An early childhood system of care ensures comprehensive, coordinated, individualized, family-driven services and supports for young children and families. The WCHS promotes the integration and coordination of discrete child and parent services across all service sectors into a comprehensive system that “connects the dots” within the service community by participating in or facilitating many collaborative activities at the state, regional, and local levels. Through multiple collaborative opportunities, the WCHS convenes internal and external partners in planning and implementation of programs, including those supported by Title V funds. The WCHS supports a system of care that uses a public health model to provide a continuum of care, promoting positive well-being, preventing problems in high-risk populations, and intervening/treating in a comprehensive manner when problems do arise. It is the collaborative relationships among the provider agencies, parents, human services agencies, schools, child care, and other stakeholders and a common set of values and goals that enables providers to see the broader needs of families, set aside turf issues, and utilize existing or build community services to benefit the health and well-being of infants, children, adolescents, and their families.
Working within this comprehensive system of care, the WCHS, and in particular, the C&Y Branch, is focused on collaborative strategies to increase the percent of children, ages 9 through 35 months, receiving a developmental screening using a parent-completed tool in the past year (NPM#6), increasing discussions with parents and caregivers about development, and accessing appropriate care. Per the 2018-19 NSCH, 48.1% of children in NC between 9-35 months had received appropriate developmental screening which is an increase from 43% in the 2017-18 NSCH and higher than the national average of 36.4%. While this makes NC the fifth leading state in the nation, there is still much room for improvement. It should be noted that the percentage for NC should be interpreted with caution as the estimate has a 95% confidence interval width exceeding 20 percentage points and may not be reliable.
The C&Y Branch helps support the provision of preventive health services to children from birth to 21 years of age primarily through LHD clinics which incorporate multiple types of screenings including developmental screenings. The ESM selected for this NPM is the number of training opportunities offered to LHD providers on appropriate use of valid and reliable developmental, psychosocial, social determinants of health, and behavioral screening tools for children during a state fiscal year. LHD providers include child health providers in the clinic providing direct clinical care as well as Care Management for At Risk Children (CMARC – formerly known as Care Coordination for Children [CC4C]) care managers providing service to clients in their homes or other locations. Screenings that are required at age-appropriate times for visits continued to be required at 6, 12, and 18 or 24 months and then at 3, 4 and 5 years of age in LHDs during well child visits. The schedule of recommended visits and screenings are based on Bright Futures guidelines which are described in detail in the most current NC Medicaid Health Check Program Guide (HCPG). Due to the impacts of the COVID-19 pandemic response, training opportunities were postponed until September 2020 to LHD providers through the Child Health Training Program (CHTP). Four training opportunities were presented during the CHTP which included information on developmental, psychosocial, and behavioral screening and were provided by utilizing the Microsoft Teams Virtual platform. A statewide webinar was also planned and held in July 2020 for all LHD child health clinical staff and CMARC care managers. This webinar was provided in partnership with the two developmental and behavioral pediatricians who were authors of the 2019 AAP policy statement titled Promoting Optimal Development: Identifying Infants and Young Children with Developmental Disorders Through Developmental Surveillance and Screening.
Training opportunities were provided by a mix of live and archived webinars. Consultation and technical assistance were provided to several new LHD providers and current providers who presented questions regarding well child visit components. Guidance was provided regarding developmental, behavioral and maternal depression screening as well as links to past webinars on these topics. The Pediatric Medical Consultant (PMC) revised and continued to use a self-assessment tool for new providers. The self-assessment tool was shared with providers so that they could rate their knowledge, skills and abilities related to all of the well child preventive visit components which include developmental, behavioral and maternal depression screening. This self-assessment tool has assisted the PMC with providing specific technical assistance to meet the needs of the individual providers.
The ability to screen and address issues regarding SDOH such as food insecurity, housing, interpersonal violence, etc., is also important to improving the lives of children. The Branch promoted the use of the NC SCHS’s SDOH by Regions website to LHDs. Screening for non-medical drivers of health and connecting individuals to resources has been a focus of Medicaid Transformation and the state’s efforts to have all payors screen for and address SDOH using the statewide resource platform NCCARE 360. NCCARE 360 was launched statewide in all counties at the end of June 2020 to assist providers with addressing community resources for food, transportation, interpersonal violence, and housing. All LHDs are currently screening for food insecurity, and many are screening for several other SDOH. In FY20, the PMC continued to work with the NC Medical Society Leadership College to provide an interactive session with panelists including the State Health Director regarding SDOH. This session has occurred for the last five years. The PMC has participated on the Technical Assistance Project Advisory Committee (TAPAC) of the AAP Screening Technical Assistance Resource (STAR) Center for the last four years with pediatricians, family and other professionals from across the country. In her role on the TAPAC for the STAR Center, she has continued to develop and review resources related to maternal depression and SDOH which she has specifically promoted to LHDs and child health providers in NC. The PMC participated in an interview about relational health with another pediatric colleague for the AAP STAR newsletter and an AAP STAR Center podcast about social drivers of health and COVID-19. The PMC also participated as faculty for a 9-month learning collaborative for several state teams which included Title V members about screening for SDOH with CYSHCN. She also participated in a nationwide webinar from the National Medical Home Implementation Center about addressing SDOH in CYSHCN.
