Vermont’s Title V is closely linked with EPSDT-funded initiatives and efforts to promote the administration of Medicaid and improve health for children and adolescents. This involves important connections with Vermont’s school health services and their school systems. This partnership between Title V and EPSDT related efforts allows to advance performance measures addressing access to health insurance, medical and dental homes, access to well care visits as recommend by Bright Futures, overweight and obesity, injury prevention, child maltreatment, youth empowerment and engagement, and mental health and wellness.
Certain key program elements of EPSDT in Vermont are administered within MCH and coordinates closely under interagency agreements with DCF and the state Medicaid agency. Services for children (families making up to 312% FPL) include: ensuring all children have health insurance, education on preventive health care/age-appropriate health screening; assistance with scheduling medical/dental/health-related appointments; assistance in locating providers to establish medical and dental homes; information/referral on health and community services, and targeted follow-up. MCH manages grants to the Vermont chapter of the American Academy of Pediatrics (AAPVT) and the Vermont Academy of Family Physicians (VAFP) to improve population-based health outcomes and access to preventive services for Medicaid-eligible children and youth, and their families. Often the work done through these grant efforts benefit all children and youth in Vermont. MCH’s annual grant to the Vermont Child Health Improvement Program (VCHIP) is designed to improve health outcomes for Medicaid-eligible children and youth (and their families) through population-based child and youth health services research and quality improvement.
MCH works with school personnel to promote the administration of Medicaid for school-aged children and youth through the State’s school-based health access program, Medicaid Administrative Claiming, and encourages the use of funds, reimbursed to schools through this program, to be used towards school health-related personnel and population-based health initiatives. Annual reinvestment planning encourages the use of the Health Department’s annual School Nurse Report and Youth Risk Behavior Survey data. Current annual reinvestment plan priorities included: school health services and school nurses; school counselors; implementation of the CDC and ASCD’s Whole School, Whole Community, Whole Child (WSCC) model; student assistance professionals for substance abuse prevention, screening, and referral; dental hygienists called, “Tooth Tutors” to connect at risk youth with dental services in a dental home; establishing, maintaining, and implementing WSCC teams to who may work on programs and policies that support health and academic achievement across their local education agency (LEA); purchase and effective utilization of electronic health records for school health services; supporting student-led YRBS analysis program (Getting to ‘Y’ offered by our partners at Up for Learning); Healthy school environment (including school climate and physical environment); tobacco use prevention; and more.
The State School Nurse Consultant (SSNC) is located within the Division of MCH. This role helps to further efforts related to promoting the administration of Medicaid while reducing barriers to access, use of services, and to further efforts related to Title V. The SSNC, works to continuously align the school nurse Standards of Practice: School Health Services manual with current best practice and to provide technical assistance on school nursing practice, services, and related policies and procedures. The SSNC integrates the concepts of the National Association of School Nurses’, Framework for 21st Century School Nursing Practice into all work with school nurses. The SSNC leads the maintenance and updating of the new school nurse online orientation, required by the Agency of Education for school nurse licensing.
The SSNC chairs the School Nurse Advisory Committee, whose tasks include continuous improvement of the Standards of Practice: School Health Services manual, the online new school nurse orientation mentioned above, implementation of the Essential School Health Services model, and school nurse workforce development. This work provides school nurses with guidance to ensure all school-aged children and youth receive the recommended age-appropriate care, as described by Bright Futures, and the management of chronic health conditions.
The School Nurse Advisory Committee includes school nurses from different locations around the state (the President of the Vermont State School Nurses’ Association is a standing committee position), an appointed professional from the Agency of Education, and the SSNC. The committee regularly connects with various subject matter experts and leaders in the state related to specific content areas. MCH continues to reach out to engage parents in committee work. MCH works with our partners at Vermont Family Network (VFN) who work with and advocate for families and individuals with special health needs, to assist us with direct family engagement in the development and revision of tools for school nurses. Additionally, this year we met with the University of Vermont Medical Center, Patient and Family Centered Care Advisory Council and created a new Manual Section for school nurses on Family Engagement and Trauma Informed Care. The Committee’s collaboration includes work with Dr. Joelle van Lent on a new School Nurse Orientation Unit on Mental Health. The SSNC collaborated with the Vermont State School Nurses’ Association to co-sponsor the Fall 2018 School Nurse Conference to build knowledge and skills in substance abuse prevention, naloxone administration, data reporting and use for quality improvement, medical and OTC cannabis use, and the use of the Bright Futures guidelines to promote annual well care visits.
