Primary and Preventive Services for Children

 

The role of Title V, through Local Health Departments (LHDs), has been to provide safety net services and assure all children have access to well child, nutrition, and immunization services. Direct preventive well child health services identify growth and development issues according to the standards recommended by the American Academy of Pediatrics (AAP).  Assuring well child exams and immunizations has been a hallmark activity for MCH Title V. During the 2020 needs assessment, this remained a priority with much discussion about early childhood development and mental health and addressing mental/behavioral health of adolescents. 

 

During 2020, LHDs reach for performing well child exams was limited by pandemic restrictions.  Initially in the pandemic, public health heard of many reports that parents were not taking their children in for routine well child exams.  Child immunization rates across the state fell. 

 

The School Health Program promotes access to preventive health services for school-aged children and adolescents and improves access to health information at critical times for influencing health behaviors. In 2020, identification of students with missing exams, or immunizations was not a priority as the school nurse workforce became pressed into COVID-19 mitigation planning and contact tracing for those schools that were open and not virtual. 

 

In Kentucky, the school nurse workforce in public schools is at a ratio of 1 nurse/100,000 students.  Many districts have no school nurse coverage, some rely upon contract agency temporary nurse staffing, and only about 15/171 districts have coverage provided through contractual agreement with the local health department. Depending on the local arrangement with LHDs, nursing services may include preventive health services, education, emergency care, referrals, and management of acute and chronic conditions in a school setting. The function of the DPH school nurse program was quickly overwhelmed with the numerous questions and need for rapid policy review and update.  To meet that need, MCH contracted for a part time 40-year veteran school nurse consultant.  This nurse and the CFHI nurse manager, collaborated with KDE nurse consultant and leadership to develop recommendations for management, mitigation, and contact tracing.  In multiple shared meetings, the MCH nursing leaders were able to influence and add recommendations for immunization surveillance, well child exam surveillance and linkage to best practice mental health trainings developed by the BHDID for schools. 

 

During 2020 legislative session, a bill was passed allowing stock albuterol to be allowed to be kept in schools and administered by non-licensed school personnel as per guidance of the school nurse program.  MCH school nurse and manager developed a protocol for distribution in school inclusive of recognition of signs/symptoms of an acute asthma attack, use of a stock inhaler as prescribed by a licensed provider, and emergency management on school grounds.  This policy was incorporated in the DPH Core Service Guidelines and presented to school staff and nurses at the Kentucky School Nurse conference, Superintendent meetings, and District Health Coordinators trainings.  During these training events, MCH school health further stressed importance of immunization and well child surveillance, and any changing information on COVID-19 management in the school environment.

 

The LHD continues to be a source for linking children to care in a medical home with community partners. While still supporting basic safety net services, the Title V program is focusing more on population-based activities such as prevention of child injury, increasing physical activity, promoting a nutritious diet, and decreasing exposure to tobacco smoke.

 

Challenges will need to be addressed as LHDs move from a primary provider of direct services to population health services. Beginning in March of 2020, DPH convened a task force to research potential ways to meet the well child exam need within the current public health transformation model.  This task force continues evaluating potential options.

 

Immunizations:

Annually, The KY Immunization Program promotes vaccine administration during well child exams and by local providers when deficits are noted. They work closely with KDE to assure children are up to date prior to entry in childcare or school. Statewide, compliance rates for vaccine administration were above 90% for all kindergarten vaccines. Per the KY Annual School Immunization Survey Report for School 2018-2019 (Division of Epidemiology and Health Planning, 2020):

• The KY Immunization Program strives to meet the Healthy People 2020 objectives of 95% or greater for each of the following vaccines: four or more DTaP, three or more polio, three or more HepB, two MMR, two varicella, and 85% or greater for HepA in kindergarteners. During the 2018-2019 survey, 48 (40.8%) of KY’s 62 counties met this standard. 85.1% reported >90% of kindergarten certificates on file were current.
• For 7th grade students, 41 counties (39.1%) met the Healthy People 2020 objectives for each antigen, (80%or greater with Tdap/Td booster and MenACWY, 85% or greater for HepA, 90% or greater for varicella, and 95% or greater for HepB and MMR).

 

The KY Immunization Registry (KYIR) developed media messages to promote routine well childcare and immunizations.  KYIR developed an agreement with Kentucky Hospital Information Exchange (KHIE) for shared immunization data.  The goal of this partnership is for any KYIR data to be universally available for the provider at the time of service.  School nurses are given read only access to the KYIR.  MCH/DPH convened meetings with KDE to determine what data sharing opportunities would be available in connecting immunization records submitted to the school to the KYIR.  These conversations are ongoing as both parties research FERPA rules related to records in the school environment.

 

In the past year, the KY Immunization program developed pivotal community relationships for distribution of COVID-19 vaccines to education staff, pregnant women and once available adolescents.  These traveling vaccination clinics, pharmacy partners, and university partners were rapidly mobilized to reach vulnerable areas of KY.

 

As described, the KY Immunization Program has many standardized processes to assure high rates continue as reported. The challenges for immunizations continue to be limited workforce and maintaining rates in current pandemic environments.

 

Injury Prevention/Child Maltreatment

 

Injury is the leading cause of death among KY children over the age of one and was a priority for children in our statewide needs assessment. In particular, child maltreatment was the highest priority. Child passenger safety and teen driving were also concerns raised by the participating groups.

