NPM 6 - Percent of children, ages 9 through 35 months, receiving a developmental screening using a parent-completed screening tool

 

Introduction: Developmental Screening

For the Child Health domain, Hawaii selected NPM 6 Developmental Screening as a priority based on the 2015 five-year needs assessment. By July 2020, the state sought to increase the proportion of children, ages 9 through 35 months, receiving a developmental screening, to 40.0%.

 

Data: Aggregated data from 2018-2019 showed the estimate for Hawaii (31.6%) did not meet the 2020 state objective (40.0%) but was not significantly different from the national estimate of 36.4%. Although the data appears to show Hawaii’s rate of screenings are decreasing over the past three years, none of the differences are significant. Due to the small sample size, results for this measure should be used with caution. The related Healthy People 2020 Objective for developmental screening (24.9%) was met. There were no significant differences in reported subgroups by health insurance, household income; but again, this may be due to the small sample size.

 

Objectives: Based on the 2020 needs assessment, this NPM will be continued into the 2021-2025 plan period. Because of the sample size of the data for NPM 12, it is unclear whether the data truly reflects a decrease in screening since the differences in the data over the past five years are not statistically significant. Reviewing the baseline data and the HP 2030 objective, the state objectives through 2026 were updated to reflect an annual increase of one percentage point.

 

Title V Lead/Funding: Developmental screening has remained a continuing priority since 2010 for Family Health Services Division (FHSD), which coordinates federal, state, and local efforts on screening, referrals, and services. The leads are the Children with Special Health Needs Branch (CSHNB) Early Childhood Coordinator and the Early Childhood Comprehensive Systems Impact (ECCS Impact) Grant Coordinator. The ECCS Impact grant funds the grant coordinator position and activities. The CSHNB Early Childhood Coordinator is a state-funded position. Title V does not directly fund development screening program staff and activities but does support management, epidemiology, data, and administrative positions that contribute to the NPM.

 

Title V convenes a Developmental Screening Workgroup comprised of FHSD early childhood programs, including:

• Hiʻilei Hawaii Developmental Screening Program – offers on-line or paper copies of the Ages and Stages Questionnaire:3 (ASQ:3) for families of children birth through five years.
• Home Visiting Services Unit – funded by the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) grant. Its home visitors work with parents to complete the ASQ.
• Newborn Hearing Screening Program – oversees the Early Hearing Detection and Intervention data system for hearing screening of children birth to age 3.
• Early Intervention Section (Hawaii’s IDEA Part C agency) – provides services and supports for children birth to age three who have a developmental concern.
• ECCS Impact Grant – focuses on developmental screening of children birth through five years for Maui County.
• FHSD Programs within the District Health Offices from Hawaii Island, Maui, and Kauai.

 

Partnerships: There is broad collaboration among statewide agencies and stakeholders working toward a statewide systematic approach to developmental screening, including medical partners, early childhood providers, and community-based nonprofits who conduct developmental screening and ensure children are connected to services or supports if a concern is identified. Development screening is also identified as a priority in several key state plans, including:

• Executive Office on Early Learning’s Early Childhood State Plan for 2019-2024;
• Preschool Development Grant (PDG) Birth through Five Strategic Plan; and
• Early Childhood Action Strategy (ECAS), a nonprofit public-private partnership, focusing on children’s issues prenatal through age eight.

 

Nationally, developmental screening is promoted through grants and guidance documents, including:

• HRSA ECCS Impact Grant that emphasizes partnership with healthcare and early childhood care/education providers to promote developmental screening;
• American Academy of Pediatrics (AAP) policy statement that recommends screening using a validated tool at 9, 18, 24 or 30 months as part of a well-child visit; and
• Medicaid Early and Periodic Screening, Diagnostic and Treatment (EPSDT) guidelines. In Hawaii, Medicaid is administered by the State Department of Human Services (DHS) Med-QUEST Division (MQD).

 

Strategies/Evidence: Hawaii’s five developmental screening strategies focus on systems-level approaches and follow guidance from three sources:

• Federal ECCS Impact Grant,
• HRSA’s Title V “State Technical Assistance Meeting” in March 2016, and
• National MCH Evidence Center.

 

The five strategies are:

• Build systems and infrastructure
• Implement family engagement and public awareness activities
• Ensure data collection and integration
• Address social determinants of health and vulnerable populations
• Assess policy and public health coordination

 

The last strategy is assessed via a Policy and Public Health Coordination Scale (PPHC) designed to monitor implementation of the systems-level approaches and is used as the NPM 6 strategy measure (ESM 6.2).

 

The HRSA ECCS Impact best practices promote working with early childhood providers to ensure that screenings are done as part of their assessment of children’s development and supported by:

• National Association for the Education of Young Children (NAEYC) Accreditation
• Head Start Performance Standards
• National Institute of Early Education Research benchmarks for early education programs

 

Hawaii works with these programs to ensure the national standards are implemented.

 

Research compiled by AMCHP and the MCH Evidence Center indicate evidence-based support for training of healthcare providers on developmental screening and screening through home visiting programs, although further evidence is needed. Following these promising practices, Hawaii provides community-based trainings on the ASQ:3 to both healthcare and early childhood providers. Although quality improvements in both healthcare settings and systems-level approaches were found to be effective, Hawaii’s Title V agency does not have direct control over healthcare settings and therefore chose a general systems approach to continue quality improvement practices. The Evidence Center indicated Hawaii’s ESM 6.2 to have ‘moderate evidence’ related to QI activities.

 

Updates for 2020 on the five strategies follow.

 

COVID Impacts: Because of COVID-19, many programs closed to in-person visits and screenings with the governor’s mandatory stay-at-home orders that went into effect in March 2020. Most residents were asked to remain home and leave for only essential goods and services. With the closures, some childcare programs and most schools stopped in-person learning and moved to online learning. Initially, many doctor’s office closed temporarily to implement ever-evolving safety protocols and secure critical PPE. In addition, parents’ fears of COVID-19 exposure resulted in appointment cancellations or delays. These factors contributed to the likely decrease in developmental screenings in 2020.  The on-going impact of the pandemic and the severe economic impact on families shifted priorities to ensuring basic needs (housing, food security, employment, and income), taking precedence over monitoring their child’s development. Many programs and services pivoted to address the critical impacts of COVID-19.

 

Strategy 1: Systems Development – Develop infrastructure to coordinate developmental screening efforts

 

The activities for this strategy focus on systems and policy development to support children’s developmental screening. Hawaii depends on its partnerships in the healthcare, early childhood communities and parent advocacy organizations to assist with the four stages of developmental screening: screenings, referrals, services and supports, and family engagement.

 

Guidelines on Screening and Referral: “Hawaii Developmental Screening and Referral Guidelines for Early Childhood and Community Based Providers” are available to provide standard information for those conducting developmental screening of children ages birth through five years of age. They are based on the following national resources:

• AAP Policy on Developmental Surveillance and Screening Guidelines;
• Centers for Disease Control and Prevention (CDC) Act Early Campaign;
• Bright Futures: Guidelines for Infants, Children, Adolescents Health; and
• National standards from the Resource Center for Health and Safety in Child Care and Early Education (NRC), Head Start Program, and NAEYC.

 

The guidelines also include local best practices and were vetted with early childhood and medical providers and other key stakeholders. Because of the pandemic and the shift to connecting with families remotely, the guidelines were revisited in conjunction with stakeholders to ensure the information was relevant, whether screenings were conducted in person or virtually. This document can be found on the Department of Health website: https://health.hawaii.gov/cshcn/hiileihawaii/.

 

Workforce Training: Before the pandemic, Hawaii had planned to conduct trainings for early childhood programs on the Stages Questionnaire 3 (ASQ-3) and Ages and Stages Questionnaire Social Emotional -2 (ASQ:SE2) throughout FY 2020. A few trainings were conducted in the fall of 2019 but trainings since March 2020 have been placed on hold.

