Child Health Domain

FY19 Annual Report

 

 

The FY19 workplan for the Child Health Domain included the following performance measures:

 

1. Oral Health
2. Injury Hospitalization
3. Early and Continuous Screening - Developmental Screening

 

Strategies within the FY19 Child Health workplan were implemented by the Division of Prevention and Health Promotion’s Dental Health (DPH) and Injury and Violence Prevention (IVPP) Programs and the Division of Child and Family Health’s Early Childhood Health Unit. Summaries of activities completed during the reporting period are presented by performance measure below.

 

Complementary efforts were implemented by the Office of the Chief Medical Examiner. These entities and their efforts are detailed in the ‘Other Programmatic Activities’ section below.

 

 

Oral Health

 

 

Objective

 

For the FY19 application, the objective was:

• By June 30, 2020, increase the percent of children (ages 1 through 11) who had a preventive dental visit in the past year from 77.8% (National Survey of Children's Health (NSCH) – NONCSHCN 2016) to 81.7%.

 

NPM 13.2 - Percent of children, ages 1 through 17, who had a preventive dental visit in the past year was 82.4%. Among children 1-11 years old, 78.9% had a preventive dental visit, which did not meet the target set for reporting year 2019 of 80.7%.

 

Related National Outcome Measures

 

The national outcome measures (NOMs) relevant to this NPM include:

 

• NOM 14 - Percent of children ages 1 through 17 who have decayed teeth or cavities in the past 12 months

 

Significance of NOM 14: Tooth decay (cavities) is among the most common chronic conditions of childhood. Untreated tooth decay can lead to pain and infections which may result in problems with eating, speaking, learning and playing. Children with poor oral health tend to miss more school and get lower grades than those who do not. Tooth decay can be prevented through recommended preventive dental care, including flouride varnish and dental sealants, community water flouridation, and oral hygeine practices, including brushing and flossing.

 

Related Healthy People 2020 Objectives:

• Oral Health of Children and Adolescents (OH) 1.1: Reduce the proportion of children ages 3-5 who have dental caries experience in their primary or permanent teeth, (Baseline: 33.3%, Target: 30.0%),
• 1.2: Reduce the proportion of children ages 6-9 who have dental caries experience in their primary or permanent teeth (Baseline: 54.4%, Target: 49.0%)
• 1.3: Reduce the proportion of adolescents aged 13 to 15 years with dental caries experience in their permanent teeth (Baseline: 53.7%, Target: 48.3%)

 

 

Progress Updates

 

The Division of Prevention and Health Promotion’s Dental Health Unit is led by Tonya McRae Adiches, RDH (Dental Health Programs Manager). Non-MCH funds support delivery of preventive dental services for MCH populations.

 

The Dental Health Program (DHP) collaborates with Title V to:

• Foster regional alliances and implement local initiatives to improve access to dental care for children and pregnant women;
• Promote medical and dental integration in safety-net settings;
• Increase public awareness and engagement around oral health by disseminating data, research, and promising practices; and
• Support workforce development and training for medical and dental providers, lay professionals, home visitors, and caregivers serving individuals with special health care needs (ISHCN).

 

The Dental Health Program (DHP) is described in more detail within the Women’s/Maternal Annual Report.

 

Top FY19 accomplishments specific to children, including children with special health care needs, included:

• The Northern Virginia Oral Health Alliance’s Children’s Workgroup reviewed data and identified 25 pediatricians in the region with a high volume of Medicaid-enrolled children and began to reach out to them to understand their current oral health screening, assessment, and referral practices. They also shared information and resources to improve integrated care and referrals to dental homes. 
• Virginia Health Catalyst issued three microgrants of $5,000 (one in Northern Virginia and one in South Hampton Roads) to implement the Brush, Book, Bed program, an American Academy of Pediatrics-developed initiative to educate families and children about the importance of oral health at an early age. The third microgrant supports an inclusion and de-sensitivity initiative to help aid in preventing dental care-related trauma for children with special health care needs in Virginia.
• Virginia’s State Oral Health Program (SOHP) has years of oral health surveillance experience including data collection from multiple populations. However, statewide Individuals with Special Health Care Needs (ISHCN) oral health data had not been collected in Virginia and limited open-mouth ISHCN oral health data is available nationally. The SOHP administered the first Virginia ISHCN Basic Screening Survey June – August 2019 by calibrated public health dental hygienists from the SOHP and the Virginia Department of Behavioral Health and Developmental Services. Thirteen examiners screened 425 ISHCN in 13 health districts. Staff analyzed the data, and findings are being prepared for publications to share with partners, participating venues, ASTDD, and funders. ISHCN BSS process information and oral health data from Virginia could be valuable to other states wishing to conduct such surveys and for comparison with similar data.
• The SOHP also maintains a web-based listing of dental providers who report serving ISHCN and children under three years of age including listings for approximately 40% of all licensed dentists residing in Virginia. The primary goal of this directory, as well as ongoing dental provider educational courses offered for dentists wanting to increase their skills in dental care of ISHCN, is to increase access to dental providers in Virginia.

