Domain: Child Health

Reporting for October 2021-September 2022

Objective

By 2025, increase the percentage of children receiving developmental screening by 10%.

National Performance Measure

(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.

The 2020-2021 National Survey of Children’s Health (NSCH) shows that 48.7% of children living in Minnesota, ages 9-35 months, received a parent-completed developmental screening. This is same rate seen in the 2019-2020 NSCH. Our target for FY2022 was 49.9% of children will receive a parent-completed development screening which means Minnesota did not met its goal for FY2022.

Evidence-Informed Strategy Measure

(ESM 6.1) Percent of developmental/social-emotional screens that were completed electronically through the Follow Along Program (FAP) in the past year.

Minnesota is tracking the percent of screens completed through the FAP that were completed using an electronic platform rather than being completed on paper. The FAP uses the Ages and Stages Questionnaires (ASQ) to assess a child’s social-emotional (ASQ®:SE-2s) and general development (ASQ®-3s). Because data on the FAP is collected on a schedule based on the state fiscal year, this ESM will utilize that timeline (i.e., July 1, 2021 – June 30, 2022).

During the FY2022, a total of 16,089 screens were conducted through the FAP, of which 997 were completed electronically. This means that approximately 6.2% of the screens were conducted electronically, which is up from 2.6% in FY2021.

Community-Identified Priority Need: Comprehensive Early Childhood Systems

Minnesota is focused on enhancing coordination and connections between families and services across a multitude of early childhood settings, to ensure that Minnesota has inclusive systems that link young children and their families to all the support and services they need.

Every family should have an equal opportunity to access health care, mental health services, early care and education, and local services and resources that are culturally honoring and support health, development, and safety. However, Minnesota faces significant challenges in implementing a coordinated, equitable, and efficient system of care for children and their families. The array of early childhood programs is complex and fragmented, due in part to differences in the way programs are funded and variations in their eligibility and other requirements, making the early childhood system in Minnesota difficult to navigate.

This complexity is especially troubling as we know that health inequities start early in the lifespan in Minnesota. Policies and practices rooted in structural racism have prevented Black, Indigenous, and People of Color (BIPOC) from having a fair life start, and this is reflected in the racial disparities seen in Minnesota’s:

• Poverty rate (100% Federal Poverty Level) – 13.3% of African American/Black, 19% of Asian and Pacific Islander, and 44% of American Indian children in Minnesota are living in poverty compared with only 7.1% of white children.[1]
• Economic and food assistance rates – 78.3% of African American/Black and 76.4% of American Indian/Alaska Native kindergarteners received economic assistance and/or food assistance, while only 20.5% of white kindergartners received assistance.[2]
• Infant mortality rates experienced by American Indian and African American families – 14.3 and 9.2 per 1,000 live births respectively, compared to 3.8 for white infants.[3]
• The developmental screening rate for children (0-60 months old) who had at least one C&TC visit (Minnesota’s Early and Periodic Screening, Diagnostic, and Treatment Program) during calendar year 2021 was 43.4%. This is a slight increase from the 2020 calendar year rate, which was 43%. However, both years are a decrease from the 2019 calendar year rate, which was 44.5%.[4]
• Developmental and social-emotional screening rates – Medicaid-eligible children in Minnesota have lower rates of screening at well-child visits than recommended, with American Indian and white children consistently having the lowest rates compared to children of other races. American Indian children has a screening rate of 34.1% while white children have a rate of 40.2% as of 2021. This is opposed to the rate of 44.1% of Asian-Pacific Islander and 46.1% of African American/Black children receiving developmental screening.[5] White and American Indian children are more heavily represented in rural areas, where rates of screenings are lower.
• Covid-19 Pandemic Impact – Minnesota has seen both reading and math proficiency scores go down during the Covid-19 pandemic. In 2021, 48.7% of 3rd graders had proficient reading scores, while 57.4% had proficient math scores. Both are down from 2019, where 54.8% of Minnesota 3rd graders had proficient reading scores, while 65.7% had proficient math scores.[6]
• Out-of-Home Care – As of 2020, American Indian children in Minnesota were 16.2 times more likely to experience out-of-home care than white children in the state (based off Minnesota population estimates from 2019).[7]

