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Joint | April 2, 2015 | Chamber | Health and Human Services

Full MP3 Audio File

Honoring of everybody's term we will begin. The meeting is called to order. First of all I would like to say good morning and thank you to our pledges from the senate we have Annabell Webb from Henderson sponsored by Senator Bright, Keila Cholders from Jacksonville Senator Brown Realey Richardson Warenson senator Brian Alex Apri Jacksonville, Senator Brown, and Drew West from Candler, Senator Apodaca, and from the House we have Asher McCasherson from lake representative Gill Dorson Clare McCog from Wilson sponsored by representative Martin and Matthew Parker from fusay representative sponsored by representative Terry thank you so much, we're glad to have you with us. I hope you've had a good week, I sergeant at arms this morning from the house are Yang Bay, Phil Morris Anjie Morren and from the senate we have Terry Hornhurt, Jim Hamilton and Dale Huff, thank you very much for being here we have very in depth presentation this morning by Mr. D. Thomas and  this time I'll ask her to begin. Good morning madam Chair and members of the committee. I realise that this is a very long presentation and I'm going to try to rush through the purpose of this presentation today is just to give you kind of an inventory of the programs that are funded at the department of health and human services that target the maternal and child health services for that population, and as a quick overview what we're going to do, I'm going to give you an overview of a lot of the programs not go into a lot of details, I asked my private staff to be here to answer specific questions about some of the programs that you may have. I'm going to do an overview of some of the North Carolina maternal and child health indicators that you heard from Dr. [xx] and Dr. [xx] are over the past month and the role of the DHHS operating divisions in having programs to target to address this indicators. Description, but a  kind of a high level description of specific programs and services and then an overview of the evidence based maternal and child health programs that are operating in the department and finally a summary of that. So as you heard Dr. [xx] presentations over the past week, well North Carolina has made a lot of progress in their infant mortality and their infant mortality and  for mobility rates over the past 20-30 years, the rates are still high particularly when compared to the US average, and North Carolina rides 40th out of 50 states in infant mortality. In 2013, North Carolina had over 2, 100 fetal and infant deaths, and that could be contributed to, the contributing factors were prematurity and low birth weight, birth defects, and then also maternal vacations, and also as you heard from one of Dr. Sellentin's presentations, nearly 30% of pregnant women in the state, did not receive any prenatal care in the first trimester and that is considered a protective factor against infant mortality is to get early access to prenatal care. There were over 10, 000 babies that were born in 2013 with low or very low birth weight, and that was about 8%, almost 9% of the births in North Carolina, and babies that are born at a low birth weight, again, have a high probability of having delayed development and some short and long term disabilities, and they are at a greater risk of dying in the first year of life. Today, you're going to hear about the DHH programs that focus on maternal and child health services, that try to address some of these indicators that you've been hearing about and there are five divisions in the department that either administer funds or provide health care services for pregnant women, for postpartum in women and for children ages 0-5.  And they are the Divisions of Medical Assistance, the Division of Mineral Health, Developmental Disabilities, Substance of this services, division public health, the division social services and division state operating facilities. So starting with division medical systems, there's a type one there that should just be divisional medical assistance they have two primary program that are operated their contract with the community care of North Carolina CCNC and those are the pregnancy medical home program and pregnancy care management program, and you

heard a little of that at the last meeting starting with the CCNC pregnancy medical home program, that program was started in 2011, it's a partnership between the community North Carolina the division medical system and division public health and the goal is to improve the quality of parenthetical care was given to medicate the recipient and hopefully improving both outcomes and reducing medical expending. But as you heard at the last presentation based out on impact on medical expanding if we can get some savings in that area, so it may take another year to tees that out the purpose of the program is to provide co-ordinated evidence based maternity care for particular women who at risk of having poor birth outcomes and recruit [xx] practice around the state to enroll and become a pregnancy medical home. And that also includes eligible health departments that provide prenatal services and in North Carolina last year there were over 48000 pregnant women that were enrolled in the medicaid and we see pregnancy medical home services. To be a pregnancy medical home the providers agreed to screen all of their pregnant patients to determine if they have a high priority risk, to coordinate the patient's care with the pregnancy care manager to eliminate elective deliveries performed before 39 weeks of gestation. To offer and provide 17P to eligible patients and I'll talk about 17P later and to try to achieve and maintain a cesarean section delivery rate at 20% or less. And in 2013, the C section rates in North Carolina were about 30%. So in exchange for agreeing to be a medicaid home, the providers receive a $50 incentive for completing a risk screening at the first visit. They get $150 for completing a postpartum office visit after the baby is born. They get an enhance-ray for a normal delivery, in medicaid for a normal delivery, a vaginal delivery. The payment rate is about $589, whereas the rate for a cesarean delivery is $698. Under the Pregnancy Medical Home they get the same rate for a vaginal delivery that they would for a C-section. Also a pregnancy care manager is assigned to the practice to work with the patients in the practice they get coordination from their local CCNC networks and they are exempted from having to get prior approval on ultrasound. Here are some of the high priority respect they are screening at that first visit, it's quite a few risk factors there, if the women has a history of pre-term births or other complications, if they're some chronic medical condition that may complicate it, and there is also some of social issues like unsafe living environment. Also substance and tobacco use, any unanticipated hospitalization, including emergency room visits. Now, I asked CCNC to provide some outcomes for the pregnant medical home for sense it launched in April 2011, excuse that typo in the title there. CCNC reports that since the program was launched launched in April, 2011, and this is a way for the Medicaid population, that the rate of low-birth weight, in the Medicaid population has decrease from 11.2% in March 2012, to 10.53% in March 2013 and it stayed at level in 2014. The rate of very low birth weight has decreased from 2.0% to 1.87% after being over 2% for over 10 years before that and the rate of their pre-term deliveries has also decreased along the first shift in longer birth pregnancy times at the time pregnancies there's also been an increase in the use of 17P to decrease recurring preterm deliveries. There's the slight decrease in the C-Section delivery rates there, but there has been no change in the rate of women who access prenatal care early in their first trimester, and there has been an increase in the postpartum, the women who come back for postpartum visits. The next program is the CCNC Pregnancy Medical Care Management Program. This is a state-wide population based

