Our 2020 Needs Assessment showed that Delaware is among the lowest of its surrounding states when comparing children, ages 9-35 months, who received a developmental screening in the past year, where only 25.5% of these children received the screening.  Delaware is also below the national average of 33.5% of children having a completed developmental screening.  Developmental Screening was selected as the Most Important National Performance Measure in the Child Health Domain according to our stakeholders.  In addition, it was ranked as the second highest priority, when ranking all priorities overall.  

Efforts during the last application year were focused on increasing the number of children who had received a developmental screen, especially coming out of the wake of the lockdown due to the COVID-19 pandemic.  The lockdown prevented many children in the early learning and education settings, as well as the healthcare from receiving the routine screens.  Delaware’s Early Childhood Comprehensive Systems (ECCS) program through collaboration with its partners such as the Office of Early Learning (OEL) in the Department of Education, the Birth to Three Program and other stakeholders focused on improving developmental screening processes within the constraints of the “virtual” environment to remind providers and encourage parents to ensure that screenings are not missed.

The development of the Ages and Stages (ASQ) Online platform led by the OEL, the year prior, set the stage for Early Childcare and Education (ECE) providers to direct parents to their school district website to administer developmental screening.  Additionally, funding from the Birth to Three (B23) program to support the hiring of two Child Development Specialist to follow-up on the screens through the OEL platform made it possible to follow up with the screening results and the subsequent appropriate referrals to early intervention.

Outreach efforts, through our partnership with the Delaware Chapter of the American Academy of Pediatrics, to assist pediatric practices with developmental surveillance and screening and referral processes also shifted to focus on the creation of a practice report card to be distributed to practices, launching a care coordination pilot project utilizing Child Health & Development Interactive System (CHADIS) and early literacy pilot projects that provides books and developmental milestones education.  Practice outreach and assistance was focused on creating practice report cards with screening and referral data as well as quality improvement and performance efforts.

Due to COVID-19, in-person provider education and practice TA visits were not possible during the fiscal year.  Efforts instead focused on continued collaboration with community pediatric partners such as Beacon Pediatrics, Bright Futures, Bear Family Practice, Rainbow Pediatrics and through the DEAAP and the Medical Society of Delaware.  This collaboration led to the Help Me Grow Advisory Committee members and Early Child Comprehensive Systems (ECCS) impact team members to develop an online education course for physicians titled, “Delaware Developmental Screening Initiative”.  This online education course currently includes five separate education modules which expands upon the PEDS Online Training from July 2018 titled “Incorporating Developmental & Autism-Specific Screening into Your Practice”. 

The five education modules include an overview of developmental screening best practices, the State of Delaware’s developmental screening initiative, PEDS Online tools, early intervention, referral process and community resources, as well as care coordination.

We continued our collaborative efforts with other community partners and stakeholders, through the ECCS Improvement and the Help Me Grow Advisory committees to identify barriers and gaps in developmental screening implementation, referral and intervention processes and explore opportunities to mitigate the identified barriers and gaps.  In the fall of 2019, we began the exploration of a care coordination system that would resolve the identified breakdown or gap in our referral system.  This led to a series of presentations of three different referral systems identified across the country (namely, IRIS, CHADIS and UNITE US). The CHADIS system was deemed the system that would resolve the gaps identified across the state.  This led to the decision to set up a quality improvement pilot project utilizing the care coordination model by the end of 2019.  The CHADIS platform was developed by physicians for physicians and collects patient-generated data that can be used to support clinical and shared decisions, track data and create quality improvement reports. 

Efforts to launch the CHADIS pilot were however delayed due to the COVID-19 pandemic and the need for additional fact finding to ensure such a pilot would align with other efforts happening in the state, such as the goals/priorities of the Preschool Development Grant (PDG).  In September 2020, we received permission to launch a CHADIS pilot in 3-4 pediatric practices throughout the state using ECCS funds.  On October 21, 2020 a CHADIS demonstration and discussion meeting was held to provide more information to three pediatric practices selected to participate in the pilot.  Between October 2020 and May 2021 multiple meetings were held to discuss the pilot to determine CHADIS functionality, questionnaires, electronic health record (EHR) integration and cost, participating practice needs and responsibilities as well as state of Delaware specific metrics and outcomes for the pilot project.

