CHILD HEALTH DOMAIN

Nebraska Annual Report for the 2020-2021 Year

 

In this section, Nebraska MCH Title V reports on the accomplishments and activities in the Child Health Domain for the period October 1 2020 to September 30 2021. This represents the fifth year of activity in the Title V needs assessment cycle.  The numerical sequence of headings used to organize the narrative below correspond to the narrative guidance for the Annual Report year as found on page 42 of the Title V Maternal and Child Health Services Block Grant to States Program: Guidance and Forms for the Title V Application/Annual Report, OMB Number 0915-0172, Expiration Date 1/31/2024.

 

From the 2020 Needs Assessment, the Nebraska Priorities selected in the Child Health Domain for 2020-2021, with NPM, SPM, and ESM statements for the period are as follows:

 

• Child Abuse Prevention

SPM: The rate of substantiated reports of child abuse and neglect per 1,000 children ages 1-9 years.

ESM: None.

 

• Access to Preventive Oral Health Care Services

NPM: Percent of children ages 1 – 17 years who had a preventive dental visit in the past year.

ESM: The number of sites participating in the Nebraska Early Dental Health Starter Kits Educational program.

 

1. Context: The State of the Child Population Domain

Title V work in the child health domain is complemented by participation in numerous vibrant networks of stakeholders and partners. Nebraska Title V partners with several significant systems-level and capacity building activities in the state, benefitting child health and life course outcomes.  These include the Preschool Development Grant (PDG); Rooted in Relationships, a child well-being initiative and enhancement of early childhood mental health comprehensive systems work within the Nebraska Children and Families Foundation; First Five Nebraska, which was awarded a Pritzker Children’s Initiative Prenatal-to-Age 3 planning grant; and Help Me Grow, currently in development, but with plans to sustain and grow to all of Nebraska. Title V is making investments in Help Me Grow at the local level through a local subaward.  Within DHHS, the Division of Children and Family Services (CFS), the Injury Prevention Program, the Oral Health Program, and the Child Lead Prevention Program have long been partners with Title V.  Important collaborations with the child welfare sector, through the Prevention Administrator at CFS, have both improved child safety and well-being at the population level and provided early intervention/prevention services to stressed families at-risk for involvement in the child welfare system.  Title V is a partner in multiple child abuse prevention activities led by CFS, including the Child Abuse Prevention Fund Board, Plan to Prevent Child Maltreatment Deaths, and the Bring Up Nebraska and Thriving Families initiatives.

 

Title V is also closely linked with, and shares priorities and objectives with, Nebraska’s Maternal Infant Early Childhood Home Visiting program.  Title V serves as lead agency for the state’s Pediatric Mental Health Care Access Program, providing additional resources and stakeholders with shared interests in improving screening in primary care and increasing access to a spectrum of pediatric mental health care services. Title V participates in Nebraska’s Learn the Signs, Act Early autism awareness and identification project. 

 

Children’s Hospital, based in Omaha, has expanded their footprint in Nebraska, with clinical service locations, clinics, and referral networks as well as community-based and school health services, providing child psychiatry and consultation services via telehealth statewide. In 2021-2022, the Nebraska Department of Education began strategic planning to expand and embrace comprehensive and coordinated school health programs and entered into an agreement with Children’s Hospital to provide additional expertise and staff support to the Nebraska Department of Education in this area. 

 

Impact of COVID on Children in Nebraska

The realities of the pandemic experience nationwide have also affected Nebraska children.  Stakeholders are concerned about lagging school performance scores as well as assorted mental and behavioral health issues, including suicide, among Nebraska children and youth.  Attention to both measuring and responding to the effects of the prolonged pandemic and related disruptions to daily routine as well as impacts on the economy and services, will need to continue.  This attention must address the disparities and inequities that continue to exist within systems. 

