NPM 6: Percent of children, ages 9 through 71 months, receiving a developmental screening using a parent-completed screening tool

As part of Iowa’s Federal/State Partnership, Iowa’s state-funded 1st Five program engaged healthcare providers in supporting the use of developmental surveillance and standardized developmental screening tools. A partnership between providers and 1st Five staff is established for developmental support services (an enhanced form of referral and follow up services).

Local 1st Five site coordinators continued to work on outreach to primary care practices. Outreach included, but is not limited to, screening information displayed in newsletters, trainings, and guide books. Local 1st Five site coordinators worked with 1st Five Medical Consultants on providing developmental screening trainings to office staff and engaged healthcare partners.

Contracts with local 1st Five sites included a revised performance measure to increase the percentage of referrals that follow results of a standardized developmental screen.  The revised measure tiered the increase expectations so that lower performing sites will need to make greater progress to achieve the measure. This strategy showed marked improvements in the numbers of primary care practices engaging with 1st Five.

1st Five’s IDPH staffing has changed to bring in staff with more direct experience working with practices to transition them to full use of standardized developmental screening tools.  Through this staffing, technical assistance for local sites included enhanced assistance with planning, preparation, and skill-building to better prepare local staff for approaching and working with primary care practices. The initiative also adjusted staffing requirements to include additional competencies with developmental support services, including efficient effective tracking of referral and follow-up services, and bring increased technical assistance to local sites for this skill set as well.

Title V Child and Adolescent Health (CAH) agencies reinforced the importance of developmental screening through the informing process for newly enrolled Medicaid families. Bureau of Family Health (BFH) provided Title V CAH agencies with needed information and resources. Title V CAH agencies continued to offer gap‐filling developmental screenings (Ages and Stages Questionnaire (ASQ)) and emotional‐behavioral screenings (Ages and Stages Questionnaire: Social‐ Emotional (ASQ:SE)). Some local agencies also administer the Modified Checklist for Autism in Toddlers (M-CHAT) for toddlers between 16 and 30 months of age.

In the FFY 2020 MCAH RFA application process and resulting contract, the BFH continued the requirement for provision of developmental screening services, including maintaining a working relationship with the Area Education Agencies (AEAs) regarding developmental screening and providing developmental monitoring for children referred to Early ACCESS (IDEA, Part C) who were not deemed eligible for Early ACCESS services. Data was collected, and quarterly reports were created based upon aggregated ASQ and ASQ:SE scores identified by Title V CAH agencies.

BFH staff continued the strong working relationship between Title V MCAH and Iowa Medicaid Enterprise (IME). BFH staff worked with Medicaid’s project manager to continue payable developmental screening services under the Screening Center provider status by both Iowa Medicaid and the Medicaid Managed Care Organizations (MCO). The Iowa Department of Human Services (DHS) began contracting with a new MCO - Centene’s Iowa Total Care  - who began processing claims for services provided July 1, 2019 and after. With the departure of UnitedHealthcare, local CAH agencies assisted clients in transitioning coverage to the remaining MCOs - Amerigroup and Iowa Total Care.  

BFH continued to enhance collaboration between Title V CAH programs and 1st Five, Early ACCESS, MIECHV, early care and education, home visiting providers, and CHSC to encourage developmental screening. BFH staff shared aggregated developmental screening data with the Children’s Justice Leadership Team related to its work regarding the health and wellbeing of pregnant women, infants, and children.

NPM 13: B) Percent of infants and children, ages 1 through 17 years, who had a preventive dental visit in the last year

Although the COVID-19 pandemic did not truly impact the I-Smile™ program until March, it was felt significantly from March through September. The burden of the pandemic on low-income pregnant women and children’s access to dental services can be seen by looking at the large decrease in Iowa dentists billing Medicaid for services provided to children. Medicaid data indicates that in SFY20, just 950 dentists billed Medicaid compared to 1,066 in SFY17, 1,038 in SFY18, and 1,035 in SFY19. 

