The 2016-2020 priority need related to child health was to promote developmental screening and appropriate follow-up to support the developmental, social-emotional, and physical health needs of children. Programmatic efforts from FY2019 aimed at addressing this priority need are discussed below.

Increase Number of Children Receiving Developmental Screening

NPM 6 addresses the need for developmental screening in children, so it is most related to this priority need. Minnesota’s annual objective for 2019 related to developmental screening was that 52.5% of children (ages 10-71 months) received screening using a parent-completed screening tool. FY2019 utilized data from the 2017-2018 NSCH. According to that survey, around 58.5% of children (9-35 months) received parent-completed developmental screening (see Figure 1). This is an increase from the 2016-2017 NSCH data (FY2018 Annual Indicator), which showed around 51.3% of children receiving screening. Statewide activities undertaken to help influence this increase are described in detail below.

Figure 1. Percent of Children (9-35 months) who Received Parent-Completed Developmental Screening (NPM 6)

The five-year Action Plan objectives related to the developmental screening NPM focus on increasing developmental and social emotional screening during well-child visits. Data from the NSCH includes a small sample size, so these objectives are measured using Medicaid billing data, which reports on the percentage of children who had at least one Child and Teen Checkups (Minnesota’s Early Periodic Screening, Diagnosis and Treatment [EPSDT] Program) visit. Though it can provide insight into screening occurring in well-child visits, the accuracy of this data in measuring screening in Minnesota is limited by several factors, including:

• Only Medicaid-eligible children are included.
• Only screening that is billed for is captured (anecdotal information indicates many clinics providing screening do not bill for it).
• Changes in billing codes over time may make data from year to year incomparable.

As shown in Figure 2 below, the developmental screening rate for children (0-60 months old) who had at least one C&TC visit during calendar year 2018 (the most recent full-calendar year data) was 42.5%. This is an increase from the 2017 calendar year rate, which was 38.2%. Figure 3 shows that for calendar year 2018, the mental health (social-emotional) screening rate for children and youth (0-20 years old) was 33.3%. This was an increase from the 2017 calendar year rate, which was 21.8%. Though annual targets were not set for the developmental and social emotional screening rates, a five-year target was established based upon baseline data from calendar year 2015 (i.e., target was a 10% increase from the 2015 baseline screening rates). As indicated in the figures below, the five-year targets for both developmental and social-emotional screening were met. More specifically, the target for developmental screening (42.2%) was met this year, and the target for mental health (social-emotional) screening  continued to increase past the target of 14.9% set in 2015.

Figure 2. Developmental Screening Rate for Children (0-60 Months) Who Have had at Least One C&TC visit

Figure 3. Mental Health (Social-Emotional) Screening Rate for Children (0-20 Years) Who Have had at Least One C&TC visit

During FY2019, strategies for increasing the percentage of children receiving developmental screening focused around the four areas discussed below.

Strategy A. Promoting Best Practices in Developmental Screening

Providing Consultation and Training for Minnesota’s Child and Teen Checkups (C&TC) Program

A continued strategy in FY2019 was providing consultation to DHS (Minnesota’s Medicaid agency) on policy to help drive improvements in developmental and social-emotional screening and referral for Minnesota’s C&TC program, which is the state’s EPSDT benefit. DHS has an interagency agreement with MDH to provide consultation, training, and technical assistance to DHS, C&TC providers, and others across the state who provide child preventive health screenings and referral. This includes coordinating web-based and in-person trainings for health care providers.

• Online Information Sharing: C&TC providers have access to robust information online about developmental and social-emotional screening of young children. Table 1 shows the website activity in this reporting year.

Table 1. C&TC Website Activity

• Online Learning: C&TC providers also have access to an online learning platform for developmental and social-emotional screening. In FY2019, there were 30 learners who completed this course, including physicians, nurses, medical assistants, and community screeners.
• In-Person Trainings: C&TC in-person trainings include information on developmental and social-emotional screening and referral, and other screening components. Training on postpartum depression is also offered. During FY2019, in-person trainings were provided across the state to health systems, individual clinics, and in partnership with conferences – in total reaching over 130 physician providers. In-person trainings were provided in collaboration with MDE to over 150 professionals who are responsible for developmental and social emotional screening for children 3 to 5 years. There were in-person trainings to 5 different advanced practice nurse practitioner programs, reaching over 70 people who will be entering provider practices and providing developmental and social emotional screening. Finally, there were 3 in-person trainings to over 50 public health nurses, tribal and community outreach workers to educate on the importance of screening and discuss how to engage families to participate in the C&TC program.

