Child's health includes physical, mental and social well-being. Ensuring healthy growth and development is a primary concern of the Maine Title V program. Maine’s efforts to improve the health status of children during the 2015-2020 period focused in the areas of developmental screening, oral health and children living in households where someone smokes.

Performance Measure: Percent of children, ages 9 – 35 months, who receive a developmental screening using a parent-completed screening tool in the past year.

According to the 2018-2019 National Survey of Children’s Health, about 39% of Maine parents of children ages 9-35 months report that they were asked to complete a developmental screening tool for their child within the previous year. Maine ranked 18th highest on this measure. The U.S. rate was 36.4%. MaineCare has been working to improve developmental screening rates among their providers and has increased awareness of the billing code available to providers for conducting developmental screens. As a result, the percent of children enrolled in MaineCare with a claim for a developmental screen increased for three year olds from 9.0% in 2012 to 25% in 2019. This increase may be due to increased awareness of claim coding for developmental screenings, along with actual increases in screenings. In 2020 the percentage of children enrolled in MaineCare who had a developmental screening decreased slightly to 21%. This may be due to the impact of COVID-19 on well-child visits.

The Women, Infants and Children (WIC) program conducted developmental surveillance using the federal CDC’s Learn the Signs Act Early tool. The WIC Nutritional Services is a voluntary program that provides low-cost healthy foods, nutritional education, breastfeeding promotion, and support and referral to other services to women, infants and children who are at nutritional risk. The program is designed to allow women to enroll during pregnancy and for children to remain enrolled up to the age of five. Beginning in 2019 and continuing through 2020, all children seen at WIC were provided with materials on age appropriate developmental surveillance. WIC documents any developmental concerns found and refers parents to the child’s medical provider for further review.

Maine Families home visitors complete the Ages and Stages Developmental (ASQ), and Social Emotional (ASQ-SE) screenings with families at regular intervals. Family visitors complete ASQs, at a minimum, at 2, 4, 9, 12, 18, 24, 30, and 36 months. Family visitors complete ASQ-SEs at a minimum of three times within the first three years of the child’s life. Family visitors worked with local child development services and other specialists to offer referrals for families as indicated by a screening result.

Public Health Nursing (PHN) provided infant physical assessments at each home visit, which included an assessment of the child’s development. PHN’s perform physical assessments appropriate for age/condition and document the results in the pediatric physical assessment tool. PHNs monitor children for ability to express needs. They monitor the child for attainment of developmental tasks expected for age as well as monitor the child’s response to stimulating/nurturing activities. Public health nurses refer to appropriate providers if any assessments are determined to be outside of normal limits.

The Children with Special Health Needs Care Coordinator assisted families in navigating the complex medical systems and guided families to organizations and resources that best fit the needs of their child. The Care Coordinator assisted families with: navigating health care systems, insurance appeals, application processes, referrals, finding resources, connecting to support from other parents of children with similar healthcare needs and advocacy.

In 2019, The Maine Department of Health and Human Services (Maine DHHS) produced a report in response to LD 1635, RESOLVE Chapter 66, To Improve Access to Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) for Children birth to eight years of age. The report provided information on the EPSDT benefit and programs providing early intervention and developmental screening services in the Maine DHHS, including work carried out under the Maine Title V Maternal Child Health Block Grant, Public Health Nursing, Maine Families Home Visiting, Women, Infant and Children’s Program, and the Office of Child and Family Services. The report also included information on the Department of Education’s Child Find and early intervention system, including Child Development Services, Early Head Start, and Head Start.

LD 1635 was signed into law at a time when several other needs assessments and evaluations of the Early Intervention System were taking place in Maine. Short and long-term recommendations included:

Short Term:

1. Identify an organizing entity at the state level to coordinate and align Child Find, EPSDT, developmental screening, and early intervention services. Ensure improvement.
2. Ensure EPSDT is firmly grounded in Maine DHHS child health priorities.
3. Review roles, responsibilities, and positions within the Office of MaineCare Services to ensure direct oversight of the administration of the State’s EPSDT and Child Health Insurance Program (CHIP), utilizing the EPSDT position created in LD 1399.
4. Ensure no wrong door for families to access services and establish a centralized entity around developmental screening and care coordination for early intervention services.
5. Establish a longitudinal data system in Maine that ensures preventive screenings are completed and outcomes data is available.
6. Develop a communication strategy for EPSDT and Child Find for the state.
7. Expand coordination of the work between Maine DOE and Maine DHHS.