Child Health Systems of Care
The WCHS continues to focus on ensuring quality and accessible health services for children, including the following: parenting education, nutrition, breastfeeding, well child care, school health, genetic services, newborn metabolic and hearing screening, child care health consultation, developmental screening, early intervention, health care transition, care management to improve linkages with medical homes with more focus on developing plans of safe care for substance affected infants with DSS, screening and treatment clinics, resource line for children with special health care needs, Health Check/NC Health Choice outreach, and support for children/youth/families with special health care needs. The following specific services and programs, while described separately, represent the components of a system of care for young children supported by Title V funding in FY20 to improve the health of all children and decrease child deaths and morbidity.
Child Health Program Educational and Technical Assistance Opportunities
The Child Health Program planned a series of live and archived statewide webinars from July through December 2019 to provide programmatic updates and continuing education for child health clinical staff in LHDs in lieu of holding another statewide conference. The topic of the July 2019 webinar was the NCCARE360 platform. LHDs learned from the NCCARE360 program community engagement coordinator how this joint vision influences health outcomes and improves the health of health department clients. There were 52 participants that completed the live webinar while 92 participants viewed the archived webinar. The August 2019 webinar was on Child Health Enhanced Role Registered Nurse Legal Issues and included information about scope of practice, nursing standing orders, critical thinking skills, documentation, consultation, appropriate ICD-10 codes, and QI processes related to the delivery of well child preventive health visits from birth through 20 years of age. There were 38 participants that completed the live webinar while 48 participants viewed the archived webinar. The topic of the November 2019 webinar was refugee health and was presented by the DPH State Refugee Health Coordinator with the PMC. The webinar helped child health clinic staff in LHDs understand how to recognize and address special considerations for children who are refugees or asylees. Health benefits and the AAP Immigrant Health Tool Kit were reviewed. Additional resources were shared with providers and clinical staff. Conversational strategies and information from the clinical perspectives were provided. The concept of immigrant health status as a SDOH for refugees and asylees were discussed. There were 72 participants that completed the live webinar while 59 participants viewed the archived webinar. The December 2019 webinar addressed the role of child health clinic providers related to vaccine hesitancy and was delivered by staff from the NC Immunization Branch and NC Communicable Disease Branch. The webinar presented current NC exemption data, evidence-based approaches and appropriate resources related to vaccine hesitancy to LHD staff. There were 73 participants that completed the live webinar while 56 participants viewed the archived webinar.
The June 2020 webinar, Making a Difference: Supporting Breastfeeding Families, was conducted by the Pediatric Nutrition Consultant, WIC Peer Counselor Breastfeeding Coordinator, and a Regional Child Health Nurse Consultant, focused on providing guidance to child health clinical staff on the role that staff can have in supporting breastfeeding families. This training assisted clinical staff in identifying barriers that keep families from continuing to breastfeed and discussed ways to create a breastfeeding friendly clinic and community environment. There were 65 participants that completed the live webinar while 42 participants viewed the archived webinar.
The C&Y Branch continues to support the Early Childhood Matrix Team, originally convened with support from a SAMSHA Linking Actions for Unmet Needs in Children’s Health (LAUNCH) grant that included staff from across the State Title V agency. The Matrix Team provided a forum for sharing information, working on collaborative projects, and getting updates on trending topics, including overview of the NC ECAP, workforce development strategies, and infant mortality reduction.
The SCHNC, Best Practices Child Health Nurse Consultant (BPNC), and PMC continued to work on several activities related to updating audit tools for well child visits based on the most current HCPG by NC Medicaid. LHDs were interested in clarification of the Child Health AA and the updated Child Health Program Well Child and Primary Care Audit Tools and Instructions which includes detailed guidance about screening and coding for maternal depression, developmental screening, autism screening, psychosocial/emotional screening, and developmental surveillance in adolescents as well as oral health assessment, dyslipidemia and anemia risk screening.
Child Health Training Program for Child Health Enhanced Role Registered Nurses
The Child Health Training Program (CHTP) is held annually to train and officially roster RNs as Child Health Enhanced Role Registered Nurses (CHERRNs). Once rostered as CHERRNs, they are considered billing providers through NC Medicaid and can provide well child visits to children from birth through 20 years of age including CYSHCN in the LHDs. The focus is to help CHERRNs improve access to preventative health care for underserved and high-risk children. CHERRNs learned to help LHDs serve as medical homes to children or partner with medical homes to serve children including CYSHCN. A total of five RNs from LHDs participated in the 2020 CHTP and successfully completed the course in order to become rostered as a CHERRN. The CHTP covers issues that come up for children during the well visit at the LHD which may require consultation with supervising advanced practice providers or physicians. Topics covered during week one of the CHTP included how to complete a comprehensive pediatric history, pediatric physical assessment skills, critical thinking skills, and Problem Oriented Health Record (POHR) and Bright Futures documentation requirements. Topics covered during week two of the CHTP included: Bright Futures services; required and recommended developmental and behavioral screenings including maternal depression, and substance use screening in adolescents; screening tools; adolescent health; immunizations; use of gender-neutral language; adolescent confidentiality; developing resiliency in adolescents; and addressing health care transition. Additional topics included nutrition assessment, food insecurity, and breastfeeding, critical thinking skills, programmatic and HCPG requirements, documentation, and CHERRN legal issues including CHERRN rostering requirements. The PMC and SCHNC continued to update several presentations for this cohort of students. Trainings by the PMC were devoted to developmental screening and surveillance and behavioral health and social emotional screening. Another presentation focused on adolescents and the importance of motivational interviewing to address social-emotional health and screening for SDOH.
