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

 

Introduction: Developmental Screening

For the Child Health domain, Hawaii selected NPM 6 Developmental Screening as a priority based on the 2020 five-year needs assessment. By July 2025, the State sought to increase the proportion of children, ages 9 through 35 months, receiving a developmental screening to 45.0%.

 

Data: Aggregated data from 2020-2021 showed that the estimate for Hawaii (41.0%) did not meet the 2022 state objective (42.0%) but was not significantly different from the 2021 indicator (41.2%) and the national estimate of 34.8%. Due to the small sample size, results for this measure should be used with caution. The related Healthy People 2030 Objective for developmental screening (35.8%) was met. There were no significant differences in reported subgroups by health insurance or household income, which may be due to the small sample size.

 

Objectives: Considering the baseline data, data limitations, and the HP 2030 objective, the state objectives through 2025 were set to reflect an annual increase of one percentage point.

 

Title V Lead/Funding: Developmental screening remains a priority since 2010 for Family Health Services Division (FHSD), which coordinates federal, state, and local efforts on screening, referrals, and services. The lead for this priority is the Children with Special Health Needs Branch (CSHNB) Early Childhood Coordinator (state-funded). Title V does not directly fund developmental screening program staff and activities but does support management, epidemiology, data, and administrative positions that contribute to the NPM.

 

Partnerships: There is a broad collaboration among state agencies and stakeholders working toward a statewide systematic approach to developmental screening. This includes medical partners, early childhood providers, and community-based nonprofits who conduct developmental screening and ensure children are connected to services or supports if a concern is identified. Development screening is also identified as a priority in several key state plans, including:

• Executive Office on Early Learning (EOEL) Early Childhood State Plan for 2019-2024 and the Strategic Implementation Plan focusing on “Early Childhood Health and Family Wellness.”
• Early Childhood Action Strategy (ECAS), Hawaii Community Foundation (HCF), and DOH's Infant and Early Childhood Behavioral Health Plan
• Maui County plan for the early childhood collective impact team, Kākou for Keiki (translation: All of us [together] for children).

 

Strategies/Evidence: The five developmental screening strategies of Hawaii focus on systems-level approaches following the guidance from three sources:

• Federal ECCS Impact Grant, which was a five-year grant from 2016-2021 focusing on establishing a system for developmental screening in Maui County
• HRSA’s Title V “State Technical Assistance Meeting” in March 2016
• The national MCH Evidence Center

 

The five strategies are:

• Build systems and infrastructure
• Implement family engagement and public awareness activities
• Ensure data collection and integration
• Address social determinants of health and vulnerable populations
• Assess policy and public health coordination

 

The last strategy is assessed via a Policy and Public Health Coordination Scale (PPHC) designed to monitor implementation of the systems-level approaches and is used as the NPM 6 strategy measure (ESM 6.2). The MCH Evidence Center identifies this ESM as an ‘innovative tool’ to track and improve developmental screening efforts and “is a strong measure of an evidence-based strategy.”

 

The HRSA ECCS Impact grant best practices promote working with early childhood providers to ensure that screenings are done as part of their assessment of children’s development and is supported by:

• National Association for the Education of Young Children (NAEYC) Accreditation
• Head Start Performance Standards
• National Institute of Early Education Research benchmarks for early education programs

 

Hawaii works with these programs to ensure the national standards are implemented.

Research compiled by AMCHP and the MCH Evidence Center indicates that there is evidence-based support for training healthcare providers on developmental screening and screening through home visiting programs, although further evidence is needed. Following these promising practices, Hawaii provided and continues to provide community-based trainings on the Ages and Stages Questionnaires (ASQ) and CDC milestones to healthcare providers, early childhood education, and interested childcare providers. Although quality improvements in both healthcare settings and systems-level approaches were effective, Hawaii chose a general systems approach to continue quality improvement practices.

 

Updates for 2022 on the five strategies follow.

 

COVID Impacts: As safety restrictions were rescinded in 2022, COVID cases remained manageable and vaccination numbers increased. Childcare spaces, early learning programs, and public schools returned to in-person learning in the past year. Doctors' offices continued to implement safety protocols and began in-person and telehealth visits. Health concerns lessened with safety measure protocols and vaccination availability, but workforce capacity remained strained. Delays in healthcare visits and limited childcare/ early education service availability could have led to fewer children receiving screenings to track development or identify delays.

 

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

The activities for this strategy focused on systems and policy development to support increased child developmental screening. The healthcare and early childhood sectors of Hawaii are crucial partners in ensuring that the four stages of developmental screening: screenings, referrals, services, and supports occur.

 

Guidelines on Screening and Referral: The “Hawaii Developmental Screening and Referral Guidelines for Early Childhood and Community Based Providers” has been available online at health.hawaii.gov/cshcn/hiileihawaii/ since 2021, providing ongoing standard information for those conducting developmental screening of children ages birth through 5 years of age. These guidelines include community-informed best practices learned from early childhood direct service, medical providers, and other key stakeholders during the ECCS Impact grant awarded to Hawaii from 2016-2021. As a hybrid of in-person and telehealth services was offered, the guidelines were revisited with stakeholders to ensure the information was relevant for in-person or virtual screenings.

 

Workforce Training: Hawaii received a second Learn the Signs, Act Early (LTSAE) technical assistance grant from the Centers for Disease Control (CDC) in 2021-2022. The Hawaii LTSAE Lead Team included the LTSAE Ambassador, a Project Assistant, and the CSHNB Early Childhood Coordinator. Under their direction, a convening was held once a month to propose ideas, support initiatives, and consider solutions to interested cross-sector partners. Additionally, participants were educated on CDC milestone updated materials and methods organizations could adopt to share materials more effectively. The LTSAE Lead Team trained WIC nutritionists statewide to conduct the CDC Developmental Milestone Checklist for 2- and 3-year-olds. WIC staff agreed to distribute the checklist to parents of toddlers via email until in-person visits resume. The LTSAE Ambassador, Dr. Jeffrey Okamoto, and Keiko Nitta, DOH CSHNB Early Childhood Coordinator, presented on developmental screening and monitoring at the Pediatrics Grand Rounds. Approximately thirty pediatricians received this training in September 2022.

 

Kākou for Keiki, a Maui community organization formed as part of the ECCS grant, continued to offer ASQ virtual trainings for direct service early childhood and P-3 health programs statewide. Programs receiving training included the DOH Public Health Nursing program, preschool programs, childcare centers, and direct service organizations providing early learning and home visiting supports. Approximately 150 participants were trained through Kākou for Keiki’s efforts.

 

Strategy 2: Family Engagement & Public Awareness

This strategy focused on engaging families to promote the importance of developmental screening and child development and to develop a website on both the Department of Health’s Children with Special Health Needs Branch page www.health.hawaii.gov/cshcn/hiileihawaii/, a stand-alone site at www.keikicheckup.com,  and the Early Childhood Action Strategy at www.hawaiiactionstrategy.org. By having three options for families with consistent information since the DOH CSHNB Early Childhood Coordinator oversees them, it is anticipated that families and providers will find information on Hawaii's resources through whatever search engine they use.

