NPM 6: Percent of children, ages 9 through 71 months, receiving a developmental screening using a parent-completed screening tool

The percent of children, ages 10-71 months, receiving a developmental screening using a parent-completed screening tool, has been steadily increasing since 2012. The change in rate has increased, in part, due to the growth and expansion of the 1st Five Healthy Mental Development Program, which promotes developmental screening to primary care. This initiative, along with other Iowa efforts, have also provided a greater awareness among practitioners and families regarding the value of developmental screening. However, the rate decreased from 34.8% in 2016 to 28.4% in 2018.

Iowa could enhance developmental screening rates if 1st Five was expanded to a statewide program. Demands on primary care providers may also decrease if the program was expanded statewide. Developmental screening rates collected and reported in the National Survey of Children’s Health may also increase if the sample size was larger and conducted more regularly.

The 1st Five program, funded by the Iowa Legislature, works with over 300 primary care practices across 88 counties in Iowa. Parents and caregivers of children who visit these engaged practices in Iowa for well child exams, are more likely to receive developmental screening information and coordination of referral based off of a screen when a developmental or social need is indicated. Parents and caregivers are more likely to become aware of routine screening through this program. 1st Five also has materials developed for parents/caregivers aimed at the importance of screening as well as developmental milestone information.

The 1st Five program contracts with Child & Family Policy Center (CFPC) for independent evaluation of the program. As part of the FY17 contract, the evaluation included surveying 1st Five referred families. The findings reported that more than 90 percent of families reported being aware of more programs and resources after working with 1st Five.  The largest improvement was seen in parents reporting an increase in knowledge of child development - how to help their child learn.

The 1st Five program operates in 18 of Iowa’s 23 local MCAH agencies and has a local Site Coordinator. 1st Five Site Coordinators provide office staff with resources and tools for the practice to implement the program; this includes newsletters, trainings offered by medical experts, incentives that promote developmental screening and/or milestones, ASQ age predictor wheels, screening tools (ASQ-3, ASQ:SE-2), 1st Five brochures & infographics. Outreach also includes local radio and newspaper ads promoting developmental screening.

As part of 1st Five contracting with CHSC, three provider champions are available for outreach on developmental screening throughout the 1st Five service area. This provider champion team includes a family medicine physician, a pediatrician and an advanced registered nurse practitioner (ARNP). The provider champion team consults with other healthcare providers through local conferences and webinars and one-on-one through email, in-person and online technologies. Also through 1st Five contracting with CHSC, developmental screening outreach is performed through monthly webinars, targeting primary care practices throughout the state. 1st Five has had a presence at many professional organizations’ conferences. Through 1st Five, CHSC also partnered with Iowa Chapter of the AAP to post social media content on the importance of developmental screening. Developmental screening videos were developed and shared on the 1st Five website.

In FFY18, the practice consultant team expects to provide 25 consultations and/or developmental screening trainings. There is renewed focus in FFY18 on consultation visits in person to primary care practices.

In SFY 2018, the performance measure incentivized peer-to-peer consultation that occurred in person at the primary care practice locations. As of April, 2018, seven of 18 sites had achieved this measure. The contracts include identification or maintenance of one referring practice in every county of the service delivery area as part of the standard expectations of the contract.

Each of Iowa’s 23 Title V Child and Adolescent Health (CAH) contract agencies is an approved Medicaid Screening Center. Each CAH contract agency is enrolled with the IME and also with the two MCOs currently operating in Iowa (Amerigroup and UnitedHealthcare). (AmeriHealth Caritas ended their MCO contract with the Iowa Department of Human Services (DHS) effective November 30, 2017.) Developmental screenings and emotional/behavioral assessments are provided by CAH agencies using the ASQ and ASQ:SE tools. IDPH staff met with IME and Medicaid MCO staff to assure proper payment for these services. Contract agencies are able to receive payment from the IME for services provided for Medicaid fee-for-service clients and the Medicaid MCO for children enrolled in an MCO. IDPH worked with IME’s Screening Center Project Manager to discuss and resolve any challenges with payment.