Care Management for At-Risk Children
The Care Management for At-Risk Children (CMARC) program, formally known as Care Coordination for Children (CC4C), is an at-risk population management model which has been provided in partnership with CCNC and NC Medicaid. Medicaid funds children enrolled in this program and Title V funds are used to support non-Medicaid children. CMARC staff serve children from birth to five years of age who meet the following priority risk factors: 1) CSHCN (per Title V definition); 2) children exposed to toxic stress in early childhood including, but not limited to, extreme poverty in conjunction with continuous family chaos, recurrent physical or emotional abuse, chronic neglect, severe and enduring maternal depression, persistent parental substance abuse or repeated exposure to violence in the community or within the family, and children in foster care; and 3) children admitted to the NICU. Referrals to the CMARC program are made from medical homes, hospitals, community organizations and agencies, or families. CCNC-identified Medicaid claims trigger referrals based on the CMARC priority populations. In addition, the C&Y Branch provides funding to LHDs to replicate this service for the birth to five non-Medicaid population.
In addition, program staff continued to meet with the Division of Health Benefits (NC Medicaid) on the transition of Medicaid from a fee-for-service program to NC Medicaid Managed Care. This will include a transition for CMARC to a new relationship with Medicaid which includes contracting with all of the PHPs as Care Management beginning July 1, 2021. The services will remain the same for children and families. The PMC and the CMARC program manager both continued to participate in the Fostering Health NC Initiative to ensure that services for children in foster care are coordinated between the medical home, the DSS worker, and the care manager. More details are in the CYSHCN Domain.
During FY20, the CMARC program continued to make available five trainings as part of the Basic Care Management series and five training topics as part of the Priority Populations series, two of which were presented or co-presented by family members. A third training series continued to be promoted to supervisors to assist them in assuring quality service delivery. An electronic case review tool continued to be used to assist supervisors in assessing service delivery. All local CMARCs continued to be required to complete an annual performance assessment using CQI techniques to identify needs and root causes and then develop effective action plans to address the identified needs. Also, an annual assessment of performance conducted by the state program resulted in five local agencies being identified for a structured performance improvement process. The number of agencies identified decreased by 62% from the previous year.
A “key messages” guidance document for families and community partners and WIC collaboration best practices document continued to be used by CMARC care managers These documents were based on recent gaps and best practices identified from a questionnaire sent out to CMARC care managers in FY18.
The NC Act Early Ambassador presented during one of the bi-monthly webinars in a previous fiscal year to introduce the CDC’s Learn the Signs. Act Early (LTSAE). During FY20, these materials continued to be used by CMARC staff to educate families. The AAP’s Books Build Connections Toolkit also continued to be used by CMARC care managers. The CMARC program electronic resource directory continued to be promoted and updated to help care managers meet the needs of children and their families.
The CMARC care managers continued to use claims data to identify children in the CMARC target populations during FY20. The CMARC program documentation system was transitioned from the Care Management Information System to a new system called Virtual Health to better serve children and families in coordination with CCNC and medical homes. This resulted in a new extensive training for CMARC program staff across the state. This also resulted in some blackout periods when data could not be accessed. The CMARC program and its care managers continued to strengthen their relationships with medical homes to ensure children in the target populations are identified and referred. Care managers continued to coordinate services with each individual child’s medical home to ensure improved health outcomes.
School health assessments (SHA) for all children new to NC public schools continue to occur. The C&Y Branch promotes best practice recommendations for doing a complete well child exam appropriate to the age of the child for the SHA which includes developmental screening and/or developmental surveillance.
SPM#2 – Number of substantiated reports of child abuse and/or neglect
In line with one of the WCHS’s priority needs to decrease child deaths and the Early Childhood Action Plan goal for safe and nurturing relationships, WCHS has selected to continue using one of its former SPMs – number of substantiated reports of child abuse and/or neglect. This is a point in time count and report-based. Thus, one report may include multiple children. In instances where different children have different finding types, only the most severe finding is counted – including abuse/neglect, abuse, neglect, and dependency. Data over the past five years (July 2015 to June 2020) show an average of about 8357 reports per year with a slight trend downward. It is too early to know if the decrease in FY20 was in part due to COVID.
