Annual Report Fiscal Year 2019:  This section provides a summary of Federal Fiscal Year 2019 (FFY19) 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 Adolescents recommends standardized developmental screening be used at 9-month, 18-month, and 2.5-year visits. Additionally, the AAP recommends developmental screening any time concerns are identified.

Strategy 1: Provide Ages and Stages training to Wyoming providers 

The Child Health Program (CHP) has continued to support efforts to increase developmental screening through training on and distribution of the Ages and Stages Questionnaire (ASQ) screening tools. In addition, the Child Health Program Manager (CHPM) has remained an active member of the Governor’s Early Intervention Council (EIC). The EIC’s mission is to advise and assist coordinated community-based programs and services for families and their children ages birth through five who are identified as having developmental delays and/or disabilities. 

As mentioned in previous years, the Maternal and Child Health Unit (WY MCH) historically provided ASQ training and resources to a wide range of partners including daycare providers, child development center staff, health care providers, PHNs, and home visiting staff. The CHP maintains a commitment to providing limited training and support of the ASQ tool to community providers and partners. WY MCH does not currently have any staff certified to train on the ASQ tool and has relied on trained partners at the Wyoming Children's Trust Fund as needed. 

In early 2019, the University of Wyoming Family Medicine residency program located in Casper, Wyoming contacted the CHPM regarding training staff, including physicians completing residency, on the use of the ASQ. The residency program is a Federally Qualified Health Center (FQHC) operating within Wyoming that has worked towards maintaining National Committee for Quality Assurance accreditation as a patient/family-centered medical home. 

The Wyoming Children’s Trust Fund completed an in-person ASQ training for the residency program’s 14 providers and two social workers in Casper, Wyoming. Upon completion of the training course, the CHP provided the clinic with ASQ resources, including Spanish versions of the ASQ-3, ASQ-SE-2, and ASQ-3, for implementation within the clinic. CHP provided four ASQ kits to the residency program, one for each of the four case managers at the clinic.

The program identified challenges collecting data on usage of the ASQ from a diverse group of partners outside of PHN offices due to the absence of any shared or central data system. However, with the implementation of a new PHN data system in October 2018, CHP and PHN can report that between October 2018 and September 2019, 5,523 ASQ screenings were completed in partnership between parents/caregivers and PHN staff. In addition, in December 2019, WY MCH distributed 17 ASQ kits to five county PHN offices and one medical clinic. CHP reached out to all county PHN offices to offer additional ASQ kits as needed. 

Strategy 2: 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 grant: Lead Testing in School and Child Care Program Drinking Water. The grant created a voluntary program to assist with testing for lead in drinking water at schools and child care programs. In late 2019, DEQ released a Request for Proposal for the selection of a contractor to facilitate the testing and monitoring program within schools. As of July 2020, a contract still has not been executed to complete deliverables related to this funding opportunity.  

The Wyoming Department of Health (WDH) lost funding for a dedicated Environmental Health/Lead Prevention Program in 2014. Due to this absence and the increased interest the DEQ lead grant has generated, WDH staff led by the State Health Officer and including representatives from WY MCH, the Wyoming Public Health Laboratory, Wyoming Medicaid, WIC, Immunizations, and PHN have partnered internally. The focus of this internal workgroup has been to better coordinate messaging, education, screening, and prevention efforts related to lead screening. Through this work, a draft letter was created to be endorsed by the State Health Officer for publication in the Wyoming Medical Society magazine addressing the need for child lead screening. The work group also drafted an application to the Centers for Disease Control and Prevention (CDC) Childhood Lead Prevention grant funding opportunity. Unfortunately, due to COVID-19, the letter has not yet been submitted to the magazine and the CDC temporarily suspended the grant opportunity. However, WY MCH was able to support the strengthening of internal partnerships and will support renewed education efforts in the future.  

Strategy 3: Train providers on Bright Futures recommendations  

Improving well visit rates and the quality of well visits for Wyoming children is a priority of WY MCH, Wyoming Medicaid, and other partners. The percent of eligible, Medicaid-enrolled children ages 1-9 who should receive at least one initial or periodic Early and Periodic Screening, Diagnosis and Treatment (EPSDT) screening in Wyoming and did receive a screen was 64.2% during FFY18. The percent of eligible children receiving at least one EPSDT screening in Wyoming has increased by 17.2% since FFY13, when it was 54.8% (Wyoming CMS 416 report).

