New Hampshire - 2021 - III.E.2.c. State Action Plan - Child Health

National Performance Measure # 6:

Percent of children, ages nine to 35 months, receiving a developmental screening using a parent-completed screening tool

Evidence Based or Informed Strategy Measure # 6.1:

The number of sites using the Ages and Stages Questionnaire (ASQ) and the ASQ - Social Emotional (ASQ- SE) screening tools and participating in the Watch Me Grow (WMG) system

Objective: To increase from 32% (2016 FAD baseline) to 46% the percent of children, ages nine months to 35 months, who receive a developmental screening using a parent-completed screening tool, by 2023.

Strategies:

Promote the training of professionals to utilize the ASQ and ASQ-SE screening tools.
Provide leadership and group facilitation to WMG and the NH Act Early Teams.
Review and identify gaps based on environmental scan and data analysis that was completed in SFY 18.
Promote developmental screening, participation in WMG, and use of the online ASQ screening tool (as soon as the data bridges have been completed).
Educate the public through dissemination of the CDC’s Learn the Signs Act Early (LTSAE) materials, NH specific ‘fact sheets’ and updated web-based information.
Support the activities of the Learn the Signs Act Early Ambassador.
Collaborate with the NH Pediatric Improvement Partnership (NH PIP) on efforts related to developmental screening.

Data Analysis

According to the NSCH, 2018, 36% of children, ages nine through 35 months, received a developmental screening using a part-completed screening tool. This is a slight drop from the combined 2017-2018 numbers but overall, an increase from the previous two years.

Those involved in the work believe that many more children are being screened that those represented in the NSCH sample. To help provide information to support this theory, Watch Me Grow, NH’s Developmental Screening System, distributed a survey in early-2019. While only 36 parents and caregivers responded, the results indicate that children are being screened in locations other than the home, including physicians’ offices (largest percentage), child care locations, Head Start, early intervention programs and schools.

WMG data (2010 to 2017) demonstrates an increase in the WMG Comprehensive Family Resource Center sites from five to 14. The number of sub-locations (that provided data to WMG sites) grew from three to 54 during the same time. As of June 30, 2019, the number of sub-locations providing data dropped to 45. However, the data shows that 1011 additional screens were reported without identification of a sub-location. This indicates a need to better support the collection of data and the potential that the actual number of sub-locations is higher than reported.

Systems Building

NH’s system for developmental screening has multiple entry points through which families with young children can access screening, evaluation and services for children with or at risk for developmental delays. Watch Me Grow (WMG) has been the foundation of the system by promoting and providing access to ASQ and ASQ-SE, through community based agencies including Family Resource Centers (FRCs), Head Start/Early Head Start, and child care. Screening also occurs in clinical settings as part of routine well-child visits and during encounters with mental health providers.

NH DHHS Maternal and Child Health Section (MCH) and Bureaus for Family Centered Services (BFCS) and Child Development and Head Start State Collaboration Office (HSSCO) have provided joint leadership for WMG, which promotes the use of the ASQ and ASQ-SE since 2008. In August 2018, Associate Commissioner Christine Tappan, appointed BFCS as the lead for developmental screening for the Department of Health and Human Services (DHHS). Since the Systems of Care Program Specialist for BFCS was given the responsibility of coordinating the WMG Steering Committee and as well was the state’s CDC Learn the Signs Act Early (LTSAE) Ambassador, the work of the Act Early Team was merged into the Watch Me Grow Steering Committee. Budget information and administration for the website, ASQ online and Welligent (web-based data collection system) transitioned to BFCS and the WMG implementation guide was revised to reflect changes.

Although the WMG plan included the promotion and effective utilization of the ASQ online version, lack of capacity to oversee the building of the “bridge” to integrate the data across the different data systems, delayed progress. Targeted education and promotions will be needed for families to learn about availability of the online version. This continues to be a priority for the WMG steering committee.

