III.E.2.c Annual Report: Perinatal/ Infant Health
The perinatal period refers to the period immediately before and after birth. Perinatal and maternal health are closely linked. Infant health refers to the period before a child's first birthday, a very critical period in growth and development. The RI MCH Program strives to ensure that all pregnant womxn receive appropriate prenatal care, which can affect both maternal and infant birth outcomes. The program is focusing on the caregiver relationship between the mother and infant. Emphasis is placed on identifying pregnant and parenting families who are at high risk of negative outcomes and linking them to appropriate services, including addressing stagnant or worsening trends in racial/ethnic disparities.
Rhode Island had the following priorities for perinatal and infant health from October 1, 2019 to September 30 2020:
- Increase breastfeeding awareness & social support
- Support the implementation of the family visiting program
Priority: Increase Breastfeeding Awareness & Social Support
The RIDOH Breastfeeding Program works to enhance supports for pregnant and breastfeeding womxn and their families by building linkages between the birthing hospitals and the community, increasing awareness of breastfeeding as the optimal method of infant and young child feeding, and creating partnerships with health professionals and advocates throughout Rhode Island. Rhode Island is especially proud to announce that T.F. Green International Airport is now offering Nursing Rooms to traveling families. These rooms provide a private area for nursing mothers with access to comfortable seating, natural light, electrical outlets, hand sanitizer, mirrors, garment hangers and space for personal belongings.
The WIC State Breastfeeding Coordinator maintains a seat on the Board of the RI Breastfeeding Coalition (RIBC) and represents RIDOH in the work they complete. The coalition usually holds a biennial conference and a community event, both of which did not take place due to the pandemic. RIBC also partners with RIDOH and the state WIC program to sustain the RI Baby Café and the Chocolate Milk Café at the Mount Hope WIC site in Providence.
An essential component of the Breastfeeding Program is providing quality breastfeeding support and education to all pregnant and breastfeeding womxn. At the program’s current funding level, the program continues to staff Breastfeeding Peer Counselors in each WIC clinic, supply hospital grade breast pump rentals or manual breast pumps as needed, and staff International Board Certified Lactation Consultants (IBCLC) to round in the birthing hospitals to provide breastfeeding support/education to all WIC active and eligible patients. The COVID-19 pandemic forced staff to pivot the way in which we support our families by offering remote services, support and education. During the reporting year, the program’s efforts focused on the following strategies:
Coordinate and standardize breastfeeding messages for all RIDOH programs that work with prenatal and postpartum womxn.
In 2019, work was completed towards coordinating and standardizing breastfeeding messages for all RIDOH programs that work with prenatal and postpartum womxn. Content experts from both the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) and Family Home Visiting programs developed new education materials that are relevant and impactful. A distribution plan for the completed materials was developed and is being executed on an ongoing basis. Materials continue to be distributed through programs administered by RIDOH, as well as healthcare providers and birthing hospitals throughout the state. Electronic versions of the materials are hosted on the RIDOH Breastfeeding website for easy accessibility. The English version of the nine tear off pads of educational materials has been developed and seven of the nine materials have been translated into Spanish. These materials were distributed to WIC clinics, Family Home Visiting programs, and community outreach events. Electronic versions of these materials are available on the Breastfeeding Web page at RIDOH.
Support efforts to increase access to International Board Certified Lactation Consultants (IBCLC) & Certified Lactation Counselors (CLC)
To increase both short- and long-term breastfeeding rates, RIDOH works to increase the public’s access to skilled lactation support; numerous studies have shown the impact of both lay and professional support in increasing breastfeeding rates. RIDOH continues to partner with the RI Breastfeeding Coalition (RIBC) and the state’s WIC program in supporting the sustainability of the RI Baby Café, a free, weekly support group that began in 2014. THe Baby Café expands access to a wide range of lactation professionals, IBCLCs, CLCs, and Peer Counselors, with no out-of-pocket cost to attendees. RIDOH and community partners continue to strategize how to increase participation and sustain support groups (Baby Café) in other communities throughout the state. Staff supporting the Baby Café are volunteers except for the WIC Peer Counselors. The Chocolate Milk Café began in the Mount Hope WIC Program in 2018. This program is staffed by a volunteer and a WIC Breastfeeding Counselor. Lactation support professionals pivoted their education and services to provide telehealth/telephonic/ text support during the COVID-19 pandemic, while some continued to provide in-person services in the clinical settings.
Support baby-friendly hospitals statewide.
Rhode Island aims to achieve the Baby Friendly Hospital Initiative (BFHI) designation for all five of our state’s birthing hospitals. Currently, all but one facility (Landmark Hospital) maintains the designation. RIDOH plans to work closely with the remaining non-Baby Friendly designated hospital, as they work towards achieving the designation. RIDOH, in coordination with the RI Breastfeeding Coalition, will provide support in training and managing the necessary steps to move the process forward for Landmark Hospital. The state’s largest birthing hospital, Women & Infants Hospital, is reapplying for the designation this year. Rhode Island is supporting them through this process by providing insight from the community, opportunities for collaboration and staff education opportunities.
Provide education on breastfeeding resources such as free breast-pumps and insurance coverage benefits.
