Developmental Screening

 

Our 2020 Needs Assessment showed that Delaware is among the lowest of its surrounding states when comparing children, ages 9-35 months, who received a developmental screening in the past year.  According to the 2021/2022 National Survey of Children’s Health (NSCH), 34.3% of Delaware children received the screening.  This is only slightly above the national average of 33.7% of children having a completed developmental screening.  Developmental Screening was selected as the Most Important National Performance Measure in the Child Health Domain according to our stakeholders.  In addition, it was ranked as the second highest priority, when ranking all priorities overall.

 

Studies indicate that each year, about three million children across the nation enter Kindergarten without the cognitive, social, and emotional skills necessary to be ready for school and life. The situation is even more dire as kids struggle through the aftermath of the pandemic and its impact on mental health, cognitive social and physical health.  Developmental health surveillance and screening, and its promotion, is critical to early identification and intervention to ensure that developmental health disorders are treated to improve the overall outcome and trajectory of the child’s growth and life.

 

The Early Childhood Comprehensive Systems (ECCS) program continues to leverage the Help Me Grow (HMG) system model to promote cross-sector collaboration to advance an efficient and effective early childhood system across the state.  Help Me Grow utilizes and builds on existing programs and services to advocate for or facilitate a comprehensive approach to early childhood systems building in Delaware.

 

The four cooperative and interdependent Core Components of the model underlie the goals and objectives of the Division of Public Health’s ECCS program.  To assist families and professionals to connect children to appropriate community-based programs and services, the ECCS program partners with Delaware Helpline (Delaware 211).  Known as the Centralized Access Point (CAP), Help Me Grow@211 improves access to existing resources for vulnerable children through age eight.

 

Through Family and Community Outreach, the ECCS program supports education to advance developmental health promotion, including increasing awareness of the HMG system amongst families and providers.  This is accomplished through Books, Balls and Blocks events as well as opportunities at health and community fairs.  Through outreach to health professionals, the ECCS program supports early detection and intervention while assuring a medical home.  The ECCS program collaborates with the Delaware Chapter of American Academy of Pediatrics (DEAAP) and other health partners to make the outreach possible. 

 

The ECCS program continues to expand its partnership with the Delaware Chapter of the American Academy of Pediatrics (DEAAP), through the engagement of community pediatric practices and addressing barriers to developmental surveillance, screening, and referrals.  From August 2023 to date, activities with the DEAAP include the work to implement a care coordination pilot project utilizing CHADIS; the promotion of Reach Out and Read (ROR) early literacy program in primary care and pediatric practices; the establishment of ROR Delaware affiliate and hiring a coordinator, as well as early childhood resources and developmental milestones education to practices and their patients. 

 

ECCS collaboration with DEAAP and other community partners and stakeholders, typically focuses on addressing barriers/gaps in developmental screening implementation including physician education and the referral/early intervention process.  Since 2021, the ECCS program and its partners have been working on a pilot project to implement the CHADIS system.  CHADIS, Inc (formerly known as Total Child Health, Inc.) has developed a Comprehensive Health and Decision Information System (CHADIS) targeting health professionals.  Delaware’s pilot project addresses identified barriers/gaps observed within the referral system.  Four (4) community pediatric practices participating in the pilot are Beacon Pediatrics (Sussex County, DE), Bear Internal Medicine and Pediatrics (New Castle, DE), Bright Futures Pediatrics (Kent County, DE) and Rainbow Pediatrics (Sussex County, DE).  The practices are representative of the state as they represent Delaware’s 3 counties, cater to patients with and without health insurance.  The practice sizes range from small-sized to large-sized enrolment and serve immigrants as well as non-immigrants.  Participating practices have access to the CHADIS platform and can select from nearly 600 questionnaires and screening tools available.  In the newly built referral platform (customized for Delaware), practices can make referrals to early intervention services, to include the Birth to Three Regional program (B23) formerly Child Development Watch (CDW), Child Find (CF) and Help Me Grow@211 (HMG/211).  All staff at pilot practices, early intervention programs and HMG@211 have been trained on how to access and use the CHADIS platform.  The pilot project, with the newly built referral platform, was officially launched in November 2022. 

 

Data tracked from November 2022 to March 2024, shows that the pilot practices have utilized the CHADIS system to administer a total of 7005 screens and have made close to 450 (6.4%) referrals to early intervention programs based on results indicating some developmental delays.  In addition to administering developmental screens on the CHADIS platform, the 4 pilot practices continue to explore other screeners available to them on the CHADIS system.  Practices are using screens to determine post-partum depression such as EPDS, (Edinburgh Postnatal Depression Scale); Patient Health Questionnaire (PHQ-9), the SCARED- (Screen for Child Anxiety Related Disorders) and the Vanderbilt Assessment Scale among others.

