Massachusetts has four priorities for Child Health for 2015-2020:

1. Promote safe, stable, nurturing environments to reduce violence and the risk of injury.
2. Promote equitable access to dental care and preventive measures for pregnant women and children. 
3. Reduce the impact and burden of environmental contaminants on children and their families.
4. Promote emotional wellness and social connectedness across the lifespan.

 

Priority: Promote safe, stable, nurturing environments to reduce violence and the risk of injury

Progress toward the first priority is measured by the rate of injury-related hospital admissions per population aged 0-9 years. Key MDPH programs that contribute to addressing this measure include the Injury Prevention and Control Program, WIC, Early Intervention Parenting Partnerships Program, MA Maternal, Infant, and Early Childhood Home Visiting program, MA Pregnant and Parenting Teen Initiative, Child Fatality Review, and School Health Services.

 

NPM 7: Rate of injury-related hospital admissions per population aged 0-9 years

In 2017, the rate of injury-related hospital admissions among children aged 0-9 years was 91.4 per 100,000, decreasing from 103.3 in 2016 and surpassing the initial 2020 objective of 110.1 per 100,000. MDPH increased the reach of its poison education trainings for child-serving agencies as a feasible and measurable primary strategy to reduce unintentional poisonings. Another strategy to reduce injury-related hospitalizations includes promotion of injury prevention in the home, community, and childcare settings by home visiting programs. These strategies align with the MA State Health Improvement Plan, MDPH’s strategic plan.

 

Injury Prevention and Control Program

Poisoning/Overdoses:

Unintentional poisoning of children is an important public health problem and poisonings are a leading cause of hospitalization among children. A 2016 meta-analysis indicated that the most successful interventions to prevent poisoning involve increasing education and awareness of poison control center services, including access to their contact numbers.[1],[2] In 2019, the most common poisoning agents for MA children aged 0-9 years among cases referred to the Poison Control and Prevention Center were analgesics and vitamins in the drug category, and cosmetics, personal care products, and household cleaning products in the non-drug category.

 

Poison prevention programming initiatives are the purview of the Massachusetts and Rhode Island Regional Center for Poison Control and Prevention based at Boston Children’s Hospital, which receives partial funding from Title V. A Community Outreach Educator works to reduce intentional and unintentional poisonings through prevention education and increasing public awareness of the Center’s services. MDPH provides both state and federal funding and oversight of the Center and of the Community Outreach Educator.

 

The Poison Control Prevention Center has two main strategies to decrease injury-related child hospitalizations: 1) increase attendance at educational collaborations with MA child-serving agencies, including WIC, Department of Early Education and Care, and Head Start, and 2) support the MA/RI Regional Poison Control Call Center. The first strategy is tracked through the following ESM: the number of providers and caregivers who attend Poison Control Center Prevention education sessions. In FY19, 526 individuals attended 11 educational sessions for parents/staff at child serving agencies. Of the total number of attendees, 318 were individuals responsible for children, such as school nurses or youth violence providers.  .

 

The second strategy to decrease child hospitalizations is support of the MA/RI Regional Poison Control Call Center. Poison centers are a cost-effective intervention to reduce hospitalizations. Of incoming calls, approximately 70% can be managed at site of exposure thus preventing unnecessary emergency department (ED) visits as well as hospitalizations. Staffed by toxicologists, a poison prevention educator, and pharmacists, the Center manages over 45,000 calls each year. Every $1 invested in poison centers saves $13.39 in unnecessary health care charges.[3] The Poison Center collects and monitors data from its calls, allowing identification of emerging public health threats, such as food-borne illnesses or new trends of drug abuse. The Center serves as a public health hotline and can be the first to raise alarm about toxic products, evidenced by recent threats of opioids, laundry detergent pods, marijuana edibles, and medication side effects.[4]

 

The Poison Control Center has continued to provide expert advice to callers to prevent unnecessary ED visits. In 2019, 67.8% of callers were able to manage the poison exposure at the site of exposure. Furthermore, in 2019, 87% of calls regarding patients between the ages of 0-9 did not require hospital visits. The Poison Control Center has continued to provide MDPH with quarterly statistics regarding poisoning trends. Any data pertaining to poisoning trends such as ingestion of marijuana edibles and laundry detergent pods is also provided upon request.

