III.E.2.b.v.c. State Action Plan Narrative by Domain

Child Health Domain Narrative

Overview

The Child Health Unit (CHU) at DOH is managed within the Thriving Children and Youth Section of the Office of Family and Community Health Improvement (OFCHI) in the Division of Prevention and Community Health (PCH). This section also includes the Adolescent and Young Adult Health Unit and the Children and Youth with Special Health Care Needs Unit.

 

Child health is viewed holistically through a life course development perspective, covering the physical, mental, emotional, behavioral, and spiritual aspects of child well-being in alignment with the phases of development. It is also considered in the socio-ecological model, recognizing the influence of family, community, societal and systemic factors on children’s well-being. Child health strategies include universal approaches (e.g., promotion of developmental screening, comprehensive system development) and more tailored approaches to address the needs of children and families who are furthest from opportunity due to social, economic, or geographic factors. A central focus of our work is identifying and addressing the historical and ongoing impacts of systemic racism on children’s health. We continue to promote the importance and availability of well-child visits, increasing and tracking the rate of developmental screenings, and addressing child mental health concerns. Through our many partnerships with state agencies, local health jurisdictions, community-based organizations, and different entities, we promote relational health and positive childhood experiences (PCEs) and work towards the preventing and mitigating child maltreatment and adverse childhood experiences (ACEs).

 

Our child-health-focused initiatives and programs are funded by different sources, including the Title V Maternal and Child Health Block Grant (MCHBG), Centers for Disease Control and Prevention (CDC), Health Resources and Services Administration (HRSA), state funds, and private foundation funding.

 

Our unit works together with other DOH units to address the priority needs of the child population (ages 1-11 years). In addition to the work within OFCHI, several additional sections of DOH contribute toward meeting our Title V child health objectives, strategies, and performance measures. The Injury and Violence Prevention program works on initiatives to promote child safety and prevent injuries. The Healthy Eating Active Living program works to reduce the burden of obesity and chronic disease, increase the proportion of children with a healthy weight, and promote breast/chestfeeding for a healthy start. The Immunizations and Watch Me Grow Health Promotion System manages a universal vaccine program. It sends child health and safety information to all families with young children in Washington by mail and e-mail. The Oral Health program promotes access to oral health care and prevention of dental disease and oversees the Smile Survey to collect data on the oral health of children in Washington. Collectively, these programs contribute to our shared vision of safe, healthy, and thriving children.

 

During FFY22, significant staff changes included a new Thriving Children and Youth section manager, a new Child Health Unit supervisor, and 2 new staff to support child health work. Personnel processes and onboarding led to some delays and modifications in planned work.

 

Data Overview of Child Health Population

In 2020, the most recent year for which reliable data exists, the Washington population of children 1 to 11 was estimated to be 1,037,834, or about 22.2% of the total state population. The population of children 1 to 5 was estimated at about 4.4% of the total; ages 6 to 11 were about 9.4%. In general, Black, Indigenous, and people of color (BIPOC) populations have a proportionally larger population of young children than the white, non-Hispanic population.

 

 

In 2021 Washington had a rate of uninsured children under six years of age that was lower than the national rate, 3% vs. 5%. Families continued to report barriers to accessing coverage, including difficulties navigating the enrollment process. Over 34% of children were covered by public health insurance (Medicaid, CHIP or other state/federal plan) with another 5% covered by a combination of private and public insurance. (KIDS COUNT), Having public only coverage can sometime make it more difficult for families to find a doctor who accepts their health insurance, make an appointment, and/or obtain specialist care (Medicaid and CHIP Payment and Access Commission [MACPAC]).

 

In 2020-2021, an estimated 46% of children in Washington ages 9 to 35 months received a developmental screening, similar to the 2019-2020 rate of 47%. The national rate for 2020-2021 was 35%. This is a statistically significant difference. In 2020-2021, approximately 66% of families needing care coordination in Washington received it, compared with the national rate of 70%, this was not a statistically significant difference. (NSCH).

 

In calendar year 2021, the rates for children having received the full recommended vaccine series is listed in the table below. 

 

Age group	Recommended series	% complete
19-35 months	4:3:1:3:3:1:4	57.4
4-6 years	5:3:4:2:4:4:2	41.8
11-12 years	1:1:1	33.2
13-17 years	1:1:UTD	41.5

 

Washington’s Title V program served 1,936,588 children, adolescents, and young adults, ages 1 to 21, in 2021. We promoted the health and wellness of children through policies and programs that support safe, stable, nurturing relationships and environments; universal developmental screening, early and ongoing learning and development, culturally appropriate and responsive supports, and services and systems improvements that support the whole child, whole family, and whole community. We also continued our work on many MCHBG objectives to meet the immediate needs created by the COVID-19 pandemic.

 

Child Health Priority 1: Enhance and maintain health systems to increase timely access to preventive care, early screening, referral, and treatment to improve population health across the life course.

Within this priority, the Child Health unit and other DOH units work to address the following National Performance Measure:

 

1. Percent of children, ages 9-35 months, who received developmental screening using a parent-completed tool in the past year.

 

The intent of this focus is to ensure early identification and intervention for developmental needs. Work in this priority area also includes broadly promoting child preventive care through well-child visits and immunizations and integrating and connecting health systems into the broader early childhood system (i.e., early learning, social services, child welfare) in Washington state.

 

Increasing Child Well-Visits and Vaccinations

During FFY22, DOH continued to promote well-child visits to increase the uptake of well-visits and immunizations to pre-COVID levels or greater. Routine child well-visits are a primary strategy to increase developmental screening and other preventive health services, like immunizations. Well-visit promotion work was largely housed within the OFCHI Health Systems Unit. The unit works together with the Health Care Authority (HCA) to coordinate joint Practice Improvement Projects (PIP) between all 5 Medicaid Managed Care Organizations (MCOs) in WA State (Amerigroup, Molina, Coordinated Care, United Healthcare, and Community Health Plan of WA. The PIP for calendar years 2021-2023 has focused on improving child well-visit rates, with an emphasis on children ages 3-11 years.

