For the Child Health domain, Hawaii selected 3 performance measures:

• NPM 6 Developmental Screening
• NPM 13.2 Oral Health
• SPM 4 Child Abuse and Neglect Prevention

 

Reports on progress to date for the three measures are described below.

 

NPM-6: Percent of children, ages 9 through 35 months, receiving a developmental screening using a parent-completed screening tool

 

Introduction: Developmental Screening

For the Child Health domain, Hawaii selected NPM 6 Developmental Screening based on the 5-year needs assessment. By July 2020 the state seeks to increase the number of children ages 9 through 35 months, receiving a developmental screening to 40.0%.  Aggregated data from 2016-2017 show that the estimate for Hawaii (39.1%) met the 2018 objective (33.0%). The Hawaii indicator was not significantly different from the national estimate of 31.1%. With this baseline data the state objectives from 2019 to 2024 have been updated to reflect an annual increase of one percentage point. There were no significant differences in reported subgroups by health insurance, household income poverty level, nativity, race/ethnicity, sex, and household structure based on the single year 2016 data provided.

 

Developmental screening is a continuing priority from the 2010 needs assessment. Hawaii’s Title V agency coordinates federal, state and local efforts on developmental screening, referrals, and services through the Children and Youth with Special Health Needs Program (CSHNP) Early Childhood Coordinator and the Early Childhood Comprehensive Systems Impact Coordinator.  An informal workgroup consists of representatives from the Family Health Services Division and is led by the CSHNP Early Childhood Coordinator.  Other members include representatives from:

• the Hi`ilei Hawaii Developmental Screening Program that offers developmental screening using the Ages and Stages Questionnaire (ASQ) for families of children birth through five years;
• the Maternal, Infant and Early Childhood Home Visiting Program which has home visitors working with parents to complete the ASQ;
• the Newborn Hearing Screening Program Coordinator that has the system for hearing screening of children birth through age 3;
• the IDEA Part C agency that provides services and supports for children birth to age three who have a developmental concern; and
• the Early Childhood Comprehensive Systems Impact (ECCS Impact) grant coordinator who is focusing on developmental screening of children birth through five years on Maui County.

 

Hawaii works collaboratively with medical partners, early childhood providers, and community-based non-profits who conduct developmental screening to help ensure all children who receive a developmental screening are connected to services or supports if a concern is identified.  The Hawaii Department of Health’s Strategic Plan identified developmental screening and referral to services as one of its priority areas.  Also, within the Executive Office on Early Learning’s Early Childhood State Plan 2019-2024, screening is one of the five-year priorities for collective action in the area of Family Health, Safety, and Wellbeing.  It is also a priority strategy for the Early Childhood Action Strategy, a non-profit public-private partnership, focusing on children’s issues prenatal through age eight.

 

National guidance from HRSA on best practices promotes working with health care and early childhood care/education providers since these two communities have recognized the importance of developmental screening.  Guidance from the national American Academy of Pediatrics Policy statement recommends that children are screened using a validated screening tool at ages 9, 18, 30, and/or 36 months.  Screening is part of the well-child visit per the Early Periodic Screening Diagnosis and Treatment (EPSDT).  Hawaii’s Title V works with the Med-QUEST Division, the state Medicaid agency, to report on data using the EPSDT Claims from its annual report to Centers for Medicare and Medicaid Services “Form CMS-416: Annual EPSDT Participation Report.”  The claims form tracks the number of individuals eligible for EPSDT, the expected number of screenings, and the total screens received.

 

Working with home visitors to ensure parents complete the developmental screening has also been identified as a best practice as home visitors can provide support through the screening and referral process if a concern is identified.  Another best practice is working with early childhood providers to ensure that screenings are done as part of their assessment of children’s development.  The National Association for the Education of Young Children (NAEYC) and the Head Start Performance Standards also offers guidance for their child care providers to ensure that a developmental screening is completed to identify any concerns or delays.  Hawaii is following evidence-based practices by using national program standards on developmental screening in child care. 

 

Hawaii’s five development screening strategies were developed with guidance from the federal ECCS Impact grant.  FHSD, as the state Title V program, serves as a convener and coordinator role for the strategy implementation. Title V does not directly fund program supports for the development screening strategies. The program is largely funded by the federal ECCS Impact grant with additional staffing provided by the state funded CSHNP Early Childhood Coordinator. However, Title V funded staff provide overall management, data/epi, and administrative support for the program. Updates on the five strategies is provided below.

 

The Evidence-informed Strategy Measure (ESM) 6.1 was inactivated in FY 2018 since it was completed. The new ESM 6.2 is to “Develop and implement Policy and Public Health Coordination rating scale to monitor developmental screening efforts around the areas of systems development, family engagement, data collection/integration, and addressing vulnerable populations.”

 

Strategy 1: Systems Development-Develop infrastructure to coordinate developmental screening efforts.

 

Guidelines on Screening and Referral

The Hawaii Title V agency worked with partners to develop “Hawaii Developmental Screening and Referral Guidelines for Early Childhood and Community Based Providers” (4-9-2018 version).  The purpose of the guidelines is to provide basic information for those conducting developmental screening of children ages birth through five years of age.  They are based on national resources (American Academy of Pediatrics Policy Statement of Developmental Surveillance and Screening Guidelines; the Centers for Disease Control and Prevention Act Early Campaign, Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents; Caring for Our Children; Head Start Performance Standards; and the National Association for the Education of Young Children).  The guidelines are based on a review of national and local best practices and was vetted for input from early childhood and medical providers and key stakeholders.  They are located on the Department of Health website and are meant to be shared with those who are doing screening.  These guidelines were updated in 2018 based on input from the ECCS Impact Maui team to clarify why these guidelines were developed and how they are to be used.  https://health.hawaii.gov/cshcn/files/2018/04/HawaiiDevelopmentalScreeningGuidelines-1.docx

 

Workforce Training: Conduct Community-Based Training on Developmental Screening

In order to build capacity in each community, training to providers on the ASQ was conducted on Hawaii Island, Kauai, and Maui.  Over 100 participants were trained on the use of the ASQ tool, the referral processes, and best practices on family and cultural considerations.  As a result of these trainings, Kauai implemented a pilot to conduct developmental screening through the WIC office which resulted in 50 children who received a developmental screening by the Public Health nurses.