 

National Survey of Children’s Health Oversample

Considering discussion about the state of Child Health in Nebraska, it is relevant to discuss an investment by Title V to increase population sampling in Nebraska by the National Survey of Children’s Health.  Nebraska originally planned to oversample by 1,500 addresses with a goal of adding 272 interviews, expecting a total of 780 interviews.  Nebraska’s response rate was 15% higher than anticipated, with nearly 1,100 interviews completed.  As a result, in 2022 Nebraska has access to a richer data set about Nebraska children, including preventive dental visits and other key measures of access to care.

 

2. Summary of Programmatic Efforts and Use of Evidence-based or Evidence-informed Approaches to Address Priority Needs

 

Priority: Child abuse prevention

2020-2021 Objectives and Strategies

 

Objective CH4a: By 2025, reduce rate of substantiated child abuse or neglect by supporting prevention, early identification, and early intervention strategies, and investigating disproportionality of children and families involved with the Child Welfare Agency

 

Summary of Programmatic Efforts

Planned strategies in this objective include expanding the reach of Nebraska’s Maternal Infant Early Childhood Home Visiting program (N-MIECHV, an evidence-based approach to child abuse prevention) through a funding collaboration with the Division of Children and Family Services (CFS) Temporary Assistance to Needy Families (TANF) program. As a result, six existing sites were able to expand their programs, and one new site was added, to take referrals specifically under the enhanced program activities and serve an additional capacity of 300 more families.  

 

In a second strategy launched in 2020-2021, the MCH Epidemiology program at DHHS was to begin assessing available data and describe existing disparities among Child Welfare involved families. Due to Nebraska’s inclusion in the Thriving Families, Safer Children national partnership as one of four states selected to continue work on community well-being; this analysis was shifted to that project.  Title V will work with CFS as a partner in this project, participating in workgroups and providing expertise.  During the period of this report, efforts were largely in communications, collaboration, and planning relevant to this strategy.

 

Use of Evidence-based or Evidence-informed Approaches in this Priority

N-MIECHV implements Healthy Families America, which has proven effectiveness in reducing risk of abuse and neglect among participating families.

 

The Child Welfare data assessment project proceeds with the expectation that disparities that are not recognized, measured, or identified, cannot be addressed.  An initial assessment of 2020 Nebraska data conducted by Casey Family Programs showed that certain minority children have a rate of screened in reports of child abuse and neglect which is at least twice that of White children. Additionally, examination of data on families engaging with prevention systems such as Community Response and Alternative Response showed that White families are most represented.  Further analysis is necessary to identify root causes and gaps in available services at the community level, as well as how Nebraska can ensure supports and services available for all families to reduce system involvement for children.

 

Nebraska DHHS participates in the Family First Prevention Services Act (FFPSA) of 2018, which calls for a greater emphasis on States providing child maltreatment prevention services that are rooted in promising, supported, or well-supported practices. While the web site https://www.mchevidence.org is silent on evidence based interventions to prevent child abuse, the field is well-studied and evidence guides are readily available.  The web site https://www.childwelfare.gov/topics/preventing/evidence/ provides extensive access to evidence registries, including https://homvee.acf.hhs.gov/ the evidence-base for home visiting.  At the child welfare site, Nebraska’s Bringing Up Nebraska project is highlighted.

 

Priority: Access to Preventive Oral Health Care Services

2020-2021 Objectives and Strategies

 

Objective CH5a: By 2025, increase the percent of children ages 1- 17 years who had a previous dental visit in the past year

 

Summary of Programmatic Efforts

Planned strategies included Title V partnering with the DHHS Office of Oral Health to translate dental health promotion materials into more languages as needed, and to assist in the distribution of Dental Health Starter Kits to children and families.  These activities remain current and in process, though slowed by the pandemic and related closures limiting client and family contacts.  N-MIECHV participated by distributing 20 cases of 200 kits each in English, and 12 cases in Spanish.  In addition to these efforts, Title V through the School Health Program and MCH Epidemiology has partnered with the Oral Health Program to launch a statewide assessment of children’s oral health by screening children in selected schools and Head Start programs.  In 2020-2021, the Oral Health Survey was largely in planning phase conducting the selection of schools, setting protocols, and planning logistics.  The Oral Health Survey itself will be completed in 2021-2022 and operationalized with technical assistance from the Association of State and Territorial Dental Directors.  University of Nebraska Medical Center College of Dentistry Pediatric Residents will be enlisted as examiners in several counties, while registered dental hygienists with public health authorization will serve as examiners in other areas. 