 

The customized referral platform allows for referrals with consent to early intervention programs while facilitating the feedback loop between the physician and the early interventionists.  With this data, Delaware can track and determine the status of a referral initiated by pediatric practices.  Regular quality improvement ensures that gaps and bugs in the system are addressed soon as observed.

 

The CHADIS pilot project is currently in the scaling up and the eventual spread phase.  This phase includes the expansion of the CHADIS referral platform to a broader community of pediatric and family practices.  We are currently in discussion with a Federally Qualified Health Center (FQHC) and a large pediatric clinic interested in implementing the system.  At the same time, there are sustainability discussions.

 

Through the state funded PEDS online portal, community pediatric practices administered a total of 6,144 (non-Nemours) PEDS Online screens on children 0-59 months between July 1, 2022, and June 30, 2023.  This corresponds to an estimated 6,012 unique children or 62.73% of total screens completed which were unique.  Additionally, childcare centers administered a total of 3,822 screens using the Ages and Stages questionnaire.  Out of the total screens 3,778 were unduplicated children.

 

The partnership with DEAAP led the ECCS program to fund Reach Out and Read (ROR) activities through a contractual agreement.  The DEAAP received a $250,000 matching grant from Longwood Foundation to support ROR in Delaware.  The ECCS program funding of ($3000) was allocated to continue the ROR activities such as purchasing books for doctors’ offices.  The DEAAP raised matching funds of $250,000 from partners to unlock the grant from the Longwood Foundation.  The project will significantly improve accredited medical provider training, accurate program evaluation, book distribution, and clinic support - variables that lead to the powerful outcomes from the ROR evidence-based model.

 

It is noteworthy to learn that Delaware’s ROR program goal is threefold – in addition to the traditional ROR message encouraging parents to read to their children to improve childhood literacy, the program distributes books on specific topics to advance health literacy - topics such as oral hygiene; kindergarten readiness and enrolment; food insufficiency, developmental and lead screening, etc.  Additionally, the approach encourages physicians to share information and build relationships with families when providing anticipatory guidance.

 

The alliance with DEAAP, has led the ECCS program to build and/or strengthen relationships with the Bureau of Oral Health, the lead program, National ROR, the Food Bank and Delaware’s Readiness teams.  Currently, six state services centers are now implementing the Reach Out and Read program.  An observation made through networking with physicians was that they were more amenable to implementing ROR than developmental screening.  For this reason, our strategy moving forward is to leverage the appeal of ROR to promote developmental screening and surveillance.  All practices interested in setting up ROR are encouraged to consider implementing developmental screening, lead screening and oral health. 

 

In July 2023, licensed childcare centers in Delaware began implementing Title 14, the legislation requiring childcare centers to administer yearly developmental screens of enrolled children using the Ages and Stages Questionnaire (ASQ).  Over 900 childcare centers have been enrolled to begin yearly ASQ screens.  This demand has elevated the support the Department of Education receives from HMG@211 staff.  As more childcare centers become familiar and step into this role, HMG@211 staff will in turn experience an increase in the number of families that need follow-up calls.  This effort is supported with funding from the Birth to Three (B23) program.  In the future, there needs to be an assessment of this effort in terms of staff capacity to accommodate the increased screens that will come from childcare centers.

 

Despite their increased roles, staff Help Me Grow@211, continue to provide support and resources to families that call the centralized access point or helpline.  For the fiscal year 2023, staff served about 3,970 families, linking them to resources, services including general information and education-related materials.  Staff also referred nearly 2,338 families for basic needs and family supports or to a program.  A feature that distinguishes HMG @211 from other helplines, is follow-up services.  HMG@211 will follow-up with callers once they have consented to it.  This is done to determine if the initial referral provided was successful in assisting the family.  Another benefit of the follow-up service is how it promotes relationship-building among staff and callers.  For fiscal year 2023, they followed up with 3,240 families out of the total calls of 3,970 received.  Sixty-six percent of the families reported their needs were met after follow-up calls were made.  HMG@211 served approximately 10,744 children who needed assistance with early identification of developmental delays, referrals and linkages to services including basic needs. The children ranged from prenatal through age 8.

