Domain: Child Health

Reporting for October 2022-September 2023

Objective

By 2025, increase the percentage of children receiving developmental screening by 10%.

National Performance Measure

(NPM DS) Percent of children, ages 9 through 35 months, who received a developmental screening using a parent-completed screening tool in the past year.

The 2021-2022 National Survey of Children’s Health (NSCH) shows that 46.8% of children living in MN, ages 9-35 months, received a parent-completed developmental screening. This is down from the rate seen in the 2020-2021 NSCH. Our target for FFY2023 was 51.1% of children will receive a parent-completed development screening which means Minnesota (MN) did not met its goal for FFY2023.

Evidence-Informed Strategy Measure

(ESM DS.1) Percent of developmental/social-emotional screens that were completed electronically through the Follow Along Program (FAP) in the past year.

MN is tracking the percent of screens completed through the FAP that were completed using an electronic platform rather than being completed on paper. The FAP uses the Ages and Stages Questionnaires (ASQ) to assess a child’s social-emotional (ASQ®:SE-2s) and general development (ASQ®-3s). Because data on the FAP is collected on a schedule based on the state fiscal year, this ESM will utilize that timeline.

During the FFY2023, a total of 15,231 screens were conducted through the FAP, of which 687 were completed electronically. This means that approximately 4.5% of the screens were conducted electronically, which is down from 6.2% in FFY2022.

Community-Identified Priority Need: Comprehensive Early Childhood Systems

MN’s five-year comprehensive needs assessment identified a significant area of need in ensuring MN has inclusive systems that link young children and their families to all the support and services they need. It is MN’s child health priority area.

MN is focused on enhancing coordination and connections between families and services across a multitude of early childhood settings, to ensure that MN has inclusive systems that link young children and their families to all the support and services they need.

Every family should have an equal opportunity to access health care, mental health services, early care and education, and local services and resources that are culturally honoring and support health, development, and safety. However, MN faces significant challenges in implementing a coordinated, equitable, and efficient system of care for children and their families. The array of early childhood programs is complex and fragmented, due in part to differences in the way programs are funded and variations in their eligibility and other requirements, making the early childhood system in MN difficult to navigate.

This complexity is especially troubling as we know that health inequities start early in the lifespan in MN. Policies and practices rooted in structural racism have prevented Black, Indigenous, and People of Color (BIPOC) from having a fair life start, and this is reflected in the racial disparities seen in MN’s:

• Poverty rate (100% Federal Poverty Level) – 26.6% of African American/Black, 10.9% of Asian and Pacific Islander, and 31.96% of American Indian children in MN are living in poverty compared with only 7% of white children.[1]
• Economic and food assistance rates – 75.8% of African American/Black and 73.3% of American Indian/Alaska Native kindergarteners received economic assistance and/or food assistance, while only 18.9% of white kindergartners received assistance.[2]
• Infant mortality rates experienced by American Indian and African American families – 16.8 and 8.6 per 1,000 live births respectively, compared to 3.9 for white infants.[3]
• The developmental screening rate for children (0-60 months old) who had at least one C&TC visit (MN’s Early and Periodic Screening, Diagnostic, and Treatment Program) during calendar year 2022 was 42.5%. This is a slight decrease from the 2021 calendar year rate, which was 43.4%. However, this is a slight increase from the 2020 calendar year rate, which was 43%.[4]
• Developmental and social-emotional screening rates – Medicaid-eligible children in MN have lower rates of screening at well-child visits than recommended, with American Indian and white children consistently having the lowest rates compared to children of other races. American Indian children have a screening rate of 31.8% while white children have a rate of 39.2% as of 2022. This is opposed to the rate of 41.9% of Asian-Pacific Islander and 42.7% of African American/Black children receiving developmental screening.[5] White and American Indian children are more heavily represented in rural areas, where rates of screenings are lower.
• Covid-19 Pandemic Impact – MN has seen both reading and math proficiency scores go down during the Covid-19 pandemic. In 2022, 48.3% of 3rd graders had proficient reading scores, while 59.2% had proficient math scores. Compared to 2021, where 48.7% of 3rd graders had proficient reading scores, while 57.4% had proficient math scores. However, this is all lower than 2019 (pre-pandemic) where 54.8% of MN 3rd graders had proficient reading scores, while 65.7% had proficient math scores.[6]
• Out-of-Home Care – As of 2021, American Indian children in MN were 16 times more likely to experience out-of-home care than white children in the state (based off MN population estimates from 2020).[7]

