Overview

Washington’s Title V program served 464,954 children ages 1 to 21 in 2018, according to our reporting from the state’s local health jurisdictions.

 

The Department of Health (DOH) Essentials for Childhood (EFC) section was renamed (it was formerly referred to as Child Health and Development and part of the Healthy Starts and Transitions unit in previous years). EFC initiatives and programs are funded by a variety of sources, including the Title V Maternal and Child Health Block Grant (MCHBG), Centers for Disease Control and Prevention (CDC), Substance Abuse and Mental Health Services Administration (SAMHSA), and others. The EFC team works closely with the Children and Youth with Special Health Care Needs (CYSHCN) unit and the Perinatal, Women’s, and Adolescent Health units.

 

We promote the health and wellness of children through policy and programs that support safe, stable, nurturing relationships and environments, universal developmental screening, early and ongoing learning and development, culturally appropriate, responsive supports, and services and systems improvements that support the whole child, whole family and whole community.

 

In addition to activities within the Office of Family and Community Health Improvement, several other sections of DOH contribute toward meeting our Title V child health objectives, strategies, and performance measures. The Injury and Violence Prevention program works on initiatives to promote child safety and prevent injuries. The Healthy Eating Active Living program works to reduce the burden of obesity and chronic disease, and increase the proportion of children with a healthy weight. The Immunizations and Child Profile Health Promotion System manages a universal vaccine program and sends child health and safety information to all families with young children in Washington by mail and e-mail. The Oral Health program promotes access to oral health care, prevention of dental disease and oversees the Smile Survey to collect data on the oral health of children in Washington. All of these programs collaborate toward our shared vision of healthy, safe, and active children.

 

National Performance Measure 6 – Developmental Screening

Percent of children, ages 9 to 35 months, receiving a developmental screening using a parent-completed screening tool in the last year.

 

The National Survey of Children’s Health (NSCH) combined survey of 2016-2017 indicates that 27.7 percent of children ages 9 to 35 months received a developmental screening using a parent-completed screening tool.

 

Going back to the 2011-2012 NSCH, 29.9 percent of children received a developmental screening using a parent-completed screening tool. In the older survey, the question was framed differently: the age range was 10 to 71 months vs. 9 to 35 months. It is important to note, therefore, that the 2011-2012 data cannot be compared to data from the surveys after 2016 due to the significant revision.

 

Universal Developmental Screening (UDS) in Washington

 

UDS and Connection to Responsive Services: A DOH Priority

A focus on UDS is core to the DOH Strategic Plan priorities. The DOH Strategic Plan for 2017–2019 includes the Healthiest Next Generation goal that we work to “ensure all children in Washington achieve their highest health potential.” One of our objectives under this domain is to ensure all children have appropriate developmental screenings and access to services.

 

DOH has been awarded various grants, in addition to the MCHBG, through which developmental screening goals and objectives are being achieved: these include the Project LAUNCH (Linking Actions for Unmet Needs in Children’s Health) expansion grant and Autism Spectrum Disorders and Other Developmental Disabilities (AS3D) grant.

 

We seek to develop contracts that facilitate implementation of UDS systems development, including Community Asset Mapping (CAM) within the Medical Home Partnerships Project (MHPP) contract; Great MINDS (Great Medical Homes Include Developmental Screening); UDS Toolkit development within the Project LAUNCH expansion grant; integration of infant and child mental health as an important part of the developmental screening process within Project LAUNCH expansion; the CDC’s EFC grant, which has identified policy priorities related to Help Me Grow (HMG) and home visiting, both related to UDS; and partnership with the state’s Medicaid administrative agency, the Health Care Authority (HCA) and several managed care organizations (MCOs). Our aim with these contracts is to reduce barriers to well child visits, increase and track rates of developmental screening, increase connection to responsive services and improve provider billing practices. MCHBG funding is used to provide oversight and direction for many of these partnership grants, to align and leverage opportunities and outcomes, and to lend content expertise as needed.