Four community pediatric practices were ultimately identified and have been confirmed to participate in the pilot.  They represent all three counties, with enrolled patients who have either Medicaid or private insurance coming from diverse cultural backgrounds.  The idea is to launch the pilot within the first year and possibly scale up and spread based on the outcomes.

In spite of the delays encountered to set up the pilot, Delaware now has a contract with Total Child Health to run the one-year pilot project to determine the effectiveness of the CHADIS platform to address gaps in the developmental screening and care coordination process.

Efforts by the ECCS Place-based Community partners in collaboration with the Office of Early Learning and other EC partners to improve developmental screening and surveillance, starting from the push in the first year of the ECCS grant to sway the changed from using the DIAL screener to the Ages and Stages Questionnaire within early child care and education settings culminated in the developmental screening Bill released at the end of the grant in May 2021.  The universal developmental screening bill is designed to increase the opportunity for Delaware children to undergo developmental screening with a validated screening instrument at an early age in order to identify children who may be eligible for early intervention or special education services.  It requires any applicant for a license or renewal of a license to operate a child care facility to commit that each enrolled child between birth to five years will undergo developmental and social emotional screening.

Aggregate data report tracked by the ECCS evaluator through a Memorandum Of Understanding (MOU) between the Office of Early Learning and the ECCS program shows a total of 13,420 (non-Nemours) PEDS Online screens completed on children 0-59 months between July 1, 2020 and June 30, 2021.  This corresponds to an estimated 8,316 unique children or 61.97% of the total screens completed that were unduplicated. (This contrasts with 2019 screens of 15,345).  This compares to 13,106 (non-Nemours) PEDS Online screens completed on children 0-59 months between July 1, 2019 and June 30, 2020 and an estimated 8,318 unique children or 63.46% of total screens completed were unique.  This equates to a 2.40% increase in total screens completed while the number of unique (i.e., unduplicated) children stayed relatively the same.  This suggests that PEDS practices were slightly less efficient and there was slightly more duplication during the contract timeframe of July 1, 2020-June 30, 2021 as compared to July 1, 2019-June 30, 2020. 

We continue with outreach efforts to educate parents on the importance of developmental screening through the Books Balls and Blocks (BBB) events.  For this fiscal year, a series of face-to-face BBB events planned for Sussex County (a partnership with the Division of Libraries) in spring of 2020 were foiled by Covid-19 Pandemic.  To show our resilience the ECCS teams and the family engagement partners pivoted to virtual sessions.  This was no easy task as it meant looking for a facilitator who could engage 1-3 year old’s (virtually), an individual who could develop a curriculum based on the issues/milestones of focus, etc.  Our partnership with Let’s Play Inc, made this possible.  The first virtual BBB occurred in the summer of 2020 and have held more than 10 virtual events.  We have learned through this challenge that we can innovate once we put our minds to it.  With more than 10 virtual sessions held, we are confident to embed this in the infrastructure and have been bold to plan for other cultural populations such as the Hispanic population while introducing participating parents to topics such as early literacy and early intervention services.  The BBB outreach efforts revealed the need to provide assistance for parents as they respond to the ASQ screens, they are encouraged to complete at the BBB events.  This led to the partnership with the Office of Early Learning and Sussex County Health Coalition to organize a series of ASQ trainings for volunteers across the state.  Through this training, over 70 volunteers with varying backgrounds have participated in the ASQ training.  This training enables them to assist parents with challenges as they attempt to complete the screener at the BBB event.