 

 

Strategy 1: Provide preventive dental services to children 1-17 with and without special health care needs.

 

The HRSA Perinatal and Infant Oral Health Quality Improvement Expansion (PIOHQIE) Grant ended in July 2019 but, with Title V MCH funding, a new program, the Maternal, Infant and Adolescent Oral Health Program was developed to continue important activities related to children through age 17. Activities completed this grant year that relate to this strategy include:

• The MIA consultant served on the Virginia Human Papillomavirus (HPV) Immunization Taskforce and played a unique role in promoting the HPV vaccine and providing data on emerging trends as it relates to HPV and oropharyngeal cancer (OPC) to dental providers and other non-medical community health workers, and promote overall health by incorporating HPV-related oropharyngeal cancer awareness strategies into oral health promotion efforts and school health curricula. 
• The RSDHs provided 90 oral screenings, 84 fluoride varnish applications, 112 oral health education, and 50413 dental referrals in WIC and other health department clinics for the (Age 6-17) population.
• The MIA Consultant has submitted a poster presentation titled “Working with Non-traditional Partners for Adolescent Oral Health:  The Human Papillomavirus (HPV) Initiative” to present at the 2020 AMCHP Annual Conference in Crystal City, Virginia on March 21-24.  The new track for this year’s poster session is “Adolescent and Young Adult Health”. HPV in oral health is an emerging topic for adolescents and young adults and therefore is an ideal topic for the conference poster session.  
• The MIA consultant serves on the Tobacco Free Alliance of Virginia to utilize oral health collaboration to create an addition to the “Saving Smiles Series, Give Teen Something to Smile About” leading to an additional section regarding Vaping. The MIA Consultant has met with the Health/PE Coordinator who has agreed to pilot upon completion in several school districts.  

 

In addition, the Individuals with Special Health Care Needs (ISHCN) oral health program completed the following:

• The ISHCN project staff along with collaborative partners provided five continuing education courses for 113 dental providers regarding dental treatment for individuals of all ages with special health care needs. Each of the courses were 11-hours in length and offered for no fee in five separate regions of the state.
• On the day before the dental provider courses, SOHP and DBHDS staff also provided five courses for 63 DBHDS Direct Support Professionals regarding oral health care for individuals with special health care needs.
• As of November 20, 2019, 2,303 dentists have an active account on the SOHP web-based listing of dental providers who report serving ISHCN and children under three years of age.
• The SOHP Special Needs Oral Health Coordinator personally provided education for 396 medical and dental professionals, lay health workers, caseworkers, teachers, families, and individuals about oral health care for ISHCN and young children through 13 presentations and 4 exhibit booths.
• A SOHP remote-supervised dental hygienist worked in the Southwest VA Care Connection for Children medical specialty clinics 14 days and provided 191 ISHCN with oral screenings and 153 with fluoride varnish applications as an extension of the Bright Smiles for Babies program.
• The SOHP conducted an ISHCN Basic Screening Survey (BSS) to assess barriers to dental care and document the current oral health status of ISHCN. The goals are to use this information to improve access to dental services for ISHCN by expanding components of SOHP oral health initiatives and share the findings with partners with power to impact positive changes in access to dental care for this priority population. The survey was administered June – August 2019 by calibrated public health dental hygienists from the SOHP and the Virginia Department of Behavioral Health and Developmental Services. Thirteen examiners screened 425 ISHCN in 13 health districts. Staff analyzed the data, and findings are being prepared for publications to share with partners, participating venues, ASTDD, and funders.

 

 

Strategy 2: Foster network of 6 regional Oral Health Alliances to conduct regional needs assessments and implement systems change and data-sharing initiatives to improve the oral health of all Virginians, with emphasis on pregnant women and children 1-17.

 

This strategy is detailed within the Women’s/Maternal Annual Report.

 

 

Evidence-Based Strategy Measures

The strategies proposed in the FY19 workplan aligned with the following ESM(s):

• ESM 13.2.1 - Number of Regional Oral Health Alliances that implemented work plans to increase dental visits among children (ages 0-11 years) and adolescents (ages 12-17 years)

 

These are detailed within the Women’s/Maternal Annual Report.

 

 

Injury & Violence Prevention

 

 

Objective

 

For the FY19 application, the proposed objective was:

• By June 30, 2020, decrease the rate of hospitalization for non-fatal injury per 100,000 children ages 0 through 9 from 101.5 (HCUP - State Inpatient Databases (SID) 2015) to 90.7.