These same policies and practices rooted in structural racism prevent American Indian children and children of color from accessing equitable educational opportunities – starting in early childhood. MN’s children are not guaranteed access to early childhood education; this education is most often financed by parent’s tuition payments to private programs, with large income disparities by race, which further disadvantages BIPOC children. Additionally, both math and reading proficiency is much lower for American Indian, Hispanic, and African American/Black children, with reading proficiency at 23.5%, 28.4%, and 28.8% respectively. This is compared to reading proficiency of White children, which is at 57.4% as of 2021. A similar trend is seen with math scores, with American Indian, Hispanic, and Black children having 29.6%, 34.4%, and 31.8% math proficiency respectively, compared to 71.2% for white children.6

Many projects and grants over the last ten years have worked to develop and improve comprehensive early childhood systems across government agencies in MN. Formal recommendations in 2016 from local partners to the state, along with the results of an audit by the Office of Legislative Auditor in 2018, confirmed the need for a centralized system for resource navigation, referral and follow-through, and documentation of gaps and barriers in the system. During the recent Preschool Development Birth to Five Grant (PDG) needs assessment and strategic planning process, parents and providers shared their perspectives on the current assets and barriers that impact families who are experiencing racial, geographic, and economic inequities. Recommendations gathered through the Title V Needs Assessment confirmed the importance of this work and elevated this as a priority for MDH and stakeholders to focus on in the 2020 Title V five-year needs assessment.

Additionally, in 2019, Governor Walz and Lt. Governor Peggy Flanagan, re-launched MN’s Children’s Cabinet, originally established in 1993, with the commitment to “Placing Children at the Center of Government”[8]. MN’s Children’s Cabinet is an interagency partnership of 22 state agencies working to bring efficiency and effectiveness to state government efforts to improve child and youth outcomes. The Cabinet utilizes a results-based accountability lens in these priority areas:

• Healthy Beginnings (addressing infant and maternal mortality)
• Child Care and Early Education
• Mental Health and Well-Being
• Housing Stability.

“The Cabinet works to take data-driven and results-oriented approach to coordinating, streamlining programs, aligning strategies, and promoting action and accountability of MN’s efforts to ensure that each and every MN child, no matter race or zip code, is prepared to be a leader of tomorrow.”[9]  

In MN, public health and human services operate under local control with services delivered at the county- and tribal-level in MN’s 87 counties and 11 tribal nations and communities.  Similarly, early education intervention services for infants and toddlers with special health care needs and their families operate in over 300 independent school districts. Tribal nations offer culturally relevant services but are often unknown or ignored as potential referral resources by outside providers. Anecdotes from statewide providers consistently indicate that services are unavailable, unknown, or hard to access, but there is no comprehensive statewide data that defines actual service gaps and barriers.

Strategies and Activities

Strategy A: Coordinate Access to Comprehensive, Family-Centered Early Childhood Services

State Level Activities

1. Coordinate the MN Help Me Connect (HMC) Online Navigator and Referral System – Title V Connected

MN HMC (www.helpmeconnectmn.org) launched in May 2021 as an online navigator to connect expectant families, families with young children birth to 8 years of age, and professionals serving these families to services in their local communities that support healthy child development and family well-being. Families and professionals can search a database of over 14,000 available programs and services closest to the family’s home address under topics such as healthy development and screening resources, early learning and childcare programs, pregnancy support services, disability resources, basic needs, and more. The online resource is also available is Spanish, Somali and Hmong. Since its launch, the site has welcomed over 390,000 unique visitors from all MN counties and neighboring states, approximately 21,000 visitors per month, with top key word searches for autism, housing, transportation, and diapers. Trends from web site analytics, feedback surveys, and ongoing community engagement activities continue to determine and prioritize technical improvements and content additions. For example, information to help families access diapers and autism resources (screening, diagnostic and intervention) were added in early 2023 due to the high number key word searches on those topics.