 

CSHNB was able to partner with Project ECHO Hawaii, which provided a virtual platform to conduct educational webinars to healthcare providers on Developmental Screening and the services provided by Early Intervention Section (EIS). Two webinars were completed in May and June 2020 to audiences of approximately 30 participants each from across the state. The CDC Act Early Ambassador for Hawaii and CSHNB Early Childhood Coordinator presented on the different screening tools and the referral processes for children identified with a developmental concern.

 

The DOH Early Intervention Section conducted an ECHO webinar on their Primary Service Provider model and the referral process for children who may be identified as having a developmental concern. The webinars are archived on the ECHO Hawaii website as a training resource for providers.

 

Strategy 2: Family Engagement & Public Awareness

 

The activities for this strategy focus on engagement with families to promote understanding of the importance of developmental screening and child development. COVID restrictions resulted in many childcare program closures and other family support programs shifting to online platforms, increasing family stress exponentially.  Families struggled with sudden job/income loss, while also assuming responsibility for the care and education of their children. This raised concerns regarding increased substance use, family violence, and mental health concerns exacerbated by social isolation imposed by the pandemic. While promoting child development remained a priority, service providers focused on public awareness and messaging on self-care and the importance of seeking help when needed.

 

Outreach to Families: Many family organizations moved to online platforms and conducted virtual family support group meetings to connect families. One parent group, Leadership in Disabilities and Achievement of Hawaii (LDAH), conducted parent groups using Facebook Live. CSHNB was asked to share information about its programs with families. Information about Hi‘ilei Developmental Screening Program, which promotes the online or paper version of the ASQ screening tool for parents, was highlighted. On Maui, the ECCS Impact Coordinator also engaged families with Facebook Live groups. Families were enlisted through partner organizations and shared their experiences on child development and other concerns during the pandemic. Socio-emotional kits were created and distributed to families through pediatricians’ offices. These kits promoted family activities and also personal parental well-being. Hi’ilei Hawaii worked with the local cable television to develop a one-minute public service announcement on developmental screening, which is posted on the DOH website: https://health.hawaii.gov/cshcn/hiilei/.

 

Screening Information Websites: Hawaii continues to work with the Early Childhood Action Strategy (ECAS), a public-private collaborative that focuses on children’s issues prenatal through age eight. The CSHNB Early Childhood Coordinator leads the ECAS On-Track Health and Development Team. Documents on screening are housed on the ECAS website, which provides information about child development (https://hawaiiactionstrategy.org/). The DOH CSHNB website houses developmental screening information on its website: https://health.hawaii.gov/cshcn/aboutus/.

 

Strategy 3: Data Collection and Integration

 

The activities for this strategy focus on acquiring population-based developmental screening data to monitor needs and identify vulnerable at-risk populations and communities. At this time, there is little timely 2020 data available to assess the pandemic impact on screening rates. However, FHSD and other direct service programs for children and families did see a decrease in client services during the pandemic. MIECHV reported many of their families postponed well-child visits and delayed immunizations due to COVID. Program referrals to EIS and Preschool Special Education also saw declines. Generally, preventive services and screenings decreased during the pandemic, reflecting national trends. It’s likely developmental screening rates also decreased.

 

National Survey on Children’s Health (NSCH) data: The latest NSCH data for this NPM is for 2019, thus does not reflect the impact of the pandemic. In addition, there are several issues with the NSCH data that limits its utility to inform planning and address health equity. While the survey provides standard state-level estimates, the data reported for this measure is small and unreliable to determine trends or identify significant Hawaii ethnic disparities to assist in developing effective prevention and treatment strategies. Also, county-level data is not available to help target geographic efforts. The racial/ethnicity data collected by the NSCH are not representative of Hawaii’s majority Asian, Native Hawaiian, and Pacific Islander population. FHSD has explored survey oversampling for several years with the MCH Bureau, but the cost and administrative procurement barriers are prohibitive. Lastly, the NSCH survey question asks parents about screenings that occur only in a healthcare provider’s office; however, developmental screening efforts include work with early childhood providers.

 

Medicaid: Currently, the Hawaii Medicaid Program (MedQuest-DHS) does not report on Developmental Screening rates for up to age 3, one of the CMS core children’s healthcare quality measures. Only 28 states report on this optional measure. The only reported Medicaid screening data is from the “Form CMS-416: Annual EPSDT Participation Report.” However, the EPSDT data really reflects medical visits vs. actual screenings. The data for this form also lags by nine-12 months.

 

While healthcare providers may document developmental screening information in client records, it is unclear to what extent health insurers are collecting and using the aggregated data for performance or quality improvements. Also, healthcare providers may not use validated screening tools but may instead exercise the option to use their clinical judgment or observation to identify concerns. Although health insurance coverage is relatively high in Hawaii, families may experience obstacles to scheduling well-child visits and miss the recommended developmental screenings.

 

Service information for early childhood programs may be a potential data source, but the same lack of infrastructure to aggregate and analyze the screening data from individual service providers is a barrier. For instance, the State Department of Human Services (DHS) Child Care Program requires all parents/caregivers at licensed child care programs to report developmental screening and other health data for each child.  However, none of this data is reported to DHS and is kept on file by the childcare provider.

 

Title V Program Data: Developmental screening data is collected and reviewed for quality assurance and monitoring from FHSD’s early childhood programs: MIECHV, ECCS Impact Grant, Hi’ilei, and Early Intervention. Data is currently available for 2020.

 

Data from the MIECHV Home Visiting program for FFY 2020 showed that 75.8% of the 561 children enrolled in the program were screened for developmental delay. Of those children with positive screens for developmental delays, 71% of children received services in a timely manner. Hawaii’s home visiting program screens follow the AAP guidance.

 

The Hiʻilei Developmental Screening Program provides parents and caregivers an option of completing an online screening or completing a paper copy of the developmental screener through the mail. FFY 2020 Hiʻilei data shows that 44 children birth through 5 years were screened. Seven of the children were found to be in the “monitoring” range. None of the children were found to be in the referral range and information on activities to support their children’s optimal development were provided to the parent.

 

Hawaii’s ECCS Impact grant collects developmental screening data from two major childcare providers serving Maui County, an Early Head Start program and a Family Child Interaction Learning Program. In 2020, two screens were added, at 40-months and 42-months, in addition to the 36-month screens for 3-year-olds. This resulted in a substantial increase in the number for screens in 2020 (470). Only a few cases required follow up and were connected to services as needed. The ECCS Impact Coordinator hosts bi-monthly community meetings to discuss the data from the ECCS project, including the number of children screened from within the referral range and number referred and connected to services.

 

Referrals to Early Intervention (EI) come from various sources. FFY 2020 shows that 2,753 children were referred, with 58% of referrals coming from Primary Care Providers, 25% from families, 31% from community providers, 0.5% from Resource Caregivers, and 1.9% from child welfare. Programs providing referrals include childcare, home visiting, public health nursing, Early Head Start, and healthcare or social service providers. Referrals to EI were down from 2019 (3,260), which may be attributed to COVID-19 closures. Of the 1,954 evaluations that were conducted, the majority of the referrals were found eligible, with close to 90% of those referred receiving services. Only 176 were found ineligible.

 

Developing a coordinated data system for FHSD and the state around screenings and referrals was hindered by the different time frames in which data are collected, and the different ages at which children are screened.

 

Strategy 4: Social Determinants of Health

 

The activities for this strategy focus on working with partners to identify vulnerable populations and assure programs exist to provide developmental screening services and follow-up to these communities. The COVID pandemic rapidly expanded the population needs in the state, including access to healthcare. Many families lost affordable employee-based healthcare insurance, resulting in a dramatic increase in Medicaid enrollments. The pandemic also highlighted existing health disparities and inequitable access to broadband internet and devices to utilize online, telehealth, and educational services.

