Massachusetts has four priorities for Child Health for 2015-2020:

1. Promote safe, stable, nurturing environments to reduce violence and the risk of injury.
2. Promote equitable access to dental care and preventive measures for pregnant women and children. 
3. Reduce the impact and burden of environmental contaminants on children and their families.
4. Promote emotional wellness and social connectedness across the lifespan.

 

Priority: Promote safe, stable, nurturing environments to reduce violence and the risk of injury

Progress toward the first priority is measured by the rate of injury-related hospital admissions per population aged 0-9 years (National Performance Measure 7). Key MDPH programs that contribute to addressing this measure include Injury Prevention and Control Program (IPCP), WIC, Early Intervention Parenting Partnerships Program (EIPP), MA Maternal, Infant, and Early Childhood Home Visiting Initiative (MA MIECHV), MA Pregnant and Parenting Teen Initiative (MPPTI), Child Fatality Review (CFR), and School Health Services.

 

NPM 7: Rate of injury-related hospital admissions per population aged 0-9 years

In 2016, the rate of injury-related hospital admissions among children aged 0-9 years was 103.3 per 100,000, decreasing from 122.9 in 2015 and surpassing the initial 2020 objective of 110.1 per 100,000. MDPH has increased its poison education trainings for child-serving agencies as a feasible and measurable primary strategy to reduce unintentional poisonings. Another strategy to reduce injury-related hospitalizations includes promotion of injury prevention in the home, community, and child care settings by home visiting programs. These strategies align with the Massachusetts State Health Improvement Plan (SHIP), MDPH’s strategic plan.

 

Injury Prevention and Control Program

Poisoning/Overdoses:

Unintentional poisoning of children is an important public health problem and poisonings are a leading cause of hospitalization among children. A recent meta-analysis indicated that the most successful interventions to prevent poisoning involve increasing education and awareness of poison control center services, including access to their contact numbers.[1],[2] In 2018, the most common poisoning agents for Massachusetts children aged 0-9 years among cases referred to the Poison Control and Prevention Center were analgesics and topical preparations in the drug category, and cosmetics, personal care products, and household cleaning products in the non-drug category.

 

Poison prevention programming initiatives in Massachusetts are the purview of the Massachusetts and Rhode Island Regional Center for Poison Control and Prevention based at Boston Children’s Hospital, which receives partial funding from Title V. A Community Outreach Educator works to reduce intentional and unintentional poisonings through prevention education and increasing public awareness of the Center’s services. MDPH provides both state and federal funding and oversight of the Center and of the Community Outreach Educator.

 

The Poison Control Prevention Center has two main strategies to decrease injury-related child hospitalizations: 1) increase educational collaborations with Massachusetts child-serving agencies, including WIC, Department of Early Education and Care, and Head Start and 2) support the MA/RI Regional Poison Control Call Center.

 

The first strategy is tracked through the following Evidence-Informed Strategy Measure (ESM): the number of Poison Control Center prevention education sessions held at Massachusetts child-serving organizations. In FY18, there were eight poison prevention education sessions with parents/staff at child serving agencies as compared to 14 in 2017, and six in 2016. This was less than the goal of 18 presentations for 2018. A key challenge to providing education sessions during FY18 was the limited amount of time the Educator was able to devote to conducting outreach and education sessions while also completing the MDPH Marijuana Baseline Health Study (MBHS). The Educator was responsible for collecting data, reading through thousands of cases, and conducting research for the MBHS in anticipation of the opening of recreational marijuana dispensaries. Another challenge was that child-serving organizations tended to plan their outreach far in advance from the time the outreach was conducted. When the educator contacted child-serving organizations in FY18, many of them planned an educational session for FY19. The Poison Control Center is confident that it will surpass the upcoming ESM goal with more time dedicated to outreach and the numerous upcoming presentations already scheduled during FY19 with an increase in provider and caregiver attendance. In 2019, MDPH anticipates conducting outreach to 400 providers and caregivers.

 

The second strategy to decrease child hospitalizations is support of the MA/RI Regional Poison Control Call Center. Poison centers are a cost-effective intervention to reduce hospitalizations. Of incoming calls, approximately 70% can be managed at site of exposure thus preventing unnecessary emergency department (ED) visits as well as hospitalizations. Staffed by toxicologists, a poison prevention educator, and pharmacists, the Center manages over 45,000 calls each year. Every $1 invested in poison centers saves $13.39 in unnecessary health care charges. [3] The Poison Center collects and monitors data from its calls, allowing identification of emerging public health threats, such as food-borne illnesses or new trends of drug abuse. The Center serves as a public health hotline and can be the first to raise alarm about toxic products, evidenced by recent threats of opioids, laundry detergent pods, marijuana edibles, and medication side effects.[4]

 

The Poison Control Center has continued to provide expert advice to callers to prevent unnecessary ED visits. In 2018, 67.5% of callers were able to manage the poison exposure at their own residence. Furthermore, in 2018, 87% of calls regarding patients between the ages of 0-9 did not require hospital visits. The Poison Control Center has continued to provide MDPH with monthly statistics regarding poisoning trends. Any data pertaining to poisoning trends such as ingestion of marijuana edibles and laundry detergent pods is also provided upon request.

 

Child Fatality Review:

The Child Fatality Review (CFR) program conducts comprehensive, multi-disciplinary reviews of child deaths to better understand how and why children die. Findings inform recommendations to prevent other deaths and improve the health and safety of children. Local recommendations contribute to the statewide prevention efforts of the State Child Fatality Review Team. At both the state and local level, CFR continues to be an unfunded mandate. Local team coordinators, based at the District Attorney’s offices, have multiple work responsibilities and limited time available for coordinating local team meetings, gathering records for the review, and submitting data to the State Team. Provision of resources (in the form of staff resources, funding, materials, or other support) would allow local teams to conduct more effective and efficient reviews and provide the State Team with improved data to inform prevention strategies.

