NC Department of Health and Human

Services
Maternal and Infant Health Priorities

Perinatal Quality Collaborative North Carolina Annual Meeting

January 2024

Elizabeth Cuervo Tilson, MD, MPH

NC DHHS State Health Director, Chief Medical Officer
Beth McDermott, MHA, Associate Director, Quality Management,
NC Division of Health Benefits
 Agenda
• State Level Plans
−Healthy North Carolina 2030/NC State Health Improvement Plan
2023
−Perinatal Health Strategic Plan
• DHHS Priorities
• Levels of Care
• Medicaid Expansion
• Other
Healthy North Carolina 2030
-NC State Health Improvement Plan

Perinatal Health Strategic Plan

3
 Healthy North Carolina 2030
Health Outcomes
1. Infant mortality Health Behaviors
2. Life expectancy 1. Drug overdose deaths
2. Tobacco use
3. Excessive drinking
4. Sugar-sweetened beverage
consumption
5. HIV diagnosis Clinical Care
6. Teen birth rate 1. Uninsured
2. Early prenatal care
3. Primary care
clinicians Social & Economic Factors
4. Suicide rate 1. Families ≤ 200% FPL
2. Adverse Childhood
Experiences
3. Unemployment Physical Environment
4. 3rd grade reading 1. Severe housing
problems
5. Incarceration rate
2. Limited access to
6. Short-term suspension healthy food
Healthy North Carolina 2030
3. Access to exercise
opportunities
 State Health Improvement Plans

Utilizes Results-Based
Accountability

Engages partners for

collective impact

Community Councils identify

and prioritize strategies to
move indicators

Clear Impact Scorecard tracks

Improvement Work and
progress in data

SHIP 2023 launches Year of

Action
Healthy North Carolina 2030
North Carolina State Health Improvement Plan 2023
9th highest in the US

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Updated Perinatal Health Strategic Plan
2022-2025
• To improve health and decrease disparities, we also need to
focus on overall MATERNAL HEALTH

• A statewide guide to improve maternal and infant health

and the health of all people of reproductive age

• Based on the “12-Point Plan to Close the Black-White Gap in

Birth Outcomes: A Life-Course Approach” by Lu, Kotelchuck,
Hogan, Jones, Wright, and Haflon

• Encompasses infant mortality, maternal morbidity and

mortality, and the health of all women and men of
reproductive age

• Increased emphasis on decreasing disparities

• Focused on whole-person health

https://wicws.dph.ncdhhs.gov/phsp/
7
Maternal Mortality Review Committee 2018-2019
Most pregnancy-related deaths preventable
disparities persist

DHHS/ Division of Public Health/ Maternal Mortality Review Committee 8

Mental health conditions and injuries comprised almost
half (45%) of pregnancy-related deaths (2018-19)

Among the 34 pregnancy-related

deaths due to mental health
conditions & injuries there were:
• 20 accidental overdoses
• 8 homicides
• 5 suicides
• 1 injury with undetermined
intent

Source: DHHS/ Division of Public Health/

Maternal Mortality Review Committee
9
NCDHHS Priorities

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 NCDHHS Priorities
These priorities and our work across the department are grounded in whole-person health, driven by equity, and responsive to the lessons learned
responding to the greatest health crisis in more than a generation.

Behavioral Health & Resilience Child & Family Well-Being Strong & Inclusive Workforce

We need to offer services
further upstream to build
resiliency, invest in
coordinated systems of care
that make mental health
services easy to access
when and where they are
needed and to reduce the
stigma around accessing
these services.
We will work to ensure that
North Carolina’s children grow
up safe, healthy and thriving in
nurturing and resilient families
and communities. Investing
in families and children’s
healthy development builds
more resilient families,
better educational outcomes
and, in the long term, a
stronger society.
We will work to strengthen the
workforce that supports
early learning, health and
wellness by delivering
services to North Carolina.
And we will take action to be
an equitable workplace that
lives its values and ensure that
all people have the opportunity
to be fully included members
of their communities.
North Carolina State Budget
Significant investments for the health and wellbeing of North Carolina:

• Behavioral Health and Resilience, $835M: This budget includes investments and policy changes that
enable a seismic step forward in improving North Carolinians’ behavioral health. Between recurring
and non-recurring funds, approximately three-quarters of the Governor’s $1 Billion Behavioral Health
Roadmap were funded, along with other significant investments across the state.

• Child and Family Well-Being, $208.9M: The budget also includes notable investments in North
Carolina’s children, including a package of services that will prevent children languishing in
inappropriate settings like Emergency Departments and DSS offices while providing additional
supports for them and their families. It also includes the long sought-after, statewide Child and Family
Specialty Plan which will better serve the care needs for children in the foster care system and funding
for maternal care. It also included funds for Medicaid to increase maternal provider reimbursements
and payments for group prenatal care.

