Priority: Early childhood obesity prevention 

Update on PM annual objectives:

NPM 8: Percent of children ages 6 through 11 who are physically active at least 60 minutes per day was 36.7%. The annual objective for reporting year 2019 was 36.0%. The objective was met. The annual objective for reporting year 2020 is 36.5%.

ESM 8.1.2: Number of licensed child care facilities (centers and preschools) assessed for a Level 3-5 that attained the Colorado Shines activity point was 406. Since ESM 8.1.2 was newly developed in 2019, we are unable to compare it to an annual objective. The annual objective for reporting year 2020 is 460.

MCH Block Grant dollars funded 1.25 FTE in CDPHE’s Early Childhood Obesity Prevention Unit to implement strategies outlined in the state action plan, and contracted with six local public health agencies (LPHAs) to implement local action plans. MCH leveraged Centers for Disease Control and Prevention (CDC) State Physical Activity and Nutrition dollars for an additional .45 FTE which enabled the Early Childhood Obesity Prevention Unit Manager, a Nutrition Specialist, and a Breastfeeding Specialist to extend the reach of childhood obesity prevention efforts. The funded strategies and associated outcomes are summarized below.

Development of basic motor skills of children in early learning settings is linked to later levels of physical activity. Early experiences learning about food sources, flavors, and textures influence food preferences into adolescence. (Loprinzia, P., et al., 2015; Mura Paroche, M., et al., 2017; Scaglioni, S., et al., 2018) To set the trajectory for healthy weight in school age children, the Early Childhood Obesity Prevention team implemented strategies to promote healthy eating and physical activity in young children including: 1) training and technical assistance for early childhood educators on physical activity, nutrition, vegetable gardens, food preparation, and wellness; 2) statewide consistent healthy weight messaging; 3) training and technical assistance to WIC Wellness Coordinators; and 4) implementation of breastfeeding strategies (see NPM 4).

The Early Childhood Obesity Prevention team completed literature reviews during this reporting period to examine the adoption of policy, practice, systems and environmental changes that increase healthy food (including breastfeeding, local produce procurement and beverages) and physical activity experiences in early learning and other community settings. These reviews informed strategy development and implementation efforts described below.

In 2015, the Colorado Department of Human Services updated child care licensing regulations to increase physical activity, reduce screen time and improve the nutritional content of meals with input from the Early Childhood Obesity Prevention team and their stakeholders. In 2019, the team submitted additional recommendations for licensing updates to Human Services. These recommendations included 18 evidence-based and best practice measures to strengthen the physical activity, nutrition and breastfeeding regulations and address areas, such as breastfeeding where provider bias may result in differing parent experiences. The final revised regulations are not yet available.

The Early Childhood Obesity Prevention team provided state level system support to Human Services through its Professional Development Information System, Quality Rating Improvement System, Early Learning Developmental Guidelines, Technical Assistance Networks, Access Initiatives and Recognition Program (see NPM 4). The team provided ten recommendations to strengthen the Quality Rating Improvement System in the areas of breastfeeding, nutrition meal environments, oral health, and staff wellness. As of July 2020, 450  early learning settings acquired points for “classroom teachers leading children in structured physical activities daily for a specific amount of time.” The Early Childhood Obesity Prevention Unit Manager contributed evidence-based and best practice nutrition and physical activity guidelines and suggested activities for updates to Colorado’s Early Learning and Development Guidelines and Parent Experience content.

The Early Childhood Obesity Prevention team expanded its technical assistance network that supports early learning providers. In previous years, the team learned early learning providers had difficulty integrating what they learned into daily schedules or policies after receiving training on structured physical activity. Since 2018, the team began training community-based individuals (e.g., local public health agency staff, child care health consultants, and early childhood council staff) to be Wellness Champions and offer ongoing training and technical assistance on physical activity, nutrition, breastfeeding, and staff wellness to early learning providers in 16 counties. In 2019, the team partnered with the Colorado School of Public Health’s Culture of Wellness in Preschools to offer training and technical assistance for the Wellness Champions on how to coach early learning providers through policy, system, and environment change processes. Wellness Champions assisted early learning providers in completing the Colorado Healthy Eating Active Living in Child Care Self-Assessment tool and documented changes to policies and practices through the pre and post assessments. Wellness Champions convened monthly via learning circle calls to support each other and share strategies. Wellness Champions coached 42 early learning centers and six homes resulting in 138 program improvements including implementation of seven new policies and strengthening of 13 policies.