 

Help Me Grow@211 recently (March 2024) started tracking callers who receive public assistance to address health equity concerns, this will provide more context to the nature of the population that’s calling the helpline and determine other needs they might have.  In less than 6 months of collecting this data, we observed that majority of the callers receive Women Infants and Children (WIC) and Medicaid benefits.  Staff also assists callers who would like to apply for benefits such as TANF, WIC, Medicaid or SNAP/EBT; so far, the majority seeks assistance with signing up for WIC.  We look forward to this data informing us of how best we can improve our services to serve vulnerable families.

 

The partnership between the Women Infants and Children program (WIC) continues with a dedicated staff from WIC referring clients to HMG@211.  WIC referrals are sent each week to HMG staff.  Some of the requests range from utilities, housing to food.  From its inception, in less than a year, approximately 85 families have been served by HMG@211.

 

Outreach to families and the community is accomplished through the Books Balls and Blocks project.  The ECCS program continues to build parent/family leadership and capacity, to advocate for themselves and their communities.  This is done either in-person or online (especially during the pandemic and its aftermath).  With the pandemic over, we have reduced the number of virtual events.  Out of the 4 virtual sessions held in 2023, the BBB project brought together 59 online interactions.  This does not consider other interactions that may have occurred on social media (Facebook, X, and Instagram) through the Delaware Thrives website.  At these sessions parents with their young children up to age 3, received information on developmental milestones, the importance of developmental screens, handling behavioral concerns, including the importance of play using ECCS/MCH’s app QT:30. 

 

From April through to October 2023, Help Me Grow’s BBB project participated in 11 events, such as Back-to-School events, health fairs and community fairs.  At these in-person events across the state, they interacted with about 86 families, who were provided information on early childhood education and health.  The events also provided the opportunity for 14 parents to complete the ASQ developmental screening tool.  The BBB program partners with several community programs such as Black Nurses Sorority; Christina Cultural Arts Center; Parent Information Center; Winterthur Museum; Highmark; libraries; United Way; Delaware Early Childhood Centers; Head Start and Early Head Start programs.

 

A collaboration with HMG@211 has also led to reaching a broad array of families.  Staff at HMG@211 promote BBB events and other HMG events by sending text messages to the target population the day before a session, including reminder emails to registrants.  We continue organizing community events (virtual and in-person, when appropriate) such as Books, Balls and Blocks events to increase families understanding of developmental screening and milestones, while creating opportunities to administer the Ages and Stages Questionnaire screener.

 

The ECCS program also intends to continue efforts to organize events targeting fathers.  A couple events held this fiscal year brought a few fathers together however we will continue to promote this initiative and will not give up on it.

 

Through our social media platforms, DEThrives website, Instagram, You Tube, and Facebook, the ECCS program works with the Social Media Coordinator to post messages on the importance of developmental screening and milestones, including BBB activities. 

 

The beginning of the year saw the ECCS program receiving technical assistance from Help Me Grow national center to begin strategic planning.  Delaware has been a HMG affiliate since 2011 and has successfully implemented the HMG model, impacting the well-being of women and children.  After 10 years, the strategic plan will facilitate reflection on HMG system current goals, objectives, and activities, while addressing gaps and challenges.  Through an environmental scan, surveys and key informant interviews, the national center led Delaware through their intended impact, theory of change and an action plan for the next 3-5 years.  The outcome of this strategic plan calls for the ECCS program to re-introduce the HMG system across the state for better understanding by stakeholders.  For the next 3-5 years, the ECCS program also intends to focus on 2 major high risk zip codes in the state, mainly in southern Delaware.

 

DEThrives advertised a Quality Time 30 (QT-30) Campaign and Interviews.  The campaign goal was to target parents/guardians and caregivers of children aged 0-8 years old in Delaware to generate awareness of the QT30 app and increase the number of app downloads.  The campaign consisted of digital media (included images and videos displayed on Facebook/Instagram newsfeed ads, ads displayed on some app games, and Google app displays shown in places such as the Google Playstore), traditional media (hardcopy printed items), public relations and social media tactics.

 

Traditional hardcopy marketing materials such as 5’x2’ stand-up banners were distributed across 42 preschools, childcare and daycare facilities focusing on low-income areas across the state.

 

The Op-Ed was published on Delaware State News’ website and in the local newspaper.  Interviews were held with WDEL (clip 1 and clip 2) and Delaware Public Media stating the purpose and some features of the app.  Crystal Sherman, Chief of the Maternal and Child Health Bureau, authored the pieces and was interviewed. In addition, the WDEL’s Lifestyle program interviewed Crystal Sherman and packaged the messaging into their public affairs program.  Lastly, WHYY interviewed Crystal and the Op-Ed was published on “Bay to Bay News: Delaware State News”.