 

Key partners in our UDS efforts in Washington include other programs within DOH, the Department of Children, Youth, and Families (DCYF), families, physicians, community organizations, university researchers, Thrive Washington, MCOs, WithinReach and other stakeholders.

 

Title V UDS-Related Activities

The non-profit agency WithinReach provides resource information, health care referrals, and developmental screening tools for children. Title V funding supports their work.

 

Operating our state’s Title V hotline, WithinReach received and responded to 16,791 calls in federal fiscal year (FFY) 2018 (4,866 October to December 2017, 3,443 January to March 2018, 4,328 April to June 2018, and 4,154 July to September 2018). WithinReach’s ParentHelp123.org website data showed that in FFY 2018, there were 21,507 page views, with 17,245 total unique page views. WithinReach’s hotline and website resources are described further in the Women’s/Maternal Health Annual Report.

 

WithinReach served not only as Washington’s Title V hotline, but also as the HMG state affiliate for Washington. In April 2018, WithinReach hosted the Annual Help Me Grow National Forum.

 

DOH continued to work with WithinReach on HMG expansion through partnerships on two platforms: (1) specifically as our state’s HMG affiliate, and (2) as a member of the EFC collective impact initiative workgroup, formerly called Systems, Services and Implementation, and now renamed Help Me Grow Workgroup. Both platforms include key partners who are vital to the UDS work as it moves forward within the larger frame of HMG.

 

We have two evidence-based strategy measures (ESMs) for national performance measure (NPM) 6 related to universal developmental screening.

 

Our first ESM is to track the number of Ages and Stages Questionnaires (ASQs) provided by WithinReach to callers. A total of 1,113 ASQs were completed by parents from October 2017 to September 2018 through WithinReach. Of these, 920 were ASQs, and 193 were ASQ:SE (ASQ:Social Emotional). This ESM measures the number of ASQs and ASQ:SEs completed, rather than number of children screened using these tools. Some children are screened multiple times, as the Bright Futures Guidelines recommend, which creates a discrepancy between what we wish to measure (number of children screened) and what we actually measure (number of screens completed). Although it has limitations, this ESM has been a reasonable measure to track.

 

Our second ESM is the number of children reported by HCA as receiving developmental screening. DOH negotiated a data sharing agreement with HCA, which added annual developmental screening reporting for Medicaid billing. Data from the first full year of billing in 2016 began to be compiled in 2017. In 2018 and 2019, DOH worked to amend and refine the agreement, and renamed it as a Mutual Information Sharing Agreement (MISA). Additional data requirements were added to the MISA in order to obtain population denominators to be able to understand the uptake of developmental screening by age group, as well as by other indicators such as managed care versus fee-for-service, provider type, by county, etc. These data will be available later in 2019 as well as for two preceding years to establish a “formal” baseline. DOH epidemiology staff will provide the analyses of the data. For reporting on this ESM, in calendar year 2017 there were 48,933 developmental screenings completed for children age 0 to 21; in calendar year 2018, there were 55,000 screenings completed.

 

In the future, Washington will be able to track developmental screening rates for all children, including those who have private insurance, as well as those who have Medicaid. This will occur when we implement a statewide UDS data system to help ensure all children receive screening for developmental delays. In 2018, we focused on systems planning and identifying funding sources. An updated decision package was written in 2018 to request funding to provide 10 percent state matching funds to support a 90 percent federal technology grant to be awarded by the Centers for Medicare and Medicaid Services. The matching funds were approved by the state legislature in April 2019, and efforts will shift to implementing the project and identifying funding to maintain the data system.

 

The data system will serve as a repository for child-level screening information, allowing appropriate access to stakeholders who contribute to or access developmental screening data for children. High-level business requirements and use case scenarios have already been documented, and the Assistant Attorney General’s Office previously supported a legal review of the proposed framework. A solicitation for Information Technology Professional Services was issued and a contractor selected to further describe the costs, technical, and governance requirements needed to implement, launch, and maintain a statewide UDS data system.