The Early Childhood Obesity Prevention team also supported the six local public health agency staff who implemented local action plans for this priority. The local coordinators disseminated early childhood obesity prevention messaging materials to 465 individuals and/or organizations; facilitated 271 physical activity, breastfeeding, and/or nutrition trainings; and provided technical assistance to 169 early learning providers, which resulted in physical activity, breastfeeding, and nutrition practice and policy changes.

The Early Childhood Obesity Prevention team collaborated with partners to develop educational resources on the benefits of quality physical activity for children, providers, and families, and standardized language and best practice recommendations for infants, toddlers, and preschoolers. The resources included an interactive Let’s Get Moving! Physical Activity in Early Care and Learning course made available in June 2019 to licensed early learning providers through the Professional Development Information System. Since its launch, 1600 providers completed the course. The training was also available to informal early learning and other professionals who promote healthy behaviors in early learning settings. CDPHE contracted with Valley Settlement, a community-based organization, to transcreate a portion of the Head Start I am Moving, I am Learning training on moderate to vigorous physical activity into Spanish and renamed it Actividad Fisica Saludable Diaria. The Early Childhood Obesity Prevention team supplemented the Head Start content for younger children, creating a webinar training, Enhancing the Active Learning of Infants and Toddlers. The Early Childhood Obesity Prevention team also contracted with a community-based organization to transcreate and record this training in Spanish. All of the trainings are available on the Early Childhood Obesity Prevention website.

In 2020, the Early Childhood Obesity Prevention team formed a workgroup to prepare a nutrition course at the request of Human Services for its Professional Development Information System. The workgroup developed the course content, narrative, imagery, and storyboard. The course will be launched by December 2020.

The Early Childhood Obesity Prevention team explored implementation strategies focused on farm to early learning settings to improve nutrition security and increase children’s access to fresh, locally grown produce. In 2019, the team hosted a planning session with partners to understand what it would take to advance farm to early learning in Colorado. Over 35 individuals (including early learning directors, food distributors, master gardeners, Kaiser Permanente, local public health agencies, early childhood councils, and others) identified Colorado’s current state and what can be achieved. CDPHE was selected to participate in a CDC-funded Association of State Public Health Nutritionists farm to early learning setting mini collaborative improvement and innovation network (CoIIN) with four other states. The Early Childhood Obesity Prevention Unit Manager and a Child and Adult Care Food Program nutrition consultant formed and co-led a team of 12 partners to develop and implement a work plan from April 2019 through July 2020. The team deployed a statewide farm to early learning survey to providers to understand their participation, motivators, barriers and future opportunities. The 250 survey respondents represented 41 counties and their data informed the selection of local food procurement as priority for study. In partnership with the San Luis Valley Food Coalition, the team implemented a series of rapid quality improvement cycles, exploring the procurement experiences of two early learning facilities as they worked with a local food hub. Throughout the project, subject matter experts provided training and technical assistance to address barriers as they arose. In one example, chefs provided knife skills training to enhance cooks’ skills in reducing the amount of time to cut produce. Over the 13-week pilot, the team learned how to remove barriers to using local foods and the funding helped providers purchase 2,700 pounds of fresh food which were served to 150 children.

CDPHE contracted with LiveWell Colorado to complete eight Quick Bite video vignettes, in English and Spanish, with handouts and comprehension checks to increase cooks’ knowledge of preparing fresh Colorado produce. The videos are posted on Colorado’s Child and Adult Care Food Program and Train.org/Colorado websites. The contractor virtually hosted a two-part knife-skills training in English and Spanish to increase cooks’ knowledge and skills in handling and using knives to prepare fresh produce efficiently. During September 2020, over 75 cooks completed the training. Post-workshop surveys planned for the fall of 2020 will measure practice changes and identify cooks’ needs.

The Early Childhood Obesity Prevention team’s success is due in part to its many partners and stakeholders who contribute to assessing the needs and resources of early learning settings and supporting the development of the team’s strategic planning. The Early Childhood Obesity Prevention team hosted annual stakeholder meetings in 2019 and 2020. Over 60 individuals attended the 2019 meeting. Stakeholders heard presentations and held discussions with a CDC behavioral scientist on using the Spectrum of Opportunity Framework to assess and plan obesity prevention strategies in early learning settings; Human Services staff on topics including the preschool development block grant; and a family engagement and health equity panel of directors from diverse organizations, such as Parent Engagement Network, the Immigrant and Refugee Center of Northern Colorado, and the Black Child Development Institute. 