 

Child Fatality Review:

In FY19, the Injury Prevention and Control Program (IPCP), which manages the CFR program, implemented a number of changes to the program in response to needs assessments conducted during previous years. To assist the State Team in meeting key responsibilities identified in those assessments, IPCP revised the structure and content of State Team meetings. The new structure shifted the focus away from the review of individual case details – a task already performed by Local Teams – and towards the identification of opportunities for systemic change and interagency collaboration. The State Team also began to hold themed meetings that examine particular causes of mortality; for FY19, the Team looked at sudden unexpected infant death and suicide fatalities in depth. In these meetings, the State Team supplemented case summaries and recommendations from Local Teams with presentations by MDPH epidemiologists and subject matter experts, who helped the Team understand trends and disparities in cause-specific mortality. This approach resulted in the State Team issuing recommendations aimed at improving mental health services for children and improving suicide awareness in schools.

 

IPCP made major strides in coordinating the efforts of the State and Local Teams by improving data management and communications. With support from the Office of the Child Advocate, IPCP redesigned the database that captures key information about Local Team case reviews. The revisions allow for retention of more granular data and automated reporting on the status of recommendations. The new version also allowed IPCP to implement a quality improvement process that identifies barriers faced in understanding the causes of child fatalities.

 

WIC

The WIC Coordination Unit collaborated with the IPCP to share timely child safety messages and product recalls with local WIC programs and to include child safety messages in WIC’s social media efforts. Topics included car seat installation, installing and checking smoke alarms, bicycle helmet safety, water safety, window safety, winter heating safety, holiday toy safety, and prevention of poisoning from household products.

 

Early Intervention Parenting Partnerships Program (EIPP)

Families served through the EIPP home visiting program receive health education, brief intervention and counseling appropriate to the families’ needs and based on a Comprehensive Health Assessment completed by the end of the second face-to-face contact. Among key educational topics are messages about car seat safety. In FY19, 195 EIPP participants received targeted education on car seat safety and 25 participants were referred to car seat safety experts. A key challenge identified by the EIPP programs was the inability of participants to afford the purchase of a new car seat. The program is addressing this by offering free or low-cost car seats to participants.  

 

MA Maternal, Infant, and Early Childhood Home Visiting Initiative (MIECHV)

Parents who are educated about safety at the appropriate points in their child’s development are better equipped to prevent unintentional child injuries. During FY19, MA MIECHV programs included a focus on injury prevention and home safety for pregnant and parenting families, including sharing information on infant passenger safety. All MA MIECHV home visitors are required to attend an injury prevention and safe sleep training.

 

During the FY19 reporting period, MA MIECHV collected and analyzed data on the rate of injury-related visits to the ED among children enrolled in home visiting. In FY19, 27 (1%) of the 1,808 children enrolled in MA MIECHV experienced a parent-reported, nonfatal injury-related visit to the ED (compared with 2% in FY18).

 

Massachusetts Pregnant and Parenting Teen Initiative

The Massachusetts Pregnant and Parenting Teen Initiative (MPPTI) aims to increase life opportunities and enhance family stability among young families. Program participants receive services tailored to their individual needs. MPPTI uses a multidisciplinary team approach that provides wrap-around services through case management and home visits to young parents aged 14-24 years. MPPTI uses program data to monitor injury prevention and child safety education, and reports on a federal measure assessing whether any child was brought to an ED for an accidental injury or ingestion during the past 12 months.  

 

In FY19, MPPTI served 241 adolescent parents and 254 children aged 0-9 years. Adolescent parents were provided with education, counseling, and referrals for child health and safety issues, including information on infant and child car seats, smoke/carbon monoxide alarms, safe infant sleep, supervising young children in and around water, Poison Control Center, and other environmental health and safety topics. In both FY17 and FY18 (the most recent data available), 8% of children in the program went to the ED for an accidental injury or ingestion, as reported by their parents.  

 

MPPTI has one year of funding remaining and will close out all services at the end of FY20. MDPH is seeking additional funding to continue to serve for expectant and parenting youth.

 

School Health Services

School Health Services is comprised of regional and central office professional staff who collaborate with MDPH and the Department of Elementary and Secondary Education to provide ongoing school health service systems development and technical assistance to the Commonwealth’s 406 public school districts and approximately 465 nonpublic schools. This represents approximately 95,163 public school students and 91,298 nonpublic school students. MDPH funds a portion of those school districts through the Essential School Health Services (ESHS), covering 680,630 students. ESHS provides the opportunity for some schools to expand basic school health services including funding for planning, program development and additional health services. The proportion of students of color in ESHS-funded districts (51%) is nearly twice as large as it is in the unfunded schools (24%); therefore, the ESHS program may lead to improvements in health equity.

 

School Health Services collects aggregate data for children and adolescents in grades K-12, so it is not possible to report data separately for the population 0-9 years. In FY19, School Health Services collected data on calls to emergency medical services due to injuries in schools from 161 school districts. During the school year, there were 1,228 calls to emergency medical services for injuries that occurred in those school districts. Among ESHS-affiliated school districts (which have expanded basic school health services), the rate of emergency service calls for injuries was 190 calls per 100,000 students. The rate was higher in the directly funded districts (250 per 100,000 students) than in the partner school districts (63 per 100,000 students), which may indicate that more injuries are occurring in lower income districts or that there are differences in injury reporting.