 

The NPM KY has selected for this domain is NPM #7: Rate of hospitalization for non-fatal injury per 100,000 children ages 0-9 and adolescents ages 10-19.

 

State inpatient hospital data shows a decline in the rate of hospitalizations from non-fatal injury in 2008 from 159.4/100,00 to 113.2/100,000 children from ages birth to age 9 in 2018.  While this improvement has steadily improved, MCH continues to be vigilant in collaborations to prevent child injury.  Injury prevention partners include the Kentucky State Highway Department, local coroner offices, LHDs, hospitals, and Safe Kids KY.  Many initiatives at the local level are specifically developed to target ongoing safety concerns specific to that community from prevention of cliff diving, bicycle trails on local roadways, safe fishing spaces at local waterways, boating/water safety, bicycle safety, safe walking paths for local school bus stops and more.   

 

KY continues to strive to reduce circumstances of Pediatric Abusive Head Trauma (PAHT). Filtering the data to the level to specifically identify children with PAHT continues to be difficult as hospital claims data does not reliably have coding for child abuse or PAHT. The 2019 goal was to compare claims data with medical record review. Secondary to workforce capacity, MCH continues to be unable to make this comparison with the university forensic pediatric programs.  Despite this circumstance, MCH has been deeply committed to continuing education and promotion of best practice to reduce PAHT. MCH will continue to work on projects with KSPAN, the Division of Pediatric Forensic Medicine at the University of Louisville, Prevent Child Abuse KY, the KY AAP, and LHDs on developing materials for specific groups of providers.

 

KY House Bill 285, passed in 2010, requires training for foster parents, health care workers, child protection officials, day care employees, and others who work with children, so they can recognize and help prevent PAHT. The web-based training modules have been available for nurses and other community providers, since 2011. In 2019, the course was updated and added to KY TRAIN for further review.  During the pandemic closures, local schools of nursing utilized the TRAIN offering for nursing students as part of the changes quickly made to nursing curriculum.

 

Under the guidance of Dr. Melissa Curry with the Division of Pediatric Forensic Medicine at the University of Louisville and in collaboration with Prevent Child Abuse of KY, Kentucky Violence and Injury Prevention Program (KVIPP), KSPAN, KY AAP, MCH, and the Northern KY District HD developed a high school curriculum to educate high school students about AHT and a safe sleep environment, Keeping Infants Safe. This curriculum enhances the KY House Bill 285, as the law encourages KY high schools to include a segment during a student’s final year of study concentrating on prevention of PAHT. The curriculum has a pre-test, to determine the knowledge base of the student, and a post-test, for administration later in the school year to determine retention of materials. The curriculum includes lecture, and interactive materials/visuals. This pilot program held a train the trainer course for three independent high schools in Northern KY. During the 2020-2021 school year, two district health departments had plans for presentation of this curriculum in multiple high schools during the spring physical education sessions.  Unfortunately, all KY schools were closed secondary to the pandemic response and these courses were cancelled as schools diverted to virtual courses or other distant learning work. With COVID 19 many of these activities were delayed or cancelled. As COVID 19 restrictions are relaxed and schools can return to normal operations KIPRC, MCH and other KSPAN partners plan to resume efforts to promote the High School curriculum in high schools.

 

The curriculum was adapted for use with drug treatment centers to at-risk expecting mothers by KVIPP.  Classes were provided by KIPRC at drug treatment centers in Fayette County in late 2019 with additional classes planned. These classes at drug treatment centers were scheduled into March of 2020 but with COVID 19 these scheduled classes were cancelled. Once COVID 19 restrictions began to be relaxed KIPRC plans to resume this activity of providing classes at drug treatment centers for at-risk females who are either pregnant or have children. KIPRC support from MCH and other KSPAN partners is essential for these classes to resume for at risk and expecting mothers in drug treatment centers. The cost for these joint collaborations is minimal. Title V funding was used for training supplies and education materials placed in a lending program at the LHD for use by area high schools. Additionally, KVIPP is working with Council for State and Territorial Epidemiologists exploratory indicator work group to establish child abuse and neglect definition and recommendation for use with population-based hospital discharge data.

 

The PAHT video developed by MCH, Prevent Child Abuse of KY, and WellCare MCO continues to be a primary resource for birthing hospitals.  Most play this on the hospital’s education channel and provide bedside discussion and written materials to the new parents prior to discharge.  LHDs engage with families through clinic visits, and HANDS home visitation by providing Period of Purple Crying materials and video.  32 LHDs engaged in this package in 2020 reaching 574 families.  LHD staff engaged the community in Nurturing Fathers classes at local detention centers, spoke at “Mommy & Me” classes, parents’ day out classes, parent classes at local childcare centers, community centers, and faith-based opportunities. 

 

The strength of MCH to reduce PAHT lies in the collaboration and communication between state departments and community partners to maintain this as a primary mission for reduction. The challenges for understanding the full scope of PAHT continues to be a reliable method to have consistent data fitting the case identification definition with the various data systems, as it is not clearly coded or recorded in multiple systems differently and not coded in a manner to provide reliable data.