Recent accomplishments include a six-month social media campaign that shared 5.5 million messages across numerous platforms, the development of several videos available on the YouTube playlist, redesigned marketing materials for professionals to order, and new connections with community organizations and Tribal Nations to improve content for culturally supportive programs. The Help Me HMC team collaborated with the MDH Women’s Health Unit to develop content for a new Pregnant and Expectant Families category that launched August 2023, which also highlighted the challenges and opportunity to connect families to doula and birth worker services through HMC. This led to the creation of a searchable database that welcomes doulas to submit their information into a survey to be displayed on HMC. Doulas voluntarily share a variety of information about their services, most notably, their language and cultural specializations.

HMC was adopted into MN State Statute 145.988 during the 2023 legislative session and now receives annual funding of $920,000 to ongoing maintenance, database management and numerous enhancement activities. The Help Me Connect program will move to a new state agency – the Department of Children, Youth and Families – in January 2025 with a variety of programs from the Departments of Human Services, Education, and Public Safety that focus on early childhood and family support services. Interagency collaboration with the Department of Health will continue long-term to maintain connections and assure information on HMC is maintained and updated consistently.

2. Collaborate with the MDH Center for Health Equity staff to implement the Community Solutions for Healthy Child Development Grant Program – Title V Supported

In 2020, 23 organizations, nine of which are Tribal Nations or American Indian serving-organizations, were awarded funding from the Community Solutions Fund (CSF) to complete a variety of projects from supporting doulas, expanding dental services, Indigenizing the state’s early learning standards, supporting fathers, and more. Each grantee determined a unique challenge in their community and is advancing community-based, culturally grounded solutions. The grants were also an opportunity to learn from a BIPOC community-based advisory council who has been a part of every step of the process from RFP development to review and selection of grantees, and now to providing support for grantees and sharing learning on equitable grantmaking with state leaders.  

The Community Solutions Advisory Council spent much of FFY2023 working on sustainability of the grant program through a legislative proposal. The Council and MDH were successful in obtaining ongoing state funding for the program through SFY27. The current round of grant projects ended on June 30, 2023. At that time, an application for new council members was released and council members were selected. The council began meeting in Fall 2023 and collaboratively drafted the Request for Proposals for a new round of grantees. The Child and Family Health Division staff also met with CSF grant management staff to understand opportunities for shared learning between CSF and CFH programs. This work will continue into future years.

3. Champion MN’s Integrated Care for Early Childhood Initiative -Title V Supported

MN is a recipient of an Early Childhood Comprehensive Systems: Health Integration Prenatal-to-Three Program grant from HRSA. MN’s project, titled the MN Integrated Care for Early Childhood Initiative (MN-ICECI), is a community-led, collective effort that aims to create more cohesive, responsive, and equitable early childhood systems for African American children (ages 0 – 3 years old) and their families. The project started in August 2021 and continues; its goals include:

• Community-Driven Leadership: Cultivate and support a community-driven leadership structure where problems and solutions are defined by, and decision-making power is shared with the community.
• Shared Understanding and Vision: Build a shared understanding and vision of gaps, assets, and opportunities in achieving an equitable early childhood system that is inclusive of the health system.
• Advance Justice, Equity, Diversity, and Inclusion: Increase MN’s capacity to advance justice, equity, diversity, and inclusion in accessing services and supports for African American children 0-3 and their families.
• Health System Change: Increase health system capacity to serve young African American children and their families.
• Financial and Policy Change: Identify and carry out innovative financial and policy strategies to support implementation and sustainability of efforts.

During the FFY2023 reporting period, the MN-ICECI Community Advisory Council completed and approved a Strategic Plan. The strategic plan has been designed as an iterative document and provides a framework for MN-ICECI and its partners to improve health outcomes for African American children (ages 0 – 3 years) and their families. The plan is intended to inform and guide systems connections, service delivery, program planning, financial incentivizing, policy development, and evaluation efforts.