 

In the Oral Health Program, capacity grew with the addition of a Community Health Educator to assist with program activities.  The position is jointly supported by Title V and preventive health services block grant funds. No decisions were made about translation of materials.

 

Use of Evidence-based or Evidence-informed Approaches in this Priority

The web site, https://mchevidence.org reviews evidence to promote the preventive dental visit in childhood.  Key findings include:

• School/preschool interventions appear to be effective.
• Public insurance coverage appears to be effective.
• Medicaid reforms appear to be effective.

 

3. Assessment of Alignment of NPMs, ESMs, SPMs, and SOMs with Priority Needs

 

Priority: Child Abuse Prevention

SPM: The rate of substantiated reports of child abuse and neglect per 1,000 children ages 1-9 years

ESM: None

 

Alignment: Nebraska stakeholders in the 2020 Needs Assessment, as in other years, expressed grave concerns about child abuse and neglect – and the possible disparities and disproportionate burdens occurring with some groups and communities.  The SPM assigned to this priority is well-aligned with associated strategies addressing the exploration and identification of disparities, though not called out in the SPM.  No ESM has been assigned to this priority in Nebraska.

 

Priority: Access to Preventive Oral Health Care Services

NPM: Percent of children ages 1 – 17 years who had a preventive dental visit in the past year

ESM: The number of sites participating in the Nebraska Early Dental Health Starter Kits Educational program

 

Alignment: The NPM of measuring preventive dental visits in the past year is well-aligned with the priority of improving access to dental care.  However, the operative means for providing increased access to care has not been with a dentist or dental home per se, but rather the incorporation of dental health promotion materials into school-based services provided by public health dental hygienists, or into home visits. The ESM is a measure of quantity of sites participating in the dental health promotion project, not children, so the unit of measure between NPM and ESM is slightly mismatched and not indicative of results or impact.

 

4. Progress in Achieving Established Performance Measure Targets along with Other Programmatic Impact

 

Since 2015, Nebraska Title V has been writing and utilizing Results-base Accountability (RBA) measures in most domains in an effort to make annual impacts and achievements more discernable to front line staff and stakeholders.  In addition, use of RBA has specifically highlighted inclusion and equity-focused efforts that have been transforming Title V work in Nebraska.

 

Results Based Accountability (RBA) measures Child Abuse Prevention
	Proposed for 2020-2021	Achieved 2020-2021
How much did we do?	How many new sites and families were added to N-MIECHV during the period?	6 sites expanded and one new site was added.  Additional capacity to serve 300 was gained.  Pandemic disruptions continued to impact outreach and enrollment.
How well did we do it?	Have points of disproportionality been identified through the CFS-MCH Epi collaboration?	Points of disproportionality have been identified, though not through a collaboration between CFS and MCH Epi.  Data analysis conducted by Casey Family Programs found disproportionate rates for screened in reports and for participation in prevention programs, as discussed above.
Is anyone better off?	Do families enrolled through N-MIECHV expansion project have the same rate of achievement on benchmarks compared with other N-MIECHV families?	“Anecdotal data indicates that families referred from child welfare providers have a more difficult time with initial engagement, but once they do engage, their success on benchmark measures is similar to families not involved with the child welfare system.”