The Health Department School Liaisons (Public Health Nurses in each of the 12 Offices of the VDH Office of Local Health) also work with the SSNC, school nurses and other school staff to assist families to obtain health insurance and encourage them to access medical and dental homes for regular preventive care or addressing potential special health needs, as reflected in Vermont’s EPSDT periodicity schedule, Bright Futures. School Liaisons engage local schools and school personnel (i.e. school nurses and school counselors) to monitor their student and family population for those that are uninsured and connect them with Vermont Health Connect (VT’s health insurance exchange) or assistor organizations. School Liaisons often have strong relationships with local primary care provider and can assist with addressing issues that may impact coordination or communication between school nurses and local practices.
In 2009, a collaboration with the AAPVT, VAFP, School Nurse Association, Principals/Superintendents/ School Boards Associations, VCHIP, and the Agency of Education resulted in a sports clearance form recommending that sport clearance be done as part of a Bright Futures well care visit, rather than in place of the wellness visit. Schools may choose to use this well child form, supporting a process that students needing a "sports physical" may now receive a complete Bright Futures well-care visit. This form has been updated but has not been rolled out to schools yet due to other competing priorities. The updated version will better highlight the importance of annual well care, as well as provide families with a few action steps they can take to access well care. We plan to work on rolling this out over the summer and fall of 2019.
In collaboration with the ongoing work on the Youth Health Improvement Initiative (YHII) at Vermont Child Health Improvement Program (VCHIP), and in partnership with Vermont MCH, Vermont was selected to join Cohort 1 and 2 of the in the Adolescent and Young Adult Health (AYAH) Collaborative Improvement and Innovation Network (CoIIN). Through this work, Vermont worked to increase both access to and quality of preventive health care visits for the adolescent and young adult population. Key success and strategies of the CoIIN work has been providing technical assistance and coaching support to recruited practices. Practices tested changes in their office systems to improve well care visit utilization, as well as the quality of these visits. Practices also had the opportunity to deploy the Adolescent and Young Adult Patient Satisfaction survey, which was developed by through the work of CoIIN. The purpose of the survey is to provide practices with information directly from youth about their experiences with care and their level of engagement with services. The information is then used to inform and direct quality improvement activities within the practice.
One highlight of this work has been the formalization of a youth health advisory council called, Vermont Raise Awareness for Youth Services (VT RAYS) The Vermont RAYS is a diverse group of young leaders committed to elevating and empowering youth voice across health care and community settings to improve the quality, safety, and effectiveness of youth services. The VT RAYS seeks to enable meaningful adolescent and young adult involvement in improving adolescent health care in Vermont. (See Crosscutting/Action Plan for more information on this.)
In partnership with the Vermont Child Health Improvement Program (VCHIP), Vermont MCH provides subject matter guidance and division leadership participation to the Child Health Advances Measured in Practice (CHAMP) project, a voluntary quality improvement which monitors measures of health care, including adolescent well-care visits and identifies strategies for practice improvement. This year’s focus was on addressing adolescent mental health and substance use, as well as provider burnout.
Practices engaged in the QI projects described above have been supported in integrating the new edition of Bright Futures and the Strengthening Families Framework to improve the quality of preventive services using innovation, including: using QI tools such as checklists and Bright Futures visit forms to guide the content of age-specific adolescent visits; convene clinicians to review the content of age-specific adolescent visits and work out a flow of content across the age spectrum to support successful transitions of care; and reminder prompts in the Electronic Health Record.
VCHIP continues to advance initiatives around improving adolescent preventive care, and finalized an Adolescent and Young Adult Resources web page for primary care practices in support of youth-friendly services. They have also been able to facilitate expert consultation around confidentiality and youth-friendly care and facilitated in-person trainings with an expert, around confidentiality. They worked with this national partner to disseminate a Vermont specific confidentiality document to serve as a toolkit for interpreting confidentiality laws impacting health care services for youth and young adults in Vermont. A youth’s understanding of confidentiality can have a big impact youth’s accessing of primary care and the quality of their visits with providers.
MCH is partnering with VCHIP’s, Youth Health Improvement Initiative and the Wisconsin-based, PATCH (Providers and Teens Communicating for Health) program to promote the use of, PATCH for Teens: Classroom Edition. This program provides school health educators, health-related professionals, youth workers, and other adults the materials and resources needed to teach young people about their rights and responsibilities in health care settings. Learning objectives include: Students will understand the importance of learning to manage their own health care experiences; Students will learn how to advocate for their own health and wellbeing in health care settings; Students will explore steps they can take to make sure they get the care they need and deserve. This year we worked with partners from VCHIP, VT RAYS, and PATCH (as well as our Agency of Education who can help us to format our messaging to health educators) to present this curriculum during the fall 2018 SHAPE Vermont conference. This conference is primarily for health and physical educators. Prior to presenting at SHAPE, MCH asked VCHIP’s YHII program to test the curriculum with the VT RAYS to hear their initial responses and inform our presentation at the SHAPE conference. PATCH materials have been purchased but not distributed at this time. Due to competing priorities we have not recruited high school sites to participate in using the curriculum yet. We plan to continue with recruitment in the summer and fall of 2019. We hope to identify schools willing to try this curriculum and report back on reactions. We also plan to share information about PATCH through other electronic communications with schools, and through the Health Department School Liaisons.