 

With the onboarding of a new Injury Prevention and Control Program (IPCP) manager who became co-chair of the State Child Fatality Review Team in January 2018, and a new Chair of the State Child Fatality Review Team at the Office of the Chief Medical Examiner (OCME), much strategic planning and reorganization of the CFR program occurred in FY18. The year began with the release of results from the Office of the Child Advocate’s Local Teams needs assessment in July of 2017, and then a second State Team needs assessment in Spring of 2018. Based on the findings from that report, the IPCP team revised the local team guidelines to provide clarity on case selection, protocols, and expectations. They also established state team guidelines for the first time. The draft guidelines as well as best pratices in CFR programming were dicussed at a miniretreat coordinated by the IPCP team, and attended by local and state team members. The guidelines were released to the state team in July 2018.

 

During FY18, IPCP also identified a consistent point of contact to attend all local team meetings, updated the case and recommendation reporting forms, and planned for communication and state team work flow improvement. Local CFR teams continued to meet periodically to conduct fatality reviews, including inviting subject matter experts to provide presentations and fatality review input that increased the Teams’ understanding of risk/protective factors and preventable causes of child death. Based on these reviews, local teams submitted recommendations for change in policies and practices. The results from this work so far are more active and engaged local teams, deeper understanding of expectations of local and state team members, and more actionable recommendations.

 

Women, Infants, and Children (WIC)

The WIC Coordination Unit collaborated with the IPCP to share timely child safety messages and product recalls with local WIC programs and to include child safety messages in WIC’s social media efforts. Topics included car seat installation, installing and checking smoke alarms, bicycle helmet safety, water safety, window safety, winter heating safety, holiday toy safety, and prevention of poisoning from household products.

 

Early Intervention Parenting Partnerships Program (EIPP)

Families served through the EIPP home visiting program receive health education, brief intervention and counseling appropriate to the families’ needs and based on a Comprehensive Health Assessment completed by the end of the second face-to-face contact. Among key educational topics are messages about car seat safety. In FY18, 303 EIPP participants received targeted education on car seat safety and 20 participants were referred to car seat safety experts. A key challenge identified by the EIPP programs was the inability of participants to afford the purchase of a new car seat. The program is addressing this by offering free or low-cost car seats to participants. Many EIPP participants rely on public transportation, and therefore use baby carriages to transport their infants. Many participants also receive car rides from family and friends. Securing a car seat in a different vehicle for each trip is time consuming and poses a risk that the car seat is not properly installed. In addition, EIPP participants may choose to borrow an old car seat from a relative or friend and this also poses a risk that the car seat does not meet current safety requirements.

 

MA Maternal, Infant, and Early Childhood Home Visiting Initiative (MIECHV)

Parents who are educated about safety at the appropriate points in their child’s development are better equipped to prevent unintentional child injuries. During FY18, MA MIECHV programs included a focus on injury prevention and home safety for pregnant and parenting families, including sharing information on infant passenger safety. All MA MIECHV home visitors are required to attend a full day injury prevention and safe sleep training.

 

During the FY18 reporting period, MA MIECHV collected and analyzed data on the rate of injury-related visits to the ED among children enrolled in home visiting. In FY18, 34 (2%) of the 1,942 children enrolled in MA MIECHV experienced a parent-reported, nonfatal injury-related visit to the ED (compared with 3% in FY17).

 

For information about MA MIECHV efforts to promote safe sleep practices, please refer to the Perinatal and Infant Health Domain.    

 

Massachusetts Pregnant and Parenting Teen Initiative

The Massachusetts Pregnant and Parenting Teen Initiative (MPPTI) aims to increase life opportunities and enhance family stability among young families in priority communities. Program participants receive services tailored to their individual needs. MPPTI uses a multidisciplinary team approach that provides wrap-around services through case management and home visits to young parents aged 14-24 years. MPPTI uses program data to monitor injury prevention and child safety education. Further, MPPTI reports on a federal measure assessing whether any child was brought to an ED for an accidental injury or ingestion during the past 12 months.  

 

In FY18, MPPTI served 304 adolescent parents and 265 children aged 0-9 years. Adolescent parents were provided with education, counseling, and referrals for child health and safety issues, including information on infant and child car seats, smoke/carbon monoxide alarms, safe infant sleep, supervising young children in and around water, Poison Control Center, and other environmental health and safety topics. In FY18, 8% of children in the program went to the ED for an accidental injury or ingestion, as reported by their parents (compared to 8% in FY17).

 

MPPTI received two additional years of funding in FY18, but the amount of funding was decreased by 35% relative to the most recent year of funding. MDPH addressed this issue by restructuring the program, changing some of the staffing structures, and eliminating one sub-contracted service delivery provider to ensure that the maximum number of young parents could continue to receive the best services for their families.  

 

School Health Services

School Health Services is comprised of regional and central office professional staff who collaborate with MDPH and the Department of Elementary and Secondary Education to provide ongoing school health service systems development and technical assistance to the Commonwealth’s 404 public school districts and approximately 546 nonpublic schools. This represents approximately 954,034 public school students and 97,646 nonpublic school students. MDPH funds a portion of those school districts, covering 687,729 students.

 

School Health Services collects aggregate data for children and adolescents in grades K-12, so it is not possible to report data separately for the population 0-9 years. In FY18, School Health Services collected data on calls to emergency medical services due to injuries in schools from 150 school districts. During the school year, there were 580 calls to emergency medical services for injuries that occurred in those school districts. Among Essential School Health Services (ESHS) affiliated school districts (which have expanded basic school health services), the rate of emergency service calls for injuries was 93 calls per 100,000 students. The rate was somewhat lower in the directly funded districts (88 per 100,000 students) than in the partner school districts (101 per 100,000 students), which may be a reflection of differences in reporting of injury rates. These differences will be explored in the years to come.

 

Additional activities to promote safe, stable, nurturing environments to reduce violence and the risk of injury

Essentials for Childhood

The goal of Essentials for Childhood (EfC) is to reduce child maltreatment by promoting safe, stable, nurturing relationships and environments. Massachusetts EfC is funded through CDC and administered by Title V staff. FY18 was the final year of the initial 5-year grant. In FY18 MDPH also applied for and was awarded a second grant for the State EfC Initiative: Implementation of Strategies and Approaches for Child Abuse and Neglect Prevention.