• Strong and Inclusive Workforce $1.56B: This budget has several important investments in our team to
support their critical work including $40 million to stabilize staffing in our state facilities, plus new
positions in Public Health, new inspector positions in DHSR, and new regional support staff in DSS to
improve outcomes in our child welfare system.
Maternal Mental Health
• NC MATTERS works to increase access
to mental health care and substance use
treatment for perinatal individuals across
the state

• Provides access to screening and treatment

support for health care professionals through
the following:
1. Clinical consultation phone line staffed by perinatal mental health specialists who
answer patient-specific treatment questions
2. Psychiatry and resource coordination services provided to perinatal patients at no
cost
3. Training and technical assistance for health care providers to increase their comfort
and capacity addressing perinatal mental health and substance use concerns
Collaboration with NCDHHS, UNC School of Medicine, and Duke Dept of Psychiatry and Behavioral Sciences
https://www.med.unc.edu/ncmatters/
13
Strong and Inclusive Workforce

Health Workforce
• Workforce Strategic Leadership Council and Governance
• Direct Care Workforce for older North Carolinians and individuals with
different abilities

Child Care Workforce

• New pathways for certification
• Funding for early childhood educators

State and County Health & Human Services Workforce

• NC DHHS Workforce
• State and Local Public Health & Community Health Workforce
• County DSS Workforce
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 Child & Family Well-Being
Child Behavioral Health
• NC Psychiatric Access Line (NC-PAL)
• Child behavioral health data dashboard
• Access to specialty behavioral services
• Intensive Alternative Family Treatment

Child Welfare
• NC Medicaid Child and Family Specialty Plan (Foster Care)
• Child Welfare Information System
• Financial Supports for Kinship Care
• Regional Support for child welfare agencies

Nutrition Security - NC DHHS State Action Plan for Nutrition Security

• NCCARE360
• Data linkages and tailored outreach to increase enrollment of eligible families in WIC and FNS
• Statewide breastfeeding hotline and WIC training - breastfeednc.com
• Healthy Opportunities Pilots

Maternal and Infant Health

• Congenital Syphilis
• Access to contraception
• Maternal bundle and group prenatal care payments
 North Carolina is experiencing an unprecedented What Can Physicians Do:
increase in congenital syphilis • Increase syphilis screening for all
2000 90 sexually active individuals

1800 80
• Screen pregnant women consistent with
10A NCAC 41A .0204 CONTROL
1600 MEASURES
Female Syphilis Cases Congenital Syphilis Cases 70
Reported Female Syphilis Infections*

Reported Congenital Syphilis Infections*

1400
60
1200
50
1000
40
800 • DO NOT discharge newborn until
30 mom's syphilis status is known
600
• Follow CDC guidelines for diagnosis
20 and treatment of congenital syphilis
400
infections
200 10
• Ensure sex partners are treated -
TellYourPartner.org allows confidential and
0 0
anonymous notifications

…
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15

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18

19

20

21

22

je
o
20

20

20

20

20

20

20

20

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• Repeat RPR/VDRL titers q2-3 months

Pr
for ALL newborns with reactive
Source: North Carolina Electronic Disease Surveillance System (NC EDSS) as of November 28, 2023.
*2023 numbers are estimates and likely to change serologies until returns to non-reactive
 Here’s what we’re doing about it
• Increasing awareness about the epidemic and how to
prevent/treat
• Public health alert to NC clinicians - November 9, 2023
• Social Media
• Media campaign (December 2023 – March 2024)
• New provider webpage with resources

• Expanding access to syphilis point of care testing

• Engaging clinics, Community Based organizations, Safe Syringe
Programs, other safety net venues

• Mobilizing levers for change within our payer infrastructure

• Hosted SE Congenital Syphilis Payer Summit - October 17, 2023
• Updating Physician Administered Drug program rates to cover
cost of bicillin and with a margin (Feb 2024)

• Continuing congenital syphilis quarterly review board

 Increasing access to Contraception
• > 50% of all pregnancies in North Carolina are unintended, which can lead to
poor maternal and infant outcomes.
• Pharmacist Initiated Medication Protocols pursuant to SL 2021-110 included oral
and transdermal contraceptives, which can increase access to contraception
• Protocols and Tools from Board of Pharmacy and Medical Board adopted July 2023
• NC Associations of Pharmacists developed required training, NC Pharmacy Board
covers cost
• UNC School of Pharmacy leading collaborative work to increase access
• NC Medicaid started enrolling pharmacists as providers and paying a counseling
code January 8, 2024
Pharmacist initiated Hormonal Contraception

Ø2000 pharmacists registered for training

Ø~1,000 completed
ØAlmost 100 pharmacies providing services
Ø48/100 counties
Other

• NCDAVE -Electronic Birth Registration System and Fetal Death

launched on January 1, 2024 – more details in appendix
• Office of Violence Prevention/Safe Storage -
https://www.ncsafe.org/
• Doula Landscape Analysis -
https://wicws.dph.ncdhhs.gov/docs/WICWS-DoulaReport.pdf
• Budget included requirements to conduct toxicology on all child
deaths in the Chief Medical Examiner system.
 Medicaid Bulletin

