Child Health Annual Report (October 1, 2021-September 30, 2022)

The 2020 comprehensive Title V needs assessment process led to the development of the

Priority Need: To increase developmental screenings and referral to early intervention services for children. Several strategies were identified and incorporated into the state action plan to impact the following performance measures:

NPM 6: Percent of children, ages 9 through 35 months, who received a developmental screening using a parent-completed screening tool in the past year.

According to NSCH data, a 7.7% increase was seen parent-completed developmental screenings from 2019-2020 (37.9%) to 2020-2021 (40.8%), but there is still work to be done to meet SC’s Title V objective of 50% by 2025. Developmental screenings are essential for all children, and early intervention is the key to improved outcomes for those children with an identified need. The Title V/MCH program has prioritized NPM 6 collaborating with numerous partners to increase access to care and resources for early intervention services for children, working towards addressing barriers and gaps in services.

In September of 2021, Title V/MCH convened a strategic planning retreat with the Child Well-Being Coalition (CWBC) Core Team to plan for action around developmental screenings, one of the 3 newly identified priority areas (other areas include childhood injury and childhood obesity). The CWBC, under the direction of Title V/MCH, continued to promote the use of the CDC's Milestone Tracker App, a user-friendly means to monitor developmental progress in children, by widely disseminating information to providers and community partners. The CWBC has also established a developmental screening advisory group to engage developmental screening leaders in the state, as plans are underway for development and implementation of a statewide registry.

Help Me Grow SC, a CWBC partner, is another key Title V partner for developmental screening as well as child development and early intervention services.  Help Me Grow South Carolina (HMG SC) established a State Office in 2020 within a new backbone organization, the South Carolina Infant and Mental Health Association (SCIMHA). With this strategic alignment, HMG SC was able to drastically expand access to developmental and behavioral health screening throughout the state, including adding 20 new community-based screening partners in 2021 and 6 new partners in 2022. Most screening partners send the screenings they complete with children and families to HMG SC for processing, follow-up, referral to services (if needed), and communication of results with a child’s medical home. In addition to adding screening partners, HMG SC made technology enhancements to its screening portal to allow free access to developmental screening to any South Carolina family with a child under six.

The result of these efforts was an over 400% increase in the screenings HMG SC processed from 2020/2021 to 2021/2022. From October 1, 2021 through September 30, 2022, 1,170 children completed developmental screenings through HMG SC or one of its screening partners. Of the 685 children whose screenings were processed through the HMG SC centralized access point, approximately 25% ended up receiving referrals for services. Of the 25% of children who were screened and subsequently referred for services, 24% were referred to IDEA Part C/Babynet, and 17% were referred to IDEA Part B (School Districts’ Child Find).

Overall, from October 1, 2021 through September 30, 2022, HMG referred 385 children for services (some referrals of which were due to a developmental screening, and some of which were not). Of this number, 21.6% (n=83) children were referred to IDEA Part C/Babynet, 23% (n=89) were referred to IDEA Part B (School Districts’ Child Find), 30.4% (n=117) were referred for mental or behavioral health counseling, 27% (n=104) were referred for communication/speech/language, and 21.3% (n=82) were referred for occupational therapy. Referrals to IDEA Part C, mental or behavioral health counseling, and communication/speech/language have always been among HMG SC’s top five referral types.

The SC Title V program as well as the CWBC continued to foster a strong partnership with BabyNet, SC’s interagency early intervention system for children under the age of 3. The BabyNet program provides critical services for this population, with the goal of increasing early intervention services for children across the state. BabyNet staff participate in public awareness activities on an annual basis, and present at various early childhood conferences at the state and national level. The BabyNet program also has a contract with Family Connection of South Carolina, Title V’s Family Voices partner organization, to develop and disseminate materials, with the sole purpose of increasing the number of referrals to the program.

