Child Health Annual Report

The Title V MCH Program staff are dedicated to improving child health outcomes by partnering with families and agencies to help children reach optimal growth, psychological development, and overall health. Child wellness is promoted through developmental screens, school-based health center activities, information sharing about the benefits of a medical home, the value of adequate insurance, and immunization schedules, and resource sharing of Bright Futures, oral health screenings, physical activity, and weight management information. The population distribution by Census tract for children, ages 0 to 21, is indicated in the map below.

Title V MCH Program staff chose NPM 6 and NPM 15 to improve child health outcomes. Title V MCH partners implement strategies to increase the percent of children, ages 9 through 35 months, who received a developmental screening using a parent-completed screening tool in the past year (NPM 6) and to increase the percent of children, ages 0-17 y.o. who are adequately insured (NPM 15). Health outcomes should improve when developmental screens are conducted and adequate insurance increases consistent medical visits. Additional efforts to improve child health include medical screenings, collection of survey data about five-year old’s for improving early childhood health planning, and referrals made through Nevada 211 and the Nevada Medical Home Portal https://nv.medicalhomeportal.org/. Specific program activities and successes related to these efforts are highlighted below.

Developmental Screening

The Title V MCH Program worked to increase the percent of children, ages 9 through 35 months, who received a developmental screening using a parent-completed screening tool in the past year (NPM 6). According to the NSCH 2019-2020 report, 22.3% of Nevadan children ages 9 through 35 months received a developmental screening using a parent-completed screening tool in the past year compared to 36.9% nationwide. 

To improve developmental screening, Title V MCH Program partners provided over 500 community, parent, and provider education courses statewide concerning developmental milestones and the importance of screening using the Pyramid Model framework. The Pyramid Model is a tiered prevention and intervention framework to avert and address challenging behavior through evidence-based practices. The Pyramid Model consists of four layers: 

• The foundation, where systems and policies are developed to ensure an effective workforce can adopt and sustain evidence-based practices 
• Tier one, where universal supports for all children occur through nurturing and response relationships and high-quality supportive environments (behavioral needs of about 80% of children)
• Tier two, where prevention through targeted social-emotional strategies is used to prevent problem behaviors (behavioral needs of about 15% of children)
• Tier three, where individualized, intensive interventions comprise the top of the pyramid (required for about 5% of children)

The Children’s Cabinet completed over 1,000 and Stages Questionnaire: Social Emotional 2nd Edition (ASQ-SE2) and ASQ 3rd Edition (ASQ-3) developmental screenings. For all participating school district classrooms, a set of materials was provided to support social and emotional skills using the Pyramid Model framework, with most materials provided in English and Spanish. Fact sheets were provided for each family, and some families received additional materials to support their abilities further to teach and support social and emotional skills at home.

The Title V MCH Program also participated in the WIC Developmental Monitoring Project, a joint project between U.S. DHHS, CDC, and the Association of State Public Health Nutritionists (ASPHN), which improves developmental screening in low-income families. The WIC Developmental Monitoring Project helps WIC staff respond to concerns from parents about their child’s development, provides an easy way to monitor a child’s early development using CDC Learn the Signs. Act Early (LTSAE) milestone checklists, help parents set goals related to their child’s growth and development, offer parent education about a child’s developmental milestones, and provide WIC staff with resources to refer a child when indicated. Title V MCH partners with the NHV Program to help support two local implementing agencies. NHV provides ASQ and ASQ-SE screenings to the families they serve and facilitates resources and referrals to care related to developmental delays. NHV shares Milestone Moments and LTSAE resources with all families they serve in addition to the screenings home visitors provide. 

The Title V MCH Program purchased Milestone Moments booklets as part of a multi-agency effort for the University Center of Autism and Neurodevelopment (UCAN) located at UNR. This ensures UNR can continue statewide screening and distribution of the LTSAE parental screening tool to increase developmental screenings statewide.

Nevada Pyramid Model Partnership Report - The Children’s Cabinet

The Title V MCH Program provides funding to the Nevada Pyramid Model Partnership, formally known as TACSEI, for Young Children in partnership with The Children’s Cabinet. Nevada Pyramid Model Partnership is a statewide, collaborative initiative to enhance the ability of early care and education personnel and families to address the social, emotional, and behavioral needs of all young children birth to five years. Using the Pyramid Model, a tiered prevention and intervention framework to prevent and address challenging behavior through evidence-based practices, Nevada Pyramid Model Partnership provides training and technical assistance (TA) for supporting social emotional competence and addressing challenging behaviors in young children at-risk for or those with identified developmental delays.