These same policies and practices rooted in structural racism prevent American Indian children and children of color from accessing equitable educational opportunities – starting in early childhood. Minnesota’s children are not guaranteed access to early childhood education; this education is most often financed by parent’s tuition payments to private programs, with large income disparities by race, which further disadvantages BIPOC children. Additionally, both math and reading proficiency is much lower for American Indian, Hispanic, and African American/Black children, with reading proficiency at 24.4%, 27.1%, and 26.1% respectively. This is compared to reading proficiency of White children, which is at 56.9% as of 2021. A similar trend is seen with math scores, with American Indian, Hispanic, and Black children having 27.9%, 30.4%, and 25.7% math proficiency respectively, compared to 68.5% for white children.6

Many projects and grants over the last ten years have worked to develop and improve comprehensive early childhood systems across government agencies in Minnesota. Formal recommendations in 2016 from local partners to the state, along with the results of an audit by the Office of Legislative Auditor in 2018, confirmed the need for a centralized system for resource navigation, referral and follow-through, and documentation of gaps and barriers in the system. During the recent Preschool Development Birth to Five Grant (PDG) needs assessment and strategic planning process, parents and providers shared their perspectives on the current assets and barriers that impact families who are experiencing racial, geographic, and economic inequities. Recommendations gathered through the Title V Needs Assessment confirmed the importance of this work and elevated this as a priority for MDH and stakeholders to focus on in the 2020 Title V five-year needs assessment.

Additionally, in 2019, Governor Walz and Lt. Governor Peggy Flanagan, re-launched Minnesota’s Children’s Cabinet, originally established in 1993, with the commitment to “Placing Children at the Center of Government”[8]. Minnesota’s Children’s Cabinet is an interagency partnership of 22 state agencies working to bring efficiency and effectiveness to state government efforts to improve child and youth outcomes. The Cabinet utilizes a results-based accountability lens in these priority areas:

• Healthy Beginnings (addressing infant and maternal mortality)
• Child Care and Early Education
• Mental Health and Well-Being
• Housing Stability.

“The Cabinet works to take data-driven and results-oriented approach to coordinating, streamlining programs, aligning strategies, and promoting action and accountability of Minnesota’s efforts to ensure that each and every Minnesota child, no matter race or zip code, is prepared to be a leader of tomorrow.”[9]  

In Minnesota, public health and human services operate under local control with services delivered at the county- and tribal-level in Minnesota’s 87 counties and 11 tribal nations and communities.  Similarly, early education intervention services for infants and toddlers with special health care needs and their families operate in over 300 independent school districts. Tribal nations offer culturally relevant services but are often unknown or ignored as potential referral resources by outside providers. Anecdotes from statewide providers consistently indicate that services are unavailable, unknown, or hard to access, but there is no statewide data that defines actual service gaps and barriers.

Strategies and Activities

A.  Strategy A: Coordinate Access to Comprehensive, Family-Centered Early Childhood Services

1. State Level Activities
   1. Coordinate the Release, Evaluation, and Sustainability of the Minnesota Help Me Connect (HMC) Online Navigator and Referral System

HMC is an online navigator that connects expectant families and those with young children birth to 8 years of age with services in their local communities that support healthy child development and family well-being. This tool was fully launched in 2021 in response to community identified needs to support providers in identifying resources in their community as they worked with children and families. Since the launch of HMC in May 2021, the navigator has consistently welcomed around 11,000 unique visitors per month to the site in their search to find local early childhood and family well-being services and is being used throughout all regions of Minnesota, as well as neighboring states. The most searched for resources by topic area are autism, housing, transportation, and diapers.