 

Media Campaign: DOH conducted a media campaign in September 2022, “Time for Checkup,” to promote the importance of preventive screenings: developmental, hearing, vision, and dental. Information and links to the campaign are found at www.keikicheckup.com. In addition, campaign follow-up occurred during morning news shows with pediatricians, DOH staff, and the Family Hui Hawaii as guests to promote developmental health and inform parents of the importance of screenings for young children.

Outreach to Families: Through various online parent cafes and parent support groups conducted across the state, screenings to encourage healthy development continued to be promoted. Hawaii families with Internet access often opt for online platforms which are more easily accessible and convenient. DOH continues to work with community partners to support outreach to families. The Family Hui Hawaii organization provides family support groups and conducts developmental screenings at community events and through their support groups. The Leadership in Disabilities and Achievement of Hawaii School Readiness Program conducts comprehensive developmental, behavioral, hearing, and vision screening for children up to age 5. Both these community partners have strong relationships with families and provide information and feedback to the DOH on emerging issues or concerns.

 

Kākou for Keiki (K4K): Maui County’s early childhood collective impact team that originated from the ECCS Impact grant continued developmental screening work with DOH funding. Activities included community outreach, social media efforts, and caregiver support groups to promote skill building/opportunities and supports for families. The caregiver support groups allow families to 'talk-story' and encourage self-care and resiliency practices. Postcards and flyers were distributed at community events that promote the CDC Milestone App, the VROOM App, and the Talking is Teaching Spotify playlist to encourage on-track development for young children. Last, the K4K Facebook and Instagram pages promote healthy development and caregiver resiliency to reach and be more inclusive of any parent seeking support.

 

Screening Information Websites: Hawaii continues to work with the Early Childhood Action Strategy (ECAS), a public-private collaborative focusing on children's issues from prenatal through age 8. The CSHNB Early Childhood Coordinator leads the ECAS On-Track Health and Development Team. Documents on screening are housed on the ECAS website, which provides information about child development (hawaiiactionstrategy.org/). The DOH CSHNB website houses developmental screening information on its website: health.hawaii.gov/cshcn/aboutus/.

 

Throughout 2022, FHSD and other direct service programs for children and families saw levels of service utilization slowly return; however, anecdotally, services did not return to 2019 levels. Lags in population-based data sources make assessing the situation statewide for specific communities/populations difficult. Monitoring developmental screenings of young children helps to serve as a proxy measure to anticipate the effects of COVID-19 on children’s development and DOH partners with the Department of Human Services Med-QUEST Division (Hawaii’s Medicaid agency) to address emerging concerns.

 

Strategy 3: Data Collection and Integration

This strategy originally focused on internal collection of developmental screening data among Title V early child programs. This activity was completed; thus, the work has shifted to acquiring population-based developmental screening data to monitor system needs.

 

National Survey on Children’s Health (NSCH) data: The latest NSCH data for this NPM is for 2020-2021, which should have begun to capture the full impact of COVID. Yet, the indicator remained largely the same as 2019-2020. This may be due in part to the small sample size, with high variability and unstable estimates. The small subset of data for NPM 6 (ages 9 through 35 months) increases the data problem. In addition, several issues with the NSCH data limit its utility to inform planning and address health equity. The race/ethnicity data collected by the NSCH cannot provide detail to reflect Hawaii’s Asian, Native Hawaiian, and Pacific Islander populations; county-level data is unavailable.

 

For several years, FHSD explored NSCH survey oversampling with the MCH Bureau, but there are too many cost/administrative barriers. Although the MCH Bureau has remedied some barriers, over-sampling remains costly and complex without an epidemiologist to help guide the project.

 

Additionally, the NSCH survey question asks parents about screenings that occur only in a healthcare provider’s office; however, the developmental screening efforts in Hawaii include work with early childhood providers and other community-based service organizations, so the data may not reflect the local state efforts.

 

Medicaid: In 2021, a new Medicaid RFP was issued that included development screening as a health priority for the five state Medicaid insurance plans in Hawaii. The following data was provided for FY 2021. The percentages represent only children enrolled in Medicaid and are somewhat lower than the NSCH data.

 

Developmental Screening in First Three Years of Life - Birth to one year	21.19%
Developmental Screening in First Three Years of Life - >1 year to 2 years	26.00%
Developmental Screening in First Three Years of Life - >2 years to 3 years	20.66%
Developmental Screening in First Three Years of Life - Total	22.41%

 

EPSDT-related data: Medicaid child providers are currently asked to complete a detailed EPSDT visit form that specifically asks about completion of developmental and other preventive screens. Medicaid successfully migrated these data to an electronic collection and management system. They are working to share the data in the future.

Title V Program Data: Developmental screening data is collected and reviewed for quality assurance and monitoring from FHSD’s early childhood programs: MIECHV, Hi’ilei, ECCS HIPP, and Early Intervention.

 

Maternal, Infant, and Early Childhood Home Visiting (MIECHV): Data from the MIECHV Home Visiting program for FFY 2022 indicated that of the total of 598 children enrolled in the program, 235 children were eligible for screening. Per AAP screening recommendations and MIECHV reporting requirements, 77% of the eligible 235 children were screened for developmental delay. Of those children with positive screens for developmental delays, 84% of children received services in a timely manner.

 

Hiʻilei Developmental Screening Program: The Hiʻilei program allows parents and caregivers to complete an online screening or a paper copy of the developmental screener through the mail. FFY 2022 Hiʻilei data shows that 17 children birth through 5 years were screened. Four of the children were found to be in the “monitoring” range. Information on activities to encourage their children's optimal development was provided to offer support. Six of the children screened were found to be in the referral range. Referral supports and suggested guidelines for follow-up assessment needs were given through mail or email.

 

Early Intervention Service (EIS): In 2022, of the 2,484 evaluations that were conducted, the majority of the referrals were found eligible. With the pivot to telehealth during the pandemic, EIS conducted partial evaluations to identify developmental delays since the standardized tool (Battelle Developmental Inventory for Young Children) could not be administered in person. If the team felt the child was within age expectations and the family concurred, the child was deemed ineligible. Effective April 1, 2021, EIS used the Developmental Assessment for Young Children (DAYC), a standardized tool that can be done remotely via interview. All children with partial evaluations were reevaluated and eligibility established unless the child exited before the DAYC was initiated.

 

EIS referrals come from various sources. In 2022, 63.7% of referrals came from primary care providers, 24.1% from families, 10.7% from community providers, 0.003% from resource caregivers, and 0.01% from child welfare. Programs providing referrals include childcare, home visiting, public health nursing, Early Head Start, and healthcare or social service providers.

 

Developing a coordinated data system for FHSD around screenings and referrals was difficult to address since programs collect data using different parameters, including timeframes and the ages at which children are screened often based on funding guidance. Though challenging, continued efforts to create an effective data collection system will be considered.

 

Strategy 4: Social Determinants of Health

This strategy focused on partnering with programs and agencies that work with underserved populations.

