there was progress in moving towards the target. (See section on "Targets Substantially Exceeded or Not Met.") Rates for FY
03 and FY 04 were essentially unchanged at 2.43 to 1 and 2.44 to 1, respectively. The target for FY 09 continues to be 2.1 to 1.

Long-Term Objective: Promote effectiveness of health care services.

10.III.A.1. Reduce the infant mortality rate.

All countries of the world measure the infant mortality rate as an indicator of general health status. The U.S. has made progress in reducing this rate; however, since 2002, the rate has been rising. Race/ethnicity, maternal age, education, smoking, and number of pregnancies are all factors that contribute to the infant mortality rate.

The overall infant mortality rate decreased slightly from 7.0 per 1,000 lives births in 2002 to 6.8 per 1,000 live births in 2004. Based on preliminary data, the rate increased slightly in FY 05 to 6.9 per 1,000 live births. The 2004 performance for this goal slightly exceeded the target of 6.9 per 1,000 live births; for 2005, the target was tentatively met pending the release of the final data. The FY 09 target for this measure is 6.7/1,000.

10.III.A.2. Reduce the incidence of low birth weight (LBW) births.

In the past 15 years, the distribution of birth weights in the U.S. has shifted towards lower weights. The percentage of infants weighing less than 3,500 grams at birth has risen. Birth weight is an important predictor of early death and long-term disability. The lower an infant's Birth weight, the greater the risk for a poor outcome.

The LBW rate (less than 2,500 grams) increased from 7.8 percent in 2002 to 8.2 percent in 2005, which is the highest level reported since 1969. The FY 05 program target of 7.4% was not met. (See section on "Targets Substantially Exceeded or Not Met.") The FY 09 target for this measure is 7.3%.

10.III.A.3. Increase percent of pregnant women who received prenatal care in the first trimester.

Overall, the proportion of pregnant women entering prenatal care in the first trimester has increased over the last decade (from 75.8% in 1990 to 83.9% in 2005). The percent of pregnant women who received prenatal care in the first trimester remained unchanged at 83.9% for
FY 04 and FY 05. While the FY 05 rate was slightly below the FY 03 rate of 84.1%, the target of 84% was essentially met. The FY 09 target for this measure is 86%.

It is important to note that prenatal care data based on the 1989 and 2003 Standard Certificates of Live Birth are not directly comparable, due to substantive changes in information reported on the timing of prenatal care in the 2003 Certificate. For 2005, data based on the 1989 Certificate (unrevised) are available for 37 States and data based on the 2003 Certificate (revised) are available for 12 States. For consistency purposes, the data presented through 2005 and the established targets through 2009 reflect the data that were reported by States using the unrevised Certificate.

Prenatal care is one of the most important interventions for ensuring the health of pregnant women and their newborn babies. High quality prenatal care begins early in the pregnancy (preferably in the first trimester), and continues throughout the pregnancy, according to accepted standards of periodicity. Accordingly, getting pregnant women into early and regular prenatal care has been a key area of emphasis for the Title V program. The program is strongly committed to achieving the Healthy People 2010 goal of getting 90% of all pregnant women into prenatal care in the first trimester.

10.2. Reduce neonatal deaths to 4.5 per 1,000 live births.
(Baseline - 1999: 4.7/1,000 live births; Target - 2008: 4.5/1,000 live births)

10.III.A.4. Increase percent of low-birth weight (LBW) babies who are delivered at facilities for high-risk deliveries and neonates.

The Title V program plays an important role in the delivery of appropriate and effective care for high-risk pregnant women and infants. Delivering LBW babies, who are at higher risk for mortality and morbidity than non-LBW babies, at facilities with specialized equipment and personnel capable of the highest standard of care for these babies, significantly assists in reducing their associated mortality.

The percent of LBW babies delivered at facilities for high-risk deliveries and neonates declined from 76.1% in FY 03 to 68.1% in FY 06. Compared to the FY 05 rate of 67.7%, there was slight improvement in the percent of LBW infants delivered at facilities for high-risk deliveries and neonates in FY 06. Despite this improvement, the rate remains lower than the baseline of 72.5% in 1997 and the FY 04 rate of 73.3%. The FY 06 target of 77% was not met. (See section below on "Targets Substantially Exceeded or Not Met.") The target for FY 09 continues to be 77%.

10.3. Increase maternal survival rate.
(Baseline - 1999: 8.3 deaths/100,000 live births; Target - 2008: 8/100,000 live births)

10.III.A.5. Reduce maternal illnesses and complications due to pregnancy.