•Retroactive to July 1, 2023

•Increased maternal bundle rate to no lower than 71% of the Medicare rate.
•Goal to increase access to prenatal care

•Establishing an incentive payment for Group Prenatal Care when five or more visits are attended
•Evidence-based program for improved birth outcomes and decreasing racial disparities
Neonatal and Maternal Levels of Care
• Perinatal Risk-Appropriate Care – strategy promoted in 1976 March of Dimes Report
and supported by literature to improve maternal and neonatal outcomes

• Recommendation from multiple entities, including the NCIOM Perinatal Systems of

Care Task Force, to update neonatal levels of care to national standards and adopt
maternal levels of care

• DHHS has partnered with NCIOM to form Neonatal and Maternal LOC Action Teams
as first step to look at the national standards from NC perspective and continue dialogue
and ongoing work since 2012

• DHHS continues to work with birthing hospitals to complete the voluntary CDC Levels of
Care Assessment Tool (LOCATe)
 Medicaid
Expansion
December 1, 2023

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 Who is Covered under Expansion?

Low-income parents Low-income childless adults 19-24

(with income less than $34,000 a year yrs (with income less than $20,000 a year
for a family of 3) for a single adult)

Low-wage workers Women who

(agriculture, Some veterans Children who age would be covered
childcare, and their families out of Medicaid if they were
construction, etc.) pregnant

25
 Child and Family Impacts of Medicaid Expansion

• How children benefit from Expansion

• Waiver from the Centers for Medicare and Medicaid Services to extend eligibility for children under
the age of 19 for recertifications due December 31, 2023 for an additional year.
• Children are 29% more likely to have an annual well-child visit if their parents are enrolled in
Medicaid
• States that expanded Medicaid saw decreases in infant mortality and decrease in infant mortality
disparities between black and white babies
• States that expanded Medicaid saw 422 fewer cases of reported neglect per 100,000 children
under 6 than non-expansion states
• How families benefit from Expansion
• Medicaid expansion increases women’s access to comprehensive care, including behavioral
health care. When moms are healthier, so are their families
• Medicaid expansion is also linked to enhanced parental financial stability
• May allow families to find care closer to home https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2017.304218
https://www.sciencedirect.com/science/article/abs/pii/S0749379722004986
https://jamanetwork.com/journals/jama/article-abstract/2731179
https://www.sciencedirect.com/science/article/abs/pii/S0091743520303923
NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES | CREATED JUNE 2022 https://ccf.georgetown.edu/wp-content/uploads/2019/05/Maternal-Health_FINAL-1.pdf 26
 Medicaid Expansion
• medicaid.nc.gov

• Bilingual toolkit
• Medicaid Expansion Flyer: An overview of who is eligible and how to enroll.
• Newsletter Template: Content to include in your newsletters and emails.
• Social Media: Graphics and posts to share on your channels.
• Family Planning Flyer: Information for people who receive limited benefits through
Family Planning Medicaid who will be automatically enrolled in full Medicaid.
• Medicaid Essentials Deck: A presentation to share with your community on who is
eligible and how to enroll.
• FAQ: Answers to common questions.
• ePass Video: An overview of how to apply online through ePass.

• Sign-up form. To get updates on latest information

Future Work
• Given CMS approval, NC Medicaid intends to offer continuous
coverage for children under the age of 6, and coverage for two
years at a time for older children

• PQCNC serves as critical partner in addressing many

Department priorities shared today
Questions?

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Appendix

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 NCDAVE
Electronic Birth Registration
System and Fetal Death Launch
(EBRS/FD)

Joseph Watkins, MBA, MSA

Section Chief
NCDHHS
State Center for Health Statistics (SCHS)
December 4, 2023
joseph.watkins@dhhs.nc.gov
 NCDAVE EBRS/FD Training Opportunities
• To explore the system functionality
− External Demo
• Logon (vitalchek.com)
• Username: FetalCert01
• Password: Playing1a
• For more test roles: Vital Records: NCDAVE EBRS: Hospitals:
Training (username: ncdave | password: ncbirths)

• To request training
− Email: vitalrecordstraining@dhhs.nc.gov
 Continuous Enrollment for Children
Re-certification
Waiver from the Centers for Medicare and Medicaid Services to extend eligibility for children under
the age of 19 for recertifications due December 31, 2023 for an additional year.

Proposed Initiatives in 1115 Waiver Renewal

Current Status:
North Carolina currently has 12-month continuous enrollment for children ages 0 to 18.

Proposed:

Provide continuous enrollment in Medicaid as follows:

• CE for children ages 0 through 5 through 6th birthday
• 24-month CE for children ages 6 through 18 (extends existing 12-month CE period for this group)
• CE for to youth who have aged out of foster care up to age 26
• Eligibility would generally not be redetermined for the duration of the CE period, unless one of the
following circumstances applies: the individual’s death, moving out of state, the individual requests
termination or fraud/abuse.