 

In late 2019, developmental screens were being conducted in Maui WIC clinic waiting rooms before COVID closures. The ECCS Impact Program Coordinator piloted Ages and Stages (ASQ) screens at the central Wailuku clinic. A sustainability plan was needed as a partnership became more clearly formed between ECCS and WIC. An additional partnership was formed with Public Health Nursing (PHN) to assist with screenings. PHN can follow through with home visiting services and language translation if needed. The partnership allowed for sustainability of the practice. A similar screening effort was also piloted in Kauai WIC waiting rooms.

 

In May 2022, PHNs across Hawaii were trained in ASQ so the practice could extend beyond Maui and Kauai County. WIC Nutritionists were trained on the simplified CDC Checklist for 2- and 3-year-olds and referral practices as another strategy to include developmental milestones in WIC appointment practices. The use of the CDC Checklist was delayed due to the closures of the WIC offices, and Hawaii will resume efforts to measure the effectiveness of this piloted practice when WIC clinics open to in-person visits.

 

SWYC: In FY 2020, Title V began discussions with the AAP–Hawaii Chapter and MEDQUEST, the State of Hawaii Medicaid agency, to promote use of the SWYC since it was added to the national AAP list of validated screening tools. SWYC is a free tool covering behavioral and family well-being (including social determinants of health). Referrals may be more extensive than IDEA Part C (EI services) and Department of Education developmental services. By 2021, SWYC became an option on medical practice Electronic Health Records (EHR). Medical practitioners could adopt the SWYC one segment at a time until the comfort level of the entire tool's usage increased. Hawaii continues to work with partners on adoption and full utilization of this tool, which can improve identification of socioeconomic needs of young children and their families and available cross-sector supports that effectively and efficiently meet their needs.

 

Four statewide efforts are underway to address physician concerns about an accessible referral site to provide information for families.

1. Hawaii State Department of Health CSHNB created a centralized resource directory of state services that includes county-specific and more accessible resources linked to the questions asked on the SWYC. This is found at health.hawaii.gov/cshcn/resourcelists.

 

2. In 2022, FHSD continues to partner with the Executive Office on Aging and the No Wrong Door initiative. This project promotes an improved coordinated intake and referral process for state agencies to receive and track referrals from other state agencies and local nonprofits. Hawaii's DOH CSHNB and Hiʻilei Developmental Screening Program are listed as a "Door" to help create and receive referrals from other state agencies. In September 2022, the Department of Education's Homeless Liaisons Program was added as another "Door" to help connect houseless families to other state services. In time, more state programs will continue to be added to the system to improve the process of connecting families to appropriate services.
3. The last effort being explored is the Central Intake and Referral System (CIRS) of Hawaii Unite Us. This platform was introduced to statewide community partners in 2020. With more state and medical provider investment, this platform could be another possible solution for referral/intake needs and its proper data collection. An ECCS HIPP performance measure is to guide and uplift a CIRS platform to better integrate P-3 system process and improve data collection. At this time, an ECCS HIPP workgroup is examining which CIRS, including Unite Us, may be the best fit to address Hawaii's needs and data collection desires.

 

4. The CDC Learn the Signs Act Early materials were translated into Chuukese, Marshallese, and Samoan to help better understand child development. The CDC children’s book “Amazing Me: It’s Busy Being 3!” translations were completed in 2022. The newly translated book versions will be distributed through community health centers, the Home Visiting program, and other early childhood partners statewide in 2023.

Strategy 5: Policy and Public Health Coordination

This strategy aims to track FHSD’s infrastructure development efforts to help improve children's developmental screening rates.

 

ESM 6.2 – Develop and implement Policy and Public Health Coordination rating scale to monitor developmental screening efforts around systems development, family engagement, data collection/integration, and addressing vulnerable populations.

 

	2019	2020	2021	2022	2023	2024	2025
Annual Objective	12.0	18.0	24.0	27.0	30.0	30.0	30.0
Annual Indicator	23.0	26.0	26.0	28.0

 

ESM 6.2 Policy and Public Health Coordination Scale

Hawaii developed a Policy and Public Health Coordination Scale (PPHC) to monitor progress on Title V efforts to improve developmental screening rates of children. The scale (below) reflects the activities in the NPM 6 logic model and work plan, including Systems Development, Family Engagement and Messaging, Data Collection/Integration, Addressing Social Determinants, and Policy and Public Health Coordination. The MCH Evidence Center rated this ESM as a strong quantifiable measure. The EC Coordinator, who oversees all the activities, self-reported the scale's completion.

 

The total possible points for the scale are 30. The FY 2022 indicator was 28.0 and met the annual objective set at 27.0. Despite statewide recovery from the pandemic, progress was made in systems development, family engagement, and addressing vulnerable populations. The EC Coordinator uses the rating scale to track progress on the NPM 6 strategies. Scores show room for improvement in systems development and social determinants of health identification.

 

Element	0 Not Met	1 Partially Met	2 Mostly Met	3 Completely Met
Systems Development
Develop guidelines and toolkit for screening, referral, and services.				x
Work with partners to develop infrastructure for ongoing training, technical assistance, and support for providers conducting developmental screening activities.			x
Family Engagement and Public Awareness
Work with families and parent organizations to develop family-friendly material explaining importance of developmental screening and how to access services.				x
Develop website to house materials, information, and resources on developmental screening.				x
Data Collection and Integration
Develop data system for internal tracking and monitoring of screening, referral, and services data.				x
Develop process for ongoing communication to review data findings and adjust for better outcomes for children and families.				x
Social Determinants of Health and Vulnerable Populations
Develop process for identifying vulnerable populations.			x
Work with stakeholders to address supports and targeted interventions for vulnerable populations.				x
Policy and Public Health Coordination
Develop Policy and Public Health Coordination Rating Scale.				x
Conduct process for annual assessment of rating scale.				x
Total Score	28 out of 30

 

Current Year Highlights for FY 2022 (10/1/2021 – 6/30/2022)

Re-examining Strategies: Hawaii is reviewing its strategic approach to improve development screening given new staffing, partnerships, and changes in healthcare delivery due to COVID.

 

Hiʻilei Program: By hiring new staff, the Hiʻilei program can expand its reach and scope to promote development screening services to families and service providers. The program may also address infrastructure issues to ensure assessment of statewide needs, ongoing training, and policy development.

 

Early Intervention Services (EIS): EIS is the lead state program for development screening, evaluation, and follow-up services for young children. The recent staff hiring of a Child Find coordinator (a position that has remained vacant for several years) will expand EI’s efforts to reach more diverse, under-served children and their families.

 

With new staff resources, Hiʻilei and EIS are poised to increase the DOH Title V developmental screening program efforts. The programs will collaborate with the CSHN Branch Early Childhood Coordinator to continue the systems-building work started by the federal ECCS grant. The team will meet over the next year to review and identify strategies and work plans.

 

ECCS Grant: As the new ECCS strategic plan is developed, the activities pertinent to development screening will be incorporated into the Title V developmental screening plans. One of the performance measures for the new ECCS HIPP grant is to support child development through developmental screening. ASQ training continues to be conducted to encourage this outcome.

 

Medicaid Data: In 2023, Medicaid provided developmental screening data for FY 2022. The percentages representing only children under Medicaid and are somewhat lower than the NSCH estimates. There was a slight improvement over the FY 2021 data, except for toddlers 1-2 years. Medicaid is working to improve the quality of these national measures that will yield disaggregated rates by county, race/ethnicity, and insurance plan.