Medical risk factors, such as diabetes and pregnancy-induced hypertension, can contribute to serious complications during pregnancy as well as maternal and infant morbidity and mortality, particularly if they are not properly identified and treated. The level of pregnancy-associated hypertension for 2005 (39.9/1,000 births) is the highest reported since these data became available. Diabetes prevalence rose by more than two-thirds between 1990 and 2005 (from 21.3/1,000 births to 38.5/1,000 births.)

The average rate for the two most common conditions in pregnancy (i.e., diabetes and pregnancy-induced hypertension) increased from 36.8 per 1,000 deliveries in FY 04 to 39.2 per 1,000 deliveries in FY 05. Due to changes in the revised 2003 Certificate of Live Birth, previous years' data are not comparable. Data reported prior to FY 04 were based on the three most common conditions in pregnancy (i.e., diabetes, pregnancy-induced hypertension and anemia.) Given the change in how data are reported for this measure, comparisons of actual performance
in FY 05 with the established target of 30% are not appropriate. The FY 09 target for this measure is 36 per 1,000 deliveries.

Long-Term Objective: Expand the capacity of the health care safety net.

10.I.A.1. Increase the number of children served by Title V.

Services for children supported under the Title V MCH Block Grant program include: the provision of direct health care, enabling services, population-based services, and infrastructure building activities. Since FY 03, the number of children served by Title V has been increasing. Due to increases in screening services, the number of children served by Title V increased by
4 million between FY 03 and FY 04. The number of children served by Title V varies within a State from year to year. In FY 06, the largest number of children (29 million) were served by Title V since data collection began in the Title V Information System in the 1990's. The number served exceeds the FY 06 target by 6.5 million. (See section below on "Targets Substantially Exceeded or Not Met.") The FY 09 target for this measure is that 29 million children will be served by Title V.

10.I.A.2. Increase the number of children receiving Title V services who are enrolled in and have Medicaid and SCHIP coverage.

The number of children receiving Title V services covered by Medicaid and SCHIP increased from a baseline of 5.9 million in FY 02 to 11 million in FY 06. The number served exceeded the FY 06 target by 4.8 million. (See section below on "Targets Substantially Exceeded or Not Met.") Between FY 02 and FY 03, the number of children served by Title V who received these services increased by 3.8 million. The Title V program has continued to served an increasing number of children with Medicaid and SCHIP coverage since FY 04, with annual increases ranging between 0.1 million between FY 03 and FY 04 and 0.9 million between FY 05 and FY 06. These increases reflect the efforts of State MCH programs to provide outreach to populations eligible for Medicaid and SCHIP coverage. The FY 09 target for this measure is that 11.5 million children with Medicaid and SCHIP coverage will be served by Title V.

10.E. Increase the number of children served by the Title V Block Grant per $1 million in funding.

The Title V Block Grant program provides States with Federal funds for a wide variety of health projects to improve the lives of all women and children. These funds are spent by the States to support services for the maternal and child health populations, including children with special health care needs, at four levels - direct services, enabling services, population-based services, and infrastructure-building.

Per $1 million in funding, the number of children receiving direct, enabling and population-based services through the Title V MCH Block Grant in FY 06 reached its highest level at 41,868 since data reporting for this measure began. This level of service exceeded the FY 06 target of 32,394 by 29 percent. (See section below on "Targets Substantially Exceeded or Not Met.") The FY 09 target for this measure is 39,000.

TARGETS SUBSTANTIALLY EXCEEDED OR NOT MET

Measure: Decrease the ratio of the black infant mortality rate to the white infant mortality rate.
FY 05 Target: 2.1 to 1
FY 05 Result: 2.38 to 1 (Preliminary data; Final data are not available for FY 05.)

While the U.S. has made progress in reducing the overall infant mortality rate, the significant disparity that still exists seriously impacts selected racial groups. The Black infant mortality rate is more than twice the White rate. Research has suggested that a higher rate of very low birth weight among Blacks may contribute to, but does not fully explain, racial differences in infant mortality rates. Additional research is needed to identify factors that contribute to the black/white infant mortality disparity and to examine potential solutions.

The Program continues to monitor the Black/White Infant Mortality Ratio and to explore promising models and effective strategies for addressing this issue. Despite the slow rate of progress, the Program's targets of 2.2 to 1 and 2.1 to 1 for FY 08 and FY 09, respectively, reflect the Program's ongoing commitment for continued improvement in this area.