Longer Term

1. Increase access to services.
2. Integrate work across Maine DHHS to support EPSDT and Child Find.
3. Increase funding to support Part C services.
4. Increase preventive health screening rates.
5. Eligibility for Part C services.
6. Workforce.

The Department is using the knowledge gained from the report generated by the Developmental Systems Integration Team to move work forward. MaineCare filled the vacant EPSDT Coordinator position in 2020.

The CSHN program reassessed past developmental screening efforts to determine future direction. Developmental screening did not emerge as a priority during Maine’s needs assessment process; however, the Title V program continued to connect with program’s working on developmental screening and provided assistance as appropriate.

To educate parents on developmental screening, the Maine Parent Federation (MPF) made all two-hour in person workshops available online. The Self-Advocacy and Bullying Workshops are online and live (http://mpf.org/trainings.html ) Module one of the Special Education workshop is completed.

The MPF’s Family Support Navigator (FSN) program is a peer to peer program which provides one to one assistance to families of children with special healthcare needs. The program is staffed by four full-time equivalents who coordinate FSN trainings and connections to families. FSNs are parents of children with special healthcare needs, professionals working with families who have children with special healthcare needs or a relative to a child with special healthcare needs. FSNs are matched to families who have needs within a FSN’s geographic region, as well as lived experience. There are currently 25 active FSN’s in Maine. During FY20, MPF added a virtual navigator who is available to assist families virtually from anywhere in the state; a strategy that was very helpful to families during the COVID-19 pandemic.The FSN program provided peer-to-peer support and assisted 2,669 families during FY20.

Maine Parent Federation held an FSN training on January 24, 2020 for the immigrant community in Lewiston/Auburn. The program successfully trained six moms with lived experience both parenting children with special health care needs, as well as immigrating to Maine. They are conducting outreach in the community to connect parents in need with the now active Immigrant Navigators, a significant success for the 2015-2020 period.

Over the past five-years, MPF served 620 families through their FSN program and 7,271 families overall. The FSN program is the most popular program for the MPF as it fulfills the need of true care coordination for parents of children with special health care needs. Routine program surveying illustrates 95% satisfaction with FSN services as well as 98% of families indicating they would recommend the program to family and friends.

Performance Measure (State): Percent of third-grade children who have received protective sealants on at least one permanent molar tooth.

Healthy teeth are essential to a child's overall health, and dental sealants can protect permanent teeth from decay. Maine promotes oral health disease prevention for children, including oral health education to school nurses, oral health screenings, application of fluoride varnish, and sealants. Maine dental providers also promote dental sealants to parents as an excellent preventive intervention for their children. Sealants are a covered benefit under MaineCare. Maine also has dental hygienists working as independent practice or under public health supervision status who provide sealants on-site at schools. School sealant application facilitates children receiving sealants, especially in more rural and underserved areas where regular access to preventive dental care can be challenging.

Maine conducts observations of children's dental health (caries experience and sealants) as part of the Maine Integrated Youth Health Survey. Maine uses these observations to determine prevalence for the percentage of third-graders who received dental sealants on at least one permanent molar. In 2019, 51.6% of third graders in Maine were observed to have dental sealants. Almost half (48%) of third graders were observed to have treated or untreated caries; 19% had untreated caries. About 1 in 5 (21.0%) third graders were observed to be in need of urgent dental care. We have seen recent increases in 2018 and 2019. The Healthy People 2020 objective is to increase the percentage of children ages six to nine years who received protective sealants on at least one permanent molar tooth, with a target of 28.1%; Maine is exceeding this target.

Contributing factors to the percent of children with sealants could be the shrinking number of dental providers accepting MaineCare insurance as well as a decrease in the number of parents enrolling their children in MaineCare; only 40% of Maine's children are enrolled in MaineCare.