 

Developmental Screening in First Three Years of Life - Birth to one year	26.43%
Developmental Screening in First Three Years of Life - >1 year to 2 years	24.17%
Developmental Screening in First Three Years of Life - >2 years to 3 years	21.16%
Developmental Screening in First Three Years of Life - Total	24.14%

 

EPSDT Coordinators meeting: Title V plans to partner with Medicaid to help increase these rates. CSHNB staff have presented at the EPSDT Coordinators meeting and continue to attend to share information and provide support. DHS invites direct service health coordinators and program staff to attend these meetings to support Medicaid-eligible children. DOH uses these meetings as networking opportunities to make connections to promote developmental screening activities.

CDC Learn the Signs Act Early: Although federal funding from the CDC Learn the Signs Act Early COVID Response funds ended in June 2022, the Hawaii CDC LTSAE Ambassador, Dr. Jeffrey Okamoto, continues to work with DOH on projects to support developmental monitoring activities and promote the LTSAE material for families and providers. During this time, activities included translating materials for families into Chuukese and Marshallese, convening stakeholder meetings to address developmental monitoring in state programs and healthcare settings, and public awareness events through morning news shows.

Project LAUNCH grant: CSHNB received a Substance Abuse and Mental Health Services Administration Project Linking Actions for Unmet Needs in Children's Health (Project LAUNCH) grant, and one of the strategies is to promote developmental screening and other screens to identify children who might have developmental or behavioral concerns and refer them to services to mitigate severe emotional disturbances (SED). 

 

Review of Action Plan

The logic model for Title V NPM 6 was developed based on the goals of the ECCS Impact Grant that ended in FY 2021. However, the system/community-level strategies remain relevant in FY 2022. The strategies reflected initiatives at the community, statewide, and national efforts and included input from partners and feedback from families and providers solicited at collective impact convenings and community events. By working on these five strategies, Hawaii planned to increase the number of children receiving a developmental screening by addressing systemic challenges.

 

Challenges Encountered

In 2022, challenges continue in several key areas.

 

Timeliness of referrals continues to be a concern. In 2022, the challenge is most impacted by pandemic repercussions on the workforce. Serious concerns have stemmed from workforce vacancies that have left medical providers, childcare, EIS, and Early Childhood Education (ECE) struggling to service community need properly. Though Hawaii’s Title V Developmental Screening partners must ensure timely and accessible interventions, connecting families with expert services has become even more strained when concerns arise. Providers conducting screenings must refer children in the "referral range" to EIS within seven days after being identified, per the Federal IDEA statute. Before Covid-19, the seven-day referral standard needed to be more widely promoted and adopted to ensure timely referrals were consistent. The added stress of workforce depletion across sectors has made this standard even more difficult to uphold.

 

Lack of Coordination. While there is some improvement in referral and intake coordination, infrastructure development to better integrate services is still necessary. With EIS's strict confidentiality standards in conferring with referring providers, the referral process is hampered when signed consents are difficult to attain. The interest in a coordinated intake and referral cross-sector system has stemmed from this statewide challenge.

 

Access School Services. Once referrals are made, parents of children with developmental concerns have difficulty accessing appropriate school services. In the pandemic recovery, this has become more salient with social-emotional concerns that are more frequently discovered. Frustration, avoidance, and adversarial perceptions are outcomes when parents combat community stigma and burden of proof as to how the newly discovered developmental issue adversely impacts their child’s education. A standardized consideration to consistently use screening results in the school evaluation to better support parents could improve the process. This and increased training opportunities and system change strategies may help services think through what is required and necessary to properly connect a child with developmental concerns with services.

 

Data Limitations: Data to help inform system improvement and policy change is another challenge. The funding and administrative barriers are too prohibitive for Hawaii to pursue an NSCH oversample that could generate more stable estimates for NPM 5, disaggregated data for Hawaii ethnic groups, and county-level estimates. While developmental screening data from Medicaid healthcare providers is important, much of the  developmental screening in Hawaii is conducted by family service agencies. Currently, there is no systematic data source to determine the actual number of screens and follow-ups, including proper ethnic/race and geographical breakdowns, conducted by these direct service providers. Improvement in cross-sector screening and referral data collection would reflect the developmental screening efforts in Hawaii more accurately.

 

Public Awareness: Building public awareness and effective messaging to encourage developmental screening are improving with media messaging and the efforts made through CDC LTSAE and community partners. As mandates were lifted and the workforce returned, prioritizing developmental screens remained challenging given the priorities faced by many families coming out of the pandemic. However, COVID also provided opportunities to create a more responsive and accessible system supported by additional federal funds.

 

Telehealth Challenge/Opportunity: With telemedicine services becoming the new normal, there is a concern that parents are opting out of in-person doctor's visits where young children would normally receive immunizations and developmental screening. Online developmental screening tools may provide greater access to parents more comfortable with online services. Moreover, federal pandemic relief funding is expanding broadband and telehealth services to under-resourced communities statewide.

 

Overall Impact

Statewide Partnerships: The Early Childhood State Plan and other early childhood coalitions continue to identify developmental screening as a key priority. Providers and partners work collaboratively to stress the importance of developmental screening through a validated screening tool. All understand the method to include the referral process, including timely and consistent communication with the child’s medical home. The work to promote a more seamless system of screening and referral continues.

 

ECCS HIPP Grant: The Hawaii ECCS HIPP grant considers a sustainable and improved integration of the maternal infant health and early childhood system. Developmental screening and referral learned lessons from the ECCS Impact grant continue to inform efforts promoting young children’s developmental health.

 

Providers: Title V continues to progress by working directly with pediatric providers in the AAP-Hawaii Chapter and collaborating with the Hawaii CDC Act Early Ambassador, Dr. Jeff Okamoto. Title V will continue to work with the Medicaid program to better reach and support this underserved population.

 

Committed efforts by programs like MIECHV and other early childhood programs to conduct developmental screenings contribute to statewide efforts. Working with early childhood providers, efforts will continue to promote developmental screening and sharing of information with the child’s medical home. Normalizing screening in early childhood services and well-child visits will ensure developmental monitoring and follow-up occur.

 

Data: Accessing Medicaid developmental screening quality assurance data was helpful but only if it can be used to engage Medicaid plans and providers to increase screenings. Approximately 40% of Hawaii’s children are insured through Medicaid, with enrollments significantly increasing during COVID. EPSDT office visit data, when available, should provide vital insights into child health and provider performance.

 

Hawaii will continue to explore and advocate for improved national and state data on developmental screening.

 

 

 

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

 

Introduction: Child Abuse and Neglect Prevention

The 2020 Title V needs assessment confirmed that Child Abuse and Neglect (CAN) prevention will continue as a priority under the Child Domain. Child maltreatment continues to be a foremost concern for the state. Community needs span the spectrum, from primary prevention services to support families and improvements to the Child Welfare Service system to promote family unity and prevent children from unnecessarily entering foster care.