 

State Performance Measure 1 – Social/Emotional Readiness for Kindergarten

One of our selected state performance measures (SPMs) will enable us to better understand the impact of adverse childhood experiences (ACEs) at two critical points in child development. We are assessing the percent of incoming kindergarteners who demonstrate having the social and emotional characteristics appropriate to their age. (The second ACEs-related SPM is located in the Adolescent Health domain.)

 

The most recent data available are from the Office of Superintendent of Public Instruction for the 2017-18 school year. They indicate 76.7 percent of incoming kindergarteners demonstrated social-emotional school readiness. Our objective for 2018 was 74.4 percent.

 

Adverse Childhood Experiences Work

Title V funds were used to support an ACEs Consultant. The ACEs Consultant provided technical assistance to local health jurisdictions (LHJs) and other community leaders by responding to requests; sharing ACEs and resilience-related information with local leaders via an email list; and attending county-level ACEs-related meetings and trainings to exchange information with local leaders and learn about their perspectives, priorities, and needs.

 

In September 2018 there were 300 people on the ACEs and Resilience email list, representing 32 of 39 counties. The ACEs Consultant traveled to 12 county or regional ACEs-related group meetings and presented at the statewide Community Health Worker conference. The ACEs Consultant updated the ACEs resources lists and developed two new resources lists: Self Care, and Fun and Inspirational Videos. The ACEs Consultant participated in DOH work, including EFC, the DOH Wellness Team and Population Health (part of Health Systems Transformation). The ACEs Consultant also participated in state-level groups to exchange information related to ACEs and trauma-informed approaches. In FFY 2018 the ACEs Consultant represented DOH on the statewide ACEs Public Private Initiative Leadership Team, the state Behavioral Health Advisory Council, Department of Corrections Community Parenting Alternative Screening Committee and Frontiers of Innovation First 1,000 Days Team Resource.

 

Essentials for Childhood held two ACEs and Resilience Community of Practice events in 2018, one in Western Washington and one in Eastern Washington. The gatherings created an opportunity to learn from peers deeply engaged in the work of building resilience and reducing ACEs. Combined attendance at the two events was about 150 people, from a large majority of the state’s 39 counties. Participants worked in fields including health services and public health, child welfare, early learning, education, behavioral health, and community organizing. They learned together and from each other. A summary of the October 2018 event is available online. Community of Practice staffing was partially supported by MCHBG.

 

Through their Title V contracts, 24 LHJs focused on work related to ACEs. Many of them worked internally and with partner organizations on adoption of trauma-informed care policies and practices.

 

National Performance Measure 7 – Injury Hospitalization

Rate of hospitalization for non-fatal injury per 100,000 children, ages 0 through 9.

Rate of hospitalization for non-fatal injury per 100,000 adolescents, ages 10 through 19.

 

In 2016, the rate of hospitalization for non-fatal injury was 88.1 per 100,000 for children aged 0 to 9; and 203.2 per 100,000 for adolescents aged 10 to 19, as reported in the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID).

 

From the Comprehensive Hospital Abstract Reporting System (CHARS), the four leading mechanisms of non-fatal hospitalization for Washington children aged 1 to 9 are fall, burn, poisoning, and motor vehicle injury. The four leading mechanisms of non-fatal hospitalization for Washington adolescents aged 10 to 19 are poisoning, motor vehicle injury, fall, and cut.

 

Local Safe Kids Coalitions have provided informational resources to local community members through community events, school events, and child safety seat check events. Areas addressed include child passenger safety, water safety, fire safety, medication safety, sleep safety, falls prevention, bicycle and wheeled sport safety, sports injury prevention, safe firearm storage, pedestrian safety, poisoning prevention, and awareness and prevention of child heatstroke in cars.

 

Eight community health and safety events were held across Washington State in April, May, and June of 2018. These events were partnerships with local fire and rescue departments, hospitals, local community businesses and organizations, local public health, and other local government entities. Local Safe Kids Coalitions provided life jackets at water safety events; child safety seats at child safety seat check events; bicycle helmets at bike safety events and bike rodeos; and firearm locks and storage boxes and window stops during spring community education events.