Edits to the RIDOH breastfeeding website have been updated with the department’s Communications team. These edits aim to provide a comprehensive resource for community members and professionals to access timely and accurate information on breastfeeding resources, such as education materials, and access to health and social service programs such as WIC and Family Home Visiting.
Support efforts to increase the number of IBCLCs and CLCs of color to address disparities in infant breastfeeding rates.
RIDOH had planned to offer a Certified Lactation Counselor (CLC) training, but it was postponed due to the pandemic. RIDOH anticipates offering this training again, (now offered virtually) in Fall 2021. The MCH Program is working with several internal partners to explore ways to recruit and increase access to this training for interested IBCLCs of color. Input from these partners suggest that the virtual format and an extended 6-month completion timeframe (instead of 1 week), will make this training and certification more flexible and accessible for black, indigenous, and people of color.
Work with the RIBC’s Licensing Committee to ensure licensed lactation consultants are incorporated in health insurance reimbursement policies.
RIDOH is continuing to work on strategies to establish reimbursement from insurance companies for lactation services. Licensure was created with the intention of expanding the lactation workforce, and improving the reimbursement potential of IBCLCs, therefore making their services more accessible 1) to individuals who cannot afford to pay out of pocket for their valuable service, and 2) outside of the hospital/clinic setting.
Continue to support breastfeeding awareness through the Health Equity Zone (HEZ) initiative despite the challenges and limitations to providing services and activities due to the COVID-19 pandemic.
Between 10/1/19- 9/30/20, the Newport Health Equity Zone offered a Women of Color Breastfeeding Support Group. The group met twice a month and was facilitated by a resident of the community, who is also a doula. The goal of this program was to create a safe space for womxn of color to practice techniques and to receive support and encouragement on their breastfeeding journey.
During these meetings the group made appropriate referrals to other RIDOH programs, such as WIC and Family Home Visiting. Building off the Newport HEZ’s commitment to innovation and resident–driven strategies to address health disparities, the HEZ established a Women of Color Collective (WoCC) to elevate their advocacy efforts and to ensure that health care and social service organizations meet community needs. Activities included recruiting members through expanding the Community Health Worker (CHW) workforce, to include six (6) members to date. This effort continued throughout the COVID-19 pandemic by moving activities, such as the annual community baby shower, monthly meetings, and annual retreat, to a virtual setting.
In the upcoming year cycle (10/1/21-9/30/22) the WoCC will continue to grow membership, meet monthly, and develop its organizational structure, mission, vision, and evaluation plan. In addition, WoCC is developing a three-year strategic plan incorporating a racial equity and civic engagement lens, placing specific emphasis on the health and wellbeing of mothers and babies.
Priority: Support the Implementation of the Family Visiting Program
RIDOH has successfully administered evidence-based family (home) visiting programs since 2010. Rhode Island supports the implementation of three evidence-based models: Healthy Families America, Nurse-Family Partnership® and Parents as Teachers. In addition, RIDOH has supported First Connections, a RI specific, short-term family home visiting program, for over 20 years. First Connections is a short-term risk assessment and referral program that often makes referrals to one of the evidence-based programs. Prioritized populations for the evidence-based models, as designated by HRSA/MCHB, include:
- Low-income eligible families;
- families that include a pregnant woman who is younger than age 21;
- families that have a history of child abuse or neglect or have had interactions with child welfare services;
- families that have a history of substance abuse or need substance abuse treatment;
- families that have users of tobacco products in the home;
- families that have children with low student achievement;
- families with children who have developmental delays or disabilities; and
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families that include individuals who are serving or formerly served in the Armed Forces, including families that have members of the Armed Forces who have had multiple deployments outside of the United States.
Strong collaborations support RIDOH implementation of evidence-based family visiting programs. Many of the community and state partners sit on the Family Visiting Governance Council, Governor’s Children’s Cabinet, Title V Maternal and Child Health Management Team, RI’s Early Learning Council, RI’s Early Intervention Interagency Coordinating Council, Successful Start Steering Committee, as well as others. The Family Visiting Program also continuously builds and maintains relationships with community-based social service providers, medical homes, behavioral health providers, substance use treatment providers and Health Equity Zone partners.
Furthermore, the Family Visiting Program collaborates with multiple programs within RIDOH including:
- WIC: WIC identifies and refers pregnant womxn for services. WIC staff provide professional development training on infant feeding, nutrition, and breastfeeding to family visitors. WIC and family visiting work together to increase breastfeeding initiation and duration. The programs worked to update breastfeeding materials and, in April 2019, they co-hosted a Certified Lactation Consultant training for WIC and family visiting staff.
- RIDOH Immunization Program: Immunization program staff regularly attend family visiting Local Implementation Team (LIT) meetings to discuss relevant topics including flu, T-Dap and varicella, and school-based vaccination clinics. The family home visiting team regularly promotes vaccination clinics and vaccine information on the Family Visiting Facebook page and newsletter. During COVID, the Family Visiting program worked with the immunization program to encourage both family visitors and their clients to get immunized against COVID-19.