The Early Childhood Obesity Prevention team supported the final years of the WIC Wellness Coordinator System. The system was a strategy to support local WIC agencies in addressing early childhood obesity through its services. The coordinators advocated for clinic environments that provide staff opportunities for healthy living, including stress management. They established community partnerships to enhance obesity prevention efforts benefiting WIC families. The team supported 14 coordinators through a system of collaboration and learning with quarterly networking opportunities and webinars on topics such as refugee health, and nutrition and autism spectrum disorder. Due to limited resources, the Wellness Coordinator System was phased out in early 2020 and its strategies were incorporated into other WIC Program activities.

The 9 Ways to Grow Healthy Colorado Kids statewide consistent messaging initiative increased  public awareness of consumer-tested, evidence-based messages to address eight maternal and early childhood health and behavioral risk and protective factors found most promising in preventing early childhood obesity. The consistent messaging initiative included print and digital materials, videos in English and Spanish, and a social media toolkit. The Early Childhood Obesity Prevention team disseminated a quarterly newsletter,  9 Ways to Grow Healthy Colorado Kids with consistent messages on healthy behaviors, and resources to over 165 partners. The initiative reached all Colorado counties and, while it will be ending September 2020, materials and reports describing messaging reach and consumer awareness surveys remain available for download on the Early Childhood Obesity Prevention website.

Priority: Developmental screening and referral promotion

Update on PM annual objectives:

NPM 6: Percent of children, ages 9 through 35 months, who received a developmental screening using a parent-completed screening tool was 50.5% The annual objective for reporting year 2019 was 51.5%. The annual objective was not met. An important data caveat for this measure is that it has a wide confidence interval (exceeding 20 percentage points) as a result of the small sample size (116 children ages 9-35 months).

The annual objective for reporting year 2020 is 51.0%.

ESM 6.1: Number of local public health agencies, community and/or health care partners in Colorado that have implemented ABCD quality standards that support early childhood screening, referral and treatment services for developmental needs was 103. The annual objective for reporting year 2019 was 100. The annual objective was met. The annual objective for reporting year 2020 is 110.

For this reporting period, MCH Block Grant dollars funded the implementation of the strategies outlined in the state action plan, contracts with local public health agencies to implement local action plans, as well as a contract with Assuring Better Child Health and Development to provide technical assistance to those local public health agencies. Block grant dollars also supported the MIT state and local MIT leads at CDPHE and Assuring Better Child Health and Development, respectively. The funded strategies and associated outcomes are described in the state action plan and are summarized below.

Colorado remains in the top tier amongst states for developmental screening rates, with rates higher than the national average (50.5% v. 33.5%, respectively). However, Early Intervention Colorado data showed that in 2016, there was no significant difference in the rate of Colorado children ages 0-3 who received early intervention services through Part C of the Individuals with Disabilities Education Act. Colorado’s rate was 3.34%, which was similar to the national average of 3.26%, which may be an indicator of barriers that exist in the process to access evaluation and intervention services after screening.

Unfortunately, Colorado lacks the ability to track, in aggregate, critical interim measures between screening, evaluation and connection to services, such as the percent of children who receive and do not pass the screen, the percent who are referred for further assessment based on screening results, and the outcome of those referrals. These data gaps provide an opportunity to strengthen data collection and data systems linkages to illuminate barriers that exist throughout the process from screening to referral to evaluation to receipt of services. Colorado’s Early Intervention Program is a key partner in finding solutions to these data linkage barriers. For state context, the Colorado Department of Human Services’ Office of Early Childhood administers the Early Intervention Colorado Program and contracts with twenty Community Centered Boards statewide to provide early intervention supports and services to infants, toddlers, and their families within their communities from birth through the child’s third birthday.