 

Additional activities to promote safe, stable, nurturing environments to reduce violence and the risk of injury

Essentials for Childhood

The goal of Essentials for Childhood (EfC) is to prevent child abuse and neglect by promoting safe, stable, nurturing relationships and environments. EfC is funded through CDC and administered by Title V staff. FY19 marked the start of a second five-year grant for the State EfC Initiative: Implementation of Strategies and Approaches for Child Abuse and Neglect Prevention. The second phase of MA EfC focuses on strengthening community support for families through strong community social connectedness, and strengthening economic supports for families. The initiative centers racial equity in response to evidence that health inequities, including childhood adversity, can be tracked by the disproportionate burden that communities of color bear from structural inequality. In FY19 four collective impact teams (Community Connection, Economic Opportunity, Racial Equity, and Data and Evaluation) were formed to begin to carry out activities to achieve the goals above.

 

Priority: Promote equitable access to dental care and preventive measures for pregnant women and children. 

Progress towards the oral health priority is measured by a) the percent of women who had a dental visit during pregnancy and b) the percent of infants and children, ages 1 through 17, who had a preventive dental visit in the last year. The first measure is discussed in the Women’s/Maternal Health domain.  

 

NPM 13 B: Percent of infants and children, ages 1 through 17, who had a preventive dental visit in the last year

Research has demonstrated the connection between oral health and overall health, indicating the need to engage children in oral health care early to prevent chronic disease later in life. NSCH 2017-2018 data indicate that 85.9% of children aged 1 through 17 years had a dental visit in the past year, with the lowest percentage among children aged 1-5 (66.3%), compared to children aged 6-11 (95.8%) and aged 12-17 (93.5%). Increasing the number of infants who have a dental visit by age one increases the likelihood they receive dental care as part of their regular health care.

 

Office of Oral Health

The MDPH Office of Oral Health (OOH) implements the SEAL (Seal, Educate, Advocate for Learning) program, which provides preventive dental care from pre-kindergarten to high school in selected communities throughout the Commonwealth. During academic year 2018-2019, SEAL operated in 13 communities in 74 schools. Throughout the year 5,986 students received an oral health screening by a SEAL hygienist. Of these, 1,772 students received 4,749 sealants. The ESM for NPM 13B is the percent of children who received a consent form for the MDPH SEAL program that were screened by one of the program dental hygienists. During the 2018-2019 school year, 19% of the students who received a consent form were screened by a MDPH SEAL dental hygienist. Over 70% of students served by MDPH SEAL were MassHealth members. MassHealth directly reimburses OOH for services provided, which sustains the program and its personnel. While OOH continues to primarily serve low-income students with limited access to care, it accepts all students and is credentialed to accept private insurance.

 

In FY19 OOH continued to collaborate with the Essential School Health Services Program to provide oral health training to school nurses in ESHS-funded districts and to increase the number of schools where school-based oral health prevention programs are available. In addition, 42,180 students received an oral health screening in school and 17% of those students were referred for treatment. Additionally, fluoride mouth rinse treatments were administered to over 12,300 students in grades 1-6.

 

Oral Health Equity Project

The MA Oral Health Equity Project (OHEP), managed by the MDPH Office of Health Equity, is a collaborative project with the OOH. It was funded by the DHHS Office of Minority Health for five years, starting in FY16. OHEP addresses the Healthy People 2020 leading indicator for oral health: persons who visited the dentist in the past year. The project focuses on children up to age 14 years in Worcester and Holyoke, two cities with inequities in oral health access and outcomes and large proportions of residents of color. OHEP seeks to establish partnerships across a variety of systems including schools and community health, EI and WIC with the goal of creating linkages to oral health care for children aged 0-14 years.

 

Findings from internal and external data, key informant interviews with subject matter experts, and survey results from community engagement participation framed the rationale for the strategic interventions OHEP designed and implemented. These interventions included partnering with public schools, Early Intervention programs, WIC, and community health centers to identify children in need of dental care and refer them to a provider.

 

Schools and Community Health:

Worcester Public Schools and Holyoke Public Schools have coordinated linkages to community dental services through a nurse care coordinator hired for this project. The nurse care coordinator at Worcester Public Schools works with school nurses in the district and with a community health worker (CHW) at Family Health Center of Worcester, hired through this project, to make and track referrals to their dental department over time. The duties of the nurse care coordinator at Holyoke Public Schools have been incorporated into the duties of all Holyoke Public School nurses. The school nurses work with the CHW hired by Holyoke Health Center (HHC) and the school-based dental program to track referrals and dental care provided by HHC. HHC increased kept dental appointments from 57% in November 2017 to 63% in January 2020. In addition, dental appointment no-shows decreased from 48% in November 2017 to 12% in January 2020.