 

Progress

During FFY22, DOH worked on the following objective:

 

• Through September 2025, in the context of the COVID-19 pandemic, promote well-child visits and up-to-date vaccination completion.

 

Launching Child Well-Visit Communications Campaign

As part of the collaborative Practice Improvement Project with MCOs, we gathered information from families about barriers to well-child visit utilization. We then developed a Request for Proposals to plan, implement, and evaluate a social marketing/communications campaign to increase awareness of the importance and value of scheduling well-care visits. This work included promoting immunizations to bring children up to date on missed vaccination opportunities during COVID-19. DOH contracted with C+C, an award-winning vendor with significant experience promoting vaccinations during COVID-19, to develop materials. C+C developed flyers promoting well-child visits and immunizations to parents of different age groups (infants/toddlers, children, adolescents, and young adults). These flyers in English, Spanish, Russian, and Vietnamese were distributed through schools and early childhood providers. Information for health care providers, including “Tips to Raise the Rate of Well-Care Visits” and “Personalized Messages for Ages 3-11,” were distributed to clinics through MCOs. Social media messages were shared through Instagram, Facebook, and other channels. All materials, including a short video ad for families and information for providers, were posted on the DOH website: Child and Adolescent Well-Care Visits | Washington State Department of Health. The campaign development began in FFY22, with ads and social media messages occurring in November and December of 2022. We also worked with MCOs and health care clinics to host special Spring and Fall events to increase well-visits, using HCA incentives for the clinics. Evaluation of the campaign and other strategies is in progress.

 

Promoting Early Identification of Child Developmental Needs through Developmental Screening and Data System Development

Increasing developmental screening for all young children remains a priority for DOH. During FFY22, DOH launched the Strong Start Universal Developmental Screening Data System and increased programmatic capacity to support the system rollout to health care providers and parents, including hiring a program manager and 2 program staff to focus on data systems and community/health care provider outreach.

 

Progress

In FFY22, DOH had 3 primary objectives related to developmental screening and made progress on each objective.

 

• By December 31, 2021, complete statewide universal developmental screening and referral data system, to be promoted with clinical, local health jurisdiction, and social services providers as component of plan to increase developmental screening completion for all Washington children.

 

• Through September 2025, increase alignment and, where possible, correct misalignment between universal developmental screening data system development, the Help Me Grow Washington system, and other state child health screening/assessment infrastructure.

 

• By September 2025, increase parent, public, and health professional awareness of developmental milestones and evidence-based well-childcare through communication strategies.

 

Completing Universal Developmental Screening data system development and launch

We have been working with state and local partners for several years to identify critical needs and gaps in developmental screening and connection to responsive services. The priority need that surfaced was the lack of a statewide system to track early screenings and referrals.

With support from the state legislature, the system went live in the fall of 2021. DOH began a focused soft launch with the Washington Chapter of the American Academy of Pediatrics (WCAAP) Bright Futures Learning Collaborative with two community health centers. Additionally, outreach began to Help Me Grow WA (HMG WA) partners, Local Health Jurisdictions (LHJs), and Tribal partners and communities. This marked the beginning of a phased implementation, with plans for a statewide rollout in 2023.

 

In early 2022, the Legislature approved additional funding for Universal Developmental Screening (UDS) system maintenance and operation and to create a dedicated UDS program within OFCHI. The UDS program was established in April 2022 with the appointment of a 1.0 FTE Program Manager. Two 1.0 FTE program staff were hired and onboarded-- UDS System Support Consultant and UDS Education and Outreach consultants in July 2022.A .50 FTE epidemiologist and a Business Analyst from DOH Health Technology Solutions support the program to provide as-needed support for ongoing maintenance and operations of the data system.

 

The program staff have been actively engaged in outreach across the state, developing communication materials, and working with the UDS system vendor to implement ongoing improvements. Staff meet monthly with key state partners, like HMG WA and the Department of Children, Youth, and Families. Training and technical assistance in Spanish and English have been offered to guide potential users about the new system.

 

Local Health Jurisdictions have also done significant work on UDS. A summary of their efforts can be found at the end of this report.

 

Maintaining statewide parent help hotline for developmental information

DOH continues to use MCHBG funds to support a contract with WithinReach to maintain the state HMG WA parent hotline and resource/referral system that assists families in completing a developmental screening and connecting to other resources. In 2022, WithinReach received and responded to 13,506 calls. HMG WA provided 41,913 referrals in 2022; developmental support was the second most common type of referral (second to basic needs). WithinReach’s ParentHelp123.org website data showed  29,992 page views with 23,245 total unique page views in 2022. WithinReach’s hotline and website resources are described further in the Women/Maternal Health Annual Report.

 

Communicating developmental screening and well-visit information to families

DOH continues to utilize a robust child health promotion tool, Watch Me Grow Washington | Washington State Department of Health (formerly Child Profile). Watch Me Grow Washington has been DOH’s primary method for delivering important health and safety information by mail to Washington state families for more than 20 years. We send over 1.5 million mailings per year, reaching 98% of families with children from birth to 6 years. DOH distributes mailers to families at scheduled intervals based on child age and in correlation with the American Academy of Pediatrics recommended schedule of well-child visits through this program. Mailers offer information about developmental milestones, immunizations, nutrition, oral health, parent health and other materials, and connections to HMG WA and other resources. Child Health staff worked with Watch Me Grow Washington to incorporate Vroom™ brain building tips into mailers to 84,426 families of toddlers from October 2021 through September 2022. Mailers also included well-visit promotion information from the social media/communications campaign project described in the section on Child Well-Visits above.