To coordinate policy and systems change across projects, MCH staff continued to lead the Early Childhood Screening and Referral Policy Council, which has met every other month since its inception in November 2016. The Council advances systems change to improve service coordination and promote optimal child development for children (birth through five) to receive developmental screening and referral to appropriate services. The Council is co-led by CDPHE and Assuring Better Child Health and Development staff and membership continues to be composed of cross-sector state and local leaders representing public health, human services, public education, public insurance, as well as community-based partners and non-profit organizations focused on child development. In this reporting period, the Council continued its core work to: 1) identify barriers and implement solutions to ensure effective, standardized developmental screening and referral systems and improve coordination of services for children and families, and; 2) coordinate efforts related to developmental screening, referral and access to intervention services across local, regional and state systems.

The Council developed a problem statement to define the solution to the data challenges experienced in Colorado and to inform next steps for collective work. “Developmental screening is critical to identify a child’s potential developmental delay and need for developmental services. Barriers between child- and family-serving systems in Colorado make it difficult to access and share data to know when children are screened, referred and are accessing recommended services. This results in children and families not receiving appropriate and timely services and providers being unable to coordinate care.” The purpose of the group’s collective work is “To support a comprehensive system to improve communication and coordination among providers, partners, and families to ensure appropriate and timely services; reduce the burden on families; allow information to be shared in a bi-directional manner; and inform policy and state and local investments.” As many statewide data initiatives are underway, council members will share the problem and purpose statements to influence the inclusion of early childhood data into existing efforts.

During this reporting period, a subgroup of the Council hosted two HIPAA/FERPA webinars for health care providers, education professionals, and community based service providers. To determine the content of the HIPAA/FERPA training, the Council surveyed 158 community-based providers statewide and collected a large number of example scenarios where providers experience barriers navigating the two different privacy laws. A subgroup of the Council reviewed the responses for themes to inform the development of learning objectives as well as identify presenters who could adequately address the content. In 2019, the Council hosted experts to present on privacy and data collection for two webinars, held in November 2019 and January 2020. The first webinar focused on the differences and distinctions between HIPAA and FERPA. A national representative from AEM Education Data Services provided FERPA content expertise and the privacy officer from the Colorado Department of Human Services (where the state's Early Intervention Program is housed) provided HIPAA content expertise. The second webinar featured case scenarios, submitted by registrants ahead of time. The webinar series generated interest from more than 250 registrants across the state, with materials distributed widely afterwards via email to registered participants from education, human services healthcare and public health sectors and multiple early childhood listserv across the state. The webinars were also recorded and posted along with slides on the CU School of Medicine website and Assuring Better Child Health and Development is also adding creating a page to house them in their website.

A different subgroup of the Council is focused on identifying opportunities to strengthen state data coordination for the developmental screening, referral and evaluation process. In 2019, the workgroup interviewed contacts recommended by the Early Childhood Data Collaborative from Utah, Minnesota, Rhode Island, Wisconsin and Pennsylvania. A final summary report and presentation of the findings were presented to the Council in May 2019. These conversations revealed a need to explicitly determine the scope of the system; to determine the purpose of the data system; and to identify and collaborate with stakeholders engaged in similar efforts. Since then, the Council has been focusing on conversations with state partners in Colorado who can further inform the opportunities for improving data linkages, governance and infrastructure. Colorado received the federal Preschool Development Grant Birth-5, and developmental screening and data coordination were included in the grant’s strategic plan. The team is involved in one opportunity to explore a technology solution with CRISPeR (Community Resource Inventory Service for Patient e-Referral), an electronic referral (e-Referral) system capable of searching a resource database from an electronic health record, receiving patient-relevant results and making closed-loop referrals with selected community-based resource providers. CRISPeR is currently being used by healthcare providers to refer prediabetic patients to the Diabetes Prevention Program. After the referral is made, the Diabetes Prevention Program communicates the outcome of the referral back to the healthcare provider. CDPHE and the Screening and Referral Policy Council are hosting exploratory conversations to determine the feasibility of using CRISPeR as a mechanism to strengthen bi-directional communication between health care providers and the early intervention system and increase the percent of children who receive an evaluation after being referred for a developmental evaluation.

During this reporting period, CDPHE continued to contract with Assuring Better Child Health and Development, a statewide nonprofit focused on improving the lives of Colorado children through early identification of developmental needs. As experts on best practices in screening and referral, Assuring Better Child Health and Development staff supported the implementation of local action plans for this priority. Assuring Better Child Health and Development provided training to 110 total agencies and partners (primary care practices, early learning sites, home visitation programs, etc) to implement the ABCD Quality Standards. The quality standards are based on current, published literature and practice based evidence, relative to each of the essential roles in the monitoring to services continuum. Assuring Better Child Health and Development staff also continued to provide technical assistance to four local public health agencies (Boulder, Larimer, Pueblo, Tri-County) who elected to work on this priority.