 

Early Intervention:

Four EI programs in Worcester and two EI programs in Holyoke collaborated with the OHEP to develop, track, and implement a referral system for children without a dental home and those without dental care in the past 12 months. Between May 2018 and December 2019, among the 2,843 children screened at either initial or six-month appointments who had teeth, 32% (n=923) had a dental visit in the past 12 months. The percent of children who were recommended by EI clinicians to see a dental provider at their initial appointment and saw a provider by their six-month follow-up appointment increased from 24% in May 2018 to 41% in December 2019.

 

WIC:

In FY19, the OHEP CHW at Family Health Center of Worcester continued to work as a liaison to follow up with families referred by WIC staff for dental care. The referral procedure developed between WIC and Family Health Center of Worcester ensures that families receive a timely referral to dental care, on-the-spot oral health counseling by the CHW, and follow-up phone calls to remind them about the dental referrals they received. The successful process developed by the CHW was grounded in a systems-based quality improvement approach and has shown an increase in kept dental appointments for WIC patients from 35% to 43% between November 2017 and December 2019.

 

MA MIECHV

During federal FY19, home visitors assessed whether children had a usual source of dental care. Based on parent self-report, 37% of children aged 12 months or older, who were enrolled in home visiting services and for whom data were available, had a usual source of dental care. Referrals and connections to services were provided as needed.   

 

Priority: Reduce the impact and burden of environmental contaminants on children and their families.

MDPH measures progress towards this priority through a state performance measure that aligns with the State Health Improvement Plan: the percent of children aged 9-47 months with blood lead level screenings. Key MDPH programs that address this priority are the Childhood Lead Poisoning Prevention Program and the Occupational Health and Surveillance Program.

 

SPM 2: Percent of children aged 9-47 months with blood lead level screenings

The MDPH Bureau of Environmental Health’s (BEH) Environmental Epidemiology Program (EEP) re-calculated the statewide blood lead level screening rates using adjusted population data. Drawing on Environmental Public Health Tracking (EPHT) funding, EEP contracted with UMass to develop better methods for estimating postcensal population numbers down to the census tract level and for various demographic groups (age, race, and sex). Employing this new method, the screening rate was calculated based on the number of children screened divided by the revised estimate of the population of children 9-47 months during any given year. Preliminary data for FY19 indicate that the screening rate remains at 71.3%.

 

Childhood Lead Poisoning Prevention Program

The Childhood Lead Poisoning Prevention Program (CLPPP) in BEH conducts primary and secondary prevention of childhood lead poisoning, case management and environmental intervention, surveillance and evaluation, and collaborates with federal, state, and local partners to prevent and reduce lead poisoning. Due in large part to old housing stock, childhood lead poisoning continues to be a significant public health problem in MA. CLPPP works closely with the EEP to collect data and conduct surveillance to guide primary and secondary prevention activities. CLPPP collects and stores approximately 170,000 blood lead test results annually, along with environmental inspection data, in its case management and surveillance database. BEH epidemiologists use these data to determine geographic areas and populations with the “highest risk” children to be prioritized for services and resources, including primary prevention. High risk communities are identified using an algorithm based on incidence rates of blood lead levels ≥ 10 µg/dL, age of housing stock, and poverty rates. The 17 identified high-risk communities account for more than 53% of cases of 10 µg/dL blood lead or greater over a five-year period beginning in January 2014. Many of these communities have a higher percentage of older housing stock than the state average of 71%. By comparison, approximately 57% of all U.S. housing was built prior to 1978.

 

In MA, state statute requires abatement of lead hazards in any home built before 1978 with a child under six years, regardless of the child’s blood lead level. While lead continues to affect children in all communities across the state, lead exposure disproportionately affects lower income communities with higher populations of people of color, making lead exposure a critical racial equity issue. CLPPP uses these and other data to direct resources, conduct outreach, and inform state and local partners. Title V supports culturally and linguistically appropriate CHWs based in seven MDPH contracted agencies across the state. CHWs provide direct services to families whose children have been identified as having elevated blood lead levels. As part of this contract, CHWs also conduct education and outreach within their regions to local partners in housing, education, and health care as well as a variety of other stakeholders.

