Priority: Access to Supports

Update on PM annual objectives:

NPM 6: Percent of children, ages 9-35 months, who received a developmental screening using a parent-completed screening tool in the past year was 39.0%. The annual objective for reporting year 2021 was 45.5%. The annual objective was not met. An important caveat is that the data for this measure has a wide confidence interval (18.8 percentage points) as a result of the small sample size (204 children, ages 9-35 months). While there are many potential contributing factors, the impact of COVID on developmental screening rates was the most significant. During the pandemic, primary care clinics/offices closed for a period of 4-6 months, and when they reopened, were conducting well child visits through telehealth. However, Colorado’s Medicaid program does not provide reimbursement for any online developmental screening tool, which may have also impacted documented screening rates. The annual objective for reporting year 2022 is 42.0%.

ESM 6.1: Percent of children referred to early intervention who do not complete an evaluation was 32.3%. The annual objective for reporting year 2021 was 40.0%. The annual objective was met. The annual objective for reporting year 2022 is 35.0%.

The two national performance measures (NPM) selected for the Access to Supports priority are NPM 6, percent of children, ages 9-35 months, who received a developmental screening using a parent-completed screening tool in the past year, and NPM 11, percent of children with special health care needs, ages 0-17, who have a medical home. NPM 11 is reflected in the Access to Supports narrative in the CYSHCN domain of the block grant application. The data for both NPMs come from the National Survey of Children’s Health that is updated annually. The evidence-based or -informed strategy measure (ESM) for NPM 6 is the percent of children referred to early intervention who do not complete an evaluation. This data comes from Early Intervention Colorado and is updated annually.

For this reporting period, MCH Block Grant dollars were braided with state General Funds to support approximately 3.0 FTE on the CYSHCN team and .5 FTE on the Health Informatics team at CDPHE; implementation of strategies in the state action plan; and contracts with local public health agencies to implement local action plans that support the CYSHCN population. The funded strategies and associated outcomes are summarized below. For a more detailed description, refer to the full state action plan.

The Access to Supports priority includes, but extends beyond, access to health care services. This is based on the understanding that the health of individuals and families is primarily influenced by non-medical factors such as food, housing, social connectedness and safety, often referred to as social and structural determinants of health (CDPHE Office of Health Equity, 2018). Policy and systems improvements are needed to support whole-person care and make it easier for women, children, youth and families living in Colorado to access the comprehensive services and supports they need. This includes strengthening partnerships, communication, coordination and collaboration across and between organizations and systems that provide support for women, children, youth, and their families.

Most systems are made up of some combination of people (i.e., both those seeking and those providing services and supports); process(es) used by those people (i.e., getting or giving a referral) and technology (i.e., interoperable data systems, a website, or an app on a smartphone). Using this lens, the state action plan for the Access to Supports priority focuses on the following strategies: 1) increase equitable access to and use of specialty care, with a focus on behavioral health; 2) enhance provider and system capacity to bridge healthcare and other partners; and 3) use data to identify, illuminate, and address access, utilization, and outcome inequities. The first strategy is included in the CYSHCN domain of the block grant application. The second and third strategies for the Access to Supports priority are reflected below.

Strategy 2: Enhance provider and system capacity to bridge healthcare and other partners to connect people to supports they need and want.

Efforts related to this objective originally included increasing the number of communities implementing an online platform to support the coordination of care across community-based organizations and systems and advancing Colorado’s vision towards a statewide social health information exchange (S-HIE) infrastructure. The intention was to increase proliferation of community-specific use cases or pilot projects that could either inform recommendations for other communities or enable the state to better understand common workflows and technologies that should be reflected in a singular Colorado S-HIE system. There are two common types of local S-HIEs that have emerged in Colorado: 1) Community-centric platforms that enable direct engagement of individual Coloradans with their care team, typically procured by local governmental agencies; and 2) E-referral platforms that enable extension of clinical referral process out to appropriate non-clinical service providers, typically procured by health systems. There has been growing acknowledgment that a single system or statewide solution is not in Colorado’s future, and, as a result, there is an increasing need to focus on the connective tissue between community- and health system-procured platforms. This became the focus of MCH S-HIE efforts, in lieu of increasing the number of individual communities that have a S-HIE. As a result, MCH staff have been actively engaged in statewide workgroups to advance interoperability of data systems that are coordinated by the Colorado Office of eHealth Innovation.

