Vermont Title V is the recipient of the federal MIECHV funding. Vermont is near to completing year two of the Maternal Early Childhood Sustained Home Visiting (MECSH) model. Vermont continues to work very closely with the model developer, home health agency leadership, and nurse home visitors to adapt MECSH to meet the needs of Vermont families and communities, including additional educational materials.

Vermont is working hard to ensure a comprehensive statewide and local early childhood systems. Evidence-based home visiting has been fully integrated into Vermont’s early childhood system of care: Children’s Integrated Services (CIS). From the outset, we sought to do this by incorporating MIECHV home visiting into CIS. By integrating all Vermont home visiting programs, we have taken measures to ensure that the program is part of Vermont’s system for early childhood, and not a standalone program. It also ensures that resources are effectively allocated so that participants are directed into the most appropriate program model. In the fall of 2018, leadership from MCH and CIS at the Department for Children and Families rebranded MECSH and built a continuum of home visiting services across Vermont. A graphic display of this continuum is attached. This continuum is now called “Strong Families Vermont”.

In the past year, we reconvened the Home Visiting Alliance (HVA). The HVA is a coalition of community and state agencies that provides leadership for collaboration and strengthening the system of Vermont’s MCH home visiting programs. Likewise, the state’s commitment to the future of home visiting is written into 2013 legislation (Act 66). Through Act 66, the “General Assembly seeks to ensure that home visiting services to Vermonters are of the highest quality by establishing standards for their administration, delivery, and utilization review that foster the contributions of diverse practice models.” Act 66 charges the HVA and others with the development of quality standards, outcome measures, training and professional development, and a coordinated system of resources and referral for families. In the coming year, the HVA will:

• Be instrumental in designing and assuring standards for Vermont’s Home Visiting Model (both Nursing and Social Work programs)
• Review programmatic data and make recommendations to CIS/VDH staff regarding fidelity to models
• Advise State staff and legislature on sustainability for Vermont home visiting programs

Vermont is one of six state participating in the Center for Health Care Strategies (CHCS) Aligning Early Childhood in Medicaid (AECM initiative). The Vermont team is comprised of the state health reform and Medicaid leadership, MCH, DCF Child Development Division, Department of Mental Health, Building Bright Futures, and Let’s Grow Kids. Our overall state goals are to: 1) implement universal screening for health and social risk, brief intervention and supports that help families navigate to the appropriate services, within the context of early childhood education, home visiting programs, and pediatric medical care; 2) enhance risk stratification models for children and families through the Accountable Care Organization by capturing data on social risks captured through screening and data systems that already exist within the Vermont; and 3) work across the three sectors to develop coordinated efforts to follow-up or intervene with children and families who have identified needs.

Vermont is currently piloting the DULCE model from Boston Medical Center. DULCE (Developmental Understanding and Legal Collaboration for Everyone) provides a Family Specialist to meet with the families at every health visit for the first six months and offers support in person, through home and community visits, telephone, email, and texting. MCH is engaged in the potential spread of this model for several reasons:

1. Opportunity to meet all new families in medical home at newborn checkup for housing, food security, substance use, mental health screenings of families (social determinants of health screening as recommended by the 4th edition of Bright Futures)
2. Vermont has incredible health access for newborns including expansive Medicaid coverage and available child health providers so this model will touch almost all families
3. Primary goal of DULCE is to screen and then connect families to the resources they need
4. This is an important strategy for supporting the pediatric work force as the family support in the office increases physician’s job satisfaction and decreases work stress
5. Using Parent Child Center (key community agency) employee in this support role in primary care is a natural bridge between medical home and human services organizations in community

DULCE in Vermont’s pilot site (Lamoille County) will soon complete its 3rd year of implementation, and indicators are very positive that it is demonstrating success. 99% of local families agree to participate, with approximately 330 families having been served to date. 90% of well child visits are with the Family Specialist present; families are screened for intimate partner violence, maternal depression, and concrete supports (income, utility, transportation, food insecurity, housing insecurity, housing safety). The goal is to ensure that 90% of parents with positive screens, who are eligible for and want support, are connected with the appropriate resource.

OneCare is providing funding to pilot DULCE with Parent Child Centers at 3 new sites in Chittenden, Franklin, and Windsor in an effort to proactively address social determinants of health. The 2018 Vermont Legislation session included new 2019 requirements that an accountable care organization must satisfy in order to obtain and maintain certification from the Green Mountain Care Board, including:  No. 204. An act relating to ensuring a coordinated public health approach to addressing childhood adversity and promoting resilience (S.261).

WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children), which is administered under the Title V MCH Director, provides individualized nutrition counseling, breastfeeding promotion and support, health screening and referral, and specific nutrient dense foods to income and nutrition risk eligible pregnant, postpartum and breastfeeding women and infants and children who are under age 5. WIC families use a WIC card to purchase their prescribed WIC foods at authorized retail grocers. WIC integrates or coordinates with other programs such as EPSDT, Lead Poisoning Prevention, Immunizations, CIS, nurse home visiting, family planning and birth defects prevention. WIC manages a comprehensive and innovative breastfeeding education and support program in all districts and consistently has the highest WIC breastfeeding rates in the northeast region. Vermont WIC has been a strong presence in promoting child health, addressing maternal and childhood overweight and obesity, and increasing breastfeeding. WIC will continue to play a key role in Title V activities to increase breastfeeding rates as described below.