program that tries to achieve positive, and healthy outcomes for pregnant women. It serves both Medicaid and non-paid Medicaid eligible women. The local health departments received funding to provide pregnancy care management to all the women in their catchment areas, and each health department gets $5.32 per member, per month payment for each female Medicaid enrollee between the ages of 14 and 44, so of childbearing age, who live in their catchment area regardless of whether they're pregnant or not and the Health Department's actually used these payments to provide non-clinical pregnancy care management services, but also to provide health promotions and prevention activities that are aimed at the entire population of childbearing women on Medicaid in their catchment area. In 2013, over 42, 000 women receive pregnancy care management services through this program. The Pregnancy Care Managers are actually registered nurses or social workers, and they provide any type of assistance that the women in the practice, who are coming to the practice need, such as assistance, we're getting medical care, transportation or food assistance. They go over her prenatal care and understand what her care plan is, they refer the women to any other programs that they need such as education classes, breastfeeding week, and they tried to help her coordinate her care across all of her providers, and they help in making follow-up appointments. Moving on now to the division in Mental Health, Developmental Disabilities, Substance Abuse Services. They have two primary initiatives, but I'm going to go for four of them in all. The first, is the North Carolina Perinatal and Maternal Substance Abuse Initiative, and this initiative provides an array of services to substance-abusing pregnant women, and also women who have dependent children in a home and these are women who have a substance use disorder, and the program services are really an array of services from treating and screening substance abuse treatment, to education and parenting skills, and to support services like transportation and child care. They also refer them for other primary and preventive care services. The residential services that are available, are available statewide, but some of other services that I've mentioned may not be available statewide. In the last fiscal year, the department reports that there were over 1300 women that entered this treatment initiative, and that included about 300 50 pregnant women and approximately 1, 250 women received some type of screening, and a brief intervention and referral services, and that included about 640 pregnant women. The total cost of the program was about $6.2 million, and it was split about 45/55% between the federal substitute of this black [xx] and the general fund. There is also perry needle substance used specialist at the department and this substance this you specialists provide information and referral services for pregnant and parenting women who have a substance abuse disorder they also refer and provide information information services to public members of the public who need those assistance but also to professions and other providers who may be working with pregnant women, and they primary provide, technical assistance training and education patient to as squining every files to the health departments and the department of social services and any other community agencies who works with this population. Now a key thing that the paradiddle substance use specialist does is they maintain a registry of the available substance abuse residential treatments, services and beds that are around the state. And they are also responsible for publicizing the availability of this program the outpatient and the residential services that're available to the program. There were 223 women who received residential services last year. and the cost of this program is really the cost for the position and that was about $83, 000 last year. and then the final program at the Division of Mental Health is the North Carolina Fetal Alcohol Prevention Program, and this targets that by trying to provide outreach and education to pregnant women on the dangers