The 2019 Title V Request for Application required all Child and Adolescent Health applicants to write activity worksheet plans to address NPM #6 Promoting developmental screening for children ages 9 – 71 months to advance children receiving age appropriate developmental screening/testing (e.g. ASQ and ASQ:SE) up to age 6 years. Applicants must address the following: Coordinating the provision of developmental screens with local providers such as child care providers, home visiting programs, and primary care practitioners to assess need, assure access, and avoid duplication; collaborating with early care and education providers to encourage developmental screening; and educating families on the importance of developmental screening at recommended age intervals. This is a part of the agency’s age-specific informing scripts. Agencies must ensure that age appropriate developmental screening is provided by trained staff, results are communicated with primary care practitioners, and ensure that related education and follow-up services are provided.

Bureau of Family Health staff completed work with the developers of the TAVConnect CAH module to incorporate a component for reporting each domain of a child’s ASQ and ASQ:SE results. Entering into TAV the results of a child’s ASQ and/or ASQ:SE scores is now a requirement of the Title V CAH program. This allows Title V to collect aggregated data pertaining to ASQ and ASQ:SE results provided by local CAH contract agencies.

Data from services provided by Title V Child & Adolescent Health Agencies (FFY 2018:  October 1, 2017 – September 30, 2018)

• Ages and Stages Questionnaire (ASQ 3) provided for screening for development in the following domains:  Communication, Gross Motor, Fine Motor, Problem Solving, and Personal-Social.
  • 6,748 children were screened; 8,571 screens were provided.
  • In the Communication domain, 88% of children were on schedule for appropriate development; 8% needed monitoring/supporting activities; 4% needed further assessment with a professional
  • In the Gross Motor domain, 89% of children were on schedule for appropriate development; 6% needed monitoring/supporting activities; 5% needed further assessment with a professional
  • In the Fine Motor domain, 86% of children were on schedule for appropriate development; 9% needed monitoring/supporting activities; 5% needed further assessment with a professional
  • In the Problem Solving domain, 88% of children were on schedule for appropriate development; 7% needed monitoring/supporting activities; 5% needed further assessment with a professional
  • In the Personal-Social domain, 89% of children were on schedule for appropriate development; 7% needed monitoring/supporting activities; 4% needed further assessment with a professional

Data from Iowa Medicaid on Paid Claims for services provided in FFY 2018 (October 1, 2017 – September 30, 2018) for Medicaid enrolled children in Iowa.  This is statewide data for screening provided across any provider type.

• 21,902 children received developmental screening (per paid claims); 31,174 developmental screens were provided (per paid claims)
• 8,400 children received social-emotional screening (per paid claims); 13,349 social-emotional screens were provided (per paid claims)

Iowa’s Title V CAH program works closely with numerous partners. Partnerships were fostered with 1st Five, early care and education programs, home visiting, and CHSC to promote developmental screening. BFH monthly meetings with Iowa Medicaid staff provided an avenue to discuss contracting, coding, and billing issues pertaining to developmental services provided by Title V contract agencies. CAH agencies included specific action plans addressing the provision of developmental screenings, referral, and follow-up within their RFA applications for FFY18. This included a plan to work with Iowa’s Area Education Agencies on referrals to Early ACCESS (IDEA, Part C) based upon screening results. Title V contract agencies provide developmental monitoring for children who are referred to Early ACCESS but ultimately do not qualify. BFH staff also met regularly with Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program staff to discuss opportunities for collaboration. Coordination of developmental screening promoted by CAH, 1st Five, and home visiting programs was discussed, including the need to avoid duplication of services. Since 2015, BFH staff have participated on a leadership team coordinated by Iowa Children’s Justice to address the impact of substance use/abuse on pregnant women, infants, and children. Promoting children’s healthy growth and development is an inherent component of this work. Aggregated data reports of results of ASQ and ASQ:SE screenings provided by Title V CAH contract agencies have been of particular interest to this workgroup.  

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

One of the primary goals of the I-Smile program is to connect children with dentists and provide needed preventive dental services. The continuous efforts of I-Smile contractors across the state have helped to get children into needed preventive dental care, despite the limited ability for Medicaid-enrolled children to access to dentists.

The lack of dentists’ enthusiasm to see and treat Medicaid patients may be negatively affecting the rates of children getting regular preventive dental visits. Despite all the work Iowa is doing to connect children with dentists and preventive services, the rate may decrease if this does not improve, and also prevent Iowa from hitting the objective. If rates of children accessing a preventive dental visit do not increase, it is likely the National Outcome Measure (reduce the percent of children and adolescents who have dental caries or decayed teeth) will increase, meaning more children will experience cavities and poor oral health outcomes.