The Title V MCH Program funds three Nevada Pyramid Model Partnership staff positions, including the Regional Coordinator (RC), Data and Evaluation Coordinator (D&EC), and Family Engagement Coordinator (FEC). The RC provides leadership, TA and training to local and regional Pyramid Model implementation sites and connects with diverse partners to expand potential sites. The D&EC handles data collection and summarization for the ASQ-SE2 and Pyramid Model evaluation activities. The FEC is a contractual position in collaboration with the statewide non-profit organization Nevada Parents Encouraging Parents, Parents Educating Professionals, and Professionals Empowering Parents (Nevada PEP).

In addition to Title V MCH funding, The Children’s Cabinet worked to expand Pyramid Model implementation and training through new funding from the Child Care and Development Fund (CCDF). CCDF supports three statewide specialists to focus on Pyramid Model entry-level skills and training to reduce the number of children, particularly children on the childcare subsidy program, being asked to leave their programs either temporarily through suspension or permanently through expulsion. This additional funding has allowed Title V MCH funded coordinators to focus on implementation and demonstration sites as well as provide statewide coordination and consistency of training and outreach to sites. In addition, CCDF now funds a coach in northeastern Nevada (Wells Family Resource Center), and the statewide Nevada Pyramid Model Partnership Coordinator, Janice Lee (University of Nevada, Reno).

The Northern Nevada Coordinator revamped all data components used for Pyramid Model programs, and ensured all programs understand what data is required and how to collect it. Participating programs now have a standardized data collection protocol and are working towards data fidelity. All but two programs were able to receive one TPOT (Teaching Pyramid Observation Tool for preschool assessment) which will allow for better classroom level supports.

The Southern Nevada Coordinator onboarded two new implementation sites in October and is in the process of onboarding a site in Clark County as an exploration site.

Coordinators attended 12 site-level leadership team meetings and spent 57 hours of coaching time with implementation and demonstration sites. Coordinators provided most of their coaching focus to Tier 1 (universal) and Tier 2 (prevention) support. Coordinators spent their main coaching hours in these top five categories: leadership team meetings, data collection, problem-solving discussions, data review and Teaching Pyramid Observation Tool for Pre-School Classrooms (TPOT) and Teaching Pyramid Infant–Toddler Observation Scale (TPITOS) assessments. Coordinators spent their secondary coaching hours in these top five categories: data review, problem solving discussion, building rapport, goal setting and action planning and reflective conversation.

Nevada Pyramid Model Partnership sites administered 440 Ages & Stages Questionnaire: Social-Emotional, 2nd edition (ASQ:SE-2) screenings. Statewide, 251 participants attended 29 Pyramid Model trainings. For Implementation/Demonstration sites, 75 participants attended 7 trainings.

Developmental Screening: Clinical Settings

Twelve public health clinics were awarded Title V MCH funding to improve child health. These entities include Carson City Health and Human Services (CCHHS) in Northern Nevada and 11 DPBH Community Health Services (CHS) nursing clinics providing services in Nevada’s rural and frontier areas. Families were provided with CDC Milestone Moments booklets or given information on how to access the CDC mobile app tracker to monitor their child’s development.

Children’s Health and Wellness Clinic Outcomes

Clinic staff from 12 Title V MCH funded clinics (CCHHS and CHS) provided information about the value of adequate insurance, developmental screens, overall child wellness, immunization schedules, oral health, and weight management. The public health clinics refer families with private insurance and Medicaid to primary care providers to establish a medical home with local pediatricians. A CCHHS-created infographic was disseminated at the local WIC office promoting the importance of a medical home. The flier was distributed to 799 people presenting for WIC services, allowing for discussion about the value of a medical home. CCHHS sent out 599 vaccination reminder cards for children aged four months through 35-months old. Childhood immunizations were endorsed through outreach events and health promotion marketing campaigns, including clinic digital signage. CHS served children within clinic settings and through community immunization events, and 2,477 vaccines were administered to 2,147 children and youth ages 1-21 y.o. Numerous webinars and resources were created and shared statewide by the MCH-Immunizations CDC Foundations Assignee which were very well attended and received.

Children’s Health and Wellness in Schools

Title V MCH Program staff funded the Nevada Department of Education (NDE) for a School Wellness Coordinator position. This project strengthened existing collaborations NDE and DPBH MCAH and NSIP Sections. This staff helped build child health alliances in several areas:

• Participated as state lead for the National Comprehensive School Mental Health CoIIN facilitated by the National Center for School Mental Health. This project provided ongoing professional development, training, coaching and technical assistance by national experts and peers. This allowed Nevada to build high quality systematic school mental health programs tailored to each district’s unique needs. NDE was awarded a grant to increase the number of mental health service providers to school districts with the highest demonstrated need.
• Conducted efforts to increase school immunization rates by collaborating with the NSIP Section Manager and district school nurses.
• Collaborated with Nevada Division of Child and Family Services (DCFS) and NDE by offering updates and events on mutual goals and outcomes during monthly meetings. The group started work on an Integrated Systems Framework to blend resources, training, systems, data, and practices to improve outcomes for all children and youth. The project emphasis will be on prevention, early identification, and intervention of the social, emotional, and behavior needs of students.