In partnership with WY MCH, Wyoming Medicaid adopted Bright Futures, 4th Edition as the standard of care for well visits in Wyoming in fall 2017. In FFY19, CHP worked to implement Bright Futures implementation recommendations made in the previous year by two interns affiliated with the Title V MCH Internship Program. Two graduate-level interns worked with WY MCH, Medicaid, and other key stakeholders to develop a plan to implement Bright Futures in summer 2018. One recommendation that emerged from this work was the need to create and support a state-level Bright Futures Implementation Taskforce.

To support the creation of the Bright Futures Implementation Task Force, WY MCH accepted a masters-level social work intern through the University of Wyoming. With leadership and support from the Wyoming Title V Director and the CHPM, who also serves as the Interim Children’s Special Health Program Manager (CSHPM), the intern convened a large group of stakeholders to identify strategy areas for the taskforce to target. Based upon the initial input of this group of stakeholders, the taskforce identified the following four main areas of focus (due to the newness of this strategy, heavy focus on infrastructure was needed in addition to providing training):

• Medical coding was identified based upon the need to explore the relationship between EPSDT well visit rates in Wyoming and possible ICD-10 coding errors
• Family/consumer education was identified based upon the understanding that adaptation of Bright Futures implementation needed to meet identified family needs
• Provider education was identified based upon the need to build provider champions with knowledge and understanding of the Bright Futures guidelines
• Access to care was selected to identify barriers and gaps impacting families’ ability to access needed health care services, including preventive well visits

WY MCH has convened the Bright Futures Implementation Taskforce four times with plans to convene bimonthly moving forward. Key strategies the taskforce plans to implement in FFY21 include family focus groups on the strengths and barriers related to well visits and coordinated messaging around the importance of well visits. In addition, CHP used Title V funds to purchase the Bright Futures online toolkit and other materials to build local clinic capacity to implement guidelines; the program plans to put heavy focus on provider training in FFY21.

Strategy 4: Pilot Help Me Grow model in two counties (inactive as of June 30, 2019)

In 2015, CHP selected the national Help Me Grow (HMG) model to support a systems-level approach to improving access to existing developmental resources and services for children through age eight, including children with special health care needs. In October 2016, WDH contracted with Wyoming 211 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 was divided into three main stages: (1) building the infrastructure, (2) building the system, and (3) sustaining the system. During FFY18, Wyoming primarily focused on stage one, infrastructure building, but also made some progress in system building in the area of developing a centralized telephone access system. 

The rural and frontier nature of Wyoming meant that centralized telephone access was necessary to link children and families to needed resources. HMG received referrals in two main ways: through direct contact with HMG by phone, mail, walk-in, or word of mouth, or through a referral from the 211 call center. Unfortunately, the number of unique contacts referred to HMG remained limited throughout the pilot, and anecdotally, community partners reported that they could not recognize the difference between Wyoming HMG and 211. 

HMG relied on 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 Wyoming 211, WY MCH, and HMG throughout the pilot but especially during FFY18 and FFY19. Turnover contributed to significant implementation gaps and delays.

In fall 2018, Wyoming 211 upgraded its data system to improve data collection and reporting. Additionally, CHP and HMG staff worked to better define the measures being collected in order to match measures with program performance and outcomes. Both of these changes allowed for more accurate data collection and usage. However, the data revealed low uptake of HMG: between October 2019 and the end of the contract in June 2019, HMG reported receiving only 14 referrals. In addition, HMG made just 41 referrals of Wyoming families to resources for support and service.   

As the three-year pilot neared its end, WY MCH met with key stakeholders and Wyoming 211/HMG staff to discuss progress and challenges. Although Wyoming 211 staff dedicated considerable time and effort to learning and implementing the HMG model, the successes were outweighed by the long-term challenges, including:

• Confusion over the difference between Wyoming HMG and Wyoming 211
• Limited stakeholder understanding on how Wyoming HMG fits within a complex early childhood system
• Concern for duplication of efforts
• Community push-back in pilot communities (especially Albany County)
• Limited data on impact/value of Wyoming HMG pilot project in Laramie and Albany counties

WY MCH and partner funding agencies (Wyoming Part C Program, Wyoming Children’s Trust Fund, and Wyoming Department of Workforce Services) 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. CHP used FFY20 to convene key statewide stakeholders within the Wyoming early childhood system, including WDH, Wyoming Department of Workforce Services, Wyoming Department of Family Services, Wyoming Department of Education, the 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. 