During this time period, the MCH Bureau’s Birth Defects Program continued to prioritize prevention, research, and referrals through partnerships with internal and external partners. All liveborn infants identified with a birth defect were referred to BabyNet/Early Intervention in South Carolina, all women with pregnancies impacted by neural tube defects were referred to Greenwood Genetic Center, and the program continued a new initiative to refer infants with hearing loss to the agency's Early Hearing Detection and Intervention program, First Sound. The program continued to work as a grantee for CDC’s Congenital Heart Defect grant and focused on enhanced surveillance surrounding critical congenital heart defects detection. Additionally, the program used clinical data to support Emory University's efforts to develop a machine learning algorithm to identify congenital heart defects through claims data.
 

Priority Need: Improve coordinated and comprehensive health promotion efforts among the child and adolescent populations. 

DHEC’s MCH Bureau supports and houses a State School Nurse Consultant (SSNC) position in partnership with SC’s Department of Education. The SSNC works closely with other DHEC public health offices such as Covid, Immunizations, Acute Disease and Epidemiology and the Regional Community Health staff assisted schools and school nurses as they faced the Delta and Omicron variant waves in SC. School nurses were integral public health partners doing contact tracing at the school level and reporting case and exposure data to public health. Covid vaccination information was provided to schools and the SSNC met frequently with school nurses and school administrators to educate about the disease and the vaccine and treatment options as they were developed.

School nurses continue to provide medication management, link students to community resources including health insurance, connect students to school-based resources and provide a safe space for struggling students. The State School Nurse Consultant in partnership with Lowcountry AHEC and the SC Association of School Nurses, facilitates professional development for school nurses to increase their skills related to prevention, intervention and postvention of mental health crises, including suicide.

The MCH Bureau's Childhood Lead Poisoning Prevention Program (CLPPP) also addresses this priority need. Through surveillance and case management, CLPPP works to improve linkages of lead-exposed children with needed services. Children and adolescents (up to the age of sixteen) meeting case management criteria based on blood lead level receive nursing services and their families receive education. Children in this group who are under the age of six are also eligible for an environmental lead assessment of their homes and secondary residences to identify sources of lead.

The CLPPP continues a close collaboration with the Catawba Indian Nation for surveillance, through a data sharing agreement. With assistance from the CLPPP, Catawba staff have received EPA Lead Risk Assessor certification and are able to conduct environmental lead assessments for Tribal children, should the need arise. The CLPPP works closely with the City of Spartanburg’s Lead Safe Healthy Homes program, referring qualifying families to the program for remediation of identified lead hazards in their homes.

DHEC’s Title V program contracts with Family Solutions (FS) of the Low Country, a program of the S.C. Office of Rural Health, which serves residents in Orangeburg, Bamberg, Allendale, Hampton and Barnwell regardless of insurance. Family Solutions is the home for Healthy Steps project aimed to improve the health of children, women and families. Healthy Steps is a program of Zero to Three that provides early childhood development support in a clinical setting. Most services are provided in pediatrician practices however FS manages a Healthy Steps initiative located in with-in a family practice that offers comprehensive care. This practice has approximately 130 children within the age requirement for Healthy Steps intervention, however not all were seen during the requested reporting period.

During the requested reporting period, the Healthy Steps specialist provided services to 23 children. Of this number 3 were Tier Level 1, 8 were Tier Level 2 and 6 were Tier Level 3. The remaining 6 were still being assessed for tier appropriateness. Tier 1 includes universal screenings and routine calls/visits. Tier 2 intervention involves everything from tier 1 but involves short-term support and resources. This tier addresses mild concerns. Tier 3 intervention involves everything from tiers 1 and 2 but is more intense and requires more team based well-child visits in addition to more frequent visits/contacts with the specialist.

The work in SC surrounding improvements to coordinated and comprehensive health efforts among the child population is extensive in hopes to address complex issues (e.g., build resiliency by providing support services at the community level, address mental/behavioral health issues in a variety of settings).  The CWBC continued to host several webinars addressing their priority areas and child health related current events.  Topics covered included child and adolescent outcomes including injury, mental and behavioral health, and suicide prevention. 

