Overview and Context of Population Domain

Childhood is a time of rapid, continuous development. As a child’s brain and body develops, their health is shaped by the foods they eat, the attention they receive, and the interactions they have with their surroundings. Critical cognitive skills develop in early childhood. The early acquisition and refinement of these executive functioning and self-regulation skills can have positive, life-long effects1. Such skills are crucial for learning, social development, and the adoption of positive behaviors. The early identification of developmental issues, therefore, is critical to the child’s wellbeing2. In 2018-2019, Louisiana’s developmental screening rates were below the national average3.

While childhood is a time of tremendous development, it can also be a time of vulnerability. Between 2016-2018, about half (51%) of childhood deaths ages 1-14 in Louisiana are due to injuries. Most of these deaths are considered preventable. The majority of child injury deaths are due to motor vehicle crashes, drowning, and homicide. Louisiana’s rates for each are approximately double the national average4. Non-fatal injuries can have life-long consequences for a child, and injury-related hospitalizations are a leading cause of child hospitalizations in Louisiana. In 2018, the top causes of injury-related hospitalization for children 1-14 in Louisiana were traumatic brain, unintentional fall-related, motor vehicle traffic-related, and assault-related injuries5.

Summary and Reflection of Domain-specific Title V Efforts to Date

A main area of work in the child health domain has been to advance the development of comprehensive local-level early childhood systems. In alignment with the national Title V priorities, strengthening developmental screening has been a particular area of focus, with much of Louisiana’s Title V developmental screening and developmental health strategies emerging out of the complementary actions of state and local level bodies described below.

State Young Child Wellness Collaborative: In 2014, the Title V Program established the State Young Child Wellness Collaborative (YCWC) to bring together various state and community agencies to work toward improving systems of care for children in Louisiana. The primary role of the SYCWC is to drive state system change and to ensure community priorities have visibility at the state-level. The body also serves as the state-level advisory board for the Maternal Infant Early Childhood Home Visiting (MIECHV) Program and the Early Childhood Comprehensive Systems (ECCS) grants. The YCWC has representation from various statewide entities, including MIECHV, Title V, the Governor’s Office, Medicaid, IDEA Part C/EarlySteps, Louisiana Department of Education-Early Education Division, LDH-Office of Behavioral Health, Department of Children and Family Services (DCFS) - Child Welfare, Tulane Institute of Infant & Early Childhood Mental Health, and the Louisiana Chapter of the American Academy of Pediatrics (AAP).

A key function of this group has been the creation of a state-level platform for highlighting, understanding, and responding to the ways in which centralized early childhood systems elements are functioning at the community level. BFH provided the staffing time to facilitate the meetings, support the tracking and follow-up communications related to identified deliverables, and keep the group focused on their identified priorities.

Comprehensive System of Care for Early Childhood Proposal: The YCWC and Title V workgroups have been instrumental in convening cross-cutting teams to develop policy briefs and proposals in particular related to developmental screening, mental health, and more recently home visiting, primary care, care coordination, and developmental health supports. This work has laid the foundation of preparedness for tangible policy proposals to be advanced formally and informally through Title V staff and partnership activities.

Over the past several years, staff from various offices across LDH have been working together to coordinate efforts on shared priorities around young children’s development, particularly social emotional development and mental health. More recently, the work has turned to the challenge of developing a cohesive shared agenda that encompasses approaches that can be brought to scale and sustainably funded. Building off of the work of the YCWC to create a defined early childhood state policy agenda, BFH led the LDH staff workgroup in the development of a proposal for a comprehensive system of care for young children and their families. The proposal drew upon BFH’s participation in technical assistance from Zero to Three, consultation with Johnson Consulting Group related to Medicaid financing of early childhood supports and services, and a call-to-action from the Governor’s Children’s Cabinet requesting that LDH develop a proposal for a Comprehensive System of Care for Early Childhood.

In January 2020, the LDH staff workgroup finalized their Developmental Health Strategic Plan that outlines priority opportunities to strengthen universal promotion, targeted prevention, and intervention for families and young children in Louisiana. Originally, BFH was charged with coordinating implementation of the plan and shepherding LDH towards a shared agency-wide early childhood agenda for a comprehensive early childhood system. However, in light of the COVID-19 pandemic and changes to LDH leadership, staffing, and agency priorities, a formally coordinated approach to implementation of the plan was put on hold.