To improve the number of children receiving preventive dental services, the Oral Health Bureau (OHB) staff managed the I-Smile program and provided assistance to I-Smile coordinators.  In January 2018, OHB staff held regional workshops with I-Smile coordinators. Time was spent reviewing local needs assessments, completed by the coordinators, and using those assessments to develop local work plans for FFY2019. Other coordinator trainings in FFY2018 included round tables identifying how to build stronger linkages with Iowa’s Federally Qualified Health Centers and the 5-2-1-0 and the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) nutrition/wellness projects. To improve consistency, OHB staff created a file-sharing method using Google Drive, providing a central location for current forms and health promotion materials that are easily accessible by coordinators. Outreach to medical and dental providers was another important component of I-Smile. Coordinators were required to visit all general practice and pediatric dental offices, as well as pediatric medical offices (or family practice offices if no pediatric office was located in a county). In addition, the I-Smile@School program - Iowa’s school-based sealant program - continued to provide services in 93 of Iowa’s 99 counties. 

The OHB water fluoridation coordinator continued to strengthen relationships with local water systems, water organizations in the state, and I-Smile coordinators, working toward increasing the number of Iowans receiving optimally fluoridated water. In addition, the bureau’s epidemiology consultant continued building the bureau’s surveillance system, identifying quality improvement methods for contractors regarding data entry in TAVConnect and helping to develop reports and strategies based on oral health trends.

In October, staff developed protocols and documents to be used by I-Smile programs for the incorporation of silver diamine fluoride (SDF) use within WIC clinics. SDF will be an important tool for preventing and arresting tooth decay, helping to reduce health care costs and improve the oral health of children. This spring, staff are organizing an oral health survey of WIC children, to be completed this summer. The epidemiology consultant has developed a calibration training for all nurses and dental hygienists who will screen children at WIC from June - August. Data will be recorded in the TAVConnect system, to be analyzed during FFY2020.  Oral Health Bureau staff provide leadership for the Cavity Free Iowa project, currently focused on medical systems in central Iowa. The project encourages use of fluoride varnish for Medicaid-enrolled children at well-child visits, including training by I-Smile coordinators and consultation from I-Smile for the medical offices, as needed. 

Data from SFY2018 were used for the Inside I-Smile report, released in February, demonstrating the continued success of I-Smile. The number of Medicaid-enrolled children receiving care from a dentist was nearly double the number in 2005, the year before I-Smile began. Nearly four times as many children receive preventive care from I-Smile/MCAH than in 2005.

SPM 2: A) Percent of children 0-21 served by Title V who report a medical home

Medical home status for children and adolescents was determined through questions located within an Intake Assessment in the TAVConnect data system:  Does the client have a usual source of medical care? Is the usual source of medical care available 24/7? Does the source of medical care maintain the client's record? If all three responses are ‘yes’, then the child is identified as having a medical home. Training with Title V Child and Adolescent Health (CAH) contract agencies on completion of Intake Assessments helped to generate data that better reflected medical homes established for children. FFY 2018 data shows that 87 percent of children have established medical homes, an increase of 3 percent over the previous year.

Responses to medical home questions are entered into an Intake Assessment in the TAV Connect - CAH module. This is a relatively new location for capturing the medical home information for a client, beginning in April 2017. In the past year, emphasis has been placed on completion of Intake Assessments as a routine course of business among local CAH contract agencies.  As a result, more complete and accurate data is being collected.  It is believed that this is the primary reason for the increase in the medical home percentage from 84% to 87%.   We anticipate the percentage of children with a medical home to gradually to increase in coming years.

Challenges that contribute to the establishment of medical homes for children include the following:  

• Title V CAH contract agencies are unable to bill for coordination of medical care for the Medicaid MCO population (approximately 95% of the child and adolescent population). This is due to the inclusion of medical care coordination in the MCO’s contract with the Iowa Department of Human Services (DHS).
• Iowa’s Medicaid MCO providers continue to undergo change. Iowa  DHS will be contracting with a new MCO - Centene’s Iowa Total Care  - who will begin processing claims for services provided July 1, 2019 and forward.   On March 29, 2019 UnitedHealthcare will be leaving Iowa as a Medicaid MCO. This departure will create great challenges in aligning the Medicaid population with the remaining MCO providers - Amerigroup and the new Iowa Total Care.

Although there are no specific National Outcome Measures (NOM) linked to SPM 2, there are two that appear relevant to the establishment of medical homes.  