Nevada Institute for Children’s Research and Policy Kindergarten Heath Survey

Title V MCH Program staff funded the Nevada Institute for Children’s Research and Policy (NICRP) to conduct an annual health survey of children entering kindergarten in partnership with all school districts. Survey data provides estimates for monitoring MCH indicators and reporting to local, state, and federal entities and informs local efforts on how to improve future programming and child health. The Health Status of Children Entering Kindergarten in Nevada annual report (2020-2021 results) was posted on NICRP’s website and the agency distributed the report statewide to partners. Title V MCH staff shared the reports with awarded partners, the MCH Coalition and PCO e-newsletters for mass distribution. 

NICRP circulated questionnaires to all public elementary schools statewide. Despite challenges related to COVID-19 the agency adapted and provided both paper and electric surveys to school districts. NICRP received 2,372 surveys (7.8% response rate) from parents in all 17 school districts. This was a significant decrease in surveys compared to all other years since most schools were virtual and focused on coping with the pandemic. Due to the low response rate, data are to be interpreted with caution. Data were weighted by district to increase state representativeness.

When compared to last year, behaviors in the health status category remain relatively steady with only minor fluctuations. There was a slight increase in reporting of underweight children (17.3% to 19.5%). A small increase was reported in children drinking non-diet soda once a day or more (7.0% to 7.5%). The percent of respondents reporting exclusively breastfeeding improved slightly this year compared to last year, in all age groups (one, three, six, and 12 months). This was the fifth consecutive year rates improved for infants being exclusively breastfed for each age category.

Families experiencing barriers to accessing healthcare increased due to lack of insurance (6.2% to 6.9%), insufficient funds (9.4% to 10.4%), and absence of quality providers (5.9% to 6.5 %). There was a slight decrease in those who had routine check-ups (90.6% to 86.8 %) or dental visits in the past 12 months (79.3% to 76.1 %). More individuals had challenges obtaining mental health services (40.0% to 44.1%). Household income decreased for those making less than $25,000 per year and revenue between $25,000 - $54,999 which places additional challenges accessing healthcare and social services.

The Nevada Institute for Children’s Research and Policy Kindergarten Health Survey: 2020-2021 Report can be accessed online at this link: https://nic.unlv.edu/files/KHS%20Year%2013%20Report%2012.6.21.pdf

Nevada 211

Nevada 211, a program of Money Management International, was awarded Title V MCH funds to provide access to health and social service information and resources for maternal and child health populations and their families. Title V MCH funding supports a portion of personnel costs to manage the Nevada 211 website https://www.nevada211.org/ and operate the telephone call center connecting people with needed services. Nevada 211 is a special telephone number and text line providing information and referrals to health and social service organizations. Resources include but are not limited to places to find food, housing, emergency shelter locations, children’s services, adoption and foster care, mental health and counseling services, safety for those affected by intimate partner violence, and resources for individuals living with disabilities. Specific services for children include breastfeeding support, diaper programs, childcare and assistance with related expenses, clothing, family support, and respite care.

Nevada 211 call specialists answered 562 calls from individuals inquiring about maternal and child health resources and services. Ninety one percent of the MCH populations callers were pregnant. Most callers were insured through Medicaid (68%) with the largest needs being housing, utility, and food assistance. Pregnant persons and new parents were provided with information to help improve maternal and infant health outcomes. Below are referrals made to Title V MCH recommended resources:

Title V MCH Program staff arranged trainings for Nevada 211 Call Specialists to expand and update their knowledge base of MCH programs. Two sessions served as refresher courses for Call Specialists. The refresher topics covered PMAD, Safe Sleep, Text4baby, PRAMS, https://sobermomshealthybabies.org/ and https://nv.medicalhomeportal.org/. Additional trainings covered information about enrolling into Medicaid and Nevada Health Link (state online marketplace); Marijuana policies, use, and its impact on pregnant persons; as well as childhood and COVID-19 vaccine resources.

Nevada 211 provided the University of Utah, Department of Pediatrics with a quarterly export of Nevada 211 agency-level information to be placed into the database supporting Nevada’s MHP webpages https://nv.medicalhomeportal.org/. A key offering of the MHP is information about local community and professional services to assist families of CYSHCN.

