Annual Report Fiscal Year 2018:  This section provides a summary of Federal Fiscal Year 2018 (FFY18) activities, accomplishments, and challenges related to National Performance Measures (NPMs) and State Performance Measures (SPMs) (2016-2020) for the Child Health Domain.

Developmental surveillance, screening, and observations are important in all aspects of a child’s growth and development. The American Academy of Pediatrics (AAP), Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescent recommends standardized developmental screening be used at 9 months, 18 months, and 2.5-year visits. Additionally, the AAP recommends developmental screening any time concerns are identified.

In FFY18, the Child Health Program (CHP) continued to support two methods to increase developmental screening: (1) implementation of Help Me Grow (HMG) in two pilot communities and (2) training on and distribution of the Ages and Stages Questionnaire (ASQ) screening tool.

Strategy 1:  Pilot HMG model in two counties (inactive as of June 30, 2019)

In 2015, the national HMG model was selected to support a system-level approach to improving access to existing developmental resources and services for children through age eight, including children with special health care needs. The WDH contracted with Wyoming 211 in October 2016 to act as the centralized telephone access point for HMG. Wyoming 211 began a limited regional pilot focusing specifically on Albany and Laramie counties. 

The HMG model is divided into three main areas: (1) building the infrastructure, (2) building the system; and (3) sustaining the system. During FFY18, Wyoming implementation of HMG remained in the infrastructure building phase. Fidelity assessment results showed progress in the area of developing a centralized telephone access system (at systems-building phase).  Wyoming saw less significant progress in areas related to community outreach and data collection.

Four cooperative and interdependent core components characterize the HMG system model. They include centralized access point, family and community outreach, child health care provider outreach, and data collection and analysis. 

Centralized telephone access is a key component of the HMG model as well as a critical component of the model for Wyoming’s implementation. The frontier nature of the State requires innovative and virtual supports to link children and families to needed resources. HMG received referrals in two main ways. Referrals came through direct contact with HMG (ESM 6.5) by phone, mail, walk-in or word of mouth or as a referral from the 211 call center (ESM 6.3).  Unfortunately, the number of unique contacts referred to HMG remained limited throughout the pilot. Anecdotally, we understand this may be due to the fact that the difference between HMG and 211 was difficult to understand for many stakeholders and consumers.

The HMG system relies upon strong child health care provider outreach to establish buy-in for HMG as a method for linking children and families to needed services and resources. The HMG Coordinator attempted to establish relationships with providers in both communities but outreach remained a challenge throughout the pilot project. Another clear challenge to effective outreach was turnover at both Wyoming 211 and the MCH Unit, leading to significant gaps in implementation and delayed training on the HMG model. The HMG program experienced turnover at the HMG Care Coordinator position four times between 2016 and 2019. In addition, the CHP position turned over once in 2018 and the Wyoming 211 Executive Director position changed three times.  Fortunately, through key staffing changes, the key funders of the Wyoming HMG pilot remained consistent and represented the MCH Unit, Wyoming Children’s Trust Fund, Wyoming Head Start Collaboration Office (Department of Workforce Services) and Wyoming Early Intervention and Education Program (Part C).  

In 2018, Wyoming 211 upgraded their data system to improve data collection and reporting. Additionally, the CHP and HMG staff worked to better define the measures being collected in order to match measures with program performance and outcomes. This new data system combined with refined measures has allowed for more accurate data collection and usage. However, the numbers reported show low uptake of HMG. 

As the three-year pilot neared its end, the MCH Unit met with key stakeholders as well as Wyoming 211/HMG staff to discuss progress and challenges. While current Wyoming 211 staff dedicated considerable time and effort learning the HMG model and attempting to reset, the long-term challenges outweighed the current success of the model. Identified challenges included:

• Confusion over the difference between HMG and Wyoming 211;
• Limited stakeholder understanding on how HMG fits within a complex early childhood system;
• Concern for duplication of efforts between HMG and other community services such as home visitation, early intervention, etc;
• Community push-back in pilot communities (i.e. lack of stakeholder support and buy-in); and
• Limited data on impact/value of HMG pilot project in Laramie and Albany counties.

In 2019, the MCH Unit and partner funding agencies decided to end the HMG pilot in Laramie and Albany counties effective June 30, 2019 instead of continuing the program in the final year of the Title V five-year cycle. The CHP will use FFY20 to convene key statewide stakeholders within the Wyoming early childhood system to include the WDH, Wyoming Department of Workforce Services, Wyoming Department of Family Services, Wyoming Department of Education, University of Wyoming, Wyoming Children's Trust Fund, and Wyoming Kids First to define the early childhood system, identify duplicate and complementary services, and identify gaps in available services. The MCH Unit recently requested technical assistance from the MCH Workforce Development Center to accomplish this work.