 

 

Dental Visit

 

According to the 2021/2022 National Survey of Children’s Health (NSCH), 75.4% of Delaware children, ages 1 through 17, have had a preventive dental visit in the past year.  Delaware is slightly below the national average of 77.0% of children with a preventive medical visit.  The Preventive Dental Visit (child/adolescent) was another priority that is important to Delaware stakeholders.  Our stakeholders recognize that dental health equals overall health and the Title V team has identified that MCH is able to align our collaborations and resources to make an impact on this population.

 

The Delaware Smile Check Program is a school-based preventive oral health and case management program serving grades pre-kindergarten through 12th grade.  The program has expanded and is offered not only at schools but other non-traditional locations.  The program has also expanded our target population to include infants through age 5, pregnant women and adults.  The school-based Smile Check program screened 2,602 children from 07/01/2023 - 06/04/2024 and administered 2,468 fluoride varnish treatments to children in PreK through 12th grade.

 

• Services were provided to 948 uninsured students.
• 786 were insured by Medicaid.
•  80 insured by Delaware Healthy Children’s insurance.
•  27 students with private dental insurance.
•  8 students that had private insurance in addition to Medicaid.

 

Screening Results:

• 767 students had suspected caries.
• 302 had an urgent dental need that included pain or swelling.

 

An oral health landing page (https://dethrives.com/smile-check) was previously posted live on our DEThrives.com website.  The term “Healthy Smiles” is where general oral health information is placed on the DEThrives site in collaboration with the Bureau of Oral Health and Dental Services (BOHDS).  The term “Smile Check” is the name of the dental program by the BOHDS, known as the “Delaware Smile Check Program”.  The “Smile Check” landing page easily allows the public to enroll their child for virtual or in-person school dental services.  Organizations and schools are also encouraged to participate in this program and to receive “Smile Check” services by signing up.  Items such as the “Dental Resource Guide”, dental tips for children with special needs, a prescreening checklist, on-site and virtual forms are available in both English and Spanish.

DEThrives displays an online sign-up form for the Delaware Smile Check Program.  Students can access the online form through a QR code or a link.  During this reporting cycle, 598 English student consent forms were completed, 150 Spanish consent forms were completed, and 127 school/organizational consent forms were completed using the DE Thrives website.

 

Families were provided with case management to connect and assist with removing barriers that are preventing the child or their family from receiving dental care.  The families were contacted using their method of choice (text, email, or direct phone contact).

• 166 students were connected to a dentist and completed all dental treatment.
• 42 students qualified for Medicaid and are now insured under Medicaid or Delaware Healthy Children Program (CHIP).
• We have no method of verifying if any student purchased private insurance.

 

Families without insurance or with an annual maximum for dental coverage indicated the primary barrier to care is cost.  Second barrier to care is finding a provider to provide care for free, accepts payment plans or accepts Medicaid.

 

Prior to the past school year beginning, contact was made with schools and organizations to distribute a Start Smiling flyer for children in English and Spanish.  The goal is to communicate with family’s importance of oral health, provide education and dental resources.  5,050 Start Smiling flyers were distributed to 57 schools in New Castle County, the United Way drive through pantry, community centers and state service centers.  In addition, 950 flyers were also distributed to school libraries, public schools, laundry mats and community centers in Sussex County.

 

 

Information regarding mouth protection and sports injuries were distributed to 14 athletic directors from schools or community programs.  Information provided to the directors pertained to what to do if an injury to the mouth occurs.

 

The Bureau of Oral Health and Dental Services collaborates with pediatricians across the state who are willing to discuss oral health and provide resources to their patients.

The Fluoride Varnish training program is offered to medical offices in addition to oral health supplies and contact points for questions.  A BOHDS dental hygienist provides training to staff at pediatric medical offices for applying fluoride varnish during a well child visit for children under the age of 5 without a dental home.  Smile for Life courses are assigned prior to training to allow staff to ask any questions.  It is discussed with staff age of first dental visit, how to take care of teeth, bottle mouth, nutrition and appropriate dental supplies and toothpaste.  All staff are given the BOHDS dental helpline phone number if they need assistance, or the families need to be connected to a provider or secure dental insurance.  After training is completed, dental supplies including infant and child toothbrushes and toothpaste as well as infant tooth wipes and education are distributed to the offices who are providing fluoride varnish.  

• 2,621 dental education, toothbrushes and toothpaste have been distributed to pediatric medical offices for their patients across the state.
• Fluoride Varnish training was given to 3 physicians, one registered nurse and 4 staff members.