 

In FY18 MA EfC, supported by a multi-sector Leadership Team and four Collective Impact Teams, finalized work in the following strategy areas: 1) The Norms Change Team finalized a Video Storytelling Project to capture the experience of real people and organizations building safe, stable, nurturing communities. 2) The Policy Change Team worked with stakeholders to complete an infographic on Paid Family and Medical Leave with a specific focus on the benefits to infants, their families, and the communities. They also worked with a local coalition to illustrate one community’s response to supporting families affected by substance use using federal recommendations for Plans of Safe Care. 3) The Raising Awareness Team supported strategic messaging and coordinated the third Annual EfC Summit, including awards for businesses and non-profits whose support of families and communities make them “Essential Agents of Change” in preventing child maltreatment. 4) The Data and Evaluation Team continued to work closely with the other teams to identify indicators and outcomes to measure the extent to which EfC has been reaching its goal through the activities of the teams.

 

EfC’s leadership team continued to define a common agenda using the lenses of collective responsibility and racial justice to guide the initiative in Massachusetts. Leadership Team and Collective Impact Team members participated in a Groundwater Training from the Racial Equity Institute[5] to better understand how systems and institutions cause racial inequity. The application for the second phase of funding built on the work of the first grant, converging on how municipalities can support families with young children and promote social connectedness within and between communities.

 

Priority: Promote equitable access to dental care and preventive measures for pregnant women and children. 

Progress towards the oral health priority is measured by a) the percent of women who had a dental visit during pregnancy and b) the percent of infants and children, ages 1 through 17, who had a preventive dental visit in the last year. The first measure is discussed in the Women’s/Maternal Health domain. MDPH’s Office of Oral Health, Office of Health Equity (OHE), Early Intervention (EI), WIC, and MA MIECHV contribute to addressing this priority.

 

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

Research has demonstrated the connection between oral health and overall health, indicating the need to engage children in oral health care early to prevent chronic disease later in life. The objective for this NPM is to increase the percent of children aged 1 through 17 years who had a dental visit in the past year from the baseline of 86.8% (NSCH 2016) to 88.3% by 2020. Combined data from the 2016-17 NSCH indicate that 85.3% of children aged 1 through 17 years had a dental visit in the past year.

 

Office of Oral Health

The MDPH Office of Oral Health (OOH) operated its MDPH SEAL (Seal, Educate, Advocate for Learning) program, a school-based oral health prevention program, in 12 communities in 86 schools during academic year 2017-2018. During this school year 6,980 students received an oral health screening by a SEAL hygienist. Among those students, 99% received a fluoride varnish treatment and 28% received at least one dental sealant. Among students who received services, 67% had insurance through MassHealth. MassHealth directly reimburses OOH for services provided, which sustains the program and its personnel. While OOH continues to primarily serve low-income students with limited access to care, it accepts all students and is credentialed to accept private insurance.

 

A new ESM was created for this measure: the percent of children who received a consent form for the MDPH SEAL program that were screened by one of the program dental hygienists. This relates to NPM 13B as the MDPH SEAL program provides preventive dental care from pre-kindergarten to high school in communities throughout the Commonwealth. During the 2017-2019 school year, 19% of the students who received a consent form were screened by a MDPH SEAL dental hygienist. A more concerted effort will be placed on ensuring that more students and families are aware of the importance of oral health care and the availability of these oral health services in schools with the goal of increasing MDPH SEAL program participation rates.

 

In FY18 OOH continued to collaborate with the Essential School Health Services Program (ESHS) to provide oral health training to school nurses in ESHS-funded districts and to increase the number of schools where school-based oral health prevention programs are available. In addition, 42,180 students received an oral health screening in school and 17% of those students were referred for treatment. Fluoride mouth rinse treatments were administered to over 11,000 students in grades 1-6 and fluoride tablets were administered to over 800 children in pre-school programs.

 

Oral Health Equity Project

The MA Oral Health Equity Project (OHEP), managed by the MDPH Office of Health Equity, is a collaborative project with the OOH. It was funded by the DHHS Office of Minority Health for five years, starting in FY16. OHEP addresses the Healthy People 2020 leading indicator for oral health: persons who visited the dentist in the past year. The project focuses on children up to age 14 years in Worcester and Holyoke, two cities with inequities in oral health access and outcomes and large proportions of residents of color. OHEP seeks to establish partnerships across a variety of systems including schools and community health, EI and WIC with the goal of creating linkages to oral health care for children aged 0-14 years.

 

Findings from internal and external data, key informant interviews with subject matter experts, and survey results from community engagement participation framed the rationale for the strategic interventions OHEP designed and implemented in FY17 and FY18. These interventions included recruiting, contracting with, and training staff in public schools, EI, community health and WIC programs in both communities to screen and refer children to oral health services.

 

Schools and Community Health:

Worcester Public Schools and Holyoke Public Schools have coordinated linkages to community dental services through a nurse care coordinator hired for this project. The nurse care coordinator at Worcester Public Schools works with school nurses in the district and with a community health worker (CHW) at Family Health Center of Worcester, hired through this project, to make and track referrals to their dental department over time. The nurse care coordinator at Holyoke Public Schools is also working with Holyoke Health Center, the CHW hired through this project, and their school-based dental program to track referrals to the community health center’s dental department over time.

 

Early Intervention:

Four EI programs in Worcester and two EI programs in Holyoke are collaborating with the OHEP to develop, track, and implement a referral system for children without a dental home and those without dental care in the past 12 months. The following data were captured through the project during FY18:

• Among children screened at either initial or 6 month EI appointments between September 2017 and May 2019 (n=2,692), 79% had teeth.
• Between September 2017 and May 2019, among the 2,692 children screened at either initial or 6-month appointments who had teeth, 30% (n=816) had a dental visit in the past 12 months.
• The percent of children who were recommended by EI clinicians to see a dental provider at their initial appointment and saw a provider by their 6 month follow-up appointment increased from 45% in February 2018 to 50% in December 2018.