 

NPM 7.1 - Rate of hospitalization for non-fatal injury per 100,000 children, ages 0 through 9 was 98.6 per 100,000, still above the target set for reporting year 2019 which was 92.8 per 100,000.

 

Related National Outcome Measures

 

The national outcome measures (NOMs) relevant to this NPM include:

 

• NOM 15 - Child Mortality rate, ages 1 through 9 per 100,000
• NOM 16.1 - Adolescent mortality rate ages 10 through 19 per 100,000
• NOM 16.3 - Adolescent suicide rate, ages 15 through 19 per 100,000

 

Significance of NOM 15: Although the risk of death for children declines sharply beyond infancy, there were still over 6,000 deaths among U.S. children ages 1 through 9 in 2014. Unintentional injury continues to be the leading cause of death in children 1 to 9 years. Other leading causes include congenital malformations, malignant neoplasms, and homicide.

 

Related Healthy People 2020 Objectives:

• Maternal, Infant, and Child Health (MICH) Objective 3.1: Reduce the rate of child deaths aged 1 to 4 years. (Baseline: 29.4 deaths among children aged 1 to 4 years per 100,000 population occurred in 2007, Target: 26.5 deaths per 100,000 population)
• Maternal, Infant, and Child Health (MICH) Objective 3.2: Reduce the rate of child deaths aged 5 to 9 years. (Baseline: 13.8 deaths among children aged 5 to 9 years per 100,000 population occurred in 2007, Target: 12.4 deaths per 100,000 population)

 

 

Significance of NOM 16.1: Although the risk of death declines sharply in early childhood, mortality rates begin to increase again in adolescence. Over 12,000 deaths occurred among U.S. children ages 10 through 19 in 2014. The leading causes of illness and death among adolescents and young adults are largely preventable. Unintentional injury continues to be the leading cause of death in adolescents 10 to 19 years, accounting for 36% percent of all deaths, followed by suicide (18%), homicide (13%), and malignant neoplasms (8%).

 

Related Healthy People 2020 Objectives:

• Objective Maternal, Infant, and Child Health (MICH) 4.1: Reduce the rate of adolescent deaths aged 10 to 14 years. (Baseline: 16.5 deaths among adolescents aged 10 to 14 years per 100,000 population occurred in 2007, Target: 14.8 deaths per 100,000) Related to Objective Maternal, Infant, and Child Health (MICH) 4.2: Reduce the rate of adolescent deaths aged 15 to 19 years. (Baseline: 60.3 deaths among adolescents aged 15 to 19 years per 100,000 population occurred in 2007, Target: 54.3 deaths per 100,000)

 

 

Significance of NOM 16.3: Suicide is the second leading cause of death for adolescents ages 15 through 19 years. In 2014, there were over 2,000 deaths due to suicide among adolescents ages 15 to 19 years, or 9.8 deaths per 100,000. Suicide and suicidal ideation is often indicative of mental health problems and stressful or traumatic life events. In 2015, 18 percent of high school students reported they had thought seriously about committing suicide in the past year. While females are more likely to report considering suicide, males are more likely to succeed in committing suicide. The suicide mortality rate for males is nearly three times that of females.

 

Related Healthy People 2020 Objectives:

• Mental Health and Mental Disorders (MHMD) Objective 1: Reduce the suicide rate. (Baseline: 11.3 suicides per 100,000 in 2007, Target: 10.2 suicides per 100,000)
• Mental Health and Mental Disorders (MHMD) Objective 2: Reduce suicide attempts by adolescents. (Baseline: 1.9 suicide attempts per 100 occurred in 2009, Target: 1.7 suicide attempts per 100)

 

 

Progress Updates

 

The Virginia Department of Health, Division of Prevention and Health Promotion,  Injury and Violence Prevention (IVP) Program is led by Lisa Wooten, MPH, BSN, RN (IVP Program Supervisor).

 

In Virginia, injury is a leading cause of death and hospitalizations for children, adolescents, and adults. Injuries and violence affect everyone—regardless of age, race, or economic status. Often, survivors are faced with life-long physical, mental, and financial problems. The good news is, injuries and violence are often preventable, and effective primary prevention strategies that are evidence based, informed, and organizationally adopted are successful for vulnerable populations.

 

The goal of the VDH Injury and Violence Prevention Program (IVPP) is to prevent and reduce the consequences of unintentional injuries and acts of violence, addressing risk factors and protective factors at the population health level through practice and policy change.

 

The program seeks to build solid infrastructure to improve the health of Virginians by increasing awareness and action to reduce unintentional and intentional injuries; and to provide technical assistance to local and state partners to assess the burden of injury, assure interventions and facilitate policy development. Title V-funded and non-funded IVPP staff continue to lead these programs.

