Child's health includes physical, mental and social well-being. Ensuring healthy growth and development is a primary concern of the Maine Title V program. Maine’s efforts to improve the health status of children focuses in the areas of developmental screening, oral health and children living in households where someone smokes.

Performance Measure: Percent of children, ages 9 – 35 months, who receive a developmental screening using a parent-completed screening tool in the past year.

Current Status: According to the 2017-2018 National Survey of Children’s Health, about 44% of Maine parents of children ages 9-25 months report that they were asked to complete a developmental screening tool for their child within the previous year. Only six states have higher developmental screening rates. The U.S. rate was 33.5%. MaineCare has been working to improve developmental screening rates among their providers and has increased awareness of the billing code available to providers for conducting developmental screens. As a result, the percent of children enrolled in MaineCare with a claim for a developmental screen increased for three year olds from 1.1% in FFY11 to 32.3% in FFY18. This increase may be due to increased awareness of claim coding for developmental screenings, along with actual increases in screenings.

Objective: Conduct quality improvement efforts with primary care providers to follow guidelines on developmental screening and educate childcare providers and parents on best practices for screening.

Strategies

• Conduct a quality improvement process with primary care providers to implement use of a developmental screening tool, documentation and referral for service.
• Educate childcare providers about the importance of developmental screening using “Learn the Signs Act Early”.
• Explore opportunities to educate parents on developmental screening

When a developmental delay is not recognized early it can make it difficult for children to learn when they begin school. During FY19, Qualidigm, formerly Maine Quality Counts, continued to work with practices to provide quality improvement (QI) with the overall goal of providing education and support to increase rates of developmental screening, educate childcare providers and parents on best practices for screening, assess options and make recommendations for implementing consistent data collection on screening in Maine. Through collaboration with MaineHealth and community partners, the Developmental Screening Community Initiative in Cumberland County (DSCI) continued quality improvement efforts to expand referrals with appropriate follow-up to those referrals.

The objective for the evidence-based strategy measure (ESM) related to the number of practices participating in a QI project around developmental screening practices was set constant while Maine's CSHN program re-evaluated this work and the QI processes.

Qualidigm hosted and facilitated monthly meetings of the Developmental Systems Integration (DSI), a group of early childhood development stakeholders, and provided feedback and guidance for promoting developmental screening referrals and follow up. This group of stakeholders helped provide feedback and tested materials as they were developed. Qualidigm continued to work with partners to collect developmental screening data and evaluated to determine if the measures required updating.

Over the past two years, the DSCI in Cumberland County focused QI efforts on increasing the rates of developmental screening as well as completed referrals to the Maine Department of Education, Child Development Services.

The DSI Workgroup created four modules for Care Coordination under the leadership of Qualidigm:

• Module #1: Approaches to Care Coordination in Maine focused on Families, Caregivers and Children, 0 through 8.
• Module 2: Family Engagement, Education and Support: Opportunities and Obligations.
• Module 3: Care Coordination with Families/Caregivers Involved in Multiple System and Services.
• Module 4: Is in development and the focus will be on providing background around developmental screening and the difference between screening vs surveillance, EPSDT, ACES and trauma screening.

The Women, Infants and Children (WIC) program began conducting developmental surveillance using the federal CDC’s Learn the Signs Act Early tool. The (WIC) Nutritional Services is a voluntary program that provides low-cost healthy foods, nutritional education, breastfeeding promotion, and support and referral to other services to women, infants and children who are at nutrition risk.  The program is designed to allow women to enroll during pregnancy and for children to remain enrolled up to the age of five. Beginning in 2019, all children seen at WIC were provided with materials on age appropriate developmental surveillance. WIC documents any developmental concerns found and refers parents to the child’s medical provider for further review.

