Child Health

Annual Report

Priority: Reducing chronic disease burden (including obesity) among children and youth.

Obesity continues to be a national and local public health concern. More than 1 in 3 children in DC is overweight or obese. Furthermore, data indicates that significant racial and geographic disparities with regards to obesity exist. In the District, Wards 5, 7, and 8 have obesity rates higher than the national average and all U.S. states. These wards also have the highest chronic disease rates, lowest median income, and a large minority population. Though food insecurity and obesity are commonly viewed as separate public health problems, there is a growing body of evidence that shows these issues are related. A lack of access to healthy foods continues to contribute to childhood obesity and poor health outcomes in the District. In economically depressed parts of the city, smoking also remains an issue. The prevalence of smoking is 30% in Ward 8; 23% in Ward 5; and, 22% in Ward 7. Additionally, Wards 5, 6, 7, and 8 are home to a majority of African American DC residents and Wards 7 and 8 have the lowest average household incomes in the city. With increased smoking rates among the poor, there is increased health risks and chronic disease burden.

Goal 1: Increase early identification of developmental delays and linkages to care to mitigate long-term sequela.

In FY18, Title V worked with the Office of the State Superintendent for Education (OSSE) Division of Early Learning to promote the integration of an early childhood system that facilitates easy access to support services for children from birth through ages three and their families. OSSE serves as the implementing agency for Part C/ Strong Start Early Intervention Program (Strong Start). Strong Start is a statewide, comprehensive, coordinated, multidisciplinary system that provides early intervention therapeutic and other services for infants and toddlers with disabilities and developmental delays and their families. As part of the intake process, infants are assessed using the Ages and Stages Questionnaire. Three key activities in the Memorandum of Understanding were to establish a: 1) DC Early Intervention Program (DC EIP) Evaluation Team to provide developmental evaluation services for families, 2) Developmental Screening Partnership, and 3) Maternal, Infant and Early Childhood Home Visiting (MIECHV) Information and Data Exchange. DC Title V continued to provide staff oversight of the Help Me Grow (HMG) program. HMG provides services to District residents through a comprehensive and integrated system designed to address the need for early identification and resource linkage for children at risk for developmental and/or behavioral delays. DC HMG also serves as a resource and referral line for perinatal women.

During FY18, both OSSE and DC Health wanted to improve coordination between agency programs that aim to improve early childhood development, including Strong Start, newborn screening programs, Help Me Grow and home visiting programs. To encourage data sharing, OSSE DEL provided DC Health with information on MIECHV participants referred for a developmental screening with Strong Start. Title V staff worked with OSSE DEL to increase number of children receiving developmental screenings so families receive appropriate and timely services as well as to reduce duplicative services. During the reporting year, the agencies developed a new MOU that will allow DC Title V to provide funding support for additional OSSE DEL evaluation staff. Other FY18 activities included creation of an ASQ HUB that would link OSSE’s ASQ and DC Health’s ASQ Enterprise to better facilitate data sharing across agencies and promote connection to timely services. This project was delayed due to OSSE DEL lowering eligibility criteria for Strong Start services, which led to an increase in children requiring screenings within 45-days of their referral. Moreover, the team experienced infrastructure issues due to a flood and had to temporarily relocate. Although the HUB could not be established in FY18, it remains a priority for DC Title V. 

Title V continued to provide staff oversight of the Help Me Grow (HMG) program in FY18. HMG provides services to District residents through a comprehensive and integrated system designed to address the need for early identification of children at risk for developmental and/or behavioral problems and to, prenatal women. The HMG model is based on four components:

1. A centralized telephone access point for connection of children and their families to services
2. Community and family outreach to promote the use of Help Me Grow
3. Child health provider outreach to support early detection and early intervention, and
4. Data collection and analysis to understand all aspects of the Help Me Grow system

During FY18, HMG was able to collect vital data based on information collected through the centralized telephone access point through care coordination. The majority of the identified concerns for HMG DC program participants in FY18 were behavioral concerns for children in the target population range (0-5). HMG care coordinators work with families to identify the specific behavioral concerns presented. HMG understands the long-term effects that children with emotional, behavioral, and social relationship problems, as well as their families, can experience distress and suffer substantially because of these problems, if not addressed. HMG works with families to address the identified concerns using a variety of approaches, including home visiting, parenting groups and a wide range of support programs to address the family concerns.