Nevada 211 Success Story

Nevada 211 Call Specialist received a call from young mother:

“A young mother with a soft choked up voice spoke and asked if we had any places where she could go and pick up some diapers for her two-month-old daughter. I was able to provide three resources for diaper assistance. Upon saying thank you, she started to cry, so I asked her if she could tell me what was going on? “I really need baby formula, I have only ½ a can left, and I don’t know what I am going to do.” I realized two of the agencies I had already given her also provided formula, but I thought it best if I give them to her again, this time just for formula. I instructed her to call ahead before she goes, to make an appointment and to tell them if she is experiencing any COVID-19 symptoms. She said, “thank you this really, really helps”. She stated that she thought she was ready and prepared and had things under control. I assured her that with a newborn in the house things can seem out of control very fast. I then gave her a text line for new parents which can be a friend and advisor for young mothers. Our help seeker said she felt like a weight had been lifted off her shoulders and was extremely grateful.”

Title V MCH Program funded agencies promoted Nevada 211 by providing information to staff and clientele about the value of the service and how to access its resources. CCHHS promoted Nevada 211 through clinic digital signage and social media. Facebook posts reached 6,486 individuals. All DHHS staff include information in their email closings to find help 24 hours a day by dialing 211; texting 898-211; or visiting https://www.nevada211.org/. Title V MCH awarded partners are also required to register and update program information with Nevada 211.

Collaboration with Child Serving Agencies 

Title V MCH Program staff served on Nevada’s state team of the National Comprehensive School Mental Health CoIIN led by NDE. This partially funded HRSA MCHB project focused on supports and services promoting a positive school climate, social-emotional learning, and mental health and well-being while reducing the prevalence and severity of mental illness. The group assessed and addressed the social and environmental factors impacting physical and mental health.

Title V MCH Program staff attended children’s mental health meetings such as the Nevada Children’s Behavioral Health Consortium (NCBHC) and the NDE and DCFS Collaboration Meetings. Topics of interest included Medicaid billing updates and policy changes (e.g., billing for telehealth visits due to COVID-19), activities conducted through the DCFS Systems of Care Grant, and School-Based Mental Health Services. The NDE and DCFS Collaboration Meetings discussed topics pertinent to COVID-19’s impact on school-aged children, school-based mental health services, and enhancements in Medicaid reimbursement to include telehealth visits, specialized foster-care, and services targeting children and youth with special health care needs. The group worked on an Interconnected Systems Framework to help state agencies involved with childhood resiliency create a unified resource list and action plan.

MCAH staff participated in implementation and evaluation meetings for the Nevada Pediatric Psychiatry Solutions (NVPeds) project. The program led by DCFS offers direct psychiatric care to children and youth. NVPeds aims to integrate emotional and behavioral health care into pediatric primary care settings using telehealth technologies. The project serves pediatric primary care clinicians by providing teleconsultation, care coordination, and training and education to increase capacity to provide emotional and behavioral health care to children and youth.

Title V MCH Program staff disseminated child health topic content to be displayed on the MCH Coalition and Office of Primary Care e-newsletters. Items contained new content in the Medical Home Portal, emotional and behavioural health tips pertinent to coping skills during COVID-19, autism resources, etc.

Title V MCH Program staff provided guidance to agencies interested in setting up school-based comprehensive health services such as primary care, preventive health, vision screenings, oral health, lab services, pharmacy, mental/behavioral health, and social services for children and adolescents. A State Plan Amendment within the Centers for Medicare and Medicaid Services (CMS) expanded pathways for Medicaid reimbursement (under the existing Provider Type 60) for care provided in schools involving physical, dental, and behavioral/emotional/mental health.

Children’s Healthy Weight CoIIN

Title V MCH Program staff continued participation in the CoIIN facilitated through the Association of State Public Health Nutritionists (ASPHN). In partnership with the Nevada Office of Food Security and Obesity Prevention and Control programs, content for the social media campaign to promote a series of fact sheets assisting Early Care and Education (ECE) centers in implementing the Child and Adult Care Food Program (CACFP) was finalized. This program is recommended to help childcare settings improve childhood nutrition, prevent obesity, and address food insecurity. The final CoIIN activity consisted of presenting a poster session at the annual conference highlighting the two-month social media campaign. The campaign included bilingual and culturally relevant messages which targeted ECEs providing care to under-resourced children ages birth to eight years old. The campaign consisting of six video posts and messages (three in English/three in Spanish) had over 182,362 media impressions. Facebook led to 66,459 media impressions, with 22,569 video views and 2,041 individuals clicking on links to learn more about CACFP. Twitter resulted in 115,903 media impressions.

