Maryland’s priority need for the child health domain is “to ensure that all children have the opportunity to develop and reach their full potential”. Maryland Title V provided preventive and primary care through direct, enabling, and public health infrastructure services to a variety of child health needs in FY 2022. Services and activities focus on the needs of children across the Title V pyramid as outlined by the State Action Plan. Child health activities for which Title V provides state leadership including local child fatality reviews, access to developmental screenings and medical homes, school-based health services such as hearing and vision screening and referral, behavioral and substance use disorder screening and referral, immunizations, and early intervention services.

National Performance Measure 6 Developmental Screen: According to the National Survey of Children’s Health 2020-2021 data, 39.9% of children ages 9 through 35 months received a developmental screening using a parent-completed screening tool in the past year.

SPM 3 Receipt of Primary Care During Early Childhood (receiving at least 5 well-care visits by 15 months): Maryland state Medicaid data reported that in FY 2022, 72.1% of children enrolled in Medicaid who reached age 15 months received five or more well-care visits in their first 15 months of life.

Local Health Departments:  Local health departments serve as Title V’s primary delivery arm for preventive and primary care services for children. Each of the 24 local health departments receive federal Title V funding through a state core funding process to support direct, enabling, and public health services and systems. In FY 2022, eleven local health departments used Title V core funding to support child health services including services such as immunizations, hearing and vision screening (in collaboration with local public and private school systems); and school based health services (elementary through high school) including wellness care and behavioral health screening.

Title V requires local health departments that provide child health services to submit performance measure data quarterly to demonstrate how their activities align with the Title V state action plan. This includes activities such as providing linkages to medical homes, providing information on developmental screenings and subsequent linkages to early intervention or speciality care when indicated, linkages to mental health or substance use treatment, and education on secondhand smoke exposure.

For FY 2022, Title V started to see an increase in provision of critical child health services across Maryland.  The table demonstrates the number of children served during the start of the COVID-19 pandemic (FY 2020), during the COVID-19 pandemic (FY2021), and later during the pandemic (FY 2022).

Medicaid continues to be a significant Title V partner. The current MOU outlines agreements and guidelines on administration and policy, systems coordination, outreach and referral activities, and data sharing. Local health department Title V funded staff work with the Medicaid Administrative Care Coordination Unit (ACCU) within their health department to identify and enroll eligible children in the Medicaid Program and other child health services.

Child Fatality Review (CFR):  A critical activity of the Maternal Child Health Bureau and Title V is the prevention of child and adolescent deaths through Child Fatality Review (CFR). CFR was established by Maryland statute in 1999 as the Maryland Health General Article §5-702-704. Maryland CFR program’s mission is to develop plans, implement change and advise on policy and practice to prevent child deaths in every jurisdiction in the state. Maryland CFR comprises 24 local teams and the state team. Local CFR programs review all unexpected deaths of children under the age of 18, in order to understand the cause and incidence of child deaths and make community-level recommendations for the prevention of child deaths. The State CFR Team, in turn, reviews statewide child fatality data to make state-agency level recommendations, implement recommended changes within the agencies represented on the State CFR team, and to advise State leadership on preventing child deaths. Title V supports the 24-member State CFR Team, which meets quarterly, as well as each of the 24 local CFR teams.  

The State CFR Team oversees the efforts of local CFR teams that operate in each jurisdiction. After each unexpected death, the local CFR teams receive notice from the Office of the Chief Medical Examiner (OCME) of the resident child’s (under age 18) death and are required to review each of these deaths. Local teams meet at least quarterly to review cases and make recommendations for local level systems changes in statute, policy, or practice to prevent future child deaths, and work to implement these recommendations, in accordance with the Health General Article. 

State CFR efforts to reduce the number of preventable child deaths continued as mandated by the Maryland Legislature. In FY 2022, CFR received 239 referrals from the Office of the Chief Medical Examiner (OCME), and teams reviewed 188 deaths, 79% of all cases referred.