 

Prior to the pandemic, the CSHNB Early Childhood Coordinator planned to pilot a development screening program at the state’s largest emergency shelter system, the Institute for Human Services (IHS), which helps children and families to find stable housing, employment, and address other critical needs. The project was put on hold because of the COVID-19 pandemic. Another pilot project to conduct developmental screenings in WIC clinic waiting rooms on the neighbor islands was initiated but disrupted by COVID closures.

 

The 2020 needs assessment completed for the state’s federal Preschool Development Grant identified rural and neighbor island communities with the greatest needs for healthcare and information about child development since medical and specialty services are concentrated in urban Honolulu. The focus of the current ECCS Impact Grant on Maui County helped to address some of this need. FHSD Neighbor Island RN Coordinators work to promote development screening in conjunction with the CSHNB program and community partners; however, the FHSD Neighbor Island nurses were deployed throughout 2020 to assist with COVID testing, outreach, and contact tracing.

 

Strategy 5: Policy and Public Health Coordination

 

The purpose of this strategy is to track FHSD’s infrastructure development efforts to improve developmental screening rates of children.

 

ESM 6.2 – Develop and implement Policy and Public Health Coordination rating scale to monitor developmental screening efforts around the areas of systems development, family engagement, data collection/integration, and addressing vulnerable populations.

 

	2018	2019	2020	2021	2022	2023	2024	2025
Annual Objective		12.0	18.0	24.0	27.0	30.0	30.0	30.0
Annual Indicator		23.0	26.0

 

ESM 6.2 Policy and Public Health Coordination Scale

Hawaii developed a Policy and Public Health Coordination Scale (PPHC) to monitor progress on Title V efforts to improve developmental screening rates of children. The scale (below) reflects the activities in the NPM 6 logic model and workplan, including Systems Development, Family Engagement and Messaging, Data Collection/Integration, Addressing Social Determinants, and Policy and Public Health Coordination. Completion of the scale is self-reported by the EC Coordinator who oversees all the activities.

 

The total possible points for the scale are 30. The FY 2020 indicator was 26 and met the annual objective set at 12. Despite the pandemic, progress was made in systems development, family engagement, and addressing vulnerable populations. The rating scale is used by the EC Coordinator to track progress on the NPM 6 strategies even prior to its formal adoption as an ESM last year. Scores show an improvement from last year’s score of 23 with room for improvement in the family engagement and social determinants of health identification and work with stakeholders.

 

Element	0 Not Met	1 Partially Met	2 Mostly Met	3 Completely Met
Systems Development
Develop guidelines and toolkit for screening, referral, and services.				x
Work with partners to develop infrastructure for ongoing training, technical assistance, and support for providers conducting developmental screening activities.			x
Family Engagement and Public Awareness
Work with families and parent organizations to develop family-friendly material explaining importance of developmental screening and how to access services.			x
Develop website to house materials, information, and resources on developmental screening.				x
Data Collection and Integration
Develop data system for internal tracking and monitoring of screening, referral, and services data.				x
Develop process for on-going communication to review data findings and adjust for better outcomes for children and families.				x
Social Determinants of Health and Vulnerable Populations
Develop process for identifying vulnerable populations.			x
Work with stakeholders to address supports and targeted interventions for vulnerable populations.			x
Policy and Public Health Coordination
Develop Policy and Public Health Coordination Rating Scale.				x
Conduct process for annual assessment of rating scale.				x
Total Score	26 out of 30

 

The Title V agency work to strengthen its ESMs by shifting from process to outcome impacts/measurements was postponed due to the pandemic.

 

Current Year Highlights for FY 2021 through June 2021

This section provides highlights of current developmental screening activities for FY 2021.

 

Hawaii continued to work with the ECCS Impact grant and other partners through virtual meetings. Access to online developmental screening through Hi‛ilei has become a vital option for parents who are not physically taking their child to see their pediatrician for well-child visits or for families who have concerns about their child’s development.  However, more promotion is needed for this under-utilized, free family service.

 

With telemedicine services becoming the new normal, there is a concern that parents are opting-out of in-person doctor’s visits where young children normally receive immunizations and developmental screening. For children younger than 2, immunizations are critical, as well as the 18- or 24-month screens reaffirmed nationally by AAP and CDC guidance. Title V will be addressing this concern for FFY 2022 in a new state priority to promote child wellness visits.

 

Plans for FY 2020 began well with the new ECCS Impact Coordinator fully prepared to expand grant activities, having been in the position for a year. Connecting Maui pediatricians to the CDC Act Early Ambassador started in FY 2019, with more activities to follow through 2020. However, the pandemic concerns and switching the in-person training to online resulted in reduced provider/client attendance. Providers showed interest in the new developmental screening tool, the Survey of Wellbeing of Young Children (SWYC), but were concerned that referrals for family well-being needs were not clearly identified. Most Maui early childhood providers continue to use the ASQ-3. Training is available for providers to learn more about this tool.

 

In FY 2020, Title V began discussions with the AAP–Hawaii Chapter and Hawaii’s Medicaid agency to promote use of the SWYC since it was added to the national AAP list of validated screening tools. Because the SWYC is a free tool and also covers behavioral and family well-being (including social determinants of health), referrals may be broader than IDEA Part C (EI services) and Department of Education developmental services. Hawaii will continue to work with partners on adoption of this new tool that can also help screen and identify social-economic needs of children and their families.

 

To support physician concerns about an accessible referral site for information for families, planning is underway to create a centralized resource directory of state services. Title V is part of a workgroup led by Hawaii’s First Lady to create the directory that is building on an existing Executive Office on Aging project, ‘No Wrong Door’ that is creating a coordinated intake and referral system to access a large array of state services.

 

Hawaii applied for and received a technical assistance grant from the Centers for Disease Control and Prevention (CDC) on COVID-19 Act Early in September 2020 work. As part of the one-year grant, a needs assessment was conducted on system partners who participate in the developmental and autism screening process, including those who promote child development, conduct developmental screenings with families, refer families for concerns, and provide services and supports for families with children identified with a developmental delay. Strategies to address barriers to care and strategies to improve resiliency among children and families are being developed/implemented.

 

Hawaii applied for and received the new iteration of the ECCS Health Integration Prenatal-to-Three Program (HIPP), which will not focus on developmental screening but will instead address the infrastructure needed for a coordinated maternal and infant childhood system of care that may help strengthen screening infrastructure and supports.

 

Review of Action Plan

A logic model for Title V NPM 6 was modified based on the ECCS Impact Grant to include Title V measures (NPM, ESM, NOM). Strategies were developed with consideration of community, statewide, and national efforts. Strategies included input from partners and additional feedback from families and providers solicited at conferences and community events. The major strategies for the work plan revolve around the areas of Systems Development, Family Engagement and Public Awareness, Data Collection and Integration, Social Determinants of Health, and Policy and Public Health Coordination.

 

 

By working on these five strategies, Hawaii plans to meet its NPM of increasing the number of children receiving a developmental screening using a parent-completed screening tool by addressing systemic challenges. This includes working with families to promote understanding of the importance of completing the screening tool, using data to address areas of concern, and working on policy and public health coordination. By addressing all areas of the logic model and rating scale, there will be consistent information and guidance to providers. Hawaii will also address social determinants of health to focus efforts on communities of greatest need. Hawaii continues to use this logic model to guide its work on strategies and activities.

 

Challenges Encountered

A recent needs assessment conducted by the Hawaii Act Early COVID-19 team found many challenges to expanding developmental screening – some of which are COVID-19 related and ongoing infrastructure development. Challenges remain in the areas of policy, data, and messaging.

 

Timeliness of Referrals: Hawaii’s Title V Developmental Screening partners have always been concerned about the timeliness of referrals and getting supports to children who have been screened. While screening itself is important, it is critical that children identified with a concern are evaluated in a timely manner in order to ensure their access to needed services. To ensure timely intervention, providers conducting screenings are required to refer children in the “referral range” to EIS within seven days after identified, per the federal IDEA statute. However, programs and providers maintain their own guidelines and protocols for referrals. The seven-day referral standard needs to be more widely promoted and adopted to assure timely referrals.