 

While CLPPP has one of the highest screening rates in the nation, for the past five years the rate has plateaued at approximately 72% statewide. To ensure all providers screen and report lead test results, CLPPP worked with the EEP epidemiologists to create an outreach document, the MA Childhood Lead Screening Community Progress Report. This report focuses on community-specific indicators of childhood lead screening and exposure, highlighting areas needing improvement in physician screening, follow-up, and prevention. The progress report specifically reminds physicians that they must conduct venous re-screenings on children with capillary blood lead levels ≥5 µg/dL and identifies communities that are at highest risk and therefore require more stringent screening of patients. Using results of an evaluation of the progress report, CLPPP revised the report in FY19 to include specific screening data for three-year olds as well as additional information on non-paint and dust exposures. While the overall screening rate remains steady, there are improvements in specific areas. Each year the re-screening rate of capillary tests between 5-9 µg/dL has improved. Before 2012, the re-screening rate was about 4%; by 2017 it was approximately 50%. The progress report, combined with in-service trainings by a public health nurse and CDC recommendations, has contributed to this improvement.

 

CLPPP provided clinical case management services to over 980 children during FY19. CHWs received referrals for home visiting services for 474 of these children. Home visiting services include in-home lead hazard reduction, nutritional and needs assessments, and linkages to other community services including EI and WIC. Since CLPPP’s regulatory changes went into effect in late 2017, the demand for conducting environmental investigations outpaced program capacity and resulted in a backlog. While CHW caseload numbers were not substantially different after the regulatory amendment, case management needs changed significantly as cases became more complex. Field staff reported an increase in the number of transient families and difficulty locating and contacting families. For these cases, the case management team relies primarily on the CHW to track down the most reliable contact information, which can include multiple phone contacts as well as visits to last known addresses. This trend continued in FY19. CHWs have had to devote considerable time and resources to support the code enforcement lead inspectors with scheduling and conducting the environmental investigations.

 

CLPPP staff continued in-services with clinicians to educate them on CLPPP’s screening requirements, the CDC reference value of 5 µg/dL, CLPPP’s regulatory amendments, and to foster screening compliance. CLPPP’s nurse case manager conducted 10 in-services for pediatric providers and two in-services with medical social workers, also attended by CHWs in the region. While CLPPP continues to focus efforts in communities at highest risk for lead poisoning, in-services were also conducted in areas with lower screening rates, including rural communities in central MA and Cape Cod. Along with the more formal in-services with the CLPPP case management nurse, in FY19 CHWs also conducted 68 information sessions with pediatric offices to improve screening compliance.

 

CLPPP contracted agencies provided 45 educational presentations in English and 15 in Spanish, reaching 920 people. CHWs also collaborate on task forces and coalitions for child health and housing and in FY19 attended 54 coalition meetings. Collectively, the contracted agencies have distributed approximately 7,273 educational materials during outreach and other primary prevention related events. This number is down significantly because CLPPP is moving away from using paper-based educational materials. Instead, during presentations and coalition meetings, CHWs are directing the public to the CLPPP website, which has educational information, downloadable documents and fact sheets, as well as interactive searches for screening progress reports and address-specific lead inspection data. CHWs also presented at 19 first-time homebuyer classes, advising prospective homeowners on the MA Lead Law, dangers and health effects of lead poisoning, and remediation requirements. Eighteen CLPPP and grantee staff members are bilingual and can provide services in 10 languages: Spanish, Portuguese, Cape Verdean Creole, Haitian Creole, Ibo, Yoruba, Tagalog, Vietnamese, Cantonese, Toisanese, and German.

 

CLPPP and the Environmental Epidemiology Program began in FY18 to design and deploy a new web-based case management and surveillance application and database. Software, security, and functionality needed to be upgraded to maintain services and improve reporting capabilities. In FY19, CLPPP worked with the database developer to include a more robust interface for CHWs to capture home visiting and exposure assessment for real-time data entry during the home visit. The web-based platform improves grantees’ ability to access the application securely and efficiently, in contrast to prior frequent network outages and other insurmountable IT challenges. The new application was launched in October 2019.

 

In the latter part of FY19, the CLPPP Director collaborated with Department of Early Education and Care supervisory staff to provide a series of three in-services with daycare licensors to review screening requirements, proof of blood lead level screening prior to enrollment in daycare, and environmental compliance requirements for family and group daycare centers.

 

Occupational Health Surveillance Program

The MDPH Occupational Health Surveillance Program (OHSP) has a long history of collaboration with the Occupational Lead Poisoning Registry in the Department of Labor Standards (DLS), which coordinates surveillance and prevention of occupational lead poisoning in the state. Through the Registry, DLS collects results of all adult blood lead tests that are above 0 µg/dL, the majority due to occupational exposures. OHSP helped develop the Registry and periodically helps DLS analyze the data on elevated blood lead levels in adults. Historically, blood lead levels greater than 25 µg/dL were considered elevated among adults. Recently, CDC has reduced this threshold to 5 µg/dL, the same as that for children. OHSP provides funding through a CDC National Institute for Occupational Safety and Health (NIOSH) grant to support some of DLS’ intervention activities, including interviews with workers who have blood lead levels greater than 25 µg/dL and healthcare providers who treat exposed workers.