In FY18, HMG was able to connect 67% of families seeking assistance to services. Seventeen percent of families were not connected to services due to a variety of issues that ranged from not having childcare or transportation, scheduling conflicts, lack of services available at certain organizations and caregiver follow-through. HMG DC Care Coordinators work with families, in order to address the aforementioned barriers.

The HMG team had program manager and outreach coordinator transitions. By June 2018, the new program manager worked with the team to identify challenges and solutions. Some of the challenges included, community visibility/ public awareness, long waiting list for clients to referring agencies, diverse outreach materials in languages other than English, lack of internal agency collaborations and certain limitations of the current database system. HMG expanded its outreach efforts by leveraging existing DC Health programs and services. For example, HMG connected with DC Health’s Vital Record department to conduct outreach once a month starting in September 2018. Many District residents visit the vital records department in order to obtain important documents. When residents visited vital records, HMG had the opportunity to speak with families about the program and benefits. HMG also presented to DC Health’s staff, so they could relay information about services to relevant external partners many of the challenges the program faces (ex. wait lists at other agencies, client transportation, language assistance) are beyond the scope of the program to address. The Title V staff overseeing HMG (Early Childhood Division Chief) is able to bring these issues to other agency and community based organizations through her involvement with Districtwide working groups, like the State Early Childhood Development Coordinating Council.

Title V staff also provided oversight of the DC Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) to help improve maternal and child health, prevent child abuse and neglect, encourage positive parenting and promoting child development and school readiness. During FY18, MIECHV implemented two evidence-based home visiting models – Healthy Families America and Parents as Teachers. The program targeted pregnant women and families with children under age three. In addition, the program served the following priority subpopulations: 1) low-income eligible families; 2) women who are pregnant and under 21; 3) families that have a history of child abuse or neglect or have had interactions with child welfare services; 4) homeless populations; and 5) families with children with developmental delays or disabilities. Title V staff represent DC Health (and the DC MIECHV program) on the District’s Home Visiting Council. The DC Home Visiting Council is a coalition of home visiting providers, local government agency representatives, early childhood advocates, managed care organizations and other partners working to strengthen the understanding, implementation, and sustainability of home visiting as a strategy to support positive child and family outcomes in the District of Columbia. Through the work, Title V is able to help ensure alignment among home visiting services within DC and receive feedback from stakeholders to help improve MIECHV services. For example, after receiving feedback from HV Council members about serving families with high-risk factors that lived in neighborhoods outside of the MIECHV target wards (Wards 5, 7, 8), MIECHV worked to develop a new methodology to assess the risk of sub populations more neighborhood clusters instead of wards. In FY18, the program identified four neighborhoods outside of Wards 5, 7, and 8 with disproportionate unmet needs, and worked with federal project officers to expand services to these areas. Progress achieved in FY18 included serving 259 families/323 children and providing 364 resource referrals (such as referrals to Strong Start, mental health services, tobacco cessation, health insurance, housing, breastfeeding, and child care services).

Title V staff continue to provide oversight of DC Health’s Early Childhood Place Based Initiatives, Smart from the Start and Early Childhood Innovation Network (ECIN) that are funded through local dollars.

Smart from the Start (Smart) is a family support, community engagement and school readiness organization with a mission to prevent the achievement gap, and to promote the healthy development of children living in the Woodland Terrace housing community (Ward 8) in Washington, DC. Smart works to prevent the achievement gap by preparing young children (ages 0-5) for school success, while empowering youth, families, and communities to provide the stable and supportive living conditions necessary to nurture and sustain strong, confident, and well-balanced children. Smart provides young children living in challenging environments with a combination of academic, social-emotional, and support services to ensure that they enter school ready to learn. In addition, they use a two-generational approach to combine parent and child interventions to interrupt the cycle of poverty. Smart collaborates closely with traditional and non-traditional stakeholders and partners to share resources and to problem-solve as a collective.