In FY 2022, Title V staff continued to actively participate in the Department of Human Services Social Services Administration’s Substance Use Disorder Workgroup to collaborate on interagency efforts to reduce the risk of harm for substance exposed newborns and their families.

The CFR program continues to participate in the ongoing efforts of the CDC Sudden Unexpected Infant Death (SUID) Case Registry, and local teams and coordinators received training and technical assistance on the utilization of the SUID Categorization Algorithm, which was utilized in all SUID reviews that occurred during FY 2022. Teams continued to work towards meeting the timeliness goals set by the CDC (270 days from date of death to case cleaning by CFR epidemiologist) with 35 cases entered in the SUID case registry during FY2022, with 29% of cases meeting desired timeliness benchmarks, and over 80% cleaned within 120 days of data entry.

The COVID-19 pandemic proved to be challenging for local CFR programs, with teams being partially or fully detailed to pandemic related duties. Remote reviews positively impacted the local CFR teams as more team members were able to join virtually than in person.   

Child Abuse Medical Providers (CHAMP) Initiative: 

Chapter 334 of the Acts of 2005 (SB 782) charged the Secretary of the Maryland Department of Health (the Department) to establish the Child Abuse and Neglect Centers of Excellence Initiative and to appoint and convene the Child Abuse and Neglect Expert Panel. In 2008, pursuant to Md. Ann. Code Health-General Art., §13-2201, the Child Abuse and Neglect Centers of Excellence Initiative was renamed Maryland Child Abuse Medical Providers (CHAMP). The CHAMP initiative was developed to provide expert consultation and training to local multidisciplinary teams (MDTs) and child advocacy centers in the diagnosis and treatment of child abuse.

According to the Maryland Department of Human Services’ Child Protective Services, in FY 2022, there were 47,258 cases of alleged child abuse and neglect in Maryland. This represents an increase in cases of alleged child abuse and neglect in FY 2020 and FY 2021, but this is likely due to the decreased reporting by school staff in FY2020 and FY 2021 due to school closures due to the COVID-19 pandemic. Data is reported on an annual basis, within the CHAMP Annual Legislative Report.

Multidisciplinary teams (MDTs) are comprised of medical professionals, Child Protective Services staff, law enforcement, mental health providers, forensic interviewers, state attorneys, and victim advocates. They are used to enhance and improve investigations and responses for children and families. These teams are required due to the complex nature of child abuse and neglect investigations. These MDTs staff child advocacy centers (CACs), which are child-friendly facilities where children and families engaged in child abuse investigations can access services. In Maryland, 24 local CACs respond to over 6,000 children each year with allegations of sexual abuse, sexual assault, and other maltreatment of children. The CHAMP initiative was developed to provide training and ongoing support to local providers, and expert consultation to local or regional CACs in the diagnosis and treatment of child physical abuse, sexual abuse, and neglect.

During FY 2022, the Department’s Maternal and Child Health Bureau administered the CHAMP initiative through staff support of five CHAMP faculty members contracted to provide ongoing training, consultation, and case review to local providers.

CHAMP Activities

In FY 2022, LifeBridge Health continued as the grantee awarded to implement the CHAMP Initiative.  In FY 2022, the CHAMP faculty developed a website, Maryland Child Abuse Medical Professionals (https://www.lifebridgehealth.org/main/child-abuse-medical-professionals-champ). The website includes information to support the CHAMP initiative including clinical resources, a list of local CAC contacts, referral guidelines, mental health resources, and resources for professionals and parents. The CHAMP faculty met monthly to discuss future educational activities, recruitment of network providers, and child maltreatment prevention efforts. The CHAMP faculty provided educational and case review support in the diagnosis and treatment of child maltreatment to local health care providers, and expert consultation to State agencies involved in child abuse and neglect investigations, such as Child Protective Services and law enforcement. Through the use of a secure, HIPAA-compliant online program called XIFIN (Telecam), CHAMP faculty provided case review services to local providers. This platform allows local providers access to consultation services and allows them to upload case information and images to the secure website, accessible only to CHAMP faculty, for review. 