The Maine School Oral Health Program (SOHP), a component of the Maine CDC Oral Health Program, provides school-based dental sealants to second graders only at eligible participating schools; thus, this number is a small proportion of the total number of Maine children receiving sealants each year. Schools are eligible to participate in the SOHP when they meet certain community-level risk factors, such as the proportion of eligible children for the Free and Reduced Lunch Program. The number of schools that can participate in the SOHP is limited due to funding availability; therefore the program targets the highest need schools as a priority. In the 2019-2020 school year, 299 (274 2nd grade and 25 3rd grade) children received dental sealants through this program. The SOHP also included school-based oral health educational outreach programs to all grades and a basic dental screening with fluoride varnish application, reaching 11,313 children.

The SOHP enrolled 25 additional schools during the 2019/2020 school year. The goal is to increase the number of schools participating in the program by 5% each year. Ten field hygienists provide screening and sealants in their school districts or in schools where their children are registered. The hygienists travel, as needed, to other areas of the State. School nurses assist hygienists by recording data. The hygienists work with school nurses to coordinate care for children identified as needing emergency treatment.

By March 2020, the COVID-19 pandemic was prevalent in Maine, the time of the year when the majority of sealants are placed. Maine schools were closed from March 20, 2020, through the end of the school year and schools were utilizing remote learning methods. Many students identified as needing urgent dental care were not able to receive it as dental offices were only seeing patients on an emergency basis and preventive care was not possible.

Sealants were placed on second graders first permanent molars, however few third graders were rescreened and/or resealed. The SOHP's focus was treating second graders who did not have sealants placed prior to school closures for the remainder of the academic year.

Educational information and face-to-face meetings with all schools enrolled in the SOHP are required. These meetings take place in the fall after the school session begins. Schools receive updates on any new requirements for the upcoming school year, including discussing evidence-based oral health and other oral health education topics. New school staff are encouraged to complete the Smiles for Life Curriculum, the School Oral Health Library (http://smilesforlifeoralhealth.org/buildcontent.aspx?tut=555&pagekey=62948&cbreceipt=) and the Basic Screening Survey video (https://www.astdd.org/basic-screening-survey-tool/).

The SOHP did not train school nurses in FY20 as the field hygienists were applying sealants in those schools enrolled in the program. The SOHP Coordinator did hold training workshops across Maine to educate both school nurses/volunteers and dental personal.

The program did compile oral health resources and made them available to school nurses via the school nurse listserv and the Maine Department of Education dashboard. In addition, during National Children's Dental Health Month in February 2020, the SOHP distributed resources and posters on the benefits of child oral health to school nurses. An example of materials provided can be found at; https://www.nidcr.nih.gov/sites/default/files/2017-11/seal-out-tooth-decay-parents.pdf.

The SOHP provided an Association of State and Territorial Dental Directors web-based training link to all school nurses however, we were unable to determine if they accessed and watched the training or implemented any of the recommendations offered through the training due to staffing constraints.

The SOHP collaborated with the Maine WIC program and a community action program in the northern part of the State to disseminate educational materials such as flashcards for parents, magnets, and an oral health curriculum.

Maine Families home visitors use educational materials provided by 'From the First Tooth' (http://www.fromthefirsttooth.org/), a privately funded initiative administered by MaineHealth, with families of children 0-three years to promote the oral health of infants, toddlers, and preschool children.

The SOHP Coordinator finalized a policy and procedures manual for Public Health Field Hygienists, and new schools enrolled in the program.

The SOHP conducted a session on basic child oral health screening as well as the benefits of child oral health at the virtual New School Nurse Orientation in the summer of 2020. The Maine CDC continues to update its website resource page on children's oral health. All information is shared through partner list-serves and the school nurse resource page.

Oral health program staff disseminated National Institute of Dental and Craniofacial Research https://www.nidcr.nih.gov/health-info/sealants and National Institute of Environmental Health Sciencesl materials explaining the benefits of dental sealants and the importance of maintaining baby teeth through such channels as the Maine Primary Care Association, rural hospitals, rural health clinics and critical access hospitals.