 

Strategy 2: Family Engagement & Public Awareness

 

Work with Family Partner Organizations

Hawaii works with the Leadership in Disabilities and Achievement of Hawaii (LDAH) who receives private funding to conduct developmental screening, behavioral screening, hearing, and vision screening for children ages two through five.  Information from this organization helps to improve family engagement efforts. LDAH has learned many of its families choose not to follow up with referrals if their child has an identified concern.  Families are still hesitant to have their children labeled with a developmental delay and are afraid of the stigma that may be attached to their children.  Hawaii also continues to work with the Family Hui Hawaii who primarily conducts parent support groups. The Hui regularly conducts developmental screening with families both in their program and at community events.  The Hui has been instrumental is assisting with the development of family-friendly messages to promote the importance of developmental screening.

 

Strategy 3: Data Collection and Integration

 

Develop Internal Family Health Services Division (FHSD) Tracking System

Developmental screening and referral data were collected from FHSD programs that work with parents to assure the screenings are conducted: the Maternal, Infant, and Early Childhood Home Visiting Programs, Hawaii Hi`ilei Developmental Screening Program, and Early Intervention Section (Hawaii’s IDEA Part C Agency).  The first two programs conduct developmental screening and the third program provides services and supports once the child is identified and found eligible for services.  Data from the MIECHV Home Visiting program for 2017 showed that 258 children were screened, 18 were referred for services to EIS.  This small pilot project did verify that needed follow-up referrals were occurring between the programs. The pilot data also yielded some interesting findings regarding referral sources and trends in developmental delays, but did not generate any additional health quality improvement information. Moreover, several significant barriers were identified to establish and maintain a standardized data tracking system across the programs requiring substantial resources and expertise with questionable value. However, lessons from the pilot were used to secure the contractor and develop the scope of work for the data system used by the ECCS Impact grant service programs.

 

The ECCS Impact grant commissioned the University of Hawaii P-20 program to develop a data system to track the number of children screened, within the referral range, number of referrals made, and the number of children receiving services for the ECCS Impact providers on Maui.  Screening began in late 2018 for a total of 79 3-year olds screened; five of which who were in the referral range; all were referred for services and three were connected with services. The other three families continued with the early childhood program and received support there. Data from the ECCS Impact grant has identified that the majority of children in the program do not have any developmental concerns.  Of the five who had a concern, all were connected to services or provided support to monitor and assure their optimal development. Currently, the data system is only available to the two ECCS Impact service providers.  However, efforts are underway to explore whether the data system could be expanded to allow more Maui County providers to submit screening data on all three-year old children, creating system level data for the entire county.

 

Strategy 4: Policy and Public Health Coordination

 

New ESM 6.2 Policy and Public Health Coordination Scale

To help track and monitor progress on Title V efforts to improve developmental screening rates of children, Hawaii developed and has been using a Policy and Public Health Coordination Scale (see below). The scale reflects the activities in the NPM 6 logic model and a workplan that includes the five strategy areas: (Systems Development, Family Engagement and Messaging, Data Collection/Integration, Policy & Public Health Coordination, and Addressing Social Determinants). The strategy area for Policy & Public Health Coordination is the tracking and monitoring activity using the scale - to ensure there is an infrastructure to monitor and track activities in the remaining 4 strategy areas. Since ESM 6.1 was completed, the PPHC scale was adopted as a new ESM 6.2. The completion of the scale is self-reported by the Early Childhood Coordinator who is responsible for all the activities.

 

The total points for the scale is 30. In FY 2017, the ECC Coordinator reported a baseline of 9 points out of 30. The FY 2018 objective was set at 12. The FY 2018 indicator is 19 reflecting accomplishments in several strategy areas including systems development, data integration (ESM 6.1 completed development of the pilot internal data tracking system), and the development/utilization of this measuring scale. The FY 2018 objective was met. Hawaii is in discussions with the MCH Evidence Center to help refine the scale to improve measures of success.

 

Element	0 Not met	1 Partially Met	2 Mostly Met	3 Completely Met
Systems Development
Develop guidelines and toolkit for screening, referral and services.				x
Work with partners to develop infrastructure for ongoing training, technical assistance, and support for providers conducting developmental screening activities.		x
Family Engagement and Public Awareness
Work with families and parent organizations to develop family-friendly material explaining importance of developmental screening and how to access services.		x
Develop website to house materials, information and resources on developmental screening.			x
Data Collection and Integration
Develop data system for internal tracking and monitoring of screening, referral, and services data.			x
Develop process for on-going communication to review data findings and make adjustments for better outcomes for children and families			x
Policy and Public Health Coordination
Develop Policy and Public Health Coordination Rating Scale.				x
Conduct process for annual assessment of rating scale.				x
Social Determinants of Health and Vulnerable Populations
Develop process for identifying vulnerable populations.		x
Work with stakeholders to address supports and targeted interventions for vulnerable populations		x
Total Score	19 out of 30

 

Strategy 5: Social Determinants of Health 

 

Work with the Homeless Shelters to Identify Children with Delays

Hawaii has a growing homeless problem and recognizes that children who may be living in homelessness may be more susceptible to developmental delays.  One of the state’s largest emergency shelters, the Institute for Human Services (IHS) provides short-term stabilization through shelters that lead to permanent housing.  The ECCS coordinator has worked with the IHS Program Director to address the challenges faced by children and families whose main concerns are finding stable housing, sufficient employment, and other concrete needs.  It is understandable that these families are facing a hierarchy of needs yet want to do the best for their children but may not have the resources or time to support their child’s development.  In FY 2018, discussions were initiated with the IHS coordinator for children’s programs and a site visit is scheduled later in 2019 to assure screening services and follow-up (if needed) can be provided to this population.

 

Review of Action Plan

A logic model for Title V was modified based on the ECCS Impact Grant to include the Title V measures (NPM, ESM, NOM). Strategies were developed with consideration of other community, statewide, and national efforts.  Strategies included input from partners and additional feedback from families and providers at conferences and community events.  The major strategies for the work plan revolve around the areas of:  Systems Development; Family Engagement and Public Awareness, Data Collection and Integration, Policy and Public Health Coordination, and Social Determinants of Health.