NC Child Fatality Prevention System
The WCHS continued to play a key role in the implementation of the NC Child Fatality Prevention System (CFP System) that serves to prevent child deaths and child maltreatment. The original legislation creating the CFP System was passed in 1991. Three main components of the CFP System include: the NC Child Fatality Task Force (CFTF); the state Child Fatality Prevention Team; and local child death review teams in each county, called Child Fatality Prevention Teams (CFPTs) and Community Child Protection Teams (CCPTs).
The CFTF is a legislative study commission that makes recommendations to the Governor and NC General Assembly focused on laws and policies to prevent child deaths as well as child maltreatment and to promote child safety and well-being.
Although the Task Force is not part of NCDHHS and is not funded by Title V, the position of the Executive Director of the CFTF is in the NCDHHS Office of the Secretary, and several section employees serve on the Task Force, one of its three committees, or have participated in various CFTF efforts. In particular, the NC Title V Director serves as a statutory member of the Task Force, and the WHB Head co-chairs the Perinatal Committee of the Task Force as a subject matter expert. Two other committees of the CFTF are the Intentional Death Prevention Committee and the Unintentional Death Prevention Committee. The CFTF provides a unique forum that brings together agency officials, lawmakers, experts in child health and safety, and community volunteers to perform the important work of understanding what causes child fatalities and determining what can be done to prevent them. Aided by the work of three committees, the Task Force meets to study data, hear from experts, and prepare policy recommendations for consideration. The Executive Director of the Task Force and other WCHS staff work closely with the staff of the Injury and Violence Prevention Branch (IVPB) and also work with additional partners including other state agencies and non-profit agencies such as North Carolina Safe Kids, the University of North Carolina Injury Prevention Center, NC Child, and the Governor's Highway Safety Program. The CFTF reports annually to the Governor and NC General Assembly. These annual reports, as well as other reports, presentations, meeting schedules, and membership lists can be found at the following link: http://www.ncleg.net/DocumentSites/Committees/NCCFTF/Homepage/.
During its 2019-2020 study cycle, the CFTF had a total of nine meetings, including seven committee meetings and two full CFTF meetings where attendees heard more than 50 presentations. Experts and leaders presenting to the Task Force and its committees represented academic institutions and state and local agencies, as well as state and community programs. The CFTF was successful in 2019 in partially advancing two of its recommendations. In 2019, the Task Force recommendations for a strengthened CFP System and a new state initiative for firearm safe storage were addressed in the 2019 Appropriations Act, but due to an unusual legislative session in which the state’s comprehensive budget bill did not become law, these initiatives did not become law. Even so, progress was made through efforts within NCDHHS to plan for a strengthened CFP System through formation of a work group, consultation with state and national experts, research, and convening of stakeholders. In addition, Governor Cooper signed a gun safety Executive Directive which set in motion the development and compilation of firearm safety tools and resources by the DPH, using elements of the Task Force’s recommendations to inform this work. A webpage on the DPH website now provides information on firearm safety. In 2020, a multi-year CFTF recommendation to require suicide prevention training and a risk referral protocol in schools finally became law.
All NC counties have one or more local teams who review the county’s child fatalities. CCPTs review all cases in which a child died because of suspected or confirmed abuse or neglect and a report of abuse or neglect was made to DSS within the previous twelve months or the child or child’s family was a recipient of child protective services within the previous twelve months. All additional child fatality cases are reviewed either by the CCPT or, if the CCPT does not review additional child fatality cases, a CFPT reviews them. Approximately eighty percent of local CFPTs and CCPTs are blended. Each quarter, local CFPTs are provided data on the number of child deaths for each county which include the child’s name, date of birth, date, and cause of death, among other information. These data are provided through the SCHS and the Office of the Chief Medical Examiner (OCME). Local CFPTs identify system problems and make recommendations for prevention of future fatalities and how to act on those recommendations. The local CFPTs provide education to their communities on ways to keep children alive and safe. The state CFPT Coordinator monitors the activities of the local teams to ensure compliance with the NC CFP System’s statutory requirements. The CFPT Coordinator makes site visits to local CFPTs and provides statewide webinars to increase the local teams’ knowledge about current health, data, and child safety issues. The state CFPT Coordinator conducted consultation and technical assistance via telephone monitoring (due to COVID-19 travel restrictions) to 15 local CFPTs in FY20.
The state CFPT Coordinator created and implemented three virtual trainings in May and June 2020. The topics were chosen based on a needs assessment survey of the planning committee members and training needs identified at the statewide Child Fatality Prevention Summit in Spring 2018. Topics covered were: Youth Suicide Prevention, Data Collection, and an Overview of the CFPT Review Process. The trainings were conducted virtually due to Covid-19 restrictions and could accommodate up to 145 people for each session. The webinars were to be posted on the CFPT Resource page for review by counties as needed.