Breastfeeding peer counseling has been shown to increase breastfeeding initiation, duration and exclusivity. The Vermont WIC program provides peer counseling services to women in 5 of 12 local health offices; 4 of the 5 historically have lower breastfeeding rates than the state average. Funding from USDA increased in FFY 2020 and the additional funds will be used to expand peer counseling to additional local health offices in the coming year.

Vermont Medicaid added coverage for in-home lactation services provided by licensed professionals with IBCLC credentials beginning June 2018. This has increased access for in-home lactation consults for Vermonters with Medicaid insurance, primarily in Chittenden, Addison, and Lamoille counties. One of the Chittenden County providers will travel 2 hours for home visits, extending the coverage into surrounding counties. Vermont has a large number of IBCLC-credentialed individuals, but many are not working in professions licensed by the State and therefore are not be eligible to become Medicaid providers. Families in areas without access to a home visiting IBCLC Medicaid provider may receive home visits through the Strong Families Vermont nurse home-visiting program or receive in-office lactation consults through their pediatric office or hospital out-patient lactation clinic.  

The latest National Immunization Survey breastfeeding data (for children born in 2015) shows that overall, Vermont has reached or exceeded the HP 2020 goals for breastfeeding initiation (goal 81.9%, Vermont 89.3%) and exclusive breastfeeding at 6 months (goal 25.5%, Vermont 38.0%).

The CDC Breastfeeding Report Card shows that 16.7% of Vermont birthing hospitals have achieved Baby Friendly status, and 10.4% of Vermont births occurred at a 10 Step Compliant/Baby Friendly Hospital.

Twenty-five percent of pregnant WIC participants received peer counseling services in 2019, basically unchanged from the 24% who received services in 2018.

Title V MCH injury Prevention continues its existing Infant Safe Sleep programming. Vermont has had elements of an infant safe sleep prevention program but never a fully developed system that was based on research and used comprehensive messaging. In 2017, Vermont contracted with JSI, Inc. to conduct formative research and develop a system for comprehensive messaging based on the findings. In order to obtain a Vermont specific perspective, interviews were conducted with Vermont parents and health care providers. Key findings have been applied to several products, such as slide presentations to be used with professionals and parents, updated Health Department website and Facebook, a video on how to create a safe crib environment, and a training for hospital nursing staff. The MCH Coordinator in Vermont’s most populous county: Chittenden County has been working very closely with the New American communities to support the integration of these messages. In 2019, Vermont MCH began work with VCHIP to establish a QI project with Birthing Unit staff statewide, creating nurse trainings and process for crib audits.

Vermont Help Me Grow is an effective, efficient system strategy for advancing developmental promotion, early detection and linkage to resources. Help Me Grow helps states implement universal developmental surveillance, screening and detection for all children through age eight, and then links families to existing community-based programs. Help Me Grow (HMG) proactively addresses families’ concerns about their child’s behavior, development and learning by making a connection to community-based programs, services and high-quality parent education resources. The Help Me Grow Vermont system leverages existing resources, like Children's Integrated Services (CIS), to build collaboration across sectors of child health care, early care and education, and family support services. The Help Me Grow Vermont system expands the reach of CIS through a “no wrong door” centralized telephone access entry point for all children and their families to link to community-based programs and services. With the Vermont Department of Health as the lead agency, our collaborating partners comprise four key system components: 1) family & community outreach; 2) child health provider outreach; 3) centralized phone access point: Vermont 2-1-1; and 4) data collection & analysis. Help Me Grow is described in further detail in the Child Health narrative section.

Through a grant agreement to the Vermont Child Health Improvement Program (VCHIP), UVM faculty research and disseminate evidence-based guidelines and current best practice recommendations in perinatal care. Examples include standards of practice for pregnancy screening, such as screening for HIV and group B strep, and routine protocols for newborn care, such as bilirubin levels. They maintain ongoing awareness of the learning and training needs of clinical providers of perinatal care and respond via an evidenced based approach to disseminate current practice guidelines. Furthermore, Maternal Fetal Medicine and Neonatal Medical faculty at UVM Medical Center conduct six Perinatal Transport Conferences via telemedicine for perinatal health care providers at Vermont hospitals. These conferences employ an evidence-based approach using published guidelines/protocols, public health priorities, and current best practice reflecting national research and clinical experience in VT.

Vermont’s Maternal Mortality Review Panel (MMRP) established by legislation May 2011 to conduct a comprehensive, multidisciplinary review of maternal deaths in Vermont for the purposes of identifying factors associated with the deaths and making recommendations for systems changes. Vermont legislation requiring annual report from VDH and DVHA on high risk pregnancy -- existing programs, scope of services including case management and women as identified as high-risk. MMRP is chaired by Dr. Holmes, MCH Director. The MMRP has been updated with new membership and review processes and will meet summer 2019.