of using alcohol during their pregnancy. They provide education to pregnant women and to women of childbearing ages and the professionals who work with them, and they also fund a hotline that persons can call in to get information about Fetal Alcohol Syndrome, and last year they spent about $72, 000 for this program and they served 285 persons, and the services are available statewide. Moving on to the Division of Public Health. This division has the bulk of the programs that target this population that we're talking about, and provide the maternal and child health services. They administer a multitude of programs as you'll see as I go through this. In general, the division does not provide direct services. Instead, they allocate state and federal funds primarily to the health departments and to non-profits and to some private contractors who in turn provide these direct services. Most of the programs that I'm going to present are under the oversight of the Women's and Children's Health Section, and they have the primary responsibilities for a lot of the maternal and child health programs in the department. The Women's and Children's Health Section has five units, five branches under that. There is a Children and Youth Branch which provides health promotion and early identification treatment and intervention for children and youth, and they administer the home visiting programs that you'll hear more about. The Early Intervention Section has the Infant-Toddler Program and also the Children's Developmental Service Agencies the CDSAs, which are undergoing some transition right now. The Immunization Section oversees the North Carolina Immunization Program, and this program provides free vaccines for eligible children between the ages of birth and 18 years of age, and they distribute these vaccines free of charge to the healthcare providers. The about 95% of the pediatricians in this state are registered with this program. Next is the nutritional services section they administer the week program, which provides counselling, referrals and food assistance to pregnant women, postpartum women and children of age 0-5, they also administer the child and adult care food program, which provides reimbursements for nutritious meals that are served in eligible child care and adult care settings and then this program also does as responsible for breastfeeding promotion and support around the state and the final section is to womens health section, and this section has primary most of the programs under this section and really at the local level by the health departments in community based agencies, but they administer a lot of the programs that again target pregnant women and postpartum women and infants and children. So next I'm going to start to identify some of the major programs that're administered in women's and children's health. The first is a large the program is called Maternal Health Program, but it encompasses other programs beneath it, but the women Children's Health Section provides the funds to the local health departments to support all of these multiple programs that are being administered there that provide prenatal care emergency care management, nurse home visits and childbirth education. And the section general ministers allocates both states and federal funds to the 85 local health departments who provide the services, and 66 of those health departments can offer complete prenatal services, and FY13/14 the DPH allocated about $2.4 million and federals receipts to the health departments for this purpose and about $3.1 million and general fund receipts but this is really 10% of the expenditures at the county level for this purpose the buying price the counties are putting in the above of funding for maternal health programs about 92 million from the counties health departments and county general funds are going to support these programs. The 17p initiative have me mention for the CCNC home pregnancy home model 17p is a evidence based initiative it's being again in a partnership between the division of public health the division of medical assistance CCNC and the USC center for maternal and child and infant health. And 70 p as a shot that is given to pregnant women each week and these are women who are at risk who had a history of spontaneous three term birth

and they have the risk of recurring preterm births and this is one of the performance expectations in all of the practices that are agreed to be part of the pregnancy home model is that they make this available for all of for the pregnant women in their practice. The Division of Public Health contracts with the UNC Center for Maternal and Infant Health, and they are the one's who ensure that there is a supply of 17P that is distributed to all of practices. In the last fiscal year, the program funds were used to provide 17P to 90 uninsured women who received an average of 10 injections each, but 17P is made available to many more women, and it's just that the rest of the women had some type of insurance coverage or were covered by Medicaid. Basically the program components is that they screen pregnant women to see if they are at risk and therefore eligible for 17P. They counsel the women to get their agreement to take the treatment, and then they help to coordinate the appointment scheduling, and provide transportation because the women do have to get a shot each week. Next, we have the high risk maternity clinics and high risk maternity clinics are designed to provide services to pregnant women who have a very high risk condition. There are 11 clinics around the women's and children's health sections provides funding to this network of high risk clinics so that they can provide treatment services to the women. The local health departments and doctors refer pregnant women who are at high risk to this clinic, to the closest high risk maternity clinic. Next are briefly for other programs the medical nutrition therapy program for pregnant and postpartum  is a program that provide medical re administer by the prime verses involve nutrition and invention to women who meet the list criteria. Then there is a womens health antibacterials program if you remember doctor Selenty[sp?] she mentioned tobacco use as one of the factor that is contributing to the lack of progress on the infant mortality rate and with [xx] and also with children, very young children who have asthma and other conditions where they are living, and environments where they are exposed to secondhand and smoke, so the women's health and tobacco use program provides funds to local health departments to implement an evidence based tobacco festation program called the five A's. Then there is also the health and behavior intervention which is a maricardium versement service which is basically providing a counseling intervention to women who have some lifestyle issues that may be affecting their pregnancy. And it's all evidence some of the health departments by licensed social worker. And then the division also has a contract with the masual dines and much of time under this contract provide preconception and education to women in this state and that in an attempt to help reduce birth defects and preterm birth deliveries and infermertality[sp]. You heard Steve mention the other day what he called PQCNC, the Perinatal Quality Collaborative of North Carolina. This is a collaborative of various stakeholders who are working in the paranoidol fill in North Carolina, is a statewide organization its headquarter at the UNC school of medicine at Chapel hill and they identified opportunities that would improve premarital care around the state and they have to implement some initiatives and [xx] to get two see if these demonstrations of these projects they work with hospitals to focus on four objectives and that is developing strategies to spread the use of best practices in prenatal area to reduce unnecessary variations and care to promote partnerships with the families and the patients, and to optimize resources. The next program is the Maternal Serums Screening Program. This screens uninsured pregnant women for the risk of having a child with a neuro through defect down syndrome or another chromosome abnormality and again this program is serving un ensured women but all pregnant women can have access to these services, but they would be paid for with Medicaid or their private insurers. The program is available statewide, and last year the program paid for screening for about 2, 300 women, and the cost was about $280, 000 and that's supported from the General Fund. The next screening program is the Newborn Screening Program. This is a statewide program, and it is done by the State Public Health Lab, and this screens all infants born