The state has hosted over 150 trainings for providers who are working with families, including staff from local public health, child welfare, early education, mental health, Head Start, and health care. Five on-demand videos are now live to support training needs and individually tailored sessions are available upon request. During the reporting period, enhancements have been made routinely based on user analytics and feedback from providers and families. Over 1000 new resource listings were added during 2022 and the development of a new section to support expectant families and a restructure of the American Indian Families section are underway. The site was also translated into Spanish, Somali, and Hmong. Karen language translations are being reviewed and will be live soon. Minnesota also increased marketing efforts around HMC. From July 1 to September 30, 2022, the HMC Facebook ad campaign garnered 330,237 impressions and the Instagram ad campaign had an additional 120,304 impressions, resulting in 1,619 clicks to the website. Additionally, a Google search campaign brought in 24,308 impressions and 1,346 clicks to the website. A large-scale communications and marketing campaign will occur in 2023 to build off this work.  

2. Collaborate with the MDH Center for Health Equity staff to implement the Community Solutions for Healthy Child Development Grant Program

In 2020, 23 organizations, nine of which are Tribal Nations or American Indian serving-organizations, were awarded funding from the Community Solutions Fund (CSF) to complete a variety of projects from supporting doulas, expanding dental services, Indigenizing the state’s early learning standards, supporting fathers, and more. Each grantee determined a unique challenge in their community and is advancing community-based, culturally grounded solutions. The grants were also an opportunity to learn from a BIPOC community-based advisory council who has been a part of every step of the process from RFP development to review and selection of grantees, and now to providing support for grantees and sharing learning on equitable grantmaking with state leaders.  

The Community Solutions Advisory Council meets monthly and spent much of FFY 2022 drafting recommendations to the state on how to make the grantmaking process more equitable. They are also leading sustainability efforts with current funding slated to end June 30, 2023. Grantees also participated in biannual grantee meetings and had the option to participate in several evaluation activities, including a storytelling workshop to help them craft the stories of their work to help support their programs.  

Based on evaluation results released at the end of FFY2022, the CSF’s success is due in large part to three key ingredients: 

• Whole person health approach: CSF-related policies and practices have aligned around a whole-person health approach, whereby people are supported across multiple dimensions and through coordinated services so they can achieve wellness.  The whole-person approach has encouraged CSF grantee organizations and stakeholders to develop successful interagency partnerships and enabled them to better serve local families.  
• Community-centeredness: The CSF has centered local communities throughout the whole process of developing, implementing, and assessing CSF initiatives. By being community-centered, the CSF and its grantees have effectively identified and leveraged local assets, priorities, and cultures. 
• Tailored grant-making practices: CSF has greatly benefited from the state’s flexible grant-making practices, which have supported grantees in developing culturally responsive, community-specific solutions and strategies. 
  3. Champion Minnesota’s Integrated Care for Early Childhood Initiative

Minnesota is a recipient of an Early Childhood Comprehensive Systems: Health Integration Prenatal-to-Three Program grant from HRSA. Minnesota’s project, titled the Minnesota Integrated Care for Early Childhood Initiative (MN-ICECI), is a community-led, collective effort to improve identification of developmental concerns or needs in young African American children (ages 0 – 3 years old) so that they can be linked with needed supports and resources to ensure better childhood and lifelong outcomes. The project started in August 2021, and its goals include:

• Community-Driven Leadership: Cultivate and support a community-driven leadership structure where problems and solutions are defined by, and decision-making power is shared with the community.
• Shared Understanding and Vision: Build a shared understanding and vision of gaps, assets, and opportunities in achieving an equitable early childhood system that is inclusive of the health system.
• Health System Capacity: Increase health system capacity to serve young African American children and their families.
• Financial and Policy Strategies: Identify and carry out innovative financial and policy strategies to support implementation and sustainability of efforts.
• Advance Equity: Increase Minnesota’s capacity to advance equitable access to services and supports for young African American children and families.