NC Essentials for Childhood Initiative
NC is one of seven states awarded a cooperative agreement from the CDC for State Essentials for Childhood Initiative: Implementation of strategies and Approaches for Child Abuse and Neglect Prevention. The NC Essentials for Childhood (NCE4C) Initiative is funded for five years (2018-2023). The CDC also provided supplemental funding to this award for Opioid Misuse/Over and Adverse Childhood Experiences (ACEs) prevention. While the NC DPH is the grantee, NCE4C is a shared initiative across multiple NCDHHS divisions and NGO partners. Results from the 2018-19 NSCH for the new SPM#2 (Percent of children with two or more ACEs as reported in the NCHS) indicate that 15.3% of children experienced ≥2 ACEs which is down from 19.2% in the 2017-18 survey, but with overlapping confidence intervals this is not a significant change. It is less than the 18.2% national rate, but again, probably not significantly different.
NCE4C is focusing on policies which promote economic mobility for families and norms change regarding support for positive parenting. The current focus is on policy, practice and norms change related to family friendly workplace policies with an emphasis on paid family leave in addition to building community resilience as an ACE prevention strategy. These strategies support the North Carolina ECAP and the NC Opioid Action Plan 2.0. Approaches and strategies include:
- Work with the business community to increase employer-based family friendly workplace policies with an emphasis on industries where employers are less likely to have access to family friendly policies/benefits;
- Build public awareness at the state and local levels about the benefits of family friendly workplace policies, including paid family leave and the impact of ACEs on the health and development of young children, which may lead to norms change;
- Increase community capacity to implement paid family leave policies at the local government level;
- Focus on racial equity and the disparate ways economic policies, including family friendly workplace policies, may impact families;
- Exploration of alternative strategies for implementation of paid family leave (e.g., insurance);
- Alignment of local plan development or implementation; and
- Build community capacity to address/prevent adverse childhood experiences and adverse community environments (the “pair of ACEs).
Obesity Prevention and Other Evidence-Based Nutrition Strategies
Preventing obesity during childhood is critical as habits formed in the early stages of life most often carry into adulthood. To best achieve obesity prevention outcomes, research indicates that obesity prevention messages and strategies should be targeted to all families, starting before child’s birth. Identification and early intervention of overweight and obesity is critical in preventing or delaying the onset of chronic diseases. During 2001–2010, the overall prevalence of overweight or obesity (combined) among young low-income children participating in NC WIC increased significantly, from 26% in 2001 to 32% in 2010. During 2010–2015, the overall prevalence decreased steadily to 29% in 2015 from 2010. In 2019, the prevalence remained steady at 30.4%. Children diagnosed with obesity may be enrolled in the school nurse case management program and receive services to improve their BMI.
Title V MCH Block Grant funds continue to support a Pediatric Nutrition Consultant (PNC) position who supports and complements the C&Y Branch’s mission of building, maintaining, and assuring access to systems of care that will optimize the health, social and emotional development for all children and youth. This includes a focus on improving and incorporating evidence-based nutrition and physical activity strategies throughout the C&Y Branch in school-based health centers, LHDs, school systems, childcare settings, and with other private providers through training, technical assistance, and consultation. This Registered Dietitian/Nutritionist (RDN) collaborates across the WCHS and with other sections of the Division, other agencies, and organizations to enhance interventions with infants, children, and youth. She shares nutrition resources with and provides nutrition consultation for C&Y Branch programs. One particular assignment of the PNC is to monitor a special nutrition project Agreement Addendum for the Durham County Department of Public Health that furnishes medical nutrition therapy and nutrition consultation services for children referred to the LHD with no other funding source.
Specific activities that the PNC was involved in during FY20 included updating nutrition sections for the 2020 NC School Nurse Manual; collaborating with Branch colleagues to put together a proposal Planning for the Care of the Whole Student which was accepted and presented at the 2019 School Nurse Conference in December (facilitated by four DPH staff and four BFPs) and conference summaries from both sessions showed Very Good to Excellent ratings; planning and presenting Whole Child Nutrition training and webinar for 30 Charter School Nurses (March 2020); leading breastfeeding activities planning for the FY21 Perinatal/Infant Health Domain of the MCH Block Grant State Action Plan; and continuing to be actively involved in the DPH Breastfeeding Coordination team whose activities are highlighted elsewhere.
In addition, the PNC researched multiple COVID nutrition and food insecurity resources and shared with a variety of external and internal partners, especially focused on infants to 21-year-olds. She participated in NCCARE360 statewide convenings focused on food insecurity and connected NCCARE 330 staff with nutrition program administrators at NCDPI and NSB. She also met with NC211 staff to ensure food insecurity and federal nutrition programs were included as part of NC211 and NCCARE360. She was asked to present on the GoNAPSACC National TA Providers webinar focused on food insecurity resources for TA and child care providers in May 2020 which attracted about 50 attendees. She also provided TA and resources to NC Partnership for Children staff members for their food insecurity and breastfeeding focus for infants and toddlers. The PNC also provided nutrition expert review of Families Eating Smart and Moving More curriculum for NC Cooperative Extension for continued national dissemination and use of this resource.