Developmental Screening Initiative: During the FFY 2016-2020 cycle, Louisiana Title V prioritized developmental screening. In FFY 2016, Title V supported a developmental screening workgroup, established through the YCWC, that was tasked with formulating guidance around comprehensive developmental screening for young children in Louisiana. The workgroup researched, selected, and endorsed a limited group of screening instruments across key developmental domains to be promoted in primary care and other settings. The Louisiana Developmental Screening Guidelines (LDSG) expanded beyond the standard developmental milestone and autism screening as recommended by Bright Futures, and followed the 2014 Standards for Systems of Care for CYSHCN, the 2012 AAP Policy Statement on childhood adversity and toxic stress, and the 2015 AAP Clinical Report addressing screening for social and emotional risk. 

The LDSG were created to support pediatric and family medicine providers who serve children 0-5 years with the tools to implement and maintain robust screening services at the practice level. These services aim to ensure that children experiencing challenges to their development will be promptly identified, referred for evaluation, and linked to early intervention services when indicated. BFH developed a comprehensive work plan around dissemination of the LDSG, supporting implementation of screening services at the clinic level, and working with key stakeholders who serve the early childhood population around establishing/improving communication channels and tracking mechanisms to support an effective early childhood system of care. In FFY 2017, Title V established a full-time Developmental Screening (DS) Coordinator position to lead the implementation of the work plan. The DS Coordinator convened a dedicated Title V workgroup to support implementation and advise upon changes to the work plan.  

The DS Coordinator and workgroup collaborated with the BFH communications team to develop resources and a suite of virtual training materials to support Louisiana providers serving young children in implementing the LDSG. In FFY 2018, the workgroup also created referral tip sheets for each of the nine LDH regions to help familiarize providers with developmental resources and supports for families in their region. In FFY 2020, the workgroup refined these tip sheets to streamline the maintenance of the resources and combine areas of similarity. Three screening resource sheets were developed for each region: General and social emotional development, Autism, and Family wellness related screens, for a total of 27 sheets.

In a process that began in FFY 2020 and concluded in FFY 2021, BFH and the YCWC reviewed the LDSG and made changes to the original guidelines based on recent scientific and policy evidence for best-practice. The LDSG were initiated in 2015 and presented in 2016, so after four years of use and potential developments in the scientific and policy literature, the DS Coordinator led the project workgroup to update the guidelines to match with best practices and evidence.

Developmental Screening Technical Assistance Pilot: The library of resources created in FFY 2017 and FFY 2018 were combined into a technical assistance package that was piloted in LDH Region 4 beginning in FFY 2018. Initial outreach efforts focused on providers identified from community systems mapping work completed in FFY 2017, and consisted of mailing a packet of resources with an invitation to participate in the technical assistance pilot. This strategy yielded no responses, at which point the DS Coordinator and RN Program Consultant decided to leverage community connections established by staff in the region. Regional staff provided a warm handoff between the providers they consulted with and DS staff, resulting in successful engagement with four primary care clinics in Region 4 and a Federally Qualified Health Center in Region 8.

For each of the five participating clinics, DS staff initially sought buy-in from at least one primary care physician in the practice, and subsequently the clinic manager if there was one. Securing sufficient buy-in to schedule time for DS staff to meet with clinic staff proved to be more challenging than anticipated in some clinics, and so getting the technical assistance (TA) off the ground took some extra work. The TA Request form allowed DS staff to customize the TA to each clinic, which varied widely in patient volume, staff capacity, and existing screening practices. TA typically consisted of one in-person training and discussion with clinic staff, additional calls with the clinic manager as necessary, and provision of online screening instrument training webinars for staff to watch when their schedules allowed.

During summer 2019, BFH hosted two student interns through the CDC and Harvard T.H. Chan School of Public Health (HSPH) Program Evaluation Practicum. The DS staff worked with the HSPH Program Evaluation Practicum students and faculty mentors to develop an evaluation plan of the DS technical assistance pilot. The plan was further refined and implemented by the new DS coordinator, the CSHS epidemiology team, and a MD/MPH student intern in early FFY 2020. Findings from the evaluation were utilized to refine the TA offerings, processes, and materials that are included in the new online Developmental Screening Toolkit that was released during FFY 2021.