 

 

By working on these five strategies, Hawaii plans to meet its NPM of increasing the number of children receiving a developmental screening using a parent-completed screening tool by addressing systemic challenges, working with families to promote understanding the importance of completing the screening tool, using data to address areas of concern, working on policy and public health coordination.  By addressing all areas of the logic model and rating scale, there will be consistent information and guidance to providers.  Hawaii will also be addressing social determinants of health to address areas of greatest need.  Hawaii continues to use this logic model to guide its work on strategies and activities.

 

Challenges Encountered

Challenges still remain in the areas of data, policy, and messaging.

 

Data: There is no unified data collection system on developmental screenings to monitor children who are screened, referred, and receiving service in the state.  Other states have similar challenges because there is not a data system that collects developmental screening and referral efforts.  Because of this, efforts to target communities of greatest need is hampered.  The only statewide data source that is available is through the Medicaid CMS-416 Claims Data which provides basic information on participation in the Medicaid child health program.  This information is used to assess the effectiveness of state EPSDT programs in terms of the number of individuals under the age of 21 (by age group and basis of Medicaid eligibility) who are provided child health screening services, referred for corrective treatment, and receiving dental services.  Child health screening services are defined for the purposes of reporting on this form as initial or periodic screens required to be provided according to a state’s screening periodicity schedule.  Approximately 40% of Hawaii’s children are insured through Medicaid. However, EPSDT data is not readily available to determine which communities may have challenges with screening and follow-up services. Only state-level utilization rates (from CMS Form 416) are available which is not helpful to identify disparities and target interventions.  Hawaii continues to collaborate with Med-QUEST (Medicaid agency) to address this concern.

 

Policy Implementation: There are national policies on developmental screening from both the medical and early childhood community.  As part of the Bright Futures Guidelines, developmental screening should be a part of the well-child visit and the American Academy of Pediatrics recommends developmental screening at the 9, 18, 30 or 36 months as well as annual screenings after age 3.  The primary care physician’s office is where most children younger than age five are seen on a regular and consistent basis.  Therefore, developmental and behavioral problems should be identified by the pediatrician or health care provider.

 

Parents expect their pediatricians to give them guidance on developmental issues but may turn to other community systems (child care providers, home visitors, community non-profits, family members) if the pediatrician does not fill this role. Lack of appropriate guidance and referrals may result in delays in diagnosis and appropriate intervention.  Over screening by different community systems may also lead to confusion if one provider says a child may have a delay and another provider says the child is fine. Oftentimes providers utilize a ‘wait-and-see’ approach, if a child misses a major milestone or will rescreen if there is a concern. Otherwise a child will be screened at the next interval if they are in an early childhood program or the next doctors visit.  It is especially important to recognize delays early since early intervention may improve outcomes for children.

 

Communication and coordination amongst providers are also a challenge as it may not always be clear if screening results have been shared between the screener, the referral, and the medical home. The Developmental Screening Guidelines were developed to address the lack of policy to ensure providers followed the proper protocol of engaging with families and referring if there is a concern, so the child may receive timely services and support.  Hawaii needs to make a concerted effort to promote and follow these guidelines.

 

Public Awareness on Importance of Developmental Screening: There is still a general lack of awareness about the importance of developmental screening.  The messaging around developmental screening has always emphasized the purpose to identify children who have a developmental delay.  However, consumers need information to understand what the screening entails, the purpose, and how it helps support child development.  Hawaii continues to work with family groups to address this issue.

 

Overall Impact

Hawaii has many engaged partners willing to promote developmental screening, who recognize the importance of timely access to services and supports if a delay is identified.  Both the Department of Health Strategic Plan and the Executive Office on Early Learning’s Early Childhood State Plan have identified developmental screening as a key priority.  By working together to address this issue, providers and partners are now more aware of the importance of developmental screenings using a validated screening tool and ensuring that referrals are timely and communicated with the medical home.  More work can be done to promote a more seamless system of screening and referral.

 

More effort could be made to reduce the stigma that may prevent families from seeking follow-up services for their child.  Normalizing the conversation and making the screenings part of a well-child visit or an early childhood practice, helps to ensure screenings and follow-up occur.  Partnerships with the American Academy of Pediatrics – Hawaii Chapter and Medicaid also help to share consistent information about the screenings and referrals including the availability of the online ASQ through the Hi`ilei program.  These partnerships help make a greater impact in Hawaii. With more promotion of accessible tools for families, an increase in the number of children receiving a standardized screening is anticipated.

 

Hawaii still shows a relatively high rate of developmental screening at 39.1% of parents reported completing a developmental screening tool as compared to the national rate of 31.1%.  Efforts by programs like the Maternal Infant, Early Childhood Home Visiting programs and many other early childhood programs who conduct developmental screenings may contribute to this high percentage.  However, there is still a large proportion of children who are not receiving developmental screenings; better outreach could be done to promote its importance.

 

Working with early childhood providers, efforts will continue to promote developmental screening and sharing information with the medical home.

 

NPM-13.2: Percent of children, ages 1 through 17, who had a preventive dental visit in the past year.

 

Introduction:  Child Oral Health

For the Child Health domain, Hawaii selected NPM 13.2 (children’s oral health), based on the 5-year needs assessment. Hawaii elected not to select NPM 13.1 (oral health for pregnant women), as this did not emerge as the primary concern among oral health or maternal-infant health stakeholders.

 

Aggregated data from 2016 to 2017 show that preventive dental visits among Hawaii children (84.9%) exceeded the 2018 state objective (84.0%), as well as the national estimate of 79.5%. With this baseline data, the state objectives were revised to reflect an approximate 5% improvement over 5 years. Children 1-5 years of age had a lower estimate (68.7%), compared to children 6-11 years (93.2%) and 12-17 years (90.9%) of age. There were no other significant differences by subgroup (i.e., household income poverty level, language spoken at home, nativity, race/ethnicity, sex, and household structure), based on the 2016-2017 data provided. A soon-to-be released survey of Healthy Start children also reveals Hawaii’s young children have high rates of tooth decay.

 

Although data from national surveys indicate Hawaii’s rates of oral health status and service utilization are similar to the rest of the U.S., clinical data reveal a different story. For example, a 2015 oral health Basic Screening Survey (BSS) revealed Hawaii’s third graders have the highest rate of caries in the U.S. and some of the highest rates of urgent care needs. Within this group, children who are low-income, have Medicaid coverage, and/or Native Hawaiian or Pacific Islander suffer disproportionately throughout the state.