The PNC also provided training and technical assistance in cooperation with breastfeeding partners and regional Child Health Nurse Consultants to local child health nurses implementing the Child Health Agreement Addenda strategies on supporting Mother-Baby Breastfeeding Friendly Outpatient Healthcare Clinics, Local Nutrition and Physical Activity Coalitions and Addressing Food Insecurity and/or Healthier Food Access. She continued to integrate work with Farm to Childcare/Early Care and Education into Branch and Division programs along with other statewide partners including the NC Farm to Preschool Network, the WK Kellogg NC Farm to Childcare Initiative, the Farm to School Coalition of NC and the Integrating Healthy Opportunities for Play and Eating (I-HOPE) Advisory Committee for Early Care and Education. She also strengthened and engaged in new partnerships aimed at creating policy and environmental change to make the healthy choice the easy choice for nutrition and physical activity especially for women, children/adolescents, and families (also with a focus on CYSHCN). Examples include the 807 CDC State Physical Activity and Nutrition grant received by CDIS; the CDC 1801 grant received by the NCDPI Healthy Schools program; Eat Smart, Move More NC; WIC; the Child and Adult Care Food Program; Supplemental Nutrition Assistance Program Education (SNAP-Ed) and the State Nutrition Action Coalition (SNAC). She continued to be actively involved in the ASPHN MCH Nutrition Council, MCH Nutrition Council Steering Committee, Fruit and Vegetable Nutrition Council, and the ASPHN Farm to ECE Advisory Committee. Lastly, she served as one of two first-line reviewers for Eat Smart, Move More North Carolina. 2020. North Carolina’s Plan to Address Overweight and Obesity.
In addition, the NSB provided educational resources in English and Spanish for local WIC agency staff to use to promote healthy weight to families and children. The Pediatric Nutrition Course was offered online to state public health nutritionists.
Nurse-Family Partnership
The Branch continues to host meetings with the HV Consortium on a quarterly basis, with recent presentations given on NC Integrated Care for Kids, Families First, and Reach Out and Read. External Consortium members include representatives from Attachment and Biobehavioral Catch-Up, Book Babies, Child First, Early Head Start-Home Based Option, Family Connects International, Healthy Families America, Home Instruction for Parents of Preschool Youngsters, NFP, Parents as Teachers, ParentChild+, and SafeCare.
Care Ring NFP participated in a multiparous pilot research project during FY19. This research was conducted through the NFP’s Prevention Research Center in Denver, Colorado. The multiparous project allows the site to enroll all pregnant women without giving restriction to parity. The pilot has ended, and Care Ring will continue serving multiparous clients with additional support provided by the NFP National Service Office. To date, Care Ring NFP has enrolled approximately 60 multiparous women into their program. The site also receives specific research consultation through the NFP National Service Office.
Triple P – Positive Parenting Program®
Triple P – Positive Parenting Program® (Triple P) is an internationally acclaimed multi-tiered system of parenting interventions (education and support for parents and caregivers of children and adolescents) that has the following overarching goals:
- promote the independence and health of families through the enhancement of parents’ knowledge, skills, confidence, and self-sufficiency;
- promote the development of non-violent, protective, and nurturing environments for children;
- promote the development, growth, health, and social competence of young children; and
- reduce the incidence of child maltreatment and behavioral/emotional problems in childhood and adolescence.
The C&Y Branch continued to support all 100 NC counties for the implementation of Triple P in FY20. There were 1,236 practitioners trained in FY20, with 14,430 caregivers being served in which impacted 18,706 children. NC continues to be recognized by Triple P America for developing a Triple P State Learning Collaborative consisting of all the local Triple P coordinators, C&Y Branch Triple P central office staff, Triple P America implementation specialists, and internal and external stakeholders. The Learning Collaborative provided quarterly opportunities for training, program planning, continuous quality improvement initiatives, peer-to-peer support and trend information for best practices for the local coordinators, and identification of efficiencies in purchasing materials and media buys in bulk. The Learning Collaborative has established a strategic planning process that provides efficient organizational efforts for supporting NC Triple P and developing networks with the funder’s group which is referred to as the Partnership for Strategy and Governance (PSG). Select facilitators of the Learning Collaborative serve as members of the PSG to inform, recommend, and provide guidance regarding challenges and successes at the local implementation level. Triple P Stay Positive Campaign, which includes print materials and a parent/provider website in English and Spanish, was purchased for the entire state Triple P Online (TPOL) program. At the end of FY20, TPOL had 21,156 access codes available for potential TPOL users statewide. Codes are purchased from Triple P America (TPA) and are available for potential TPOL users statewide. Parents and caregivers statewide in North Carolina request codes and are issued individual codes to access the modules through an automated distribution system. These access codes, which are available to any NC family, allow families to work through Triple P in eight online modules for children and six online modules for teens. This online access is also available in Spanish. A trained Triple P practitioner continues to manage the TPOL program, providing support services to parents and managing the state outreach program. NC is the first state to develop a statewide data collection and reporting system. Data points include the number of practitioners trained and the levels of Triple P in which they have been certified, the number of families served, the number of children impacted, and a pre/post-survey of the parents’ assessment of their ability to manage their child’s behavior. Data are reported quarterly and are used at the state and local implementing site levels to monitor the progress of the program and to drive continuous quality improvement strategies to improve the program. A Triple P Data team of local and state data specialists, state data managers, the TPOL manager, and a Triple P America Implementation Specialist meet weekly to secure NC Triple P data and provided continuous quality improvements.