The expansion of the Ages and Stages screener through early childhood led to a demand for more assistance in the follow up of results and linking parents with the early intervention services.  This challenge was mitigated through a partnership between the Help Me Grow/2-1-1(centralized access point) and the Birth to Three program.  Two additional staff were hired to support the ASQ follow-up done by the Help Me Grow /2-1- staff.  Funding came from the Birth to Three program.  This partnership and the subsequent improvements implemented, has led to significant increase in the number of families that have been referred to early intervention (Child Development Watch).  From March through May of 2021, 17% of the families for whom a referral was recommended made the referral.  However, the numbers were increased to 23% from June to July of the same year.  Continuous improvement is key, and we’re confident that as new processes are introduced that the referral rate will further improve. 

Delaware will continue to implement activities that will improve and increase developmental screenings across the state, especially to anticipate the obvious increase with the passing of the universal developmental screening bill in the state.  We will continue with the following:

• Training and education targeting early child care and health providers to increase the number of children who are screened.
• Collaborating with early intervention services to streamline referrals, especially for children with high-risk results.
• Launch and implement the CHADIS pilot project to determine its efficacy, scale-up and spread.
• Continue outreach efforts to educate families about developmental screening and milestones through the BBB events.
• Collaborate with EC community to craft consistent messages on developmental screening.

Dental Visit (child/adolescent)

According to the 2018/2019 National Survey of Children’s Health (NSCH), 20.3% of Delaware children, ages 0 through17, have not had a preventive dental visit in the past year.  The Preventive Dental Visit (child/adolescent) was another priority that is important to Delaware stakeholders.  Our stakeholders recognize that dental health equals overall health and the Title V team has identified that MCH is able to align our collaborations and resources to make an impact on this population.

MCH continues see value in supporting the activities of the Bureau of Oral Health and Dental Services (BOHDS) to improve the oral health and literacy of the children in Delaware.  The Delaware Smile Check Program (DSCP) anticipated screening 14,000 school children during the 2020/2021 year.  Unfortunately, the impact of the COVID-19 restricted most screening and preventive activities for oral health for most of the year.  Dental had many barriers with the program being viewed as a non-essential services and apprehension of the community.  During this time MCH supported BOHDS as they worked on web-based solutions to resolve barriers to oral health care and dental education for children ages 0 -18 years.

MCH provided funds for the Bureau of Oral Health and Dental Service (BOHDS) to add online enrollment, consent forms, screening forms and flyers for the DSCP to DEThrives for portable dental operations.  The portable program includes dental screenings and prevention programs onsite that include fluoride application, oral health education and case management.  Dental sealants and dental cleanings were not available this year.  Although this project was not completed during the 2020/2021 year it will allow schools, organizations and parent/guardians to complete consent forms and other required documents online and eliminate complications for distributing paper documents to these locations and sending them home to students to return.  This link is a staging link we are currently working to complete.  Smile Check | Delaware Thrives (dethrives.com)  Our goal is to have the link and website live for the beginning of the 2021//2022 school year to help children and families. 

In addition, we made a great deal of progress with completing a web-based sign up for a newly developed virtual dental screening option for children and adults who are unable to access onsite dental screenings or dental care throughout the year.

The virtual dental screening is separated into different age categories for infants 0 - 1, ages 1 - 5, ages 6 - 12, ages 12 - 18, adults and pregnant women.   Once completed the public will be able to sign up to receive the services provide by the DSCP.  An organization will be able to complete a consent and submit it directly to the program to sign their location up for an onsite event.  Individuals who want virtual services will be able to complete the documents and it will be submitted to a dental hygienist who will review the information submitted to highlight areas of concern and contact the parent/guardian or individual to discuss the screening questions and their concerns.  The questions allow the dental hygienist to determine the caries risk for the child, oral health needs of the child, barriers to care, and provide education and case management to improve oral health of the child and family.  In addition, the questions are designed to help the dental team identify any children and youth with special health care needs.