 

Tracking screening rates

DOH tracks developmental screening rates primarily for children on Medicaid through a HCA-DOH data share agreement. Among children covered by Medicaid, 11% received a developmental screening in 2020 and 14% in 2021. County-specific screening percentages in 2021 ranged from 1% (Okanogan County) to 29% (Pacific County).

 

Promoting Health Systems Integration into Broader Early Childhood Systems

During FFY22, the Child Health team focused on launching the HRSA Early Childhood Comprehensive Systems (ECCS): Prenatal-to-Three Health Systems Integration initiative, a 5-year project beginning in August 2021. This initiative blends HRSA ECCS and MCHBG funds to advance effective integration, collaboration, and asset sharing to strengthen maternal and early childhood systems.

 

Progress

In FFY22, DOH added a new objective related to early childhood health systems integration:

 

• Through January 2023, develop an early childhood comprehensive systems (health systems integration) strategic plan in collaboration with state partners and families.

 

Early Childhood Comprehensive Systems Planning

Initial efforts centered on building the foundation to carry out the work plan activities necessary to ensure quality and equitable access to perinatal and early childhood systems of care for the P-3 population. We engaged in strategic conversations to: (1) understand barriers to participating on the ECCS advisory council, (2) determine related initiatives (e.g., WA State Essentials for Childhood, Washington Prenatal-3 Coalition, Preschool Development Grant Birth through Five, etc.) with complementary aims, and implement meeting strategies to coordinate/promote systems, programs, and policies, (3) strategize about opportunities to amplify community/caregiver voice in the development of early childhood programs and services with specific efforts to improve access for Black, Indigenous, and people of color (BIPOC) and rural populations.

 

To guide the ECCS implementation, we explored several potential approaches to establish an inclusive and representative governing body. During this process, we learned of concerns around the capacity to participate in additional meetings and the potential for duplication across existing bodies already serving prenatal-to-3 initiatives. Collaborating with community-based and state partners, we determined that coordinating the ECCS work with existing bodies was the most promising strategy for initiating the ECCS work. Partners also shared a desire to revisit advisory structures as implementation progressed.  

 

Development of a Systems Assets and Gaps Analysis (SAGA) of the current maternal and early childhood systems of care was initiated to explore the extent to which the health sector is integrated into early childhood systems and identify strengths and gaps in advancing early developmental health and well-being. Through SAGA, several cross-sector strategic planning documents were identified and assessed to determine points of distinction and areas of alignment with the ECCS initiative.

 

Washington’s Early Learning Coordination Plan (ELCP), a shared vision and plan co-created by a broad coalition of families, community members, and state partners to advance equitable early childhood outcomes in Washington state, emerged as an ideal framework to build statewide capacity and grow the integration of maternal and early childhood systems of care including health systems with a focus on early developmental health and family well-being. We worked on the ECCS strategic plan to demonstrate the alignment of ECCS activities with the ELCP framework (e.g., outcomes, goals, strategies). Key outcome areas of the ELCP include:

• powerful communities and responsive systems
• strong, stable, nurturing, safe, and supported families; and
• healthy children and families.

 

Family engagement activities were ongoing throughout the reporting period. Initially, efforts included a series of conversations with an established community leader with lived experience and expertise in collaborating with parents/caregivers to inform strategies for intentionally amplifying the voices of parents/caregivers in the ECCS program. We partnered with the same community leader to co-design and host a focus group in August 2022. The purpose of the focus group was to learn how to strengthen and build systems (health care, childcare) for pregnant/parenting families and those caring for and raising young children at the community and state level that center families. The following insights about equity considerations emerged from the focus group:

• Regarding access to health services, participants shared that inflexible scheduling, long waitlists, inconvenient locations, and lack of access to providers who accept state insurance were barriers.
• Participants expressed feeling shame around requests for mental health support, treatment for substance use disorder, and resources for concrete supports (i.e., food).
• Increasing access/availability of family navigators arose as an opportunity to help families connect to resources, including state-sponsored health care.
• Expanding eligibility to paid leave programs and easy application processes were also identified as areas of opportunity.

 

Following the focus group, the facilitator reviewed the notes summarizing the discussion and shared them with participants to ensure accuracy. We created a summary document detailing key findings and shared it with participants, the facilitator, and other ECCS partners like the Preschool Development Grant Project Director, the WA Prenatal-to-3 Coalition, and the Family Voice Learning Network Lead supporting the Washington Communities for Families Coalitions.

 

Centering family and community voice and expertise remain a key focus in work supported by the CHU and OFCHI. The CHU team has also explored more approaches to support meaningful family and community engagement in ECCS and other child health initiatives. For example, CHU staff began participating in an effort supported by the Association of Maternal and Child Health Programs to receive technical assistance on implementing the Family Engagement in Systems Tool. 

 

A central component of the ECCS initiative is to increase the participation of health providers (e.g., pediatricians) in statewide coordinated intake and referral systems (CIRS). In Washington, Help Me Grow Washington (HMG WA) serves as the identified CIRS. The ECCS funds supported a Health Care Provider Outreach manager position at WithinReach, the state affiliate for HMG WA. The Health Care Provider Outreach manager conducted outreach activities to establish partnerships with child health providers and statewide associations/networks (e.g., Washington Chapter of the American Academy of Pediatrics) to increase awareness of the HMG WA system and the number of providers included in the statewide resource directory. Communication materials and trainings were developed and delivered. Additionally, opportunities and proposed solutions to improve technical systems functionality to enhance statewide systems linkage and closed-loop referral pathways were identified.