- Oral Health Program: The Oral Health program provides ongoing training about oral health issues to family visitors. The Oral Health team created community-specific materials that family visitors use to support families’ participation in oral health services. The Oral Health Program staff attends Local Implementation Team meetings to understand barriers to accessing oral health care in specific communities. The two programs share data and work to promote preventative dental care for pregnant womxn as well as the age 1 dental visit.
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MomsPRN: MomsPRN partners with the MomsPRN program to support family visitors that are working with caregivers who have postpartum depression. Family visitors are now able to access and receive support from the MomsPRN line, just as physicians and other health care providers can.
Continue to use evidence-based screening tools to identify family needs and make appropriate referrals to necessary services that support positive health outcomes for all family members.
The Family Visiting program continues to use evidence-based screening tools with families. The screenings assist in guiding visits, prioritizing family needs, and planning visits around those needs. The screenings begin during the first two to three visits with a family and continue periodically throughout a family’s participation in family visiting. Caregivers are screened for prenatal and postpartum depression, alcohol and substance use, and interpersonal violence. Families are offered referrals and are linked to care based on screening results. Children are also screened for developmental milestones as well as physical, social, and emotional health. Based on screening results, children are referred to supportive services, such as Early Intervention. With consent, family visitors also share concerns with medical providers including obstetricians and pediatricians. Throughout 2019 and 2020, the Family Visiting program participated in numerous CQI initiatives to improve screening rates and linkages to care for postpartum depression and reduce depressive symptoms in womxn with postpartum depression. The MCH Title V Coordinator is the CQI initiative’s senior sponsor. This work was spread to all family home visiting teams in Fall 2020.
Identify, engage, and retain more families at risk for poor outcomes.
As of June 2020, MIECHV was at 78.64% contracted capacity. The Family Visiting program remains committed to working with RI’s most vulnerable families and providing support at critical points during the life course. In July of 2020, the family visiting program expanded the Parents as Teachers program by an additional 300 families statewide with Preschool Development Block Grant funding. By working with community partners such as the birthing hospitals, healthcare providers, substance use providers, and the Department for Children, Youth and Families (DCYF), family visiting is able to engage pregnant womxn that may be at risk for poor outcomes. Through the Newborn Developmental Assessment done for every mother and baby at time of birth, 60-65% of newborns and their families are automatically referred to First Connections at birth. First Connections works with families to refer and engage vulnerable families in long term, evidence-based family visiting. The family visiting program also works closely with DCYF to identify and refer families that are involved with the child welfare system. DCYF has also increased referrals for families that are being investigated for child abuse but may not have an indicated case open to DCYF for further services. Additionally, the Family Visiting program is working with RI’s Department of Human Services to refer and engage families participating in TANF. Policies and procedures put in place by RIDOH’s Family Visiting program provide clear guidelines for consistent efforts to engage and retain families, as does ongoing sub monitoring of program implementation. Family visiting agencies are encouraged to use continuous quality improvement to test strategies to support both initial engagement and retention in services. Family visitors are also working with their Health Equity Zones to identify and refer families to family home visiting.
Improve the professional development system that is based on national core competencies for family visiting staff, including standardized orientation for all new staff and supervisors, including Title V priorities.
The Family Visiting Program provides high-quality professional development opportunities to all home visitors in order to ensure a skilled workforce that is able to respond to the complex and evolving needs of families. RIDOH works closely with contracted agencies to identify additional training needs. Most recently, family visitors have been offered training on the following topics: reflective practice and supervision, working with families with substance use, safe sleep, infant feeding, breastfeeding, self-care, oral health, car seat safety, public benefits and supporting mothers with maternal depression and extensive Motivational Interview training. To support reflective practice and supervision within all contracted agencies, RIDOH developed a framework for reflective practice and supervision and infant/early childhood mental health consultation. The Family Home Visiting Program works closely with RI’s Association for Infant Mental Health to support family visitors and provide training related to behavioral health. The RIDOH family home visiting team has also connected agencies with the Rapid Response in Virtual Home Visiting webinars to support teams during the time of COVID-19 and has shifted all professional development activities to virtual offerings for the foreseeable future.
Sustain and expand the Family Visiting Program by finding additional revenue streams.
Currently, with MIECHV funding, RIDOH’s current capacity for evidence-based family visiting is 1,400 families statewide. However, many more vulnerable families could benefit from long term, evidence-based family visiting. While RIDOH has successfully maintained its federal funding, additional resources are needed to support the program. RIDOH was able to begin expanding Parents as Teachers in July 2020 with funding to serve 300 additional families through Preschool Development Block Grant funds. In 2018, RIDOH worked with RI Medicaid to include Healthy Families America and Nurse-Family Partnership Home Visiting Programs in RI’s 115 Medicaid Demonstration Waiver. Approval by CMS was granted in December 2018. RIDOH worked closely with the Governor’s office to secure state funding in 2021. Additionally, these programs have also been added to the Medicaid State Plan Amendment and RIDOH is working to identify a state match. RIDOH continues to work with state partners to identify opportunities for braided and blended funding. As RIDOH works to identify and engage more families in family visiting there is a need to have more family visiting availability across Rhode Island.
Develop and implement a model of mental health consultation to the Family Home Visiting Program.