 

In FY19, DLS conducted follow-up with all healthcare providers who ordered blood lead tests showing elevated blood lead levels ≥ 25 µg/dL reported to the Registry (67 tests among 56 unique individuals). To date, 91% of healthcare provider questionnaires have been returned and follow-up is in progress for the rest. All healthcare providers that responded to the questionnaire received information on the clinical management of lead poisoning, including local resources and contacts. Providers were also given the brochure “Protect Your Family, Stay Ahead of Lead,” developed by CLPPP, which explains what families can do to prevent lead poisoning in children and emphasizes the importance of screening. DLS has distributed this brochure directly to 88% of the 56 workers with elevated blood lead levels. Addresses were not available for the remaining 12% of workers.

 

OHSP is collaborating with DLS and BEH to incorporate lead data into the Environmental Public Health Tracking (EPHT) data system and the MDPH Population Health Information Tool (PHIT), which are used for local area public health planning. The addition of these critical data to EPHT and PHIT will provide the occupational lens to the lead poisoning story in MA, supplementing the childhood lead data that are already available through the EPHT portal. This work is currently ongoing.

 

WIC

WIC and EEP/CLPPP entered into a Memorandum of Agreement to share WIC lead screening and lead testing result data. This agreement will assist the WIC Program with lead poisoning education and prevention outreach and will assist EEP/CLPPP in contacting families that have not been able to be reached by offering additional WIC follow-up with children to facilitate lead screening. The Agreement allows WIC to identify and target specific communities with elevated and/or poisoned blood lead levels for children enrolled in WIC, helping to eliminate the racial and ethnic inequity in testing children for lead poisoning.

 

Additional activities to reduce the impact and burden of environmental contaminants on children and their families

School Health Services

The asthma prevalence in ESHS-affiliated schools is high compared to national data: of the 680,630 students enrolled in districts submitting ESHS data reports in FY19, 10.5% were reported to have asthma, compared to a 2018 national asthma prevalence of 7.5% for children less than 18 years.[5] The prevalence of asthma in MA is among the highest reported for U.S. states.[6]  During FY19, school nurses administered 86,391 medications for asthma on an “as needed” (PRN) basis, which can indicate poorly controlled asthma. The PRN asthma prescription rate among students enrolled in ESHS-funded districts was 36.7 per 1,000 in the 2018-2019 school year. These data need further review to understand whether asthma management in schools is inappropriate, the medical directive treatment plans need amendment, or the treatment plans are misinterpreted. These issues will be addressed by school nurses in the coming years.

 

Priority: Promote emotional wellness and social connectedness across the lifespan.

In addition to addressing maternal depression, as described in the Women’s/Maternal Health domain, MDPH promotes emotional wellness and social connectedness in the early childhood period. The key initiatives addressing this priority among children are Project LAUNCH; the Young Children’s Council; MA Early Childhood Comprehensive Systems; Early Intervention; and MA MIECHV.

 

Project LAUNCH Expansion

Project LAUNCH (Linking Actions for Unmet Needs in Children’s Health) is a SAMHSA initiative that aims to promote the wellness of young children, age birth to eight years, by integrating early childhood mental health promotion and prevention practices into the pediatric medical home. Although SAMHSA has funded this work, it was administered by Title V staff. In partnership with an early childhood Systems of Care Grant also funded by SAMHSA, MA LAUNCH developed a model for integration of early childhood mental health promotion and prevention practices into pediatric medical homes in Boston. The LAUNCH/MYCHILD (MA Young Children’s Health Initiative for Learning and Development) model embeds an early childhood mental health clinician and a family partner with lived experience (having a child with social and emotional challenges) in the primary care clinic. This team works together to assess and support families with children who are identified by primary care providers as showing early signs of social and emotional difficulties or who experience risk factors known to lead to poor social and emotional development outcomes.

 

FY19 was the final year of the MA LAUNCH Expansion program, which replicated LAUNCH/MYCHILD in three new community health centers across in Springfield, Worcester and Boston. The LAUNCH/MYCHILD model is recognized as a Promising Practice by AMCHP. The Project LAUNCH Expansion grants emphasized addressing racial and ethnic inequities and the LAUNCH/MYCHILD replication sites have a particular focus on effectively serving Latinx and immigrant/refugee families. MDPH continued to contract with the local lead for the original grant, the Boston Public Health Commission (BPHC), to provide technical assistance using the Early Childhood Mental Health Toolkit: Integrating Mental Health Services into the Pediatric Medical Home, which was developed during the original grant. To evaluate the expansion, service data were collected on LAUNCH-participating children’s social-emotional risk and their parents’ levels of stress and depression.