The Colorado Office of eHealth Innovation staffs the state’s eHealth Commission and the Commission’s associated workgroups. CDPHE’s Center for Health and Environmental Data Division Director is the state’s public health representative on the eHealth Commission, which was created to provide advice and guidance on advancing health information technology in Colorado. MCH-funded staff have been active participants in a variety of workgroups during this reporting period to ensure alignment of MCH investments with the design of a statewide infrastructure. The table below provides a summary of the purpose of each workgroup.

 
Information from these workgroups was used to inform revisions to the state’s Health Information Technology Roadmap. In November 2021, a refreshed Roadmap was unanimously approved by Colorado’s Lieutenant Governor Dianne Primavera and Colorado’s eHealth Commission. It charts a path for harnessing and expanding the digital tools and services that support the health of all Coloradans. This roadmap sets a course for aligning efforts across a broad range of stakeholders to achieve three primary goals by 2024 including: (1) Coloradans, providers, payers, community partners, state, local, and Tribal agencies share data and have equitable access to needed health and social information, (2) Coloradans access high quality in-person, virtual, and remote health services that are coordinated through information and technology systems, and (3) Colorado improves health equity through inclusive and innovative use of trusted health information technology and digital health solutions. Policy, service and funding recommendations in support of these three goals were also identified to inform the direction of existing and new Office of eHealth Innovation workgroups.

To coordinate public health efforts to support the social-health information exchange infrastructure (S-HIE), the MCH Director and the Department’s Health Information Systems Branch Director co-led an internal CDPHE S-HIE team. This team reviewed the revised S-HIE white paper and identified specific areas where the Department is uniquely positioned relative to other state agencies or invested partners to advance the state’s S-HIE approach. The team clarified both internally and with external partners that CDPHE’s role is not to provide ongoing funding for core S-HIE infrastructure, but instead to foster its development through use cases or pilot projects that can be taken to scale to enhance population health data.

A S-HIE pilot that is currently in progress emerged from the Early Childhood Screening and Referral Policy Council and aligns with NPM 6 for the Access to Supports priority. While Colorado remains in the top  tier amongst states for developmental screening rates, barriers in the process to access evaluation and intervention services after screening still remain. In 2021, approximately 32% of Early Intervention Colorado referrals were closed before completing the process. Half of these referrals were closed because the program intake was unable to contact the family, and half were closed because the parent/caregiver decided not to proceed. Having more integrated data system linkages and communication between the family, health care provider and Early Intervention Colorado could help increase the number of evaluations that are completed.

The Early Childhood Screening and Referral Policy Council, which is co-facilitated by Assuring Better Child and Health and Development (ABCD) and a CYSHCN team member, is comprised of representatives from the Department of Education, Department of Human Services’ Office of Early Childhood, Parent to Parent of Colorado and other organizations that are involved in early childhood systems improvement.

In late 2020, the MCH program engaged partners from the Early Childhood Screening and Policy Council, Denver Public Health, Mile High United Way 2-1-1 and CORHIO (one of Colorado’s two health information exchanges) in a facilitated exploratory process to determine if a closed loop e-referral model could be implemented to strengthen bi-directional communication between health care providers and the early intervention system to increase the percent of children who receive an evaluation after being referred. The envisioned e-referral system would relay electronic referrals from a provider’s electronic health record through the CORHIO health information exchange to Early Intervention Colorado’s statewide data system. Then following assessment of the child, close the referral loop by relaying a progress note back to the referring provider’s electronic health record. The goal of this timely, cross-system communication and coordination throughout the evaluation process is to illuminate opportunities to help the family complete the evaluation process and increase their access to needed services.