Maine Families home visitors complete Ages and Stages Developmental (ASQ), and Social Emotional (ASQ-SE) screenings with families at regular intervals. Family visitors complete ASQs at a minimum at 2, 4, 9, 12, 18, 24, 30, and 36 months. Family visitors complete ASQ-SEs at a minimum of three times within the first three years of the child’s life. The Parents as Teachers Curriculum guides home visits in monitoring development and offers family activities and information to promote healthy social emotional development and family visitors update the developmental surveillance tool after every visit. In addition, family visitors discuss protective factors with families to help new parents understand how the family’s overall wellbeing connects to their child’s ability to thrive. Family visitors also work with local child development services and other specialists to offer referrals for families as indicated by a screening result. The Parents as Teachers Curriculum guides home visits in monitoring development and offers family activities to promote healthy social emotional development.

Public Health Nursing (PHN) provides an infant physical assessment at each home visit, which includes an assessment of the child’s development. PHN’s perform physical assessments appropriate for age/condition and document the results in the pediatric physical assessment tool. PHNs monitor children for ability to express needs. They monitor the child for attainment of developmental tasks expected for age as well as monitoring the child’s response to stimulating/nurturing activities. Public health nurses refer to appropriate providers if any assessments are determined to be outside of normal limits.

The Maine Parent Federation’s (MPF) Family Support Navigator (FNS) program is a peer to peer program which provides one to one assistance to families of children with special healthcare needs. The program is staffed by four full-time equivalent positions who coordinate FSN trainings, connections to families, and feedback. FSNs are parents of children with special healthcare needs, professionals working with families who have children with special healthcare needs or a relative to a child with special healthcare needs. FSNs are matched to families who have needs within a FSN’s geographic region, as well as lived experience. The Family Support Navigator program provides peer-to-peer support and over the last 37 months provided direct support to 450 families. The program assisted 125 families during FY19.

During the past four years, MPF has worked with about 531 families who have/had their own support plan and assisted families navigate all systems of care including MaineCare, Katie Beckett, state waivers such as 28, 21, and 29, case management, social security, special education, including early intervention services, transition to adulthood, assessments and screenings and guardianship, including supported decision making.

To educate parents on developmental screening, the Maine Parent Federation (MPF) is making all two-hour in person workshops available online. Currently the Self-Advocacy and Bullying Workshops are online and live (http://mpf.org/trainings.html ) Module one of the Special Education workshop is nearing completion.

Maine was awarded a one million, one-year Preschool Development Grant (PDG), B-5 in January 2019. This grant enables Maine to learn more about the birth-5 mixed delivery system, including early care and education and services supporting our youngest children and their families, with a strong emphasis on vulnerable children and their families. The two main objectives of the grant were to conduct a statewide needs assessment and develop a strategic plan. The final report was submitted to US DHHS in December 2019. Unfortunately, Maine was not awarded the implementation grant but has continued work on the strategic plan through the PDG extensions.

The Children with Special Health Needs Care Coordinator worked to assist families navigate the complex medical systems and guide families to organizations and resources that best fit the needs of their child. The Care Coordinator can assist families with:

• Navigating health care systems
• Insurance appeals
• Application processes
• Referrals
• Finding resources
• Connecting to support from other parents of children with similar healthcare needs
• Advocacy

Current Efforts

The Maine Department of Health and Human Services (Maine DHHS) created a report in response to LD 1635, RESOLVE Chapter 66, To Improve Access to Early and Periodic Screening, Diagnostic and Treatment Services for Children birth to eight years of age. The report provides information on the EPSDT benefit and programs providing early intervention and developmental screening services in the Maine DHHS, including work carried out under the Maine Title V Maternal Child Block Grant, Public Health Nursing, Maine Families Home Visiting, Women, Infant and Children’s Program, and the Office of Child and Family Services. The report also includes information on the Department of Education’s Child Find and the early intervention system, including Child Development Services, Early Head Start, and Head Start.