In 2019, WY MCH requested technical assistance from the National MCH Workforce Development Center in hosting an in-state National MCH Workforce Development Center Learning Institute. This in-state learning institute brought together a large and diverse group of stakeholders positioned across the Wyoming Early Childhood system. This request was made based upon the recognition that the Wyoming early childhood system remains fragmented and opportunities for systems-level improvement exist. The initial goals of convening this diverse group together were:

1. Develop a shared vision for delivering high-quality services to children and families that meet identified needs
2. Create a unified mission statement
3. Set a plan to convene regularly to assess gaps and barriers
4. Develop common messaging
5. Set measurable short-term and intermediate strategic goals
6. Evaluate success

At the conclusion of the three-day, in-person learning institute, the group established several action items to move forward together. Those actions included the reinvigoration of the Wyoming Governor's Early Childhood State Advisory Council and the successful pursuit of the Birth to Five preschool development grant. The CHPM was appointed by the Governor of Wyoming to represent WDH and the Public Health Division on the Wyoming Governor's Early Childhood State Advisory Council. In addition, the governor directed that the Wyoming Governor's Early Childhood State Advisory Council oversee and direct the activities of the Wyoming Preschool Development grant.

The CHPM and other team members directing the Wyoming Preschool Development Grant incorporated the mission and vision drafted during the National MCH Workforce Development Center Learning Institute as the foundation for Wyoming's successful Preschool Development Grant Application. Throughout the first year of this funding opportunity, the CHPM has actively participated in the creation and review of a Request for Proposal to conduct a comprehensive needs assessment and action plan in support of early childhood system improvement. In addition, the CHPM has served on two workgroups connected to the grant activities. The CHPM sits on the Family and Provider Engagement Workgroup and the Data and Evaluation Workgroup.   

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

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

Over the past several years, CHP has maintained a partnership with CDPP to implement nutrition and physical activity promotion efforts in early childhood settings. In FFY18, CDPP adjusted its programmatic activities based upon changes in grant funding opportunities. As a result, CDPP received zero funding to address childhood obesity or to target children ages 0-18 for FFY19, so CHP adjusted strategies to fill an important gap. In FFY18 and FFY19, 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. A distribution plan was created in partnership with the Wyoming Department of Workforce Services, Wyoming Department of Education, Wyoming Department of Family Services, and the University of Wyoming to distribute kits to licensed childcare providers and the public. This toolkit was distributed to all 633 licensed childcare providers in Wyoming and all 249 public elementary schools. The Wyoming Department of Family Services (the Wyoming agency responsible for licensing child care providers) continues to distribute the toolkit to all newly licensed providers. In addition, the toolkit is available online for free download; CHP will work with the Wyoming Department of Workforce Services to determine if data on the number of downloads can be tracked moving forward.

The University of Wyoming Centsible Nutrition Program maintains Certified Nutrition Educators (CNEs) in all 23 Wyoming counties and the Wind River Indian Reservation. The CNEs have targeted childcare facilities serving low-income populations for site-specific technical assistance and training. All CNEs utilize the policy toolkit as a standardized framework to support settings in increasing physical activity and reducing obesity.

The Centsible Nutrition Program Manager and the CHPM conducted in-service training on November 19, 2019 for all CNEs related to the use of the toolkit to support consistent and uniform implementation of the toolkit.

Injury-related hospitalization and death remains the leading cause of preventable hospitalization and death in Wyoming. CHP remained committed to reducing the rate of children being hospitalized due to preventable injury. CHP was also equally committed to reducing the child mortality rate.

One July 2020 public input survey respondent stated, “I have grandchildren and their safety and wellbeing is always on my mind […] More tools and resources for parents is always a good thing.”

Strategy 1: Implement community based grants with targeted evidence-based strategies to address the major causes of childhood injury/hospitalizations in Wyoming

Wyoming MCH adjusted efforts related to childhood injury prevention in order to expand our reach and impact. Wyoming MCH historically focused primarily upon child passenger safety, but in response to emerging priorities like adolescent motor vehicle safety and adolescent suicide prevention, CHP and Youth and Young Adult Health Program shifted the funding model for this priority away from statewide Safe Kids Worldwide coordination and toward a statewide mini-grant program. This mini-grant program increased the amount of resources going directly to local implementation of evidence-based or evidence-informed childhood injury prevention strategies. WY MCH utilized the Child Safety Networks established child injury prevention change packages to highlight suggested evidence-based interventions for mini-grant applicants.

