National Performance Measure #6: Percent of children, ages 9-71 months, receiving a developmental screening using a parent-completed screening tool.

 

Evidence Based or Informed Strategy Measure #6.1: The number of sites using ASQ/ASQ-SE screening tools and participating in the Watch Me Grow (WMG) System.

 

Objective: To increase from 32% (2016 FAD baseline) to 42%, the percentage of children, ages 10-71 months, who receive a developmental screening using a parent-completed screening tool by 2024.

 

Strategies:

 

• Redesign the Watch Me Grow (WMG) system to expand to include monitoring, screening, education, evaluation, diagnosis, treatment and services
• Provide technical assistance on developing, creating and increasing partnerships
• Target public awareness about developmental screening and techniques for interacting with families
• Engage in Preschool Development Grant (PDG) work and website
• Promote developmental screening utilizing targeted toolkits for medical providers, early care educators and for families
• Watch Me Grow will explore possible training mechanisms to address:

• The importance of developmental screening, including how to embed it into their process and bill for EPSDT services, in collaboration with NH PIP and Dartmouth Hitchcock
• Support continued training to child care providers through Child Care Aware for ASQ, ASQ SE and WMG
• Expand trainings to include how to have challenging conversations with families
• Explore e-learning opportunities that can be posted or used through WMG

• Collaborate with implementation of the Pyramid/‘iSocial’ model using the ASQ SE2 under the State Personnel Development Grant
• Data will be collected from Medicaid using CPT codes for specific developmental screening tools, which will allow tracking what is being used in the medical field
• Work with the NH Charitable foundation, Spark NH and other partners to secure an increase in funding for developmental screening
• Utilize the PDG information to identify needs and gaps in developmental screening
• Assess the need and feasibility to create an integrated cross-agency statewide early childhood data system to improve program effectiveness, gather data on developmental screening and increase the success of child and family outcomes. Some of this work will be identified in the needs assessment from the Preschool Development Grant
• WMG will be able to provide technical assistance and some quality assurance to provide consistent, comprehensive overviews to the FRCs and WMG partners on the inputting of data related to the current Welligent system. This may include an e-learning module on this data input.
• Create and distribute summary reports of the WMG data to partners on a quarterly basis.
• Complete pilot project and begin to implement the online ASQ and ASQ: SE sites as funding allows and to provide families with another mechanism to screen their children.
• Partnership with WIC to provide developmental monitoring at three of their locations

 

Data Analysis

 

The National Survey of Children’s Health data for indicator 4.10 “Did the child receive a developmental screening using a parent-completed screening tool in the past 12 months, age 9-35 months?” for years 2018-2019 shows a slight decrease in parent-completed screening tools as compared to 2016-2017 data, 35.1% down to 32.8%.[1]

 

Throughout FY20, Watch Me Grow, NH’s Developmental Screening System, continued to promote the use of the ASQ-3 and the ASQ SE2 and required partner sites who have completed screenings to report their screening activities and any resulting referrals in Welligent, an online Electronic Health Record. FY20 was on track to closely match FY19, however, the COVID‑19 pandemic and subsequent public health emergency impacted partner sites’ ability to complete screenings. Some partners were closed for a period of time and then only opened to essential workers with reduced numbers of staff and children being served. It was reported that some sites had many restrictions including working with only small groups and limits on staff interactions, which also impacted their ability to complete screenings. 

 

 

 

Medicaid claims data indicated that payments made in FY20 using the Developmental Screening code 96110 dipped in the number of screenings (tool used is unknown) completed March through May 2020, but by June screenings had returned to typical levels. In fact, Medicaid data for the year shows a slight increase over the previous year. It could be that developmental screenings billed to Medicaid during the State’s “Safer at Home” period did not decrease as much as screenings completed by community agencies due to the ability to provide the screening in an office setting versus in a classroom or during a home visit. 

 

 

 

Systems Building

 

NH’s system for developmental screening, Watch Me Grow (WMG), is comprised of a Steering Committee, Ages and Stages Questionnaires (ASQ‑3 and ASQ‑SE2) and related materials, and partner agencies including Family Resource Centers (FRCs), Head Start/Early Head Start, and child care programs. 