• The NSCH 2016 linked NOM 19 found 92.4 percent of Iowa’s children, ages 0 through 17 years, to be in excellent or very good health. This exceeds the national measure of 89.7 percent.
• The American Community Survey 2011 linked NOM 21 found the percent of Iowa’s children, ages 0 through 17, without health insurance to be 4.6 percent.  This compares favorably to the national measure of 7.5 percent.

Title V MCAH RFP/RFA Application and Reporting

The FFY18 RFA included requirements for each CAH applicant to develop activities related to SPM #2: Assuring children and adolescents have an established medical home with a primary care provider. Each of the 23 CAH agencies assessed medical home status and assisted families with health literacy so that they understood their health care coverage, how to use it to access services, and any issues related to transitioning coverage. 

Each CAH agency provided presumptive eligibility services for children and adolescents. Approvals for presumptive eligibility allow Medicaid coverage of medical and dental services for a limited period of time while a full eligibility determination can be made for either Medicaid or Hawki coverage. Agencies were able to bill Iowa Medicaid for preventive health care services provided during the presumptive period under the Screening Center provider status. Establishment of a primary care provider as a medical home is of primary importance during this period. CAH contract agencies met with local primary care providers to educate them on the Title V CAH program and their role in serving the EPSDT population. They tracked providers willing to accept Medicaid clients within their service area and monitored which providers are enrolled with each MCO. BFH and local contract staff monitor data, trends, and reports regarding medical home and provider availability. Referral relationships were promoted between primary care providers and local Title V contract agencies, enhanced in agencies offering the 1st Five Healthy Mental Development Initiative.

Medicaid Managed Care and Impact on Title V

The implementation of Medicaid Managed Care in Iowa resulted in challenges within Iowa’s Title V CAH program related to the provision of care coordination services. Included in Iowa contracts with the MCOs is the provision of medical care coordination. As a result, TItle V CAH agencies remained unable to bill for medical care coordination services for MCO enrolled clients. Where Title V CAH agencies formerly worked with Medicaid enrolled children to coordinate medical care (including reminding families of needed well child exams), these activities became the responsibility of the Medicaid MCOs. Although establishing a medical home remained a program priority, this added a barrier in coordinating medical care for a large segment of the CAH population (approximately 95%).  Local Title V CAH contract agencies were able to provide medical care coordination services for the Medicaid fee‐for‐service population (non‐MCO enrolled), the remaining 5%. Despite the challenges, CAH agencies continued to assess medical home status when providing presumptive eligibility, EPSDT informing, and direct care services for all children served. They continued to educate families about the importance of establishing medical homes and made appropriate referrals. 

Regular monthly meetings with Iowa Medicaid Program Managers provided the opportunity to address medical home, review key CAH data, and advocate for services for the EPSDT population. They also served in part to address challenges that local Title V MCAH agencies experienced in working with the MCOs. These include establishing accurate designation as a Medicaid Screening Center, proper payment of services, pay and chase related to third party billing, prior authorization, denial of payments due to ‘lack of medical necessity’, and transportation services now offered through IME or MCO transportation brokers.

Statewide medical home percentages are tracked on the Child Health Program Profile and the IDPH Executive Scorecard.

Medical homes continue to be established and presumptive eligibility services for children continue to be provided.  Local Title V CAH agencies continue to assist families with understanding their Medicaid or Hawki coverage and connect with enrolled primary care providers. BFH staff works with Child Health Specialty Clinics regarding efforts to promote medical homes for children with special health care needs to support NPM #11 through referrals.

Local CAH agencies strive to advance public-private partnerships with local medical providers of preventive health care services, including educating practitioners on the CAH agency’s role in assuring medical homes and serving children in the EPSDT program. CAH agencies with a FFY 2019 RFA adolescent well visit plan work with primary care practitioners to increase the number of adolescents served and enhance the quality of the well visit. They partner with school districts and other adolescent serving organizations to promote adolescent well visits in an established medical home. Promoting annual adolescent well visits per Iowa’s revised EPSDT Periodicity Schedule remains  a program  priority. 