 

WIC:

In FY18, a CHW at Family Health Center of Worcester was hired by OHEP to work as a liaison to follow up with families referred by WIC staff for dental care. The referral procedure developed between WIC and Family Health Center of Worcester ensures that families receive a timely referral to dental care, on-the-spot oral health counseling by the CHW, and follow-up phone calls to remind them about the dental referrals they received. The successful process developed by the CHW was grounded in a systems-based quality improvement approach and has shown an increase in kept dental appointments for WIC patients from 35% to 39% between November 2017 and December 2018.

 

MA MIECHV

During federal FY18, home visitors assessed whether children had a usual source of dental care. Based on parent self-report, 44.3% of children (including newborns and infants) enrolled in home visiting services, for whom data were available, had a usual source of dental care. Although it is not possible to exclude newborns from these data, it is expected that low utilization of dental care in this age group contributes to the low percentage. Referrals and connections to services were provided as needed.   

 

Priority: Reduce the impact and burden of environmental contaminants on children and their families.

Massachusetts measures progress towards the environmental health priority through a state performance measure: the percent of children aged 9-47 months with blood lead level screenings. This SPM aligns with the Massachusetts State Health Improvement Plan (SHIP). Key MDPH programs that address this priority are the Childhood Lead Poisoning Prevention Program, the Occupational Health and Surveillance Program and the Asthma Prevention and Control Program.

 

SPM 2: Percent of children aged 9-47 months with blood lead level screenings

The MDPH Bureau of Environmental Health’s (BEH) Environmental Epidemiology Program (EEP) re-calculated the statewide blood lead level screening rates using adjusted population data. Drawing on Environmental Public Health Tracking (EPHT) funding, EEP contracted with UMass to develop better methods for estimating postcensal population numbers down to the census tract level and for various demographic groups (age, race, and sex categories). Employing this new method, the screening rate was re-calculated based on the number of children screened divided by the revised estimate of the population of children 9-47 months during any given year. The revised statewide screening rate for calendar year (CY) 2016 was 72.9% for children 9-47 months of age, which remained stable in CY2017 at 72.6%. Screening rates for CY18 are not yet finalized; however, preliminary data suggest that the screening rate remains at approximately 72.5%.

 

Childhood Lead Poisoning Prevention Program

The BEH Childhood Lead Poisoning Prevention Program (CLPPP) conducts primary and secondary prevention of childhood lead poisoning, case management and environmental intervention, surveillance and evaluation, and collaborates with federal, state, and local partners to prevent and reduce lead poisoning. Due in large part to old housing stock, childhood lead poisoning continues to be a significant public health problem in Massachusetts. CLPPP works closely with the EEP to collect data and conduct surveillance to guide primary and secondary prevention activities. CLPPP collects and stores approximately 200,000 blood lead test results annually, along with environmental inspection data, in its case-management and surveillance database. BEH epidemiologists use these data to determine geographic areas and populations with the “highest risk” children to be prioritized for services and resources, including primary prevention. High risk communities are identified using an algorithm based on incidence rates of blood lead levels ≥ 10 µg/dL, age of housing stock, and poverty rates. The 19 high-risk communities identified in CY17 account for more than 56% of cases of 10 µg/dL blood lead or greater over a five-year period beginning in January 2013. Many of these 19 high-risk communities are gateway cities and have a higher percentage of older housing stock than the state average of 71%. By comparison, approximately 57% of all U.S. housing was built prior to 1978.

 

In Massachusetts, state statute requires abatement of lead hazards in any home built before 1978 with a child under six years, regardless of the child’s blood lead level. While lead continues to affect children in all communities across the state, our data show that lead exposure disproportionately affects lower income communities with higher populations of persons of color, making lead exposure a critical health equity issue. CLPPP uses these and other data to direct resources, conduct outreach, and inform state and local partners. Title V Block Grant supports culturally and linguistically appropriate CHWs based in seven MDPH contracted agencies across MA. CHWs provide direct services to families whose children have been identified as having elevated blood lead levels. As part of this contract, CHWs also conduct education and outreach within their regions to local partners in housing, education, and health care as well as a variety of other stakeholders.

 

While the MA CLPPP has one of the highest screening rates in the nation, for the past five years our rate has plateaued at approximately 73% statewide. To ensure all providers screen and report lead test results, CLPPP worked with the EEP epidemiologists to create a new outreach document, the Massachusetts Childhood Lead Screening Community Progress Report. This report focuses on community-specific indicators of childhood lead screening and exposure, highlighting areas needing improvement in physician screening, follow-up, and prevention. The progress report specifically reminds physicians that they must conduct venous re-screenings on children with capillary blood lead levels ≥5 µg/dL and identifies communities that are at highest risk and therefore require more stringent screening of patients. CLPPP mailed this report to nearly 4,000 pediatric and family practice providers in Massachusetts in spring of 2017. This project also included an extensive evaluation of the outreach tool which included a survey and two focus groups conducted in FY18. The evaluation demonstrated that the program met its short-term goals for the progress report, which included educating clinicians about:

• their role in preventing lead exposure parent education;
• the limitations of capillary tests and methods to improve test reliability;
• the CDC reference value, the dangers of low-level lead exposure, and a community’s high risk status.

 

Using evaluation responses, CLPPP will send a revised report to providers in early 2019 and annually thereafter. While the overall screening rate has plateaued, we have seen improvements in specific areas. Each year the re-screening rate of capillary tests between 5-9 µg/dL has improved. Before 2012, the re-screening rate was about 4%. After the new CDC reference value was announced in 2012 the rate rose to 28%, and in 2017 it was approximately 50%. The progress report, combined with in-service training by a public health nurse, has contributed to this improvement.