Data integration continued to challenge NH’s efforts. Primary care providers are typically reluctant to partner with WMG for two main reasons: time and means. Providers report having little time to discuss screening and results with families and do not have additional means needed to share the data with WMG. In addition, providers use a variety of screening tools that are not part of the WMG data collection system.

The Title V agencies (MCH and BFCS) continued to coordinate with partners across the systems of care for children with and without special health care needs to ensure that families have access to developmental screening. Families have been assisted with the completion of ASQ and ASQ: SE through MIECHV home visiting programs and Comprehensive Family Support Services-Family Resource Centers (CFSS). MCH and BFCS worked with partners to promote and support connections between professional organizations and service providers including area agencies for developmental services, behavioral health, child welfare/protection, Community Action Programs, pediatric providers/FQHCs, advocacy organizations, early intervention programs, the Department of Education, birthing hospitals, higher education, philanthropy, the state legislature, early care and education providers/programs, visiting nurse associations, child care licensing, and programs for grandparents raising grandchildren.

Although NH promoted the need for training of professionals to utilize the ASQ and ASQ-SE screening tools, Child Care Aware of New Hampshire reported that they were unable to provide trainings for child care providers to learn about WMG and how to implement the ASQ and ASQ-SE, in State Fiscal Year (SFY) 2019. This was due to the extended leave of absence of the primary trainer.

The WMG Steering committee continued to engage in cross system planning and coordination of activities, while working to expand the system based on recommendations that were made by the Developmental Screening Referral, Diagnosis, and Services (DSRDS) Task Force in SFY 2018. These recommendations became part of the plan for enhancing the State’s developmental screening system.

From BFCS, the Systems of Care Program Specialist participated in the Spark NH Policy Subcommittee and the Title V Director and Part C Coordinator participated in the state’s Early Childhood Integration Team (ECIT) representing CYSHCN for NH’s early childhood systems work which “envisions that all children and families are healthy, learning and thriving now and in the future; families have access to the supports and services they need for optimal development, including a comprehensive, coordinated, and sustainable multi-tiered system providing targeted as well as universal services.”

In November 2018, the University of NH submitted NH’s application for a Preschool Development Grant (PDG) which identified “developmental screening early and often to identify concerns and timely linkages to appropriate, needed services” as one of three fundamental elements critical in fostering the state’s vision. The application acknowledged that “many communities are working to increase developmental screening of children in partnership with the Watch Me Grow state developmental screening systems, as well as, providing early childhood care and education professionals first responders, early learning teachers, and police with trauma informed training.”

The PDG identified the existing developmental screening system called Watch Me Grow as locally based and included in the Family Resource Center infrastructure but without adequate funding to be expanded and implemented rigorously. With input from parents during a needs assessment process and informed by BFCS, responsible for leading the state-level work on the developmental screening system, the strategic plan task force will evaluate the effectiveness of the current system and partner with the Watch Me Grow Steering Committee to develop NH’s strategic plan.

BFCS provided input to the grant application with recommendations that DHHS’s work be aligned with the Title V goals for Developmental Screening: (1) promote the training of professionals to utilize the Ages and Stages screening tools, (2) review and identify gaps based on environmental scan and data analysis; (3) promote developmental screening, participation in Watch Me Grow, and use of the online ASQ screening tool; (4) educate the public through dissemination of the Centers for Disease Control and Prevention’s Learn the Signs Act Early materials and NH specific ‘fact sheets; and (5) collaborate with the NH Pediatric Improvement Partnership on any efforts related to developmental screening.

Title V Specific Activities

In September 2018, NH was selected to work with the National MCH Workforce Development Center as part of the Fall Cohort 2018. The project goal was to design a comprehensive system that expands beyond the promotion of ASQ and ASQ-SE to address the needs and gaps occurring throughout the State in an enhanced version of Watch Me Grow.