 

A major contributor to the problem of dental disease is the lack of community water fluoridation. In the U.S., Hawaii has the lowest proportion of residents with access to the benefits of fluoridated drinking water, at 11.7%. Only Hawaii federal military bases have fluoridated drinking water.  Fluoridation efforts in the past have generated substantial public opposition. Also, despite Hawaii’s favorable ratio of dentists to residents, most of the State’s primary and specialty care providers are located on the island of Oahu (Honolulu County).  Like many states, Hawaii also has a shortage of providers willing to treat Medicaid clients. The situation is particularly acute on the neighbor islands and in low income urban/rural areas of Oahu.

 

The critical nature of Hawaii’s oral health has been reflected in the five consecutive “F” grades received by the Pew Charitable Trusts’ state report cards for children’s oral health. While not mandated, the Hawaii State Department of Health (DOH) does have statutory responsibility for assessing state dental needs and resources, planning and providing services, conducting education and training, and applying for federal funds.

 

To address the oral health priority, the Hawaii State Department of Health applied for, and received, a five-year Centers for Disease Control and Prevention (CDC) oral health state infrastructure-building grant in 2013. FHSD, the Title V agency, is the lead for oral health population-based activities and administered the CDC grant. The Department of Health (DOH) also maintains several dental clinics serving individuals (primarily adults) with disabilities and other special needs, which are administered by the DOH Developmental Disabilities Division. The infrastructure grant, however, ended in August 2018. While Hawaii did submit a new application for the next CDC Oral Health Funding Opportunity and the application was approved, is was unfortunately not awarded due to insufficient CDC funding.

 

The five NPM strategies are taken from the CDC oral health grant, but have been revised in the FY 2020 plans due to the loss of program staff and funding. Strategy updates for FY 2018 are discussed below.

 

Strategy 1: Develop program leadership and staff capacity

 

The importance of dental program leadership cannot be understated. With no local health departments or dental school, the State Oral Health Program (SOHP) is key in providing statewide leadership for critical public health surveillance, evaluation, and planning functions. In addition, given the state’s unique diversity in ethnicity, language and cultural practices, many best practices may not translate to Hawaii. The SOHP plays an important role to promote and adapt evidence-based oral health practices in both public and private settings by supporting workforce training, policy guidance, and research.

 

With the end of the five-year CDC oral health infrastructure grant in August 2018, FHSD lost staff for the SOHP, including a half-time Dental Director and Office Assistant and full-time Program Manager. The FHSD Division Chief now serves as the state dental contact. Along with the Division Chief, the Division Planner, Rural Health program coordinator, and research statistician continue to provide some support for continuing activities.

 

In 2019 the Department of Health submitted a budget funding request through the Department of Health to support the SOHP staffing and operations, but it was not included in the Governor’s budget proposal. Title V will continue to explore other funding options to support oral health activities. Title V is also contracting with community partners to complete ongoing project work. Moreover, the partnership-/coalition-building work conducted under the CDC grant has helped to re-establish the State Oral Health Coalition and network of oral health stakeholders. The Coalition continues to convene stakeholders to coordinate around policy, programing, and systems-building.

 

Strategy 2: Develop or enhance oral health surveillance

 

Following the state oral health surveillance plan, the SOHP contracted the Hawaii Children’s Action Network to conduct a statewide BSS reaching all enrolled Hawaii Head Start and Early Head Start children. A Steering committee was formed to manage/monitor project progress. Members included the State Head Start Collaboration Office, public health nursing, and the Hawaii Primary Care Association. Agreement to participate in the BSS was secured from all Head Start/Early Head Start programs in the state.

 

Technical assistance for the project was provided through a contract with the Association of State and Territorial Dental Directors (ASTDD) for project design, screener training/calibration, and report writing.  Screeners were recruited through the Hawaii Dental Association and the Hawaii Dental Hygiene Association, in addition to screeners used in the previous 3rd grade BSS. Supplemental funding for the project was awarded by the Hawaii Dental Service Foundation, the local Delta Dental affiliate. Screenings began in August 2017 and were completed in May 2018. A final report is expected in August 2019.

 

Strategy 3: Assess facilitators/barriers to advancing oral health

 

Several activities were conducted to assess facilitators/barriers to advancing oral health. An environmental scan report was completed which was contracted by the SOHP, utilizing CDC infrastructure grant funds. The report included a data review, summary of key informant interviews, and key findings and recommendations, and was submitted to the CDC.

 

A stakeholder survey was broadly disseminated electronically by planning contractor, the Hawaii Public Health Institute, to identify key issues/concerns regarding oral health and kick-off a year-long statewide action-planning processes. Additionally, Town Hall meetings were conducted across the state to capture input from stakeholders and the community with regards to oral health needs and recommendations to develop a state oral health plan. The final plan document is scheduled for release in August 2019.

 

Strategy 4: Develop and coordinate partnerships with a focus on prevention interventions

 

The CDC oral health grant required the SOHP to build partnerships throughout all its project work. Partnerships have allowed Hawaii to leverage limited resources to achieve public health functions. One major example of these beneficial partnerships is the Virtual Dental Home (VDH) teledentistry project. The project is funded by a grant from the Hawaii Dental Services Foundation. The DOH Developmental Disabilities Division’s Hospital and Community Dental Services Branch, which operates several DOH dental clinics on Oahu, is the project lead. The Pacific Center for Special Care (PCSC) at the University of the Pacific, Arthur A. Dugoni School of Dentistry provides technical assistance. PCSC created the VDH system of oral health care which has been successfully deployed in California and is being replicated in Colorado and Oregon in addition to Hawaii.  This system has been shown to reach people who do not traditionally receive dental care until they have advanced disease, pain, and infection.

 

FHSD participates on the VDH project planning team because the populations targeted are underserved children. Also, Women, Infant, and Children (WIC) services, one of FHSD’s three branches, is participating. This measure also supports FHSD’s state priority to promote telehealth in Title V programs.

 

The pilot project was completed from 2016 to 2018, with West Hawaii Community Health Center (WHCHC), a Federally Qualified Health Center (FQHC), serving as the project dental provider. The population served is low-income and underserved children aged 0-5 years old at Head Start, WIC, a Traveling Preschool, and a Transitional Housing program for homeless families.