Families living in Woodland Terrace experience disproportionate levels of community and family violence, substance abuse, mental health challenges, teen pregnancy, and unemployment compared to other parts of the city. The DC Housing Authority provided the program with a six-bedroom unit, which was converted into program space including classrooms, a computer lab, and a relaxation space for counseling and parent support.  Smart conducts their original programing from this space and use it as an anchor space for other service providers and partners to reach families in Woodland Terrace.  Some of these partnerships include the American Federation of Teachers, DC Public Library, Howard University, PBS Broadcasting, and DC Public Schools Early Stages.

By the end of FY18, 127 families were enrolled in Smart. Enrollment means they engaged in Smart’s programing around Prenatal Education, Parenting Education, Address the Stress, Leadership Empowerment and Advocacy Program (LEAP) for fathers, and various workshops and community events held in Woodland Terrace. In particular, the Address the Stress therapy program provides participants with the option to receive group therapy, couple’s therapy, family therapy, and individual therapy.  Children receive art and music therapy while adults participate in programming. Two clinicians work in the program, facilitating group sessions and workshops and providing residents with behavioral health diagnoses, referrals, and crisis management. LEAP provides fathers of children 0-5 in Woodland Terrace with parenting information, cultural experiences, and workforce development. Fathers attend programming every day for eight weeks and receive a stipend. In FY18, 13 out of 15 participants received permanent job offers after completing LEAP.

As the startup and base year for funding from DC Health, FY18 provided the opportunity for Smart to refine their program designs through conducting community asset mapping, conducting a Needs Assessment, and receiving technical assistance from DC Health, among other activities. In particular, asset mapping identified and organized resources and programs in each neighborhood. This process was done parallel to the Needs Assessments, which described the health, developmental and social needs of children aged 0-5 and their families, living in the place-based communities, and identified where these families receive early childhood care and education, home visiting, and other prenatal and early childhood services. The Needs Assessment interviewed caregivers, youth, residents, faith-based community representatives, private sector stakeholders, agency partners, volunteers, educational institution staff, and government officials. Results revealed the need to increase the community’s knowledge of available educational resources, improve participants’ workforce readiness skills, increase assistance provided for victims of domestic violence, and create more awareness around civic events and activities. Additionally, DC Title V provided varying levels of technical assistance to Smart. This technical assistance mainly focused on assisting Smart with creating reporting and evaluation structures to ensure that their models could be replicated in other communities. Smart moved through the IRB approval process during FY18 and received approval in October 2018 to start their program evaluation. Woodland Terrace experienced several incidents of violence, which affected program participation at some points when families were not comfortable leaving their homes. DC Title V assisted Smart with identifying resources to assist with response to related trauma.

Early Childhood Innovation Network (ECIN) provides a comprehensive, coordinated place-based initiative to improve educational, developmental and health outcomes for families with children aged 0-5 in communities in Ward 8: Historic Anacostia, Berry Farm, Sheridan, and the Buena Vista. Specific project goals include increasing collaboration and coordination among neighborhood networks that serve or support families with young children (0-5) in the target neighborhoods, improving the health, education, and wellbeing of parents and their young children (0-5) living in the target neighborhoods, and increasing families’ access to resources and their sense of connectedness to other families. The program model is based upon the development and implementation of a Neighborhood Family Champion (NFC). ECIN partners with Far Southeast Family Strengthening Collaboration, Parent Watch, Total Family Care Coalition and Health Alliance Network to recruit and train NFCs, to reach families where they live. NFCs serve as social capital builders, making important contacts and connecting with families with children ages zero through five. The NFCs will utilize the ECIN mobile app to connect families to physical and mental health supports that reduce the duration and severity of maternal depression, food insecurity, and other family stressors that perpetuate poor health outcomes.

Far Southeast Family Strengthening Collaborative, Parent Watch, Total Family Care Coalition, and the Health Alliance Network, which are all grass roots community based organizations in Wards 7 and 8, are key in implementing the program. These organizations serve as senior advisors to the initiative and help develop the training program for the NFCs and ensure community ownership and voice in the asset mapping, Needs Assessment, and evaluation process. The program also collaborates with Children’s Health Center at Anacostia (CHC-Anacostia), which delivers HealthySteps. HealthySteps is a nationally recognized evidence-based model of health promotion, screening, prevention, and wellness for families with infants and toddlers. CHC-Anacostia located in Ward 8, provided an ideal setting to launch this initiative given the disparities in access to quality health care and rates of maternal and infant mortality and morbidity that exist in the surrounding communities.