LD 1635 was signed into law (June,2019) at a time when several other needs assessments and evaluations of the Early Intervention System were taking place in Maine. Short and long-term recommendations include:

Short Term:

1. Identify an organizing entity at the state level to coordinate and align Child Find, EPSDT, developmental screening, and early intervention services. Ensure improvement.
2. Ensure that EPSDT is firmly grounded in Maine DHHS child health priorities
3. Review roles, responsibilities, and positions within the Office of MaineCare Services to ensure direct oversight of the administration of the State’s EPSDT and Child Health Insurance Program (CHIP), utilizing the EPSDT position created in LD 1399.
4. Ensure no wrong door for families to access services and establish a centralized entity around developmental screening and care coordination for early intervention services.
5. Establish a longitudinal data system in Maine that ensures preventive screenings are completed and outcomes data is available.
6. Develop a communication strategy for EPSDT and Child Find for the state.
7. Expand coordination of the work between Maine DOE and Maine DHHS.

Longer Term

1. Increase access to services.
2. Integrate work across Maine DHHS to support EPSDT and Child Find.
3. Increase funding to support Part C services.
4. Increase preventive health screening rates.
5. Eligibility for Part C services.
6. Workforce.

Currently, the CSHN program is reassessing past developmental screening efforts and determining future direction as well as crafting a plan to utilize the modules created by the DSI workgroup. Developmental screening did not emerge as a priority during Maine’s needs assessment process, however the Title V program will continue to connect with those program’s working on developmental screening and provide assistance as appropriate.

Maine Parent Federation’s Family Support Navigator program links families of children and youth with special health care needs/disabilities in Maine with an experienced person for information and support. Maine Parent Federation trained 13 new candidates at its fall FSN training on September 19-20, 2019. On the second day of the training, all current and newly trained FSN’s received continued professional development on Supported Decision-Making and Special Education.

The CSHN program issued an RFP for family navigation services in the fall of 2019 and the Maine Parent Federation submitted the successful proposal. There are currently 25 active FSN’s in Maine. Maine Parent Federation held a winter FSN training on February 27-28, 2020 and continues to provide professional training presentations for Vocational Rehabilitation, Office of Aging and Disability Services, Office of Children Services/MaineCare, and Disability Rights Maine.

Maine Parent Federation held a FSN training on January 24, 2020 for the immigrant community in Lewiston/Auburn. We anticipate that the newly trained navigators will begin working with families in the Fall of 2020.

Performance Measure (State): Percent of third grade children who have received protective sealants on at least one permanent molar tooth.

Objective: Increase work to promote/provide sealants to third grade children in Maine.

Strategies

• Enroll schools in oral health programming and provide training
• Educate school nurses about benefits of oral health practices for children
• Educate providers about best practice use of dental sealants for children

Healthy teeth are important to a child's overall health and dental sealants can protect permanent teeth from decay. Maine promotes oral health disease prevention for children, including education through school nurses and application of fluoride varnish and sealants. Maine dental providers also promote dental sealants to parents as a good preventive intervention for their children. Sealants are a covered benefit under MaineCare. Maine also has dental hygienists working under public health supervision status who provide sealants on-site at schools. School sealant application facilitates children receiving sealants, especially in more rural and underserved areas where regular access to preventive dental care can be challenging.

Maine conducts observations of children's dental health (caries experience and sealants) as part of the Maine Integrated Youth Health Survey. Maine uses these observations to determine prevalence for the percentage of third graders who received dental sealants on at least one permanent molar. In 2019, 51.6% of third graders in Maine were observed to have dental sealants. Almost half (48%) of third graders were observed to have treated or untreated caries; 19% had untreated caries. About 1 in 5 (21.0%) third graders were observed to be in need of urgent dental care

Contributing factors to the percent of children with sealants could be the shrinking number of dental providers accepting MaineCare insurance as well as a decrease in the number of parents enrolling their children in MaineCare; only 40% of Maine's children are enrolled in MaineCare. The Healthy People 2020 objective is to increase the percentage of children ages six to nine years who received protective sealants on at least one permanent molar tooth, with a target of 28.1%; Maine is exceeding this target.