In addition to improving adolescent well care visits, Vermont aims to promote healthy behaviors among youth through an empowerment model. To this end, Vermont MCH has joined with other organizations in highly innovative and effective programming. We partner with Up for Learning who leads teams of school personnel and youth in the Getting to ‘Y’ program. Getting to 'Y' is an opportunity for students to take a lead in bringing meaning to their own Youth Risk Behavior Survey data and taking steps to strengthen their school and community based on their findings by addressing risks and promoting strengths. Following an action research model, teams attend a training day to learn tools and strategies to organize their own retreat to analyze data, producing a “Student Executive Summary.” This summary includes three strengths, three areas of concern and a preliminary plan of action, based on an exploration of root causes. Examples of the student’s work can be found in the Getting to ‘Y’ newsletters located here. The 2018-2019 newsletter is in the process of being completed.
MCH is also continuing to support, M3: Mindset, Metacognition and Motivation. The more students know about how they learn and believe in their potential as learners, the more successful they will be. The M3: Mindset, Metacognition and Motivation project is a means to these ends. Youth become messengers with their advisory group peers, sharing the latest research and learning implications relating to:
- Mindsets: a critical examination of both youth and adults’ ingrained beliefs about ability and the role of self-expectations and others’ expectations on academic performance and life in general,
- Metacognition: learning about how we learn, and
- Motivation: key variables that impact the level of learning engagement.
Our support of this approach connects work on youth empowerment, in partnership with our Alcohol and Drug Abuse Prevention division.
Over the last year, MCH partnered with the Center for Health and Learning to support funding for Umatter for Youth and Young adults. Umatter YYA “is a youth leadership and engagement initiative. The goal is to promote mental health wellness: healthy coping mechanisms among youth and young adults, and the ability to recognize when a peer needs help and how to provide it. The aim is to foster healthy community cultures for youth and young adults that promote mental health and resiliency, and which address issues such as bullying and substance abuse prevention within a continuum for prevention through recovery.
The MCH Adolescent Health Unit team meets monthly. There are 5 members of the unit who represent a range of adolescent health related work across the division. Unit members created a planning document which includes our unit’s vision, mission, scope, core objectives, and guiding principles. Each program topic area supported will be looking at performance indicators/measures, partners, funding sources, program strategies, etc. to find places to coordinate, align, and potentially partner on priority areas. A few examples of these areas are school health, injury prevention, Youth Thrive, adolescent well care visits, and sexual and reproductive health. Our unit has sought the expert insight of our partner Kristin Teipel from the University of Minnesota who is involved with the State Adolescent Health Resource Center and the Adolescent and Young Adult Health National Resource Center. Kristin Teipel joins our unit meetings quarterly by phone to provide guidance, share experiences from other states, and to get updates from our group about the progression of our efforts.
The Division of MCH’s Personal Responsibility Education Program (PREP) grant works with high risk youth ages 10 – 19, and 20 and under if pregnant or parenting, on healthy relationships and life skills in an “upstream” approach to preventing pregnancy or delaying second pregnancies. MCH presently has 11 PREP subrecipients and the program is implemented across 13 community-based youth serving sites, including Parent Child Centers, Boys and Girls Clubs, the Association of Africans Living in Vermont, among others. In April 2017 MCH hired a fulltime Adolescent Sexual Health Program Manager to focus on adolescent sexual and reproductive health. The Adolescent Sexual Health Program Manager serves on several youth and young adult related statewide initiatives, including the Youth Thrive Statewide Coordination Team, and the Youth Services Advisory Council (YSAC). She is also a trainer in the Youth Thrive framework, which grew out of the Center for the Study of Social Policy’s development of the Strengthening Families model. Youth Thrive utilizes the most current science on adolescent brain development, trauma, and resilience. During the reporting period, the MCH Adolescent Sexual Health Program Manager trained 10 in the Youth Thrive framework and served on the statewide Implementation Team, with a special focus on trainer supports.
In 2017 VT undertook an extensive curriculum review process based on feedback from funded PREP programs, and with guidance from the Family and Youth Services Bureau (FYSB). As a result, two new curricula were chosen for implementation in VT: Making Proud Choices, and Be Proud, Be Responsible, Be Protective. In the fall of 2017 the Georgia Campaign for Adolescent Power and Potential (GCAPP) trained 18 PREP facilitators in both new curricula and Reducing the Risk, which had been used in Vermont for more than six years was phased out. Funded PREP programs have now completed 6 quarters of work with the new models. In general, we are finding the new curriculum to be better trauma-informed, inclusive of all identities, culturally sensitive, and asset focused than the curriculum we had been using. The curricula continue to be supplemented with trainings and resources around consent, affirmative, inclusive classrooms, LGBTQ+ youth, adult preparation skills, and positive youth development..