Smile Check Intro | Delaware Thrives (dethrives.com)

Smile Check Intro – Spanish | Delaware Thrives (dethrives.com)

From March 2020 to February 2021 when program access was restricted, toothbrushes, toothpaste, dental floss, and oral health education was delivered to 6,320 children ages to 0 - 8 years of age to childcare facilities, day camps, urgent care, baby showers, lactation counselors and pediatricians that included a business card with a new dental help line number that began November 24, 2020.  The dental helpline is staffed by the dental team to help address oral health concerns and connect the public to a dental provider that is accepting patients.  They can also address their specific needs as well as assist with securing dental or medical insurance, and other resources.  The information was shared with CYSHCN, Family Shade, school districts, school nurses, urgent care, home visitors, pediatricians, Delaware Medical Society, and other partners.  From November 2020 - June 2021, 1,742 calls were received from the public looking for a dentist or having a dental problem.  Calls are triaged and separated into adults and children, pain, swelling or people with disabilities get transferred to a dental hygienist to obtain additional information to assure they are connected to a dentist. 

During the 2020/2021 year, DSCP opened the program to encourage early intervention for   children ages 0 - 4.  The dental flyer was an effective tool to help the employees at the location be more at ease with the program and provided options for outdoor screenings to allow the BOHDS team to move forward with the program.  DSCP visited 23 childcare facilities to provide dental education to staff children and oral health resources in additions to dental screening.

During the year, a total of 1,304 children received dental screenings, fluoride varnish application, customized oral health education and case management to assist with eliminating barriers to care and assisting them with connecting to other services needed.  Through this program 62 were identified as having an urgent dental need (pain and swelling), 309 had suspected caries, 86 children had no dental insurance, and 379 had no dental home.  Through case management completed by dental hygienists, 60 children with urgent needs received dental treatment within 30 days after the dental screening, 86 children who had suspected dental caries were treated in 30 days and 155 received dental treatment within six months, 33 children secured dental insurance, and 315 were connected to a dental home.

Another way MCH has found to provide support to the Bureau of Oral Health and Dental Service was through collaborative efforts to inform home visitors and other community partners about the oral health education program for pregnant women and their infants

Many of these women are part of a Home Visiting program.  Through this program, women are inspired and empowered to take control of their prenatal health and birth outcomes through oral care and learn how to give their babies bright futures that start with simple oral hygiene practices and nutrition.  From 07/20 - 06/21, 25 women received dental screenings, case management, oral health education, practiced oral health techniques for their infants using a baby simulation doll.

Due to COVID restrictions, the live presentations where discontinued.  Virtual training sessions were developed and implemented.  Several barriers existed with connecting virtually via Zoom, Teams, Web ex to the participants.  Staff on both sides had a learning curve had to be overcome to develop a plan how to implement the technology, share, utilize and coordinate activities.  March trainings resumed and two presentations were given where 56 women attended.  Due to the challenges of virtual learning, the education is being split up into oral health for pregnant women and one for infants after delivery.

MCH has also supported developing a virtual screening for pregnant women.  This will be shared to encourage pregnant women to receive a virtual or onsite dental screening that includes case management and oral health guidance and resources.

Smile Check — Pregnant Women | Delaware Thrives (dethrives.com)

MCH assists with marketing oral health activities, events, and education through DEThrives Facebook, twitter and sharing with other partners.  During this time period BOHDS implemented several new programs to connect with the families with children to improve oral health, nutrition, safety, physical fitness, vaccination, and preventive visits for dental and medical. 

Reach out and Read is an example of one program.  The Delaware Chapter, American Academy of Pediatrics (DEAAP) is a professional association of pediatricians committed to promoting optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults in Delaware.  In support of its mission, the DEAAP recently established an Early Literacy Committee (ELC) tasked with the goal of engaging and supporting Delaware primary care pediatricians to promote early literacy from birth to five years.  The DEAAP ELC’s efforts are guided by its vision that “beginning at birth, every Delaware child is read to, every day.”