The Maine School Oral Health Program (SOHP), a component of the Maine CDC Oral Health Program, provides school-based dental sealants to second graders only at eligible participating schools, thus this number is a small proportion of the total number of Maine children receiving sealants each year. Schools are eligible to participate in the SOHP when they meet certain community-level risk factors, such as the proportion of children who are eligible for the Free and Reduced Lunch Program. The number of schools that can participate in the SOHP is limited due to funding availability therefore the program targets the highest need schools as a priority. In the 2018-2019 school year, 1,477 children received dental sealants through this program. The SOHP also includes school-based educational outreach programs to all grades and a basic dental screening with fluoride varnish application, reaching 10,996 children.

A restructuring of the SOHP included hiring a full-time SOHP Coordinator to oversee all SOHP functions. The program enrolled 25 additional schools during the 2018/2019 school year. The goal is to increase the number of schools joining the program by 5% each year. The re-design plan provided for 12 field hygienists to travel across the State however, the current model is comprised of 12 field hygienists providing screening and sealants in their school districts or in schools where their children are registered. The hygienists travel, as needed, to other areas of the State. School nurses work with the hygienists by assisting with recording data. The hygienists work with school nurses to coordinate care for children identified as needing emergency care.

Educational information and face-to-face meetings with all schools enrolled in the SOHP are required. These meetings take place in the fall after the school session begins. Schools receive updates on any new requirements for the upcoming school year, including a discussion of evidence-based oral health and other oral health education topics. New school staff are encouraged to complete the Smiles for Life Curriculum and the School Oral Health Library (http://smilesforlifeoralhealth.org/buildcontent.aspx?tut=555&pagekey=62948&cbreceipt=) and the Basic Screening Survey video (https://www.astdd.org/basic-screening-survey-tool/).

The SOHP did not hold a training for school nurses in FY19 as the field hygienists were applying sealants in those schools enrolled in the program. The program did compile oral health resources and made them available to school nurses via the school nurse listserv and the Maine Department of Education dashboard. In addition, during National Children’s Dental Health month in February 2019, the SOHP distributed resources and posters on the benefits of child oral health to school nurses. An example of materials provided can be found at; https://www.nidcr.nih.gov/sites/default/files/2017-11/seal-out-tooth-decay-parents.pdf.

The SOHP provided an Association of State and Territorial Dental Directors web-based training link to all school nurses however, we are unable to determine if they accessed and watched the training or implemented any of the recommendations offered through the training due to staffing constraints.

The SOHP has been challenged in its ability to demonstrate improved outcomes for this measure as there are a number of public health hygienists across the State applying sealants, but do not report their numbers. In addition to the numbers tracked by the hygienists going into participating schools across the State, Maine has access to MaineCare data; however, we do not have a complete picture of the number of sealants applied.

The SOHP collaborated with the Maine WIC program and a community action program in the northern part of the State to disseminate educational materials such as flash cards for parents, magnets and an oral health curriculum.

Maine Families home visitors use educational materials provided by 'From the First Tooth' (http://www.fromthefirsttooth.org/), a privately funded initiative administered by MaineHealth, with families of children 0-three years to promote the oral health of infants, toddlers and preschool children.

The SOHP initiated discussions with ‘From the First Tooth’ program staff and presented at the Children’s Oral Health Partnership meeting in December 2018. The goal of these connections was to determine how the SOHP could collaborate with the work of these initiatives to increase the number of providers educated on the importance of oral health and share best practice on the use of dental sealants.

Current Efforts

The SOHP Coordinator is in the planning phase for a conversion from paper based data collection to an electronic data entry system. The SOHP is reviewing several potential data sources that can create efficiencies in the reporting of data.