 

CLPPP amended its regulations in FY18. The most significant change was lowering the definition of lead poisoning from a venous blood lead level of 25µg/dL to 10µg/dL with a level of concern added for children with venous blood lead levels 5-9µg/dL. By comparison, the CDC reference value is 5µg/dL, which indicates lead exposure and recommends that action be taken. Other important changes to the screening regulations required venous re-screening for all children with blood lead levels 5µg/dL or higher and enhancing the required proof of screening compliance to enroll in day care or pre-kindergarten programs. CLPPP also amended abatement standards to align more closely with federal HUD standards. Families and community advocates provided considerable input to the revised regulations through their attendance at the two public hearings and two Public Health Council meetings and via participation on the Governor’s Advisory Committee (whose membership criteria includes two parents of children under age six who live in low-income urban areas).

 

CLPPP provided clinical case management services to over 928 children during FY18. CHWs received referrals for 490 of these children, conducted 481 home visits for families, providing in-home lead hazard reduction, nutritional and needs assessments, and linkages to other community services including EI and WIC. During the last six months of FY18, after the regulatory changes went into effect, the demand for conducting environmental investigations and code enforcement rose by approximately 40%. CHW caseload numbers were not substantially different after the regulatory amendment; however, the management needs for cases did change significantly. Field staff reported an increase in the number of transient families and difficulty locating and contacting families. For these cases, the case management team relies primarily on the CHW to track down the most reliable contact information, which can include multiple phone contacts as well as visits to last known addresses. CHWs have had to devote considerable time and resources to support the code enforcement lead inspectors with scheduling and conducting the environmental investigations.

 

CLPPP staff continued in-services with clinicians to educate them on CLPPP’s screening requirements, the CDC reference value of 5 µg/dL, CLPPP’s proposed regulatory amendments, and to foster screening compliance. CLPPP’s nurse case manager conducted 13 in-services for pediatric providers and three in-services with medical social workers, most of which were also attended by the region’s CHWs. While CLPPP continues to focus efforts in communities at highest risk for lead poisoning, in-services were also conducted in areas with lower screening rates, including rural communities in central MA. Along with the more formal in-services with the CLPPP case management nurse, in CY17 CHWs also conducted 70 information sessions with pediatric offices to improve screening compliance.

 

CLPPP contracted agencies provided 104 educational presentations in English and 25 in Spanish, reaching 3,782 people. Collectively, the contracted agencies have distributed approximately 18,285 educational materials during outreach and other primary prevention related events. This number is down to nearly half of materials distributed the prior year, because CLPPP is moving away from using paper-based educational materials. Instead, during presentations, CHWs are directing the public to the CLPPP website, which has educational information, downloadable documents and fact sheets, as well as interactive searches for screening progress reports and address-specific lead inspection data. CHWs also presented at 30 first-time homebuyer classes, advising prospective homeowners on the Massachusetts Lead Law, dangers and health effects of lead poisoning, and remediation requirements. Eighteen CLPPP and grantee staff members are bilingual and can provide services in 10 languages; Spanish, Portuguese, Cape Verdean, Haitian Creole, Ibo, Yoruba, Tagalog, Vietnamese, Cantonese, Toisanese, and German.

 

Due to the increased awareness of lead in drinking water brought on by the crisis in Flint, Michigan, CLPPP strengthened collaborations with the Massachusetts Department of Environmental Protection and the Massachusetts Water Resource Authority regarding potential exposure to lead in drinking water. While lead paint in homes continues to be the primary source of exposure for Massachusetts children, in FY18 CHWs collected drinking water samples for 172 families during their home visit. Sampling revealed seven exceedances for six families (samples were collected twice in one home). In all but one case, staff identified other likely sources for the child’s lead exposure. In three homes, inspectors identified paint and dust hazards. Turmeric, a spice frequently linked to lead exposure for Southeast Asian families, was identified as the likely exposure source for one family. Renovation work as a parental occupation/hobby was the likely exposure source for another child. Drinking water may have been the exposure source for one case; however, there were also lead paint hazards present on the porch that could have contributed to the exposure. In all cases where an exceedance was found, staff counseled the family on proper flushing techniques as well as other options to reduce lead exposure, including resources for water service line replacement.

 

CLPPP and the Environmental Epidemiology Program (EEP) began to work with an approved vendor in FY18 to design and deploy a new web-based case management and surveillance application and database. Software, security, and functionality need to be upgraded to maintain services and improve reporting capabilities. In FY19 CLPPP worked with the developer to include a more robust interface for CHWs to capture exposure assessment data that will be accessible for real-time data entry during the home visit. The web-based platform should improve grantees’ ability to access the application securely and efficiently, which has continued to pose an IT challenge for grantees who frequently have to manage network outages. The planned application will also include laboratory management functionality that will allow EEP to monitor laboratory reporting compliance and more easily identify data quality errors and omissions.

 

In the latter part of FY18, the CLPPP Director collaborated with Department of Early Education and Care supervisory staff to provide a series of in-services with daycare licensors to review screening requirements, proof of screening prior to enrollment in daycare, and environmental compliance requirements for family and group daycare centers. The first training took place in May 2018 and was well received. Three additional trainings were scheduled across the state for FY19.

 

Occupational Health Surveillance Program

The MDPH Occupational Health Surveillance Program (OHSP) has a long history of collaboration with the Occupational Lead Poisoning Registry in the Department of Labor Standards (DLS), which coordinates surveillance and prevention of occupational lead poisoning in the state. Through the Registry, DLS collects results of all adult blood lead tests that are above 0 µg/dL, the majority due to occupational exposures. OHSP helped develop the Registry and periodically helps DLS analyze the data on elevated blood lead levels in adults. Historically, blood lead levels greater than 25 µg/dL were considered elevated among adults. Recently, CDC has reduced this threshold to 5 µg/dL, the same as that for children. OHSP provides funding through a CDC National Institute for Occupational Safety and Health (NIOSH) grant to support some of DLS’ intervention activities, including interviews with workers who have blood lead levels greater than 25 µg/dL and healthcare providers who treat exposed workers.