in the state, newborn infants in periodontitis. This is required by statute, and they screen the children, I think for about 31 different conditions using blood that's collected at birth. If the results of this screening are abnormal, then the Newborn Screening Program will contact the infant's doctor for that infant to undergo further testing to confirm if they need further referral and treatment. If they do there are a network of treatment centers that are around the state, but they're not limited to these ones that are listed on the sheet, these are mostly the large major teaching and research hospitals, but there are other hospitals that participate in this. This is available statewide and last year they screened almost 130, 000 newborn infants basically all of the infants born in the state and the cost of the program was about $3.1 million and that was supported totally with federal receipts. The baby lab program is the maternal child health that basically serves all of the pregnant women that are enrolled in medicaid. They provide post mental prenatal and postnatal services up to 60 days after delivery to the women. Last year, Medicaid payed for about 65, 000 births, and so this program is designed to serve all of those women. Basically, they're giving childbirth education, they have a medical home and then they get referrals to any other needed services. baby love also has a home visiting component which each women gets at least one home visit during pregnancy, they get another follow up home visit home program and then there is an home is also medically program, it is located counties particularly high inter mortality rate and is trying to address the racial disparities and mortality cause the Africa America infant mortality is supose to a two at the 12% over the state 8%. The program provide outreaching case management services education and it is also provide some support services for the fathers, there were about 2500 women served in those 14 counties last year, and the cost of the program was $1.4 million from the general funds healthy beginnings is a another program that tries to target minority and morality, it provides addition support to pregnant women and women who are not pregnant and also their children, and provides case management and support activity that promote best practices, it is about 10 counties and there were 650 individuals served last year, the cost of program was $730 million, about evenly split between federal receipts in general fund, and the department they were actually able to provide some outcome measures for the programs to show that it is having an effect that last year in that area there was no infant mortality among the participants and those counties who participated in the program, the low birth weight was about 12.5% and across the state it's about 13.4% per African Americans, and that the children who were born in this program about 90% of them did receive a well child does visit within three to five days after birth. Next is the Maternal and Infant Early Childhood Home Visiting Program. These are evidence-based programs that have been shown around the on the country to increase the use of pre-natal care and improve birth outcomes, prevent child injuries, abuse, decrease emergency department visits and place children's cognitive development and then later years improves through readiness and school performance. It serves first time low income mothers and at this families receive regular plan home visit, their participation is voluntary an they may to leave the program at any time, the home visitors maybe nurses or social workers or lay persons that have been trying to do this. The home visiting basically the home visitors asses the families need and they provide any this is based on the news they teach parenting skills, the help provide services just refers to all kinds of services that babies needed, they screen children for developmental delays also help them to access services that they need them. The US department of health and human services provides some funding to state to the state for this

program and the funding may only be used on evidence based model and they have identified, they recognized 17 models that meet the criteria and that are considered to be evidence based and North Carolina uses 4 of these models. The nurse family partnership program which you have provided funding for for a number of years now, Healthy Families America, The Early Head Start Program and the parents as teachers, and this next slide shows you where these programs are located around the state and since it's kind of hard to see it up on a screen. You also should have a hand out that is just a table form that provides you the same information for each county it shows which counties have home visiting programs and which models they're using. The expenditures for this program in the last fiscal year was about $4.1 million with about 3/4 of it coming from federal receipts and the 1253 clients that were served and the home visiting services are available in 78 counties. The special supplement on nutrition program for Women, Infants and Children formally  known as WIC, it serves pregnant women, postpartum women, infants and children up to the age of five who are at nutritional or medical risk and are also low income and it provides nutrition education breastfeeding promotion and support, it provides some supplemental foods including specialized infant format formulas, and referrals to other healthcare services, it's available statewide. The FY13, 14 costs was about $186 million, and that was all supported with federal receipts, and on average there are a little less than 260, 000 participants who are served each month in this program. About 25, 000 were pregnant women and then with a 60, 000 infants and over 130, 000 children up to age five. Now there is another pregnancy care management program that's operated by the women's and children's health section. This is not the CCNC program this is separate it provides specialized prenatal and postnatal services to low income, uninsured women, who are not eligible for Medicaid. It is then the counties that you see listed served about 1, 400 women last year, and the cost was just under $400, 000 with about $130, 000 of that coming from federal receipt. The triple P, Positive Parenting Program is a program that is, gives parents skills to, in attempt to reduce, to reduce child emotional, and behavioral, and mental health problems. It is an evidence based program that has been shown to reduce child abuse, to decrease hospitalizations resulting from child abuse injuries, and to try to reduce foster care placement. And the parents who basically give a knowledge and some skills based training, and it can be provided as one one counselling, in group settings, or as online courses. And the program is designed to help the parents to address specific family situations such as having a child with serious behavior problem, a child with a disability, parents that may going through a divorce or separation, and also to help them learn about healthier more active lifestyles for them and their children. The program is currently available in 32 counties and the state through the local health departments, the cost is about, last year was about $2.4 million where about two third of money coming from federal receipts. The next program is Young Families Connect engaging communities. This helps providers who are serving pregnant or parenting women and also men ages 13 to 14 so a younger population. It provides community education and support to these young families, it is in the 5 counties listed it served about 170 individuals last year at a cost of over $600, 000 in federal receipts. So moving on to the division of social services they have one program that serves the pregnant women population and these are the residential maternity homes. These are facilities which provide residential and other services to teenage and adult women doing their pregnancy and after delivery. The DSS contracts with seven homes around the state to provide women board services and the contract is for these residential services only, it doesn't include any other services under the contract. The services are available statewide and about 140 women were served in the homes last year. at a cost of about