Each year, Assuring Better Child Health and Development hosts an annual day of learning for local public health agencies working on the development screening priority. In 2019, topics included: supporting social-emotional development, family engagement through Community Cafes, and navigating challenging partner relationships. Facilitators shared the Bay Area Regional Health Inequities Initiative (BARHII) framework and the local public health agency partners led a robust discussion of how to better measure efforts around community specific outreach and engagement of providers.

As local public health agencies have been working on this priority for many years, their needs for technical assistance have lessened and internal capacity has increased. Tri-County Health Department's Douglas Early Childhood/ABCD partnership group has created processes and mechanisms to ensure parent representation on their council and they have discussed ways they may translate those successes to other groups and/or share with other partners that could benefit from more intentional family engagement.

Larimer County provides technical assistance to physician offices and has had success in building strong partnerships. Assuring Better Child Health and Development staff and Larimer County MCH staff partner on these visits. Assuring Better Child Health and Development provides Maintenance of Certification credits to clinics who participate in their quality improvement process and Larimer County MCH staff provide community-based resources and foster local relationships. They also use the opportunity to provide information about maternal mental health screening and referral resources, which is another MCH statewide priority. Additionally, the Larimer coalition has focused on partnership development with families, early care and education providers, Child Find, mental health providers, and human services. The group built a strategic plan that is driving local efforts to raise awareness of the importance of social emotional and developmental needs of young children.

Pueblo County has focused on engagement and partnership and is building a strong sustainability plan to ensure the work continues regardless of transition of people or funding streams. They are building a Train the Trainer curriculum for "How To Deliver Technical Assistance" for healthcare providers and early childhood providers. Partner training will be offered, asking for feedback on refinement of key messaging. A timeline has been created identifying partners, actions taken, challenges, wins, policy changes, and sustainability.

Boulder County Public Health is providing continuous quality improvement guidance and support to early learning professionals and is developing a closer relationship with the Early Intervention Program, housed within Boulder County Housing and Human Services. The Boulder County ABCD Partnership workgroup is composed of early childhood stakeholders and recently surveyed families on their experiences with services to inform future activities to be addressed. Family surveys revealed that families trust the perspectives of those who spend time with their child and those who have professional expertise. Families also shared that a written explanation of the referral, with contact information, would be helpful. Boulder now provides that. Time and difficulty making an appointment appear to be the largest barrier to participating in evaluation. The team used family feedback to develop two additional TA materials to include in their Referral Tool Kit. One is focused on the emotion and feelings a family experiences related to a referral recommendation and one focuses on systems improvement to overall processes. Strong partnerships have been built with local Family Resource Centers and Boulder Court Appointed Special Advocates to ensure children receive the proper screening and support services.

Lastly, on June 1, 2020 the state’s Medicaid program implemented new developmental billing code guidance that will allow for more accurate local data collection for developmental and autism screening. Prior to June,  autism  and developmental screenings  were billed under the same code and may impact the accuracy of the developmental screening rates in our state.  So being able to differentiate between autism and developmental screening codes is important for both data integrity and for reporting purposes. Colorado Medicaid has also proposed that providers use diagnosis codes to indicate when a developmental or autism screen is passed or failed. At this time, those diagnosis codes are voluntary and do not impact the provider being reimbursed for screening. Colorado Medicaid has asked the Early Childhood Screening and Referral Policy Council to work on a messaging document that would be shared with a Medicaid provider group to convey the importance of using the diagnosis code. By providers using diagnosis codes, Colorado would have more information about screening efforts for young children on Medicaid, but would also help us understand the outcomes of those screenings. The hope would be that eventually this diagnosis data could be linked to state early intervention data to determine if the children that fail connect with state early intervention services.

Priority: Substance misuse reduction (tobacco, marijuana and prescription drugs) among pregnant and postpartum women

Tobacco

For an update on NPM14B: Percent of children, ages 0 through 17, who live in household where someone smokes, see section III.E.2.c. Women/Maternal Health – Annual Report.