 

In FY18, DLS conducted follow-up with all healthcare providers who ordered blood lead tests showing elevated blood lead levels ≥ 25 µg/dL reported to the Registry (177 tests among 98 unique individuals). To date, 82% of healthcare provider questionnaires have been returned and follow-up is in progress for the rest. All healthcare providers that responded to the questionnaire received information on the clinical management of lead poisoning, including local resources and contacts. Providers were also given the brochure “Protect Your Family, Stay Ahead of Lead,” developed by CLPPP, which explains what families can do to prevent lead poisoning in children and promotes the importance of screening. DLS has distributed this brochure directly to 92% of the 98 workers with elevated blood lead levels. Addresses were not available for the remaining 8% of workers.

 

OHSP is collaborating with DLS, BEH, and the Bureau of Community Health and Prevention (BCHAP) to incorporate lead data into the EPHT data system and the MDPH Population Health Information Tool (PHIT), which are used for local area public health planning. The addition of these critical data to EPHT and PHIT will provide the occupational lens to the lead poisoning story in Massachusetts, supplementing the childhood lead data that are already available through the EPHT portal. This work is currently ongoing.

 

Additional activities to reduce the impact and burden of environmental contaminants on children and their families

Asthma Prevention and Control Program

In 2014, the rate of asthma ED visits among children aged 18 years and younger in Massachusetts was 57.3 per 10,000, a decrease from 76.3 per 10,000 in 2012 (the most recent data available). The MDPH Asthma Prevention and Control Program (APCP) led and participated in a variety of initiatives to support the continued decrease in ED visits. The APCP’s three goals are:

1. Ensure universal access to high-quality CHW-led asthma home visits for children in Massachusetts;
2. Improve asthma management and environmental policies in Massachusetts schools;
3. Ensure guidelines-based primary care is provided to all Massachusetts children with asthma.

 

In FY18, the APCP collaborated with asthma stakeholders to ensure universal access to high-quality CHW-led asthma home visits for children in Massachusetts. To increase the number of home interventions for asthma, the APCP made available tools and technical assistance for successful implementation of asthma home visiting programs. For example, a stakeholder-driven process was used to design the Massachusetts Asthma Home Visiting Toolkit which includes a Program Summary and a Protocol Manual. The toolkit has been distributed to asthma partners across Massachusetts and the country and is now available on the APCP’s website. The toolkit provides standardized visit protocols and educational materials.

 

APCP assisted school districts during the implementation of evidence-based programs aimed to improve asthma management and environmental policies. The Promoting Policies for Asthma in Local Communities project will better protect Black and Hispanic children with asthma by improving public housing and school environments by focusing on six of the highest needs communities for asthma in Massachusetts: Boston, Framingham, Worcester, Holyoke, Lynn and New Bedford. These communities have large inequities in poor asthma outcomes by race/ethnicity. There are 27 policies being implemented in 10 schools, 11 housing authorities, and six affordable housing management companies affecting up to 22,348 students, 6,396 housing units for smoke-free policies, and 39,300 housing units for integrated pest management (IPM) policies. IPM is a prevention-based pest management method that targets the underlying causes of pest infestations through simple pest proofing strategies, such as fixing leaks and holes. If pesticides must be used, IPM uses the least toxic chemicals, applied in the safest manner to protect people and pets. APCP developed an IPM referral tool for CHWs to assist them in making referrals for further pest elimination activities. This referral form will be posted on the APCP website for further dissemination.

 

APCP and internal MDPH asthma partners developed a poster to reinforce a Department of Early Education and Care policy on cleaning, sanitizing and disinfecting intended to reduce unnecessary exposures to asthma triggers and asthmagens (e.g., bleach) in early education centers. This poster was translated into Spanish and Portuguese, printed and distributed to centers across the state in 2017. These resources are now available in the Massachusetts Health Promotion Clearinghouse.             

 

The APCP also worked on increasing demand and reimbursement for its initiatives. The APCP developed a provider-focused white paper to promote the use of global payments received by providers to implement asthma home visiting programs and is promoting increases in the voluntary coverage of asthma services, medications, and equipment consistent with the national asthma guidelines by public and private insurers. APCP also developed Case Study videos that show the benefit of CHW Asthma Home Visiting from the CHW, medical provider, and patient/family perspective. The videos are available on the APCP website at http://www.mass.gov/dph/asthma.

 

In FY18, APCP offered an Asthma Learning Collaborative to participants of the Prevention Wellness Trust Fund to work intensely with expert faculty to explore ways to improve their clinic-based asthma work, school-based asthma work and asthma home visiting programs. Over fifty individuals from six organizations participated in the Learning Collaborative. The goal of this project was to equip clinical organizations with the tools and resources to sustain asthma home visiting programs and deliver quality services to patients and families impacted by asthma.

 

In FY18, APCP made strides in its commitment to racial equity work by developing a racial equity reframe document that will accompany its Massachusetts Asthma Home Visiting Toolkit. This reframe document will be posted on the mass.gov website when complete.

 

School Health Services

School Health Services serves the entire population of Massachusetts’ children in school. Since 1993, Essential School Health Services (ESHS) has provided the opportunity for some schools to expand basic school health services including funding for planning, program development and additional health services. The Title V partnership funds 68 ESHS schools. The proportion of students of color in ESHS-funded districts (49%) is nearly twice as large as it is in the unfunded schools (26%); therefore, the ESHS program may lead to improvements in health equity.

 

The asthma prevalence in ESHS-affiliated schools is high compared to national data: of the 687,729 students enrolled in districts submitting ESHS data reports in FY18, 13.0% were reported to have asthma, compared to a 2014 national asthma prevalence of 8.6% for children less than 18 years. During FY18, school nurses administered 100,586 medications for asthma “as needed” (PRN). Since the 2009-2010 school year, the PRN asthma prescription rate among students enrolled in ESHS-funded districts has ranged between 34.5 per 1,000 and 44.3 per 1,000, and currently stands at 36.1 (2017-2018). These high rates suggest the need for school nurses and students with asthma and their families to more effectively manage their asthma. The preliminary data need further review to understand whether asthma management in schools is inappropriate, the medical directive treatment plans need amendment, or the treatment plans are misinterpreted. These issues will be addressed by school nurses in the coming years.

 

Priority: Promote emotional wellness and social connectedness across the lifespan.