$1.1 million in general funds. Now as I said they contracted the seven homes to provide the room and board services and the contract is for the residential services only so it's not for any health care services treatment, education services or any other services that the women do. We just wanted to point out that the rate that's has been paid since this is 100% general funds support. When we compare it to some of the other residential programs that are receiving state reimbursement, the rate appeared to be a little high with close to $4, 000 a month which is much higher than what's being paid for the adult care homes and the adult care home special units and is a little lower than what you are paying for skilled nursing home care. And then the final division is the division of state operated healthcare facilities and the Walter B Jones Alcohol and Drug Abuse Treatment Center or ADATC has a pre-natal program and it provides services for pregnant and postpartum women who have substance should be a sprout[sp?] issues. The women can bring their infants, up to 12 months of age, with them in treatment, and the program is available to women from around the state but I believe most of the people served are coming from the Eastern counties. The perinatal services are provided to these women in an inpatient setting, and so there's no predetermined the length of stay. The women may choose to remain in the program until they deliver and then return afterward and bring their baby with them to complete the treatment. They can accommodate any number of pregnant women, but that's based on their capacity, I think they have about 66 beds, and up to five infants in the program. Last year they served 104 pregnant women and 13 postpartum women, and the estimated cost was about $2.3 million with most of that coming from the General Fund. So, next I'm going to just go over some of the limited space programs that are available then through the department, that I reviewed with you. Medical Homes is an evidence-based program and you've heard about that with the CCNC Initiative. 17P has been able to demonstrate it evidence-based program and then also the Home Visiting Programs that you heard about, the four models that are operating in the state. PQCNC, the Perinatal Quality also and then there's also a program called Thinner in Pregnancy and although I didn't cover it isn't actually provided directly from the department, and it is a this is a program that offers both pre-natal care and well mom, well baby care and they are eight approved programs that are operating in North Carolina right now including two health departments at [xx] and 12 other health departments have applied and are awaiting approval and that includes Gilbert County. And then alcohol screening and breathe intervention  is also an evidence based program and you heard about that program as offered to the department of mental health. Dr, Selenty also talked about the importance of breastfeeding and improving infant health. Breast feeding promotion is an evidence based program and you heard about that when I talked about the wake program, tobacco prevention and smoking secession bares several interventions being offered now that our evidence face the five A's intervention the quick line North Carolina which I didn't talk about, it used to be funded with the health and wellness trust fund and when those funds went away the general certainly started to provide general fund support for that quick line that is operated over in the division of public health and pregnant women are refered to the quick line if they needed, there's also a program called You Quit to Quit that also was funded with the health and wellness trust fund and when those funds went away, UN funded it through a contract. The program still exists and it has been proven to be an evidence-based effective program for helping pregnant women who smoke quit smoking. Then there are the community-wide campaigns that educate people on the use of folic acid supplements, and you heard about the March of Dimes contract that does that and then there are group-based parenting programs that have proven to be effective, Triple P is one of them, which you also heard about today. So in summary as you can see the when you ask Dr. [xx] what could be done and she said there are ranges of programs which she talked about the availability of programs and the dosage amount, obviously you do have in a ray of programs that