 

Data: The latest data is for confirmed child abuse cases from the 2021 DHS State Child Abuse and Neglect Report, which showed increases in confirmed cases in 2021 over the previous year. The increases may not reflect a worsening trend but rather a return to pre-COVID case levels.

• The number of confirmed duplicative cases for children ages 0-5 increased from 1,276 in 2020 to 1,495 in 2021

• Infants under one year of age continued to account for the highest percentage of abuse (15.7% of total confirmed cases).
• Children five and under accounted for 41.9% of all confirmed cases, a slight decrease from 2020.
• Geographic and ethnic disparities remained: Hawaii, Honolulu, and Kauai counties experienced increases in the number of confirmed cases in 2021, with Maui County indicating a decrease in confirmed cases.
• Hawaiian/Part Hawaiian children continued to be overrepresented among confirmed CAN cases for all age groups, largely due to historical, systemic racism, social factors, historical discrimination policies and practices, and poverty.

 

All types of reported cases of child abuse & neglect increased in 2021:

• Threatened harm remained the most common type of reported maltreatment (5,337),
• Neglect was the 2nd most common type of reported maltreatment (1,080),
• Physical abuse was the 3rd most common type of reported maltreatment (703), and
• Sexual abuse was the 4th most common type of reported maltreatment (294).

Sex trafficking cases almost doubled in 2021, from 60 cases in 2020 to 114 cases.

 

In 2021, the highest-reported precipitating factors of abuse or neglect of children of all ages were:

• inappropriate child-rearing methods (70%),
• inability to cope with parenting responsibility (67.9%), and
• drug abuse (34%).

 

The number of confirmed cases attributable to mandated reporters increased in 2021 from 2020. This was likely due to 2020 stricter COVID-related policies, such as school closures and use of virtual case management.  Other than medical personnel, the sources of mandated reporters increased in 2021, particularly for legal, law enforcement, and criminal justice personnel (388 to 459).

 

Objectives: After reviewing the baseline data, the objective was a 5% improvement through 2025.

 

Title V Lead/Funding: The Title V Child Abuse and Neglect Prevention Program (CANP-P) is administratively located in the Maternal and Child Health Branch (MCHB) within the Family Support and Violence Prevention Section (FSVPS). The section also includes programs: Sexual Violence Prevention, Domestic Violence, Parenting Support, and Maternal Infant and Early Childhood Home Visiting (MIECHV). The CANP-P is funded by the Administration for Children and Families (ACF) Community-Based Child Abuse Prevention (CBCAP) formula grant. Initially, The CANP-P coordinator position was vacant since October 2022 but was filled in April 2023. While Title V does not directly fund CAN prevention activities, it does fund key staff positions related to the program, including MCH Branch support staff, such as the Branch research statistician.

 

Strategies: Child abuse and neglect (CAN) are complex problems rooted in social and health inequities, unhealthy relationships, and environments. Preventing CAN requires addressing individual, relational, community, and societal factors. For the new period 2021-2025, CAN strategies were revised to reflect more of a public health systems approach:

• Support the collaboration and integration of family strengthening and child maltreatment prevention programs and activities across federal, state, local, and private programs and organizations.
• Provide training and technical assistance to community-based, prevention-focused programs to strengthen families,  prevent child abuse and neglect, and foster appreciation and knowledge of diverse populations.
• Promote Health Equity by systemically addressing disparities in confirmed CAN cases.

 

CANP-P addresses primary prevention and secondary prevention work. Grant funds are used to support the following activities:

• Community-based efforts to develop, operate, expand, enhance, and coordinate initiatives, programs, and activities to help prevent CAN
• Support the coordination of resources and activities to strengthen and support families to reduce the likelihood of CAN
• Foster understanding, appreciation, and knowledge of diverse populations in order to effectively prevent and treat CAN

 

Evidence: While CAN Prevention is not a Title V NPM, research presented by the MCH Evidence Center from the Child Safety Network supports Hawaii crosscutting strategies that leverage partnerships supporting evidence-based/informed CAN programs and practices.

 

COVID Updates: While life in 2022 largely returned to pre-COVID norms, the social consequences of the pandemic continue to impact Hawaii families, mainly due to rising economic stressors. The social consequences are typically associated with family stress and violence due to under- and unemployment, lack of affordable childcare, housing, and increased financial insecurity. Poor coping strategies, including the increased use of alcohol and other substances, elevate the risk of abuse and neglect. Client contacts with the Domestic Violence Action Center have increased nearly sixfold, from 519 in 2019 to 3,038 in 2020. The Center reported that the need to develop safety plans with clients rose almost twofold, from 692 to 1,066 in the same period.

 

Updates for 2022 on the three strategies follow.

 

Strategy 1: Support the collaboration and integration of family strengthening and child maltreatment prevention programs and activities across federal, state, local, and private programs and organizations

This strategy focuses on the key system partnerships CAN-P supports to assure a coordinated statewide system of services to prevent and address CAN. State, local, and community programs have specific strengths and expertise in reducing CAN and building safe and resilient families and communities. Interagency collaborations across child-serving systems include: public health, child welfare, education, early childhood service providers, and other public and private agencies and organizations. Together, these diverse partners help to strengthen and support families by addressing the needs of children and their parents/caregivers. A list of the primary CAN agencies/programs follow.

 

Department of Education (DOE): DOE is a key agency partner in efforts to identify, report, treat, and prevent CAN. The DOE Trauma Recovery Project ensures that low-income students who have experienced trauma receive trauma-specific mental health services. The Project expands the capacity of DOE counselors and other staff on using Trauma-Informed Care (TIC) as the standard across the DOE system. TIC practices ensure that agencies and programs serving children and families who experience any form of violence understand the impact of trauma on child development and how to minimize its effects when providing TIC services. DOE staff are regularly invited to participate in CANP-P-sponsored training events.

 

Department of Human Services (DHS). DHS is a key partner for Hawaii in addressing CAN since it houses Child Welfare Services (CWS) and entitlement programs, such as SNAP, Medicaid, and affordable housing support. The 2018 federal Family First Prevention Services Act (FFPSA) shifted the focus of the child welfare system toward maintaining children's safety within their families via family-strengthening supports. The CANP-P has partnered to develop and implement the State Child and Family Services Plan (CFSP). Efforts focused on improving connections to family strengthening resources, including identifying service gaps and piloting family programs, such as the Zero to Three Family Court and the ‘Ohana Visitation Time System of Care model (‘Ohana means family in Hawaiian).

 

Family Resource Centers. CANP-P joined in successfully supporting legislation in 2022 to create a 5-year program that coordinates statewide efforts to develop Family Resource Centers (FRC). The FRC program will be located within DHS and coordinate partners across state departments and private providers. FRC are community-based resource hubs where families can access supports to promote health and well-being. FRCs are a critical way to prevent CAN while strengthening families. They have effectively connected families to services, created opportunities for community-level coordination and connections to resources and support systems, and increased family engagement. National research has shown that FRCs have lowered rates of CAN cases, reduced the number of children entering foster care, and decreased parent unemployment.

 

The new FRC program ensures that community and school-based FRCs coordinate as a statewide network, establishing practice/training standards and developing referral/data protocols to serve families.