In addition to addressing maternal depression, as described in the Maternal/Women’s Health domain, MDPH actively promotes emotional wellness and social connectedness in the early childhood period as well. The key initiatives addressing this priority among children are found in Project LAUNCH; the Division of Pregnancy, Infancy, and Early Childhood; MA Early Childhood Comprehensive Systems; EI; and MA Maternal, Infant, and Early Childhood Home Visiting Initiative (MIECHV).

 

To promote emotional wellness and social connectedness in early childhood, MDPH has set the following objective: “By 2020, increase to 70% from baseline (67.2% in FY14) the percent of pediatric/well-child visits for children aged 0-6 years on Medicaid in which a screening for behavioral health is completed using an approved screening tool.” In FY18, 63.5% of visits received a behavioral health screen, which represents a 5% decrease from the FY14 baseline. The lowest screening rates are among infants less than six months. This decline is believed to be due in part to changes in the CPT codes for screening in recent years as well as decreasing outreach and training efforts by MassHealth to support providers in implementation of behavioral health screens. The MA Title V program does not have direct control over Medicaid screening rates; however, the efforts of several Title V programs will help to raise awareness and build workforce capacity for social-emotional wellness promotion and contribute to progress towards this five-year objective. The FY18 activities and accomplishments of these programs are described below.

 

Project LAUNCH Expansion

Project LAUNCH (Linking Actions for Unmet Needs in Children’s Health) is a SAMHSA initiative that aims to promote the wellness of young children, age birth to eight years, by integrating early childhood mental health promotion and prevention practices into the pediatric medical home. Although SAMHSA has funded this work, it is administered by the Title V program. Massachusetts LAUNCH developed a model for integration of early childhood mental health promotion and prevention practices into pediatric medical homes, which includes an early childhood mental health clinician and a family partner with lived experience (having a child with social and emotional challenges) embedded in the primary care clinic. This team works together to assess and support families with children who are identified by primary care providers as showing early signs of social and emotional difficulties or who experience risk factors known to lead to poor social and emotional development outcomes.

 

FY18 was the third of the four-year Massachusetts LAUNCH Expansion program, which is replicating the MassLAUNCH model developed in Boston in three new community health centers across the state (located in Springfield, Worcester and Boston). The MassLAUNCH model has been recognized as a Promising Practice by AMCHP. The Project LAUNCH Expansion grants place a strong emphasis on addressing racial and ethnic inequities and the MassLAUNCH replication sites have a particular focus on effectively serving Latino and immigrant/refugee families. MDPH continued to contract with the local lead for the original grant, the Boston Public Health Commission (BPHC), to provide technical assistance using the Early Childhood Mental Health Toolkit: Integrating Mental Health Services into the Pediatric Medical Home, which was developed during the original grant. To evaluate the expansion, service data are being collected on LAUNCH participant children’s social-emotional risk and their parents’ levels of stress and depression.

 

Through MDPH’s partnership with BPHC and their Young Children’s System of Care statewide grant, family engagement and family leadership are also emphasized in program and governance activities. The three communities – Boston, Worcester, Springfield – convene Parent Councils that guide development of community family engagement activities, including an annual Family Summit for System of Care and LAUNCH family members and other community members who are interested in developing their community engagement and leadership skills (held in Worcester in FY18). In FY18, a cohort of 16 parents from these three communities attended the Strengthening Families conference in Colorado to build skills that they can apply as family leaders in their communities.

 

Division of Pregnancy, Infancy, and Early Childhood (DPIE)

In FY18, the Young Children’s Council, convened by DPIE staff and chaired by the Director of the Bureau of Family Health and Nutrition, continued to meet quarterly. The Young Children’s Council has been a state level council required for MDPH’s Project LAUNCH grant, which in recent years has been restructured to align with MDPH and community-based partners’ work related to infant and early childhood mental health and to advise DPIE programs that focus on systems building (e.g. LAUNCH Expansion, ECCS Impact, MA MIECHV). In FY18, council meeting topics included opportunities for financing early childhood prevention services in the current landscape of Accountable Care Organizations (ACOs), racial equity reframing and strategic planning for the Mass Early Childhood Comprehensive Systems (MECCS) work, and    a new council effort to better promote parent engagement and leadership on the council and related initiatives. Council membership includes representatives of state and community agencies, two family organizations (the Federation for Children with Special Health Needs and the Parent Professional Advocacy League), and two parents.

 

MA Early Childhood Comprehensive Systems

In FY18, MECCS completed the second year of a five-year grant from HRSA that aims to improve children’s (age 0-5) developmental health by strengthening local and state-level early childhood systems. MECCS partners with teams in Springfield and Chelsea, two MA MIECHV communities, in a national Collaborative Innovation and Improvement Network (CoIIN) to test, evaluate and scale program and systems-level strategies for promoting young children’s developmental health.  

 

MECCS conducted a needs assessment to determine priority areas for action within the CoIIN. The results highlighted persistent inequities in access to developmental health services as well as health outcomes for young children of color in Massachusetts. To address these inequities, MECCS initiated a strategic plan to embed a racial equity lens across grant activities. Outcomes of the plan include training and coaching for MECCS community teams on racial equity and elevation of family leadership within early childhood services and MECCS teams. Specifically, MECCS is partnering with two family leaders to re-configure an MDPH early childhood advisory council structure to increase family involvement. MECCS is also facilitating a convening of early childhood partners across the state to grow an aligned racial justice partnership and learning network. MECCS continues to broaden its advisory groups to include diverse voices and perspectives, including racial justice organizations.

 

In partnership with the community teams, MECCS is using GIS mapping (drawing from census data) to visualize structural racism and developmental health inequities for young children of color in Chelsea and Springfield. The teams are using the data to hone in on priority action areas, motivate and educate stakeholders, and further conversations about racial equity within their communities.

 

Through the CoIIN, Chelsea and Springfield are expanding strategies to more effectively reach and serve young children of color. To address disparate rates of developmental screening and referral to services for these families, the MECCS teams support parents from each community to help other parents complete the Ages and Stages Questionnaire (ASQ), a developmental screening tool. In each community, the screening data are being captured in a central database that includes screens from a range of community agencies. These data will provide a community-level picture of the developmental health of young children and can be used to identify areas of need for intervention and support. Each community team has also formed a family advisory group to build connections among families with young children and ensure the parent voice is well represented in grant activities.