 

Through MDPH’s partnership with BPHC and their Young Children’s System of Care statewide grant, family engagement and family leadership were also emphasized in program and governance activities. The three communities convened Parent Councils that guided development of community family engagement activities, including an annual Family Summit for System of Care and LAUNCH family members and other community members who are interested in developing their community engagement and leadership skills.

 

The Project LAUNCH Expansion grant also required early childhood systems building/policy development activities. In FY19, MDPH LAUNCH staff co-led a public-private workgroup with Boston Children’s Hospital focused on Integration of Social Emotional Wellness. The group promotes policies and practices that allow for more comprehensive integration of early childhood mental health services (perinatal – age 5) with a focus on visits to primary care as point of service. The group conducted a landscape assessment and key stakeholder interviews which served as the basis for a set of recommendations for a continuum of infant and early childhood mental health integration in MA.

 

MA Early Childhood Comprehensive Systems

In FY19, MECCS completed the third year of a five-year grant from HRSA that aims to improve children’s (age 0-5) developmental health by strengthening local- and state-level early childhood systems. MECCS partners with teams in Springfield and Chelsea, two MA MIECHV communities, in a national Collaborative Innovation and Improvement Network (CoIIN) to test, evaluate and scale program and systems-level strategies for promoting young children’s developmental health.  

 

Early childhood systems-building activities in Springfield and Chelsea prioritized multi-generation strategies to promote children’s developmental health, including: 1) strengthening connections and trusted relationships between providers and families, 2) providing spaces for families with young children to support each other in their roles as caregivers, and 3) opportunities for parent leadership training and coaching. These strategies are part of MECCS’ work to embed a racial justice and equity lens across all grant activities to address persistent racial inequities in developmental health outcomes.

 

In Springfield, the MECCS backbone hired and trained three mothers from the community to seek out and engage families with young children who are isolated and hesitant to connect with service providers. These parent leaders provide support and offer to administer the ASQ developmental screening tool with families and connect them with referrals and resources if needed. The parent leaders also facilitate a monthly meeting of Springfield families with young children. Meeting agendas are developed by the families and feature speakers on topics of interest, such as special education policy, civics, and challenging behavior. The meetings also provide a space for families to build relationships and connections with their peers. At the provider level, the MECCS lead in Springfield partnered with an early literacy initiative to hold quarterly cross-systems networking and community of practice meetings for any who work with young children and/or their families. The goal of these meetings is to move towards a more streamlined and coordinated approach to service delivery to ensure all families can smoothly access and maintain the services they want.

 

Chelsea has also created opportunities for family leadership development and family-to-family support and connection. Chelsea has a large Latinx and immigrant community, including many residents who do not speak English as their primary language and those who have expressed fear of seeking services due to concerns about their immigration status. Chelsea MECCS stakeholders aim to meet the needs of these families through the creation of a Family Navigator position. The Navigator is a bilingual, bicultural parent from Chelsea who engages with families in spaces throughout the community. She provides peer support, information, resources and warm referrals to families who do not feel comfortable using the front door of an agency as an access point to the system of care. Chelsea has also developed a Family Advisory Committee, which is composed of 10 family members and was co-designed, and is co-facilitated, by a parent from Chelsea and the MECCS lead. Chelsea agencies bring a proposal or issue to the Committee for their expertise and input. One of the Chelsea parent leaders has also worked with the MECCS lead to bring parent support and leadership groups to the community.

 

At the state level, MECCS has partnered with family leaders to re-design the Young Children’s Council (described below) to elevate a diverse range of family voices. MECCS is also partnering with other MCH programs to develop a coordinated and equitable approach to partnering with families to inform MDPH service design and delivery. MECCS continues to co-facilitate a convening of early childhood partners to grow an aligned racial justice partnership and learning network.

 

Young Children’s Council

In FY19, the Young Children’s Council, chaired by the Director of the Bureau of Family Health and Nutrition, continued to meet quarterly. The Young Children’s Council has been a state level council required for MDPH’s Project LAUNCH and MECCS grants, which in recent years has been restructured to align with MDPH and community-based partners’ work related to infant and early childhood mental health and to advise programs that focus on early childhood systems building (e.g. LAUNCH Expansion, MECCS Impact, MA MIECHV). In FY19, the Council served as a stakeholder meeting for the Title V and MIECHV needs assessments, provided feedback on the draft Title V 2020-2025 priorities, informed Preschool Development Grant activities, and contributed to MECCS racial equity strategic planning efforts. Council membership includes state and community agency representatives as well as increasing family and consumer representation, including male caregivers and families with a diversity of life experiences. MDPH staff are growing family representation on the Council and working to change meeting practices and structure to ensure families have an equitable seat at the table.