In FY 2022, CHAMP held two half-day continuing education events for health care providers to review a variety of child maltreatment topics, including: “Practical Approaches to Caring for Children with Trauma” and “New National Children’s Alliance Medical Standards for Sexual Abuse and Physical Abuse”. Each educational event also included an interactive case review session, where providers presented child abuse cases and participated in a discussion of the case, their evaluations, and findings. The case review sessions were led by a faculty member and were an opportunity for providers to review and discuss suspected incidents of child abuse and neglect. The case review sessions were particularly helpful for those who practice in lower volume jurisdictions and may not have opportunities to observe and assess less common findings in a clinical setting. CHAMP faculty members also provided quarterly reports on the number of cases reviewed through Telecam.

Medical Evaluation Capacity

Insufficient medical evaluation capacity continues to be a persistent challenge across the State. The CHAMP faculty identified all the medical partners associated with Maryland’s CACs, and continued significant outreach throughout FY 2022 to identify both CACs lacking medical support, and those medical partners who were not yet engaged with CHAMP training and peer review services. Medical staff who serve the CACs include pediatricians, sexual assault forensic nurse examiners, medical directors, and medical representatives for the multi-disciplinary team. The vast majority of centers do not employ their own medical providers. Almost all centers work with local hospitals to provide medical staff on a part-time, as-needed basis. In order to enhance medical evaluation capacity, especially in Southern Maryland, CHAMP faculty have continued outreach to providers in St. Mary’s, Prince George’s and Charles County to recruit medical staff who serve the CACs. CHAMP faculty also purchased a Cortexflo camera for Carroll and Talbot County, to ensure their ability to take evidence grade photographs and videos with secure storage capacity for forensic medical examinations.

Training and Standards

In order to expand access to training, expert consultation and peer review, CHAMP faculty are working to identify ways to collaborate with physicians and nurses from around the state of Maryland. Currently, the majority of our faculty are located in Central Maryland, with one faculty member located on the Eastern Shore and another in Frederick County. CACs in Western, Southern, and Eastern Maryland are often at a disadvantage when it comes to identifying and training new providers. Therefore, it was necessary to improve the quality of virtual training experiences and to reduce barriers to in-person clinical training opportunities. To address this barrier, the CHAMP faculty experimented with a hybrid training for both virtual and in-person attendees.

Accreditation Process

Each year, the Maryland Children’s Alliance (MCA) reaffirms the establishment of their CAC standards to meet national accreditation. These standards include the presence of multidisciplinary teams, cultural competency and diversity, fact-finding forensic interviews, victim support and advocacy for caregivers, a formal case review process, and creating a comfortable, safe, private child-focused setting. Along with MCA, CHAMP faculty have committed to continue to ensure medical providers at the currently unaccredited CACs have access to the required training and advanced medical consultation needed to meet the medical evaluation standards for gaining National Children’s Alliance (NCA) accreditation. Additionally, CHAMP faculty will continue to assist CACs in meeting newly updated medical evaluation standards.

The Department intends to assist the CHAMP Initiative in engaging other key stakeholders who work with children and child maltreatment. The CAC needs assessment provided the Department with a starting point in bridging gaps in the continuum of care. Recommendations in the needs assessment included providing more training opportunities for school nurses on child maltreatment, as well as a recommendation that all Maryland medical staff who see children should screen for Adverse Childhood Experiences at their well visits. The Department intends to work more closely with the MCA, the CACs, and the CHAMP Faculty to increase collaboration and reduce gaps in the identification and evaluation of victims of child abuse and maltreatment.

[1] This includes the number of immunization records reviewed as well as immunizations provided

[2] This includes children (1-21) who were screened for hearing.