 

Early Intervention

The Massachusetts Part C/EI program universally screens and identifies early social-emotional delays in children (0-3 years old) and provides interventions to promote social connectedness. A priority within the State Systemic Improvement Plan (SSIP) is improving the statewide percentage of children with improved positive social-emotional skills (including social relationships). A five-year objective is to increase the number of infants and toddlers enrolled in EI who demonstrate improved positive social-emotional skills by 0.4% (equivalent to approximately 180 children) by 2020 (from 56.7% in FY14 to 57.1%), as measured by the Battelle Developmental Inventory 2nd Edition (BDI-2). Analysis of BDI-2 scores at EI entry and exit demonstrate trends across the system as changes in practice are implemented. The target for improvement is small due in large part to the length of time it takes to change program infrastructure and practice to support a new model for promoting social and emotional development, which needs to occur before improved outcomes for children can be realized.

 

Massachusetts EI observed a decrease in the percent of children exhibiting positive social-emotional outcomes, from 56.2% in FY17 to 55.7% in FY18. In FY18, key activities to address this related to improving the fidelity of BDI-2 administration, such as training resources for local programs, reviewing videos of BDI-2 administration, and developing a BDI-2 Fidelity Checklist. The decrease in positive social-emotional outcomes is believed to be due to the change in data accuracy. As the accuracy of administration improves it is possible that the entry score could be less accurate than the exit score (indicating improvement in data quality over time).

 

In FY18, 100% (n=60) of EI programs completed training on the Parents Interacting with Infants (PIWI) model for promoting social and emotional development, which guides the EI practitioner in supporting the parent-child dyad. The training and evaluation were rolled out in three cohorts to ensure the program had sufficient resources and capacity to support implementation. As each EI program was trained on PIWI, it designated one or more PIWI Champions to be coached by a PIWI Master Cadre trainer. PIWI Champions act as the program-specific resource for quality assurance and PIWI sustainability. They are responsible for ensuring the successful implementation of the PIWI at the local program through supporting staff in its use, documenting coaching and other technical assistance activities, and conducting program-level evaluation of the PIWI. The PIWI Champions are responsible for collecting evaluation data through observation of staff conducting home visits. All Cohort 1 & 2 Champions have been identified and trained; they are currently in the process of collecting evaluation data to be reported in the federal FY17 SSIP.

 

MA MIECHV

Developmental screenings:

Many children with developmental delays are not being identified as early as possible. As a result, these children must wait to get the help they need to do well in social and educational settings. Research shows that early intervention treatment services can greatly improve a child’s development. During federal FY18, 9.0% of households enrolled in services reported having a child with developmental delays or disabilities. MA MIECHV home visitors conduct developmental screenings (using the ASQ-3 and ASQ-SE) on enrolled children to identify developmental concerns as early as possible and make referrals to EI and other appropriate community resources.

 

During federal FY18, 67% of children enrolled in MA MIECHV programs were screened for developmental delays using a validated, parent-completed tool (ASQ) at the AAP recommended screening intervals (nine months, 18 months, 24 months, and 30 months). This represented an increase from 61% in FY17. During federal FY18, 92% of children enrolled in home visiting with a positive ASQ screen for developmental delay received services in a timely manner (meaning that they were referred to EI and received an evaluation within 45 days, or were referred to community services and received services within 30 days).

 

Parent-child interaction:

Home visitors play an important role in nurturing parent-child relationships and helping parents develop and strengthen parenting skills. MA MIECHV home visitors conduct observations of parent-child interaction to identify opportunities to support participants with parenting behaviors. MA MIECHV continued to report on the percent of primary caregivers enrolled in home visiting who received an observation of caregiver-child interaction by the home visitor using a validated tool as a federal performance measure. In federal FY18, 17% of MA MIECHV participants met this performance measure (an increase from 8% in FY17). Although this is an improvement from federal FY17, this performance measure is lower than anticipated due to changes in validated tools used. The MA MIECHV model that serves the largest proportion of MA MIECHV participants piloted the CHEERS check-in (Cues, Holding, Expression, Empathy, Rhythm, Smiles) during the first quarter of federal FY18 and intended to use that tool program-wide after the pilot. However, based on pilot results, the model decided not to adopt the CHEERS check-in and decided to transition to using the PICCOLO (Parenting Interactions with Children: Checklist of Observations Linked to Outcomes). Programs began piloting the PICCOLO in the fourth quarter of federal FY18 which resulted in a high proportion of missing data.

 

Home visitors also assessed the percent of children enrolled in home visiting with a family member who reported that during a typical week s/he read, told stories, and/or sang songs with their child every day. In FY18, 44% of MA MIECHV participants met this performance measure, an increase from 28% in FY17. This increase was due primarily to improved data collection for the MA MIECHV Parents as Teachers programs. In FY17, this performance measure was assessed using a checkbox in the home visit record that was frequently overlooked during data entry. In response, different tools were developed (e.g., list of questions to be asked at every home visit and data tracking sheet) to draw attention to the checkbox and improve the completeness of documentation.

 

 

[1] Prevention of childhood poisoning in the home: overview of systematic reviews and a systematic review of primary studies, Wynn et. Al, Int J Inj Contr Saf Promot., 2016 Mar, 23(1):3-28.

[2] The use of poison prevention and education strategies to enhance the awareness of the poison information center and to prevent accidental pediatric poisonings, Krenzelok, EP, J Toxicol Clin Toxicol, 1995;33(6):663-7.

[3] The impact of poison control centers on poisoning-related visits to EDs-United States, 2003, Zaloshnja, E et. Al., Am J Emerg Med, 2008 Mar;26(3):310-5

[4] Forging a poison prevention and control system, Institute of Medicine (US) Committee on Poison Prevention and Control, 2004.

[5] https://www.racialequityinstitute.com/groundwaterapproach