 

Discussion – Other Programmatic Impacts

Work towards expanding evidence-based home visiting through braided, cross-divisional, state and federal funding sources at DHHS, in order to serve more families in collaboration with child welfare services, has been groundbreaking for service delivery.  Title V leadership and alignment has been instrumental in guiding the process.  In addition to expanding capacity for families across Nebraska, the efforts have created new organizational processes, networks for communication and collaboration, and enhanced the visibility and credibility of DHHS as a provider of preventive services for families. Additionally, Nebraska’s inclusion as one of four states in the Thriving Families, Safe Children Initiative has far-reaching implications for strengthening the community well-being system in the state.  Assistance from the Casey Family Programs, support from the First Lady of Nebraska, and strong engagement by local partners has set the stage for a successful expansion of critical services and supports for all families in Nebraska.

 

Results Based Accountability (RBA) measures Access to preventive oral health care services for children
	Proposed for 2020-2021	Achieved 2020-2021
How much did we do?	How many dental health starter kits were distributed by the Office of Oral Health during the period?	212 cases of dental kits to N-MIECHV
	How many materials were newly translated?	None
	How many schools participated in the Oral Health Survey?	The survey will occur in 2021-2022
How well did we do it?	How many schools participated in the Oral Health Survey?  Are diverse children and underserved areas represented in the Oral Health Survey?	The selection of schools for invitation to participate in the survey was an intentional representative sample, which provided urban and rural diversity as well as racial and ethnic diversity.

 

Discussion - Other Programmatic Impacts

 

5. Challenges and Emerging Issues

COVID Response

As the pandemic extended into 2020-2021, Title V MCH began to identify the effects of program operations on subrecipients and on families.  The 2020 Needs Assessment was conducted primarily using virtual platforms.  Many participants were engaged in response activities within their programs, while others were primarily affected by shutdowns and disrupted operations.  Some were dealing firsthand with illness and loss.  By the close of the 2020 program period for Title V, it was becoming clear the consequences of the pandemic could potentially be impacting life course trajectories for MCH populations for some time, especially those already vulnerable and experiencing social needs. By 2021, Title V MCH was responding with partners and approaches to help families with diapers and other critical supplies.

 

Equitable access to pediatric mental health care

In 2018, Title V MCH became the lead agency for Nebraska’s HRSA-funded Pediatric Mental Health Care Access program, called NEP-MAP (Nebraska Partnership for Mental Health Access in Pediatrics).  In doing so, stakeholders, partners, and Title V staff, were recognizing the rising tide of mental health issues in the population, so Title V leadership in this federal area was a natural fit.  In 2021 NEP-MAP published the results of a family survey, with intentional oversampling of rural areas to represent all regions of the state.  Findings underscore the extent to which families identify ways they see their children’s mental and emotional well-being affected during the COVID pandemic.  In addition, as needs and screening increase, with increasing referrals to mental and behavioral health care, waiting times are increasing for families to access care. 

 

Medicaid Expansion in Nebraska: Heritage Health Adult

In October of 2020, Nebraska opened enrollment for Heritage Health Adult, enacting Nebraska’s Medicaid Expansion program.  Throughout this Annual Report, as well as the 2023 Application, Nebraska touches on the benefits of Medicaid Expansion to MCH populations, particularly women of childbearing age and their domestic partners.  Medicaid Expansion means access to physical, dental, mental, and behavioral health services as well as medications for an estimated 80,000 adults between 19 and 64 years of age in Nebraska. Adults who care for their own preventive health needs are more likely to care for the needs of their children.

 

6. Overall Effectiveness of Strategies and Approaches: Addressing Needs and Promoting CQI

 

The COVID pandemic continues to have an impact on outreach and disrupt the usual means of connecting at the community level.  Where feasible, alternative methods such as telecommunications are in place and working as well as can be expected. Pandemic response has also contributed to a growing sense of flexibility and agility about maintaining communications by effective means. The Oral Health Survey, by nature a high contact undertaking by examiners, was only in planning phase during this period.  

 

In terms of strategic directions, it is important to make the connection between the pandemic, family stress, and risk of child abuse and neglect. All parties have proceeded with expanding home visiting as well as other supports and resources, with patience, compassion, and persistence.