The CWBC addressed the priority area of childhood injury through firearm safety education and providing gun locks for distribution in pediatric provider settings. The CWBC hosted a webinar on the topic of firearms safety in the home, which included injury statistics as well as helpful ways have open discussions about firearms with parents. The Core Team met with advocacy groups in the state working to prevent gun violence in schools and in the community to discuss ways to provide support. Since January 2022, the CWBC has provided nearly 2,000 gun locks at no cost to providers. The gun locks were promoted through newsletters, webinars, and various in-person events. A survey was sent out to those who received locks from CWBC, and the feedback was overall very positive on how these have helped encourage firearm safety in their communities.

The Title V program supports the efforts of DHEC’s Immunization Program through promoting resources and outreach and awareness. The Division of Immunization at DHEC plays an important role in improving coordinated and comprehensive health promotion efforts among the child and adolescent populations in South Carolina, per statutory authority allowing DHEC to have general direction and supervision of vaccination, screening, and immunization in this state. The Federal Vaccines for Children (VFC) Program in South Carolina is administered by the DHEC Division of Immunization and covers vaccines for children 18 and under.

The DHEC regional immunization programs coordinate school-located influenza vaccine clinics with school nurses and other partners to provide a safe, convenient opportunity for school-aged children to obtain the seasonal influenza vaccine with parent/guardian permission. As a result of parent and school engagement activities, a total of 345 schools participated across the state in the 2022-23 flu season, resulting in 4,911 children receiving at least one dose of the flu vaccine.

A large focus of the outreach program within DHEC’s Division of Immunization is identifying and partnering with immunization champions in the community to create and deliver quality vaccine education and promotion activities that positively impact vaccination rates among adolescents.

NPM 8.1: Percent of children, ages 6 through 11, who are physically active at least 60 minutes per day.

Title V continued to support the work surrounding NPM 8.1 by working with partners and school districts. Through strategic coordination and collaboration between MCH and DHEC’s Division of Nutrition, Physical Activity, and Obesity Prevention (DNPAO), school environment improvements were made to support active living and to improve student health through the implementation of a statewide, web based FitnessGram system.  

DHEC’s DNPAO continued to work with the SC Department of Education (SCDE), the Alliance for a Healthier Generation (Healthier Generation), the MUSC Boeing Center for Children’s Wellness (BCCW), the SC Alliance for Health, Physical Education, Recreation, and Dance (SCAHPERD), BlueCross® BlueShield® of South Carolina Foundation, and the University of South Carolina (USC) to increase physical activity rates of children and adolescents in SC public schools before, during, and after school hours. Through SC FitnessGram, DNPAO partnered with the Healthy Palmetto Leadership Council to support the prioritization of physical activity in schools through communication strategies to create awareness of the status of student health and proven practices to improve it. In addition, DNPAO has established Memorandums of Agreement with three school districts (Cherokee, Georgetown, Kershaw) to serve as SC FitnessGram Influencers through December 2024. As Influencers, school administrators, teachers, and staff received tailored training and technical assistance to increase physical activity opportunities and improve student health. Their successes and lessons learned will be shared broadly to support similar outcomes statewide.

As of September 30, 2022, 15 school districts had adopted the SC School Boards Association’s (SCSBA) Open Community Use of School Recreational Areas model policy. This number is less than previously reported due to school district consolidations. Sixteen trainings were provided by DNPAO and partners including statewide and regional conferences, workshops, and webinars. These trainings were offered to state and local public health and education stakeholders, including school district administrators and PE teachers, on proven practices and policies to enhance physical activity opportunities for students, including the use of SC FitnessGram data. During this reporting period, 64 of 79 (81%) public school districts received professional development on evidence-based practices for providing a school environment supportive of active living, potentially impacting over 775,000 students (ESM 8.1.1).