During FFY 2022, MN-ICECI:

• Contracted a community-based research and evaluation firm, to facilitate the launch of the MN-ICECI Community Advisory Council. The contract firm, known for its experience working with the African American community in the state, including the state’s Integrated Care for High-Risk Pregnancies initiative, gathered the first Advisory Council meeting on April 6, 2022. The purpose of the initial meeting was to convene a variety of community partners with potential interest in the goals of the initiative, orient them to the work, and assess their interest in serving on the council for the five-year project period. The Advisory Council continues to meet quarterly to guide the initiative through its stages of work.
• Contracted with a local social justice focused research and evaluation firm to begin work on a comprehensive, equity-focused systems assessment. The contractor engaged with the Community Advisory Council to identify guiding principles for the work and has been provided the various needs assessment, surveys, and evaluations that have been conducted for other early childhood work in the state. Given the work that has been done on other early childhood projects, the state and the Community Advisory Council have a good understanding of what gaps and needs exist within our early childhood system. The intent of the systems assessment, therefore, is to explore “why” these problems exist – digging into root causes of the problems and coming up with solutions to resolve those root issues. Conducting the systems assessment to understand the landscape of the state’s early childhood system and its impacts on African American families with young children (ages 0 – 3 years old) will lay the foundation for the MN-ICECI Strategic Plan.
  4. Collaborate with the Preschool Development Grant (PDG) Team to implement Community Resource Hubs

Minnesota has 12 contracts, and one non-funded collaborative partnership, for implementation of Community Resource Hubs – organizations across the state that act as a single location and human connection for pregnant and parenting families looking for services. Community Resource Hubs, through the PDG:  

• Make it easier for families to get what they need through development of universal access to and navigation of culturally appropriate, relationship-based programs and systems.  
• Increase access to services for families and providers through collaboration of state agencies to test and evaluate HMC’s use in and by communities.  
• Grow community engagement and support community-developed solutions that are unique – solutions that look and feel different in every community.  

Site partners for the 12 grantees include community action agencies, Tribal Nations, counties, community childcare centers, and other community-based organizations. They each offer direct services and exact services that vary by location with a variety of implementation models. More about each Community Resource Hub is available on the Community Resource Hubs Locations and Biographies web page.

To foster relationships, networking, and multi-directional learning, grantees, site partners, non-funded partners, and state agency partners participate in monthly communities of practice, quarterly networking meetings, reflective mental health consultation, technical assistance office hours, and more.

Preliminary results from the pilot include:   

• As of September 30, 2022, Hubs have served 9,528 families. This includes 8,475 parents, 478 guardians, 312 grandparents, and 263 other caregivers.  
• Hubs have developed tailored recruitment and outreach strategies to engage families.  
• All Hub activities will continue through June 30, 2023.  
• Family navigators were hired and have made hundreds of successful referrals to services and supports for families.
• The most frequent services sought by families during the reporting period were food (20%), childcare needs/access (15%), financial assistance (13%), and affordable housing (13%). 

Hubs have built capacity for trauma-informed approaches through participation in Infant and Early Childhood Mental Health Consultation to support the mental health needs of children and families they serve.

B.  Strategy B: Maximize and Increase Funding to Support Statewide Programs that Serve Families Who are Pregnant and Parenting Young Children

1. State Level Activities
   1. Increase Access to Developmental and Social-Emotional Screening and Follow-Up

Follow Along Program (FAP)

MDH oversees the state’s FAP, which is an early childhood developmental and social-emotional screening and follow-up program delivered through LPH departments for families with children primarily birth to 3 years of age. The program provides families periodic guidance on early childhood developmental and social emotional milestones, access to age-appropriate Ages and Stages Questionnaire®, Third Edition (ASQ®-3) and Ages and Stages Questionnaire: Social-Emotional, Second Edition (ASQ®:SE-2) intervals, timely referral to assessment/evaluation and community services, and follow up to assure connections have been made.

The FAP is partially funded via an Interagency Agreement between MDH and Minnesota Department of Education’s (MDE), Part C Infants and Toddlers with Disabilities Program. MDE serves as Minnesota’s Part C agency and provides funding to MDH to assist in implementing a comprehensive system that looks for, finds, and evaluates children who need special education. MDH uses the funding from the agreement to provide grants to LPH agencies to coordinate the FAP at the county level. MDH also provides training and technical support to the LPH agencies and manages the FAP data system.  