The Family Home Visiting Program will continue to support its 14 family visiting agencies with access to mental health consultation and similar supportive resources. With support from national experts, TA and local mental health consultants, RI has developed a tiered framework to support mental health consultation within family visiting so that family visitors, supervisors and program managers have levels of support while working with complicated families. Two levels provide for mental health consultation to family visitors and to families. The Family Home Visiting Program provided each family home visiting agency with dedicated funding in the agency’s contract for the past few years. That funding may be used for mental health consultation and supportive services. The Family Visiting Program will continue to provide that dedicated funding in future contracts. There is also funding in the Preschool Development Block grant, beginning in Fall 2020, to support mental health consultation.
In addition to providing funding to each family home visiting agency, the Family Home Visiting Program has partnered with the RI Association for Infant Mental Health (RIAIMH) to provide additional support to the family home visiting workforce. The Family Home Visiting Program works with RIAIMH on training and support related to infant mental health. The Family Home Visiting Program is also supporting family visiting staff by funding home visitors engaged in the process of Endorsement for Culturally Sensitive, Relationship-Focused Practice Promoting Infant Mental Health® (RI-IMHEndorsement®). This endorsement process ensures that family home visiting staff have the competencies and skills to support the parent-child relationship and promote positive parenting practices that address the needs of infants. The family home visiting program has worked with training providers of the reflective practice and supervision to align their training curriculum with the competencies for Endorsement so that their reflection practice and supervision training and group sessions support a family visitor that is working on Endorsement.
Teleconsultation for behavioral mental health among caregivers
At the end of 2018, the Rhode Island Department of Health (RIDOH) was one of seven states awarded a 5-year Health Resources and Services Administration (HRSA) grant to implement teleconsultant line to help obstetrical, adult primary care, pediatric, and psychiatric providers providers treating pregnant and postpartum patients screen and manage behavioral health disorders. To achieve this end, the RIDOH partnered with the Center for Women’s Behavioral Health at Women and Infants Hospital (CWBH) to implement the teleconsultation line and the Care Transformation Collaborative of Rhode Island (CTC) to provide intensive quality improvement coaching about behavioral health screening, treatment, and referral to contracted prenatal care practices.
The RI MomsPRN teleconsultation line is staffed by perinatal experts at the CWBH and is modeled after Rhode Island’s successful Pediatric Psychiatry Resource Network (PediPRN) program (see Child domain for more information). The goal of the RI MomsPRN psychiatry teleconsultation line is to empower providers in effectively managing their perinatal patients’ behavioral health and substance use concerns, by initially providing treatment guidance from RI MomsPRN perinatal psychiatric specialists, and/or offering information and referral for additional supports and services in their patients’ geographic area. In addition to providing perinatal behavioral health teleconsultation and practice transformation services for healthcare providers, RI MomsPRN program also collaborated with RIDOH’s Family Home Visiting Program and the Women, Infants and Children (WIC) Program to create, distribute, and promote a public service campaign about perinatal depression and anxiety and the importance of seeking help by connecting with a healthcare provider. The 30 second spot featured a patient testimonial and was aired on a local news station in June 2020. To help further amplify this campaign, the RIDOH created a new mental health resource page for new moms and featured the campaign on its various digital platforms.
During this reporting period (October 2019 - September 2020), the RI MomsPRN teleconsultation line fielded 346 teleconsultation calls, with 55 coming directly from perinatal patients and the remaining 291 calls coming from 182 unique providers (39 behavioral health clinicians, 38 OBGYNs, 19 family visitors, 18 midwives, 15 nurse practitioners, 13 social workers, 11 pediatricians, 10 family physicians, 6 residents, 2 internal medicine/general practice physicians, and 11 others). In total, 328 women (including 103 pregnant women) were helped because their provider contacted the RI MomsPRN teleconsultation line during this reporting period. These perinatal patients vary in:
- age (15-19 (4%), 20-24 (16%), 25-29 (22%), 30-34 (21%), 35-44 (19%), or are unknown (18%)),
- race (1% American Indian or Alaska Native (2), 2% Asian (7), 10% Black or African American (31), 1% Native Hawaiian or Other Pacific Islander (4), 49% White (162), 9% multiple race/other (29), or 28% unknown (93)),
- ethnicity (20% Hispanic/Latinx (65), 54% non-Hispanic/Latinx (178), or 26% unknown (85)),
- insurance coverage (50% Medicaid (164), 40% commercial (133), 4% other (13), <1% uninsured (1), or 5% unknown (17)),
- primary language spoken (English, Spanish, and Chinese),
- reported provisional behavioral health diagnosis by provider, with 39% of calls involving depression (201), 30% involving anxiety (154), 6% involving PTSD (33), 5% involving bipolar disorder (28), 5% involving SUD (24), 4% involving ADHD (19), 3% involving complicated grief (14), and 5% involving other disorders (29), (psychotic disorder (7), personality disorder (6), eating disorder (5), OCD (4), among others (7)), and 3% involving no provisional diagnosis (17), and
- reported psychiatric prescriptions by provider, with 42% of calls involving patients taking psychiatric medication(s) (137 in total, with 133 for mental health and 4 for SUD).