In response to the Governor’s pandemic declaration, dental offices were required to close for more than a month. Once reopened, the additional costs of personal protective equipment, changes in office procedures for patient appointments, and backlog of patients from the closures resulted in many dental offices limiting or declining to see Medicaid-enrolled patients. Prior to dental offices reopening, the Iowa Dental Board adopted specific COVID-related infection control recommendations; OHDS staff then developed infection control guidelines for I-Smile and I-Smile@School based on dental board requirements. OHDS staff provided a great deal of technical assistance to I-Smile™ contractors with the ever-changing COVID-19 protocols and research.

I-Smile@School offered no services from mid-March through August and resumed very limited direct services in September 2020. Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics used virtual appointments, reducing the maternal and child health clients’ access to preventive dental services (which are only available in-person). The inability to provide direct dental services resulted in some local I-Smile™ staff to be laid off. County health departments enlisted I-Smile™ staff to assist with pandemic response efforts.

Local I-Smile™ program activities were modified from original plans to reflect what was possible during the pandemic. For example, Coordinators’ outreach to dentists and physicians were completed by phone or virtually, rather than in person. I-Smile™ Coordinators found new ways to reach families including: oral screenings during drive-through meal pickups at schools, creating YouTube oral health education videos, and offering care coordination and preventive services at vaccination sites. Care coordination continued, with additional focus on contacting families due for regular check-ups.

SPM 2: A) Percent of children 0-21 served by Title V who report a medical home

In FFY2020, the medical home percentage was 82.47. This rate is down from previous years, however it exceeds the annual objective set for 2020 (81.5%).In FY20, Title V changed how medical home was documented in the MCAH database from a one-time report to an ongoing measure. Prior to FY20, medical home was asked at first contact with the family, and may not have been updated after that. Families face ongoing barriers to establishing a medical home. This question is now asked at each contact with the family. This way of assessing medical home will be a truer picture of families’ access to care in a medical home. The drop this year, may also reflect the change in data collection. Contractors had to document medical home differently, and it took some time for contractors to adjust and document correctly. We anticipate the rate will go up slightly, after contractors have adjusted to the documentation. However, COVID-19 may also have an impact on medical home in the coming years.

BFH staff continued to monitor data for the percent of children and adolescents served with a medical home.  This was accomplished through reports from the signifycommunity - CAH module.  Local CAH contract agencies continued to assess a child’s medical home status regularly when providing presumptive eligibility, informing for new Medicaid eligibles, care coordination, and gap-filling direct care health services through completion of the Intake  Assessment. A medical home was identified for those children with a ‘yes’ response to three questions:  

1. Does the client have a usual source of medical care?  
2. Is the usual source of medical care available 24/7? 
3. Does the source of medical care maintain the child’s record?  

Medical homes were established for uninsured or underinsured children as well as those on Medicaid.  Presumptive eligibility services for children continued to be provided, offering a window of Medicaid coverage while a full determination of eligibility for Medicaid or Hawki is made.  Local Title V CAH agencies continued to assist families with understanding their Medicaid or Hawki coverage.  For Medicaid enrolled children, they assisted families to connect with primary care providers within their child’s Medicaid status.  Local CAH agency staff promoted health literacy by striving to assure that families understood their health insurance coverage, knew how to use it to access health care, and assisted with needed transitions to new providers or alternate types of health care coverage.

Local CAH agencies advanced public-private partnerships with local medical providers of preventive health care services, including educating practitioners on the CAH agency’s role in assuring medical homes and serving children in the EPSDT program.  This work was especially strong among CAH agencies that also held a contract for Iowa’s 1st Five Healthy Mental Development Initiative.  

At the state level, BFH staff worked with Iowa Medicaid and MCOs to address challenges regarding provision and payment of services for the EPSDT population provided by Title V CAH agencies (Medicaid Screening Centers). Monthly Medicaid Team meetings continued to be held.  Local CAH agencies continued to strive to work effectively with the MCOs to maintain access to care that meets the needs of the families they serve.