 

Child Fatality and Near Fatality External Review Panel

 

The Child Fatality and Near Fatality External Review Panel was created and established in 2012 by KY Revised Statute 620.055 for the purpose of conducting comprehensive reviews of child fatalities and near fatalities suspected to be the result of abuse or neglect. The Panel is a twenty-member multidisciplinary team of professionals, including representatives from the medical, social services, mental health, legal, and law enforcement communities, as well as others who work with and on behalf of KY's children. The MCH Title V Director and the MCH Nurse Manager for the Child and Family Health Improvement (CFHI) Branch attend the Child Fatality/Near Fatality External Panel Review meetings. The Nurse Manager reviews cases that are to be discussed by the External Panel for a final determination of the cause of death or injury, systems issues, preventable problems, and recommendations for prevention. Local cases in which suspected abuse/neglect could be part of the final determination are referred to the External Panel through the MCH CFR Nurse Coordinators.  During local review, if suspicion of abuse/neglect are discussed, the referral is made by the local panel through the MCH CFR Nurse Coordinators. 

 

MCH actively collaborates with the Department of Child Protective Services (DCBS) to provide safe sleep education, materials, and information learned from child death reviews. DCBS is essential with HEART, participation on local and state review panels, and it participates as a presenter at MCH annual and regional meetings. 

In 2019, the Department for Community Based Services (DCBS) partnered with Collaborative Safety to develop a new internal review process known as the Culture of Safety, System Safety Review (SSR). The SSR process uses safety science to guide the analysis of critical incidents and the response to areas identified for improvement.  The process focuses on understanding the complex nature of child welfare work and the factors that influence decision-making and practice in real-time. It moves away from the simplistic approach, which has a tendency to assess blame and results in the application of “quick fixes” that fail to address the underlying issues.  Particular attention is given to history occurring within the 24 months prior to the fatal/near fatal incident. The analyst presents the cases to the multi-disciplinary team (MDT) to determine if a further analysis is needed to identify systematic themes or trends. 

Upon selection for further analysis, the System Safety Analyst will identify DCBS personnel, and others who may have been involved in the decision making of the agency’s previous involvement, to participate in human factors debriefing. Human factors debriefing provides staff with the opportunity to share their experiences related to the critical incident and/or historical cases. At this time, the reviewer explores the decisions and interactions with the child and family. The analyst compiles the information gathered, with the findings from the initial case review, and provides this information to the Regional Mapping Team for analysis of systematic influences that may be affecting decision-making. The analyst evaluates the information gathered from the Regional Mapping Team using the System Safety Scoring Tool. Data from this tool is collected and used to identify underlying systematic themes. Aggregate data is presented during the MDT data review in order to develop the components that will be presented to the Safety Action Group (SAG).

 

The MCH CFHI Nurse Manager is an active member at these System Safety Review Multi-Disciplinary meetings.  

 

Recently the External Panel formed subgroups to look at recommendations and to evaluate possible legislative changes for requirement of toxicology screens at the time of a child death, or other measures for further understanding case details, or for development of prevention materials.  These subcommittee meetings have been impactful in understanding the many discipline, laws, and best practice strategies available and in identifying areas of potential education. 

 

2020 work completed by the External Panel included:

 

• Panel members presented their overdose/ingestion data at the quarterly PILLS (Prescribing Information for Law Enforcement and Licensure Boards) meeting. The board consists of representatives from healthcare regulatory boards (Board of Medical Licensure, Nursing, Pharmacy, etc.) and law enforcement agencies (KSP, DEA, KYOAG, LMPD, etc.). The committee was very engaged and interested in partnering with the panel to distribute prevention information to providers through newsletters and other forms of communication.
• To better understand the full scope of unintentional drug ingestions and firearms injuries, the Panel has been able to partner with the Kentucky Poison Control Center and the Kentucky Injury Prevention and Research Center to access additional data which demonstrated Panel cases are a subset of a larger preventable causes of injury and death.
• The Panel partnered with the Kentucky Safety and Prevention Alignment Network (KSPAN), a statewide network of agencies and individuals focused on injury prevention, to address prevention of unintentional pediatric injuries due to access to firearms and pharmaceuticals in the home. The goals of this effort include enhanced data sharing among partner agencies, promotion of public awareness practices, and implementation of prevention strategies.
• Panel members have worked internally within their own agencies and in partnership with other governmental and NGOs to increase public awareness of critical prevention messages such as recognition of the TEN—4 Bruising Rule, the need to report child abuse, etc. 
• Panel members met with representatives from the Kentucky Attorney General’s Office to discuss how they can collaborate and ensure the protection and safety of children across the Commonwealth. (Child Fatality and Near Fatality External Review Panel, 2021)

 

In the External Panel report they note that substance use/abuse is the most prevalent risk factor in cases and was identified in 48.9% of cases.  They identified systems improvements would be to expand Family Drug Court systems statewide.  Currently this practice exists in only one jurisdiction. Additional recommendations were related to ongoing work for plans of safe care, increasing MAT provider intervention, and regulatory mandates regarding collaborative services for pregnant mothers, and compliance for Medicaid funding be tied to MAT services. Additionally, the External Panel recommends drug testing protocols be required at the time of the fatal/near fatal event. 

 

Child Fatality Review

 

Prior to the pandemic, the Title V MCH Program made strides in improving the quality and timeliness of data in our Public Health Child Fatality Review Program to better inform our injury prevention strategies. MCH is the lead for this program, which was established in 1996 by statute. The program supports and encourages reviews of child deaths by local multidisciplinary teams to assist the coroner in determining an accurate manner and cause for each child death.