 

The Bureau for Family Centered Services (BFCS)) continued to provide leadership for WMG. The Systems of Care Specialist coordinates the WMG Steering Committee and was the State’s CDC Learn the Signs Act Early (LTSAE) Ambassador for this reporting period. FY20 proved to be a challenging time for the Watch Me Grow System in NH. In February 2020, the Systems of Care Specialist moved to a new position at the Department of Education. The Bureau was unable to fill the vacancy because of a hiring freeze put in place by the governor due to the COVID‑19 Emergency. Other BFCS staff filled in by leading the Steering Committee so that the work could continue.

 

FY20 had other challenges as well. The WMG Action plan included the promotion and effective utilization of the ASQ Online Management System and efforts were made to launch the system across the state at WMG partner sites, however, unforeseen roadblocks delayed progress. The Watch Me Grow Steering Committee worked to identify and remedy these roadblocks which included lack of training on the ASQ Online Management System for partner site staff, turnover of trained staff, lack of capacity or a plan for families accessing the system who were unknown to the partner site, and the crashing of the Watch Me Grow Website.

 

While this work was happening, the COVID‑19 emergency further impacted partner sites’ ability to conduct screenings with families. It became increasingly clear that the ASQ Online Management System needed to be up and running as soon as possible. It also became clear that WMG needed to rebuild the infrastructure supporting developmental screening throughout the state. 

 

The WMG Steering Committee had already been investigating the Help Me Grow (HMG) Model and how it might be applied in NH. One of the four components of the Help Me Grow model, the Centralized Access point (CAP), became the focus of the committee as a way to address the identified roadblocks by providing a centralized hub to support partners and families in NH around child development and screening, and to build the structure needed to expand from a developmental screening system to a system that supported developmental monitoring, referral, education, evaluation, diagnosis, treatment and services. WMG made a commitment to HMG National in Connecticut and became a state affiliate. Members attended webinars, the HMG National Forum (a virtual 3-day event), and Building Expertise of (HMG) Model Implementation sessions held on Zoom.

 

The group also reached out to other states’ Centralized Access Points to find out how they implemented the HMG model and to explore what it might look like in NH. This continues to be a priority for the WMG steering committee as the remaining three of the four Help Me Grow components (Family and Community Outreach, Child Health Provider Outreach, and Data Collection and Analysis) align with WMG’s identified strategies to increase developmental screening and resulting family connection to services in the state. Help Me Grow National offers technical assistance and a robust website which provides step by step guidance in setting up a system that has been shown to be successful in other states. The Steering Committee has embraced this work and is excited to move forward.

 

Developmental Monitoring: Partnering with WIC and Learn the Signs Act Early

 

Watch Me Grow partnered with WIC to support implementing a pilot of the Center for Disease Control’s Developmental Milestone Checklist Program in NH. Based on a program developed by the CDC with Missouri WIC, the program helps engage parents in monitoring their children’s development and support them with timely referrals when needed. The pilot launched in February of 2020 and NH WIC staff reported it was going phenomenally well, and then everything was put on hold during the COVID emergency. The goal with this project had been to go statewide in the fall of 2020 with training and rollout to other WIC agencies in the state. In the interim, WIC program staff added a link to the Milestone Tracker App on the WIC shopping App. Monthly reports show there has been interest in the link by WIC families but there is not currently a way to know if it was downloaded or if they are using it, only that they clicked on the link.

 

 

 

New Hampshire Family Voices continues to be the hub for distribution of WMG materials. In FY20, they distributed 876 of the following materials by direct mail, conference displays, and in workshop resource packets.

 

• Milestone Moment Handbooks
• Milestone Brochures
• Amazing Me packets
• First Five Years Booklet
• Where is Bear books
• Amazing Me books
• Spanish Where is Bear

 

 

 

*  *  *  *  *  *  *

 

 

National Performance Measure #8.1: Percent of children ages 6-11 who are physically active at least 60 minutes per day.

 

Evidence Based or Informed Strategy Measure: Percentage of children ages 6-11 enrolled in Comprehensive Family Support Services (CFSS) whose parent reports that the child gets at least one hour of physical exercise per day.