Also, during this time, the RI MomsPRN program was able to launch its first perinatal behavioral health quality improvement learning collaborative through a statewide call for applications. After applications were scored and reviewed by a selection committee, 4 prenatal care practices (Care New England Medical Group-Women’s Care, Lifespan Physician Group OBGYN Associates-Women’s Medicine Collaborative, South County Health-Center for Women’s Health, and WIH Obstetrics and Gynecology Care Center) were invited to participate. Taken together, these four practices manage 36% (5,903) of all the estimated perinatal patients in RI (16,235). Each practice formed a quality improvement team that included a practice champion, a practice leader, and an IT/EHR staff member. The teams met monthly with CTC practice transformation experts, attended joint learning sessions, and were welcome to call the teleconsultation line for patient specific clinical advisement. In exchange for providing cumulative de-identified quarterly screening data, updating and finalizing behavioral health Plan-Do-Study-Act (PDSA) forms, and completing practice- and provider-level baseline and follow-up self-efficacy surveys from RIDOH and HRSA, practices were eligible to receive practice payments. During this reporting period, cumulative de-duplicated screening data from January through August 2020 was reported, which showed that 59% (2,815) of attributed perinatal patients were screened for depression, 27% (1,306) were screened for substance use disorder, and 25% (1,168) were screened for anxiety at least once using a validated instrument. Practices had until the end of 2020 to increase those percentages further. Finalized aggregate performance period data of this first learning cohort (January 2020-December 2020), showed 65% (3,823) of attributed perinatal patients were screened for depression, 36% (2,116) were screened for substance use disorder, and 30% (1,754) were screened for anxiety.
In addition to providing perinatal behavioral health teleconsultation and practice transformation services, during this reporting period the RI MomsPRN program also engaged with 1,560 providers through various outreach (35) and professional education (16) sessions that included information about perinatal behavioral health and available program services.
Postpartum depression screening
In addition, the MomsPRN line supports family home visitors that are working with caregivers with postpartum depression. Family home visitors can access and receive support from the MomsPRN line, just as physicians and other health care providers are. During the reporting period, RI MomsPRN clinical staff supported five family visiting agencies that were participating in a HRSA Home Visiting Collaborative Improvement and Innovation Network (HV CoIIN) maternal depression continuous quality improvement initiative. Twenty-eight staff at these agencies were able to call the line for resource and referral support and/or attend relevant outreach/professional education sessions hosted by RI MomsPRN program staff to support their maternal depression quality improvement work. In total, 19 staff members (68% of staff participating in HV CoIIN) called the line for resource/referral support and 5 outreach/professional education sessions were held by RI MomsPRN staff during this reporting period.
Finally, RI MomsPRN Program collaborated with the RIDOH’s Family Visiting Program and the Women, Infants and Children (WIC) Program to create, distribute, and promote a public service campaign about perinatal depression and anxiety and the importance of seeking help by connecting with a healthcare provider. The 30 second spot featured a patient testimonial and was aired 42 times on a local news station in June 2020. It reached 48,846 individuals aged 25-54 residing in RI and Bristol County Massachusetts (9.9% of that targeted demo). To further support this campaign, the RIDOH created a perinatal mental health webpage that was promoted with this news partnership and regularly on the RIDOH homepage and social media channels, which resulted in 458 page views during this reporting period.
Other Programs/Projects Related to Perinatal/Infant Health
Rhode Island Task Force to Support Pregnant and Parenting Families with Substance-Exposed Newborns (SEN Task Force)
The mission of the SEN Task Force is to improve the bio-psycho-social health and well-being of children and families affected by prenatal substance use by developing comprehensive and supportive preventive and interventive systems of care.
The SEN Task Force was re-convened by the Rhode Island Department of Health (RIDOH) in Spring 2016 at the bequest of then-Governor Gina M. Raimondo. In addition to RIDOH, SEN Task Force membership includes the Rhode Island Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH); the Rhode Island Department of Children Youth and Families (DCYF); the Executive Office of Health and Human Services (EOHHS); multidisciplinary healthcare professionals; and, community-based providers in the arenas of maternal child health, and substance use. The SEN Task Force reports to the Governor’s Overdose Prevention Task Force.
In 2019, the SEN Task Force embarked upon a strategic planning process that resulted in a comprehensive, ambitious, and achievable Strategic Plan to drive the work of the Task Force for the next three years. Framed by four overarching priorities -- (1) increase education and workforce development; (2) improve interdisciplinary, family-centered care coordination; (3) expand and increase access to treatment and recovery; and, (4) use data to inform program activities and improve outcomes -- the Strategic Plan represents a collective vision of improved health outcomes and systems of care for Rhode Island families affected by substance use.
Starting in March 2020, SEN Task Force meetings were suspended when Task Force leadership was deployed to RIDOH’s COVID-19 pandemic response. It started meeting again in March 2021.
SEN Achievements (October 2019 – September 2020):
- Over 100 people attended the Fourth Annual Rhode Island SEN Conference, held November 21, 2019 in Warwick, Rhode Island. Topics included: developmental outcomes of children with prenatal opioid exposure; supporting DCYF families impacted by substance use disorders; Rhode Island’s Safe and Secure Baby Court, and Family Treatment Drug Court; and, addressing fear and discrimination in the presence of substance use disorders.