 

We continue to partner with the Drowning Prevention Network to maintain and distribute life jacket loaner boards. This partnership is led by Washington State Parks and Recreation, Seattle Children’s Hospital and DOH through our Safe Kids Washington program.

 

A number of coalitions hold Bike Rodeos and work with local schools to organize Bike to School Days, and share bike and pedestrian safety information at these events during the spring. In the fall of each year, coalitions and schools work together to hold Walk to School Days. These events involve collaborations with local first responders, school employees, coalition members, parents, and local bicycle and running clubs to teach about pedestrian safety, and encourage healthy and active lifestyles.

 

In partnership with the Washington Traffic Safety Commission’s Child Passenger Safety Program, regular child safety seat events have been conducted across the state each month, as well as child passenger safety technician certification courses (certified through Safe Kids), to address infant and young child passenger safety.

 

Our Safest Ride campaigns work with elementary schools to educate caregivers on placing children under age 13 in the safest riding position in the back seat, and why Washington has a back seat until age 13 law. Funding for the Safest Ride Campaign has ended, so no new sites were added in FFY 2018. Existing sites did follow-up sessions with remaining supplies for high-need elementary schools.

 

Semi-monthly meetings were held with Safe Kids Coalition coordinators to disseminate best practices and provide technical assistance on injury prevention strategies developed by DOH, the Western Pacific Injury Prevention Network, the Children’s Safety Network, and CDC’s Injury Center. The Washington Safety Summit was held in March of 2018 to provide training and best practice strategies in injury prevention to public health, medical staff, and first responders, with over 100 people in attendance.

 

In analyzing data on injury rates we found our older teens had a significantly higher rate of injury and mortality related to motor vehicle injury. For this reason we changed our ESM for NPM 7 for the FFY 2018 reporting period to track curriculum focused on teen drivers. Additional information on this is included in the Adolescent Health Annual Report and Plan.

 

Other Work, 2018 to Present

 

Essentials for Childhood

The Essentials for Childhood collective impact partnership closed out our first five-year grant (2013-2018) from the CDC and was awarded a second five-year grant (2018-2023). This past year saw the continued evolution and maturation of the partnership. The partnership and our approach to staffing has evolved and adapted over time as the work transitioned from visioning and planning to implementation and action, and staff and leaders learned what worked and what did not. We made adjustments to respond to an ever-changing landscape at the state level that included creation of a new state Department of Children, Youth, and Families, and reorganizations and changing leadership in other state agencies and private partners, continued health services transformation, and a public education funding crisis.

 

The EFC Help Me Grow Workgroup continued to focus on supporting implementation of HMG in Washington. The workgroup created a theory of change that illustrates how HMG implementation will result in “Systems [that] are aligned and enable family-centered and culturally relevant service provision,” and “Systems and services are transformed to build protective factors, mitigate the impact of trauma and adverse childhood experiences, and contribute to dismantling historical, structural racism and building resilience for safe, stable, nurturing relationships and environments.”

 

Workgroup members helped plan the annual Help Me Grow National Forum held in Seattle in April 2018, and WithinReach was the local host. It was the largest HMG Forum yet. The forum showcased Washington work in multiple ways. EFC Steering Committee members and partner organizations were featured throughout the agenda. About 20 people from around the state participated in a lunch meeting for Washington participants, where they learned about EFCs effort to advance HMG. Many expressed interest in ongoing connection as we plan to convene a learning group of communities working on HMG.

 

The workgroup informed a governor’s legislative proposal in support of HMG and created a fact sheet making the case for better collection of protective factor data.

 

The EFC Steering Committee focused on expanding the HMG system approach as one of its two legislative priorities for the 2018 legislative session. Members were part of a push from many directions that resulted in state supplemental budget proviso funds allocated to “develop and plan an intervention using the HMG model to prevent child abuse and neglect” in Pierce County. That might not have happened if the executive director of the Pierce County early learning coalition hadn’t learned about HMG as a participant on the workgroup.