 

Objectives: By July 1 of 2021, increase the average by at least five percentage points overall of children who have had a high BMI and documentation of counseling/referral at the MCH funded CHCs in state fiscal year 2021.

 

Strategies:

• Screening and intervention on physical activity among MCH funded contract agencies (e.g. home visiting-MIECHV and CFSS and CHCs)
• Professional training on increasing physical activity
• Include physical activities during home visits with families
• Encouragement of clients by health and social service providers for children and families to increase physical activity through fun, family-centered, local, community-based opportunities

 

Data Analysis

 

Childhood obesity continue to be a problem among children of all ages in the State of NH. According to the State of Obesity report, some 15.8% of 2-4 year old WIC participants are obese and 13.7% of children age 10-17 are obese (https://stateofobesity.org/states/nh, accessed May 5, 2021), giving NH rankings of 8/51 and 30/51 in the US.

 

Data from the National Survey of Children’s Health in 2019 for this NPM#8.1 shows a rate of 28.8% of children ages 6-11 in NH who are physically active at least 60 minutes per day.  

 

MCH provides Title V funding leveraged with that from the DCYF and administered by the Division of Economic and Housing Stability (DEHS) through the CFSS program to eight (8) agencies that offer a Family Resource Center (FRC) for center-based activities and resources, and for doing home-visiting with families with children in 13 different communities statewide. This program provides education, coordination of care, and support for safe and healthy families to aid in the prevention of child maltreatment. In an effort to expand the focus of a healthy family, this performance measure has focused on working to improve the physical health of enrolled children and their families by increasing physical activity, to promote a healthy lifestyle. In 2020, a total of 1,285 families were served by these funded services, which included 2,336 children.[2] Services were provided primarily at the agencies’ CFSS FRCs, but also at home visits, some of which were reimbursable by Medicaid. The strategy being used is that of the "5-2-1-0 Healthy NH,"[3] a statewide public education campaign to bring awareness to daily recommendations for nutrition and physical activity which identifies steps that families can take to prevent childhood obesity.

 

Upon enrollment into the CFSS program, if there is a child of age 6-11 in the family, the parent was asked if the child currently participates in at least one hour of moderate to vigorous physical activity every day. A data element was added to the DEHS/DCYF electronic data collection form to capture this information. At discharge, the parent of the child was asked again about having at least one hour of physical activity per day, and again, data entry was made into DCYF’s electronic data collection form.

 

As of April 2021, FY20 results showed that 91% of the parents with a child enrolling in CFSS services indicated that the child had at least one hour per day of physical exercise. At the time of discharge, 91% of parents indicated their child had at least an hour, which was a slight decrease from the 92% reported the previous year. The children were not necessarily the same ones from enrollment to discharge in FY20, as some had been enrolled the previous year. However, at the time of discharge, ten (10) had improved since enrollment from No exercise to Yes, exercise; 471 indicated no change;.432 continued to respond Yes; and 39 continued to respond No.

 

 

Children between 6-11
Final FY databases	Discharge
	Children Discharge FY20	Y	N	No Data		Receiving Services DURING FY20
Berlin	34	34	0	0		Families			1,285
Claremont	21	21	0	0		Children			2,336
Concord	51	49	2	0
Conway	16	16	0	0
Keene	89	83	6	0
Laconia	55	52	3	0
Littleton	17	17	0	0
Manchester	52	31	21	0
Nashua	42	42	0	0
Portsmouth	26	24	2	0
Rochester	72	61	11	0
Salem	13	12	1	0
	488	442	46	0
		91%	9%	0%
	Improve	10	N to Y
	No Change	471	Y to Y = 432, N to N =  39
	No Data	0
		488

 

 

MCH continues to require its Title V-funded Community Health Centers to report on BMI and counseling related to the 5-2-1-0 campaign. In SFY20, the MCH primary care contract agencies were required to report on the following performance measure, derived from HEDIS:

 

Percentage of patients aged 3-17 who had evidence of BMI percentile documentation

AND who had documentation of counseling for nutrition

AND who had documentation of counseling for physical activity

during the measurement year.