 

MCH assists with marketing oral health activities, events, education through DEThrives Facebook, X and sharing with other Title V partners.  The Bureau of Oral Health and Dental Services coordinates with MCH to release information through DEThrives at a minimum monthly on Facebook and Twitter.  This includes preventive education and oral health events available to the public to support children and their families to maintain good oral health and improve oral health literacy.

 

Dental Hygienists from the Bureau of Oral Health and Dental Services hosted 11 educational events at Delaware Public Libraires for Storytime.  Children attended the events with an adult.  Each session was one to two hours long.  Children are read a book about oral health, given an oral health activity and assistance is provided to families if they need help with finding a dentist, securing dental insurance or have dental questions.  Of those children, 25 received a dental screening and 10 received a fluoride varnish.  Five students were uninsured, 7 students were insured by Medicaid, and 13 had private dental insurance.  Two children had suspected caries and no child had an urgent dental need.  In addition, educational sessions were held about oral and systemic health.  The sessions included doctors and nurses from Christina Hospital.

 

BOHDS coordinated and participated a Special Olympics event during this reporting cycle.  Olympians received dental screenings and education.  In addition, BOHDS provided assistive devices for oral health products and instructions on use.  There were also 27 Community events attended by BOHDS representatives.  Staff used puppets, food games, nutrition games and more to engage the public in conversations about oral health and HPV vaccination.  Oral health education information was targeted to the population at each event. 

 

In addition, Reach out and Read is an early literacy program collaboration with oral health education.  BOHDS buys the books needed for this program, provides fluoride varnish training to staff who are participating, as well as provides the oral health supplies.  During this past grant cycle, 1,000 Brush, Brush, Brush books were purchased and distributed by a dental hygienist to pediatric dental offices.  We recently ordered an additional 3,000 books in English and Spanish due to the number of new providers that recently signed up for the Reach Out and Read program. 

 

Through collaboration with WIC, the Delaware Breast Feeding Coalition, Sussex Pregnancy Center, DAPI and Doula’s in Delaware, women’s shelters, and other community organization for women, we distributed 675 infant oral health kits that included infant oral health education, infant toothbrush, toothbrush teether, tooth tissues, finger brush and toothpaste.  Pregnant women received oral health education, oral health supplies and case management to a dental provider, if needed.  Training programs were provided to 75 pregnant women and their infants.  The training provides life like infants and guidance on how to hold the infant and use the oral health devices in the infants’ mouth.

 

A dental helpline was set up to assist the public with finding a dental provider, for medical providers to contact and speak with a dental hygienist about and oral health problem or asking questions about a dental screening form that was sent home with the child. 

• July 1, 2023 through June 17, 2024 - 370 phone calls were received from the public who needed assistance with finding a dentist and scheduling an appointment.

 

A cooperating and supportive dentist, Dr. Susan Pugliese and Dr. Karla Testa (Westside Family Health Care physician and Delaware’s Oral Health Champion) presented to Acadia PA students at Christiana Care regarding oral health and the relation is shares with systemic health.

 

BOHDS support staff were assigned and completed training for Quality Improvement and Principles of Quality, Telephone Customer Service, Attitude for Service, HIPAA, and Client Confidentiality, and people of Cuban Heritage to enhance their skills when handling sensitive information and speaking with the public on the dental helpline.  The new administrative specialists completed Smiles for Life to give them a basic understanding about dental health.  Clinical staff were assigned CPR and completed the training.

MCH continues to support BOHDS through expanding oral health information, messaging, and marketing on the Delaware Thrives website.  Periodically, DEThrives ran single image newsfeed ads to promote the Delaware Smile Check program.  The ads targeted women (since women usually schedule their family’s health appointments), new parent and parents of children aged 0-17 audiences who live in Delaware.  The objective was to maximize clicks to the Healthy Smiles program page. 

MCH has also helped build a lasting connection and relationship between CYSHCN and BOHDS.  Information has been shared to assist families with finding a dental provider.  The Delaware Smile Check Program has targeted schools that have many children with disabilities and collaborated with dental specialist that can meet the needs of the families for treatment.  The Delaware Smile Check Program is designed to provide parents, dental personnel, and medical providers with the tools needed to improve our state’s oral and overall health.  

 

The Family SHADE website continues to promote the Bureau of Oral Health and Dental Services (BOHDS) to expand their reach to the CYSHCN population by putting the BOHDS information on their Family SHADE website.  This continues to afford families easy access to dentists that are able to serve their CYSHCN.  Having the BOHDS information on the Family SHADE website continues to make it more convenient for families to access the dentists that will best serve their CYSHCN and eliminate them calling each dentist to ask if they can serve their child.