 

MCH provides Title V funds to 120 LHDs to support local CFR review teams and to implement evidence informed strategies in alignment with state priorities. Title V funding allocations for LHDs supports local CFR team meetings, implementation of injury prevention/community interventions, and reimbursement for training costs to certify Child Passenger Safety (CPS) technicians if no CPS technicians are available to that community.

 

Beginning in February 2018, MCH began evaluating and improving program structure for the CFR program. During this evaluation, the CFR nurse found:

• Coroner turnover and LHD CFR coordinator turnover greatly impacted the timeframe of review, knowledge of review, and reporting requirement knowledge
• 78 counties reported the death on forms to the state MCH program but did not conduct formal child death reviews. 
  • Today, 103 counties have active local multidisciplinary CFR teams. 

 

The CFR nurse consultants collaborate with KIPRIC, DBHDID suicide coordinator, KY Chief Medical Examiner, and KDPH to conduct intensive training with local coroners at the KY New Coroner Training, Coroners Convention, and LHDs at sites across the state. During 2020, the pandemic negatively impacted the depth of detail for reviews and the number of counties hosting reviews.  Ongoing technical support was provided by state level staff to identify cases and collect many case details.  Coroners collectively voiced concern of virtual reviews and refused to conduct a review for any cases in litigation virtually.  As restrictions lesson, CFR nurses and the CFHI Nurse Manager has been traveling statewide to rebuild and support local review.  It is anticipated 2020 cases will not be closed at the same level of timeliness as in 2019.  Workforce capacity at coroner office and LHD also impacts the success of these reviews. 

 

During 2020, CFR grappled with a way to collect case details impacted by the pandemic restrictions.  At each review the nurses inquired about stay-at-home changes the family or community may have had that could be considered a risk factor.  At one review of the death of the 4 teenagers, the local pediatrician clearly stated COVID stay-at-home as a risk factor noting the death occurred in adolescents who were fishing at the local dam on a school night.  They were from families who normally would not have permitted them to be out on that day if school had been in session the following day.  Other case discussions revolved around alternate caregivers at home while parents worked remotely such as older siblings, mental health concerns of the adolescents missing school and peer to peer interaction, and lack of childcare resources.

 

Trends in preventable child death in Kentucky has remained somewhat stagnant with rates of preventable deaths in Kentucky between 254 in 2016 to 245 in 2019. 

 

Prevention of these deaths remains with developing an understanding of the manner of death, and community or familial influences, decisions, or understanding of risk factors.  In Kentucky, most child deaths (59.7%) are related to natural causes of birth defects, prematurity, and other childhood congenital or genetic diagnosis.  Prevention for these resides with primary care for early identification, treatment, and ongoing follow-up. 

 

 

MCH focuses efforts of the child injury prevention program on the other manners of accidental/unintentional injury, suicide, and homicide deaths. As noted in the annual CFR report, and demonstrated in the graph below, the bulk of child deaths continues to be related to child passenger safety.  Alarmingly the second subcategory was related to Suffocation, strangulation, and asphyxiation for which 82% of cases are infants, and 18% are children 1-17 years of age.

 

 

Efforts made locally specifically are targeting SUID, suicide and improving mental health access, screening and evaluation, and promotion activities to reduce accidents. The CFR best practice initiative allows LHDs to develop and review child death cases and to use MCH Title V block grant funds for preventive efforts designed to address local resources, culture, and collaborate with local child injury influencers/champions such as the local pediatrician, faith base leaders, school leaders, and more. 

 

Additional data are available in the CFR report included as an upload with this report.

 

LHDs collaborate with the child fatality and injury prevention team and Safe Kids KY to promote best practice injury prevention messaging and activities. One activity has been to develop TRAIN webinars with nursing contact hours for promotion to schools, childcares, and other community partners. Currently MCH hosts 7 TRAIN webinars related to injury prevention, child abuse/neglect, and addressing mental health in children. 

 

With the improved CFR processes, the teams are using lessons learned from review to promote prevention activities in their communities. This has led to community prevention plans that included safety prevention campaigns for safe pedestrian walkways for children to bus stops, safe sleep campaigns, gun safety and storage campaigns, and smoke alarm programs in which smoke alarms are purchased via local grants and installed by the local fire department.  In 2020, lockboxes for medications to reduce accidental ingestion was a large part of many workplans.  Accidental ingestions and subsequent care at a local hospital is on the rise.  From death reviews, concerns have been noted about the number of children with Clonidine, Suboxone, opioid, benzodiazepine or other substances in toxicology screens when these near fatalities are treated in the local emergency room.  

 

Many rural LHDs and MCH contract with the KY Injury Prevention Research Center (KIPRC) at the University of KY, the bona fide agent for injury prevention for the KDPH. KIPRC applies for and coordinates the CDC Injury and Violence Prevention Cooperative Agreement for KY.

 

Title V funds the Pediatric Injury Prevention Program at KIPRC, which includes a pediatrician with expertise in injury prevention and child death reviews. This pediatrician provides technical assistance and training to child-serving agencies including LHDs, health professionals, local CFR teams, and community partners across the state on injury prevention activities and resources. In addition, she serves as the state Safe Kids Coordinator, facilitating the training and sustainability of a rural child passenger safety workforce.