Training family home visitors on screening

Minnesota focused efforts specifically on training partners from LPH, tribal health, and community-based non-profit agencies on the Ages and Stages Questionnaires® (ASQ). The ASQ® is a reliable and accurate tool for developmental and social-emotional screening for children between birth and six years old. MDH FHV public health nurse consultants provided training on the ASQ®-3 and the ASQ®:SE-2 to local home visiting staff. The majority of these trainings are conducted via live webinar but in FY2019, two small in-person ASQ®-3/ASQ®:SE-2 combined trainings were provided for individual agencies per special request. Live WebEx trainings in FY2019 included five on the use of the ASQ®-3, and five on the use of the ASQ®:SE-2. A total of over 100 home visitors were trained in the ASQ®-3 and nearly 150 trained in the ASQ®:SE-2. Home visitors across the state in 87 LPH home visiting programs, 9 tribal health departments, and 21 non-profit agencies provided ASQ-3 and ASQ®:SE-2 screenings to participants in FHV programs. ASQ®-3 and ASQ®:SE-2 screenings are required elements of the evidence-based home visiting models implemented by many of these home visiting programs. In FY2019, 13,791 families were served through home visiting programs in Minnesota. Providing these trainings on best practices in screening ensured many children in Minnesota received appropriate screening.

Implementing Minnesota’s Follow Along Program

MDH oversees the state’s Follow Along Program (FAP), which is an early childhood developmental and social-emotional screening system delivered through LPH departments for families with children birth to 3 years of age. The program provides families periodic guidance on early childhood developmental and social emotional milestones, access to age-appropriate ASQ®-3 and ASQ®:SE-2 intervals, timely referral to assessment/evaluation and community services, and follow up to assure connections have been made. During FY2019, over 21,000 children participated in the FAP, with 27,500 screens completed.

FAP staff from LPH agencies are brought together regionally, either in-person or by the phone, on a quarterly basis to receive training and technical assistance. During the meetings, LPH learn about updates on the ASQ®-3 and/or ASQ®:SE-2 instruments, participate in discussions receiving case studies, and receive overall program guidance.

During FY2019, a focus of the FAP was ensuring that children who are identified at-risk do not fall through gaps in the early childhood system. A particular gap occurred when children were identified with a developmental concern and referred to the state’s Part C – Infants and Toddlers with Disabilities Program (through the Individuals with Disabilities Education Act (IDEA)), but were not found to be eligible for services. Though these children did not need early intervention services, they were at-risk of needing services if the concern did not resolve itself over time. To help solve this problem, MDH and local FAP staff worked with the Minnesota Department of Education to work on referring these children back to the FAP to continue periodic monitoring. Several LPH agencies also tested new models of the program to offer ongoing periodic screening and developmental guidance until kindergarten entrance for children that had received beyond-the-cut-off screening scores during their first three years.

An additional focus during FY2019 was increasing collaboration between local FAPs and FHV programs. As the state’s capacity to offer evidence-based FHV services has expanded, additional collaboration between the FAP and FHV services has been essential to assure that the program standards are complimentary to each other. Local agencies have identified data components that are routinely shared to assure that screening scores, referrals, and follow up information are shared appropriately among public health staff. In addition, web-based trainings were held quarterly for FAP and FHV on the use of specific instruments, such as the ASQ®-3 and the ASQ®:SE-2, and quality improvement and practice changes to support efficient, accurate, and family-centered screening and referral practices.

Promoting an Infant Mental Health Module

A key strategy area to improve access and quality of developmental screening in Minnesota is developing and promoting trainings on the topic for health care providers and LPH staff. Minnesota’s evidence-based strategy measure (ESM 6.2) related to developmental screening falls within this strategy area, and measured the number of pediatric residents from the University of Minnesota (U of Minnesota) Medical School that completed the online modules on infant and toddler mental health. The original intent of the ESM was to offer the online modules to a variety of primary care providers across the state, such as pediatric nurses, pediatricians, and family practice physicians. However, the U of Minnesota has the ownership of the module, and attempts to make it accessible to the public were not successful. Minnesota was successful in achieving the FY2019 ESM target to have 50 health care providers or trainees complete the module (see Figure 4). Fifty-two pediatric residents completed the online module, and the medical school plans to continue offering this module to all residents that rotate through the pediatric curriculum (1-2 residents per week). They are also compiling a research paper that highlights the success of this module development, including pre- and post-testing results. Staff from the state’s EPSDT outreach program will continue to work with the University of Minnesota to make the online module available to statewide pediatric primary care providers.

Figure 4. Number of Providers and Trainees who Completed Online Module on Infant Mental Health (ESM 6.2)

Efforts to enhance the state’s infant mental health professional development opportunities were also included in the work of the Preschool Development Birth through Five Planning Grant (PDG). In partnership with the Minnesota Departments of Education and Human Services and the Children’s Cabinet, MDH contracted with the National Childhood Traumatic Stress Network and Duke University to create a trauma-informed toolkit. The toolkit included trauma-informed curricula and resources that focus on early childhood development and transitions – mapping these resources to the eight competencies identified in the Knowledge and Competencies Framework for Early Childhood Professionals. Ongoing efforts to implement early childhood trauma-informed training across health, human services, and education providers will continue during the state’s PDG Implementation Grant through December 2022.

Strategy B. Collaborating with State Agencies in Implementing Expanded Help Me Grow

Minnesota’s current Help Me Grow system (the intake process related to Part C and Part B/619 of the Individual’s with Disabilities Education Act) is dedicated to referring young children with developmental and social emotional concerns to early childhood special education services. A referral to Help Me Grow does not typically connect families to additional services that may be beneficial to their current situation. As a result, many families face the complex and often challenging prospect of navigating the early childhood system on their own, leading to preventable inefficiencies and service gaps.