 

Coordination with Medical Home: Coordination with referring agencies may become strained, since EIS is not allowed to share follow-up protected information/results unless a parent signs a consent form allowing EIS to share information with the referral source. Since the consent is not always easily attained in a timely manner, referring providers can get frustrated and stop referring clients to EIS for services.

 

Educational Services: For children over 3 years of age, parents of children with developmental issues are often challenged to access school services because the evaluation must clearly show a direct impact on a child’s learning or education. However, screening results may not always be considered as part of the evaluation by the school system. It became the responsibility of parents to demonstrate how a developmental concern adversely impact a child’s education and learning. This can be a frustrating process for families.

 

Data: There is still no unified/population-based data collection system on developmental screenings to monitor children who are screened, referred, and receiving service in the state. Other states have similar challenges because no one data system collects developmental screening and referral efforts. Because of this, efforts to target communities and populations of greatest need are hampered. Medicaid may be the best option if MQD can begin to report on the CMS core children’s healthcare quality measures on Developmental Screening. Approximately 40% of Hawaii’s children are insured through Medicaid and enrollments significantly increased in 2020. Generating screening data for this population would be invaluable to develop effective strategies.

 

Currently, EPSDT data use is limited because the data tracks healthcare visits and not actual screenings. Hawaii hopes to address this issue via Medicaid and other health insurers as part of the new ECCS grant.  More accurate data would help allow the state to pinpoint promotion and education efforts. 

 

Public Awareness and Messaging: Prior to COVID, parents/providers identified many barriers for parents to complete a development screening of their children, including lack of time, lack of understanding of the importance of parental engagement, and fears of stigmatizing children. COVID created additional challenges to accessing preventive care/screenings, given the drastic shift of family priorities to more immediate survival concerns. Service providers shared insight on other barriers faced by families during COVID:

• Parents having competing priorities (food, rent, work)
• Parents are stretched to the limit with school/working from home
• Parents do not have tools to assist with monitoring, lack of supports if there are concerns
• Parents lack of confidence in their parenting skills and in serving as observers
• Lack of understanding about child development and developmental milestones and lack of awareness of children’s different rates of learning
• Closures of programs (preschools, schools, peer education, etc.)
• Lack of bandwidth in rural and insular areas of the state
• Disconnect between providers and families on the use of telehealth

 

Efforts through the CDC Act Early grant and the new ECCS grant will assist with addressing these problems raised by the needs assessment; however, work may be delayed based on the course of the COVID virus.

 

Overall Impact

Over the past five years, Hawaii was successful in convening statewide stakeholders to develop and complete standard guidelines for development screening, which can be used for all programs and services working with young children. The guidelines are available through several public and early childhood websites. Training on the guidelines have been widely conducted, and trainers on the guidelines are embedded in early childhood agencies in all the counties as resources for their community partners.

 

The Early Childhood State Plan and other early childhood coalitions identified developmental screening as a key priority over the past five years. By working together to address this issue, providers and partners are now more aware of the importance of developmental screening using a validated screening tool, ensuring needed referrals are timely and communication with the medical home. The work to promote a more seamless system of screening and referral will be continued and expanded.

 

Although population-based data remains an issue, Title V was able to coordinate routine data sharing around development screening for four of its early childhood service programs to assure development screening was occurring and needed referrals were made for follow-up when needed. Although, the creation of an integrated data system proved too costly and challenging to develop, the four programs meet regularly to share developmental screening data for quality assurance purposes and now readily collaborate to address any issue/barriers that emerge. Thus, ESM 6.1 was retired since it was completed.

 

Title V has also made great progress working directly with pediatric providers in the AAP-Hawaii Chapter, by collaborating with Hawaii’s CDC Act Early Ambassador, Dr. Jeff Okamoto. Title V has also strengthened its collaboration with the Med-QUEST Division over the past year and looks forward to addressing policy and data issues and promoting the new SWYC screening tool to address the social determinants of health.

 

While service system providers are more aware of the development screening, continued effort is needed to reduce the stigma that may prevent families from seeking follow-up services for their child. Normalizing the conversation and making screenings part of a well-child visit or a routine early childhood practice helps to ensure screenings and follow-up occur. Partnerships with the AAP-Hawaii Chapter and Medicaid will help to share consistent information about screenings and referrals availability of online screenings through the Hi`ilei program.

 

Hawaii will continue to explore and advocate for improved national and state data on developmental screening. The NSCH reports less than one in three children in Hawaii received a developmental screen, which is comparable to the national estimate. Committed efforts by programs like MIECHV and other early childhood programs to conduct developmental screenings contribute to statewide efforts. However, the vast majority of children are not receiving developmental screenings. Thus, improved outreach is needed to promote its importance. Working with early childhood providers, efforts will continue to promote developmental screening and sharing of information with the child’s medical home.

 

 

 

SPM 1 - Rate of confirmed child abuse and neglect cases per 1,000 children aged 0 to 5 years.

 

Introduction: Child Abuse and Neglect (CAN) in Hawaii

The 2015 needs assessment confirmed that Child Abuse and Neglect (CAN) prevention should continue as a priority under the Child Domain. Child maltreatment stands as a foremost concern for the state. Community needs span the spectrum from primary prevention services to support families as well as improvements to the Child Welfare Service system to prevent children from entering foster care.

 

Data: The latest data for confirmed child abuse cases are from 2019 as reported by the state Child Welfare Services program. The rate increased slightly between 2019-2020, from 5.5 to 5.7 per 1,000 children aged 0-5 years, thus the state objective was not met. There was a slight increase in the number of cases for ages 0-5 years (from 584 to 591). Among all age groups, infants experience more abuse at nearly 16%. Overall, children five and under accounted for 44% of all confirmed cases.

 

Among confirmed cases for all age groups, one death occurred due to abuse in 2019 and three children experienced permanent disabilities.  Another 30 children experienced serious injuries. While most cases were reported as requiring no treatment or injuries, research studies have found residual emotional trauma due to abuse and neglect is a possibility.

 

In 2019, the highest reported factors contributing to the abuse or neglect of children of all ages were inappropriate child-rearing methods (64%), inability to cope with parenting responsibility (58.7%), drug abuse (41.5%), and parental mental health problems and spousal fighting/physical abuse (13.8 and 12.9%) respectively. Hawaiian/Part Hawaiian children were over-represented among confirmed CAN cases for all age groups (40%). Caucasian children are second, at 20%. The reasons for these disparities are unclear, but for the Hawaiian/Part Hawaiian children, are likely related to colonization and the overthrow of the Hawaiian government by the U.S., historical trauma and resulting socio-economic inequities suffered since western contact.

 

Continuing priority: The 2020 needs assessment confirmed that CAN prevention remained a state priority. Input from stakeholders was considered to revise the CAN strategies for 2020-2025. The objective is set at a 5% improvement over the next 5 years.

 

Title V Lead/Funding: The Title V Child Abuse and Neglect Prevention Program (CANP-P) is administratively located in the Maternal and Child Health Branch (MCHB) Family Support and Violence Prevention Section (FSVPS). The Section is made up of the sexual violence, domestic violence prevention, parenting support programs, as well as the Maternal Infant and Early Childhood Home Visiting (MIECHV) program. The CANP-P is funded by the Administration for Children and Families (ACF), Community-Based Child Abuse Prevention (CBCAP) formula grant. While Title V does not directly fund CAN prevention activities, it does fund key staff positions related to the program, including the FSVPS Section supervisor and other MCH Branch support staff such as the Branch research statistician.

 

Strategies: Child abuse and neglect are complex problems rooted in health inequities, unhealthy relationships and environments. Preventing CAN requires addressing factors at the individual, relational, community, and societal levels. Hawaii’s 2016-2020 CAN prevention strategies reflect a broader public health systems approach:

• Collaborate on and integrate child wellness and family strengthening activities across programs.
• Raise public awareness about the importance of safe and nurturing relationships to prevent child abuse and neglect.
• Provide workforce training and technical assistance for service providers to promote safe, healthy, and respectful relationships to prevent child abuse and neglect.
• Collaborate with the Hawaii Department of Human Services Primary Prevention Initiatives.