 

A WHCHC dental hygienist and dental assistant comprise the community dental team. This team provides preventive dental services and collects diagnostic records at the community sites. Two dentists, located at the WHCHC dental clinics, review patient records that include digital intraoral photos and radiographs that are uploaded to a secured cloud site by the community team for review by the dentists.  The photos and x-rays are not reviewed in real time, but at the convenience of the of the dentists (including before and after clinic hours, and during openings in the clinic schedule). Based on the review, the dentists diagnose and complete the exam and develop treatment plans. These dentists also provide dental care to patients who are referred to the WHCHC dental clinic by the community dental team for more complex treatment.

 

ESM 13.2.2 focuses on the completion of a pilot demonstration project: “Completion of a teledentistry pilot project at three early childhood settings to reach underserved children.” The measure is tracked by a 15-item inventory of specific project activities.  The overall FFY 2018 indicator is “Yes,” since all 15 project activities have been completed. Over 500 children have received dental services through the pilot project, far exceeding initial estimates. WHCHC has been able to successfully bill Medicaid for reimbursement under the state’s telehealth parity laws at the enhanced prospective payment system rate (PPS), demonstrating the program to be cost-effective and sustainable. Moreover, the project was able to expand to include an additional site at the transitional housing program. The activity checklist is below.

 

Project Activity	FFY 2018 10/1/15-9/30/18
Demonstrate need for project and barriers/facilitators that exist.	Completed
Educate and inform community oral health stakeholders and others about the teledentistry delivery of care system and applications to Hawaii.	Completed
Develop planning committee for teledentistry projects.	Completed
Develop proof of concept for teledentistry projects.	Completed
Secure funding for three-year pilot project.	Completed
Develop program orientation for community partners, providers, and site staff to introduce concept.	Completed
Identify locations and execute Memorandum of Understanding with three pilot sites.	Completed
Develop program protocols and policies and procedures for both dental services and case management.	Completed
Develop consents and other communications to parents.	Completed
Purchase dental equipment and computer software.	Completed
Provide necessary training for providers and site staff.	Completed
Develop evaluation plan including economic feasibility analysis.	Draft Completed
Teledentistry operational at three sites.	Completed
Provide adequate case management to ensure participants establish a dental home.	Completed
Inform public of project results, lessons learned, and future considerations.	Completed, ongoing

 

A new ESM has been created tor FY 2020 that focuses on sustaining the state coalition work while Title V reassesses options to rebuild the State Oral Health Program.

 

Strategy 5: Develop plans for state oral health programs and activities

 

As noted earlier, the SOHP initiated a year-long planning process which began with stakeholder surveys, revitalizing the state oral health coalition, town hall meetings on each of the islands, and a statewide meeting in May 2018 to review a summary of community comments. The new plan identifies the concerns expressed by stakeholders, and summarizes them into four major priority areas:

• Oral Health Public Health Infrastructure;
• Community Engagement and Education;
• Oral Health Workforce Development; and
• Access to Oral Health Care for All.

 

These identified priorities provide a framework to organize collective community action to improve oral health across the state. Within each priority, overarching goals and recommendations are provided in order to address various key issues. The priorities also utilize CDC’s National Oral Health Recommendations, as well as the Healthy People 2020 Oral Health Objectives, to help establish a firm foundation to advance the status of oral health in the state.  The framework and recommendations in the plan can be adopted and implemented by oral health and dental professionals, community members, agencies, government entities, and individuals who advocate for improving oral health and health equity.  The final draft is slated for release in August 2019.

 

Review of Action Plan

A logic model was developed for the CDC oral health grant to assure progress and show where there are levers that can help move the efforts through a collective impact approach.  The logic model was modified to include the Title V measures (i.e., ESM, NPM, NOMs). With the grant ending, the strategies and logic model will be revised in next year’s report.

 

 

Overall Impact

The CDC oral health grant helped support program activities to rebuild the SOHP leadership, data surveillance system, partnerships and coalition-building activities, and capacity for assessment and planning. The grant’s accomplishments helped to elevate dental disease as an important public health issue and build community capacity to support ongoing oral health work, including rejuvenation of the state Coalition. The Coalition will continue to convene and coordinate the state’s dedicated oral health stakeholders and community-based programs.

 

These community-based efforts have also been supported through private funding including two national DentaQuest foundation grants, and locally, through several Hawaii-based foundations.

 

Challenges, Barriers

The primary barrier to progress will again be securing sustainable funding for SOHP staffing and operations. FHSD continues to explore funding options to help support ongoing public health functions including surveillance.

 

Community stakeholders have continued to support the restoration of Medicaid adult dental benefits which was the priority policy issue in 2019. A study being conducted by the state Medicaid agency will help to identify accurate estimates of funding that would be needed to restore adult preventive dental benefits.

 

SPM-4: Rate of confirmed child abuse and neglect cases per 1,000 children age 0 to 5 years.

 

Introduction: Child Abuse and Neglect in Hawaii

The five-year needs assessment confirmed that Child Abuse and Neglect (CAN) should remain a priority under the Child Domain. Even though the last high-profile case involving the death of a child due to major physical abuse occurred in 2016, CAN and child maltreatment stands as a foremost concern in the state. Community needs span the spectrum from expanded primary prevention services, to improvement in the referral system and family services.  While death due to the abuse of a child is an infrequent event, there were still 1,297 confirmed child abuse victims in 2017 in Hawaii.  By maltreatment type, 64% of victims experienced neglect or medical neglect, 31% suffered psychological abuse, 29% were sexually abused, 36% were threatened with harm, and 29% experienced physical abuse (Hawaii Department of Human Services, Child Abuse and Neglect in Hawaii, 2017, https://humanservices.hawaii.gov/wp-content/uploads/2018/06/2017-CAN-report-print.pdf).  The average rate in Hawaii per 1,000 children 2012 – 2017 was 6.5.

 

Originally, Hawaii aligned this priority with NPM 7, which addresses hospital-related injuries. However, this proved not to be a specific enough benchmark to measure progress specific to CAN prevention, given that hospital-related injuries result from many causes.  With the flexibility of the new Title V grant guidance, Hawaii elected to retain CAN prevention as a SPM, evaluated by a new benchmark (i.e., confirmed cases).