Measure: Reduce the incidence of low birth weight (LBW) births.
FY 05 Target: 7.4%
FY 05 Result: 8.2 % (Preliminary data; Final data are not available for FY 05.)

The increasing rate of LBW births is a recognized concern across the Nation. The percentage of infants born LBW has increased 17 percent since the mid-1990s and 22 percent since 1984. Recent increases are influenced by the rise in the multiple birth rate, greater use of obstetric interventions, and increases in maternal age at childbearing. While multiple births are much more likely to be born LBW than singletons, the LBW rate for infants born in single deliveries has also been on the increase. Singleton LBW rose from 6.3 to 6.4 percent for 2004-2005, and the rate has risen 7 percent since 2000. LBW levels also increased for 2004-2005 among each of the largest racial/ethnic groups (non-Hispanic White births rose from 7.2% to 7.3%; non-Hispanic Black births rose from 13.7% to 14%; and Hispanic births rose from 6.8% to 6.9%).

The Program continues to monitor the rate of LBW and its causes. The full reasons for the increasing rate of LBW births are unclear and are under investigation. Despite recent increases, the Program remains committed to improvement in this area. The Program's performance targets for FY 08 and FY 09 are 7.4% and 7.3%, respectively.

Low birth weight is associated with short-term morbidity and mortality, as well as long-term disabilities, such as cerebral palsy, autism, mental retardation, vision and hearing impairments, and other developmental disorders. The reduction of the incidence of low birth weight babies would substantially reduce the risk of, and therefore the number of, babies that die in their first year of life, or suffer from long-term disabilities.

 Measure: Increase percent of low-birth weight (LBW) babies who are delivered at facilities for high-risk deliveries and neonates.
FY 06 Target: 77%
FY 06 Result: 68.1%

A noted decline occurred in the percent of low birth weight babies delivered at such facilities between FY 04 and FY 05, with the rate dropping from 73.3% in FY 04 to 67.7%. The full reasons for this decline are unclear and are under investigation. The rate slightly improved in
FY 06 to 68.1%.

To ensure that high-risk pregnant women have access to appropriate levels of obstetric care, many States have implemented perinatal regionalization strategies and protocols for the transfer of high-risk women to level III facilities. Evidence, however, indicates that these systems may be eroding as health care networks and financing systems change.

The Program continues to monitor the percent of LBW babies delivered at facilities for high-risk deliveries and neonates. In addition, the Program's continuing efforts to examine the reasons for the recent decline will support the development and implementation of effective strategies to address the problem. The proportion of very low birth weight (VLBW) infants who are delivered in the level III obstetric hospitals needs to continue to be measured to monitor the continuing appropriateness and effectiveness of the level of care delivered to high-risk pregnant women and infants.

Much research has demonstrated the benefits of delivering high-risk infants in settings that have the technological capacity to care for them. Specifically, research has shown that VLBW infants have lower death rates when they are delivered at level III hospitals, which are equipped to care for very small infants. The Title V program continues to play an important role in the delivery of appropriate and effective care for high-risk pregnant women and infants.

Measure: Increase the number of children served by Title V.
FY 06 Target: 22.5 million
FY 06 Result: 29 million

The number of children served by Title V is a critical measure of the degree to which the program is successful in reaching and providing services to one of its key target populations.
From 1997 through 1999, the number of children served by Title V increased steadily. In 2000, there was a temporary slight decrease from 23.0 million to 22.8 million. Increases in screening services contributed to a large increase in the number of children served by Title V in FY 04. Given the variability in screening services provided for children within the States from year to year and the reductions in State MCH Block Grant allocations since FY 04, participation data for multiple years were collected to determine if the increases in the number of children served by Title V performance could be maintained.

The Program continues to monitor the number of children served by Title V. Targets for
FY 08 and 09 were adjusted to reflect the current program participation levels for children in the Title V program.
Measure: Increase the number of children receiving Title V services who are enrolled in and have Medicaid and SCHIP coverage.
FY 06 Target: 6.2 million
FY 06 Result: 11 million

Between FY 02 and FY 03, the number of children receiving Title V services who had Medicaid and SCHIP coverage increased from 5.9 million children to 9.7 million. The continuing increases in the number of children served by Title V who have Medicaid and SCHIP coverage since FY 03 reflect the ongoing efforts of the State to do outreach to eligible populations and to increase participation in these programs.

The Program continues to monitor the number of children served by Title V who have Medicaid and SCHIP coverage. Targets for FY 08 and 09 were adjusted to 11 million and 11.5 million, respectively, to reflect current performance.