 

CAN-P helped provide training/technical assistance for the four DOE school-based centers established on Oahu and joined the newly-established statewide FRC organization, the Hawaii Family Ohana Support Network: https://www.hawaiiohanasupportnetwork.org/ 

 

Office of Wellness & Resilience. Another CANP-related state legislative bill passed in 2022 creates the country’s first statewide Office of Wellness & Resilience focused on promoting wellness and resilience efforts across state departments to develop a trauma-informed service system that better assists Hawaii families while improving community health. CANP-P and several Title V programs are involved in this collaborative effort.

 

Hawaii Children's Trust Fund (HCTF): HCTF is a public-private partnership between the Department of Health (DOH) and the Hawaii Community Foundation (HCF), which administers grant-making funds for HCTF operations. The funds are used to build and maintain a strong network of family-strengthening services that promote and support child abuse and neglect prevention work. HCTF work is carried out through a statewide coalition, an advisory board (AB), and an advisory committee (AC) to ensure that diverse/broad community input is incorporated. The DOH serves on all HCTF governing bodies.

 

Broad public and private sector community collaboration ensured the success of the many CANP Awareness Month events held statewide during April 2022, building awareness about preventing CAN.

 

Strategy 2: Provide training and technical assistance to community-based prevention programs to strengthen families and prevent child abuse and neglect.

Throughout the 2020-2022 COVID period, the CANP program continued to sponsor and support virtual trainings open to community partners.

 

Webinars: CANP-P funded four unique webinars in 2022 that were open to private and public agencies and their staff involved in CANP and family strengthening. The webinar topics addressed included: the effects of trauma, common responses to trauma, and ways to mitigate negative responses. The webinars included:

• Stamp Resilience Into Your Brain – building mental resources and inner strengths
• Using our Brains to Create Safe, Connected, Empowered Organizations and Communities – how neuroscience informs actions that help regulate the stress response system
• When Stress Becomes Toxic – addressing stress
• Micronesian Migrants in the US: – how health issues, social determinants of health, and effects of COVIDwas evidenced in disparities and inequities in the Micronesian community; improving culturally aware services.

 

Certified Trainings. CBCAP grant funds sponsored FRC Standards Certification Training, developed by the National Family Support Network (NFSN) to build the quality of staff practice as more FRC centers are created in the state.

 

Parent Leadership Training. The CBCAP supports parent leadership and participation in planning and implementing grant-funded CANP initiatives. In 2022, CANP-P funded two virtual Parent Leadership Training Institute (PLTI) cohorts. PLTI is an evidence-based model that provides parents core technical and practical skills/knowledge to be effective advocates for their children and change agents in their community. Parents attended 20 evening sessions and completed a community project, putting learned skills into practice. Several PLTI community projects addressed CANP, such as creating a peer-peer support group for pregnant women who were abused as children and an indigenous-focused leadership program for mothers and daughters.

 

Conferences. The FSVPS and MCHB Home Visiting Unit collaborated on a two-day virtual Kahewai Summit in Fall 2021 to provide educational training support for early childhood providers on trauma-informed care. This included culturally-informed approaches to prevent Adverse Childhood Experiences (ACEs) by acknowledging and addressing the historical and generational trauma experienced by Native Hawaiians and other ethnic groups.

 

Strategy 3: Promote health equity by addressing disparities in confirmed CAN cases.

Each island has pockets of geographic areas with higher numbers of confirmed CAN cases. Based on existing CAN disparities-related data, CBCAP funds were awarded under the American Rescue Plan Act (ARPA) and distributed to community-based providers serving communities and populations at risk, including Native Hawaiians and Micronesians, families with lower income levels, as well as those adversely affected by COVID. Contracts included support for the Maui CAN Prevention Coalition and the Hoʻoikaika Partnership. Additional state general funds were distributed to support neighbor island CAN prevention projects.

 

In 2021, CBCAP supported launching the new Early Child Action Strategies initiative, Aloha At Home. It is rooted in traditional Hawaiian values and the protective factors that can help to guide and ground families as they pursue family resiliency. The first phase of the Aloha At Home project promoted activities that build positive and healthy interactions between young children and their parents/caregivers, using simple activity ideas and free activity boxes available through alohaathome.org.

 

Current Year Highlights for FY 2023 (10/1/2022 – 6/30/2023)

Over $600,000 in ARPA CBCAP funds were contracted with community organizations statewide to provide services to help prevent family violence while supporting family strengthening/resiliency. The services help to promote specific protective factor strategies to prevent CAN. These services include:

• public awareness events and family fun activities
• development of educational materials to support family resiliency, mental health information
• new parent support classes for families with newborns
• neighbor island coalition-building around family violence prevention
• a directory of asynchronous online (self-directed) learning websites, with protective factors serving as the framework
• support for a peer-to-peer support/learning program for families of young children
• media campaigns to promote family support services and resiliency messages
• parent leadership trainings

A contract was also executed with the Department of Education to provide sexual health education training to educators and develop a sexual health curriculum for students and their families.

 

Funds were allocated to community organizations in all counties to address CAN prevention strategies in collaboration with county public and private partners. CAN prevention initiatives targeted vulnerable populations, such as those with children with disabilities, homeless or at-risk for homelessness, Native Hawaiian/Pacific Island families, and/or families residing in shelters or public housing. The CBCAP funds were supplemented with an additional $200,000 in state general funds.

 

Family Resource Centers (FRC) FRC are an evidence-based approach to provide coordinated, accessible program supports that target communities/populations. The state FRC Coordinator was hired and convened a cohort of public-private agencies in a team-building process facilitated by One Shared Future (OSF). OSF is a unique firm created by the former state Department of Human Services director to support public professionals (and their community partners) to initiate effective organizational and community change by fostering collaboration and innovation. The 10-session collaborative cohort established strong cross-sector relationships and ideas to lay a strong foundation to drive future FRC work. The FHSD Adolescent Health Coordinator and CSHN lead for developmental screening were part of the cohort.

 

Nā Kama a Hāloa A group of Native Hawaiian organizations and service providers, Nā Kama a Hāloa, has been meeting since 2018 to improve outcomes for Native Hawaiian children and families involved in CWS. Native Hawaiians are over-represented in the CWS program. The network has improved the child welfare system by:

• Created an advisory council of parents with experience in the CWS system to improve child welfare services.
• Created a peer support program for parents currently in the system and pregnant women experiencing substance use disorder.
• Developed a new hire training on Native Hawaiian history and cultural training module for CWS staff and contracted providers.
• Made practice changes to better support sibling connections for children in foster care.

 

In FY 2023, FHSD was invited to participate in the network to share information on family support and healthcare services.

 

Mālama Ohana Working Group In 2023, the governor signed legislation to establish within the Office of Wellness and Resiliency, the Mālama Ohana Working Group to help transform the existing CWS program and integrate community perspectives and existing work into state government. The focus of the working group will be expanded to include representatives from those representing families who have special needs/disabilities, as well as LGBTQ families.

 

Conference. The FSVPS and MCHB Home Visiting Unit collaborated on a two-day virtual Summit in April 2023 that focused on wellness and resilience for providers serving children ages 0-5 years.