Strategy 2:  Provide ASQ Training and Tools to Wyoming providers

Historically, the CHP provided ASQ training and resources to a wide range of partners including day care providers, child development center staff, providers, PHNs, and home visiting staff. The program identified challenges collecting data on usage of the ASQ from a diverse group of partners due to the absence of any shared or central data system. The CHP maintains little to no direct control over most sites utilizing the ASQ tool and therefore, cannot accurately report on distribution or use. The ASQ is, however, utilized by PHN in their home-visiting programs and the CHP has better access to PHN’s data system. Therefore, the CHP elected to only measure the usage of the ASQ by PHNs.

The CHP maintains a commitment to providing training and support of the ASQ tool to community providers and partners. The MCH Unit does not currently have any staff certified to train on the ASQ tool but can rely on trained partners as needed. In September of 2018, the CHP partnered with HMG staff and the Wyoming Children's Trust Fund to provide ASQ training at the Wyoming Public Health Association (WPHA) annual conference. WPHA conference attendees were child care providers, child healthcare providers, and public health nurses. Additionally, the CHP and the Wyoming Children's Trust Fund supported the training of staff at the University of Wyoming Family Medicine Residency Clinic in Casper, Wyoming. The CHP provided ASQ kits and the Wyoming Children's Trust Fund provided the training needed to administer the ASQ.

Strategy 3:  Increase the availability and quality of vision screening training (inactive as of October 1, 2018)

In 2018, the University of Wyoming’s Wyoming Institute for Disabilities (WIND), a University Center for Excellence in Developmental Disabilities, completed a multi-year project which developed a comprehensive child vision screening training program to support the Wyoming Vision Collaborative. Through this joint relationship, a well-established high-quality virtual learning environment was created to support the long-term training and support of child vision screeners across Wyoming.

Strategy 4:  Promote lead screening

In Fall 2018, the Wyoming Department of Environmental Quality (DEQ) applied for and received a Water Infrastructure Improvements for the Nation Act (WIIN Act) Grant: Lead Testing in School and Child Care Program Drinking Water. The grant creates a voluntary program to assist with testing for lead in drinking water at schools and child care programs. WDH staff (including State Health Officer and representatives from Wyoming Public Health Laboratory, MCH Unit, Wyoming Medicaid, WIC, and PHN) will partner with DEQ, schools, and child care centers to support this grant initiative, as needed. In addition, WDH representatives formed a workgroup to discuss strategies to improve lead screening and surveillance data, community and provider education, and public health response to lead exposure.  Next steps include recruiting provider champions to support this initiative.

Strategy 5:  Train providers on Bright Futures Recommendations

In 2017, the MCH Unit received technical assistance related to Early and Periodic Screening, Diagnostic and Treatment (EPSDT), a topic prioritized by both the MCH Unit and Wyoming Medicaid. Dr. Wendy Davis from the University of Vermont, College of Medicine presented during Wyoming’s 2017 Block Grant Review and during an October 2017 Wyoming Medicaid Medical Advisory Group (MAG) meeting. Following Dr. Davis’ presentation on Bright Futures, 4th Edition and the promotion efforts in Vermont, the MAG voted to adopt the Bright Futures Guidelines, 4th Edition in Wyoming. In order to maintain momentum on this important cross-division project, the MCH Unit submitted a successful application for the Title V MCH Internship Program. Two graduate-level interns worked with MCH, Medicaid and other key stakeholders to develop a plan to implement Bright Futures, 4th Edition during Summer 2018. This joint project supports Wyoming’s 2016-2020 Title V priority to improve preventive and quality care for children and adolescents, a priority which directly aligns with three Title V NPMs. They include NPM 6: Developmental Screening, NPM 10: Adolescent Well Visit, and NPM 12: Transition. The student-developed plan to implement Bright Futures can be viewed in Appendix C. In 2019, the MCH Unit will reconvene interested stakeholders to prioritize and implement the students’ recommendations. The first step is to form a Bright Futures Implementation Task Force. So far, the MCH Unit has commitment from Wyoming Medicaid, WYhealth, and the Immunizations Unit to participate. 

The prevention of childhood obesity was selected as a Wyoming priority for 2016-2020.  Physical activity remains the key strategy to reduce childhood obesity. 

In FFY18, the CHP transitioned NPM 8--percent of children (6-11 years) who are physically active at least 60 minutes per day (NSCH) into SPM 5. This change was made at the encouragement of Title V reviewers who acknowledged the MCH Unit was focusing on too many strategies with limited resources. 

Strategy 1:  Partner with the Wyoming Chronic Disease Program to implement evidence based prevention strategies in early childhood facilities and schools

The CHP partnered with the Wyoming Chronic Disease Prevention Program (CDPP) to support the Comprehensive School Physical Activity Program (CSPAP). During FFY18, Title V funds supported training of 118 secondary education teachers across the state.  Thirty-three training participants represented schools on the Wind River Indian Reservation serving both the Northern Arapaho and Eastern Shoshone tribal nations. CSPAP reached an estimated total potential population of 3,186 Wyoming children in FY18 based upon the average class size of 27 students per Wyoming secondary education classroom.   