COVID-19 Efforts

COVID-19 guidelines requiring masks to be worn in public can pose communication barriers for individuals who are living with D/HH. The Title V MCH Program funded the purchase of face masks with a clear window to nine school districts and 13 partners working with children or parents who are experiencing D/HH. The transparent section of the mask allows the wearer's lips to be visible, making lip-reading and the speaker's facial expressions possible.

MCAH staff added COVID-19 MCH population related content into the DPBH website http://dpbh.nv.gov/Programs/TitleV/TitleV-Home/. Materials contained Nevada’s response to the pandemic, as well as information and resources for children with and without special health care needs, in addition to all other populations served by the award. Identified links sent viewers to the CDC COVID-19 resources in American Sign Language via YouTube and Spanish language content. The CDC materials and placement of the links were shared widely with funded partners and collaborators. The statewide MCH Coalition and PCO disseminated the materials through listservs.

Title V MCH Program staff requested all funded partners promote the DPBH awarded Nevada Resilience Project https://www.nevada211.org/nevada-resilience-project/ helping individuals and families with children experiencing struggles and challenges due to COVID-19. Bilingual ambassadors provided education, information, counseling, and resource navigation over the phone, text, and video chat, and face-to-face while promoting resilience, healthy coping, and empowerment. Additionally, state staff shared the launch of two Nevada 211 mobile apps to help Nevadans connect with needed resources in response to the pandemic. The Nevada 211 Youth app complements the initial one for individuals and families and specifically helps young people locate services and resources such as health care, crisis support, employment services, food pantry locations, and emergency housing programs.

In response to the psychological impacts of COVID-19 on school age children, Title V MCH as part of MCAH created a mental health action plan to outline approaches to address social, emotional, and behavioral health during a pandemic for elementary and middle school children. This plan synthesized ongoing mental health efforts by agencies and partners throughout the state and provided both national and state recommendations that would be helpful in supporting positive mental health outcomes for children and youth.

Securing a CDC Foundation MCH-Immunizations Assignee helped MCH capacity in preparedness related COVID-19 response in increasing education to MCH populations on COVID-19 vaccines. This position was supported by CYSHCN Coordinator, MCH Manager, MCAH Section Manager, and MCAH staff sharing partner networks and expertise and reported to the MCH Director and Immunization Section Manager.

Child Health Domain Accomplishments

Title V MCH Program staff focused on improving the health status of children to reduce negative long-term implications for health, productivity, and longevity. Despite challenges posed by the pandemic, funded partners could dedicate efforts to help children reach optimal physical growth, psychological development, and overall health. MCAH staff added COVID-19 child health and wellness-related content into the DPBH website and shared pandemic information and resources with partners pertinent to children with and without special health care needs. Parents/caregivers, providers, and partners received best practice information about developmental screens, school-based health services, benefits of a medical home, value of being adequately insured, immunization schedules, oral health screenings, and physical activity and weight management. 

MCAH staff created new partnerships with state agencies to build childhood resiliency due to gaps identified in the Title V Five-Year Needs Assessment. Title V MCH staff funded NDE for a School Wellness Coordinator strengthened existing collaborations between the NDE and MCAH. Furthermore, COVID-19 necessitated collaboration to leverage program information and resources.

The Health Status of Children Entering Kindergarten in Nevada annual report revealed despite COVID-19, when compared to last year, behaviors in the health status category remain relatively steady with only slight fluctuations. This was the fifth consecutive year rates improved for infants being exclusively breastfed for each age category.

Child Health Data

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

According to the 2019-2020 NSCH, 22.3% of Nevadan children ages 9 through 35 months received a developmental screening, which is down from 30.6% in 2018-2019. Nevada is significantly below the 2019-2020 national average of 36.9%, and ranks 49th out of the 50 states and D.C.

NPM 15- Percent of children, ages 0 through 17, who are continuously and adequately insured

According to data from the NSCH the percent of children who are continuously and adequately insured has remained relatively stable from 62.2% in 2016 to 61.4% from 2019-2020. This is significantly lower than the 2019-2020 U.S. national average of 66.7%, and Nevada ranks 48th lowest out of the 50 states and D.C. Disparities exist in Nevada for this measure, as Non-Hispanic Black children are least likely to be continuously and adequately insured (52.7%). Hispanic and Non-Hispanic Asian children are also slightly below the Nevada average at 61.8% and 55%, respectively. Non-Hispanic White and Non-Hispanic Multiple Race are above the Nevada average, at 62.6% and 68.5%, respectively.