 

CBCAP Staffing. In April 2023, the CBCAP vacancy was filled. The new staff person is learning about the position, partners, the CBCAP grant, and the grant service contracts.

 

Review of Action Plan

The revised CANP logic model provides an overview of the strategic approach to prevent CAN. The effort cannot be addressed as a standalone public health concern, instead incorporating a diverse array of public partners/resources to address CAN in Hawaii. The logic model also confirms the importance of acknowledging and addressing contextual conditions that impact and influence CAN negatively or positively in tandem with programs that specifically target family violence prevention.

 

 

Challenges and Barriers

Reaching Families during COVID: Services to communities and families were offered online virtually from 2020-2022, resulting in several logistical challenges. Some service providers did not have sufficient IT equipment. Clients residing in rural areas of the state often lacked access to broadband, digital devices, and skills to use software programs. In response, federal relief funds were used to support the purchase of IT equipment for selected community providers and families. CBCAP funds were used to support at-risk Micronesian communities to procure IT supplies and subscriptions; help assist children better participate in educational distance learning; and schedule and attend telehealth and related services appointments. Many services/resources continue to be offered remotely; thus, the assistance provided to communities/families continues to expand access.

 

Workforce Shortages: In 2021, Hawaii Children’s Trust Fund Coalition members participated in a workforce development/training survey. Members reported common staff-related recruitment and retention challenges, including;

• Job applicants often lacked the necessary position-related credentials.
• Low salary levels did not attract qualified applicants.
• Staff workload stress grew due to number of agency’s staff vacancies.
• Required use of hybrid virtual work scheduling did not always support staff needs.
• Lack of professional development and career pathways for current staff.

 

In response to the challenges, some organizations expanded professional development trainings and widely share position recruitment announcements. The DHS/CWS expanded online learning opportunities for staff. The CANP is contracting to expand online educational modules for service providers and families.

 

Overall Impact

Key overall CANP activities and partnerships that are helping to support service system improvements:

• Developing collaborative prevention strategies reflected in the DHS 2020-2024 Child and Family Services Plan, such as expanding Ohana Time with families.
• Continued CAN coalition building and partnerships with state and community-based programs and organizations
• Timely disbursement of federal ARPA funds, supplemented by state funds, to strengthen family services and prevent CAN.
• Sponsoring and expanding accessibility of trainings via virtual platforms, to increase knowledge, skills, and/or attitudes of staff who work with families, including those who may be at risk for CAN.  
• Act 129 signed into law in 2023 by the governor established the FRC Pilot Program within the DHS with coordination with DOH and DOE. Requires the Departments of Human Services, Education, and Health to work with public and private entities to develop and implement family resource centers.

 

 

 

SPM 5: The percentage of Medicaid children receiving six or more well-child visits in the first 15 months of life

 

Introduction: Well Child Visits

For the Child Health domain, Hawaii added this state priority in 2021 to promote child wellness visits and routine immunizations, especially for young children ages birth through five. The priority is a result of ongoing assessment and concerns raised during COVID that many families were postponing or delaying care due to provider office closures, lockdowns, and safety concerns. Initially, the effort was to ensure that families continued with well-child in-person or telehealth visits to ensure medical providers could complete their developmental surveillance of children. The effort continued to focus on well-child visits and ensuring that comprehensive screenings for development, behavior, hearing, vision, obesity, mental health, and oral health were being conducted to identify children in need of more intensive follow-up and services.

 

Data: The data for this measure is from the annual state CMS Medicaid Core quality assurance measure: Children receiving six or more well-child visits in the first 15 months of life. The 2022 data shows child wellness visits remained stable over 2021-2022 (63.8%) but did drop somewhat from 73.2% in 2019. Using 2019 data (latest available national data), Hawaii ranked ninth highest among states for CWV, exceeding the national average of 65.6%

 

A second CMS quality measure for well-child visits for ages 15 to 30 months (with two or more visits) showed 68.6% had a CWV in 2022, slightly lower than 76.0% in 2021. At this time, there is no disaggregated data for these measures and no national comparison data for FFY 2021.

 

Data from the 2020-2021 National Survey on Children’s Health indicated 75.1% of children 0-17 years had one or more preventive visits in Hawaii, a slight decrease from 79.7% in 2019-2020. An estimated 73,495 children did not receive a preventive visit. The percentage of those receiving a preventive visit by age group:

• 87.6% of children ages 0-5 years (from 85.5% in 2020-21)
• 72.9% ages 6-11 years (from 78.2% in 2020-21)
• 66.3% ages 12-17 years (from 73.4% in 2020-21)

 

All Hawaii rates were comparable to the U.S. estimates, which saw similar decreases in preventive visits.

 

Objectives: Considering the baseline data and the HP 2030 objective, the state objectives through 2025 were set to reflect one percentage point increase annually.

 

Title V Lead/Funding: The Title V leads for this project include the Home Visiting Services Unit Supervisor, the Children with Special Health Needs Branch Early Childhood Coordinator, FHSD Public Information Officer (PIO), and Title V grant coordinator. The PIO, an essential lead for the effort, is funded by Title V. Other programs include EI, Lead Screening, WIC, and CSHN. State general funds were used to cover the major media and community outreach campaign costs.

 

Partners: The key external partners are the American Academy of Pediatrics-Hawaii Chapter (AAP-H), State Medicaid program, and Hawaii Children’s Action Network (HCAN).

 

Strategies/Evidence: Hawaii plans to conduct a public awareness campaign to promote child wellness visits, particularly for young children.

 

Strategies include:

• Collaborate with pediatric providers and community advocates to promote messaging on the importance of well-child visits
• Conduct a public awareness campaign and measure the effectiveness of messaging (i.e., increased visits to the doctor, increased number of vaccinations for the home visiting population)
• Build capacity for developing pediatric champions to promote ongoing messaging campaign

 

Although no specific MCH evidence exists on well-child visits, the evidence for Adolescent Well-Visit strategies and Medical Home was reviewed. Patient reminders are identified as emerging evidence in increasing well-child visits. Another added value of the medical home model indicates collaborating with home visiting serves as emerging evidence. An MCH Evidence Center brief on public health messaging also indicated emerging evidence for this strategy, especially in reinforcing a mass media campaign with social media and community coordination.

 

Strategy 1: Collaboration with Pediatric Providers

As part of the initial public health COVID-19 mitigation strategies, mandatory closures meant that services for children and families became virtual and in-person well-child visits to the doctor were limited. Through 2022, the increased availability of adult COVID vaccinations resulted in safety restrictions being removed with services reopening.

 

In Fall 2021, a workgroup consisting of FHSD, Med-QUEST, DOH’s Chronic Disease Prevention and Public Health Promotion Division, AAP-Hawaii Chapter (HAAP), and HCAN convened to develop messaging for the public awareness campaign to encourage more Child Wellness Visits (CWV), especially for young children. While the COVID cases appeared to be decreasing towards the end of 2021, the Delta variant started to surge. Some doctors’ offices were reopening for in-person visits with well-established safety procedures and easy access to PPE (initially in short supply); however, the Delta variant heightened concerns for closures again. This partnership with the HAAP and Med-QUEST Division and Title V continues to meet to support efforts to promote the medical home. Some of the efforts included:

• FHSD established a connection with the HAAP President and Vice-President to serve on the workgroup, which held monthly meetings. 
• The HAAP representatives shared information with their chapter members through articles in their newsletter and even identified pediatric champions to be filmed in the Public Service Announcement (PSA) commercials.
• A website, Keiki Check Up (www.keikicheckup.com), was created where families could find information about where to find a pediatrician and other resources.