 

ECCS funds also supported the Washington Communities for Children work, a network of early childhood coalitions committed to improving the well-being of children, families, and communities. WCFC helped coordination among the 10-region-based early childhood coalitions to support identifying local culturally appropriate services/support to include in the HMG WA resource directory and extend partnerships between local HMG WA systems and local health care providers. Focused work occurred with a cohort of 4 partners serving small rural populations (an ECCS population of focus) to develop a low-cost, replicable process for enabling the local collection of resource information to exchange with HMG WA.

 

Child Health Priority 2: Promote mental wellness and resilience through increased access to behavioral health and other support services.

Within this priority, the Child Health Unit and other units worked to address the following State Performance Measures:

 

1. Percent of sixth grade students who have an adult to talk to when they feel sad or hopeless, and
2. Ease of receiving mental health treatment or counseling.

 

Preventing and Mitigating Adverse Childhood Experiences to Improve Child Mental Health and Resilience

During FFY22, work in this area focused less on individual interventions related to connecting children to caring adults and more broadly on efforts to reduce Adverse Childhood Experiences and to strengthen families at the community and system level. This involved: 1) collaborating with Essentials for Childhood partners to identify policy and programmatic direction in anticipation of the upcoming 2023 legislative session and new EfC grant funding cycle, 2) continuing our work to identify current state landscape of programs and policies to prevent and mitigate the social, emotional, and behavioral health impacts of Adverse Childhood Experiences (including child abuse and neglect)  to determine where to focus future attention, and 3) strengthening our focus on racial equity and the underlying social and economic conditions that impact child and family well-being and resilience.  

 

Progress

In FFY 22, DOH had 3 primary objectives related to ACEs and resilience and made progress on each of the objectives with modifications in timelines due to staffing capacity. These included:

 

• By April 2022, complete dynamic, community-driven inventory of statewide evidence-based and evidence-informed practices and policies that promote child and family mental, emotional, and behavioral health and resilience, to increase access and ethnicity/race specificity of models.

 

• From January 2021 to September 2025, advocate, seek funding, and widen access for evidence-based and promising policy and practice strategies that promote mental wellness and resilience.  

 

• By June 2021, finalize an enhanced EfC data dashboard to measure outcomes and effective practices related to child maltreatment prevention. Include adverse childhood experiences measures. (This objective was carried forward and modified into FFY 22 due to limited data staffing capacity in 2021).

 

Completing Inventory of Policies and Programs

From June-September 2021, DOH (in collaboration with the Essentials for Childhood Initiative) funded “Inventory of What Works”, to better understand the different community, state, and national programs, policies, and practices that exist in Washington state and LHJs to promote family resilience and prevent abuse/neglect for children ages 0-5 years. In mid-2022, we contracted with Camber Collective to refresh the work to date and develop a set of next step recommendations based on an assessment of the Statewide Inventory and LHJ assets (4 LHJs); identify any immediate data gaps to develop strategic options on how to strategically utilize information, and key operational next steps.

 

Based on a review of the 2021 inventory, the following insights emerged through phase 2 of the Inventory of What Works project:

• A wide variety of child and family programs and services focused on the direct service level exist within Washington state, with potential gaps at the community capacity building and policy/systems development level.
• There is a need to better understand where existing programs are being implemented across regions (e.g., Western, Central, or Eastern WA).
• Washington state has a set of programs considered national fidelity-based models (e.g., Nurse-Family Partnership, Circle of Security, Family Spirit Home Visiting Program, Parents as Teachers, etc.) that can be customized, funded, and implemented in specific regions of the state. An opportunity exists to better understand the breadth of current community-based implementation for these national programs and then identify ways more communities can apply for funding and assistance in implementing national fidelity-based models. Similarly, efforts are needed to support emerging effective community-based programs that could be evaluated as an evidence-based practices and funded for large-scale implementation.
• While the current inventory includes some equity definitions (racial equity, economic equity, geographic equity), these are insufficient from a strategic planning or policy standpoint on identifying programs and practices to address systemic and structural inequities. Recommend using a targeted universalism approach to address the gaps.
• There are significant ongoing efforts at DOH, DCYF, HCA, Governor’s office, and other agencies related to the policies and programs for early childhood (B-5). There is an opportunity to better coordinate across agencies to reduce duplication and improve coordination.

Consultants suggested the following future strategic efforts:

• Systems mapping of all WA state agency-related efforts (projects or initiatives) that touch early childhood resilience to help improve coordination, align success outcomes, and ultimately sharpen an overall Theory of Change / Theory of Action.
• Reporting and tracking of ongoing cross-agency initiatives. Potentially aligning all early childhood resilience efforts to the 5 CDC Child Abuse and Neglect strategies (i.e., economics, social norms, health and education, parenting skills, and interventions).
• Identifying internal/external facing information and audiences for outputs and assets of the Inventory, including 1) LHJs and community partners and 2) other state-wide agencies, and 3) community organizations and families.
•  

DOH will consider findings and recommendations as we move forward with the EfC work, and next steps with the inventory.

Advancing Policies and Programs to Strengthen Family Economic and Community Resources/Supports

Based on the Inventory of What Works Project findings, DOH worked with Essentials for Childhood partners to focus EfC conversations on racial equity and prioritized ACEs prevention/resilience strategies for building community capacity and advancing policy/systems-level change. The EfC partners met quarterly for Steering Committee meetings and bi-monthly for Leadership Group meetings.