- Rhode Island was invited to participate in ASTHO Opioid Use Disorder, Maternal Outcomes, and Neonatal Abstinence Syndrome Initiative (OMNI) Learning Community. The action plan highlighted developing a reimbursable standard-of-care to screen all womxn of child-bearing age for mental health and substance use disorders and ensure that intentional pregnancies are supported for all womxn.
- The SEN Program continued to provide support to Health Equity Zones that are addressing maternal opioid use and substance exposed newborns as part of their work under the HEZ Opioid Overdose Response Grants.
- Between October 2019 – September 2020, 36% of all identified substance exposed newborns received a Plan of Safe Care. Work began on building the Plan of Safe Care into KIDSNET, Rhode Island’s secure database for vital health information.
- The First Connections Substance Exposed Newborns Project received a second year of State Opioid Response funding from the Rhode Island Department of Behavioral Health Developmental Disabilities and Hospitals (BHDDH) for First Connections Substance Exposed Newborns Teams to provide intensive care coordination to substance exposed newborns and their families. Between October 1, 2019 – September 30, 2020, nearly 70% of all referred SENs were outreached within 48 hours of referral receipt, and over 50% received at least one home visit.
- Established a bi-weekly SEN-DYF Case Conference to support preventive referrals for pregnant and parenting womxn who use substances and are open to DCYF.
Safe Sleep Workgroup
The mission of the Safe Sleep Workgroup is to decrease preventable sleep-related morbidity and mortality in Rhode Island through education, training, and provision of resources.
Established by RIDOH in 2017, Safe Sleep Workgroup membership includes DCYF, EOHHS, multidisciplinary healthcare professionals, and community-based providers who work with families with young children. In 2020, the Safe Sleep Workgroup became part of EOHHS’s Child Well Being Workgroup, a dynamic, multi-agency workgroup tasked with facilitating the efficacy of the State’s existing children’s health and welfare programs by aligning shared goals, policies, and practices. The Child Well Being Workgroup reports to the Rhode Island Children’s Cabinet.
As with The SEN Task Force, the Safe Sleep Workgroup was paused in March 2020 when key personnel were deployed to RIDOH’s COVID-19 pandemic response.
Safe Sleep Achievements:
- Established data-collection processes between the Office of the State Medical Examiner (OSME) and the RIDOH Safe Sleep Program to ensure all infant sleep-related deaths are accounted for
- Established a mechanism for case conferencing between Safe Sleep, WIC, and Family Visiting when an infant sleep-related death is identified
- Provided tangible safe sleep assets (cribettes and sleepsacks) through First Connections, Family Visiting, and DCYF for families in need
- Established a Safe Sleep Communications Workgroup to align messaging across all State departments and ensure the topic of safe sleep is consistently addressed.
- Provided Safe Sleep Training to 366 providers including substance use treatment providers, DHS frontline staff, family visitors, pediatric residents, and Early Head Start professionals
- Purchased over 13,000 English and Spanish “Sleep Baby Safe and Snug” books by RIDOH and DCYF for Rhode Island birthing hospitals to distribute to families who deliver a newborn
- Made NIH safe sleep posters and fliers in English and Spanish continuously available to hospitals and community-based providers through RIDOH’s Publication Center
Newborn Screening Program
The Newborn Screening Program provides universal newborn screening for 33 core blood disorders, Critical Congenital Heart Disease, and Hearing and Developmental Risk Assessments. On July 1, 2020, RI began screening for 1 new condition, Spinal Muscular Atrophy. The Newborn Screening Program assures screening and diagnosis for all infants born in the state. Abnormal results are tracked by the Newborn Screening Coordinator until resolved or a diagnosis is confirmed. Rhode Island’s six specialty clinics (endocrine, metabolic, hemoglobin, cystic fibrosis, neurology, and immunology) are responsible for reporting the diagnosis and treatment plan for all infants identified with a positive screen.
In 2020, 99.98% of eligible infants received a newborn blood spot screening and 99.89% were screened for Critical Congenital Heart Disease (CCHD). The Newborn Screening Program and the Birth Defects Program continue to collaborate to track and identify cases of CCHD. All screening continued, as usual, during the COVID-19 pandemic.
In 2019, the RI Newborn Screening Program applied for and received a grant from the Health Resources and Service Administration to improve evaluation of RI’s newborn screening programs and to build state-level capacity to assess and report on the effectiveness of screening, including timeliness and follow-up, in reducing the morbidity and mortality caused by heritable disorders in newborns and children. This program will evaluate the effectiveness of RI’s newborn screening systems by collecting data on newborn screening quality indicator information.
The Newborn Screening Advisory Committee, which advises the Newborn Screening Program on strategic planning, policies and procedures, new conditions to be added to the RI newborn screening panel, and associated services, continues to meet on a bi-monthly basis. Members include health care providers, public health experts, and people involved in delivering services, follow-up, and treatment in the state.
The Newborn Screening Program continues to train Fellows and Family Visitors to allow them to better educate parents on the urgency of newborn screening. The Newborn Screening Program will continue to work to educate more obstetrics/prenatal providers about newborn screening and increase the distribution of Newborn Screening brochures to these providers.