 

Child Health Efforts

The IVPP statewide Low Income Safety Seat Distribution and Education Program leverages Title V grant funds to remove financial barriers for income eligible families and high risk populations statewide through a network of 154 distribution sites by providing no cost child safety seat devices, in addition to proper installation and usage education. The program provides transportation safety awareness as it relates to Virginia Child Passenger Safety Law (Code of Virginia, Chapter 10, Article 13). Title V-funded and non-funded IVPP staff continue to lead these programs.

 

IVPP staff also routinely utilize data on deaths and hospitalizations attributable to injury to inform programmatic activities. The Injury and Violence Epidemiologist, partially funded by MCH Title V, maintains the Virginia Online Injury Reporting System (VOIRS), which provides the public with data on deaths and hospitalizations attributable to injury. VOIRS allows quick and easy access to basic injury data and enables users to customize data reports on various types of injury hospitalizations and deaths. Data are available for both intentional and unintentional injuries, and some demographic and geographic information is included to allow for more detailed analysis. The Injury and Violence Epidemiologist routinely responds to data requests from constituents that can not be addressed through the VOIRS system.

 

Top FY19 accomplishments included:

• Disseminated one injury prevention prenatal curriculum for dissemination to maternity hospitals, local health departments, and community prevention programs
• Distributed child safety seats with parent/guardian installation and usage education to eligible families
• Hosted gatekeeper trainings for school based mental health professionals
• Equipped healthcare providers with the primary prevention skills in reducing Neonatal Abstinence Syndrome through evidence based models

 

 

Program Logos, Branding, & Communications:

 

The IVPP Title V team partners with the OFHS Communications Team to assist with programmatic material design, and dissemination of injury and violence prevention public awareness and targeted campaigns.

 

 

Strategy 1: Provide an injury prevention curriculum to maternity hospitals.

 

In FY18, IVPP completed the development of Project Patience, an evidence informed initiative supporting statewide delivery of prenatal and postpartum education on child maltreatment and infant injury prevention, in preparation for dissemination in FY19.

 

Project Patience is an evidence informed initiative supporting statewide delivery of prenatal and postpartum education on child maltreatment and infant injury prevention for newborn and infant caregivers. Project Patience focuses on providing technical assistance to maternity hospitals, libraries, local health departments, and community comprehensive maternity case management programs and be trained in educating community participants in injury prevention. The program is framed by Bright Futures, American Academy of Pediatrics, National Traffic Highway Safety Administration, and Centers for Disease Control and Prevention. In FY19, IVPP partnered with the Virginia Department of Behavioral Health and Developmental Services Prevention program and with the VDH Program Manager overseeing the local health department public health nursing network to expand its FY20 dissemination plan among the local health districts, libraries, and maternity hospitals.

 

Continued Project Patience activities are included in Title V’s FY21 Application.

 

 

Strategy 2: Eliminate financial barriers to safety devices by equipping income-eligible families with child safety seats through the Low Income Safety Seat Distribution and Education Program.

Limited Title V and non Title V funded staff/volunteer staff, working in the health departments provide the services of applicant screenings, programmatic reporting, and dissemination and education training sessions. Low Income Safety Seat Distribution and Education site staff are housed in Health Departments of thirty-one of the thirty-five Health Districts. The remaining non-participating Health Districts include Eastern Shore, Prince William, Three Rivers, and Pittsylvania/Danville. (The Pittsylvania/Danville Health District will become operational December 2019.) MCH funded and non funded sites, support efforts in providing safety seats to income eligible clientele following education in correct usage and installation of the restraints.

 

In FY21, Title V staff will explore capacity for local health districts to address this strategy using their allotted Title V funds.

 

 

Strategy 3: Equip healthcare providers with primary prevention skills for reducing Neonatal Abstinence Syndrome through the evidence-based model Project ECHO.

 

IVPP partners with the University of Virginia to facilitate Project ECHO (Extension for Community Healthcare Outcomes), a technology-enabled collaborative learning and capacity building model which connects specialists and subspecialists to primary care providers and clinicians in rural and underserved areas throughout the Commonwealth to deliver best practice care for complex conditions like Neonatal Abstinence Syndrome.

 

 

Evidence-Based Strategy Measures

 

The strategies proposed in the FY19 workplan aligned with the following ESM(s):

• ESM 7.1 – number of maternity centers with prenatal courses including Virginia’s Injury Prevention Curriculum
• ESM 7.2 – number of child safety seats disseminated through the LISSDEP network
• ESM 7.3 – number of healthcare providers receiving Project ECHO content in reducing the impact of NAS

 

ESM 7.1: Number of maternity centers with prenatal courses including Virginia’s Injury Prevention Curriculum

 

During FY19, IVPP worked with 25 hospitals to continue technical assistance in the readiness for adopting Project Patience. During the course of the year, 3 Bon Secours maternity hospitals agreed to infuse the VDH curriculum into their current Love and Learn maternity hospital education. In addition, 1 VDH local health district in Alexandria Virginia adopted Project Patience contents in Violence Prevention, Abusive Head Trauma prevention. Work was expanded into one implementation plan for Henrico County, Virginia libraries for FY20.