are trying to the target and improve birth outcomes and improve the health of young children, you have evidence based programs that are in use so many other programs unfortunately there's not an [xx] accessible relevant outcome data so that may be something that the department may need to focus on in the incoming years but one of the biggest issue is that they really doesn't seem to be any one entity into the department that appears to be in charge of the maternal and child health programs and services and trying to coordinate all of them I know the department is in the process, the division particularly is in the process of developing a strategic plan for maternal and child health and I don't know what that plan will address it. But as you see you have at least five divisions that are funding a variety of programs but I think what complicates it is that most of the programs really is just that the department funds of programs provide the allocations down to the health departments but they don't really provide the direct services and each health department may take a different approach to how they budget and target these programs and but also more significantly is when we looked at a range when we asked for the health department, the local health department expenditures on public health and prior. Last year there was over $550 million spent by the local public health departments on a set of programs that we asked about. Well the counties pays for 420 million of that from their own general fund, so it may make it a little difficult for the department to really direct how public health program, I'm sorry, administered at the local level when the department is paying for it, the state it's really only paying for about 5% this expenditures and federal receipts are paying for about 5%. So Madam Chairman that concludes my summary, I realized I went through that really fast and was a lot of information, and we asked the department to have division staff here to answer any questions about this programs in particular. Thank Miss Thomas, Representative Pendleton? OK I learnt a lot, thank you. May I address dislocated [xx] yes. Some observations in the health insurance market when dealing with corporations and nonprofits that are important sponsored medical plans, only thing that really matters is unit cost and I would ask if it's okay with the leadership that in the future you do the maths for us give us a unit cost for example if you flip up page three. On this, 30% of pregnant women in North Carolina did not receive prenatal care while else I go to more slides I'm going to perform that for you, that is one area may be we need to shift more funds into to help those people out because those can turn into big medical claims you don't do it, follow up, this all part of one question. Page slide 15 Okay on this 1, 300 women were served at a cost of to $6.2 million, that's $40, 000 ahead, so that's the kind of thing that I'm talking about, the only way to really budget things if you go up and I hope you go up you said much of the time I hope you go up and counties go at it and try to get all profits to compete against county health departments and other governmental entities to get the lowest calls per unit per person that we can do, but $40, 000 seem is extremely high, I don't know if you don't have the answer, I'm just pointing out that that's a big unit cost follow up 33. Follow up. If you turn over here and you look at Baby Love plus 1.4 million about 2, 500 women serve at $600 per person, and then go on over to page 34 on the healthy beginnings I can see that some of the differences on that sought of thing but that's a unique cost of $1200 per unit so this are just things that I wanted to point out to you and he staff that the way to save money on some of this and you can in every county but as fast and non-profits to give you URFP's to compete against the health departments. Thank you, Senator Baranga[sp?]

Thank you madam Chair, I have two lines of questions, the first one I guess we would like to see your last slide which doesn't appear to be anyone incharge or only department charges I'm very glad to hear that there is a move to rectify that, there are so many programs here do we know if there is an overlap or inefficiency in this that the same this is being offered, too often not too often but in duplication do we know that, that's one of the things that all these different programs that there may be an inefficiency in that regard? Senator [xx] I would agree it does here is I was trying to put us together it was very confusing particular when you talk about baby love baby love first, healthy this health that, but Madam of chair I'd like to defer to maybe the department may be their active division director public health Denis Tailly just that. Please identify yourself. Madam chair Denis Tailly acting director of division of public health and former local health director and a couple of things we do have multiple programs and we have very separate focuses and they've build upon each other in many cases like baby love and baby love plus we may have a different target or subset of skills they bring to a very specific set of the population is we look at health disparities which is quite, quite great in this state in some very specific counties. We will target very specific initiatives that build upon sort of that general basic case coordination that we may be doing to try and address those. We have tried within the division, as you saw the presentation, we have quite a few programs based on prevention and evidence based practice, to really look at where one picks up and one leaves off. We talk about tobacco sensation, you may identify that as part of your general case coordination and then have the beginning basics and refer back to the provider who can offer more assistance in getting Nicotine Replacement Therapy or proper care. Follow-up, please. You use the word case management, and that's really what I was getting down to. Is there a big effort, and again I want to make sure that I'm clear with this, that I'm not laying this at the feet of the department, I know you have inherited all of these, this myriad of services. Is there active case management because I see that as a possible way to eliminate some of the inefficiencies because we have heard much testimony about how important it is to have community-based services and targeted services, but they also do not need to be duplicative. Madam Chair. Please. To address the question, we do have active case management. So, once the provider has identified the women we try to have that one point through our OB care management and our child care coordinate CC4C, which is Care Coordination for Children. They always throw these acronyms at me, I have to think about them, and so that gives you one person in contact and they then can direct the most appropriate source at the local level, I always talk about that. It's really important at the local level because they know what community services, what churches, what groups can be there to assist with that mum's care and that child's care in the most appropriate way, and it does prevent a lot of duplication, it's very evidence-based. Thank you, follow up in a different direction. Follow up. The other line of questioning I have really relates to the representative's line of questioning. One of the things that I've seen when I've worked on non-profit boards is a calculation of how much of this actually gets to the ground, and my concern too is when you see numbers like $40, 000 per person. My question is, how much of that $40, 000 is actually being delivered to that mother, and how much of it is being consumed in overhead through the process of government and administration. Do we have any numbers at this point about that because I do know that non-profits now are basically selling themselves on how much goes to actual delivery and how much is overhead. Please. Senator Barringer I would have to get this, I can work with the department to get the detail on, particularly the $40, 000 initiative that