 

Early Intervention

The MA EI program universally screens and identifies early social-emotional delays in children 0-3 years old and provides interventions to promote social connectedness. A priority within the State Systemic Improvement Plan and the MA State-Identified Measurable Result (SIMR) is improving the statewide percentage of children with improved positive social-emotional skills (including social relationships). EI and its advisory groups selected this SIMR because it is a measure for which MA is below the national average.

 

The SIMR moderately declined from 55.7% in federal FY17 to 52.8% in federal FY18, likely due to improvements in data accuracy. As the accuracy of administration of the Battelle Developmental Inventory, 2nd Edition (BDI-2) improves, it is possible that children’s entry scores could be less accurate than their exit scores (indicating improvement in data quality over time). This theory is supported by program data showing that low fidelity of BDI-2 administration was associated with higher scores of children’s social-emotional outcomes, suggesting that these scores may be inflated due to non-uniform administration of the BDI-2.

 

Key strategies that EI implemented in FY19 to support positive social-emotional development included: offering BDI-2 and Individualized Family Service Plan (IFSP) support to local EI programs; incorporating the Parents Interacting with Infants (PIWI) training, which guides the EI practitioner in supporting the parent-child dyad, into required orientation for new EI staff; and offering Learning Institutes for the BDI-2, PIWI, and reflective supervision.

 

EI will continue to monitor the data and adjust its implementation activities to address concerns and improve outcomes. It is expected that positive social-emotional outcomes will improve in the coming years as each implementation strategy has time to improve program practice.

 

MA MIECHV

Many children with developmental delays are not being identified as early as possible. As a result, these children must wait to get the help they need to do well in social and educational settings. Research shows that early intervention treatment services can greatly improve a child’s development. During federal FY19, 5.5% of households enrolled in services reported having a child with developmental delays or disabilities. MA MIECHV home visitors conduct developmental screenings (using the ASQ-3 and ASQ-SE) on enrolled children to identify developmental concerns as early as possible and make referrals to EI and other appropriate community resources.

 

During federal FY19, 64% of children enrolled in MA MIECHV programs were screened for developmental delays using a validated, parent-completed tool (ASQ-3) at the American Academy of Pediatrics recommended screening intervals (nine months, 18 months, 24 months, and 30 months). This represented a decrease from 67% in FY18. In addition, 81% of children with a positive ASQ screen for developmental delay received services in a timely manner (meaning that they were referred to EI and received an evaluation within 45 days, or were referred to community services and received services within 30 days).

 

WIC

MDPH received the WIC Developmental Monitoring Program grant from CDC’s National Center on Birth Defects and Developmental Disabilities and the Association of State Public Health Nutritionists. The purpose of this grant is to integrate the “Learn the Signs. Act Early.” developmental monitoring program into MA WIC.

 

Seven local WIC programs (Cambridge/Somerville, Framingham/Waltham, Holyoke/Chicopee, North Central, Northern Essex, Quincy, and Worcester), were selected as pilots. Parents and caregivers completed an age-appropriate developmental milestone checklist during their mid-certification and certification appointments. If the completed checklist indicated a potential developmental concern, staff completed a referral for screening and further assessment to a variety of resources, including the primary care provider, Early Intervention, Family TIES, and/or the local public school’s special education department.  Staff followed up on these referrals at subsequent WIC appointments. The pilot continued into FY20, when evaluation and plans for statewide WIC rollout were implemented.

[1] Prevention of childhood poisoning in the home: overview of systematic reviews and a systematic review of primary studies, Wynn et. Al, Int J Inj Contr Saf Promot., 2016 Mar, 23(1):3-28.

[2] The use of poison prevention and education strategies to enhance the awareness of the poison information center and to prevent accidental pediatric poisonings, Krenzelok, EP, J Toxicol Clin Toxicol, 1995;33(6):663-7.

[3] The impact of poison control centers on poisoning-related visits to EDs-United States, 2003, Zaloshnja, E et. Al., Am J Emerg Med, 2008 Mar;26(3):310-5

[4] Forging a poison prevention and control system, Institute of Medicine (US) Committee on Poison Prevention and Control, 2004.

[5] https://www.cdc.gov/asthma/most_recent_national_asthma_data.htm

[6] https://www.mass.gov/service-details/statistics-about-asthma