 

MCH partners on prevention activities with KIPRC’s KY Violence and Injury Prevention Program (KVIPP) and the statewide injury coalition, the KY Safety and Prevention Alignment Network (KSPAN). KSPAN is a network of public and private organizations and individuals that are dedicated to promoting safety and preventing injuries throughout the Commonwealth of KY. KSPAN is specifically working to improve the state's capacity to conduct injury prevention and control activities across a wide range of injury causes and types and risk factors to increase the reach, efficiency, and effectiveness of existing prevention efforts through greater coordination and alignment of resources. KSPAN published the KY Strategic Plan for Violence and Injury Prevention 2017-2021 which has several injury and violence prevention focus areas, nine which align with the KY Violence and Injury Prevention Plan). Emphasis areas include, but are not limited to:

 

• Motor Vehicle, Child Passenger, and Teen Driver Safety
• Prevention of Impaired Driving
• Pedestrian and Bicycle Safety
• Prevention of Drug Overdose
• Fall Prevention for Older Adults
• Residential Fire Safety and Prevention
• Child Maltreatment Prevention (e.g., Abusive Head Trauma, Safe Sleep Promotion, and Adverse Childhood Experiences)
• Sexual Violence Prevention
• Child Home Safety (unintentional adolescent injuries)
• Kentucky Safe Communities Network
• Occupational Safety and Health (Total Worker Health and Safety)

 

KSPAN is in the process of updating the KY Strategic Plan for Violence and Injury Prevention 2022 -2026. During this update additional topics will be included in the strategic plan, addressing adverse childhood experiences and suicide prevention.

This partnership has deep impact in the community with an ability and scope as a recognized leader to advocate and educate for injury prevention.

 

In addition, MCH works with KSPAN and KIPRC work to promote and support the Safe Communities America accreditation of KY Safe Community coalitions. Currently Marion and Mason Counties are going through the process of becoming accredited Safe Communities. This enhances the MCH capacity to disseminate best practice injury prevention programming.

 

Child Passenger Safety:

 

Rates of motor vehicle related deaths continues to decrease in Kentucky.  Multiple legislative safety measures instituted in the past 20 years have made significant impact.  In 2007, Kentucky instituted the graduated driving license law to curb teen driving accidents.  For drivers age 16 or 17 years, the law requires an intermediary period of six months restricting driving from midnight to 6 AM and restricting driving to only one unrelated passenger under the age of 20.  The second change in 2010 required parents to use booster seats for children.  This law had some deficiencies related to best practice for child passenger safety and in 2015, MCH along with Safe Kids partners, UK Pediatrics, KY AAP chapter and more were successful in getting a revised booster seat law in place. KY improved its booster seat bill to meet national recommendations, increasing the height requirement to 57 inches and the age requirement to 8 years.  In 2012, these same partners were successful in getting a cell phone ban legislated.  All of these measures have resulted in a decline in motor vehicle collision deaths from 80 children annually (2007) to 41 in 2018. 

 

 

MCH Title V Block Grant funding is available for local health departments to support training for a staff member to become a certified car seat installer and educator for the caregivers on correct fit and installation of car seats. This person is able to provide community education regarding the correct age and size appropriate child safety seat and child passenger safety, including “Look Before Locking.”

 

The Child Passenger Safety work completed for KY MCH injury prevention program is reliant local community supports.  Many LHDs partner with organizations for donation of cribs and car seats as many parents will come to a car seat fitting station without a child seat in the car. Additionally, the Child Passenger Safety work is challenged by turnover of technicians in the community, re-education of local program staff, and limited resources for purchasing child seats.  In 2020, local fitting stations remained open for families.  LHDs and fire stations were creative in education at the 6 foot or greater distance and verbal instructions for families. 

 

Teen Driver Safety

 

In 2018, MCH joined other KSPAN members in promoting the implementation of an evidence-based program for Teen Driver Safety called Checkpoints™. Checkpoints educates Parents/Teens on GDL requirements and about risks teens face when they first start driving on their own. Funding for Checkpoints is available for new eligible counties to implement Checkpoints and new ways have been developed during this time of COVID to deliver the Checkpoints training to parents/teens over the internet using Zoom.  Due to this partnership with KSPAN and funding made available through the KY Office of Highway Safety communities are eligible to receive up to $500 for completing the application and providing a letter of commitment from the school where Checkpoints will be targeted. Upon successful completion of a Checkpoints class the community/school would be eligible to receive an additional $750 for a total budget of $1250 for each new school to use in implementing the program. Funding availability is limited and has been targeted using epidemiology of at-fault teen motor vehicle crashes in Kentucky developed by KIPRC available at https://kspan.egnyte.com/dl/UuOqjSFTea. It is through our continued partnership with KSPAN that we will be able to leverage limited resources to provide continued support to communities to implement the Checkpoints program for teen driver safety.

Primary Prevention Home – Visiting

 

The Kentucky HANDS model is one of nineteen MIECHV approved implementation models.  HANDS is KY’s statewide home visiting program for overburdened parents. The supportive phrase often used and imbedded in this program is “Every parent needs a second pair of HANDS”.  KY HANDS is one of the oldest home visitation programs in the nation. Goals of the program include healthy pregnancies and births and for children to live in healthy/safe homes. Home visitors emphasize child safety checklists for appropriate ages; healthy child growth and child development, child abuse prevention; and family self-sufficiency. Family self-sufficiency includes goal setting, resource development, positive parenting, and even anger management, so that families are less likely to use harsh discipline or have violence in the home.