 

Project Patience dissemination activities were included in the FY20 and FY21 Applications. The total deliverable goal for implementation is expected to actualize in FY20.

 

ESM 7.2: Number of child safety seats disseminated through the LISSDEP network

 

IVPP leveraged MCH funds to disseminate child safety seats through the Low Income Safety Seat Distribution and Education Program (LISSDEP) network. During FY19, 1,342 convertible safety seats and 218 boosters, totaling 1,560 distributed to income eligible families. The LISSDEP network experienced a decrease in eligibility applications by clientele during the FY. The program continued its programmatic evaluation to determine the root cause.

 

ESM 7.3: Number of healthcare providers receiving Project ECHO® content in reducing the impact of NAS

 

IVPP contracted with the University of Virginia to facilitate the NAS Project ECHO® project in FY19. Based on a hub and spoke model, Project ECHO® is free to health care providers, and delivered right to their clinic through a virtual platform. Providers are exposed to a community of learners, and are offered continuing medical education units, opportunity to present de-identified cases, and access to a virtual community of tools and resources. Partially funded and non funded MCH staff provided technical assistance to the University of Virginia in curriculum development and delivery of the Project ECHO® model with fidelity and integrity.

 

Curriculum content for FY19 was inclusive of maternal discharge planning from the injury lens, pharmacotherapy for stabilization of the mother, and prevention of maternal substance use prenatal and postnatal for harm reduction.

 

Activities continued in the FY20 work plan and included the following NAS Project ECHO sessions:

• December 5, 2018, 20 participants.
• December 19, 2018, 16 participants.
• January 9, 2019, 15 participants.
• January 23, 2019, 8 participants.
• February 6, 2019, 9 participants.
• February 20, 2019, 5 participants.
• March 6, 2019, 8 participants.
• March 20, 2019, 10 participants.
• April 3, 2019, 7 participants.
• April 17, 2019, 8 participants.
• May 1, 2019, 6 participants.
• May 15, 2019, 7 participants.

 

Total of 12 Project NAS ECHO sessions:

• 119 participants
• 60 Unique participants
• 17 Health Centers/Clinics who participated
• Virginia Regions Represented: Southwest, Northeast, Central and Southeast

 

Participants in the University of Virginia NAS Project ECHO included a multidisciplinary group from throughout the Commonwealth including, medical doctors, nurse practitioners, licensed counselors, nurse managers, lactation consultants, and NICU RN’s and neonatologists. NAS Project ECHO content was delivered to providers with as many as 483 miles between them. The topics taught at Project ECHO NAS sessions were SAMSHA approved effective interventions for Opioid Use Disorder, including medication assisted treatment. The Substance Abuse and Mental Health Services Administration (SAMSHA) developed the clinical guidelines to meet the urgent needs among professionals who care for women with Opioid Use Disorder and substance exposed infants for reliable, useful, and accurate information that can be applied in clinical practice to optimize the outcome for both mothers and infants.

 

Topics for these specialized Project ECHO sessions included:

• Prenatal Screenings and Assessments
• Initiating Pharmacotherapy for Opioid Use Disorder
• Changing Pharmacotherapy During Pregnancy
• Managing Pharmacotherapy Over the Course of Pregnancy
• Pregnant Women with Opioid Use Disorder and Comorbid Behavioral Health Disorders
• Addressing Polysubstance Use During Pregnancy
• Planning Prior to Labor and Delivery
• Peripartum Pain Relief
• Screening and Assessment for Neonatal Abstinence Syndrome
• Management of Neonatal Abstinence Syndrome
• Breastfeeding considerations for Infants at Risk for Neonatal Abstinence Syndrome
• Infant Discharge Planning

 

The University of Virginia NAS Project ECHO held bi-weekly labs from December 2018 to May 2019. The remaining of the contract period was spent to evaluate progress and develop additional content for the following FY.

 

 

Developmental Screening

 

 

Objective

 

For the FY19 application, the proposed objective was:

• By June 30, 2020, increase the percent of children (ages 10-71 months) receiving a developmental screening using a parent-completed screening tool from 26.8% (NSCH 2016) to 28.1%.

 

NPM 6 - Percent of children, ages 9 through 35 months, who received a developmental screening using a parent-completed screening tool in the past year was 31.4%, exceeding the target set for reporting year 2019 which was 27.9%.