As the startup year, FY18 provided the opportunity for ECIN to refine their program design through conducting community asset mapping, conducting a Needs Assessment, and receiving technical assistance from DC Health.  As a part of this process, ECIN facilitated a series of listening conversations with families, providers, and community leaders to create an informal setting to define the sources of trauma for families and to gather information regarding caregiver experiences with service systems and providers’ perspectives on the needs of families. Analysis of needs assessment data helped ECIN to identify neighborhood clusters where program efforts should be focused. Data highlights include:

• the highest percentage (35.05%) of children hospitalized for chronic conditions in 2017 resided in neighborhoods in Ward 8;
• the highest percentage (18.07%) of children who visited the emergency department resided in Wards 8;
• the highest number of families living below the poverty line (2390.6) and with single mother household (1103.9) resided in Ward 8; and
• the lowest overall education level (2094.4) (number of residents with less than a high school diploma) resided in Ward 8.

Using this data ECIN made neighborhoods in Ward 8 the official geographic areas to target for the initiative. Other start up activities included working with their partners to create a training plan for the NFCs, solidifying the NFC model, and starting the NFC hiring process.  ECIN also worked with the CHC-Anacostia healthy Steps team to develop recruitment materials and to determine how NFCs will be incorporated into the current clinical practice and workflow.

ECIN experienced challenges during the startup year including major delays with the development of the mobile app due to issues with the app developer. They plan to choose another developer to complete the mobile app. Completing development of the mobile app and rolling it out for the community to use is essential for the initiative to have its intended impact. ECIN completed the IRB approval process during FY18 and received conditional approval in May 2019 to start the evaluation. 

Goal 2: Increase the number of children and adolescents engaging in recommended daily physical activity.

In partnership with the Office of the State Superintendent of Education (OSSE), Division of Wellness and Nutrition Services (WNS), Title V continued to support local education agencies to: increase the capacity of food personnel, school staff, and organizations that collaborate with schools to promote physical activity, healthy food options, and nutrition and physical education policies; increase the number of schools providing quality nutrition and physical education/activity and meet the recommended guidelines identified by the District’s state education agency; increase the number of District schools and early care and education centers (ECEs) that have evidenced-based, research-based, and/or promising nutrition and physical education/activity programs; and improve prevention and control methods to address hypertension, diabetes, and overweight and obesity in schools. In FY18, the following achievements were reported:

• 91,537 students were enrolled in local education agencies where staff received professional development and technical assistance on strategies to create a healthy school nutrition environment 
• 65 local education agency staff received professional development and technical assistance on the development, implementation or evaluation of recess and multi-component physical education policies  
• 91,537 students were enrolled in local education agencies where staff received professional development and technical assistance on developing, implementing or evaluating recess and multi-component physical education policies
• 15 state-level multi-component physical education policies for schools were developed and adopted by the state
• 1 state-level recess policies for schools was developed and adopted by the state
• 90 ECEs adopted strategies to increase physical activity
• Due to the development of local wellness policy tools and technical assistance provided by OSSE, 34% of ECEs developed food service guidelines that impacted 4,902 children compared to 2,300 children in 2015.

The program faced challenges that impeded their overall goals. Such challenges included limited capacity and resources to serve centers in need, high staff turnover, and difficulty with receiving buy-in from stakeholders.

Goal 3: Increase access to healthful foods for children living in food deserts.

Title V continued to provide programmatic oversight of locally funded food access programs geared to serve low-income children and their families, particularly those living in food deserts: Joyful Food Markets, Healthy Corner Stores Partnership, Produce Plus Program, and Mobile Farmers’ Markets in FY18.

Martha’s Table, in partnership with the Capital Area Food Bank, launched Joyful Food Markets (JFM) in 2015 to improve food access, reduce food insecurity, and encourage consumption of fresh fruits and vegetables for families with elementary school age children in Washington, DC. The markets are held once a month in elementary schools in Wards 7 and 8 where many residents live in a food desert. At the markets, students receive up to 23 pounds of healthful foods along with targeted health and wellness education. In each school, colorful tables are filled with baskets of fresh produce and piled high with healthy non-perishable food, while festive music plays. The markets are joyful community events, where families and children can mingle with volunteers and school administrators while selecting from fresh, seasonal produce and healthy pantry staples.