Key accomplishments included:

• Incorporated a facilitated equity activity in all EfC Steering Committee and Leadership Group meetings.
• Updated the Child Abuse and Neglect Prevention State Action Plan with a focus on 4 primary buckets of work: Collaboration and Partnership, Child and Family Supports and Services, Community Capacity and Norms, and Policy and System Change strategies.
• Highlighted and supported DCYF’s Strengthening Families Locally Project within EfC.
• Planned for and secured Maternal Infant Opiate state funding to conduct a Community Resilience/Protective Factors Measurement Project. The intent of the project is to develop an approach to measure and monitor community level protective factors associated with the reduction and mitigation of childhood adversity and intergenerational transmission of trauma. This project is scheduled to be completed during FFY23-24.
• Prepared for 2023 Legislative Session by developing a policy approach including the launch of a series of EfC Policy Working Sessions and creation of a policy framework in November 2022. We did not pursue a policy agenda in 2022 due to the short session.
• Began exploration of opportunities to evaluate and monitor implementation of state family support programs resulting from state policy action, such as Paid Family and Medical Leave Program, to understand and reduce barriers to access and utilization of these programs, including structural barriers associated with racism.

 

DOH continued to provide technical assistance to the LHJs on child health and development. We supported LHJs in community-level planning and initiatives to prevent ACEs and promote resiliency. Eleven of our state’s 35 LHJs chose to conduct activities related to trauma-informed services and ACEs prevention as a strategy for their FFY22 contracts. Some have focused on providing education to LHJ staff and community partners on trauma informed practices, programs, and policies; others engaged in general community awareness on approaches to prevent ACEs and promote resilience.   

 

Increasing Child Maltreatment and ACEs/PCEs data

DOH continued to increase the availability, access to, and use of ACEs, child maltreatment, and child well-being data. We decided not to create a stand-alone EfC data dashboard due to challenges with accessing some child maltreatment data from other agencies.

 

During FFY22, DOH surveillance and evaluation and child health staff.

• Relaunched the EfC Data Workgroup.
• Re-evaluated and updated child maltreatment, family well-being evaluation metrics, and  EfC work.
• Identified data sources and website links for child maltreatment and other child/family well-being data. Complied the list to share with EfC partners and formatted for inclusion on new EfC web pages (planned for 2023).
• Began research for and initial work on a child maltreatment data brief.

DOH surveillance and evaluation staff participated in developing a WA ACES Index through the Fall of 2021 administration of the state Healthy Youth Survey for children/youth in the 6th, 8th, 10th, and 12th grades. This new index included questions addressing exposure to some of the 10 original ACEs and other issues associated with childhood trauma, such as being a victim of bullying and experiencing family housing insecurity. 2021 WA ACEs data was released in 2022 and is available on the Healthy Youth Survey website.

 

To increase data and information about preventable child deaths to guide prevention planning in Washington, initial planning for a new state Child Death Review process, in partnership with Local Health Jurisdictions (LHJs), began in Fall of 2022. State Foundational Public Health Services funds were allocated to support LHJs’ work in this area.

 

 

Improving Access to Behavioral Health Services and Supports

During FFY22, as staffing capacity increased, Child Health became increasingly involved in efforts to address growing child and youth mental health concerns. The primary focus during this time was coordinating with other internal and external entities working in this area.

 

Progress

In FFY22, DOH staff pursued the following objective:

• From January 2021 through January 2025, work with partners to expand access to behavioral health and other support services for children ages 11 and under and families.

 

Coordinating Child/Youth Behavioral Health Efforts Across DOH and Partner Agencies

Child Health staff were involved in cross-agency efforts related to child/youth behavioral health. Efforts included participating and contributing to cross-divisional Behavioral Health coordination meetings with DOH internal staff to elevate children and youth mental health needs, cross-agency meetings hosted by the Division of Behavioral Health and Recovery Prenatal-to-25 staff related to the implementation of new child/youth behavioral health legislative requirements (such as School Based Health Center program and funding). Staff also followed the work of the state Child and Youth Behavioral Health Work Group (CYBHWG) and subcommittees (i.e., Prenatal-to-Five, K-12, Workforce) and began attending and contributing to the CYBHWG Strategic Plan Advisory Group meetings, which launched in August 2022.

 

Promoting Standardized Screening Tools and Interventions for Mental Health and Suicide Ideation

Work on child/youth mental health screening and child/youth suicide prevention was primarily concentrated within the Adolescent Health Unit as they worked on establishing the new School Based Health Center Program and the OSHC Injury and Violence Prevention Section as they rolled out the 988 National Suicide Prevention Lifeline and the evidence-based Sources of Strength youth suicide prevention curriculum. While there was limited capacity within Child Health to make progress on mental health screening and suicide ideation for younger children in FFY22, there are plans to address this in future years with an emphasis on school settings: elementary age/middle school age groups.

 

Enhancing Access to Child Behavioral Health Services through Health Care Practice Improvements

DOH staff participated in several efforts to enhance access to and utilization of child behavioral health services. Three specific efforts included the launch of the pediatric Community Health Worker (CHW) pilot program, the child mental health-focused Health Equity Performance Improvement Project with Medicaid Managed Care Organizations, and the planning and awarding of School Based Health Center (SBHC) grants, including specific grants to enhance behavioral health services through existing SBHCs.

 

CHW Pilot Program:  In the 2022 legislative session, the Children and Youth Behavioral Health Workgroup’s Behavioral Health Integration into Primary Care subgroup and the Washington Chapter of the American Academy of Pediatrics’ (WCAAP) First Year Families steering committee (members include DOH Title V staff) provided legislative priority recommendations included for funding non-licensed professionals, such as health navigators or CHWs, in pediatric primary care settings. Rationale for this recommendation included: rising behavioral health concerns, delays in accessing mental health services, and improving care coordination across primary care and behavioral health services. Advocates for health equity indicated CHWs are critical to supporting clinics in culturally and linguistically relevant services in primary care clinics and medical homes. The result of legislative advocacy was Engrossed Substitute Senate Bill 5693, Section 211 (103), which directed the Health Care Authority (HCA) to establish a two-year grant program for primary care clinics to embed CHWs as part of care teams working with children and youth birth through age 18, develop and submit legislative reports on the impacts of the grant program, and explore longer term reimbursement in collaboration with key partners. The bill also directed DOH to establish a curriculum and provide training for CHWs in primary care clinics serving children and youth from birth through age 18 to support the grant. To comply with the legislation, the DOH Community Workforce and Partnerships Section within OFCHI established a contract agreement with WCAAP to support training curriculum development and hired new program staff to assist the effort. Implementation of the CHW grant program to clinics started in early 2023. CHWs will focus on either Early Relational Health (birth-age 5) or K12 Mental Health (age 5-18).