 

Evidence: While CAN Prevention is not a Title V NPM, research presented by the MCH Evidence Center from the Child Safety Network supports Hawaii’s cross-cutting strategies that leverage partnerships to support evidence-based/informed programs and practices.

 

The CANP-P focus is primary prevention. Grant funds are used to support community-based efforts to develop, operate, expand, enhance, and coordinate initiatives, programs, and activities to prevent child abuse and neglect and to support the coordination of resources and activities to better strengthen and support families to reduce the likelihood of child abuse and neglect. Also important is efforts to foster understanding, appreciation, and knowledge of diverse populations in order to effectively prevent and treat child abuse and neglect.

 

COVID Impacts: Hawaii’s COVID-19 stay-at-home orders instituted in March 2020 alarmed many social service agencies concerned about the increased potential for family violence, including CAN. Limited real-time data is available at this time to confirm this concern. The widespread closure of businesses, public amenities, and shelter-at-home orders along with COVID fears; created unprecedented social isolation and stress for families. Furloughs and layoffs imposed a serious economic strain on families. The closure of schools and daycare services added to the burden on families with young children, particularly for mothers.

 

Services like the Domestic Violence Action Center reported dramatic increases in calls for information and assistance during the pandemic, while Child Welfare Services staff reported a marked decrease in suspected CAN reports.

 

Strategy 1: Collaborate on and integrate child wellness and family strengthening activities among programs.

 

The complexity of risk factors relevant to prevent and reduce CAN requires collaboration with diverse private and public organizations, including those that directly engage in CAN work, as well as agencies addressing broader community concerns (e.g., housing, employment, safe neighborhoods, substance use, etc.). Key collaborations are described below.

 

CANP-P collaboration continued with the Department of Education five-year Trauma Recovery Project, developed to ensure that low-income students who experienced trauma received trauma-specific mental health services from providers that best meet their needs, and to move the CAN system to use Trauma-Informed Care/Responsive standard of care. The Project is an important collaboration for DOH, the DHS and community organizations. The CANP-P Coordinator serves as a member of a Core Implementation team for the project.

 

Family Strengthening and Violence Prevention Section (FSVPS) programs supported prevention activities and trainings, sharing resources and data, and coordinating training and technical assistance (TA) opportunities. These efforts serve to create a foundation for healthy relationships between parents and with children, including the Sexual Violence and Domestic Violence Prevention programs.

 

Federal MIECHV funds supported the Hawaii Home Visiting Program (HHVP), providing voluntary, evidence-based home visiting services to at-risk pregnant women and parents with young children. In fiscal year 2019-20, the HHVP provided direct preventive services to 565 adults and 561 children. The HHVP also partners with Title V early childhood and perinatal programs to promote family/child wellness.

 

The MCHB Parenting Support Program (PSP) administers family strengthening contracts for parenting and child development services statewide. Services include The Parent Line (http://www.theparentline.org/), a telephone warm-line for parents, information dissemination on child development and community resources; short-term in-home parenting support, and parent-child interactive education groups for homeless families. CANP resources and services are available through these contracts. The PSP also supports the Safe Sleep Hawaii coalition.

 

The CANP-P Coordinator participates in the Early Childhood Action Strategy (ECAS) Initiative, a statewide public-private collaborative focusing on children from prenatal to age eight to strengthen and integrate the early childhood system services. The team is involved in the implementation of the Nurture Daily project, which supports the dissemination of informational tools and products to enhance the quality of interactions within families.

 

The Hawaii Children's Trust Fund (HCTF), a public-private partnership between the Department of Health and the Hawaii Community Foundation (HCF). Its structure includes a statewide Coalition, an Advisory Board (AB), and an Advisory Committee (AC). The mission of HCTF is to ensure that Hawaii's children develop into healthy, productive, and caring individuals by promoting the advancement of community family strengthening programs to prevent child abuse and neglect.

 

Representatives from the Department of Education, the Judiciary, the Department of Human Service's Office of Youth Services, and the DOH serve on the AC, with the DOH serving as the lead public agency. The CANP-P Coordinator supports the AC Chair for various administrative functions. The HCTF is a grantmaking vehicle under the HCF.

 

Efforts to develop Hawaii’s first CAN Prevention Plan continued under the direction of a Steering Committee which is comprised of a subgroup of members of the HCTF Advisory Committee and several community-based agencies. The Centers for Disease Control and Prevention's “Essentials for Childhood” was adopted as the framework for the plan. Work on the plan was delayed due to COVID-19 and meetings shifted from in-person to virtual. The impact of COVID-19 raised new needs and challenges as well as opportunities for expanded collaborative efforts.

 

Strategy 2: Raise public awareness about the importance of safe and nurturing relationships to prevent child abuse and neglect.

 

As a result of the COVID pandemic, efforts to support families and communities shifted from in-person to largely commercial media and virtual formats. Health and social service agencies responded with messaging campaigns on social media, TV, and radio, creating new remote resources for family support, and providing information on family violence, mental health resources, and essential services/resources to address immediate family needs.

 

One example was Maui County’s virtual CAN prevention event hosted by the Ho‘oikaika Partnership, CoMMIT for Keiki, and Islands of Hope-Maui (IOH). The Maui mayor’s office encouraged residents and county staff to wear blue that day to promote CAN prevention and to participate in the event through virtual fun family activities. John Cruz, a Hawaii Grammy-winning performer, recorded a video of his song ‘Island Style’ to use as the theme for the day. Families were encouraged to post videos or pictures of their families wearing blue and dancing to the song. The Maui Family Support Services created a YouTube video to help support families through the pandemic.

 

Partnering with Aloha United Way, the Ho`oikaika Partnership created multi-lingual flyers and social media graphics about the free 2-1-1 resource hotline to help families access a comprehensive listing of support services. Flyers were printed and distributed statewide through the DOE grab-n-go meal program that reached 68 schools. The goal of the project was to ensure that non-English speaking families across Hawaiʻi were aware of the hotline that provided information in over 150 languages.

 

MCHB developed several public service announcements (PSA) focusing on safe and nurturing families, healthy relationships, and promoting the state Parent Line resources. The PSAs were broadcast statewide on major local media outlets. MCHB also secured three time slots on a local television station with tips on staying connected, keeping children busy and happy at home, and managing stress.

 

CBCAP funds originally designed for in-person events were shifted to support programs directly addressing risk factors for CAN such as poverty, stress, mental health issues, and social isolation due to COVID. Examples of a few of these initiatives were:

• On Oahu, a food distribution program provided meals to 250 new and pregnant moms each week, with culturally appropriate education materials for pregnant women, mothers, and their families that were created and distributed.
• Hawaii County's efforts included expanding professional mental health services to para-professional family strengthening and CAN prevention services.
• A community provider on Molokai adapted an in-person sexual violence prevention curriculum for elementary and middle schools to an online format.
• Kauai partners implemented a variety of small projects related to CAN prevention including: a Marshallese translation of family strengthening information and other resources; a list of on-island community resources, information on child abuse reporting, and COVID-19 testing sites (information was made available in English and other languages). They also started a new parenting group.

 

During the pandemic, ECAS conducted a soft launch of three PSAs to promote healthy family engagement with the theme: Nurture Daily. The PSAs broadcast on TV, radio, and social media with themes: Take Time to Share a Story, Take Time to Share a Compliment, Take Time to Teach Life Skills, and Share Time Helping Each Other. This effort occurred in conjunction with the dissemination of Safe and Nurturing Families Educational Resource Guides, informational tools, and products utilizing Nurture Daily messages and promoting Trauma-Informed-Care (TIC) trainings to support more quality family interactions.

 

Strategy 3: Provide workforce training and technical assistance for service providers to promote safe, healthy, and respectful relationships to prevent child abuse and neglect.