Program goals during FY18 were to: 1) Provide the families of elementary school students with high-quality fresh produce and other healthy foods and nutrition knowledge through an important community hub – their elementary schools – and through other food access points in their community (e.g. recreation centers and community centers);
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11111111111111111111111111111111111111111111111111111111111111111111111 2) Increase consumption of healthy foods, and especially fruits and vegetables, by families participating in the program; and 3) Establish key partnerships with schools, affiliated groups such as parent organizations, and key food access organizations, notably the Capital Area Food Bank. In FY18, education activities were conducted in conjunction with DC Central Kitchen. The Hunger Vital Sign Questionnaire (HVSQ) was implemented as part of a parent survey. DC Title V worked with the food programs to adopt this questionnaire to measure program impact and create a shared indicator across DC Health’s food access programs.

In FY18, Joyful Food Markets operated at 39 of 49 elementary schools in Wards 7 and 8. During the year 336 markets were held, 47,726 food packages distributed to students, and 1,036,958 pounds of food distributed. Customer intercept surveys were conducted at the beginning and end of the school year. Significant findings included:

• At the beginning of the school year, 36% of sampled JFM families reported consuming vegetables at least 5 days per week. While at the end of the school year 59% of sampled JFM families reported consuming vegetables at least 5 days per week.
• At the beginning of the school year, 30% of sampled JFM families reported consuming fruit at least 5 days per week. While at the end of the school year 57% of sampled JFM families reported consuming fruit at least 5 days per week.
• At the beginning of the school year 52% of sampled JFM families reported food insecurity based on the Hunger Vital Signs questionnaire, which measures whether families are concerned with not being able to purchase foods due to insufficient funds and food. While at the end of the school year 37% of sampled JFM families reported food insecurity according to the Hunger Vital Signs questionnaire.

JFM experienced challenges with the ability to determine median visits per person, unique visitors, and percentage of participation by school.

Produce Plus Program is a healthful food access program that provides low-income DC residents in federal safety net assistance programs, particularly those with limited proximity to available healthy foods, farmers’ market incentive checks to purchase locally sourced fresh fruits and vegetables. District residents pick up program checks between June 1st and September 30th at 51 DC distribution and sign-up sites including farmers’ markets, farm stands, housing complexes, senior wellness centers and WIC sites. Each participant is eligible to receive two (2) $5.00 dollar checks twice per week throughout the season to spend at more than 75 farmers’ market locations. Nationally, Produce Plus is the only program of its kind to include both Medicaid and SSI participants as well as TANF, SNAP, and WIC.

During FY18, approximately 5% of Produce Plus participants in farmer’s market programs also participated in Joyful Food Markets and 4% of participants were parents of young children who participate in WIC. Program goals in FY18 were to: 1) increase access to fruits and vegetables for low-resource DC residents, 2) increase community participation and investment in neighborhood markets, and 3) improve the viability of farmers’ markets selling fresh produce in communities with high poverty rates. Partnerships included non-profit farmers market and food education organizations including FRESHFARM, Arcadia, Community Foodworks, Fresh Vista, Markets and More, DC Urban Greens, Petworth Community Market, Mount Pleasant Market, Ward 8 Market, and Diverse Markets Management. By the end of the fiscal year, Produce Plus supported the operation of 77 Farmers’ Markets in the Metro area; including 15 in areas have limited availability of healthy foods. Nearly all funds for vouchers were distributed and redeemed (99.7% and 94.87%, respectively), and 9,041 unique participants were served. In addition, focus groups held with participants, volunteers, and Farmers’ Market organizations helped inform program changes such as creating more weekend markets in high need areas and increasing multi-vendor markets.

The Healthy Corners Stores Partnership (HCSP) continued to collaborate with DC Central Kitchen (DCCK) to support healthful food options at 65 neighborhood retailers. These markets also coordinate health education sessions and food demonstrations for participants. The program targets low-income neighborhoods that are underserved by the food distribution system. In FY18, the program targeted low-income families in areas with limited food options with the aim to:

• increase availability of healthful food;
• improve the capacity of small stores to provide healthful food options;
• develop and implement a long-term sustainable model.