Rhode Island Newborn Hearing Program (RI-NBHS)
RI’s NBHS program is also known as RI’s Early Hearing Detection and Intervention (RI-EHDI) program. RI has a longstanding commitment to ensuring that hearing loss in newborns is detected and treated at the earliest possible point. Early detection with appropriate and timely follow-up is the best way to ensure that children with hearing loss have the opportunity to reach their full potential.
The RI-EHDI program is integrated into the state’s system of early childhood services; this has ensured that the program is coordinated at the state and community levels with other early childhood systems. The RI-EHDI integration also supports RI in achieving high rates of follow-up for children who fail a newborn hearing screen. However, due to recent challenges such as reduced capacity of audiologists, changes in hospital procedures and insurance co-pays and deductibles, and expanding income disparities in the state, RI is seeing a greater need to support families of newborns and infants who do not pass a newborn hearing screen to ensure those families are able to access appropriate evaluation and intervention follow-up at the earliest possible point, consistent with the JCIH 1:3:6 guidelines.
Goals during 2020 thru 2024 focus on baseline data from the 2014 CDC EHDI Hearing Screening & Follow-up Survey (HSFS). According to that survey, the number of newborns who received timely diagnosis was 51.2%. The 2019 CDC EHDI HSFS numbers showed that, although 58% received a confirmed diagnosis, only 35% of infants received a diagnosis by 3 months of age. At the end of 2016 and into 2017, Rhode Island replaced all of the hearing screening equipment at all birthing hospitals. In addition, in RI, there are only two diagnostic centers that perform diagnostic ABRs, both of which have struggled with staffing issues, causing a delay in the diagnosis of some children. In November 2020, Rhode Island reported screening over 99% of all infants born in the state to the Centers for Disease Control and Prevention (CDC). Of those screened, there were 16 confirmed cases of permanent Hearing Loss. Additional accomplishments include the continued effort to improve data reporting and data collection with the goal to expand the EHDI-IS capacity. During 2019-2020 Rhode Island Early Hearing detection and Intervention (RIEHDI) made great gains in migrating the two main data systems.
Despite all the follow-up efforts, an overwhelming number of newborns that should have completed recommended EHDI follow-up did not do so due to the COVID-19 pandemic. COVID-19 negatively impacted parent willingness to take infants to follow-up appointments. Also, the pandemic crisis may have reduced completion of screening due to early hospital discharge, disruptions to pediatric hearing healthcare, such as delayed diagnosis, and interruptions of audiological management services caused by closures of diagnostic centers. RI has seen an increased number of infants lost to diagnostic follow-up, particularly for those who were seen once but did not yet have a conclusive diagnosis.
RI continues its multistep attempt to engage families. If an infant needs follow-up, the hearing screening database automatically generates a follow-up letter, which instructs the family about next steps. The family’s pediatrician also receives that same letter to ensure that the pediatrician is aware of the child’s referral and to encourage the physician to engage the family in follow-up. Additionally, there are multiple phone calls made to families and primary care providers to ensure follow-up is completed. Once all these attempts have been exhausted, families are referred to First Connections, one of RI’s family visiting programs. The goal of this referral is for a First Connections home visitor to assist the family with hearing screening follow-up at the family’s home.
The RI Department of Health (RIDOH) has worked for decades and continues to develop and maintain a high-quality system of newborn hearing screening and follow-up based on the understanding that early support for children and their families plays a significant role in mitigating negative outcomes that can be associated with hearing loss.
The Special Supplemental Nutrition Education for Women, Infants and Children (WIC)
The mission of WIC is to ensure healthy pregnancies, positive birth outcomes and healthy growth and development for infants and children up to age five who are at nutritional risk. The WIC Program refers to healthcare and critical social services as well as to an array of agencies to meet the needs identified by participants/guardians; gives participants the opportunity to make informed decisions on healthy food choices, optimum feeding options and knowledge of food safety by providing nutrition education and breastfeeding promotion and support; offers access to nutrition professionals for questions and assistance; and prescribes tailored food package options to meet individual needs for optimal growth and development. The program serves roughly 19,513 women, infants and young children throughout Rhode Island, approximately 53% of the births in the state of RI. Overall, the WIC program serves approximately 49% of the total WIC eligible population in Rhode Island, based on the 2020 WIC State Plan. The reduction in the eligible population served in 2020 was due to the pandemic, which closed clinics to the public and provided telework appointments. The state was mandated to transition to eWIC and to transfer to a new MIS system, Crossroads, as the eligibility system in RI. These factors created confusion for WIC participants, including issues with reporting and limited staff availability, leading to a drop in WIC caseload. A nutritionist, with a BS, LDN or RD, will provide client centered counselling, referrals and food prescriptions based on individual needs. A care plan will be developed with the participant and follow up will occur at least every quarter, sometimes more frequently depending on the needs of the WIC participant.