 

The numerator for this is the number of patients in the denominator who had their BMI percentile (not just BMI or height and weight) documented during the measurement year and who had documentation of counseling for nutrition and who had documentation of counseling for physical activity during the measurement year. This is based on one of the current UDS Primary Care Clinical Performance Measures.

 

The denominator for this is the number of patients who were one year past their second birthday (i.e., were 3 years of age) through adolescents up to one year past their 16th birthday (i.e., up until they turned 17) at some point during the measurement year, who had at least one medical visit during the measurement year, and were seen by the health center for the first time prior to their 17th birthday.

 

The SFY20 results indicated that agency results ranged from 17% to 100%; the average has decreased from the previous year of 70% to 68%, mostly because of the lowest performing agency. This agency is receiving technical assistance from MCH’s QI and Clinical Services programmatic unit staff.

 

 

Source: MCH Performance Measure Data

 

 

National Outcome Measure 20

Percent of children and adolescents, ages 10-17, who are obese (BMI at or above the 95th percentile)

 

 

 

 

Percent of Children (ages 10-17) who are overweight or obese6

 

Childhood obesity is an issue that theState continues to struggle with; over a quarter of children aged 10-17 are overweight or obese,6 although NH is doing better than some states ranking 30th (https://stateofchildhoodobesity.org/states/nh/) in the nation for least obese or overweight children, this issue still impacts many children in the State. Both the high score in overall child health and measures for BMI can be dramatically impacted by the systems within which the children live.

 

Systems building

 

On January 23, 2020, Governor Chris Sununu signed Executive Order 2020-03[4] establishing the Council for Thriving Children as NH’s Early Childhood Council, alongside officials from the NH Department of Education (DOE), Department of Health and Human Services (DHHS) members from the University System of NH and Early Childhood Development Stakeholders.

 

Beginning with the Birth-8 needs assessment over two (2) years ago and continuing through strategic planning efforts, recommendations for a new governance structure have emerged to guide the future work of NH’s Birth-8 Early Childhood Care and Education system. The proposed structure is charged with developing and advancing the State’s vision for children, families and communities; formalizing collaborations and connections to foster efficient, high quality services for children and families; and using an equity lens to guide implementation based on agreed principles and goals. This effective and inclusive structure also formalizes governance at the state and regional/local levels and engages stakeholders with defined roles and a shared vision. It addresses inconsistencies in regulations and service eligibility requirements, reduces duplication of services and uses ongoing evaluation, robust data, and current research to inform decision-making.[5]

 

MCH staff participates in DHHS Early Childhood Integration team which includes representatives from all early childhood-serving programs housed in DHHS. Over the last year meetings and presentations have been structured to support greater understanding of the impacts of social determinants of health (SDoH) and the impacts that these have on early childhood and families. With presentations from various programs designed to support specific SDoH to support greater awareness of programs to support young children and their families.

 

MCH specific activities

 

MCH has continued to co-facilitate the monitoring of the CFSS agencies with staff from the Division of Economic and Housing Stability, through quarterly meetings and analysis of performance measure outcomes. As stated previously, funded agency staff work with families who have children of ages six 6-11 on strategies to sustain or increase daily physical activity. Materials from the 5-2-1-0 campaign are reviewed and distributed.

 

In addition to assessing if the child gets at least one hour of physical activity per day, and integrating education on how to include exercise into the day, the CFSS-funded agencies carry out a variety of other healthy lifestyle/exercise promotion activities that impact many of the children enrolled in their program. Home visiting allows for growth as it is responsive to the family’s needs, meeting them where they are, to support growth in the areas the family is driven to shift. Home visiting in general does this through engaging families in activities that support physical activity in the home and often in the community. Visits often occur on playgrounds or safe natural spaces, where learning opportunities are paired with fun activities which increase valuable parent/caregiver interaction with their children and support parenting skills. 

 

Agencies have access to evidence based curriculum which provide ideas for fun physical activities. They also have a myriad of educational materials such as pamphlets on a variety of health topics, the provision of which can support messaging that they may be hearing at health appointments, but for some families receiving these same materials in their own homes can create greater comfort to ask questions that they may not have asked at their last health appointment.