The stores receive technical assistance, refrigeration equipment suitable for produce and minimally processed fresh food at cost. In FY18, DCCK collaborated with Dreaming Out Loud, a local-nonprofit social enterprise dedicated to food justice and local food system improvement to provide herbs grown within the District of Columbia. DCCK signed a Memorandum of Understanding with Unity Health Care wherein DCCK provides nutrition education at health care sites and Unity provides health screenings at HCSP events. Conversations continue with the Department of Small and Local Business Development about the funding of food co-ops in low-income neighborhoods but prospective partners have not identified a suitable partner. By the end of the fiscal year, DCCK conducted a 1-month marketing campaign to increase the sales at selected Healthy Corner stores, which generated an 80% increase in total visits and new visits to the Healthy Corners web page. DCCK also surveyed all corner stores’ using the Nutrition Environment Measures Survey for Convenience Stores (NEMS-CS) for the first full fiscal year to assess availability of healthy food options. By the end of FY18: the 26 stores surveyed in FY17 showed an average of a 108% improvement in their NEMS-CS score, 3 participating stores received refrigeration equipment, and 47 nutrition education sessions and cooking demonstrations were conducted in conjunction with SNAP-Ed and DCCK.

The Mobile Farmers’ Markets Program operated by Arcadia Center for Sustainable Food and Agriculture, are farm-stands-on-wheels that regularly distributes locally grown, high quality, sustainably produced food to underserved communities in the District. Markets offer farmed products at affordable prices; accepting all forms of payment, including food assistance benefits (WIC, SNAP, and Produce Plus benefits); doubling the purchasing power of food assistance benefits through a “Bonus Bucks” program; and providing educational resources for how to prepare the market’s offering in nutritious, cost-effective, delicious, and easy ways. In FY18, the program established 200 markets, had 8,700 transactions, and 939 WIC participants redeemed their WIC/FMNP vouchers at the markets.

Goal 4: Reduce childhood tobacco exposure.

In FY18, Title V continued to fund Breathe DC East River Tobacco Free Project (EOR) to provide tobacco cessation services and support to pregnant women and adults who smoke and live in households shared with children under the age of 12 and children with respiratory illness. During FY18, Breathe DC collaborated with three Managed Care Organization (MCO)—Amerigroup, Trusted Health Plan, and AmeriHealth Caritas to:

• implement cessation support programs for members;
• provide accessible cessation classes to MCO members;
• engage MCO and CBO staff to adopt the Ask, Advise, Refer. model to connect smokers to the East of the River Tobacco Free project’s cessation support services or to the Quitline;
• train United Medical Center staff to facilitate cessation groups to its patients;
• refer residents of Wards 7 and 8 to the project to receive cessation support services (individual counseling, group counseling, text messaging service, etc.);
• increase awareness of smoking cessation services among CBO participants and MCO members, especially high-risks groups; and
• improve the accessibility of the District’s existing cessation support resources by promoting the Quitline (1-800-QUITNOW) through community outreach.

With guidance from Title V staff, Breathe DC developed a recruitment strategy to better reach the target population. Breathe DC re-engaged relationships with partners to recruit and refer the target population to EOR smoking cessation services by: 1) executing 4 Memorandum of Agreements (MOAs) with AmeriHealth Caritas, Trusted Health Plan, Amerigroup, and Mary’s Center (a community based organization; 2) promoting AAR training via word of mouth, referrals and outreach; 3) conducting outreach while attending WIC meetings and Wards 7 & 8 Health Committee meetings; and 4) re-establishing DC WIC partnership through a formal agreement. Title V staff also provided technical assistance to improve Breathe DC’s program evaluation and data collection processes. By the end of the fiscal year, Breathe DC conducted 18 smoking cessation sessions to 89 participants, of which 61 or 68.5% were females and 28 or 31.5% were males. The majority (64 or 71.9%) of the participants were from Ward 7 (27 or 30.3%) and Ward 8 (37 or 41.6%) in the District of Columbia. The program provided 5 AAR trainings to 44 participants (9 physicians, 3 nurses, 2 social workers, 2 outreach workers, 1 case manager, and 27 community health workers), enrolled 33 participants in “Text to Quit”, and provided 1:1 cessation counseling to 4 participants.