 

Despite COVID, the CANP program continued to conduct virtual statewide trainings on:

• TIC strategies for early childcare providers,
• the impacts of Adverse Childhood Experiences, the effect of toxic stress on infant brain development,
• the Strengthening Families Protective Factors Framework, an Approach to Resilience Building,
• Standards of Quality for Family Strengthening and Support, and
• Be Strong Families curriculum based on the Parent Café model.

 

The FSVPS program staff and the Early Childhood Coordinator under the Children with Special Health Needs Branch put together a cohort of community-based service providers who received training to expand their skill sets on ACEs and resilience in their daily work with families. In-depth training was provided by Dr. Sara Watamura, from the University of Denver. Cohort members were tasked to use their skills within their own organizations and with their larger community. The training was paused due to COVID demands on service agencies and may be resumed later.

 

The HHVP offered ongoing training and TA to their contractors in promoting child development, encouraging positive parenting, and working with caregiver participants to set attainable goals for the future to prevent CAN.

 

Strategy 4: Collaborate with the Hawaii Department of Human Family First Prevention Service Act (FFPS)  

 

CANP-Program collaboration with the Hawaii Department of Human Services focused on supporting planning efforts for the Family First Prevention Services Act (FFPSA) and implementing the new 2020-2024 Child and Family Services Plan (CFSP). Under the FFPSA it was critical to determine which programs and services used in the state were rated as well-supported, supported, promising, or does not meet evidence-based criteria according to the Title IV-E Prevention Services Clearinghouse. The CANP-Program participated in an environmental scan of services. As a result of the scan, a matrix of services was created showing a range of parameters such as geography, interventions used, funding source, and the cultural responsiveness of the organization.

 

The CANP-P Coordinator continued to serve on the Hawaii State Team to support the implementation of select 2020-2024 Child and Family Service Plan (CFSP) strategies.  The Team focused on three areas: (1) supporting the Hawaii Zero To Three Court initiative and the families and children served by this program (2) expanding the Department of Human Services (DHS), Child Welfare Ohana Time system of care and services, and (3) reviewing connections to resources for families including identifying any gaps in services.

 

Highlights for FY 2021 through June 2021

COVID-driven workplace closures continued to temporarily halt/disrupt CANP activities. The CANP-P Coordinator worked with the contractors to modify contracts to move from in-person to virtual services and events to meet COVID safety guidelines. Contractors were largely successful in shifting to virtual trainings and events to meet the needs of their communities, despite COVID restrictions.

 

Both the Parenting Support Program and the Hawaii Home Visiting Program also worked with their contractors to move from in-person services and activities to virtual home visits with parents and community activities.

 

Ongoing impacts due to the pandemic generated an urgent need to develop new approaches to expand services and resources for families, service providers, state and county offices, and the general public. Most outreach/services pivoted to virtual formats and use of social media platforms.  However, this shift highlighted existing inequities in community broadband access and digital devices. Many service providers and clients did not have ready access to internet service, computers, hot-spots, and/or flash-drives. With greater federal flexibility, the CANP-Program expanded funding criteria allowing for the procurement of IT equipment to ensure uninterrupted virtual connection between clients and providers as well as offering school supplies for children, sanitary and cleaning supplies for families, and other emergency supports.

 

COVID also amplified interest in and application of Trauma-Informed Care (TIC). The CANP-Program convened private and public program leaders to share TIC practices and policies promoted in their organizations, emerging needs, and next steps for collaboration. The group identified several needs including: standardized TIC language and practices; the ongoing workforce development/training on TIC models and practices; and addressing trauma-informed systems of care.

 

A draft of the Hawaii Statewide CAN Prevention plan was released to the HCTF Steering Committee for review and comment. The Steering Committee agreed the document would serve as a conceptual framework based on five key pillars – Commitment, Supports and Services, Communities, Policy and Coordination - to build a successful public health approach to CAN prevention.

 

Hawaii CBCAP received a five-year, $1M award under the American Rescue Plan Act (ARPA). Use of both ARPA and CBCAP formula funds follow a prevention approach to expand and enhance community-based, prevention-focused programs and activities and specific family resources that focus on healthy and positive development of parents and children. Hawaii’s funds will be used to plan and develop an integrated prevention continuum of services, policies and practices across state and county government offices and programs to support and facilitate families to provide safe, stable, nurturing relationships and environments for their children.

 

The State Departments of Health, Education, Human Services, and Judiciary currently collaborate on several important CAN prevention initiatives that are a combination of primary, secondary, and tertiary prevention efforts. The collective impact of the existing collaborations will be enhanced by developing a common understanding of the CAN prevention service system continuum. The vision is to expand the current collaboration to include the Hawaii State Departments of the Attorney General, Public Safety and Executive Office of Early Learning under the Governor’s Office, as well as integrating county-level CANP resources.

 

Funds may also be used to support the expansion of school-based Family Resource Centers in the state.

 

The CANP Program serves on the Ohana Family Support Network core team that is planning near- and long-term initiatives and provided funding of Standards Certification training for education and community partners.

 

Review of Action Plan

The revised CANP logic model describes the 2020 strategic approach. Preventing CAN cannot be addressed as a stand-alone public health concern. The logic model confirms the importance of acknowledging and addressing contextual conditions that impact and influence CAN negatively or positively, in tandem with programs that specifically target violence prevention. The logic model also captures the broad array of public partners/resources to address CAN in Hawaii.

 

 

Challenges and Barriers

COVID challenges: A 2021 survey commissioned by the DOH found that COVID-19 is affecting the mental health of a majority of Hawaii residents. Of 445 Hawaii adult residents surveyed, 82% said that they have experienced a mental health condition at some point over the last six months, and about 50% of those say their symptoms began during the pandemic. Consistent with these findings, Hawaii CARES (formerly the Crisis Line of Hawaii) received its highest annual volume of calls in 2020 compared to the prior seven years of operation, receiving more than 16,000 calls in September 2020. The increased stressors on households and social isolation of children and families continues to raise concerns regarding the potential of unreported family violence.
 

Title V FSPVS contracted service programs have rapidly shifted from largely in-person services and community events to virtual outreach and visits. However, some service providers did not have sufficient IT equipment. Clients also often lacked access to broadband, digital devices, and skills to use the software programs. Rural communities were impacted by the lack of reliable broadband service. Innovative outreach to the professionals and the public required shifting to virtual platforms to learn new methods of engagement. Using federal relief funds state programs responded by issuing laptops, hotspots, as well as training on using the equipment. CBCAP funds were used to support at-risk Micronesian communities to procure supplies and subscriptions to assist children to participate in distance learning as well as attend telehealth appointments.

 

CANP training and activity contracts were written requiring expertise in providing and facilitating virtual platforms as well as creating new mechanisms or vehicles to engage community members and new partnerships.

 

Moving to virtual events and trainings produced positive outcomes in terms of cost-savings and capacity. With dollars traditionally spent on logistics, food, travel and other in-person costs eliminated funds were used to expand services and resources. The use of virtual platforms supported a significant increase in the number of people who could participate in trainings, webinars, and other events as policies restricting travel were no longer relevant. As the competencies of those bringing the training and those attended grew, the full array of virtual platforms, i.e., breakout rooms and software, i.e., Padlet almost duplicated the in-person experience.

 

Overall Impact

Key overall CANP impacts over the past five years include:

• Building and expanding the inclusion of prevention strategies in DHS 2020-2024 Child and Family Services Plan and FFPSA initiatives.
• Coalition building and partnerships with state and community-based programs and organizations.
• Creation of a CANP Plan in partnership with private and public partners.
• Workforce development trainings and conferences on ACEs, resilience, trauma-informed care, toxic stress, and Standards of Certification.
• New collaboration with the Hawaii Department of Education on a 5-year Trauma grant and piloting of school-based Family Resource Centers.
• Reconvening of the Hawaii Children’s Trust Fund Coalition.
• Adoption of the trauma-informed model by private and public organizations.
• Ongoing funding of community-based programs addressing CANP awareness and strategy building and strengthening families.
• Launch of Nurture Daily, an internet resource for families and providers.