BFH staff continue to work with Iowa Medicaid and MCOs to address challenges regarding provision and payment of services for the EPSDT population provided by Title V CAH agencies (Medicaid Screening Centers). Iowa’s Medicaid MCO providers continue to undergo change.  Iowa  DHS will be contracting with a new MCO - Centene’s Iowa Total Care  - who will begin processing claims for services provided July 1, 2019 and forward.  BFH staff met with Iowa Total Care staff to provide information on Title V and the Medicaid Screening Center provider status to facilitate a smooth enrollment and credentialing process for CAH contract agencies. On March 29, 2019, UnitedHealthcare announced that they will be leaving Iowa as a Medicaid MCO. This departure will create great challenges in aligning the Medicaid population with the remaining MCO providers - Amerigroup and the new Iowa Total Care. TItle V CAH agencies expend numerous resources helping clients to understand their health care coverage and establish medical homes during such times of transition.

SPM 3: Percent of children with a payment source for dental care

Two goals of the I-Smile program are to connect families with children with dentists who can provide care and to help families find a payment source for dental care. There has been a decrease in this indicator from 2015-2016 school year data, which is likely due to the inconsistencies from the transition of data systems (CAReS to TAVConnect) in March 2017.

In FFY2018, the I-Smile program served as the statewide oral health/dental home initiative for children. Oral Health Bureau (OHB) staff managed I-Smile, working with the 23 local I-Smile coordinators. Through quarterly trainings and regular communication, OHB consultants and coordinators worked on strategies to help families identify payment sources for dental care, including Medicaid and Hawki. OHB staff continued regular meetings with Medicaid staff to troubleshoot issues experienced by contractors and also identify strategies to improve access to dental care.  I-Smile coordinators worked with Hawki coordinators to educate families and employers about the dental only option in Hawki.  In Iowa, if a family has medical insurance but not dental, they can apply to Hawki for dental only coverage.  I-Smile coordinators also encouraged dental offices to accept this payment option.

SPM 4: Percent of early care and education programs that receive Child Care Nurse Consultant Services

Seventy-five percent of Iowa households with children under the age of 6 have all available parents in the workforce. There is a great need for out of home care, however 24% of Iowa residents live in a child care desert. Child care supply is especially low in rural areas, where 37% of residents live in areas without enough licensed child care providers. Since 2012 there has been a 38% decrease in the number of child care programs (from 9,963 regulated providers in 2012 to 6,132 regulated providers in 2017) with only a 2% decrease in the number of children age birth to 5 years old. In FFY18, the number of counties with CCNC services increased, with 91 out of 99 counties receiving CCNC services. The number of child care providers statewide continued to decline by 14.4% from the previous year (5,265, June 2017; 4,507, June 2018). 1,562 Licensed Child Care Centers/Preschools, 2,660 Registered Child Development Homes and 285 Child Care Homes [homes caring for 5 or less children with a Child Care Assistance Agreement.

Improving access to services, a slight increase in funding, quarterly training to CCNCs on performance measure data collection, continued partnership between agencies, and collaboration/referrals with child care consultant staff (DHS licensing/home regulation, Child Care Resource & Referral) has helped to increase the number of providers receiving CCNC services.

• 33 Child Care Nurse Consultants statewide
• 1,558 child care programs working with a CCNC with 94% improving in health and safety (up from 1,347 in FY17)
• 4047 on-site child care visits completed (up from 3,756 in FY17)
• 8,147 technical assistance provided (up from 7158 in FY17)
• 1,064 children with special health needs identified, 83% with a care plan in place (up from 869 in FY17)
• 226 trainings given statewide, 2,252 providers trained

Improving access to local CCNC services as well as quarterly training to CCNCs at statewide and regional meetings on the CCNC Role Guidance, PM data collection, documentation, and reporting has been critical for increasing SPM4.

State HCCI staff have continued to facilitate the development of partnerships between Title V Child Health agencies/CCNC programs with local Early Childhood Iowa boards and other local stakeholders. This has helped braid state and local funding to support CCNC services.

Children with chronic health conditions (asthma, allergies/anaphylaxis, seizures and diabetes) has been increasing nationally as well as Iowa school health data. Identification of children with special health needs during all on-site child care visits rather than just during child health record review has demonstrated an increase in the number of children identified by the CCNC which has increased the percent of children with a care plan in place.

Federal Child Care Development Block Grant requirements for states to ensure all regulated child care providers received pre-service/orientation health and safety training as well as action plans for children with severe allergies. This requirement encouraged increased collaboration with Iowa Department of Human Services regulatory staff, Iowa Department of Public Health/Healthy Child Care Iowa and other partners for increased referrals to local CCNCs for consultation to child care programs on health and safety topics as well as special needs care planning.