Triple P successfully piloted the Positive Early Childhood Education (PECE) program in one county in FY19. Based on the success of this pilot, NC will launch the PECE program in FY20. PECE is another evidence-based program that Triple P International offers to early childhood education programs that presents tailored solutions for early education directors, consultants, teachers, and caregivers and potentially impacts whole communities. PECE helps build confidence in all those involved and increase their ability to deal with childhood behaviors with the result of helping develop children’s full potential. Early childhood directors and consultants are trained to offer coaching to teachers and support for caregivers through attending a Triple P level three training and an online skills training course. Early childhood teachers receive the online skills training to build new skills for classroom management, and directors or consultants offer level three training or TPOL to caregivers. One NC site (Mecklenburg County Health Department) piloted the program and there are plans to replicate this program in other target county/regions as well.
The Triple P Program continues to experience several challenges in rural counties including: 1) establishing peer-to-peer support networks across multiple sectors; 2) reaching families with Triple P services because of distance and lack of transportation; 3) assisting families with finding the appropriate trained practitioner to meet their level of need; and 4) engaging trained practitioners in delivering Triple P to parents. In FY20, sites continued to offer additional specialized workshops (refresher courses for practitioners) to help reengage them in delivering Triple P and participating in peer-to-peer support networks. These workshops were provided to strengthen implementation and encourage creative initiatives to bolster provider participation in peer-assisted supervision and support. To further strengthen practitioner re-engagement, sites participated in a practitioner assessment survey, referred to as the “Practitioner Round-Up,” to offer re-engagement strategy planning as a part of the implementation planning team activities to develop opportunities to build relationships with practitioners to keep them engaged in delivering Triple P. The Practitioner Round-Up process informs both the local level and state leaders about the service potential of practitioners who have been trained in Triple P implementation across the state. Data Specialist continue to enhance data collection across all service regions of the state, assisting with data collection and evaluation tools that are consistently revised to offer stronger analysis for the Triple P Program and offering additional support to coordinators to assist them with sharing data reports with practitioners and stakeholders. Data reporting, collection, and continuous quality improvement training are offered to assist local data specialists in areas that often create challenges relative to data collection.
NC Child Care Health Consultation Resources
The State Child Care Nurse Consultant (SCCNC) position supported by Title V funding collaborated with programs within the C&Y Branch as well as other state partners addressing early childhood efforts. The SCCNC worked closely with the NC Child Care Health and Safety Resource Center (CCHSRC) to support the health and safety of children ages zero to five attending early education settings through child care health consultation. The Resource Center is jointly funded through Title V and the Child Care and Development Block Grant. The Resource Center and the SCCNC offers training, technical assistance, and coaching services supporting 55 Child Care Health Consultants (CCHCs) providing local and regional coverage. In early FY20, the Resource Center offered training to one cohort. Four participants completed the course and received qualification. The Resource Center in collaboration with the SCCNC began working on a redesign and update of the NC CCHC Training Course. The Resource Center worked with The Carolina Office for Online Learning (UNC COOL) to build online content, updating with new resources, content and interactive components. The course content was developed to align with the National CCHC Competencies issued by the National Center on Early Childhood Health and Wellness in May 2019. The Resource Center maintained a website (www.healthychildcare.unc.edu). The NC Child Care Health and Safety E-Newsletter was distributed four times during the year to local child care health consultants, NC Division of Child Development and Early Education (DCDEE), and other external partners for widespread distribution to early educators via email list serves. The E-Newsletter was also made available on the Resource Center website. Topics for FY20 included communicable diseases, infant and toddler care, injury prevention, and COVID-19. The Resource Center also maintained an online CCHC Resource Library that included materials on health and safety issues, Medication Administration, Emergency Preparedness and Response, Infant/Toddler Safe Sleep and SIDS Risk Reduction, and Child Care and Development Block Grant Health and Safety Overview trainings for early educators to complete every 5 years, as required by the NC child care rules. Through a toll-free phone line and online request form, the Resource Center supports local CCHCs, child care providers, and families across the state by providing technical assistance and resources, including posters which are required by NC child care regulations. These services are available to more than 5,746 licensed child care centers and family child care homes in NC.
The Resource Center staff and SCCNC completed updates to the CCHC Service Model. The Service Model was originally developed in FY15 in collaboration with the NC Partnership for Children and the Resource Center under the Race to the Top – Early Learning Challenge. The Model is used to standardize the practice of child care health consultation across the state and also aligns with the National CCHC Competencies. The Service Model is available on the CCHC Resource Library. The Resource Center provided ongoing support for Health and Safety Assessment tool and the implementation through a “coaching” framework by CCHCs.