4. Collaborate with the Preschool Development Grant (PDG) Team to implement Community Resource Hubs – Title V Supported

MN has 12 contracts, and one non-funded collaborative partnership, for implementation of Community Resource Hubs – organizations across the state that act as a single location and human connection for pregnant and parenting families looking for services. Community Resource Hubs, through the PDG:  

• Make it easier for families to get what they need through development of universal access to and navigation of culturally appropriate, relationship-based programs and systems.  
• Increase access to services for families and providers through collaboration of state agencies to test and evaluate HMC’s use in and by communities.  
• Grow community engagement and support community-developed solutions that are unique – solutions that look and feel different in every community.  

Site partners for the 12 grantees include community action agencies, Tribal Nations, counties, community childcare centers, and other community-based organizations. They each offer direct services and exact services that vary by location with a variety of implementation models. The federal PDG funding for the Hub program ended on June 30, 2023.

Final evaluation results for the Hubs included the following:

• Hubs served more than 9,698 Minnesotans during the program.
• Almost half (45%) of people served by Hubs are Indigenous and/or families of color.
• Hubs and navigators developed tailored, effective outreach strategies to reach new families and populations including virtual services delivery.
• Hubs want to expand their reach to serve more families but lack capacity to do so.

A final report summarizing the work of the Community Resource Hubs is available on the MN Department of Education’s Preschool Development Grant website under Grant Projects. A legislative proposal to fund a similar program called Community Resource Centers (CRCs) received one-time appropriations that can be used through SFY2027.

The new state funded CRCs will be led by a community advisory council as well as a cross-agency steering team. Applications for council members were made available in Fall 2023 and council members were selected in late 2023. The council will guide the development of the RFP.

Strategy B: Maximize and Increase Funding to Support Statewide Programs that Serve Families Who are Pregnant and Parenting Young Children

State Level Activities

1. Increase Access to Developmental and Social-Emotional Screening and Follow-Up – Title V Led

Follow Along Program (FAP)

The FAP helps to identify developmental and social-emotional areas of need in young children, birth through kindergarten entrance, by providing caregivers at-home access to the Ages and Stages Questionnaires (i.e., ASQ®-3 and ASQ®:SE-2) at age-appropriate intervals. If needs are identified through these screening activities, LPH staff follow-up with families to provide timely referrals to additional assessments and evaluations for their child, as well as connect caregivers and their families to support services within their communities.

The program is available in all but six counties of the state (not available in Anoka, Blue Earth, Crow Wing, Mower, Ramsey, and Stearns counties) and served over 12,000 children with 3,962 new enrollments between January and December 2023. Additionally, around 15,036 screens were completed during this period. The following activities were accomplished: 

• MDH continued work on a comprehensive, multi-year program evaluation and redesign of the FAP.
• MDH provided a base amount of funding for implementation to community health boards (CHBs). This funding was made possible through an Interagency Agreement between MDH and the MN Department of Education (MDE) related to Part C of the Individuals with Disabilities Education Act. Many counties also report using a portion of the Title V funds allocated to them to support implementation of the FAP. 
• The program was formally established in state legislation through the Healthy Beginnings, Healthy Families Act. This legislation ensured a more sustainable funding structure for the FAP to support the redesign of the program to include more culturally and linguistically inclusive resources and strategies for families eligible for or currently participating in the program.
• FAP staff from LPH agencies were brought together regionally, either in-person or by the phone, on a quarterly basis to receive training and technical assistance. During the meetings, LPH learned about updates on the ASQ®-3 and/or ASQ®:SE-2 instruments, participated in discussions, reviewed family stories, and received overall program guidance.             

Electronic Developmental Screening

MN convenes an Interagency Developmental Screening Task Force comprised of MDH, DHS, and MDE staff that oversee various early childhood programs that provide developmental and social-emotional screening, including the FAP and FHV. Providing electronic access to developmental and social-emotional screening to families has been a priority among state and local early childhood partners for the past several years in efforts to identify strategies to assure all children are receiving recommended screening guidelines. A wide array of early childhood providers are providing periodic or one-time screening to families with young children – there are currently six state-administered programs that use the ASQ®-3 and ASQ®:SE-2 instruments. In most situations, there is no communication between screening providers to share screening information that may help avoid duplication, but more importantly, to identify which children have not been screened. 