 

Certain child characteristics are associated with an increased risk of being abused and/or neglected. For example, looking at trends by age, children younger than 4 years are at particularly high-risk. In 2017, 44% of confirmed CAN cases occurred among children ages 0 to 5 years old.  Also, children with special needs (physical or behavioral health issues, including chronic conditions) are at increased risk of CAN. National studies have shown that children with disabilities are at least three times more likely to be abused or neglected than their peers without disabilities.  Statistics on the number of children with disabilities in the child welfare system are difficult to obtain. The National Child Abuse and Neglect Data System does not require states to report on the number of children with disabilities, or the types of disabilities among children who enter the child welfare system after age 3.

 

Similarly, parent and/or caregiver factors can also increase the chance a child may be a victim of maltreatment.  These include parents’ lack of understanding of child development and parenting skills, parent substance abuse and/or mental health issues, family violence including intimate partner violence, parenting stress, parents who are young, single parents, and the presence of nonbiological transient caregivers in the home (e.g., mother’s male partner).  Such precipitating factors were found in cases of confirmed CAN in Hawaii including inability to cope with parenting responsibilities (63%), drug abuse (46%), chronic family violence (15%), mental health problems (16%), spousal physical abuse/fighting (13%), alcohol abuse (9%), and lack of tolerance of the child’s behavior (9%).

 

Adverse childhood experiences (ACEs), which includes CAN, are traumatic events that occur before age 18. These are:

• Emotional abuse
• Physical abuse
• Sexual abuse
• Emotional neglect
• Physical neglect
• Mother treated violently
• Household substance abuse
• Household mental illness, including maternal depression
• Parental separation or divorce
• Incarcerated household member

 

Findings from the 2017 National Survey of Child Health found that nearly 24% of children in Hawaii experienced one or more ACEs.  For children age 0 – 5 years, almost 18.2% experienced one ACE, and 5.7% experienced two or more ACEs.  On the positive side, of the children who experienced one or more ACES, nearly 37% of their families demonstrate resilience.  Unfortunately, a larger percent of families (46.5%) do not demonstrate resilience. The presence of ACEs does not mean that a child will experience poor outcomes. Research shows that protective factors are “promotive” factors that build family strengths and a family environment that promotes optimal child and youth development. These factors include living in a supportive family environment, having social networks, parents that are employed, and communities that support parents and take responsibility for preventing abuse.

 

Hawaii’s Child Abuse and Neglect program (CANP) is part of the Family Support and Violence Prevention Section (FSVPS), one of three violence prevention programs that also includes sexual violence and domestic violence prevention. The programs work collaboratively, including pooling resources and sharing data, given the common determinants and approaches to violence prevention. The CANP is funded by the Administration for Children and Families (ACF), under a Community-Based Child Abuse Prevention (CBCAP) grant. While Title V does not directly fund CAN prevention activities, it does fund key staff including the FSVPS Section supervisor and other MCH Branch support staff including the research statistician. The goals of the program are to: 1) support community-based efforts to prevent CAN; 2) coordinate resources and activities to strengthen and support families; and 3) foster understanding of diverse populations to prevent and treat CAN.

 

Strategies to address SPM-4 and its objectives are discussed below.

 

Strategy 1: Collaborate on and integrate child wellness and family strengthening activities among programs.

 

Because families at risk of child abuse or neglect often face challenges in multiple areas of their lives, effective collaboration with a variety of service providers and systems is essential to supporting families' many unique needs. System-building efforts can create greater cross-sector partnerships, reduce duplication of services, improve service delivery systems, and increase program effectiveness.  Title V’s CANP program plays a key role within the statewide network: sponsoring state conferences, supporting state/community planning efforts, creating networking opportunities, brokering national technical assistance, leveraging funding, and convening coalitions and workgroups.

 

Within the Title V agency, CANP partners with the Domestic Violence, Sexual Violence Prevention, and Home Visiting programs, Child Death Review, Domestic Violence Fatality Review, and the Pregnancy Risk Assessment Monitoring System.  The DOH Injury Prevention program, which is external to Title V, is also a key partner. In FY 2019 CANP participated in updating of the Hawaii Injury Prevention Plan around child injury and drowning prevention.

 

The Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV Program) supports the Hawaii Home Visiting Program (HHVP) and provides voluntary, evidence-based home visiting services to at-risk pregnant women and parents with young children, particularly those considered at-risk. In fiscal year 2016, the seven home visiting programs in Hawaii made 4,407 home visits to 828 parents and children, serving a total of 429 families across all four counties. In addition, 409 new parents and children were enrolled into the program. Home visiting services are provided on all six of the major islands with services based on one or more of the following evidence-based programs – Healthy Families America, Parents as Teachers, and Home Instruction for Parents of Preschool Youngsters

 

FHSD also administers family strengthening contracts for parenting and child development services statewide, including: a telephone warm-line for parents, caregivers and service providers; the dissemination of child development information including community resources; short term in-home parenting support; and parent-child interactive parenting education groups for homeless families. The contracts provide resources and services to families to help prevent CAN.

 

To ensure statewide reduction of CAN, the FSVPS partners with neighbor island FHSD staff at the District Health Offices (DHO) on Maui, Kauai, and Hawaii Island to provide violence prevention trainings and TA. DHO staff assure collaboration and integration of CAN prevention with community-based programs and promote family engagement for child and family wellness services in their rural communities. In addition, DHO staff also participate in the Child Welfare Services Citizen’s Review Panel, contributing recommendations for continuous improvement around CAN prevention program planning and policy development.

 

Because of the complexity of risk factors relevant to prevent and reduce CAN, CANP also collaborates with diverse private and public organizations in the community, including those that directly engage in CAN work, as well as agencies addressing community concerns (e.g., housing, employment, safe neighborhoods, substance use, etc.).

 

In May 2018, CBCAP grantees were invited by the ACF Children’s Bureau to establish state teams to address CAN. Teams were to include representatives from the Department of Human Services (DHS), Child Welfare Services, the Judiciary (Family Court), and the CAN Prevention program coordinator. Convening of the state teams was in part a response to the Family First Prevention Act which moves to reform the federal child welfare financing streams, Title IV-E and Title IV-B of the Social Security Act, to better provide services to families who are at risk of entering the child welfare system. The focus is on preventing children from entering foster care by allowing federal reimbursement for mental health services, substance use treatment, and in-home parenting skill training. Since convening, the Hawaii state team has been working on creating the next five-year Child and Family Service Plan.