 

Related National Outcome Measures

 

The national outcome measures (NOMs) relevant to this NPM/SPM include:

 

• NOM 13 - Percent of children meeting the criteria developed for school readiness (DEVELOPMENTAL)

 

Significance of NOM 13: The early years are a critical period where experiences impact structural development of the brain and neurobiological pathways for functional development. Although early experiences do not determine children’s ongoing development, interventions around school readiness and early childhood education can act as a protective factor against the future onset of adult disease and disability. Studies have shown that children’s literacy and numeracy skills at school entry are a good predictor of later academic achievement, high levels of education and secure employment. Social gradients in language and literacy, communication and socioemotional functioning emerge early for children across socioeconomic backgrounds, and these differences persist into the school years. There are also disparities in the US as to who participates in an early childhood program. Children at risk of poor developmental and educational out

 

Related Healthy People 2020 Objectives:

• Early and Middle Childhood (EMC) 1. (Developmental) Increase the proportion of children who are ready for school in all five domains of healthy development: physical development, socialemotional development, approaches to learning, language, and cognitive development.

 

Progress Updates

 

Developmental screening represents an emerging priority for the state Title V program. Three ESMs have been developed to reflect planned FY19 efforts aligned with this priority. These efforts are jointly expected to support implementation of the Bright Futures guidelines and to encourage a more comprehensive, coordinated approach to providing pediatric care at the community level.

 

Developmental Screening as a State Priority

 

Virginia ranked 39th in the nation in 2018 for developmental screening rates for children under age five years, which was up from 42nd in 2017. Parent report of developmental screening hovers around 22% meaning that over 2/3 of young children in Virginia are not screened prior to school entry.  

 

VDH’s Plan for Well-Being prioritizes investing in the health, education, and development of Virginia’s children. Among the key strategies outlined in the Plan for giving children a strong start are: (1) increasing developmental screening for childhood milestones and delays; and (2) expanding programs that help families affected by ACEs, toxic stress, domestic violence, mental illness, and substance abuse to create safe, stable, nurturing environments.

 

According to a report by the University of Virginia’s Curry School of Education, one in three children in Virginia is not prepared to succeed in the areas of self-regulation, social skills, literacy, and/or math at the beginning of kindergarten. Being developmentally ready to learn and participate in classroom activities not only sets the stage for successful school entry but can have lifelong influence on well-being. The report found that “children who enter kindergarten behind their peers rarely catch up; instead, the achievement gap widens over time.” Investing in programs that prepare children to succeed in school and facilitate early intervention for those requiring additional support helps to prevent them from falling behind and experiencing poor educational outcomes, such as dropping out of high school.

 

The earliest years of life represent vulnerability as well as promise. From the time they are born and until the time they enter school, children’s brains undergo dramatic development. They acquire the ability to think, speak, learn, and reason. Early experiences form the foundation and the scaffold upon which to build additional skills throughout life. Positive, nurturing relationships with parents and other key caregivers during this period are critical for healthy growth and development.

 

Violence, neglect, social and economic hardships, negative family and community environments, and other sources of trauma negatively impact the mental and physical health of children and have lasting effects into adulthood. Toxic stress can trigger hormones that wreak havoc on the brains and bodies of children, increasing their lifetime risk for disease, homelessness, and early death. Seven out of ten leading causes of death are linked to adverse childhood experiences (ACEs).

 

The VDH Plan for Well-Being recognizes the importance of supporting children’s social and emotional health and prioritizes working with healthcare providers, social services, community organizations, childcare providers, and other partners to increase the number of providers and educators who screen for adverse childhood events (ACEs) and are trained in using a trauma-informed approach to care.

 

The work of 2018 coalesced around a statewide Developmental Screening Initiative to help close the gap in developmental screening care for the children in the Commonwealth who are without access to supportive and coordinated screening services. The Virginia Developmental Screening Initiative is a new statewide initiative dedicated to improving developmental screening services in Virginia. The primary goal in moving forward on the work of the prior year was to develop a strategic developmental screening work plan with community stakeholders, through six regional hubs, to build a continuum of developmental and behavioral care to reduce barriers and gaps and promote equity for all young children and their families. In FY21, partnerships will be developed with the community’s performing the screening and Child Development Centers who receive referrals to form a continuous seamless loop. The core outcome is for all children to be screened early and continuously for special health care needs. This work is funded entirely through Title V.

 

Top FY19 accomplishments included:

• In FY19, a series of internal brainstorming sessions and in-person state and regional stakeholder meetings were held with support from the staff from AMCHP and the National MCH Workforce Development Center.