The team began this project in a true NH way by hitting a few potholes, including one of the travel team members needing to drop out at the last minute for health reasons, and the realization that an entire system could not be changed or built in just nine months. The team realigned priorities and committed to completing the task. The perspectives of new partners was refreshing and provided new and exciting energy for the project, and the team was able to articulate the following Aim Statement: “To align developmental screening efforts to support young children and their families across the State because we see inefficient use of resources, gaps in access, and duplication. We will convene stakeholders with a role in DSRDS; to create a work plan by June 1, 2019, for improving the coordination of the system.” Cross system collaboration on the Core and Full teams was foremost through the entire process.

The Developmental Screening Stakeholder Meeting was planned and held in May 2019 with the theme of “Engaging Stakeholders” to inform the creation of a state-wide plan for improving the coordination of the developmental screening system in NH. Stakeholders participated in small group system mapping exercises and the results were compiled to create a large system map. Sixty-five participants included Medical Provider Teams, Home Visiting, Spark NH (the state’s early childhood advisory council at the time), Family Centered Early Supports and Services (Part C), and Family Resource Centers; to name a few.

It was critical to recognize the accomplishments that were already done and the foundation of the system that was Watch Me Grow. Creating a plan to move forward and continue to engage stakeholders more consistently would strengthen partnerships.

When the Watch Me Grow Steering Committee met on May 17, 2019, the recommendations based on the results of the Stakeholder meeting were presented and the committee voted unanimously to expand the existing WMG Developmental Screening System to become the WMG Developmental, Screening, Referral, Diagnosis, Treatment, & Services System.

NH’s Title V Cohort Team gained a critical piece of knowledge from working with the Center: how to work through a process to ensure stakeholder involvement. Critical skills gained from engagement with the Center included the ability to use tools to enhance how to work as a team to engage stakeholders. Overall, this project enhanced the ability of NH’s Title V workforce to support health transformation by providing tools to continue to work on moving forward with a state plan after the time with the center was complete. The

BFCS was somewhat successful, encouraging a dialogue about and providing educational materials from the LTSAE campaign and sharing information on best practices. However, due to the extended leave of absence of the Systems of Care Specialist in FY 2019, the dissemination of the CDC’s Learn the Signs Act Early (LTSAE) materials, NH specific ‘fact sheets’ and updated web-based information along with the activities of the Learn the Signs Act Early Ambassador, were delayed.

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National Performance Measure #8.1: Percent of children ages 6 through 11 who are physically active at least 60 minutes per day .

Evidence Based or Informed Strategy Measure: Percentage of children ages 6-11 enrolled in Comprehensive Family Support Services (CFSS) whose parent reports that the child gets at least one hour of physical exercise per day.

Objectives: By July 1 of 2021, increase the average by at least five percentage points overall of children who have had a high BMI and documentation of counseling/referral at the MCH funded CHCs in state fiscal year 2021.

Strategies:

Screening and intervention on physical activity among MCH funded contract agencies (e.g. home visiting-MIECHV and CFSS and CHCs)
Professional training on increasing physical activity
Include physical activities during home visits with families
Encouragement of clientele by health and social service providers for children and families to increase physical activity through fun, family-centered, local, community-based opportunities

Data Analysis

Childhood obesity continue to be a problem among children of all ages in the State of NH, According to the State of Obesity report, some 15.8% of 2-to-4 year old WIC participants are obese and 12.3% of children age 10-17 are obese,[1] giving NH rankings of 8/51 and 38/51 in the US. Data from the National Survey of Children’s Health (NSCH) in 2018 for this NPM#8 shows that 27.6% of children ages 6-11 in NH are physically active at least 60 minutes per day.[2]

MCH provides Title V funding leveraged with that from the DCYF and administered by the Division of Economic and Housing Stability (DEHS) through the CFSS program to eight agencies that offer a Family Resource Center (FRC) for center-based activities and resources, and for doing home-visiting with low income families with children, in 13 different communities statewide. This program provides education, coordination of care, and support for safe and healthy families to aid in the prevention of child maltreatment. In an effort to expand the focus of a healthy family, this performance measure has focused on working to improve the physical health of enrolled children and their families by increasing physical activity, to promote a healthy lifestyle. In 2019, a total of 1,389 families were served by these funded services, which included 2,410 children.[3] Services were provided primarily at the agencies’ CFSS FRCs, but also at home visits, some of which were reimbursable by Medicaid. The strategy being used is that of the 5-2-1-0 Healthy NH, a statewide public education campaign to bring awareness to daily recommendations for nutrition and physical activity, and which identifies steps that families can take to prevent childhood obesity.