The SOHP Coordinator is finalizing a policy and procedures manual for the Public Health Field Hygienists, and new schools enrolled in the program.

The SOHP conducted a session on the benefits of child oral health at the New School Nurse Orientation in the summer of 2019. The Maine CDC continues to update its website resource page on children's oral health. All information is shared through partner list-serves and the school nurse resource page.

The SOHP continues to collaborate with such partners as the Maine WIC program and a community action program in the northern part of the State to disseminate educational materials such as flashcards for parents, magnets, and an oral health curriculum.

Web-based training is under development, and the SOHP plans to offer a breakout session on the importance of child oral health at the annual School Nurse Institute in the summer.

The SOHP continues to enlist schools to participate and support those schools receiving sealant funds to work with hygienists in their local area. The SOHP held a training at the annual New School Nurse Orientation. The trainings covered basic child oral health screening, as well as education about the benefits of child oral health. The SOHP is also working with schools to encourage varnish application on children’s teeth.

Oral health program staff disseminated National Institute of Dental and Craniofacial Research https://www.nidcr.nih.gov/health-info/sealants and National Institute of Environmental Health Sciences https://kids.niehs.nih.gov/games/songs/childrens/smile-song/index.htm materials explaining the benefits of dental sealants and the importance of maintaining baby teeth through such channels as the Maine Primary Care Association, rural hospitals, rural health clinics and critical access hospitals.

The SOHP continues to collaborate with From the First Tooth Program and the Children’s Oral Health Partnership to increase the number of providers educated on the importance of oral health.

Performance Measure: Percent of children, ages 0 through 17, who live in households where someone smokes

Current Status: Based on the 2017-2018 National Survey of Children’s Health (NSCH), 16.0% of children in Maine live in a household where someone smokes; 2.1% live with someone who smokes inside the home These rates are slightly higher compared to the those at the national level being respectively 14.9% and 2.0%. https://www.childhealthdata.org/browse/survey/results?q=7156&r=21.

Exposure to environmental tobacco smoke is highest among children living in homes in which the highest education level of an adult in the household is high school diploma; 44% of these children live with someone who smokes. Similarly, among children insured through MaineCare, 30% live with someone who smokes compared to 9% of those with private insurance.

Objective: Maintain the Smoke-Free Home Pledge program. Reach out to landlords, municipalities and multi-unit housing authority to adopt smoke-free building policies. List rental housing on the MaineHousingSearch.org website to change social norms around tobacco use and smoking.

During FY19, The Tobacco Prevention and Control (TPC) team used a multi-layered approach to implement strategies that support social norms change to decrease tobacco use acceptability in the home. Through MaineHealth’s Center for Tobacco Independence (MaineHealth-CTI), TPC implemented several environmental strategies aimed to protect children from secondhand smoke (SHS) exposure, change social norms and decrease acceptability of tobacco use. The environmental strategies included adoption of smoke-free home pledges and smoke free policies by landlords, municipalities, multi-unit housing, and youth-serving entities. The following outcomes reflect the successes achieved.

• The Smoke-free Home Pledge is a strategy implemented to encourage families in Maine to protect their children from SHS and live a healthier life.

For the reporting period, adults across Maine took 7,491 Smoke-free Home Pledges. This number failed to meet the cumulative annual target of 8,500 by 1,009 pledges. Potential factors contributing to the shortfall may be population motivation and readiness to take the pledge. TPC used this evidence-based strategy measure to create community recognition around the importance of preventing children’s exposure to SHS. Targeted venues included housing authorities, schools and employer fairs. MaineHealth CTI disseminated 258 smoke-free home toolkits that support the smoke-free home pledge initiative.