Prenatal womxn on WIC are provided education on breastfeeding and are introduced to a WIC Breastfeeding Peer Counselor (BFPC). The BFPC builds rapport with the participants, provides ongoing education and promotes and supports breastfeeding. Any issues that exceed the ability of the BFPC are referred to an International Board- Certified Lactation Consultant (IBCLC). WIC IBCLC’s round at the three largest hospitals in the state, provide BF education, help with latch and any other issues and see only WIC participants or WIC eligible patients. The IBCLC will send their notes to the BFPC so the BFPC can follow up either at the clinic or while the client is home.
The WIC Program provides referrals and opportunities that help positively impact the health of womxn and children. WIC collaborates with the RI Breastfeeding Coalition working on many topics from licensing IBCLCs to the Baby Café in Providence RI. WIC also collaborates with the following RIDOH Programs: Healthy Homes (to address exposure to lead) ; PRAMS (to increase response rates) ; Diabetes Prevention program; Oral Health; Health Equity Zones (farmer’s markets, breastfeeding promotion and support) ; Center for Emergency Preparedness and Reponses (community resilience) ; Family Home Visiting; Safe Sleep; Drug exposed Newborns; and Tobacco cessation.
The WIC Program will continue with current services with a focus on increasing caseload, referrals and collaborations with new partners (i.e. Brown University Hassenfeld collaboration), assessing strategies to improve caseloads, and offering innovative opportunities (i.e. working with the Council on the Arts). Nationally, WIC is due to be reauthorized and receive ARPA funds for innovations that will offer possible changes in the program to reduce barriers and streamline services.
Zika Surveillance
The Center for Acute Infectious Disease Epidemiology (CAIDE) continues to conduct surveillance for Zika virus disease. Since February 2016, RI obstetricians have been instructed to call CAIDE and request testing when they identify a pregnant female who has spent time in a region with local-transmission of Zika virus or has another risk factor. When testing is requested, a public health nurse will review the CDC Zika virus testing guidelines with the provider and approve testing at the Rhode Island State Health Laboratory (RISHL), if appropriate. The nurse will then coordinate the specimen collection and educate the patient about strategies to prevent sexual transmission of Zika. If CAIDE receives any Zika virus laboratory reports from reference laboratories on females who are of childbearing age, CAIDE will follow-up with the provider to see if the female was pregnant, and if so, ensure appropriate testing was performed. If appropriate testing was not performed, testing recommendations are provided and Zika virus testing at the RISHL is offered.
Since February 2016, CAIDE has enrolled all pregnant females with laboratory evidence of possible Zika virus infection and their infants into the United States Zika Pregnancy and Infant Registry (USZPIR). The registry closed for new entries on March 31, 2018. CAIDE continued to follow-up on the infants born to registered mothers up to 3 years of age, with check-ins on infants at 2, 6, 12, 18, 24, 30 and 36 months of age. This was accomplished by reaching out to the infant’s pediatrician and utilizing the USZPIR Infant Follow-up Form to assess developmental delays and birth defects that may not have been evident at the time of birth. No pregnant females with laboratory evidence of possible Zika virus infection have been identified since the USZPIR closed for new enrollees. CAIDE continues to reinforce Zika-prevention messaging when conducting public education about mosquito-borne illness and travel. Given that there have been no cases of Zika in recent years, this activity was not impacted by the COVID-19 pandemic.
Rhode Island’s Perinatal Hepatitis Prevention Program (PHBPP)
The Perinatal Hepatitis B Prevention Program (PHBPP) coordinates with healthcare providers and birthing hospitals to prevent perinatal mother-to-child hepatitis B virus (HBV) transmission in routine preventive services before, during, and after labor and delivery.
The program recommends testing all pregnant womxn for HBsAg during an early prenatal visit (e.g., first trimester) in each pregnancy, even if they have been previously vaccinated or tested. Healthcare providers are required to report all HBsAg positive pregnant womxn to the RIDOH. During the COVID-19 pandemic, the program was not interrupted and providers must continue to ensure that HBsAg-positive pregnant womxn are able to advocate for the proper care of their HBV exposed infants in case labor and delivery occurs at an unplanned facility or is attended by staffs that are not knowledgeable about managing HBV exposed infants (e.g., providing education and supplying documentation to HBsAg-positive pregnant womxn). The program also recommends identification of HBVs of all womxn presenting for delivery. If a woman’s HBsAg status is positive or HBsAg status is unknown, post-exposure prophylaxis (PEP) - single antigen hepatitis B vaccine and HBIG (Hepatitis B Immune Globulin) should be administered to her infant within 12 hours of birth per ACIP recommendations, and provide the birth dose of hepatitis B vaccine to all other newborns within 24 hours of birth to prevent horizontal hepatitis B virus transmission from household or other close contacts. The program works with the mother and infant’s immunization provider to ensure HBV-exposed infants complete the hepatitis B vaccine series and post-vaccination serology testing (PVST). This follow-up ensures PEP and vaccinations were effective in protecting against disease transmission and that the infant developed immunity to hepatitis B. If PVST was delayed beyond 6 months after the hepatitis B series is completed during the COVID-19 pandemic, it was recommended that the provider consider administering a “booster” dose of single antigen hepatitis B vaccine and then ordering post vaccination serologic testing (HBsAg & antibody to HBsAg [anti-HBs]) 1-2 months after the “booster” dose per ACIP recommendations.
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