 

Child Mental Health Care Utilization Performance Improvement Project: In early 2022, the DOH Health Systems Unit partnered with Medicaid Managed Care Organizations to form a Health Equity Performance Improvement Project Workgroup to address racial and ethnic disparities in Washington State Mental Health Penetration rate among children aged 6-17. The Workgroup considered multiple aspects of mental health care delivery, evidence-based outcomes, and systemic mental health biases faced by vulnerable members of our populations. The Workgroup sought input from communities and enrollees regarding mental health inequities and service disparities. 

 

Child behavioral health care provider shortages and reduced availability of service appointments driven by the COVID-19 pandemic were of concern, as was evidence of racial/ethnic disparities for those with conditions that warranted mental health services and those who actually received services (“Mental Health Service Rate”). The Workgroup aimed to close any race/ethnicity disparities among children aged 6-17 of greater than or equal to a 3% difference from the Statewide average of 67.5% for the Mental Health Service Rate (MHSR) through targeted communications, provider, and community partnerships, and designing the Youth Mental Health Access Project by March 31, 2023.

 

During the first year of the project (2022), the Workgroup:

• Collected and analyzed data to understand identified disparities and identify regions of focus.
• Designed and distributed a provider survey to understand how behavioral health and primary care providers communicate and collaborate to serve young people with mental health concerns, including the perceived barriers.
• Developed tailored communications in partnership with the Community Health Worker Coalition for Migrants and Refugees, and DOH-driven campaigns to reduce mental health stigma.  
• Designed Youth Mental Health Access Project curriculum to promote MCO/clinic partnerships to increase outreach to youth with gaps on the Mental Health Service Rate, prioritizing youth from communities with an identified disparity.

 

SBHC Program, including behavioral health grants: Further information about this effort is outlined in the Adolescent Health Domain. One of the 17 SBHC grants is for an SBHC in an elementary school serving primarily low income and BIPOC children in the Seattle area.

 

Assessing Middle Childhood (ages 6-11 years) Needs related to Mental Well-being and Resilience

Child Health staff began an assessment of middle childhood needs with an emphasis on mental well-being and resilience. This grew from concerning data on depression, anxiety, suicidal ideation, and bullying in elementary-age children. Staff conducted an initial review of data related to children ages 6-11, including examining the HYS 6th grade data. This will be an area of focus in FFY23 and 24.

 

Child Health Priority 3: Optimize the health and well-being of children and adolescents, using holistic approaches

Within this priority, the Child Health Unit and other units worked to address the following State Performance Measures:

 

• Percent of incoming kindergarteners who demonstrate the social and emotional characteristics appropriate to their age
• Family resilience composite measure (measure added in FFY22)

 

Promoting Positive Parenting Skills and Norms

During FFY22, work in this area focused on projects promoting positive parenting skills and norms, as strategies to increase healthy early child development, family well-being, and resilience. These projects and staff time used blended funding from MCHBG, Essentials for Childhood, and private funds.

 

Progress

During FFY22, DOH had 3 primary objectives focused on promoting positive parenting:

 

• By December 2021, work with two home visiting technical assistance providers to train home visitors (DCYF/NFP) in using Vroom to promote resilience.

 

• By December 2021, share Vroom Brain Building messages and tools with at least 50 community partner organizations (such as local health departments, community services offices, early learning coalitions, tribal organizations, etc.) that connect with families of infants and children up to age 5.

 

• By October 2021, determine need for and feasibility of a social norms campaign to promote positive parenting focused on early relational health and brain development per current research. (This objective was postponed until early 2022 due to issues with staffing capacity and contracting delays)

 

Activation of Vroom™ Tools and Resources

For the past 3 years (through April 2022), DOH Child Health partnered with the Bezos Family Foundation (BFF) to share Vroom™ brain-building tips and tools with families across Washington State through contracts and trainings with early learning and health providers and direct distribution to families through health promotion mailings. While the BFF funding officially ended in April 2022, Vroom™ remained part of ongoing work through Essentials for Childhood to enhance parenting skills to promote healthy child development. Technical assistance, learning opportunities, and funding were available to support Vroom™ promotion in several communities across the state.

 

Key activities during the reporting period included:

• Collaborated with 7 community-based subcontractors to incorporate Vroom into their work with families of young children. Each subcontractor implemented an activation plan to leverage existing capacity, resources, and partnerships. For instance, Snohomish Health District coordinated with ChildStrive. This organization works with families and community partners to support young children’s success in daily life to incorporate Vroom strategies/resources into several family-serving programs (e.g., Nurse-Family Partnership, Parents as Teachers). Monthly emails, including a Vroom tip in English and Spanish were sent to service providers.
• Engaged state-level partners to integrate Vroom into their parent-family/provider engagement strategies. For example, program partners at the DCYF (i.e., home visitors and child welfare early learning navigators) continued to share Vroom resources with families. HMG WA also added Vroom information to a web page of resources on child development.
• Received data on local efforts to promote Vroom. More than 5,000 Vroom materials were distributed to over 500 families between January and April 2022. During the same period, 163 partners participated in Vroom trainings.
• Disseminated and promoted Vroom to partners across the state using the Vroom Brain Building distribution, including 2,893 subscribers.