 

Like many other MCH programs/initiatives, COVID-19 impact on the ability to reach the public stopped for a period of time while program processes were updated to include virtual visits and education opportunities.  While HANDS formal evaluations have not been conducted, local HANDS staff have provided ongoing input to state leadership about the barriers and work done to overcome these throughout 2020.  Currently HANDS has an ongoing project to update the data system to meet program needs. 

Early Childhood Obesity Prevention

 

Obesity remains a significant public health issue in KY. As made evident during the Covid-19 pandemic health risks associated with long term overweight issues and the impact on child development, obesity data remain concerning. Obesity reduction goals focus on education of healthy nutrition and activity beginning in early childhood to build healthy behaviors and promote these behaviors throughout the lifespan. Activities include training for caregivers in environments in which children spend large portions of their day and consume many of their daily meals.

 

In the more recent years, MCH has promoted the 5-2-1-0 public awareness:

 

• Five: Eat five or more servings of fruits and vegetables daily
• Two: Limit screen time to no more than two hours daily
• One: Be physically active at least one hour daily
• Zero: Do not drink sweetened beverage

 

While this messaging continues, the priority has shifted to education on the use of GoNAPSACC in the ECE setting. Go NAPSACC works with childcare providers to improve the health of young children through practices, policies, and environments that instill habits supporting lifelong health and well-being. We offer modules on key topics like healthy eating, physical activity, and oral health. KDPH received funding to support the GoNAPSACC work on a statewide level.

 

Prior to COVID workforce demands, childcare health consultants (CCHCs) provided information and education for the campaign and other measures for obesity prevention through face-to-face visits, consultation, newsletters, and outreach to local childcare centers across the state. KDPH supports CCHCs in their work to promote wellness in caregivers working in ECE. This wellness opportunity is another aspect of the health environment.  In 2020, CCHCs were not able to develop and provide obesity/nutrition training for childcares.  They were able to address technical assistance requests and ongoing education related to COVID mitigation in childcares.

 

In FY2020, the Healthy People, Active Communities Package was selected by 24 LHDs. Work in this package continues to be innovative and relies heavily upon community engagement to promote engagement of adoption of healthy behaviors for nutrition and activity. LHDs participated in local health coalitions, performed walkability studies of their communities for planning purposes of walking paths, and implemented media campaigns and other physical activity plans.

 

In KY, young children are cared for in many settings including Head Start, public preschool, regulated childcare, and in out of school time programs. Each setting has different strategies and goals to address the child’s needs and support the family such as:

• School readiness.
• Wrap-around services with more intentional health screenings.
• Support parent employment or ability to attend school.
• Extended service before and after school to provide additional support for education and wellness opportunities.

 

Additionally, the various childcare settings have different state agencies governing them and different regulations may apply to the various settings. Any effort to improve the health environments of young children in care in KY requires intentional collaboration between agencies and solidifying strategies that align with the goals for these agencies.

 

Currently, KY has licensed childcare centers that mirror the minimum nutrition practices set by the Child and Adult Care Food Program (CACFP) and limit screen time for children based on national benchmarks. Although these guidelines ensure basic needs are met, KY’s children deserve more.

 

While research links optimal nutrition and physical activity with brain development and long-term health outcomes, these behaviors are not a consistent value among early care professionals, agencies, or technical assistance providers. KY has made progress increasing awareness of the impact and importance of health behaviors in young children through the 5-2-1-0 campaign, social media/blogs, and the Nemours Early Care and Education Learning Collaboratives. Additionally, OST and 21st Century programs have provided training on HEPA standards in OST settings. Studies show that healthy, active children learn better, perform better academically and experience fewer behavioral problems. But many children are not getting the healthy food and physical activity they need each day. Afterschool and summer learning programs are well positioned to be key partners in a comprehensive effort to help children grow up healthy.

 

The State Physical Activity and Nutrition (SPAN) program at the state level continues to support web trainings about:

 

• Staff and Child Wellness in the ECE setting.
• Go NAPSACC.
• Farmers Market and Nutrition Access.
• Creating a Supportive Environment for Breastfeeding in Childcare.
• Nurturing Healthy Eaters in Early Childhood Education.
• Safe Routes.

 

The strengths of this program are based upon the ability to engage early childhood caregivers to promote healthy behaviors at the youngest ages. Turnover at the program level make awareness and education on the importance of child health a continuing challenge.

 

Obesity and overweight remain a significant public health problem in KY. While very little data exists on young children, CDC obesity data for children 2-5 years is 13.9% as compared to the national average of 9.4% (Centers for Disease Control and Prevention, 2018). Obesity data remain concerning due to the health risks associated with long term overweight and obesity and the impact on child development.