 

 

SPM 5 - The percentage of Medicaid children receiving six or more well-child visits in the first 15 months of life

 

Introduction: Well Child Visits and Immunizations

For the Child Health domain, Hawaii added this new state priority to promote child wellness visits and routine immunizations especially for young children. The priority is a result of ongoing needs assessment and concerns raised during the COVID-19 pandemic that many well-child visits and immunizations were postponed or delayed due to lockdowns and safety concerns.

 

Importance of Well Child Visits: These visits are an important venue for counseling, as well as vaccine administration and documentation. At well-child visits, providers can also screen for developmental delays and parents can raise concerns about a child’s physical problems, behavior, and mental health and receive personalized guidance on healthy nutrition, exercise, and safety. In-person visits help with capturing biometric data such as the height/weight/head circumference, hearing and vision screening, blood tests (lead and cholesterol), immunizations, blood pressure and other vitals, oral exam, autism screening, and tuberculosis screening. Healthcare providers can provide anticipatory guidance and help support parents or caregivers with any questions or concerns about their child’s development.

 

National concerns: Nationally, the Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services released data early in the pandemic documenting dramatic decreased rates of child immunizations and well-child visits. Data from the U.S. Census Pulse survey also confirmed overall trends in postponed medical care during the pandemic. The concern was amplified by the American Academy of Pediatrics, which launched a national ‘Call Your Doctor’ campaign in May 2020. The federal MCH Bureau also launched a similar social media campaign, WellChild Wednesdays, in 2020; and in 2021, funded a national challenge for innovative projects to increase child wellness visits.

 

Hawaii: Preliminary Medicaid data showed a decrease in child wellness visits in 2020 (although the data likely also reflected a 9-12-month reporting lag by the health plans). DOH Hawaii’s Immunization Branch also reported a sharp decline in vaccination requests by providers once the pandemic began in 2020.

 

Title V programs: In 2020, most Title V direct service programs saw overall reductions in service provision due to the pandemic as in-person visits were halted and all services pivoted to virtual or phone visits. The pandemic also shifted family priorities to addressing essential daily needs. However, the Title V programs did notice similar trends in reduced child wellness visits and vaccinations for those served. Early Intervention Section (EIS), Hawaii’s IDEA Part C Agency, also saw a decline in referrals from pediatricians, traditionally the largest referral source. The Hawaii Home Visiting Program convened a meeting to share data, information, and develop a response.

 

Partners: The Title V leads for this project include the Home Visiting Program, the Early Childhood Systems Coordinator, and FHSD Public Information Officer. Other programs include EI, Lead Screening, WIC, and CSHN. The key external partners are the AAP-Hawaii Chapter, State Medicaid program, and Hawaii Children’s Action Network (HCAN).

 

Title V Lead/Funding: State general funds were used to cover the major costs for the media and community outreach campaign.

 

Evidence: Although there is no specific MCH Evidence on well-child visits, the evidence for Adolescent Well-Visit strategies and Medical Home were reviewed. Patient reminders are identified as Emerging Evidence as a way to increase well-child visits.  Another tangential topic of the medical home shows collaborating with home visiting as an emerging evidence. Since Hawaii will be using the data from home visiting and the home visiting families to develop and test the messages, this may be a useful strategy. An MCH Evidence Center brief on public health messaging was also reviewed that showed some evidence for this strategy, especially when reinforcing a mass media campaign with social media and community coordination.

 

Objective: By July 2025, increase the percentage of Medicaid children receiving six or more well-child visits in the first 15 months of life.

 

Messaging/Outreach Strategy: This new project will work with pediatric providers, community advocates, and the Title V/FHSD programs to promote well-child visits and immunizations. Hawaii plans to conduct a public awareness campaign starting in September 2021 through December 2021.

 

Strategies include:

• Collaborate with pediatric providers and community advocates to promote messaging on importance of well-child visits.
• Conduct public awareness campaign and measure effectiveness of messaging (increase number of visits to the doctor, increase number of vaccinations for the home visiting population).
• Build capacity for developing pediatric champions to promote messaging campaign.

 

Report on Current Activities through June 2021

Hawaii convened a Child Wellness Visit workgroup (CWV) to develop the public awareness campaign starting in September 2021 through December 2021. As part of promoting the importance of the well-child visit and immunizations, a critical partnership is with the pediatric providers as they will be impacted by efforts to promote in-person visits and immunizations. By working with AAP-Hawaii Chapter leadership, this will be an opportunity to make sure that the pediatricians are aware that this campaign will be launched and what is expected and anticipated. AAP leadership gladly joined the workgroup, which has been meeting regularly through 2021. The Medicaid Medical Officer, who is also a pediatrician, has joined the workgroup along with the Clinical/Community Services Nurse. Both are helping to secure data and coordinate with the state’s health plans.

 

Once funding was secured, contracts were executed with AAP-Hawaii, media vendors, and HCAN to coordinate the community campaign. The workgroup is meeting to:

• Develop messaging
• Collect parent input to identify the barriers to care
• Test messaging with families in home visiting, Parent Leadership Training Institute (PLTI), and other Title V service programs
• Identify referral for families to secure insurance or find a provider if needed

 

 

 

NPM 13.2 – Percent of children, ages 1 through 17, who had a preventive dental visit in the past year

 

Introduction: Child Oral Health

For the Child Health domain, Hawaii selected NPM 13.2 (children’s oral health) based on the 2015 five-year needs assessment. By July 2020, the state sought to increase the percent of children, ages 1 through 17, who had a preventive dental visit in the past year to 86.0%.

 

Data: Aggregated data from 2018-2019 show that the estimate for Hawaii (85.5%) nearly met the 2020 state objective, and was significantly higher than the national estimate of 79.6% for preventive dental visit among children. Children 1 through 5 years of age had a lower estimate (72.4%) compared to children 6 through 11 years of age (90.4%), and 12 through 17 years of age (92.7%). There were no other significant differences in reported subgroups by household income, poverty level, language spoken at home, nativity, race/ethnicity, sex, and household structure based on the 2018-2019 data provided.

 

The related Healthy People 2020 for this measure is: increase the proportion of children, adolescents, and adults who used the oral healthcare system in the past year to 49%. Hawaii far exceeds this target for children.

 

Objectives: This performance measure will be dropped in FY 2020, so no objectives have been set beyond 2020.

 

Although data from national surveys indicate Hawaii’s rates of oral health status and service utilization are similar or better than the rest of the U.S., clinical data reveal a very different story. A 2015 oral health Basic Screening Survey (BSS) revealed Hawaii’s third graders have the highest rate of caries in the U.S. and some of the highest rates of urgent care needs. Within this group, key disparities exist. Children who are low-income, have Medicaid coverage, and/or are Native Hawaiian or Pacific Islander suffered disproportionately throughout the state. A BSS of children enrolled in the Hawaii Head Start program reveals similar findings for young children from low income families.

 

A major contributor to the problem of dental disease is the lack of community water fluoridation. In the U.S., Hawaii has one of the lowest proportions of residents with access to fluoridated drinking water at 8.75% according to the Centers for Disease Control and Prevention (CDC). In Hawaii, only federal military installations have fluoridated water sources. Fluoridation efforts continue to generate broad community opposition, including all four county water agencies that contend fluoridation will create undue operational costs and management burden.

 

Title V Lead/Funding: While not funded, the Hawaii State Department of Health (DOH) does have statutory responsibility for assessing dental needs and resources, planning and providing services, conducting education and training, and applying for federal funding for oral health infrastructure/services.

 

Family Health Services Division (FHSD), the Title V agency, is the DOH lead for oral health population-based activities. Currently, there is no dedicated staffing or funding to operate the state oral health program (SOHP). In 2018, FHSD’s five-year CDC oral health infrastructure-building grant ended. Dental staffing was lost and activities curtailed. Hawaii submitted a new application for CDC funding, but the grant was not awarded due to insufficient funds.