Learn the Signs. Act Early (LTSAE): In FFY 2020, the Developmental Screening Coordinator continued to serve as the Act Early Ambassador to Louisiana, representing the Learn the Signs. Act Early. program. This program is run collaboratively between the Centers for Disease Control’s (CDC) National Center for Birth Defects and Developmental Disabilities and the Association of University Centers on Disabilities (AUCD). LTSAE aims to improve early identification of children with autism and other developmental disabilities by creating materials to engage parents in developmental monitoring. These materials include age-specific milestone checklists, a milestone tracker app available for both Apple and Android, children’s books written to be developmentally specific to two- and three-year-olds, and trainings for medical and child care providers.

The Act Early Initiative supports Ambassadors in nearly every US state and territory to work collaboratively within their state to integrate the LTSAE materials in young child-serving systems, with the goal of improving early identification and connection to early intervention and other needed supports and services. As Act Early Ambassador to Louisiana, the DS Coordinator created a work plan to integrate LTSAE materials into the Developmental Screening Technical Assistance package to primary care providers, as well as into the statewide MIECHV program.

Primary care integration proceeded seamlessly, and the materials were provided to all providers participating in the TA project. Information about the program was also immediately integrated into all developmental screening presentations given, including the screening instrument training webinars. A link to the LTSAE website was also included on the Developmental Screening page on the Partners for Family Health website.

MIECHV integration was also very successful, but due to the much larger workforce and reach of MIECHV compared to the developmental screening TA, implementation proceeded at a slower pace. After consulting with MIECHV leadership, it was determined that piloting integration of materials in one home visiting team from each model (Nurse Family Partnership in the Monroe area and Parents as Teachers in the Shreveport area) would help inform successful statewide integration. Regional leadership identified a home visitor from each team willing to work with the Ambassador to determine which materials would be most useful, when to introduce the materials to families, and what context would be helpful for home visitors to appreciate the value of the materials. Training presentations were created for each team and reviewed by MIECHV leadership and the volunteer home visitors.

In FFY 2020, Louisiana LTSAE team added a deputy ambassador from the Louisiana Department of Education (LDOE) to integrate LTSAE materials into the state early childhood education system. The ambassadors worked together to co-brand and customize LTSAE materials for each of the 64 parish school systems. The customized materials included LDH and LDOE logos, as well as the logo for each parish school system. Each checklist or brochure contains logos for LDH, LDOE, and the respective parish school system, as well as the contact information for two key resources: EarlySteps (early intervention: birth to 3) and Child Find (3-21 years).

Beginning in FFY 2020, the expanded cross-agency LTSAE team also led the development of a reference guide for LDOE early childhood program staff on how to 1) best support healthy growth and development of children in their care throughout key developmental intervals, and 2) identify children who may benefit from specialized support. In December 2020, LDOE published the Louisiana Early Childhood Developmental Screenings Guidebook on their website and the LTSAE team began promoting it through their networks. The resources within the guide are intended to help program staff deepen their understanding of how children develop, regardless of their individual needs, and establish a comprehensive early identification system.

Developmental Screening Presentations: In FFY 2020, BFH continued to conduct trainings and presentations on developmental screening presentations were also given. Presentation content varied somewhat by audience, but the core content included brief background on early brain development; the purpose and unique contributions of developmental screening, surveillance, and monitoring; the LDSG; using LTSAE materials to engage parents in developmental monitoring; and tips for providing resources and making referrals. Clinical and child care staff were also trained on the administration and scoring of specific screening tools.

Medicaid Policy Efforts: Over the past few years, it has become clear that working with Medicaid to implement a reimbursement policy that will incentivize DS is critical to the widespread adoption of the LDSG. In the absence of Medicaid incentives for screening, significant effort is needed to secure provider buy-in to implement systems of developmental screening in their clinics using the recommended screening instruments. Therefore, BFH began discussions with Medicaid to inform and explore reimbursement strategies for developmental screening as part of the Louisiana Medicaid Early and Periodic Screening, Diagnostic and Treatment (EPSDT) schedule. A policy proposal on the expansion of developmental screening submitted to Medicaid in FFY 2017 was determined not to be feasible for adoption in FFY 2018. However, the BFH Director and BFH Health Systems Strategy Manager facilitated ongoing dialogue with Medicaid staff in order to inform potential policy and managed care contract changes. 