 

EFC was awarded a Robert Wood Johnson Foundation Project HOPE grant. We are using this two-year grant in conjunction with our HMG work to support an initial learning cohort of counties that have active efforts to pilot and promote a HMG system. Each setting has existing capacity to convene and organize local partners around this issue. We are exploring additional capacity to provide at the local level for partners to get community perspectives on HMG development and fully participate in technical assistance activities.

 

EFC received funding from the Bezos Family Foundation to support Vroom in Washington State. Vroom is a set of asset-based, tested tips for parents of kids from birth to age 5. Content is deployed in a variety of ways, including an app, website, and printed materials. Vroom messages promote positive adult-child relationships, back-and-forth interactions that create neural pathways in developing brains, and life skills that promote executive function. Vroom is intended to help children benefit from parent/caregiver interactions throughout the day that promote brain building.

 

Vroom is part of our EFC strategy of promoting parent and caregiver knowledge of parenting skills, child development, and community social environments that support and empower families. We are planning a layered activation strategy that will include light touch, broad reach through statewide partners and networks, and more intensive, funded activation in a few communities.

 

The WithinReach Chief Strategy Officer and HMG Director is a Help Me Grow Workgroup co-chair. Other workgroup members include pediatricians who have voiced the importance of HMG serving as the larger frame encompassing UDS efforts, and county-level advocates for families and HMG. Their work focuses on the four core components of the national HMG model, shown and outlined below:

 

1. Physician Outreach: Children’s health providers are trained in the process of developmental health and screening.
2. Community Outreach: Events to promote parent education include networking among and across community-based programs and services.
3. Centralized Call Center: A single access point connects families with programs and services statewide.
4. Data Collection: Data track the effectiveness of the linkage to programs and services and are used to inform advocacy at local, regional, and state levels.

 

WithinReach has taken an increasingly strong role directing the efforts of HMG in Washington. Ensuring provider and family understanding of and access to developmental screening; increasing numbers and diversity of family voices within UDS and HMG efforts; educating providers on best practices, including Reach Out and Read and screening tools; increasing collaboration with Washington Early Learning Regional Coalitions and home visiting providers; and supporting LHJs in UDS efforts remained core activities of our Washington HMG affiliate, WithinReach.

 

Project LAUNCH

In 2018, we continued to implement the Project LAUNCH expansion grant, with funding from SAMHSA. Early learning professionals at licensed child care centers and homes were trained to provide opportunities for parents to complete the Ages and Stages Questionnaire and ASQ:SE in English or Spanish. 455 ASQs and 74 ASQ:SEs were completed by parents across the three Project LAUNCH communities this year. 178 referrals were made to early intervention services. In fall of 2018 we began to provide infant and early childhood mental health consultation in licensed child care centers and homes. Technical assistance and scholarships were provided to support early learning professionals moving through the Infant Mental Health Endorsement® process through the Washington Association for Infant Mental Health.

 

Community Asset Mapping

The Community Asset Mapping (CAM) project continued to work with 17 of the state’s 39 counties to promote and improve access to screening, referrals and interventions, including primary care coordination and development of new services. This work establishes coordinated and accessible systems of care, enabling families to receive timely and appropriate developmental screening and support through the diagnostic process for all developmental concerns. Organizations involved with the CAM project include multidisciplinary diagnostic centers across the state, the local school districts, community health providers, early childhood providers, public health, and many others.

 

All 17 CAM counties (14 CAM groups) are doing UDS systems work to varying extent. The communities that are specifically focused on UDS (not associated with autism work) are Snohomish, Clark, Benton-Franklin and Spokane. Yakima County continues to focus on both UDS and autism work. The CAM team is working with an urban hospital and primary care clinic with a high population of immigrants to promote screening using culturally appropriate tools. Additional details about the CAM work are included in the CYSHCN Annual Report in the NPM 11 section on System Coordination and Collaboration.