MDH finalized an agreement with the Brookes Publishing team in early 2020, which allows MDH to partner with LPH agencies to test the ASQ® Online system. In April 2020, MDH offered the system to local Follow Along Programs to remedy challenges the programs were having in providing timely screenings to families during the COVID-19 pandemic. A virtual Community of Practice (CoP)continues to bring together programs using the online system so they can share strategies, address barriers, and learn from one another in implementing the online system. Feedback from the CoP has been used to generate recommendations to be included in a Request for Proposals being developed for a statewide mobile developmental screening application.

Local Public Health and Community Spotlight

1. Increase Access to Developmental and Social-Emotional Screening and Follow-Up through the FAP – Title V Led

Through funds from the state’s Healthy Beginnings, Healthy Families Act, MDH provides a base award to CHBs to implement the FAP – these funds go toward distributing the screening tools to families, scoring them, and following-up when concerns are noted. Currently, all but six counties have decided to accept these funds and are implementing the program. Many counties also report using a portion of the Title V funds allocated to them to support implementation of the FAP.  The program served over 12,000 children with 3,962 new enrollments between January and December 2023, with around 15, 036 screens completed.

Additional Related Activities

State Level Activities

1. Promote Best Practices in Developmental Screening through Child and Teen Checkups (C&TC)- Title V Connected

C&TC is MN’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. MDH has a long-standing C&TC interagency agreement with MN DHS (MN’s Medicaid agency) to accomplish two categories of work: 1) provide training, technical support and resources to health care providers, clinics and clinic systems to improve quality and scope of C&TC care; and 2) clinical consultation to DHS on issues such as clinical care guidelines, updates on the C&TC periodicity schedule. In FFY2023, C&TC addressed developmental screening through C&TC Best Practices and C&TC Refresher trainings to 180 health care professionals, local public and tribal C&TC Coordinators. In addition, 12 public health nurses were trained and evaluated to provide C&TC exams – which includes developmental screening. 

In addition, C&TC co-leads the Interagency Developmental Screening Task Force with MDE. This task force sets developmental screening tool standards and provides the guidance for C&TC evidence based developmental screening procedure recommendations.

2. Promote Connections between FHV and Early Childhood Systems – Title V Connected

MDH promotes connections between FHV grantees and their local early childhood system to help ensure better collaboration and alignment of efforts. Local FHV agencies often participate in community inter-agency groups and meetings that focus on young children and their families, and many include representation from their early childhood system partners on their Community Advisory Boards (CAB). Grantees report on CAB activities in their narrative reports. Grantees are encouraged to have knowledge of other agencies in their area providing home visiting services to families with young children to decrease duplication and encourage collaboration to best meet the needs of all families in their community. Both their CAB and their networking with other local family serving agencies is discussed at site visits and regularly scheduled check-in calls. 

MN also focused efforts specifically on training partners on the ASQ®. ASQ®-3 and ASQ®:SE-2 screenings are required elements of the evidence-based FHV models implemented by home visiting programs across the state. MDH FHV public health nurse consultants provided training on the ASQ®-3 and the ASQ®:SE-2 to local home visiting staff via live webinar – including one on the use of the ASQ®-3, and one on the use of the ASQ®:SE-2. A total of 39 home visitors were trained in the ASQ®-3 and 37 in the ASQ®:SE-2. The training was updated and offered as combined ASQ®-3 and ASQ®:SE-2 sessions where an additional 61 home visitors were trained. Providing these trainings on best practices in screening ensured many children in MN received appropriate screening and follow up services.

[1] US Census American Community Survey (ACS) Microdata Sample, 2021

[2] MN ECLDS, 2021-2022

[3] 2021 MN’s Final Linked Birth-Infant Period Cohort Death File

[4] MDH Developmental and Mental Health Screening File

[5] MN Health Care Programs Developmental and Mental Health Screening Data, 2021

[6] MN ECLDS, 2021-2022

[7] MN’s Out-of-Home Care and Permanency Report 2021

[8]Executive Order 19-34:  2019_08_07_19-34_tcm1055-397454.pdf (mn.gov)

[9] Children's Cabinet / MN Management and Budget (MMB) (mn.gov)