 

Strategy 2: Conduct Public Awareness Campaign

Initially, the media campaign launch was set for September 2021, well-after public schools opened in August to full in-person instruction (after more than a year of distance learning due to COVID). The September launch was timed to avoid any conflict with health messaging promoting routine immunizations required for school entry and COVID vaccinations for eligible adolescents (from age 12 at the time). Because of the Delta Variant surge, the campaign was postponed until November 2021 when the COVID numbers started declining. The group decided on the message "Time for a Checkup" after conducting focus groups with families from the Home Visiting program. The following are the activities that were conducted:

 

• Public Service Announcement (PSA) commercials targeted adults, ages 25-54, in approximately 245,271 households. The paid media campaign included television spots, live morning news interviews, and taped news stories with pediatricians discussing the importance of well-child visits. The radio spots also ran over the two months and were translated into Chuukese, Tagalog, Ilocano, and Marshallese languages, which were determined to be the populations having the lowest number of well-child visits per service provider. Print campaign materials were developed and shared on community websites.
• The team relied on media viewership measures (i.e., number of views) and hits to the website to document the reach of the messaging campaign. Title V programs that track CWV as a part of their client visit data would also monitor changes, as Med-QUEST shared that their data was based on claims data and may not be available until the end of the reporting year.
• The website was launched in November 2021 and had 6,862 page views with 5,197 unique views with 208 clicks on the page (links to other resources we listed).
• The messaging was also shared through the DOH Community Bulletin, the state source for COVID-related information and resources. The Bulletin featured short interviews with families, providing a family-focused perspective on the importance of CWV.
• Display ads were drafted and shared with community partners and agencies to post on their websites. Medicaid also shared the PSA and digital ads to promote more wellness visits via their managed care contractors. Previews of the commercial were shared with pediatricians via the AAP to prepare providers for potential increased calls from families wanting to schedule a visit.
• As more moneys became available, FHSD launched a second campaign that promoted screening efforts using the same footage as the first and updated the website. The script for the second campaign was developed with input from the team and is listed here:  Do you have questions about how your child is developing? The next time you take your child to the doctor, ask them to check their hearing, vision, and behavior. Your child's doctor has the latest information on what to look for. It's a quick way to answer your questions and get support for any concerns. It's time to check up on your keiki! To learn more, visit keikicheckup.com.

 

Strategy 3: Build Capacity for Pediatric Champions

 

Although the project's primary focus was to conduct the public awareness campaign promoting annual well-child visits, Hawaii used this opportunity to build capacity for pediatric champions by supporting AAP members as speakers for improving child health. Pediatric providers actively participated in media activities, including producing public service ads (voiceovers, “actors”) and providing live and taped interviews on morning TV shows and news programs. These providers represented diverse populations by race, ethnicity, and gender.

 

Efforts included:

The local AAP-Hawaii Chapter also worked on developing pediatric champions and assisted providers with professional training in public speaking. Hawaii partners continued to work together on the following:

• CSHNB worked with AAP-Hawaii Chapter on other medical home messages, COVID-related information, the national CDC Learn the Signs Act Early campaign, and other Title V priority issues.
• The AAP-Hawaii Chapter helped identify a local pediatrician to be interviewed on a morning news television show in a special segment focusing on the well-child visit.

 

Current Year Highlights for FY 2023 (10/1/2022 – 6/30/2023)

The group continues to meet to work on a toolkit of resources for families and to keep the connection between DOH and AAP-Hawaii Chapter. Some of the activities included:

• FHSD PIO secured media spots to promote the AAP-Hawaii Chapter's work on the CDC Learn the Signs Act Early campaign, which promotes developmental monitoring of children's health. The AAP-Hawaii Chapter's President, who is also the CDC Learn the Signs Act Early Ambassador, was featured on several morning news shows talking about the campaign. This spot was the most clicked link on the homepage on 11/30/2022, which gave the segment more visibility. 
• HCAN drafted a magnet with the well-child visit schedules with the website QR code that can be given to families. A frame where parents can insert their child's photo with the well-child visit schedule can be downloaded from the website. These mockups of the magnet and baby photo props would be distributed to families through DOH programs.
• With the news of the COVID Public Health Emergency (PHE) Unwinding, the group decided to continue to meet to monitor the situation to ensure pediatric providers are aware of the situation and continue to monitor children's eligibility. Many of the FHSD programs have assisted by ensuring their families are aware of the important letters from Med-QUEST to ensure they are aware of the situation and to help when needed.
• The website has been updated to provide information about the PHE Unwinding with information from Med-QUEST and other supports for families.

 

Challenges Encountered

Hawaii is fortunate to work with AAP-Hawaii Chapter and Med-QUEST on these important issues and to help promote the medical home. However, even with these partnerships, challenges remain, such as:

• Lack of access to timely data from Med-QUEST, which usually has a one-year lag to access the data from their claims data. Providers have until the end of the reporting year to enter their claims data, which means there is no timely data available to measure the campaign's effectiveness based on the airing of the PSAs. 
• Although Hawaii identified children who are Native Hawaiian or Filipino as having the lowest number of well-child visits based on home visiting data, there is limited disaggregated data on this target population. Fortunately, home visiting data was available to track if there were improvements to the well-child visit. However, the NSCH sample size is too small and FHSD is still waiting to see if race and ethnicity data for pregnant women will be available. 
• FHSD has several vacancies that limit connections between community partners and key target populations. 

 

Overall Impact

While launching the public service announcements was a great activity to accomplish with this SPM, the overall impact is the establishment of the workgroup, which continues to support this collaborative partnership. Some of the other impacts include:

• FHSD is still waiting for the data to assess the campaign's effectiveness. It is easy to see the number of views or hits to the website; however, the more important evaluation is whether there was behavioral change because of the PSAs. FHSD hopes that data from Med-QUEST will help to show an increase in well-child visits that may be attributed to this effort.
• There are positive responses from the pediatric community, and many of the champions featured on the news shows continue to get recognized.
• FHSD received many compliments from the home visiting program collective, Your ‘Ohana, who was able to recognize their logo on the campaigns.
• The website continues to be updated, and with the campaign, the hope is that it helped increase awareness of the importance of well-child visits and developmental, hearing, vision, behavioral, lead, and oral health screenings.
• The workgroup continues to meet, especially as there is concern that due to the PHE Unwinding, there may be children who lose their healthcare coverage. The members recognize the critical role they can play in supporting these families.
• While FHSD has always had a strong relationship with the Med-QUEST program, the Medical Director made a connection with the Title V Children and Youth with Special Health Needs Section Supervisor and invited her to participate in regular meetings with their EPSDT Medicaid Coordinators.