 

Positive Social Norms Campaign (delayed start)

Shifting social norms toward positive parenting approaches and community support for parents and families is increasingly associated in research with the optimization of protective factors and resilience for parents, children, and youth of all ages. In the Summer of 2022, DOH contracted with The Montana Institute (TMI), an organization that helps communities and organizations apply the Positive Community Norms approach to grow healthy norms and positive protective factors, to conduct an assessment and determine the initial need for and feasibility of a social norms campaign to promote positive parenting focused on early relational health and brain development in alignment with current research. This work was accomplished by 1) interviewing key stakeholders in Washington to identify Positive Community Norms (PCN) campaigns that seek to increase positive parenting in parents of children aged 0-8; 2) identifying existing data sources that could potentially be used to develop a statewide PCN campaign and 3) reviewing social media and existing published literature for evidence and/or evaluations of existing campaigns.

 

Although an abundance of positive parenting resources and messages were identified, the assessment did not uncover any campaigns that 1) identified positive norms, 2) identified misperceptions of the norms, and 3) messaged positive norms to counter misperceptions to grow more positive behaviors and outcomes. A total of 14 potential data sources were also assessed to support developing a statewide PCN campaign. While some data sources included measures to identify possible positive parenting norms (such as reading with children), none of the data sources reviewed provided the data needed to develop a PCN campaign with fidelity.

 

Based on the assessment findings and TMI's experience in other states, they recommended that primary research in Washington be conducted to develop, implement, and evaluate a PCN-positive parenting campaign for parents of children aged 0-8. Further discussion of goals and desired outcomes is necessary to determine the focus of future survey work, which could include questions related to numerous positive parenting practices, PCEs, and HOPE. Plans are in place to continue this work in FFY23.

 

Family and Community-Based Primary Prevention and Well-Being Promotion

During FFY22, this area focused on elevating the needs of fathers in child and family well-being promotion and promoting strengths-based protective factor and resilience frameworks with community partners.

 

Progress

In FFY22, DOH had 1 broad objective in this area:

 

• By September 2025, increase family and community-focused primary prevention practices, policies, and systems, based on the brain development of children and adolescents and community need.

 

Promoting Family Resilience through Fatherhood Inclusion

Fathers are often left out of conversations about family well-being. Intentional efforts for fatherhood inclusion are needed to support the vital role that fathers play in promoting child and family well-being. During this reporting period, DOH Child Health partnered with the Department of Social and Health Services (DSHS) colleagues to support fatherhood inclusion activities through the Washington Fatherhood Council. Along with active participation on the Fatherhood Council Steering Committee, DOH Child Health contributed funding resources and support for:

1. Dad Allies Provider Learning Series (virtual) trainings for service providers, including:
   1. Early Relationships Matter: The Parallel Journeys of Fathers and Their Children Across the Early Years (February 2022; 181 registered)
   2. Queer Dads, Myths and Factors; gay parenting (March 2022; 152 registered)
   3. Parenting Together; Even if You’re Not (April 2022; 88 registered)
   4. Strategies for Helping Unmarried Parents Establish Co-Parenting Agreements (July 2022; 191 registered)
2. Fathers Matter Community Cafes for fathers to assess fatherhood support needs.
   1. Cowlitz County Café (March 2022; 25 participants)
   2. Re-entry Fathers Café-Pierce County (April 2022; 18 participants)
   3. Spokane Fathers Matter Café (May 2022; 24 participants)
3. 4th Annual Statewide Fatherhood Summit (May 24-26, 2022)
   1. 3 half-days, 248 participants, included international, national, and local voices with a broad background in a variety of critical issues for fathers.

 

Adverse Childhood Experiences/Resilience Community of Practice

In 2019, as part of the state Essentials for Childhood Initiative, DOH began convening an ACEs and Resilience Community of Practice (CoP), which brought together community and state partners to learn and share approaches to reducing child, family, and community adversity and promoting resilience. While this group continued to meet virtually during the first year of the COVID-19 pandemic, convenings were put on hold in 2021 to reassess the need and structure of the initiative. Staffing and community partner capacity to support this work led to a continued pause during 2022.

 

While the group remained on pause, DOH staff pursued an opportunity to bring together previous ACE/Resilience CoP members in a learning session focused on the Science of the Positive. In August 2022, ACEs/Resilience CoP participants were invited to attend a 2-hour interactive workshop led by The Montana Institute, which provided an overview of the Science of the Positive, Positive Community Norms, and Healthy Outcomes from Positive Experiences (HOPE) frameworks and how they can be used in harmony to promote child development, grow Positive Childhood Experiences, and promote a healing-centered approach to help children and adults increase resiliency. The workshop included current research findings and applications of these frameworks. It allowed participants to consider and discuss how they might advance these applications in their own unique contexts. A total of 335 people from communities across the state registered for the workshop. Approximately 150 participated in the workshop. Others were able to view the recorded version after the session. Evaluations were overwhelmingly positive and indicated high engagement and value from the session. Evaluation respondents also expressed interest in similar future events.

 

Shortly after the workshop, EfC members discussed the potential value of convening smaller, more targeted communities of practice. Interest grew in establishing a Local Health Jurisdiction Community of Practice focused on the HOPE framework. During Fall 2022, DOH Child Health staff applied for and were granted additional staff capacity to support an LHJ HOPE CoP through the DOH Workforce Pathways Program.