The SOHP continued to collaborate monthly with From the First Tooth Program and the Children's Oral Health Partnership to increase the number of providers educated on the importance of oral health.

The SOHP has been challenged in its ability to demonstrate improved outcomes for this measure as there are several public health hygienists across the State applying sealants but do not report their numbers. In addition to the numbers tracked by the hygienists going into participating schools across the State, Maine has access to MaineCare data; however, we do not have a complete picture of the number of sealants applied.

Performance Measure: Percent of children, ages 0 through 17, who live in households where someone smokes

Based on the 2018-2019 National Survey of Children’s Health (NSCH), 16.4% of children in Maine live in a household where someone smokes; 1.4% live with someone who smokes inside the home These rates are slightly higher compared to those at the national level; 12.4% and 1.9% respectively. https://www.childhealthdata.org/browse/survey/results?q=7903&r=1

During FY20, The Tobacco and Substance Use Prevention and Control Program (TSUPCP) team used a multi-layered approach to implement strategies that support social norms change to decrease tobacco use acceptability in the home. Through MaineHealth-CTI, the TSUPCP implemented several environmental strategies aimed to protect children from secondhand smoke (SHS) exposure, change social norms, and decrease acceptability of tobacco use. These environmental strategies included: adoption of smoke-free home pledges by Maine residents and implementation of smoke free policies by Landlords /property owners (for multi-unit housing), municipalities, and youth-serving entities. The following outcomes reflect successes achieved.

Digital Strategies - Smoke-Free Homes Pledge

The paid social media /digital strategy regarding the Smoke-free Homes Pledge launched on March 11, 2020 with messages about secondhand smoke and encouragement to make the home a smoke-free space. From launch through the end of the month, the campaign generated 606,303 impressions (ad views) that led to 627 new smoke-free home pledges. The Smoke-free Homes Pledge is a strategy implemented to encourage families in Maine to protect their children from SHS and live a healthier life by keeping smoke outside of the home. For this reporting period, 1,956 adults across Maine took the pledge. Maine Health-CTI continued to use the Smoke-Free Homes Pledge as an engaging strategy to eliminate exposure to SHS in the home.

Smoke/Tobacco-Free Policy Initiatives

In FY20, MaineHealth-CTI and the District Tobacco Prevention Partners (DTPPs) worked with landlords/property managers to adopt 18 smoke-free policies for their multi-unit housing (MUH) properties, protecting more than 1,226 people, including children, from the harmful effects of SHS exposure. These policies resulted from MaineHealth-CTI’s efforts to deliver regular outreach and technical assistance highlighting the importance of a comprehensive smoke-free policy for their properties. To support smoke-free policy compliance in MUH, Maine Health-CTI distributed 90 smoke-free toolkits to landlords, property managers, and housing authorities, which cover 90 buildings and at least 430 tenants. In addition to the policies passed and signage, currently, 45.0% of rental housing listed on the MaineHousingSearch.org is advertised as Smoke-free.

MaineHealth-CTI and the DTPPs also worked with municipalities on smoke or tobacco-free policies in FY20. MaineHealth-CTI continued efforts to outreach and deliver technical assistance to municipalities, with a special focus on encouraging social norms change through policy adoption and education on the dangers of SHS. The DTPPs outreach and technical assistance resulted in the adoption of 28 new tobacco and smoke-free policies that include ENDS and Marijuana. These policies cover 16,488 residents.

In working with MaineHealth-CTI and the DTPPs to prevent tobacco initiation and SHS exposure among youth, 44 youth-serving entities adopted new tobacco-free and smoke-free policies in FY20. DTPPs met with these institutions on a regular basis to discuss the importance of comprehensive tobacco and smoke-free policies that include ENDS.

Other Efforts

The Maine Families Home Visiting program continued to provide information on the impact of SHS on children’s health and development. If a family is ready, family visitors develop harm reduction strategies that lessen the impact of SHS on the child. Family visitors support these strategies by providing cessation resources that include information on the QuitLink website.