Throughout the spring and summer of 2021, staff from Denver County’s Early Intervention program, Office of Early Childhood, CDPHE’s CYSHCN team, ABCD and CORHIO, scoped the pilot and determined the resources needed to support the project. Salud Family Health Centers (which has seven clinics across the state) was selected to be the health system to participate in the project. Implementation of the project began in March 2022 and the system will go live in July 2022.

The Early Childhood Screening and Referral Policy Council also continues to focus on advancing policies that remove barriers to children accessing needed developmental services, from screening to evaluation to connection to Early Intervention Colorado and other needed services. Additional activities led by the Policy Council are included in the Positive Child and Youth Development action plan and are included in the narrative for that priority.

Strategy 3: Use data to identify, illuminate, and address access, utilization, and outcome inequities.

Two of the strategic anchors for the MCH program are racial equity and community inclusion. This strategy reflects the intentionality of using data to identify future objectives and activities that explicitly reduce racial inequities between different population groups. The data from the National Survey of Children’s Health (NSCH) indicates that there are disparities among children of different races/ethnicities across the United States related to access to care and a medical home. Based on Colorado data from the 2018-2019 NSCH, about half (50.4%) of all children living in Colorado do not have a medical home (62.8% of children with special health care needs and 47.5% of children without special health care needs). Disparities in access to a medical home are apparent by race/ethnicity and household income among CYSHCN. In Colorado, only 39.7% of CYSHCN who are Hispanic have a medical home compared to 59.2% of white non-Hispanic children. 30% of CYSHCN with a household income between 0 and 299% Federal Poverty Level (FPL) have a medical home, compared to 50.4% of CYSHCN at 400% FPL or greater (NSCH, 2018-2019). This data is not available for other races and ethnicities. More information about Colorado’s oversample of the National Survey of Children’s Health to address this issue is described in the MCH Data Capacity section.

Part of the Access to Supports action plan is to intentionally explore ways to make data on equitable access and use of supports simpler and more digestible. Examples of related activities completed during this reporting period include compiling information on data available related to equitable access to supports in a single space; exploring value for Colorado in partnering with the Casey Family Programs to create interactive community opportunity maps that would present information from various sources in a single place to facilitate local planning; and creating a Developmental Screening and Referral Data Dashboard. A first iteration was completed for internal use to compile data from Early Intervention Colorado, Healthy Steps, and Medicaid Early and Periodic Screening, Diagnostic and Treatment (EPSDT). Refinements and goals for an external-facing dashboard have been identified and partner meetings to review data and collective action steps are in progress. Here is the most recent version of the internal dashboard.

In addition to these state strategies to increase access to supports, eight of the 15 local public health agencies that are required to implement local MCH action plans (based on the size of their awards), selected the Access to Supports priority for local implementation. Twelve agencies of the 15 continue implementing MCH-funded care coordination, and nine of the 15 agencies have expanded their CYSHCN work into other areas such as economic mobility and safe and protected built environments.

Priority: Positive Child & Youth Development

CDPHE staff partnered with Nourish Colorado to co-lead Colorado’s Farm to ECE efforts and be the fiduciary agent co-manage oversight of a Farm to ECE mini-grant initiative. Nine Farm to ECE mini-grant recipients were selected from 87 applicants to focus on children and/or youth in communities historically not prioritized for healthy food access. Two projects include an intentional focus on children with special health care needs, one project serves monolingual Spanish-speaking refugee/immigrant children. The total amount of funding for the mini-grants was $35,000 ($16,000 ASTHO, $11,000 CDC SPAN grant, and $8,000 leveraged from MCH funds), which enabled nine applicants to receive awards of up to $4,000. The addition of MCH dollars into the mini-grant funding opportunity, expanded the number of awards to include two programs that impacted approximately 175 families and their 225 children and/or youth with special health care needs. Both programs included core farm to child strategies centered on children working together toward a goal, learning about nutrition and how produce is grown, engaging in fine and gross motor activities, and benefiting from targeted therapeutic horticulture interventions.