	Children ages 6-11
	Discharge FY19	Yes		No	No Data
Berlin	31	31		0	0
Claremont	19	19		0	0
Concord	33	27		6	0
Conway	25	23		0	2
Keene	81	74		4	3
Laconia	79	78		1	0
Littleton	15	15		0	0
Manchester	42	40		2	0
Nashua	33	26		7	0
Portsmouth	29	25		4	0
Rochester	92	81		11	0
Salem	11	11		0	0
	490	450		35	5

	Improve		27
	No Change		449
	No Improvement		9
	No Data		5
			490

Upon enrollment into the CFSS program, if there is a child of age 6-11 in the family, the parent was asked if the child currently participates in at least one hour of moderate to vigorous physical activity every day. A data element was added to the DEHS/DCYF electronic data collection form to capture this information. At discharge, the parent of the child was asked again about having at least one hour of physical activity per day, and again, data entry was made into DCYF’s electronic data collection form.

Of 1,389 families and 2,410 children receiving services during FY19:

As of April 2019, FY19 results showed that 92% of the parents with a child enrolling in CFSS services indicated that the child had at least one hour per day of physical exercise. At the time of discharge, again 92% of parents indicated their child (450 of 490) had at least an hour, which was an increase from the 86% initially reported. As this was a multi-year measure, growth can be seen from the first year of data collection in the CFSS program in 2016 which demonstrated 60% of families (27 of 45) at discharge, a decrease from 70% (91 of 130)[4] at enrollment. A marked difference between the general population, reporting 30% in 2016 [5] can be seen in this subgroup of participants of home visiting. In the most recent year of data, this difference has grown with 27.6%[6] reported in the Data Resource Center for Child and Adolescent Health compared to the 92% found in home visited families in the most recent year of data. These differences could be related to data collection practices of each data source, it could be lifestyle differences found in families served in home visiting, or it could be related to the specialized support and family centered practices that home visiting employs. The children were not necessarily the same from enrollment to discharge in FY20, as some had been enrolled the previous year. However, at the time of discharge, 27 had improved since enrollment. Four hundred twenty three (423) continued to respond Yes; 26 continued to respond No. Nine indicated a negative change in initially responding Yes, but by discharge, admitting to No.

MCH continues to require its Title V-funded community health centers to report on BMI and counseling related to the 5-2-1-0 campaign. In SFY19, the MCH primary care contract agencies were required to report on the following performance measure, derived from HEDIS:

Percentage of patients aged 3 to 17 who had evidence of BMI percentile documentation

AND who had documentation of counseling for nutrition

AND who had documentation of counseling for physical activity during the measurement year.

The numerator for this is the number of patients in the denominator who had their BMI percentile (not just BMI or height and weight) documented during the measurement year and who had documentation of counseling for nutrition and who had documentation of counseling for physical activity during the measurement year. This is based on one of the current UDS Primary Care Clinical Performance Measures.

cid:image003.png@01D63450.78F1F840 The denominator for this is the number of patients who were one year past their second birthday (i.e., were 3 years of age) through adolescents up to one year past their 16th birthday (i.e., until they turned 17) at some point during the measurement year, who had at least one medical visit during the measurement year, and were seen by the health center for the first time prior to their 17th birthday.

Update: The SFY19 results indicated that agency results ranged from 6-100% with a weighted average of 70%, the average has slightly decreased from the previous year of 72%, although, it should be noted that the lowest performing agency changed its EMR system during this reporting period, contributing to this year’s decrease.