 

Training and Technical Assistance on Developmental Screening

During calendar year 2018, developmental screening training for physicians continued to be available through the extension of the Great MINDS training model, using a combination of state funds from MCOs and funds from the Office of Rural Health. In partnership with the Washington Chapter of the American Academy of Pediatrics (WCAAP), nine Great MINDS trainings were conducted during calendar 2018, four in rural areas and five in more densely populated areas across the state. Trainings are coordinated by WCAAP and facilitated by parent and physician co-trainers. Great MINDS trains physicians, physician assistants, and advanced registered nurse practitioners, along with clinic staff to become family-centered medical homes and incorporate UDS into their practices. Physicians learned about community referrals and how to refer families to WithinReach for online access to an ASQ or for connection to specific family resources and follow-up. At the end of training, most participants reported knowledge gain in medical home, developmental screening, and where to refer families for follow-up and community-based resources.

 

The AS3D project works to improve access to coordinated, comprehensive systems of services that lead to early diagnosis and entry into services for children with autism spectrum disorders (ASD) and other developmental disabilities. Through this project, we modified the developmental screening training curriculum to focus on ASD screening. This is called Great MINDS-ASD, a continuing medical education (CME) accredited training for primary care physicians serving medically underserved communities on ASD screening. It also covers where and when to refer families for diagnostic and intervention services, family navigator resources, and other community-based services; and how to provide culturally and linguistically responsive care. During FFY 2018, using AS3D funding, there was one training in Central Washington for providers, including pediatricians, family practitioners, registered nurses, and representatives from early intervention and public health agencies.

 

In addition to the statewide work described above, 10 of 35 LHJs used Title V funds in FFY 2018 to expand availability of UDS in their communities. Primary areas of focus included provision of training and technical assistance to cross-sector partners, and engaging in policy and systems change efforts. A Title V funded UDS Consultant (approximately 0.25 full-time equivalent [FTE]) offered technical assistance to LHJs and other community leaders by providing information regarding developmental screening and responding to requests.

 

Promoting Healthy Weight

As our SPM for healthy weight is for the 10th grade age group, our activities related to promoting healthy weight for all youth are described in the Adolescent Health Annual Report.

 

Child Death Review

Title V funds previously supported a State Child Death Review (CDR) Coordinator (0.10 FTE) and CDR Assessment Coordinator (0.05 FTE). This changed in 2018. All the DOH child death review work is now done by one of our agency’s epidemiologists, who is funded at 0.05 FTE for this work.

 

State legislation authorizes, but does not require, LHJs to conduct child death reviews. Currently there are ten CDR coordinators in the state, covering nine of the 39 counties. This includes King County, the largest county in the state. In addition, several LHJs that no longer conduct child death reviews continue to maintain access to the national CDR database. State legislation requires DOH to provide technical assistance to local teams. State CDR staff served as the liaison between LHJs and the National Center for Fatality Review and Prevention, which hosts the national database. State CDR staff also coordinated with the DOH Injury and Violence Prevention team, hosted calls with CDR coordinators on a regular basis, performed quality checks on cases entered in the national database, and updated reports and information on the Washington CDR website, as well as the National CDR website.

 

Child Health Workgroup

The Child Health Workgroup met once in 2018. This workgroup engages participants from across DOH to provide opportunities to co-learn, leverage knowledge and skills, engage in policy development and related activities. Participants include representatives from Environmental Health, Children and Youth with Special Health Care Needs, Essentials for Childhood, Community Based Prevention, Healthy Eating Active Living, Injury and Violence Prevention, Women, Infants and Children Nutrition Program, Breastfeeding, Immunizations, Diabetes, Asthma, Surveillance and Epidemiology, and Cancer Prevention.

 

The goals of achieving health equity and eliminating health disparities infuse our work. The Child Health Workgroup charter is formally aligned with the governor’s Healthiest Next Generation initiative, which stresses the importance of the health and well-being of the children of Washington.

 

In Summary

Title V staff in the Child Health domain continued to promote statewide universal developmental screening and appropriate follow-up and referral for intervention services; safe, stable, and nurturing relationships in families, communities, early learning and school environments; ACEs prevention and mitigation; whole child, whole family, whole community, and importance of resiliency; and health equity for all populations, especially for those who continue to face health disparities. In addition, Title V efforts in this domain are aimed at reducing child and adolescent injuries through state and local level work.