Increased coverage under Medicaid and SCHIP for children receiving Title V services assures greater access, availability and continuity of care for the Nation's children through the provision of a wide range of services.

Measure: Increase the number of children served by the Title V Block Grant per $1 million in funding.
FY 06 Target: 32,394
FY 06 Result: 41,868

The number of children receiving services through the Title V MCH Block Grant funding mechanism has increased annually since FY 03. Per $1 million of funding, the number of children who have received direct, enabling and population-based services through the Title V program has increased from 31,515 in 2004 to 41,868 in 2006. The FY 06 performance was impacted by an increased number of children being served by the Title V program. This increase has been largely due to a greater number of screening services being provided to school-aged children in the States. Performance for this measure was further impacted by a reduction in the Title V MCH Block Grant funding from FY 04.

The Program continues to monitor the number of children served by Title V and to explore opportunities for greater program efficiencies. Performance targets for FY 08 and 09 were adjusted to 38,000 and 39,000, respectively, to reflect program funding and the increasing number of children that are being served by Title V.

The increase in the number of children served per $1 million in Title V funding shows some level of improvement in program efficiency in using Federal funds as well as a shift toward more population-based services. Programs have also had to rely more heavily on other sources for program funding, including Medicaid and SCHIP, and to increasing the level of payments made by those receiving services.

Notes:

^a A long-term health outcome measure has been proposed and tentatively accepted by OMB.

^b The FY 07 target was changed from that shown in the FY 08 Congressional Justification to reflect full-year CR funding

for FY 07.

NA = Not applicable because the program has no proposed budget.

INTRODUCTION

The Traumatic Brain Injury Program’s performance measures link to HRSA’s Strategic Plan goal to improve public health and health care systems, and to the related objective to increase collaborative efforts to improve the capacity and efficiency of these systems.  Performance data are used to inform the Program’s strategies to provide guidance and technical assistance to grantees in efforts to improve performance.

DISCUSSION OF HEALTH CARE MEASURES

Long-Term Objective:  Increase collaborative efforts to improve the capacity and efficiency of public health and health care systems.

11.V.B.1. Increase the number of States and Territories that have achieved minimum TBI core capacity.

Coordinated, community-based and culturally competent systems that address the needs of individuals with TBI advance the goal of access to high quality care that can improve health outcomes.  The number of States and Territories that have achieved minimum core capacity to serve individuals with TBI and their families is an indicator of the extent to which the U.S. is able to provide systematic, appropriate care for individuals with TBI, including veterans with TBI who return home to continue their post-acute care in the community. In FY 06, the number of States with core capacity was 50, meeting the target.  This measure does not have a FY 09 target because the program is not proposed for funding.

11.V.B.2. Increase by three the number of States and Territories that have begun to implement their TBI plan of action.

As states actually begin to put in place their Statewide Action Plan (based on their Statewide Needs and Resources Assessment) they are demonstrating their ability to correctly assess and meet the needs of individuals with TBI and their families.  The number of States increased from 39 in 2004 to 45 in 2005 and 2006, meeting the target.  This measure does not have a FY 09 target because the program is not proposed for funding.

11.V.B.3. Increase by 6 per year the number of State/Territories that have completed at least 50% of the objectives in their TBI plan of action.

Moving to completion of 50% of program (action plan) goals indicates steady progress towards implementation of a coordinated, community-based and culturally competent system of care for individuals with TBI and their families.  The number of States that have completed at least 50% of their objectives increased from 12 in FY 05 to 17 in FY 06.  This measure does not have a FY 09 target because the program is not proposed for funding.

11.E. Decrease the application and reporting time burden of grantees by 5% per year for 4 years, thereby collecting more accurate and timely data. 

(Baseline – 2004)

A new on-line application and reporting system was implemented in FY 05 and was fully operational in FY 06.  This system provides grantees with information from previous years, including budget and service data.  This alleviates the grantees from having to supply information that was previously provided.  Also, the system pre-populates figures into subsequent forms so that grantees do not have to enter the same data more than once.  Reporting is also easier on the on-line system and provides program management with performance data that are far more reliable and valid, with a shorter lag time. The number of hours of application and reporting time burden of grantees decreased from 171 in 2005 to 162 in 2006, meeting the 5 percent target reduction; but the time for reporting only decreased to 155 in 2007, reflecting a slower than expected adjustment to on-line processing.  This measure does not have a FY 09 target because the program is not proposed for funding.