National Outcome Measure #20

Percent of children, ages 2-4, and adolescents, ages 10-17, who are obese (BMI at or above the 95th percentile).

Childhood obesity is an issue that the State continues to struggle with, over a quarter of children ages 10-17 are overweight or obese with 13.5 % classified as obese in 2018. NH is doing better than many states ranking 8th in the nation for least obese or overweight children aged 2-4, and 38th for children aged 10-17 [7] but this issue still impacts many children in the State. Both the high score in overall child health and measures for BMI can be dramatically impacted by the systems within which the children live.

Systems building

On January 23, 2020, Governor Chris Sununu signed Executive Order 2020-03 [8] establishing the Council for Thriving Children as NH’s Early Childhood Council, alongside officials from the NH Department of Education (DOE), Department of Health and Human Services (DHHS) members from the University System of NH and Early Childhood Development Stakeholders.

Beginning with the B-8 needs assessment over 2 years ago and continuing through strategic planning efforts, recommendations for a new governance structure emerged to guide the future work of NH’s Birth - 8 Early Childhood Care and Education (ECCE) system. The structure proposed is charged with developing and advancing the state’s vision for children, families and communities; formalizing collaborations and connections to foster efficient high quality services for children and families; and using a strong equity lens to guide implementation based on agreed principles and goals. This effective and inclusive structure also formalizes governance at the state and regional/local levels and engages stakeholders with defined roles and a shared vision. It addresses inconsistencies in regulations and service eligibility requirements, reduces duplication of services and uses ongoing evaluation, robust data, and current research to inform decision-making.[9]

MCH staff participates in the DHHS Early Childhood Integration team with representatives from all early childhood serving programs housed in DHHS, including but not limited to childcare, children’s mental health, child welfare, WIC, Medicaid, and health equity. In addition MCH home visiting program staff have been appointed to be the designated liaison to the B-8 ECCE Advisory group which, although participants have not been specifically designated as of yet, will likely have the voice of families and family-serving organizations represented. This will allow greater collaboration with a variety of programs that serve families and children and the engagement of families in the planning to support systems serving children and families in NH. Meetings are now focused categorically by the social determinants of health with updates from programs that seek to support these. WIC and DEHS for example provided a presentation to discuss food insecurity and strides being made to support families in accessing healthy foods, with specific attention made to barriers that have arisen due to the COVID-19 pandemic and systems change that could be implemented to better meet the needs of families to access healthy foods during this time.

The DPHS Chronic Disease Program (CDP) has worked closely with schools and child care throughout the State to implement environmental strategies that reinforce healthful behaviors and expand access to healthy choices. In the past year, it has continued its activities in working with licensed child care programs to improve nutrition and/or physical activity policies and practices; has provided health and wellness trainings as part of the annual regional Caring for Our Children Health, Safety and Nutrition conferences [10] offered throughout the State which are organized by Child Care Aware of New Hampshire; and, through a contract with Keene State College, has worked with NH School Administrative Units (SAUs) to assist school food directors in assessing and improving school nutrition environments and local wellness policies.

MCH works closely with health care providers and other community based child-serving agencies to promote parent education, health systems interventions, and community and clinical interventions. There are several initiatives throughout the State involving integration of community-based nutrition, physical activity, built environment and transportation system projects. Across NH is a project funded by the NH DHHS Child Development Bureau which provides consultation and training to afterschool professionals. Additionally, the Child Care Licensing Unit adopted regulations requiring that full-day programs provide at least one hour of physical activity each day.

The MCH-contracted Primary Care agencies and the Home Visiting agencies continue to work with their local WIC agencies in getting eligible pregnant women and children enrolled in WIC. The state WIC Program continues to emphasize breastfeeding, and encourages enrollment for its food package with fruits and vegetables, which is all focused on obesity prevention. The WIC program has successfully rolled out and is currently implementing eWIC throughout the State. The program just finished participating in a rebranding campaign for retention and outreach.