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

The Title V Program coordinates with DHEC’s Division of Oral Health (DOH) to ensure that the oral health needs of infants and children are addressed within the medical and dental setting. Medical and dental providers play an important role in improving the oral health of young children and their families by providing risk assessments, preventive care and patient education. The Postpartum Newborn Home Visitation training course reconvened on an annual basis post Covid and DOH staff trained participants in preventive oral health.  The Division of Oral Health also continues to promote their online training for medical providers and their staff titled, Improving Health through Oral Health Integration. This oral health integration training is an expansion of the Connecting Smiles Initiative and is a collaborative project with the South Carolina Department of Health and Human Services. Completion of the online training specifically trains staff in fluoride varnish application. The current fluoride varnish policy provides up 4 fluoride varnish treatments within the medical setting and 2 within the dental setting for children through age 6. Data for 2021 showed that 21,633 children received at least one fluoride varnish application. Fluoride varnish protects the tooth enamel and makes the tooth resistant to new decay and slows down or stops existing decay from getting worse.

In addition to equipping medical teams with the skills needed to apply fluoride varnish, the online training also provides information about preventive oral health including early care of the mouth even before teeth erupt; good feeding habits; the importance of the age 1 dental visit; how to reinforce good nutritional habits for the body and the mouth and how to determine a child’s level of risk for tooth decay. Healthcare providers and staff members also have access to resources that support oral health education for parents and children that can be given to families during well child visits. The medical setting is the perfect place to promote and support early oral health. Providers can access the Improving Health through Oral Health Integration training through the Connecting Smiles website, www.connectingsmilessc.org and there is a link to it on the SC Department of Health and Human Services (SCDHHS) site.

The SCDHHS Quality through Technology and Innovation in Pediatrics (QTIP) project re-engaged around oral health in 7/1/2022 with a focus on increasing the frequency of fluoride varnish application in the medical setting and working towards a collaborative referral system between physicians and dentists. Several provider trainings and workshops have occurred to support these efforts with participating pediatric practices. The QTIP program works to improve health care for children in South Carolina by working on quality measures and incorporating strategies for working on core measures, including oral health.

Regarding school-age oral health, oral health screening data for kindergarten and 3rd grade students was collected through a statewide Oral Health Needs Assessment that began in October 2022. This assessment will provide a comprehensive snapshot of the current oral health status of students to help determine what additional interventions need to take place to effectively address and support preventive oral health.  The Division of Oral Health continued to collaborate with South Carolina Area Health Education Consortium (AHEC) to reach school nurses through an online training that supports the utilization of a basic screening survey to assess a student’s oral health status and support school-based efforts to reach families with preventive oral health messaging. The Foundations for School Nurses course was revised, recorded and re-launched in July 2022 to reflect current best practices to support adolescent oral health. AHEC connects students and professionals with the tools, training, and resources necessary to develop an effective healthcare workforce, with a focus on primary care for rural and underserved areas.  In addition to the online training, the Division of Oral Health developed a standards-based oral health curriculum for 1st-3rd graders and 4th-5th graders to support oral health education and outreach in the classroom. The curriculum was disseminated to schools that participated in the statewide oral health needs assessment.

The SC Department of Health and Human Services (SCDHHS) developed a new policy and clinical criteria for orthodontic services for children under the age of 21 years that was effective 1/1/2022.  SCDHHS also participated in a learning collaborative coordinated by the Centers of Medicare and Medicaid services for improving health care access and health outcomes for children in foster care. One of the goals of the learning collaborative was to increase the number of foster children that receive an initial dental visit within 60 days of entry in the foster care program. This goal is supported by SCDHHS policy that allows a comprehensive exam, cleaning, fluoride, and radiographs designated as an initial dental visit regardless of the child’s dental history.

Table 3. Significance* Testing for Child Health Measures

*p<0.05