 

KY Strengthening Families Initiative

 

In a more socio-ecologic, preventive approach to injury prevention, specifically child maltreatment prevention, MCH Title V is leading the KY Strengthening Families (KYSF) initiative in collaboration with the Governor’s Office of Early Childhood. KY’s initial focus is children prenatal through five years and their families and follows a collective impact model, similar to the CDC “Safe, Stable, and Nurturing Environments” work. KY is an affiliate of the national Strengthening Families Network, which is a research-based framework of protective factors for child maltreatment prevention. KY’s initiative is somewhat unique, in that KY developed a cross-sector, cross-agency, public-private framework so that families will be supported in strength-based environments no matter what systems or child-serving agencies they access within their community. It is an intentional approach to systems change and common messaging among all child-serving agencies to respond to the science of toxic stress and early brain development. MCH is raising awareness of ACEs and toxic stress and is laying the groundwork for why Strengthening Families and building protective factors are critical to children’s health and well-being.

 

KYSF workforce had many transitions. As of midyear 2020, this program has one opening. In the past year, this team (with the new parent/family representative) has begun planning for the parent advisory council and supported training for HEART engagement and evaluation plans.

 

Help Me Grow Developmental Screening

 

Although KY did not choose the NPM for developmental screening, MCH worked with the KY Chapter of the AAP to implement “Help Me Grow,” an evidence-based, national program model for promoting developmental screening. The KY Help Me Grow model has been implemented in a limited capacity in KY secondary to lack of MCH funding and workforce resources. Help Me Grow KY (HMGKY) continues to work with four pediatric practices, two childcare centers, and one local health department.

 

Metro United Way’s Ages and Stages Program has become an affiliate of HMGKY and assistance has been provided to the pediatric expansion program.

 

Although KY did not choose the NPM for developmental screening, MCH worked with the KY Chapter of the AAP to implement “Help Me Grow,” an evidence-based, national program model for promoting developmental screening. The KY Help Me Grow model has been implemented in a limited capacity in KY secondary to lack of MCH funding and workforce resources.  Help Me Grow KY (HMGKY) continues to work with four pediatric practices, two childcare centers, and one local health department.

Metro United Way’s Ages and Stages Program has become an affiliate of HMGKY and I have been assisting them with the pediatric expansion program.

 

Tobacco Use

 

Broad goals for tobacco cessation and prevention are to prevent initiation of tobacco use among youth and young adults, promote tobacco use cessation among youth and adults, eliminate exposure to secondhand smoke, and identify and eliminate tobacco-related disparities. Efforts are targeted to NPM 14.2) Percent of children, ages 0 through 17, who live in households where someone smokes. Specific strategies to achieve these goals include:

• Increasing the use of smoking cessation therapy
• Supporting tobacco-free schools, campuses, and communities

 

The Tobacco Prevention and Cessation Program was part of a CHFS reorganization moving it to the Division of Prevention and Quality Improvement in December 2018. Ongoing collaboration and efforts continue regardless of reorganization as both divisions mutually work toward reduction of tobacco use.

 

A statewide 100% Tobacco Free School (TFS) bill was signed into law in 2019. This new law will prohibit the use of tobacco products by students, school personnel and visitors in schools, school vehicles, properties, and activities beginning in school year 2020-21. Several cities have strengthened their already existent partial smoke-free laws in 2018. For the past few years, smoke-free law protected 32.7% of Kentuckians. With local changes, this has improved to 34.7% of Kentuckians protected.

 

 

 

In FY20, eight LHDs chose the MCH Evidence Informed Strategy, 100% TFS for their community. Local health departments provide assistance to local Boards of Education in passing and implementing 100% TFS. The package supports collaboration with appropriate student groups and distribution of survey results and information about policies to key stakeholders.

 

Broad goals for tobacco cessation and prevention are to prevent initiation of tobacco use among youth and young adults, promote tobacco use cessation among youth and adults, eliminate exposure to secondhand smoke, and identify and eliminate tobacco-related disparities. Efforts are targeted to NPM 14.2) Percent of children, ages 0 through 17, who live in households where someone smokes. Specific strategies to achieve these goals include:

• Increasing the use of smoking cessation therapy

• Supporting tobacco-free schools, campuses, and communities

The Tobacco Prevention and Cessation Program is organizationally located within the Division of Prevention and Quality Improvement. Ongoing collaboration and efforts share a common mission as both divisions mutually work toward reduction of tobacco use.

 

Smoke-Free Child Care Centers

 

One LHD piloted a program for tobacco-free childcare centers, which encourages childcare centers to pass policies prohibiting tobacco use on center property and requires caregivers to remove smoke-residue when returning to work after a break by removing a smoking jacket/shirt, washing hands, and rinsing mouths. In the 2017-2018 fiscal year, two additional LHDs have decided to encourage smoke-free childcare centers in their community as well. LHDs create signage for the centers, provide technical assistance on policy change, and create mass media to increase community demand for smoke-free facilities. As of this time, 30 childcare centers are known to have smoke-free policies.

 

Adverse Childhood Experiences

 

Recent data released for KY has shown KY children and families have higher ACEs scores than seen nationally. Per the ACEs study, the higher the ACEs score is, the greater the risk for poor health outcomes later in life. Some ACEs information shown here is from the 2018 National Survey of Children’s Health as it relates to children in KY.

 

 

 

Children in KY (15.3%) as young as 0-5 years report two or more adverse family experiences. This percentage increases with age to 31.9% of children 12-17 reporting adverse family experiences. These rates for KY are under in-depth review as suicide rates for children as young as 10 years of life are rising, and more children have been placed in outside home care secondary to NAS, abuse, and neglect. Comparatively, over 80 percent of children have reports of living in homes demonstrating positive resilience responses, to all or most of the time, to all four items on the survey.