 

 

Program Logos, Branding, and Communications:

 

The developmental screening program included two communications efforts. The first efforts incorporated the communication team and involved re-establishing the child health website on a new server and reconstructing the transferred parent videos. The videos are a B-5 approach to child health using Bright Futures and normal child development and screening. The second phase of work with the communication team will be to continue to build out a more interactive developmental screening web page as an extension of the work of the six regional developmental screening hubs.  http://www.vdh.virginia.gov/brightfutures/ 

 

The second effort was the creation of a Developmental Screening Model following the fall 2018 stakeholder meeting. It provided input from partners and families as part of a visioning exercise. The exercise created visual models of an ideal developmental screening system.

 

Diagram: Developmental Screening Initiative Model

 

 

Strategy 1: Through early childhood partnerships, support ongoing workforce development through training, technical assistance, professional development and education with evidence-based tools for LHDs and their community partners.

 

Rxploration of the need and number of LHDs, community partners, and providers receiving developmental screening resources, training, and TA showed that at the local level, LHDs serve as a safety net for providing child health physicals and developmental screenings and play a key role in linking families to community resources to ensure continuity of care. In FY17, each LHD was provided with copies of the fourth edition of the Bright Futures Guidelines and accompanying reference materials. ECH staff have also conducted trainings on Bright Futures and ASQ tools for LHD staff. Sustaining the number of trained LHD staff is a priority. 

 

 

Strategy 2: Provide messages for families and the community about the importance of ongoing screening, monitoring, referral and follow-up of child development using social media.

 

The state website was revised and updated to reflect the work around Bright Futures and medical home. A communications plan was developed with the communications team for implementation.

 

 

Strategy 3: Strengthen the continuum of child health care infrastructure for screening, assessment, referral, and follow-up for developmental screening.

 

In FY17, an internal report was developed summarizing developmental screening efforts in Virginia. While the state has engaged in a variety of efforts, existing data reflect primarily grant or program requirements.

 

Virginia is slowly building a system around referrals, determined eligibility, and receipt of services primarily through Early Intervention and Child Development Centers. These are primarily due to program or grant requirements.

 

Data do exist for children accepted into service delivery for developmental delays. However, there is currently no centralized information on referrals for children with suspected delays not accepted into or who are ineligible for services and subsequently discharged back into the community.

 

Qualitative data point to a larger systems issue of care, connection, and coordination for comprehensive service delivery for at-risk children. This is particularly true for children of color. The lack of systemic supports for centralized referral and data are some of the barriers to building stronger systems of developmental care.

 

Examination of existing information and/or studies had too small of a sample size or paid insufficient attention to establishing causality and quality data; others did not sufficiently engage stakeholders appropriately, and as a consequence, results were never put to use.

 

There currently is no state mandate to report individual developmental screening; it is not included on school health physicals nor is it required for school entry, childcare programs cannot do a screening and referral without parent permission, and medical practices report not having sufficient staff time to pull and review records unless the information is electronically compiled. Without a centralized data or referral system, developmental screening information is not easily accessible. Little data exists to understand screening practices and referrals by personnel performing developmental screening. The questions that could not be answered from the environmental scan was primarily, “What is it about the design of the current system that is insufficient to meet the needs of the family and provider, and how can we improve it?”

 

More work remains to adequately capture and assess what happens to children following a developmental screen to ensure they get the care they need. There exists the need to examine further the system of developmental care to understand the need, desire, limitations, motivation, and importance of completing a screening and referral by the provider. It had been over a decade since a stakeholder group met to discuss developmental screening.

 

In FY19, the Title V team sought technical assistance from the National MCH Workforce Development Center.

 

As of 2020, the state still lacks a common agenda for providing comprehensive and coordinated care. A key next step is to bring stakeholders together to identify developmental screening needs from screening to referral aligned with national evidence-based recommendations.

 

In FY21, the Early Child Health Consultant and Title V Director will work jointly to reconvene state and regional partners to develop a Shared Agenda for Developmental Screening with partners from the Virginia Early Childhood Foundation, home visiting, social services, behavioral health, early child education, the state Family-to-Family program, AAP, Early Intervention, and Medicaid.

 

Through an iterative process, the stakeholder group plans develop shared goals, metrics, and recommendations for appropriate allocation of resources to help develop building blocks towards a seamless system of service delivery.