Comprehensive Obstetrical Services Program, administered by OB/GYN, University of Vermont Medical Center, provides comprehensive, team based, maternity care to women who are socially/economically at-risk. The care coordination team includes an obstetrician, a social worker, a nurse and a nutritionist. Services include comprehensive prenatal care, lab and genetic testing, birth and postpartum services, enrollment in WIC, breastfeeding support, and contraception counseling. Service coordination also happens with the NICU and the intensive services for women who have chemical addictions.

Vermont was chosen to participate in the 2017 Policy Academy: Improving Outcomes for Pregnant and Postpartum Women with Opioid Use Disorders and their Infants, Families, and Caregivers sponsored by National Center on Substance Abuse and Child Welfare. A team of leaders from across the private and public sectors have been working together to create a state-specific policy agenda and action plan and strengthen collaboration across systems to address the multiple and complex needs of this population. The work of the policy academy team primarily focused on developing Vermont’s Plan of Safe Care and outreach and integration with the OB and pediatric communities. The Vermont team worked hard to balance the requirements of the federal legislation, Vermont’s well-established system of identification and treatment of pregnant women with substance use disorder, and the needs of women and families.

Vermont has a robust Newborn Screening Program (NBS), with exceptional outcomes. The NBS program works closely with hospitals, health care providers, and parents in the implementation of the program and assures that the program operates according to current standards of practice. The Vermont Newborn Screening Program is made up of a small but dedicated team of staff and clinicians who work to ensure that newborns are screened in a timely fashion and receive essential follow up services for abnormal results. Vermont’s program is undeniably thorough; staff cross-reference birth records and hospital census data with laboratory reports to make sure all infants have documentation of screening or refusal. This important work has continued uninterrupted during the COVID-19 pandemic. Staff quickly transitioned to a mostly remote model. This has improved efficiency without compromising outcomes. All babies with out of range screening results have promptly received follow up testing or have been referred for diagnosis and management despite challenges presented by the pandemic. The NBS program was quick to reach out to hospitals and health care providers with information about newborn screening in the context of COVID-19 and has worked to address questions or concerns.

In 2019, Vermont became one of eight states in the nation to screen for all 35 of the core conditions on the Recommended Uniform Screening Panel (RUSP). This achievement was the culmination of over a year of work involving the Vermont Newborn Screening Advisory Committee, providers and health systems, families, the newborn screening laboratory, and the state legislature.

The NBS program provides hospitals with quality improvement reports that detail their performance on key indicators such as timeliness, specimen quality, and time from collection to receipt at the screening laboratory. These reports have been effective in encouraging hospital staff to examine internal processes and provide additional education for clinical staff. Additionally, these reports have encouraged laboratory staff and nurse managers to have more regular communication with the Newborn Screening Coordinator.

In the coming year the NBS Program aims to enhance service delivery by pursuing electronic reporting of results to hospitals and providers. The program is also in the process of translating educational brochures and forms into eight different languages to better serve Vermont families.

The Vermont Early Hearing Detection and Intervention Program (VTEHDI) works with hospitals and other community providers, including Early Head Start, home-birth midwives, audiologists, early intervention and primary care professionals to provide newborn and early periodic hearing screenings, audiological diagnosis and early intervention services. The program provides support, education, training, and clinical care management to families and their babies, and to community providers. These partnerships ensure timely hearing re-screening, referrals for diagnostic testing and entrance into early intervention services for newborns, infants and children identified with hearing loss throughout early childhood. As part of Children with Special Health Needs and with federal and state funding, VTEHDI contracts with organizations that support family engagement. Vermont Hands&Voices and 9 East Network, Vermont's single point of entry for early intervention and school-based services for Deaf, Hard of Hearing and DeafBlind children are two examples of organizations that provide support to families. Additionally, VTEHDI supports learning community initiatives for families that include leadership training, accessibility training, legal education for parents of Deaf, Hard of Hearing and DeafBlind children, trauma-informed care and retreats for families to share their emotional journeys. The Program Director for VTEHDI serves on the Governor appointed Deaf, Hard of Hearing and DeafBlind Advisory Council that makes recommendations to the legislature for improving the lives of children and adults that are Deaf, Hard of Hearing or DeafBlind. The Council members include Deaf Community adults, Hard of Hearing adults, DeafBlind adults, Parents, Educators, ASL Interpreter, Teacher of the Deaf, Speech Language Pathologist, Audiologist, Agency of Education representative and Agency of Human Services representative. Furthermore, VTEHDI works with state and national agencies and organizations to achieve the National EHDI goals of screen by 1 month, diagnose hearing loss by 3 months and entrance into early intervention by 6 months of age. The VTEHDI program, early intervention and school-based services are now combined under one director leading to a streamlined continuum of child and family-centered care statewide.