The Minnesota Departments of Health, Education, and Human Services, in partnership with the  Children’s Cabinet, continue to work to create a robust, online navigator that will help families learn about and access early childhood and prenatal supports and services for optimal health and development. In FY2019, the efforts to expand the state’s Help Me Grow system were renamed to Minnesota Help Me Connect. The change was made to assure that the current Help Me Grow identity to connect children to Part C and Part B/619 services remained intact, and to avoid confusion for local early childhood providers and families accessing the new navigator.

MDH supported the second year of an interagency agreement that was established to fund and develop a statewide, continuously updated, online navigator: Minnesota Help Me Connect. Extensive early childhood and prenatal resources were modified and added to an existing resource database, MinnesotaHelp.info. The navigator test site was built in early FY2019, and focus groups and individual interviews were conducted throughout the year with various early childhood providers across the state, including the eleven Tribal Nations, such as primary health care providers, LPH, child protection services (CPS), Head Start, and early education programs. Help Me Connect will be initially marketed to help providers connect pregnant people and families with young children (birth – 8 years old) with services available in their communities. Providers will be able to make referrals and receive follow-up information that a family has been connected to services that support their child’s healthy development and family well-being. The navigator will be available for anyone to use, including families, but efforts to design a family-friendly Help Me Connect front page will occur after the first year of implementation. Minnesota Help Me Connect is scheduled for launch in early October 2020. MDH Title V staff led the cross-agency Help Me Connect planning and technical teams, and will continue to provide oversight to the Help Me Connect system into the future as the efforts move forward with the PDG Implementation Grant through December 2022.

Strategy C. Exploring Sustainability/Funding for Electronic Developmental Screening

Providing electronic access to developmental and social-emotional screening to families continues to be a priority among state and local early childhood partners as we identify strategies to assure all children are receiving recommended screening guidelines. Continued review and evaluation of electronic screening efforts in Minnesota and nationwide have been ongoing in order to understand if there is a system available that meets the needs of the state’s screening agencies and their families. Three LPH agencies have used two electronic screening systems over the past year. Dakota and Morrison Counties have implemented the ASQ® Online system through Brookes Publishing, which has allowed electronic screening implementation for FHV and FAP. The Dakota County screening system has been built to interface directly with the county’s public health data collection system, as well as a larger early childhood data system shared between local health and education programs. Unfortunately, the staff implementing the Morrison County system struggled to maintain the day-to-day functions of the system and decided to discontinue their subscription mid-year until they could identify adequate and sustainable staffing to reevaluate their next steps. Horizon Public Health made impressive advancements in using the Patient Tools electronic screening system, including customization and integration with the existing FAP software. MDH staff routinely connect with the Horizon screening team and the technical vendor to learn about new enhancements and review next steps for implementing a statewide comprehensive electronic screening system.

MDH has continued to work with the Brookes Publishing team and the MDH legal team to amend the ASQ® Online system’s license agreement and technical policies, which will allow MDH to partner with LPH and human services agencies to test the ASQ® Online system. Final amendment language was approved in late 2019. During the PDG Needs Assessment, electronic screening access was identified as a priority to include in the Help Me Connect navigator. Funding to support inclusion of the ASQ® Online system in the navigator will be supported during the PDG Implementation Grant through December 2022, and ongoing funding for the electronic screening system is included in state agency discussions as legislation is considered.

Strategy D. Promoting and Measuring Fluoride Varnish in Children

In acknowledgement of the importance of screening and treating the whole child, a commitment was made by MDH to increase the use of oral health tools and techniques as part of the Child and Teen Checkup. Data from the federal Centers for Medicare and Medicaid Services (CMS) from state fiscal year 2018 demonstrated that the percentage of Minnesota Medicaid eligible children (5 years and younger) who received oral health care by a non-dental provider increased significantly as compared to state fiscal year 2017, and continued to increase for state fiscal year 2019 (see Figure 4). This increase is largely attributed the requirement that C&TC medical providers apply fluoride varnish at well child visits for children 5 years and under, as of October 1, 2017.

Figure 5. Oral Health Care by Non-Dental Providers for Minnesota Medicaid-Eligible Children

FY2019 efforts to promote fluoride varnish application during the C&TC visit was accomplished through in-person training and on-line information sharing.

• Online Information Sharing: C&TC providers have access to robust information online about oral health and fluoride varnish. There were over 450 unique visits to the web page between January 2019 and September 2019.
• Online Learning: C&TC providers also have access to an on-line learning platform for oral health and fluoride varnish. During FY2019, there were 15 learners who completed this course, including physicians, nurses, and health educators. In addition, training modules on oral health and fluoride varnish application were developed in 2018 in collaboration with the MDH Oral Health Program for students in the Metro State Bachelor of Nursing Program. During the 2018-2019 school year, an estimated 70 students completed the modules.
• In-Person Trainings: C&TC in-person trainings include information on the best practices of all screening components including oral health and fluoride varnish. In FY2019, trainings were held across the state for providers, health care systems, and community outreach workers, and reached over 130 people.