Senator Pendleton was referring to, to see if how much of that goes into what you would traditionally think of as overhead versus what goes to provide services. So follow up, final. Follow up. And so, you do think there is data available for that? Because one of the things we're learning here is that we don't have data on a lot of things. I believe for that particular initiative that was so high that, as representative Pendleton was referring to, we do have the data because that's a state funded initiative at the department. I don't believe it is a contracted initiative where they are passing it down to health departments, but we do have a representative from mental health here who could, Madam Chair, Miss Edwards? Sterling? OK. Hi, Starleen Scott Robbins. Madam Chair, may I respond? Starleen Scott Robbins with the Division of Mental Health, Developmental Disabilities and Substance Abuse Services. As of funds that go to support the para natal and maternal substituent initiative are substance abuse prevention, treatment programs and state funds and those are passed on to our local management entities, our LME-MCOs at the local level and they contract with private providers in the community to provide those services, and there, that contract would have the amount of money that has the indirect cost for those particular services, so we could get that information for you, and actually, the additional number that was in the slide, for the women who received the outreach and the, screening intervention and referral services, are also a part of the cost, so its, actually not 40 thousand dollars per women it's actually spread across a couple a thousand women in terms of the cost. Thank you. Senator McKissick. Some of my concerns are very similar to Senator Barringer's, and I guess that the thing I'm trying to understand, and I'm not sure if the department can help me out or if Denise can. I would assume that this vast proliferation of programs which appear to be overlapping in many instances might be the result of funding opportunities that become available, that you might seek out because there is inapropriate federal mark and things of that sort. Now is that the case or is there a true absolute need? I can see where some of these are completely separate, independent, narrowly focused, but so much of this I would assume might be a result of I guess, for lack of a better way of putting it, legacy in seeking funding opportunities to help us out, so we don't have to pick up some much of this cost with the General Fund, but can someone help me with that? Is anyone in the, Mr. Staley looks like you're nominated. Thank you Senator. Thank you for the question. There's couple of thoughts, we have traditionally had our Women's and Children Health Ward Grant which has funded a lot of activities and decades of work along those lines, and through that we often find out the barriers to care or improved evidence based practices, and the feds have looked at this over time and picked up and then offered the funding opportunities. So sometimes, and most of the time, it is to enhance the sort of basic maternal and child health block grants. So they'll offer what the Intensive Home Visitation Programs, that's a good example, which picks like Nurse Family Partnership and some of those initiatives they have shown to improve health outcomes, and we have waited for those grants to help support the state in trying to reduce infant mortality, increase the health status of the zero to five population. So we have been very selective I know since my time I've 20 years at the local level in coming to the state now, we have really tried to look at our time and invested into what enhances some of those legacy programs in meeting the changing health needs and improving health status. So we've tried not to go after every grand opportunity that has presented because it doesn't always apply to North Carolina, but what we have tried to do is focus our work to the that grand opportunities which would enhance what has already been offered, or which

it helps us to move our evidence based practices forward. Follow up Madam Chair. Follow up. And I guess the question is kind of twofold. First I would assume for those grant applications that we seek out, there obviously will be criteria which you establish in terms of performance in many instances. I assume that there would be, what I call, Grant Administration Costs, which could be recovered maybe 10 or 15% is for monitoring the activities that flow through as funds coming through the agencies, plus some type of critical data that would need to be provided annually or periodically to the funding agency or entity. Now is that in fact going on where that data is available, that could be shared, that might answer some of the questions that I think Senator Barringer and I might have? Mr. Taylor? Yes. We do try to provide not only the data. A lot of our work is done with an evaluation component done through a university or a group to perform and look at the evaluation of the data. So that it is available, we'd be glad to get you that, and it's oftentimes specific on the outcome so we try not to duplicate on getting data so alot of times we identify the data source earlier on, maybe a sensitive detect or emergency department data or error, pregnancy survey data so we don't duplicate, we've put in measures that allow us to collect the data without duplication. And last follow up here. Follow up. Let's say the thing that I think would really help as much as anything is not just having some centralized person or persons in charge or somebody oversight here in administration, but really having what I call an overall vision and plan for how you might be more strategically able to carry out what you want to do what I mean logistically programatically in every other way has there been any focus part of this time in doing that type of strategic planning in a centralized way or strategic way that would help articulate what the vision is in terms of caring for this populations, and what we need to do to move forward in accomplishing the goals and objectives that might have been set. Miss Thomas, I think I see volunteer. Would you identify yourself please? Thank you. I'm Nancy Henley. I'm the Chief Medical Officer for North Carolina Medicaid, and I'd like to address your question from the view of the Medicaid population. North Carolina Medicaid covers over 50% of the births in North Carolina in most tiers[sp?]. We work with the Pregnancy Medical Home and Pregnancy Case Management Programs, both of which are partnerships between our obstetric providers and local health department center obstetric providers might also include family physicians in some instances, Division of Public Health, so this is a partnership thats been developed so that we can provide pregnancy and medical home services in 100 counties in North Carolina. So for that program where the deliveries actually occur, the prenatal care occurs, the postpartum care occurs we have very strong planning and we have very strong evaluation and lots of numbers that could be shared with you, if you'd like to see those. So yes, there is definitely a strategic look at how we can take care of all of these women, and how we can direct risk-based care to them, so that all of them are risk-screened and those who are at highest risk for negative pregnancy outcomes or at risk to the mother are then referred to the Pregnancy Case Management Program, and we do see variations from, as you may imagine across 100 counties, in the services and resources that are available in those counties. However we we go ahead and we apply the evidence based evaluation to the care overall so that we're following the C-Sections and the preterm birth weights, those kinds of things that you're familiar with from other presentations, I won't detail them here. Thank you. If I might ask, limited questions and short answers. We're coming up on quitting time shortly. Chairman Hise. Thank you, Madam Chairman.