 

 

Evidence-Based Strategy Measures

 

The strategies proposed in the FY18 work plan aligned with the following ESM(s):

• ESM 6.1: Number of LHDs, community partners, and providers receiving developmental screening resources, training, or TA
• ESM 6.2: Number of hits to the VDH web pages by individuals seeking information about the importance of regular developmental screening and Bright Futures
• ESM 6.3: Completion of actionable 2-year plan (FY19-FY20) for strengthening the comprehensive, complex developmental screening system of care for children 0-8

 

 

ESM. 6.1: ECH staff provided statewide training, technical assistance, and resources to LHD nurses that provide these services. Efforts focused on sustaining and expanding the number of LHD staff that have up-to-date knowledge and skills to provide developmental screenings using the revised ASQ3 and ASQSE2. Trainings permit continued technical assistance and support and prevent loss of staff knowledge and capacity due to turnover. Future activities may include: exploring billing practices for developmental screening reimbursement; exploring the feasibility of allotting a minimum thirty minutes of clinic time to working with each family to complete, score, and review results of screening tools; and ensuring LHD staff are equipped to link families to community resources for follow-up and referrals, as needed. VDH ECH staff also continued to participate in critical interagency initiatives related to developmental screening. For example, the Early Childhood Mental Health Advisory Board is a statewide multi-agency, multidisciplinary stakeholder group tasked with addressing infant and child mental health issues in Virginia. All key state agencies serving infants and children are represented, with multiple staff participating on behalf of each agency’s various programs. Since its inception, the number of agencies represented has grown from four agencies to 24 agencies. Among the interests represented are advocacy, social services, health, education, behavioral health, early intervention, and parents/families. Early childhood special education professionals and clinical providers also offer input, including a psychologist, a pediatrician, and various rehabilitation associates (e.g. occupational, speech, and physical therapists).

 

ESM 6.2: VDH efforts focused on providing messaging and education to providers. Family-focused efforts have been largely limited to families of CSHCN; however, a number of partners are working together to educate parents on the importance of well-child visits. Specifically, ECH staff expanded engagement and education efforts to families of children with and without special healthcare needs. Promotion of the Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents to LHD staff and external providers continued. Efforts included development and dissemination of messaging to providers via channels such as electronic newsletters and the VDH website. ECH staff developed and disseminated social media messaging targeting families and community members on the importance of regular child health check-ups linked to Bright Futures and normal child development and screening.

 

The OFHS Communications Team provided ongoing support and expertise in messaging and distribution. In FY18 and FY19, the web site migrated to a new platform necessitating the re-development of existing materials. This ESM will continue into the upcoming year with a revised communication plan under development with the hiring of a new internal webmaster. In addition, a plan was developed to incorporate CDC’s Know the Signs, Act Early.

 

ESM 6.3: This ESM builds on early momentum with key partners to flesh out a 2-year state action plan to promote developmental screening. A planning meeting with key stakeholders took place in the Fall of 2018 and Spring of 2019. Outcomes from the meetings included:

• Exploring why screening matters with the recommendation to continue to begin meetings with this question to penetrate more for the bigger why to make sure the details of the work driven by the important impacts on children, families, and communities;
• Compilation of a draft vision statement for the developmental screening initiative with visualizations based off the work in the room;
• Initiating mapping of the current state system through causal loop diagramming; and
• Beginning to think about how to contextualize data needs within a larger system.

 

 

Other Programmatic Activities

 

Office of the Chief Medical Examiner

OCME continued to lead child fatality review with Title V funds. These activities are described in detail in the FY21 Application.

 

Child Fatality Review

 

The Virginia State Child Fatality Review Team is unique when compared with child death review processes in other states. Virginia’s Team does not review every child death every year, but instead chooses a specific type of child death on which to focus its review. For example, in FY17, the state child fatality review team reviewed cases of overdose poison deaths to infants and children up to age 17 that occurred in Virginia during the five-year period between 2009-2013.

 

 

Reviews typically cover child deaths from certain causes or manners of death or injury patterns. The Team is tasked with developing recommendations for prevention, education and improved child death investigation.

 

Membership of the multi-disciplinary team is defined in statute and includes physicians and representatives from state and local agencies who provide services to families and children or who may be involved in the investigation of child deaths. The Team also appoints special advisors whose areas of specialization provide additional insight to the Team.

 

The Team is chaired by the Chief Medical Examiner and includes the following persons or their designees:

• Commissioner of Behavioral Health and Developmental Services
• Program Manager for Child Protective Services, Virginia Department of Social Services
• Superintendent of Public Instruction
• State Registrar of Vital Records
• Director of Criminal Justice Services

 

One representative from each of the following is appointed by the Governor to serve for three-year terms:

• Local law enforcement agencies
• Local fire departments
• Local departments of social services
• Medical Society of Virginia
• Virginia College of Emergency Physicians
• Virginia Chapter, American Academy of Pediatrics
• Local emergency medical services providers
• Attorneys for the Commonwealth
• Community services boards

 

In addition, special advisors are appointed to the Team based upon their area of expertise and include representatives from:

• Child advocacy
• Child psychiatry
• Forensic pathology
• Public health
• Juvenile justice
• Toxicology

 

Additional details about the child fatality review team, along with data and reports, can be found here.