 

MCH in partnership with its many partners (KIPRC, KSPAN, and Ky FaceIT Bluegrass) have during this time of COVID 19 worked together to provide practical information to caregivers and parents to support children as they navigate public health emergencies, focusing on calling for help, organizing one on one connections, noticing triggers that indicate children may need more help, and taking time to talk as a family. Through the Child Home Safety KSPAN Committee, firearm locks and medication boxes are being distributed by partners to Kentucky families, supported by KVIPP funding (KIPRC).

 

Inherent, in the KYSF cross-agency approach for integrating protective factors into systems, are a number of challenges as each agency has its own constraints and specific purposes. Evaluation of this cross-agency, multi-layered effort is also challenging, as measures and measurement are quite different across agencies and depend on whether agency outcomes, front-line staff changes in behavior, or outcomes for families are measured.

 

 

Childhood Lead Poisoning Prevention Program:

 

During this reporting period, the KY Childhood Lead Poisoning Prevention Program undertook a needs assessment that identified barriers encountered by local health departments when dealing with lead poisoning cases. The main issue identified was a lack of adequate training and guidance for health department staff about childhood lead poisoning causes and appropriate interventions. Each of KY’s 120 counties are responsible for handling case management of any child under 6 years of age who has a confirmed blood lead level greater than or equal to 5μg/dL. This comes out to around 150 local health department environmentalists and nurses across the state who require a comprehensive understanding of childhood lead exposures. To address this barrier, the KY Childhood Lead Poisoning Program is working toward conducting a series of trainings across the state. These trainings will cover every aspect of lead from what it is and where it comes from to how they can help families control and mitigate known exposures. In addition, all materials, including educational materials, are in the process of being reformatted based on local health department feedback obtained through this needs assessment.

Oral Health:

While this NPM #13 was retired last year, work completed by the KY Oral Health Program (KOHP) promotes improved health outcomes across the lifespan.

Per KY Department for Medicaid Services (DMS), the proportion of KY children with Medicaid who accessed at least one dental service in 2019 was

• 36% under the age of 6
• 54% between ages 6 and 14
• 50% between ages of 15 and 18 (2019 CMS 416 Report)

This same report shows that while 43% of all eligible received a preventive service, it revealed a significant lack of these services for those under 6 years old at only 32%.

Fourteen percent of Medicaid patients 6-9 received a molar sealant, and only 10% of those between 10-14 had a sealant placed.  The KOHP houses programs dedicated to improving oral health for all Kentuckians.

 

Community Fluoridation Program:

 

The Community Fluoridation Program works with municipal and private water systems to assure compliance with KY’s statewide law that requires fluoridation at optimal levels to reduce decay rates in the state. KY continues to have the highest rate of municipal system customers having optimally fluoridated water than any other state in the country.

Fluoride Varnish Program:

Fluoride varnish and the application of dental sealants are preventive health strategies used to improve outcomes for children residing in areas of the state lacking access to pediatric dentists and Medicaid providers. To improve access to care, LHD public health registered hygiene programs or LHD contracted dentists screen, place sealants or treat patients in these areas. This program assures linkage to a dental home in the community for any higher-level dental needs. The target audience for this outreach is children that do not have a payment source for sealants and are under 300% FPL.

Ongoing training in dental development and disease prevention is provided to public health nurses throughout the state annually to assure competence with assessment and treatment. The cost of fluoride varnish and treatment is a reimbursable service through Medicaid. Since inception of the program, fluoride varnish has been recognized as a primary oral health preventive service. KOHP provides fluoride varnish education for interested primary care providers, or pediatricians, and encourages them to perform an oral health screening with application of fluoride varnish during well child exams if the child is not seen/followed by an oral health provider. For the 2020 year, trainings were put on hold due to the restrictions in place for the Coronavirus Pandemic. 

The MCH fluoride varnish package had many LHDs opt to provide outreach activities, train RNs to establish school-based varnish clinics, and perform quality assurance for fluoride varnish and education activities Due to the pandemic, local health departments shifted their focus to pandemic response responsibilities and activities, reducing many clinical services to almost zero; almost no varnishes were performed due to this shift. 

KRS 156.160 requires all children entering public school to have a dental assessment. The training provided by KOHP ensures nurses are prepared to complete this screening. In collaboration with KOHP, KDE adopted the Smiles for Life Curriculum training for school district nurses to complete prior to performing these dental assessments. Despite a requirement for screening, less than 50% of children entering school report a dental assessment. (Source:  KY Oral Health Coalition meeting: June 2021)

Public Health Dental Hygiene Program:

To improve access to care in rural and underserved areas of KY, KRS 313.040 established a special licensure category for public health registered dental hygienists (RDH) expanding the scope of preventive dental work performed by the RDH without requiring the presence of a dentist on site. This expanded scope allows the public health RDH to provide preventive dental services to healthy children who may be at high risk for dental disease. KY has nine public health RDH teams serving underserved areas providing a comprehensive range of primary preventive services with a clinical focus on the placement of sealants on erupting molars and linkage to a permanent oral health home. Since program inception in 2014, these programs have an 83% success rate of referral to comprehensive dental treatment to these high-risk patients.