 

Additional Work Supporting Child Health at the Local Level   

Many LHJs opted to conduct activities in support of improving child health. LHJs selected activities related to the UDS system rollout, supporting nutrition and physical activity best practices in schools, community centers and other programs accessed by children, supporting community partners in utilizing trauma-informed practices and policies, participating in statewide coalitions to promote the importance of maternal and child health, and monitoring emergent needs and helping families, especially those with children with special health care needs, and improving their emergency preparedness. The following paragraphs summarize the efforts of LHJs in each of these areas.

 

Universal Developmental Screening (UDS)

Ten LHJs chose to work on the UDS system, including Chelan-Douglas, Columbia, Garfield, Grant, Jefferson, Lincoln, Mason, Seattle-King, Skagit, and Whatcom. Of these LHJs, several conducted outreach to pediatric providers within their communities to gauge their readiness to participate in the UDS rollout. One LHJ (Chelan-Douglas) surveyed childcare providers and found a desire for more training on conducting screenings and the UDS system. Providing training to communities is also an activity that will increase in importance during the coming year as DOH prepares to fully implement the UDS system. The LHJs continue to meet with DOH UDS staff and participate in state peer-to-peer calls, webinars, and other activities.

 

Healthy Nutrition and Physical Activity Best Practices

Four LHJs (Garfield, Seattle-King, Spokane, and Wahkiakum) selected activities under this strategy to support best practices in schools, before-and after-school programs (including Safe Routes to School), early learning programs, youth community centers, and community settings accessed by children. Approaches included:

• Attended school wellness council/committee with the school district to find out what they (and families) are interested in changing, and share expertise on best practices, including models from the CDC.
• Reviewed childcare center menus, for centers and for family home childcare providers. The reviews were followed up with suggestions to meet Child and Adult Care Food Program (CACFP) nutritional suggestions or substitutes for certain food groups. Additional menu ideas were provided. Food costs and food insecurity were identified as areas of concern for childcare programs due to the economic effects from COVID-19.

• Provided an outline of best nutrition and physical activity practices to add to monthly newsletters for early learning center directors and staff. LHJ staff shared farm to early learning resources with Child Care Aware of Eastern Washington to include in their newsletter updates. Met quarterly with school and Early Childhood Education and Assistance Program (ECEAP) staff to discuss approaches to ensure adequate healthy nutrition can be accessed by families in the communities that may be experiencing food insecurity. LHJ staff met with school and ECEAP representatives to determine how they could provide support to meet the food needs of families in need. For example, staff are working to set up a sustainable plan to get food that can provided on weekends and over breaks for those in need. LHJ staff are also assisting in finding programs/businesses that can be accessed and what agreements may be put in place to ensure continued food availability for families.

 

Trauma-Informed (TI) Services/Adverse Childhood Experiences (ACEs)

Of the 35 LHJs, 11 (Adams, Asotin, Benton-Franklin, Columbia, Cowlitz, Grays Harbor, Kittitas, Northeast Tri-County Health District, Sea-King, Snohomish, and Spokane) chose to conduct activities related to TI services and ACEs. These LHJs chose a wide variety of approaches to conducting this work including:

• Collaborated with providers to provide training on ACEs, including strategies to prevent ACEs.
• Provided education to LHJ employees on TI practices, programs, and policies. Encouraged communication between staff members on methods to educate providers within the community.
• Implemented an internal TI agency policy.
• Educated staff on integrating TI approaches into existing work.
• Collaborated with schools and community partners to assess the need for staff and/or community trainings around ACEs/Resilience/TI approaches.
• Planned and implemented local resilience trainings for school staff and other adult influencers, in collaboration with local partners.
• Developed and implemented an assessment of existing programs, organizations and coalitions in the larger community that aim to prevent ACEs and promote resilience.
• Increased the number of opportunities for LHJ staff, community service providers, and/or community members to learn about ACEs, complex trauma, brain science and resilience.
• Conducted “grand rounds” style meetings during which community providers (health care workers, childcare providers) met to share, build community, and collaboratively problem solve about ACEs and trauma and connect providers with the growing body of resources for building resilience.
• Facilitated discussions and provided support to help childcare providers and families understand the importance of how ACEs and complex trauma affect children.
• Met with providers supporting families to understand the community resources to help them build resilience, healthy coping, and prevent ACEs.
• Provided education about “pair of ACEs” and Healthy Outcomes from Positive Experiences (HOPE) via presentations, tailored trainings, and listserv information sharing to cross-sector community partners working with pregnant people and families with young children (0-5).
• Promoted the mitigation and prevention of ACEs by providing education on HOPE and sharing resources from “Project Pinwheel”, a webpage created with the “Our kids: Our business” child abuse and neglect prevention coalition. The main messaging includes information about how the community can support parents so that children grow, play, and learn in safe and nurturing environments.

 

Maternal and Child Health Coalitions and Task Forces

Four LHJs (Grays Harbor, Skagit, Spokane, and Wahkiakum) chose to work on activities in support of this strategy. The LHJs chose activities such as:

• Continuing participation in local, regional, and statewide early learning coalition meetings.

 

The LHJs believe that involvement and engagement with these groups will continue to help inform services and highlight the need for local MCH programs, work, and resources. LHJ staff use the information shared at these coalition meetings to continue to educate their staff and other local groups such as Boards of County Commissioners and Accountable Communities of Health.

 

MCH Emergency Preparedness Capacity

Three LHJs (Cowlitz, Okanogan, and Whitman) chose to conduct activities in support of this strategy. Activities included:

• Acted as surge capacity during public health emergencies and sharing resources with CYSHCN families, including planning for emergencies.
• Attended quarterly local/regional North Central Accountable Communities of Health (NCACH) meetings and ensured families of children with special health care needs had information about emergency preparedness, like having a physical address on file for EMS purposes.
• Used the Community Health Needs Assessment to look specifically for COVID-related gaps in service and barriers to care in the MCH and CYSHCN communities in the county.