The CHP partnered with the Wyoming Chronic Disease Prevention Program (CDPP) to support a contract with the University of Wyoming Cent$ible Nutrition Program to support training of Cent$ible Nutrition Educators (CNE). This activity was part of the Centers for Disease Control and Prevention (CDC) and Nemours Children’s Health System, Let's Move initiative. The work brought together partners from the WDH, Workforce Services, Family Services, Education, and the University of Wyoming Cent$ible Nutrition Program. At the end of this 18-month project, national trainers from Nemours Children’s Health System supported by CDC were able to certify 45 University of Wyoming Extension service, nutrition educators (CNE) as child obesity prevention educators. These CNE’s represent all 23 Wyoming counties as well as both Tribal nations on the Wind River Indian Reservation.

Over the past several years, CDPP implemented nutrition and physical activity promotion efforts in early childhood settings.  In FFY18 the CDPP received zero funding to address childhood obesity or to target children 0-18. As a result of the CDPP’s loss of targeted funding to address children 0-18, the CHP adjusted strategies to fill an important gap. The CHP partnered with the Head Start State Collaboration Office to develop a Wyoming Healthy Policies Toolkit targeting early childcare centers, Head Starts, Early Head Starts, licensed childcare providers, and elementary schools. This tool kit will incorporate evidence-based policy recommendations and will be distributed soon.

* The CHP and MCH Epidemiology Program will also track NPM 7.1 and NPM 7.2 in FFY20 due to a change in program strategy to focus on childhood injury prevention for ages 0-19. Due to it being the last year of a federal cycle, we will not add new SPMs.

Strategy 1:  Support Safe Kids Wyoming (inactive as of October 1, 2018)

In FFY18, the CHP continued to fund Safe Kids Wyoming (SKW) to focus on activities to prevent the leading causes of death and injury in Wyoming children ages 1-11 with a primary focus on child passenger safety. The CHPM, the WDH Injury and Violence Prevention Program (WIVPP) Prevention Coordinator, and MCH Injury Epidemiologist advised the work of SKW as members of the SKW Leadership Team. Activities employed by local SKW coalitions across the state to reduce child injury hospitalizations and deaths included child passenger safety events; traveling safely with newborn classes; car seat installation and inspection station events; helmet distribution; and bike rodeos, among others. SKW reported that 1,477 infant and child car seats were inspected across the state by 205 certified child passenger safety technicians. Additionally, SKW reported that 859 car seats were distributed to families in need. 

The CHP recognized the need to adjust strategies within this priority to align with leading causes of childhood injury. Historically (in Wyoming and nationwide), SKW primarily focused on childhood injury in younger children. The focus of SKW on younger children also aligned with the ‘target age group’ for the CHP--ages 1-11. With new CHP leadership and recommendations from MCH Epidemiology to look more broadly at childhood injury, emerging topics of adolescent suicide and adolescent driver safety surfaced. The broadened focus requires significant collaboration between the CHP and Youth and Young Adult Health Program. Due to changing focus on this priority, the program will also track NPM 7.1 and 7.2, the rate of hospitalization for non-fatal injury per 100,000 adolescents, ages 0-9 and 10-19, respectively; however, we have not set new SPMs nor targets for these measures due to insufficient time in this block grant cycle to see a considerable change. The needs assessment will determine how we proceed on this topic beginning in FFY21.

Strategy 2:  Implement community based grants with targeted evidence-based strategies to address the major causes of childhood injury/hospitalizations in Wyoming

In order to respond to changing data needs related to injury prevention in children, the CHP shifted its funding model for this priority away from statewide SKW coordination and towards a mini-grant program to increase the amount of resources going straight to local implementation evidence-based or evidence-informed childhood injury prevention strategies.  As a result, the contract to support SKW coordination was not extended for FFY19. The YAYAHP and the CHP developed and released a MCH Community Mini-Grant Program with a focus on childhood injury prevention. Nine organizations applied for funding and all were awarded. The mini-grant projects address a wide variety of injury topics from safe sleep, to prescription drug monitoring to adolescent motor vehicle safety and adolescent suicide prevention.  Projects will begin Summer 2019 and continue into FFY20. 

In 2018, the CHP, YAYAHP, and Injury and Violence Prevention Program joined the Child Safety Learning Collaborative (CSLC), through the Child Safety Network (CSN), to focus efforts to reduce fatal and serious injuries among infants, children, and adolescents by building and improving partnerships and implementing and spreading best practices, especially among the most vulnerable populations. Upon review of available data and capacity, the team selected Suicide & Self-Harm Prevention (SSHP) and Motor Vehicle Traffic Safety (Child Passenger and Teen Driver/Passenger) (MVTS) as CSLC topic areas of focus for Wyoming. The YAYAHPM took lead on the SSHP topic while the CHPM leads MVTS. 

The CHPM is a member of Safe States Alliance. Some of the components of active membership includes serving on the Plains to Peaks (P2P) steering team. P2P is the regional Safe States Alliance networking committee that brings together public health injury and violence prevention professionals from the rocky mountain region and the west coast. Participations allows for sharing of information and resources and professional development. The CHPM served as an abstract reviewer on infant, child, and adolescent injury topics ahead of the September 2019 conference.