During state fiscal year 2022 (July 2021 – June 2022), over 16,340 children participated in the FAP, with around 18,530 screens completed. Additionally, FAP staff from LPH agencies were brought together regionally, either in-person or by the phone, on a quarterly basis to receive training and technical assistance. During the meetings, LPH learned about updates on the ASQ®-3 and/or ASQ®:SE-2 instruments, participated in discussions, reviewed case studies, and received overall program guidance. 

During FFY 2022, MDH continued work on a comprehensive, multi-year program evaluation of the FAP. This program evaluation concluded with a series of workshops where we explored the strengths and weaknesses of the current program and began to envision ways to move the program forward into the future with a more sustainable infrastructure.

Electronic Developmental Screening

Minnesota convenes an Interagency Developmental Screening Task Force comprised of MDH, DHS, and MDE staff that oversee various early childhood screening programs, including the Title V-supported programs – FAP and FHV. Providing electronic access to developmental and social-emotional screening to families has been a priority among state and local early childhood partners for the past several years in efforts to identify strategies to assure all children are receiving recommended screening guidelines. A wide array of early childhood providers is currently providing periodic or one-time screening to families with young children – there are currently seven state-administered programs across state agencies that use the ASQ®-3 and ASQ®:SE-2 instruments. In most situations, there is no communication between screening providers to share screening information that may help avoid duplication, but more importantly, to identify which children have not been screened. 

Electronic screening priorities for MDH include:

• Promoting access to the ASQ®-3 and ASQ®:SE-2. 
• Having the technical ability to integrate and share screening information between the electronic screening system and various public health reporting data systems.
• Ensuring functionality that will allow LPH agencies to collaborate with other community-level screening agencies to share screening data and coordinate referrals for children experiencing concerns. 

MDH finalized an agreement with the Brookes Publishing team in early 2020, which allows MDH to partner with LPH agencies to test the ASQ® Online system. In April 2020, MDH offered the system to counties to use for their FHV, FAP, and CPS screening programs to help remedy challenges the programs were having in providing timely screenings to families during the COVID-19 pandemic. 

2. Local Public Health and Community Spotlight
   1. Implement Family Home Visiting (FHV) Models to Support All Families with Newborns

As of 2023, an evidence-based FHV program exists in all 87 Minnesota counties and CHBs often use Title V funds to provide and/or supplement FHV services. The city of Minneapolis CHB implemented Family Connects – a short-term, evidence-based home visiting program. During FFY 2022 the program achieved full accreditation with the model and saw over 600 families directly after birth of child. Visits ranged from one to three visits and many families were successfully referred to a long-term home visiting program. The program has leveraged additional funding from the city of Minneapolis and Hennepin County to expand services to additional families.

2. Increase Access to Developmental and Social-Emotional Screening and Follow-Up through the FAP

Forty-two of the 51 community health boards receive funding to coordinate the FAP at the county level, and report using Title V funds to support these endeavors. During state fiscal year 2022 (July 2021 – June 2022), over 16,340 children participated in the FAP, with around 18,530 screens completed.

C.  Additional Related Activities

1. State Level Activities
   1. Promote Best Practices in Developmental Screening through Child and Teen Checkups (C&TC)

C&TC is Minnesota’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. Staff from the MCH section provide consultation to DHS - Minnesota’s Medicaid agency - on policy to help drive improvements in developmental and social-emotional screening and referral for the C&TC program. MDH has an interagency agreement with DHS 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 providing consultation to DHS on important aspects of developmental social-emotional, autism screening and coordinating web-based and in-person trainings for health care providers. One important DHS policy change in FFY 2022 that resulted from this collaboration was the change from maternal depression screening to postpartum depression screening and the expansion of the definition of the person eligible to receive the screening to include any care giver accompanying an eligible infant to a C&TC visit.