During FFY 2018, BFH staff and Medicaid partners consulted with Johnson Group Consulting to analyze and create a vision for maternal and child health policy within the Louisiana Department of Health. Recommendations were created as a result of this work, including improving performance of and access to pediatric medical homes, increased use of developmental screening, increased access to developmental supports and services for young children identified by developmental screening, financing additional home visiting capacity, increasing access to infant and early childhood mental health services, and adoption of a shared measurement and accountability framework for perinatal and early childhood services. These recommendations influenced the establishment of developmental screening as a Healthcare Effectiveness Data and Information Set (HEDIS) and incentivized measure for Medicaid MCOs. The recommendations were used to inform language in the new Medicaid Request for Proposals, to which Managed Care Organizations submitted applications in FFY 2019.

In FFY 2020, Medicaid announced plans to implement the most consequential developmental screening policy changes to date:

• Beginning in December 2020, Medicaid would formally adopt the AAP Bright Futures periodicity schedule for pediatric preventive pediatric health care, including developmental, autism, and perinatal depression screenings.
• Beginning January 2021, Medicaid would begin reimbursing pediatric providers for the provision of developmental screening, autism screening, and perinatal depression screening. The new policy enables providers to bill for these services and requires them to use a standardized tool, documentation, and follow-up steps for each of the screenings. This change in billing policy represents an important step to incentive providers to complete screenings according to the periodicity schedule and use standardized tools for follow-up and documentation in accordance with recognized best practices.
• Beginning February 2021, the Medicaid Quality Improvement and Innovations section would instate a new requirement that makes MCOs responsible for creating and implementing performance improvement plans (PIPs) for developmental screening for children ages zero to three.

In preparation for the rollout of these new Medicaid policies, BFH accelerated the timeline for the development and release of an online Developmental Screening Toolkit to help medical practices implement the LDSG and integrate developmental screening services into their day-to-day practice. The toolkit is designed to house all of the information and tools needed to put the LDSG into practice in one, convenient location.

Addressing Child Injury and Violence

Regional and State Child Death Review (CDR):  As described in the previous sections, Title V supports a mortality epidemiologist and a statewide network of nine Regional Maternal and Child Health (MCH) Coordinators who work within their communities on critical maternal and child mortality surveillance activities. For CDR, the MCH Coordinators abstract comprehensive information from vital records, coroner, law enforcement, and medical reports, and summarize information on deaths among children under the age of 15 years for local panel review and systems action. The local panels are complemented by a state CDR that serves as a platform to elevate local level issues that require state-level action or the support of state CDR partners to generate change. Local and state-level CDR panels are comprised of subject matter expertise in infant and child health and safety. In addition to the nine Regional MCH Coordinators, Title V provides funding support for the mortality epidemiologist, leadership, communications support, and policy and legislative support.

The local and state-level reviews have resulted in recommendations for interventions related to the investigation and prevention of sleep-related, motor vehicle crash, drowning, homicide, and suicide deaths. During the 2019 state legislative session, BFH provided research, data (including CDR findings), and talking points for recent successful legislative efforts to improve the child passenger safety law – one of most protective in the country and based upon standards published by American Academy of Pediatrics. BFH was also awarded a grant from the U.S. Consumer Product Safety Commission that aims to reduce deaths and injuries from drowning and drain entrapment incidents in pools and spas.

Monitor and analyze trends in child injury and violence: In FFY 2020, Title V partially funded an injury epidemiologist in their work with the DCFS. By linking DCFS child welfare victim and perpetrator data with health system data and vital records, BFH has been able conduct comprehensive predictive analyses on topics such as relationships between repeated allegations, substance use and mental illness and perpetration of child abuse and neglect, and outcomes for substance exposed newborns.

Emergency Medical Services for Children (EMSC): In FFY 2018, the state’s EMSC program was moved under the purview of BFH. Louisiana’s EMSC program works with EMS agencies, emergency departments, healthcare providers, policymakers, communities, and families to reduce pediatric morbidity and mortality rates caused by acute illnesses and injuries. Louisiana EMSC does not directly receive Title V funding, but the program is supported by Title V infrastructure positions. EMSC program staff also participate in several collaborative projects with Title V programs and participated in the Title V Needs Assessment process.