DEAAP ELC has partnered with the Bureau of Oral Health and Dental Service (BOHDS) to promote early literacy and a dental home for children by age 1.  To help accomplish this goal, partners are working to collaborate on the distribution of the ‘Brush, Brush, Brush’ book to pediatric practices that are implementing the evidence-based Reach Out and Read (ROR) literacy program.  The book, to be distributed during the 12-month, well-child visit promotes healthy habits using rhyme to engage and inspire little ones to brush their teeth.  Included on the back of the book will be a sticker with the Bureau of Oral Health Dental Services Help Line that supports families to help them find a dentist.  

Practices expressing an interest in distributing the ‘Brush, Brush, Brush’ book as part of the Reach Out and Read program will be contacted by a dental hygienist who will coordinate book delivery, engage in oral health conversations around available resources and supplies (toothbrushes, dental floss, toothpaste, etc.,) and training for caries risk assessment and fluoride varnish application, as requested by the practice. 

DEAAP Early Literacy Committee is pleased to be working in collaboration with the Bureau of Oral Health and Dental Service on this initiative to combine two important messages – early literacy and a dental home by age 1. 

Through this program, BOHDS dental hygiene team has delivered over 300 ‘Brush, Brush, Brush’ books to pediatricians, built relationships with the staff and has scheduled trainings with three pediatric medical offices to assist the doctors, physician assistant and nurses with implementing fluoride varnish application, caries risk assessment, referrals and discuss the systemic relationship between oral and medical health.  

In addition to this program, oral health education has been provided in person for 77 pediatricians to assist them with identifying oral health problems, assist with fluoride application, caries risk assessments, what to do for a dental emergency, HPV, and dental referrals.  The course included information about the lack of access to care, hesitancy of the community to visit a dentist and how to partner with oral health. 

The Storytime program is another collaboration with the Delaware Libraries to improve oral health literacy and early literacy of children.  A children’s book about dental is read by a dental hygienist from BOHDS.  A demonstration is given on proper brushing and flossing using a puppet.  After Storytime, the dental hygienist answers oral health questions, assists families with connecting to resources and can provide dental screenings, fluoride application, and case management.  A new oral health web page was developed that is shared with the public.  https://guides.lib.de.us/oralhealth

The Bureau of Oral Health and Dental Services coordinates with MCH to release information through DEThrives at a minimum monthly on Facebook and twitter.  This includes preventive education and oral health events available to the public to support children and their families to maintain good oral health and improve oral health literacy.  In addition, MCH has assisted with releasing an updated dental resource guide to over 950 community partners and stakeholders.  This resource guide assists families with finding a dental provider since the landscape of the dental community has been rapidly changing.  The guide includes information about dental benefits, transportation, how to find a provider, how to enroll with dental coverage and oral health tips.  Over 10,000 dental resource guides were distributed, and information posted on websites for different organizations.

MCH also distributed Impression’s newsletter through the Sussex County Health Coalition (SCHC) network of over 500 community partners including home visiting programs.  The newsletter is developed to address specific oral health concerns in the community and to garner interest in oral health among partners.  Below are two of the Impressions newsletters distributed to over 600 community partners and home visiting. 

Impressions Summer 2020_Final (delaware.gov)

Impressions Summer 2021_Final (delaware.gov)

MCH has also helped build a lasting connection and relationship with CYSHCN and BOHDS.  Information has been shared to assist families with finding a dental provider and approval is waiting for Helpful Tips For Scheduling a dental visit and maintaining good oral health at home.  DSCP has targeted schools that have many children with disabilities and collaborated with dental specialist that can meet the needs of the families for treatment. 

The last MCH was provided, our Medicaid claims data illustrated a dramatic uptick in the services being provided in the FY18 annual reporting year.  Additionally, the data also shows an increase in the number of physicians who billed for fluoride varnish application to 16.  This reflects an increase from 12 in 2018 to 16 in 2019.  Several individual pediatricians are still moving to the large health system networks of Nemours and Christiana Care Health Services and are billing under those entities.  Nonetheless, we continue be encouraged that many of our pediatric providers are taking an active role in offering limited oral health services to children in Delaware.  Unfortunately, MCH was advised that contract negotiations are still ongoing, so we are not able to access the updated data at this time.