C&TC providers have access to robust information online about developmental and social-emotional screening of young children. Additionally, C&TC providers have access to an online learning platform for developmental and social-emotional screening. In FY 2022, there were 35 learners who completed this course, including nursing students, public health nurses, licensed practical nurses, social workers, school nurses, and medical assistants. During FY 2022, C&TC staff provided both in-person and live webinar trainings. One in-person training was provided to a clinic system with 13 medical professionals, including clinic nurses and advanced practice registered nurses . Two live webinar Best Practices trainings were provided to 23 medical professionals, including public health nurses, community outreach workers, and school nurses. There were live webinars and in-person trainings given to four different advanced practice nurse practitioner programs, reaching 58 people who will be entering provider practices and providing developmental and social emotional screening. 

2. Promote Connections between FHV and Early Childhood Systems

Minnesota promotes connections between FHV and the early childhood system to help ensure better collaboration and alignment of efforts. One way that has continued to promote connections in FFY 2022, was the FHV requirement that all grantees include an objective on developing a plan with community partners to improve integration within the early childhood system. Local agencies often address this by participating in local community inter-agency groups and meetings that focus on young children and their families. Grantees report on progress in their narrative reports and it is discussed at site visits and regularly scheduled check-in calls.  

Minnesota also focused efforts specifically on training partners on the Ages and Stages Questionnaires® (ASQ). ASQ®-3 and ASQ®:SE-2 screenings are required elements of the evidence-based FHV models implemented by home visiting programs across the state. MDH FHV public health nurse consultants provided training on the ASQ®-3 and the ASQ®:SE-2 to local home visiting staff via live webinar – including five on the use of the ASQ®-3, and five on the use of the ASQ®:SE-2. A total of 88 home visitors were trained in the ASQ®-3 and 69 in the ASQ®:SE-2. Providing these trainings on best practices in screening ensured many children in Minnesota received appropriate screening and follow up services. Currently, evidence-based FHV models are being implemented in all 87 of Minnesota’s counties through FHV grants with 24 Local Public Health Agencies, four Tribes, and 15 non-profit agencies who served 7,106 households through Evidence-Based Home Visiting (EBHV) funds in FFY 2022 – including 1,716 households served through Maternal, Infant, and Early Childhood Home Visiting (MIECHV) funds, and 5,390 households served with non-MIECHV funds, including Title V.  

3. Support Child and Adolescent Health through School-Based COVID-19 Response and Recovery Efforts

Title V staff collaborated with the Center for Emergency Preparedness and Response and received Centers for Disease Control (CDC) CDC Crisis Response Cooperative Agreement: COVID-19 Public Workforce Supplemental Funding (CDC-RFA-TP18-1802). The primary goal of the funding was to establish, expand and sustain a public health workforce to fill the gap left behind by the pandemic.   

School nurses are an identified workforce gap in Minnesota. Minnesota is one of the largest geographical states in the nation serving child and adolescent in-person education, across 2,000 public schools, accounting for over 350 school district jurisdictions where policies and budget are uniquely determined. MDH administered $6,000,000 to establish regional licensed school nurses to provide active coordination, training and technical assistance across school districts in each region, via the  Minnesota Education Service Cooperatives . Additionally, MDH administered $2,493,508 to serve 26 school-based health centers via seven grantees, one statewide organization that provides capacity building, MN School Based Health Center Alliance .

More details can be found under Strategy B of the Cross-Cutting/Systems Building – Accessible & Affordable Health Care 2022 Report.

[1] US Census American Community Survey (ACS) Microdata Sample, 2021

[2] Minnesota ECLDS, 2020-2021

[3] 2021 Minnesota’s Final Linked Birth-Infant Period Cohort Death File

[4] MDH Developmental and Mental Health Screening File

[5] Minnesota Health Care Programs Developmental and Mental Health Screening Data, 2021

[6] Minnesota ECLDS, 2020-2021

[7] Minnesota’s Out-of-Home Care and Permanency Report 2020

[8]Executive Order 19-34:  2019_08_07_19-34_tcm1055-397454.pdf (mn.gov)

[9] Children's Cabinet / Minnesota Management and Budget (MMB) (mn.gov)