The SCCNC and Resource Center staff members collaborated to create the Stay Healthy, Stay Clean training, which includes modules on handwashing, diapering/toileting, cleaning, sanitizing and disinfection in child care. Additionally, health and safety posters were updated and reprinted for use, including Assisting Children with Handwashing.
The Resource Center, in collaboration with the SCCNC, the North Carolina Partnership for Children (NCPC), DCDEE, and the NC CCHC Association, participated in the CCHC System Building Technical Assistance Pilot led by the National Center on Early Childhood Health and Wellness. NC participated with 6 other states in the nine-month pilot which consisted of monthly meetings, collaborating, networking and learning from other states. The pilot included completing a state self-assessment of our current CCHC system; as well as looking at regulations and standards, funding and sustainability, the role of the CCHC, and workforce supports such as professional development. The NC group convened an additional monthly meeting to discuss and prepare for each large group meeting.
The SCCNC participated on the NC DPH Breastfeeding Coordination team representing breastfeeding promotion, education and support in the child care setting, through the Breastfeeding Friendly Child Care Initiative. She also worked collaboratively with the Carolina Global Breastfeeding Institute (CGBI) at UNC Chapel Hill Gillings School of Global Public Health and the Resource Center to begin providing the Breastfeeding Friendly Child Care Train the Trainer course for CCHC and other technical assistance providers working with child care facilities. In FY20 the SCCNC provided one train the trainer course to nine child care health consultants and one technical assistance provider.
The PMC and SCCNC continued to partner with Our Children’s Place and other early childhood education stakeholders to work on developing a toolkit for child care facilities addressing Supporting Children of Incarcerated and Returning Parents. The toolkit will include a training and resources offered by child care health consultants or healthy social behavior specialists providing support to early educators. The goals of this workgroup include addressing the social emotional development of young children and the impact of incarceration, trauma and toxic stress. The toolkit will serve to identify strategies early educators can use to assist children and families who have parents who are incarcerated or returning to the community after being incarcerated.
In response to the COVID-19 pandemic, beginning on March 16, 2019, the SCCNC and Resource Center began providing CCHC coverage to all counties in NC without a local CCHC (27 counties) with the Resource Center staff covering 15 counties and the SCCNC covering 12 counties. This limited coverage included the provision of health and safety guidance relate to COVID-19. It also included working with local Smart Start Partnerships and Child Care Resource and Referral agency staff to meet the comprehensive needs of child care facilities.
Additionally, the Resource Center and SCCNC collaborated with DCDEE and NCDHHS to develop the initial draft of the Interim -19 COVID Health Guidance for Child Care Settings, now referred to as the ChildCareStrongNC Public Health Toolkit. A sample door sign, Cloth Face Coverings and COVID-19 Frequently Asked Questions documents were developed by the Resource Center and the SCCNC for CCHCs to use in supporting child care facilities. The Resource Center and SCCNC partnered with the DCDEE to provide four COVID-19 related Health and Safety webinars offered to child care providers across the state and also held six special COVID-19 webinars for CCHC to discuss NC guidance as well as other documents created as COVID-19 resources developed by the Resource Center and SCCNC.
The SCCNC collaborated with the PMC and the SCHNC to join and share information about child care at two webinars for child health clinics at LHDs as part of a weekly and then monthly webinars focused on strategies and recommendations to help with delivery of child health services during COVID-19. The SCCNC presented information related to COVID-19 health and safety guidance specifically related to child care.
Vision Screening
Vision screening was carried out in the schools for children in grades K-6 by certified vision screeners through state funding. The C&Y Branch contracts with Prevent Blindness North Carolina (PBNC) to train and certify a cadre of 3,000 vision screeners on an ongoing basis. This cadre, which includes volunteers, school nurses, and school staff, is available to screen at least 65% of the school population in grades K-6 statewide. More than 434,218 school age children had their vision screened in 2020 with 8% referred for further care. The PBNC contract also provides photo-refractive screening for children in Pre-K classrooms and regulated child care. In FY20, 28,112 children were screened prior to the pandemic shutdowns, and 12% were referred for further care. School nurses work with children and their families to secure appropriate follow-up care.
C&Y Branch Data Dashboard
The C&Y Branch staff include in their workplans the use of data to make programmatic decisions and communicating data to internal and external partners. The Branch collects a wide variety of data points, including both qualitative (text) and quantitative (numeric) data. Data comes from within the C&Y Branch as well as from external sites, including LHD data and data from the SCHS. Additionally, both process and outcomes data are collected for monitoring, evaluation, and continuous quality improvement purposes. Recently, infographics and maps (brief handouts with visuals) have become popular methods of sharing data. Data for C&Y programs is typically reported on a monthly, quarterly, biannual and/or annual basis, and reports reach a variety of audiences; some reports are for internal, branch staff, whereas others are shared with others throughout the WCHS, family partners, and other state partners/agencies. The C&Y Branch has created a Data Dashboard to display some of the main process and outcome measures, as well as to highlight other notable achievements that are not measured (for instance, trainings and webinars offered). The Data Dashboard can help increase an understanding of some of the branch’s activities, as well as highlight areas of success and areas where there is room for improvement.
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