Seven organizations received funding through this mini-grant program and each developed an independent project workplan. A brief description of each grant recipient’s project is listed below:

• Youth Emergency Services, Inc. (Y.E.S. House) (adolescent suicide prevention) 

Campbell County has a large demand for adverse childhood experiences (ACEs) training and support. Y.E.S. House conducted community ACEs training and partnered with the local school district to strengthen community relationships. For more detail on this grant project, refer to the Adolescent Health Section. 

• Campbell County School District (adolescent suicide prevention) 

The Campbell County School District worked to establish active HOPE Squads (which work to change school culture around suicide by reducing stigmas) with the aim of identifying, protecting, and helping students in crisis. For more detail on this grant project, refer to the Adolescent Health Section. 

• Cheyenne Regional Medical Center (CRMC) (child passenger safety, water safety)

CRMC used the mini-grant funds to support advertising for community events on child passenger safety and water safety/drowning prevention. CRMC also released a large media campaign connected to drowning prevention, which had wide newspaper circulation reaching 28,000 recipients. CRMC was unable to conduct targeted outreach training due to COVID-19 but did reach 325 children through in-person, school-based education outreach activities. Additionally, 271 parents received targeted educational material related to child water safety.

• Cheyenne Regional Medical Center (CRMC) (prescription drug monitoring system) 

CRMC integrated its electronic health record called EPIC with the Prescription Drug Monitoring System (PDMP). In addition, CRMC worked to conduct training for providers on the use of newly available integrated data. This tool, in conjunction with the PDMP linkage to EPIC, enables practitioners to follow best practices identified by the American Academy of Pediatrics’ Committee on Substance Use and Prevention to screen, treat, and refer adolescents with substance use disorders. Though integration was successful, data is not yet available regarding the effect on the prescribing practices and patient outcomes. However, this is an evidence-based approach and research suggests that ease of access and more abundant data will drive better outcomes for patients and reduce opioid prescribing. Ultimately, less prescribing should lead to less misuse among adolescent patients and less availability to adolescents through family members.

• Johnson County (child passenger safety, pedestrian safety, infant and child fall prevention, safe sleep, water safety)

Johnson County provided water safety education and a developed classroom-based curriculum to 72 second grade students. In addition, the local elementary schools will utilize the curriculum in the next academic year to instruct the incoming class of second graders. Johnson County was also able to support child passenger safety education through community outreach events and documented a reach of 26 families prior to the onset of COVID-19. Johnson County also reported that it provided safe sleep education and support directly to 24 families.   

•  Wyoming Highway Patrol (WHP) (child/adolescent motor vehicle safety)

The WHP utilized the mini-grant funding to enhance program materials to help educate young drivers on the dangers of distracted driving and driving without seatbelts. WHP reached 948 children and adolescents in 68 schools across the state, targeting children 6-18 years of age. 

• Uinta County (safe sleep, child passenger safety, medication safety, water safety)

Uinta County was able to recertify two Public Health Nurses as car seat technicians and purchase car seats for replacements for families in the community that cannot afford a new and safe car seat. Due to COVID-19, the normal Safe Kids Fair was cancelled, but Uinta County was able to generate information that would normally be discussed at this fair for an insert in the paper. Earlier in the year they were able to bring in a national level speaker to discuss ACEs with service providers in the county as well as incorporate the messaging around ACEs into the home visitation program. In line with work around ACEs, the county has incorporated PURPLE Crying and Shaken Baby Syndrome education into its home visitation program through the distribution of videos and magnets.

CHP, the Youth and Young Adult Health Program, and the WDH Injury and Violence Prevention Program also joined the Child Safety Learning Collaborative through the Child Safety Network to focus efforts on reducing fatal and serious injuries among infants, children, and adolescents by building and improving partnerships and implementing and spreading best practice and evidence-based approaches, especially among the most vulnerable populations. Upon review of available data and capacity, the team selected Suicide & Self-Harm Prevention and Motor Vehicle Traffic Safety (Child Passenger and Teen Driver/Passenger) as learning collaborative topic areas of focus for Wyoming. The Youth and Young Adult Health Program Manager has led the suicide and self-harm topic and the CHPM led motor vehicle traffic safety.

The CHPM has remained an active member of Safe States Alliance and served as a moderator at the 2019 annual conference in Atlanta, Georgia. In addition, the CHPM serves on both the Safe States Alliance Annual Conference Planning Committee and the Plains to Peaks Regional Network Steering Team. Plains to Peaks 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. Participation allows for sharing of information and resources and professional development. The CHPM also served as an abstract reviewer on infant, child, and adolescent injury topics ahead of the September 2019 conference and again in advance of the 2020 virtual annual conference.