BFH staff continued to work with Child Health Specialty Clinics regarding efforts to promote medical homes for children with special health care needs to support NPM #11 and assure appropriate resources for referral from CAH agencies. These included telehealth projects like Phones for Families.

SPM 3: Percent of children with a payment source for dental care

OHC continued to monitor the climate in Iowa for a possible transition to managed care for dental services for children through regular communication and face-to-face meetings with Iowa Medicaid Enterprise, Delta Dental of Iowa and Managed Care of North America (MCNA), a carrier for Medicaid’s adult dental services. The dental director continued his role as a leader in the state through his work on the Hawki board, with stakeholder groups, and with national organizations with insight to other state’s policies. 

I-Smile coordinators were required to make outreach visits to all pediatric medical offices as well as general and pediatric dental offices, intended to build the referral network for I-Smile and in the end increase not only access to dental care but also assistance for families to receive care. Coordinators provided oral health training and implemented tooth brushing protocols for child care centers to help meet child care Quality Rating System requirements. Enrollment information about Medicaid and Hawki were shared with child care providers through this outreach. In addition, through the regular contacts with families via the services provided by I-Smile at WIC, Head Start, schools, and other public health sites, children found to have no payment source for dental care were screened for presumptive eligibility.

SPM 4: Percent of early care and education programs that receive Child Care Nurse Consultant Services

In Iowa, 75% of working families with children under the age of 6 years utilize child care. Iowa has over 4,100 regulated child care providers (centers, preschools and homes). 76% of child care remained open during the COVID-19 pandemic however many at reduced capacity. Programs that closed were mostly associated with local school districts. Currently there are not enough child care slots to meet the needs of working families and almost one-fourth of Iowans live in child care deserts. That number is even higher when looking for infant and toddler child care. Nationwide and in Iowa there has been an increase in childhood chronic health conditions and allergies. Child Care Nurse Consultants (CCNC) provide best practice guidance, assessment visits, training and care planning for children with special health needs to help ensure equitable access and improve child care quality. The CCNC program is non-regulatory and is available statewide with all 99 counties having local CCNC services. In FY20, we exceeded our goal for the percentage of child care programs participating with their local child care nurse consultant, with 42% of programs receiving CCNC services. Services included 3082 child care visits (on-site and virtual), 9,113 technical assistance (increased 47%) and 680 children with special health needs identified, 91% with a care plan in place at the child care program.

Healthy Child Care Iowa continued to provide support to Title V Child Health partners/local CCNC agencies in the following activities:

• Developed/revised data collection tools for streamlined tracking and reporting data
• State and regional CCNC meetings for review of the Child Care Nurse Consultant Role Guidance to achieve SPM 4 and standards of services; data collection tools; program fidelity
• Continued to facilitate the development of partnerships between Title V Child Health agencies/CCNC programs with local Early Childhood Iowa boards and other local stakeholders
• Statewide coverage for CCNC services in all 99 counties
• Collaborated with state partners on identified PM adding in chronic health conditions data to align with Iowa school data collection for special needs care planning
• Continued participation on the QRIS Oversight Team for development of required CCNC services for meeting Medication Administration Skills Competency and on-site health and safety assessment utilizing a nationally recognized research based assessment tool for child care programs applying for Iowa’s new quality rating system (Iowa Quality For Kids - IQ4K)
• Provided oversight and guidance to the TA and Mentoring CCNC Team for supporting local CCNCs, precepting of nurses enrolled in the Iowa Training Project for Child Care Nurse Consultants, mentoring of local CCNCs and providing on-site child care provider visits to programs in the 3 county area without access to local CCNC services     

Title V staff and HCCI staff will continue researching potential partnerships to increase funding for gap filling services throughout the state.