 

Title V partners closely with the DOH Developmental Disabilities Division (DDD) dental staff, which operates five dental clinics on Oahu, serving primarily adults with disabilities and other special needs. DDD’s dental director, Dr. Andrew Tseu, provides critical leadership and technical assistance for FHSD’s program efforts. In 2020, he was appointed to the State Dental Licensing Board. Because he is also an attorney, Dr. Tseu has been instrumental in the department’s dental policy work.

 

With the loss of program staff and funding, strategies were revised to reflect Title V’s reduced resources and activities.

 

Strategy 1: Explore and pursue options to staff State Oral Health Program

 

The importance of dental program leadership and staffing is critical to sustain any program activity. With no local health departments or dental school, the State Oral Health Program (SOHP) is key in providing statewide leadership for public health surveillance, evaluation, and planning functions.

 

Prior to COVID restrictions, an FHSD budget request to support the SOHP staffing and operations was not included in the governor’s budget proposal.

 

In February 2020, Title V partnered with the State Oral Health Coalition (SOHC) to support the national Oral Health Progress & Equity Network’s Virtual Congressional Hill Day. The advocacy agenda included:

• Dental coverage for Medicaid adults and Medicare enrollees, and
• Increased CDC funding for the state infrastructure grant program.

 

Title V staff was able to join the Zoom meetings with Hawaii’s four congressional offices to provide information on the CDC grant achievements and state oral health data.

 

Strategy 2: Surveillance – Maintain oral health surveillance activities

 

Following the state oral health surveillance plan, DOH continues to collect oral health data through surveillance surveys including PRAMS, BRFSS, and YRBS. Limited oral health data is available on the DOH data warehouse website, http://www.hawaiihealthmatters.org/. Data activities were limited in 2020 with vacancies in FHSD’s two epidemiologists positions.

 

The Title V Office of Primary Care and Rural Health continued to monitor workforce shortages and establish federal designations for health professional shortage areas (HPSA) for dental services. In 2020, dental HPSAs existed on all islands and the entire islands of Hawaii, Maui, Molokai, Kauai, and Lanai are dental shortage areas (see HPSA maps in Supporting Documents).

 

Strategy 3: Partnership/Coalition-Building-Support ongoing partnerships and coalition-building activities

 

The CDC oral health grant helped to rebuild Hawaii’s state oral health coalition, providing funding to the Hawaii Public Health Institute (HPHI) and Hawaii Children’s Action Network (HCAN) to support the Hawaii Oral Health Coalition (HOHC). The coalition continued to grow and develop its identify and infrastructure: 

• Convened regular committee, leadership, and neighbor island task force meetings.
• Registered coalition members now numbering 376
• Updated the coalition website with community information and resources
• Finalized logo selection

 

HOHC routine activities were halted in March due to COVID-19. During this time, however, HOHC was able to pivot and worked on the following activities:

• Provide two webinar trainings with CE credits provided by the state Department of Health. Both webinars featured Dr. Paul Glassman: Teledentistry in the Era of COVID-19 and Beyond and A Deep-Dive into Implementing Teledentistry into the Dental Practice Confirmation. Both webinars were recorded and posted on YouTube.
• Shared initial safety/infection control guidelines for the pandemic emergency and, as of June, regular dental visits.
• Served as a hub for communication around PPE access for dental practices and encouraged purchasing partnerships among dental professionals
• Provided oral hygiene kits to vulnerable children through grab-and-go meal sites on Oahu.
• Continued advocacy for Medicaid coverage of adult dental benefits during the legislative session. Prior to COVID, the legislation was progressing toward passage.

 

A new ESM was created for FY 2020, focusing on the state coalition work. ESM 13.2.3 is the number of organizations and individuals participating in State Oral Health Coalition meetings and activities. Although the formal membership enrollment registration system was not established in FY 2019, there were 64 participants in the meetings that helped establish the HOHC organizational structure, a slight increase over the previous year’s meeting participants.

 

ESM 13.2.3 – The number of organizations and individuals participating in State Oral Health Coalition meetings and activities.

	2018	2019	2020	2021	2022	2023	2024	2025
Annual Objective		55	60	65	70	75	80	85
Indicator	48	64	64

 

Other partnership activities included the pilot teledentistry programs on Hawaii Island and Maui. The DOH dental director for the Developmental Disabilities Division is providing technical assistance for the project. The site at the West Hawaii Community Health Center is in its fifth year providing services to young children at Head Start, WIC, and a traveling preschool. The Native Hawaiian Health Center on Maui is the teledentistry provider on Maui serving children at Head Start and WIC as well as a senior assisted living facility. The project also included an oral health professional educational component in collaboration with the Maui Community College Dental Hygiene School. Both programs were halted due to COVID restrictions that closed Head Start, preschool, and senior living programs and ended in-person WIC visits.

 

Title V continued to contract with 16 community-based health service programs, including the Federally Qualified Health Centers (FQHC) to provide primary care and dental treatment services for the uninsured and under-insured. Many FQHCs, like private dental practices, largely closed their offices for several months during the initial shutdown following national guidance as well as a severe shortage of PPE. Eventually, dental practices slowly resumed services during the summer with increased infection control measures. Anecdotally, dental practices have reported incurring greater cost and reduced appointment availability due to additional sanitation measures. Several FQHC dental directors have also reported seeing more severe cases of dental disease as offices reopened.

 

Current Year Highlights for FY 2021 through April 2021

Activities in FY 2021 are briefly described below.

• HOHC continued its advocacy work despite COVID restrictions during the 2021 Legislative session. Many of the bills were not heard due to policymakers’ focus on COVID-related priorities. The coalition policy agenda included:
  • Adult preventive dental benefits for Medicaid enrollees
  • Expansion of dental assistants practice act to participate in teledentistry
  • Support for other public health related legislation for Sugar Sweetened Fee and Smokefree multi-unit dwellings

FHSD was able to shift state fund savings from direct service programs to support several oral health projects:

• Support for oral health messaging and promotion to encourage dental check-ups delayed due to COVID-19 shutdowns and safety concerns. Targeted messaging will be developed for high-risk populations.
• Provide general State Oral Health Coalition support
• Complete update of an environmental scan, including opportunities to advance medical-dental integration.
• Develop of an oral health data tracker in the state data warehouse.
• Purchase data for 2020 oral health related visits to hospital emergency departments statewide. Data analysis is pending due to limited staffing.
• Contract the University of Hawaii Office of Public Health Studies for data analysis and interpretation of state-added BRFSS oral health questions from the 2019 survey focusing on barriers to dental care.
• Develop an oral health training curriculum for community health workers.
• Contract the University of Hawaii School of Nursing and Dental Hygiene to develop a training video and toolkit to integrate oral health in a pediatric wellness visit.

 

Review of Action Plan

The logic model reflects the reduced work of FHSD due to the loss of dedicated funding and staffing. Efforts focus on activities by the State Oral Health Coalition. Oral health data sources critical for ongoing surveillance efforts were also detailed to reflect the infrastructure services supported by Hawaii Title V.

 

Overall Impact

The CDC oral health grant was critical to provide leadership, data surveillance, coalition-building, assessment, and planning. The grant’s accomplishments helped elevate dental disease as an important public health issue through the completion and publication of the BSS survey of 3rd grade and Head Start children. More importantly, the grant helped build community capacity to support ongoing oral health work through the state and neighbor island coalitions. The coalition will continue to convene and coordinate the state’s dedicated oral health stakeholders, community-based programs, and strong advocacy agenda.

 

FHSD will continue to support surveillance, prevention, and workforce development activities through its Office of Primary Care and Rural Health.

 

Challenges, Barriers

The primary barrier to progress will again be securing sustainable funding for SOHP staffing and operations. While FHSD continues to explore funding options to help support ongoing public health functions, little program activity is possible without dedicated staffing and resources. Thus, this priority was deleted as part of the 2020 Title V needs assessment.