 

Support is also provided in linking families to resources and other services in their communities, to overcome barriers that could impede healthy outcomes such as accessing health care or finding funding for summer camp, gym memberships, or sporting equipment so their children may participate even if family funds are not available. Home visiting is offered in NH prenatally until the age of 21, and although this particular measure is focused on age 6-11, healthy habits created in the younger years provide a foundation for families to adopt healthy habits throughout that child’s development. Agency staff have shared the importance of supporting families by joining with them in fun or simple activities that support the family in overcoming anxiety about navigating the world around them. Examples include going to the park or walking with a family during home visits, and over time that same family now weaving after dinner family walks into their regular routine.

 

The agencies are local organizations that are embedded in their communities and by visiting families in their homes create bridges between families and their communities. This allows greater awareness, exposure, and comfort to engage in fun activities, such as playgroups, healthy affordable cooking classes, 5K races, group hikes, or family fun days that not only provide time for physical activity but increase social connection and supports between community members. With various restrictions in place due to COVID‑19, agencies tried other creative strategies to encourage physical activity and social connection even when not in-person. Some examples were providing or referring to free online groups that encouraged singing, dancing, and yoga. Or creating a series of hikes, where families could come together outside with plenty of space. 

 

Due to the COVID‑19 pandemic, agencies quickly altered their home visits to virtual ones for a period of time; if in-person visits were needed and levels of community transmission, mitigation strategies, and agency policy allowed, home visitors carried out the delicate balance of providing services in the safest way possible for families. At certain periods during the pandemic this meant doing only virtual visits and phone calls, sometimes delivering activity packages to families or talking through screen doors with families to answer questions and make sure families had what they needed to be supported. Family Resource Centers, many of which hold the Comprehensive Family Support Services contract also became hubs to get supplies out to families; some of these supplies included fun activity grab bags that encouraged time outdoors, such as activities to use food coloring to paint snow and nature based scavenger hunts.

 

This period of time also highlighted how families living in different areas of the State faced different challenges. Families in cities with less green space, who needed to travel to get quality outdoor time sometimes felt uncomfortable using public transportation to access green space. Also, in rural areas where green space may have been plentiful, broad lack of access to technology, whether that was access to necessary equipment or connectivity, were pronounced, although it should be noted these were also issues for families even in less rural regions of the State.

 

As agencies thoughtfully considered re-opening strategies for home visiting, it has been noted that for high-need families home visits might occur outdoors to limit risks from a more traditional home visit that would occur inside the home. This strategy would likely support physical activity and time in a natural environment. Time spent in nature, physical activity, and yoga are all strategies that can support better coping mechanisms and stress reduction, which are helpful for families currently facing heightened stress in response to the COVID‑19 pandemic.

 

Feedback from agencies also provide state staff with greater awareness of systemic issues that can impede physical activities, and greater understanding of why physical activity for young children can be harder for those living in apartment complexes in the city; or that sidewalks are not available in certain parts of the State. And the challenges that long NH winters bring for those who may not have snow tires and who feel unsafe walking with their children in the street when sidewalks are unplowed. Technology access for parents trying to support remote schooling and additional difficulties that arose in providing this support for families who were English language learners was also noted. These examples all provide a deeper understanding of the diverse challenges encountered through a family’s particular context, including economic challenges or the environmental context that the family is navigating. This allows state staff to then bring these voices to larger interdepartmental meetings, such as the Early Childhood Integration Team, to strategize solutions for more equitable environments to support greater health outcomes for all of the people in NH.

 

(This NPM and ESM are being discontinued)

 

 

[1] Child and Adolescent Health Measurement Initiative. 2018-2019 National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). Retrieved 04/30/21 from www.childhealthdata.org.

[2] email communication 4/30/21 between Aurelia Moran, MCH, and Kim Aubertin, DCYF

[3] http://www.healthynh.com/5-2-1-0-healthy-nh.html

[4] https://www.governor.nh.gov/sites/g/files/ehbemt336/files/documents/2020-03.pdf

[5] Education Commission of the States, Governance in Early Childhood Education, Bruce Atchison and Louisa Diffey, December 2018