Grantees developed resources and shared presentations pre and post program implementation to the Farm to ECE Coalition. Additional resources that were developed through the Coalition include: a Farm to Child website; an Eating, Growing, Learning: Colorado Farm to Child Guide with a Farm to ECE Assessment Tool; Harvest of the Month enews in English and Spanish; a Farm to ECE training presentation at the Rocky Mountain Early Childhood Conference; two webinars for garden activities - one for Master Gardeners to understand how to work with ECEs and one for ECEs to learn to create a sustainable garden. The Colorado Farm to Child Roadmap was drafted in the fall of 2021 and posted online in English. The Roadmap is considered a living document that will be updated continuously as new information and active work provide context or additional information. The Roadmap was translated to Spanish in the early spring of 2022 and dissemination is ongoing.

State staff provided technical assistance to three local public health agencies that selected Positive Child and Youth Development as a priority: Boulder, Garfield and Weld counties. Garfield County Public Health successfully implemented Farm to ECE programming at the Parachute Head Start Center. Garden boxes were built by a local community member and successful implementation was supported by Colorado State University Extension Master Gardeners. Children engaged in agriculture education, soil amendment and activities surrounding pollinators and bugs. Parent volunteers were engaged to assist with planting and education events. The Rifle Head Start facility in Garfield County finished construction at the end of the grant period, however garden beds were constructed and seeds, bulbs, and soil will be installed and programming will begin in the spring of 2022. To connect families with local produce, a 4-week community-supported agriculture box was distributed to families enrolled in the Head Start program, increasing access to local food and building relationships with local farmers. The Head Start centers are excited to continue their journey with local food and have future plans to teach families culinary skills such as freezing, preserving and cooking fresh produce in new ways. A continued partnership with Cooking Matters will ensure that programming in the future includes culinary skills, and nutrition education.

In addition to the nutrition security strategies included in the Positive Child and Youth Development action plan, another strategy is to strengthen cross-sector systems of support to enhance positive child and youth development. Specific to young children, MCH supports the Early Childhood Screening and Referral Policy Council. This collaborative group, co-facilitated by Assuring Better Child and Health and Development (ABCD) and a CYSHCN team member, is comprised of representatives from the Department of Education, Department of Human Services’ Office of Early Childhood, Parent to Parent of Colorado and other organizations that are involved in early childhood systems improvement. The Policy Council continues to focus on advancing policies that remove barriers to children accessing needed developmental services, from screening to evaluation to connection to Early Intervention Colorado and other needed services. Given the passage of state legislation during the 2021 session that will directly impact the state’s early childhood services and supports, the Policy Council will be monitoring the impact of the changes and providing input to ensure smooth transitions that enhance access to services and supports for young children. The most significant piece of early childhood legislation is the passage of House Bill 1304 to create a new state Department of Early Childhood. The Early Childhood Leadership Commission is tasked with approving a plan to transition to the new agency, as well as to guide the state’s new universal preschool program. As part of this transition process, the Early Childhood Leadership Commission has engaged a wide range of stakeholders (including parents/families, members of the early childhood workforce, providers, school districts, human services leaders, and others) to ensure recommendations are representative of the unique and diverse voices across Colorado. The transition plan includes the identification of early childhood programs, including Early Intervention Colorado, that will move into the new agency. More information is included on the Early Childhood Leadership Commission’s website. Colorado’s MCH Director represents CDPHE on the Commission and will continue to participate in transition conversations throughout the upcoming year.

The Early Childhood Screening and Policy Council will also be monitoring the impact of the change to the eligibility criteria for Early Intervention Colorado and the statutorily mandated creation of the Early Start Program. The program will be housed within Early Intervention Colorado to provide services/supports to children exhibiting a 25-32% delay and/or child and family risk factors associated with a high probability of developmental delay. An ABCD staff member is participating on the workgroup, which is drafting recommendations for the program design, including eligibility, referral, services, funding and marketing/communications. The workgroup recommendations have been compiled in a report for the Office of Early Childhood. ABCD staff will serve as liaison between the MCH program, the policy council and the workgroup throughout the process.