• Work with Multi-Unit Housing (MUH) authorities to implement or maintain smoke-free policies

To support smoke-free policy compliance in MUH, Maine Health-CTI distributed 157 smoke-free signs to landlords, property managers, and housing authorities. The smoke-free signs cover 16 buildings and at least 153 tenants. MUH passed or revised six (6) smoke-free policies as a result of 78 outreach sessions and 40 technical assistance (TA) sessions provided by Maine Health-CTI to municipal administrators and employees. The adopted policies protect more than 500 tenants. Evidence shows that exposure to SHS is never safe. Therefore, the adoption of the six (6) policies is ‘considered substantial success’.

The 82 TA sessions offered to municipal administrators resulted in 13 new policies adopted by municipalities prohibiting the use of tobacco products, including Electronic Nicotine Device Systems (ENDs).

• Work with schools and Youth-serving entities to increase the adoption of tobacco and smoke-free policies

Youth-serving entities adopted 25 new tobacco and smoke-free policies to protect children from SHS as the result of 212 outreach sessions and 30 TA sessions. These sessions provided discussions on the importance of comprehensive tobacco and smoke-free policies. The policies included ENDS.

• Promote the Mainehousingsearch.org as a means to increase change in social norms.

Maine Health-CTI promoted the MaineHousingSearch.org as a website where landlords can list their smoke-free rental housing. For the reporting period, 39.8% of rental housing were advertised as smoke-free. MaineHealth-CTI delivered 32 outreach sessions to landlords, property managers and housing authorities to highlight the importance of adopting a comprehensive smoke-free policy to prevent death, disease and disability among tenants, especially children.

The Maine Families Home Visiting program provided information on the impact of SHS on children’s health and development. If a family is ready, family visitors develop harm reduction strategies that lessen the impact of SHS on the child. Family visitors support these strategies by providing cessation resources that include information on the QuitLink website.

Current Efforts

TSUPCP and MaineHealth-CTI continue to implement strategies associated with the elimination of SHS exposure to protect the health of children during FY20.

To date, a cumulative number of 8,091 pledges were taken by adults across Maine. Maine Health-CTI continues to use the Smoke-Free Homes Pledge as an engaging strategy to eliminate exposure to SHS in the home. Additionally, Maine Health-CTI distributed 212 smoke-free home toolkits that support the smoke-free home pledge initiative.

During the first six months of FY20, MaineHealth CTI delivered seven (7) pre-policy and implementation TA sessions to landlords/property managers. To date, no policy has been adopted.

As a result of the 23 TA implementation sessions delivered, two municipalities adopted eight (8) tobacco and smoke-free policies that include ENDS and Marijuana. These new policies cover 20,853 residents in the Waldo County areas.

Municipalities adopted eight (8) new policies prohibiting the use of tobacco products, including ENDS. MaineHealth-CTI delivered 97 outreach sessions and 32 TA sessions to municipalities to educate and raise awareness on the dangers of SHS and to encourage social norms change through smoke and tobacco-free policy adoption.

Multi-unit housing adopted six (6) smoke-free policies protecting more than 153 people, including children, from the harmful effects of SHS exposure. These policies resulted from MaineHealth-CTI’s effort to deliver 82 outreach sessions and 38 TA sessions to landlords, property managers and housing authorities to highlight the importance of a comprehensive smoke-free policy resulting in smoke-free policy adoption.

Youth-serving entities adopted four (4) tobacco-free policies as a result of 12 TA and 82 outreach sessions to discuss the importance of comprehensive tobacco and smoke-free policies that include ENDS. These took place with schools and youth-serving entities to prevent tobacco initiation and SHS exposure among youth.

Currently, 41.0% of rental housing listed on the MaineHousingSearch.org advertised as Smoke-free. MaineHealth-CTI delivered 82 outreach sessions to landlords, property managers and housing authorities to highlight the importance of adopting a comprehensive smoke-free policy to prevent death, disease and disability among tenants, especially children.

A combination of factors such as participant readiness and provider limited capacity to carry new projects may be challenges that slow down progress. As in the past, TSUPCP is working with its team to allocate more resources to this work.