I think as most people have kind of seen looking through this presentation, when we get beyond what we're paying for births and services for children and adults which is more than half the births that occur in North Carolina that we pay for under Medicaid, that we have this hodge-podge of funding systems that range from, if I go through the presentation I've got some services that are available in the 8 counties, some that are available in 21 counties, I've got some that are $80, 000 in the program that are spread over a 100 counties, so I don't even know if it shows up in the size of counties that I represent. And this is an interesting mix of Federal Block Grant Funds that come through the state and the state's matching funds, and General Fund coming in and that's excluding our big spend of Medicaid that comes in all of pregnancy services. The question I just want get to is, and this is a direction. Would it be possible with the way the funding and grant sources work that the state backed out of all of this and just did a block grant to the health departments for maternity and child health services, stepped over that process and said to the counties, here's your source of funding to take care of the program you're really running, and as I see it, stop wasting so much on meeting the requirements for every little dollar we send. Ok, any volunteers for that one? Just to cut that out, for our authority is it possible to do that in program situation? Miss Jacobs. Madam Chair senator Haise members of the committee we lay that out as a part of one of our recommendations on options for you to consider when a couple, last week when we were in here, we talked about new sources of funding, or re-allocations of funds and so to the extent that, the federal limits, don't direct, that the funds have to go to a specific county for a specific service. So, to the extent that there are not is that don't prohibit that, we believe as staff that that's something that we could explore, and you could talk about matching funds at the local level, whether its income or direct match, or just a more creative way of sending money out and tying outcomes to how that money would flow out. That would take some time and work with the departments trying to figure that out, but we do believe that that's one option you should consider as a committee. Representative Pendleton, I want to have the Senator Wells as he has not had a turn at it. Senator Wells. I'd like to follow up on Senator Hise's question. With all these numbers, and we've seen a lot of them over the last few weeks, is there a total number that we are spending on trying to stop low birth weight babies? The 10, 000 a year low birth rate babies, is there a total number of all programs that we're spending, combined state and federal numbers? I'd like to see the big number. Miss Thomas or Miss Jacobs. Senator Wells, what we can do is combine Denise's numbers with Steve's numbers from last week and give you the numbers that we have. I'm not are sure that we have the numbers at the local health departments that are being spent as well, but we'll give it a shot. We'll give you the numbers that we have and then find out if we can get the numbers from local health departments as well. Follow up. Just a comment. We've talked about moving to investment. You can't invest if you don't know what your return is going to be. If you put money in something with no measurement that's not an investment, that's something that I probably shouldn't say here. Lord Kelvin said, if you can not measure it you can not improve it. So until we get to where we're doing measurements, we're not going to get any improvement and we're talking about letting babies die by neglect. We're killing babies not intentionally, but because we don't do the right things, and we are not doing anything to improve it because we are not measuring it. Representative Pendleton. One of the things that, and Senator Barringer has said, when I first became a county 20 something years ago based on the type of business I'm in, I said why don't we allow more competition on these services that's way I make my living and they said oh! no  we don't pay any property tax, income tax, sales tax actually there is no way anybody could bit us I say what about nonprofits they don't pay him that either.

Well, after two years I became chairman and then I told them we are going to do it, we are going to see, another way you can see is get RFP and compare and RFP you want good quality too and if they don't you should fire him and get somebody else, but the bottom line is, a couple of things, Triangle Family Services in White County is one of the oldest [xx] in the institutions in White County, and there were somethings that they did, the county bid, had to produce a bid against them and they bid them 59 cents on the go, that's alot of money, another instant is whene the concerned people is city rolly managing our land  fields as it was to  go up for our proposals waste industries took it away from them at a savings of 2.1 million, and a list goes on and on and on if you don't get an RFP, you do not know if you're paying a fair price. We are coming any, final comments or questions that we have from members of the committee? If not, we stand adjourned. Happy Easter to everyone.