MCH specific activities

MCH has continued to co-facilitate the monitoring of the CFSS agencies with staff from the Division of Economic and Housing Stability, through quarterly meetings and analysis of performance measure outcomes. As stated previously, funded agency staff work with families with children of ages 6-11 on strategies to sustain or increase daily physical activity. Materials from the 5-2-1-0 campaign are reviewed and distributed.

In addition to assessing if the child gets at least one hour of physical activity per day, and integrating education on how to include exercise into the day, the CFSS-funded agencies carry out a variety of other healthy lifestyle/exercise promotion activities that impact many of the children enrolled in their program. Home visiting allows for growth as it is responsive to the family’s needs, meeting them where they are to support growth in the areas where the family is motivated to change and grow. Home visiting in general does this through engaging families in activities that support physical activity in the home and in the community. Visits often occur on playgrounds or safe natural spaces, where learning opportunities are paired with fun activities which increase valuable parent/caregiver interaction with their children and supports parenting skills.

Due to the COVID-19 pandemic, agencies have quickly altered their home visits to virtual ones. Even with this loss of in-person interaction many home visiting agencies have responded creatively to encourage physical activity such as providing opportunities for weekly virtual yoga classes for families and continuing to wonder and support the types of physical activities families can engage in within their particular contexts [ed: “Explore and Wonder” is a tool used by home visitors that utilizes nonjudgmental language to wonder and explore behaviors and barriers, to make a comfortable space to talk about behavior change].

As agencies thoughtfully consider re-opening strategies for home visiting, it has been noted that for high-need families home visits might occur outdoors to limit risks from a more traditional home visit that would occur inside the home. This strategy would likely support physical activity and time in a natural environment. Time spent in nature, physical activity, and yoga are all strategies that can support better coping mechanisms and stress reduction, which would likely be helpful for families currently facing heightened stress in response to the COVID-19 pandemic.

Agencies have access to evidence-based curriculum which provide ideas for fun physical activities. Some agencies, in response to the stay-at-home order due to the COVID-19 pandemic have led virtual groups or videos demonstrating how to do the activities. For families reluctant to engage virtually, home visitors have left materials and curriculum handouts for families on their doorsteps as a way to continue to support families in having access to activities to support their child’s development. Family resource centers and home visitors also have a myriad of educational materials such as pamphlets on a variety of health topics, which can support messaging that they may be hearing at health appointments, but for some families receiving these same materials in their own homes can create greater comfort to ask questions that they may not have asked at their last health appointment.

Support is also provided in linking families to resources and other services in their communities to overcome barriers that could impede health outcomes such as accessing health services or finding funding for summer camp, gym memberships, or sporting equipment so their children may participate even if family funds are not available. Home visiting is offered in NH prenatally until the age of 21, and although this particular measure is focused on age 6-11, healthy habits created in the younger years provide a foundation for families to adopt healthy habits throughout that child’s development. Agency staff have shared the importance of supporting families by joining with them in fun or simple activities that support the family in overcoming anxiety about navigating the world around them. Examples like going to the park or walking with a family during home visits have led, over time, to that family now weaving after dinner family walks into their regular routine.

The agencies are local organizations that are embedded in their communities and through visiting families in their homes create bridges between families and their communities. This allows greater awareness, exposure, and comfort to engage in fun activities, such as playgroups, healthy affordable cooking classes, 5K races or family fun days that not only provide time for physical activity but increase social connection and supports between community members.

Feedback from agencies also provide state staff with greater awareness of systemic issues that can impede physical activities – greater understanding of why physical activity for young children can be harder for those living in apartment complexes in the city, or that sidewalks are not available in certain areas of the State. And the challenges that long NH winters bring for those who may not have snow tires and who feel unsafe walking with their children in the street when sidewalks are unplowed. These examples all provide a deeper understanding of the diverse challenges encountered due to economic challenges or the environmental context that the family is navigating. This allows state staff to then bring these voices to larger interdepartmental meetings, such as the early childhood integration team, to strategize solutions for more equitable environments to support greater health outcomes for all of the people in NH.