 

Collaboration also occurs via the Early Childhood Action Strategy (ECAS) Initiative. This statewide public-private collaborative brings together government and non-government organizations to align priorities for children prenatal to age eight, and to strengthen and integrate the early childhood system by streamlining services, maximizing resources, and improving programs to support our youngest children. The FSVPS leads for CAN, DVP, and SVP serve as co-conveners of the Initiative’s Safe and Nurturing Families Workgroup. The goals of the group are to reduce the actual cases of family violence in homes with young children, and strengthen early childhood providers’ capacity to educate families on the protective factors and refer at-risk families when needed.

 

The neighbor islands’ most robust CAN prevention collaborative is Maui’s Hoʻoikaika Partnership, a coalition of more than 60 Maui County agencies and individuals committed to preventing child abuse and neglect. Hoʻoikaika focuses on protective factors and family strengthening using a strengths-based, family-centered approach. At present, the Partnership is focusing on increasing overall awareness of CAN and expanding knowledge of the importance of protective factors in preventing CAN.  The Partnership was instrumental in providing Maui County coalition members with training and education around protective factors.

 

Other key partners in CAN prevention include the Domestic Violence Action Center, Hawaii Children’s Trust Fund, Healthy Mothers Healthy Babies, Prevent Child Abuse Hawaii, and Keiki Injury Prevention Coalition.

 

Strategy 2: Develop a child abuse and neglect (CAN) surveillance system.

 

Surveillance is vital to provide health information to guide planning, implementing, and evaluating public health practice, policy, and programming. Without consistent, reliable data it is difficult to accurately assess the magnitude of child maltreatment in relation to other public health problems, and would limit the ability to identify groups at highest risk, monitor the effectiveness of ongoing child maltreatment prevention and intervention activities, and measure changes in the incidence and prevalence of CAN over time.

 

Developing a centralized repository for public and private Hawaii CAN data could help create a clearer and accurate understanding of CAN in the islands.  The biggest challenge is fragmentation of data sources due to separate program purposes, reporting time periods, definitions, and data collection/analysis methodologies, despite the fact the programs often target the same families for services and information. Also, data standards and quality may vary considerably. Title V is committed to convene stakeholders and lead a process to identify existing and needed data, break down silos among existing data sources, and establish a statewide CAN surveillance system that will better inform prevention programs, policies, and systems.

 

In June 2018, a team comprised of the FHSD Planner, DVP and CANP program Coordinators, and a child welfare attorney consultant was accepted to participate in the 2018 Maternal Child Health Workforce Development Center (WDC) Strategic Skills Institute three-day workshop on “Leveraging Strategic Skills to Advance Outcomes.”  The purpose of the Institute was to expose teams to new thinking, tools, and knowledge, and apply this information to an issue or project. Hawaii’s issue was to support the development of a statewide child maltreatment surveillance system.  The team developed a preliminary action plan for implementation by the CANP coordinator upon return.

 

Strategy 3: Raise awareness about the importance of safe and nurturing relationships to prevent child abuse and neglect.

 

The primary activities under this strategy include engagement and awareness-building with parents and other caregivers. FSVPS programs coordinate large- and small-scale activities year-round and across all islands.  Events take place at a range of public sites such as shopping malls/centers, libraries, and parks, to maximize reach to the public. Staff provide families with resource materials and information on child development and parenting tips.  Specific examples of awareness and training activities are described below.

 

Large-scale annual events often coincide with the specific months designated to violence prevention topics.  For example, April is recognized as Child Abuse and Prevention Month.  Each year, hundreds of blue and silver pinwheels (the national symbol for child abuse prevention) are displayed across the islands at schools, military bases, government buildings, and other sites. The event is conducted in collaboration with Hawaii Girls Scouts. The Scouts learn about the risk factors associated with CAN, and the factors that can protect a child from abuse or neglect. An evaluation was conducted validating increased awareness about the issue.

 

Sexual Assault Awareness Month is also in April and includes a number of events and activities highlighting sexual assault as a public health, human rights, and social justice issue, and reinforcing the need for prevention efforts.  October is Domestic Violence Awareness Month (DVAM), with statewide activities that promote peace in families, homes, and communities. The community, supported by state, county, and non-profit agencies, organizes the Hawaii Men’s March, which is one of the major DVAM activities that seeks to bring together all those opposed to violence against women and children.

 

The Hawaii Children’s Trust Fund (HCTF) is a legislatively-created public-private partnership between the Department of Health and the Hawaii Community Foundation.  The mission of HCTF is to ensure that Hawaii’s children develop into healthy, productive, and caring individuals by promoting the advancement of community and family strengthening programs to prevent child abuse and neglect.  To accomplish their mission, the Trust has invested approximately $8.1 million in child abuse and neglect prevention programs over the years, including public awareness efforts. In 2017, the Trust funded nine community-based prevention programs focusing on young parents of young children. The programs were required to address at least two protective factors in their work. The cohort is in its final year.  Public awareness efforts focused on CAN prevention public service announcements (PSAs).  Evaluation of the PSAs included the number of “clicks” to the website, and more importantly, increase in funds donated through the Hawaii State income tax form check-off box.

 

The ECAS Safe and Nurturing Families Workgroup contracted with the FrameWorks Institute (FWI) to assist with message design for a communication campaign to build awareness of all forms of family violence - including child neglect, child abuse, and intimate partner violence.  Messages will convey a series of themes that build understanding of early childhood development and the impacts of violence on developmental and family-level outcomes, promote more effective caregiving interactions, and ultimately reduce and prevent family violence. The themes will be released in a specific sequence, working from foundational concepts (e.g., children are a shared responsibility) and simpler behavioral shifts (e.g., interact more with young children), to more complex concepts and behaviors. The messages will also be delivered from initially the most positive, non-threatening themes, followed by those potentially more sensitive and difficult to address. The plan is to begin implementation in FY 2019.

 

Strategy 4: Provide community-based training and technical assistance promoting safe, healthy, and respectful relationships to prevent child abuse and neglect.

 

The violence prevention community in the islands is well represented by private and public agencies and programs. Major stakeholders include the Hawaii Coalition Against Sexual Assault, Hawaii Youth Services Network, the State Department of Education - School-Based Behavioral Health, Children’s Justice Center and First Circuit Court, Injury Prevention Advisory Committee (IPAC), and Maui County Domestic Violence Task Force. FSVPS staff continued to strengthen partnerships through the ECAS teams by identifying areas of intersection for CAN prevention to promote healthy and welcome births, early child health and development, and access to programs and services.

 

Among stakeholders, there is a growing awareness of the co-occurrence of child maltreatment and other forms of violence. Research suggests that in 30 to 60 percent of the families where either domestic violence or child maltreatment is identified, it is likely that both forms of abuse exist.  In addition, children can suffer from a range of emotional, psychological, and behavioral problems when witnessing or being exposed to violence in the home, even if they are not the direct victim. As a result of this identified need, training and technical assistance has focused on topics such as the short- and long-term impacts of children exposed to violence, adverse childhood experiences (ACEs), protective factors, and promotion of safe, healthy, and respectful relationships. Specifically, the FSVPS has sponsored trainings addressing sex trafficking, integrating ACEs research, violence among at-risk populations including the LGBT community, cyber-sexual exploitation of minors, and the Period of Purple Crying. Trainings have expanded the community’s understanding of violence, helped inform providers about best practices, and facilitated systems coordination.

 

The Sexual Violence Prevention program sponsored several trainings from Futures Without Violence Coaching Boys into Men (CBIM) curriculum which provides high school athletic coaches with resources to promote respectful behavior among players, and helps prevent relationship abuse, harassment, and sexual assault. The CBIM curriculum consists of a series of coach-to-athlete trainings that illustrate ways to model respect and promote healthy relationships. The Centers for Disease Control and Prevention recognizes CBIM as an effective and promising prevention program.  As discussed, CAN prevention requires a long-range view, particularly for primary prevention. By learning about healthy relationships at a young age, these boys will carry forward the learned skills and behaviors into their own families and communities.

 

With respect to parent training, the Home Visiting Program provides supportive parent education and nurturing activities with the over-arching purpose of improving the health and well-being of families. Trainings focus on promoting child development, encouraging positive parenting, and working with caregiver participants to set attainable goals for the future.

 

The CAN Prevention program conducted a statewide needs assessment to identify (1) existing child abuse prevention programs on the island with  special attention on programs that serve children with a disability, (2) existing materials and resources addressing child maltreatment prevention in children and young adults up to age 30 with disabilities, (3) whether there are limitations or missing pieces in the prevention materials and information, and (4) possible training needs to raise awareness and/or increase knowledge and competencies about preventing child abuse and neglect for children and young adults with special needs. Information was collected through focus groups of parents and community-based organizations that serve children with special needs.  The information gathered is being analyzed and will be part of a CAN training assessment document.

 

Review of Action Plan

In previous years, Hawaii’s Title V child abuse and neglect prevention measure was National Performance Measure (NPM) 7.  This measure was inactivated and converted to State Performance Measure (SPM) 4 – the rate of confirmed child abuse and neglect reports per 1,000 for children, with emphasis on children aged 0 to 5 years.  NPM 7 was removed because it does not align with the strategies and activities currently employed by the Family Support and Violence Prevention programs to reduce CAN and domestic and sexual violence in the state, and therefore was not accurately capturing progress specific to CAN prevention.

 

The CAN logic model below describes an overview of current activities.

 

 

Preventing child abuse and neglect cannot be addressed as a stand-alone public health concern.  The logic model confirms the importance of acknowledging and addressing contextual conditions that impact and influence CAN negatively or positively, in tandem with programs that specifically target violence prevention.  Fortunately, CANP has a broad base of resources within the Family Health Services Division and other State Executive Departments, namely the Department of Human Services/Child Welfare Section, Judiciary, and Office of the Attorney General.  Other critical local partners include funded programs (e.g., Healthy Mothers Healthy Babies, Prevent Child Abuse Hawaii), programs under Child and Family Services, and Parents and Children Together (PACT), and the military.  National partners support CAN prevention in the islands with funding, technical assistance, and training, and they also serve as data sources.

 

Challenges and Barriers

Different grant-related mandates (e.g., funding requirements, timeframes and budget periods, use of specific indicators/performance measures and data collection methods, etc.) pose a challenge to creating an effective statewide, cross-agency/sector CAN prevention service system.  Given the complexity and scale of such a task, time and flexibility are needed to maneuver administrative barriers that are encountered.  Discussions continue with partners and stakeholders to brainstorm out-of-the-box strategies to address these challenges and continue progress toward the outcome that is very much needed to move CAN prevention forward.

 

In addition, internal procurement and administrative procedures have also impacted the timeliness of establishing contracts, MOA/U’s, and other mechanisms to procure services.

 

Overall Impact

CAN prevention is a long-standing priority within child health, which receives a high level of public support in Hawaii. As a result of advocacy efforts, a number of important bills were passed by the 2019 Hawaii State Legislature supporting CAN prevention (currently awaiting Governor’s signature).  These include: extending the period during which a victim of child sex abuse may bring civil action (will apply retroactively to April 24, 2012); authorization to disclose information regarding confirmed cases of child abuse or neglect; support for survivors of domestic abuse to relocate and keep relocation and contact information confidential; and millions of dollars to address the homeless problem.

 

Having the FSVPS Section encompass the CANP, DVP, SVP, and PSP programs under the Maternal and Child Health Branch facilitates collaboration, braiding of funds, leveraging of in-kind support, and coordination of program activities and plans. The FSVPS has well-established internal collaborations with essential programs such as Women, Infants and Children (WIC), the Children with Special Health Needs Branch (CSHNB), Development Disabilities Division, Child and Adolescent Mental Health Division, and the Statewide Council of Developmental Disabilities.  Also, long-standing partnerships with external organizations have been maintained and strengthened, knowing that these agencies deepen our reach to communities and families, including across the neighbor islands.  For example, the Early Childhood Action Strategy, composed of diverse public and private partners, developed a five-year communication/messaging plan to build awareness about all forms of family violence and promote safe and healthy family relationships.

 

On the national level, Hawaii has access to multiple sources of federal TA and resources for the prevention of child abuse and neglect including MIECHV, CBCAP, Rape Prevention and Education, and Preventive Health and Health Services Block Grants. Title V also partners closely with the DOH EMS and Injury Prevention and Control System Branch, which receives TA from both the CDC and the Child Safety Network.