MCH also responded to an RFP from the national organization, Advocates for Youth (AYF) for the opportunity to receive no cost training and TA in approaches to gender and sexual inclusivity in sexual health education programming. This opportunity included a one day in person training for 25 participants from AFY for all PREP facilitators and several community partners engaged in adolescent health work across the state.
For a third year MCH partnered with Dr. Gibson, a pediatrician and adolescent medicine specialist to provide training and technical assistance to Vermont’s PREP program to further enhance the training opportunities for program facilitators who implement evidence-based curriculum. In addition, MCH has worked collaboratively with the health department’s division of Alcohol and Drug Abuse Prevention (ADAP) to incorporate activities into the scope of work to include a focus on decreasing prescription drug misuse and abuse among Vermont’s youth, and increase awareness of safe use, storage, and proper disposal of prescription medication.
The Youth Services Advisory Council (YSAC) promotes shared responsibility across state and community stakeholders for achieving positive outcomes for youth and young adults in Vermont. The YSAC includes representation from the Health Department’s Divisions of Maternal and Child Health and Alcohol and Drug Abuse Programs, as well as the Department of Mental Health, Department for Children and Families, Department of Vermont Health Access, Department of Labor, Agency of Education, Vermont Afterschool, and adolescent treatment providers, among others. The Council has identified several core outcome measures which include improving health care access and having a medical home; successfully completing high school, preparing adults to work with youth, youth having employment or vocational training, stable housing, and at least one supportive relationship; youth being free from incarceration, and engaged in planning for their future. MCH’s Adolescent Sexual Health Program Manager previously represented MCH on the Council and now serves as a Co-Chair.
The MCH Adolescent Health Sexual Health Program Manager continues to participate in the work of the Family Planning Action Team, organized by the Chittenden Accountable Community for Health’s Women’s Health Initiative. As part of this work, a Youth Sexual Health Services binder has been created for youth-serving organizations. Agencies that receive the binder receive an hour-long orientation to the material, and targeted technical assistance around using it with their adolescent clients. We would like youth-serving community organizations to have the resources and supports they need to connect their clients with accurate and up-to-date information on family planning methods and services. It contains information about safer sex, birth control options, STIs, healthy relationships, gender identity, and local teen-friendly resources for health and other needs. The binder was designed to be a quick and accessible resource for adults and young people to look at together. The binder provides 1) visuals and talking points for methods of STI and pregnancy prevention, 2) a tool for identifying and making referrals to local sexual and reproductive healthcare providers, and 3) reliable information and sources of information on several other topics related to sex and sexuality.
In 2017 MCH initiated a new collaboration with Vermont Afterschool Inc. Vermont Afterschool Inc. has a mission to: support organizations in providing quality afterschool, summer, and expanded learning experiences so that Vermont’s children and youth have the opportunities, skills, and resources they need to become healthy, productive members of society. MCH staff are able to provide guidance on best practice approaches to out of school programming, performance measurement and stakeholder engagement. In April, the MCH PREP Coordinator joined a Vermont team to attend the national Mott Afterschool conference.
The MCH Adolescent Health Sexual Health Program Manager serves on the VT9to26 Coalition, which is an action-oriented coalition working in partnership to achieve positive outcomes for all youth in Vermont. The focus of this coalition is to ensure that all young people ages 9-26 are safe, healthy, supported, educated, and engaged. VT9to26 is Vermont’s youth systems building effort that continues the work of Building Bright Futures and the early childhood system in Vermont for children ages 0-8. MCH staff are able to provide guidance on best practice approaches to out of school programming, positive youth development, and communications/messaging. During this reporting period, MCH supported Coalition and afterschool leaders in hosting international experts on youth voice and community-wide prevention efforts, and in piloting a statewide participatory budgeting process for and with youth.
Partnerships
The Primary Care and Public Health Integration meeting, which convenes monthly and includes pediatric, family practice, women’s health/adult, and Ob providers is an important partner in identifying innovative strategies to increase access to, utilization of, and quality of adolescent well care; as well as other youth empowerment strategies.
The Vermont Pediatric Council (VPC) is based upon a national model developed by the AAP; its purpose is to foster enhanced communication among pediatricians, insurers, public health professionals and others committed to improving the health status of and health care for Vermont’s children. VPC membership includes leaders from the following organizations and agencies: MCH; Vermont chapters of the AAP and the AAFP; the Department of Vermont Health Access (state Medicaid agency) and other Vermont insurers (e.g., Blue Cross Blue Shield of Vermont, CIGNA, MVP); VCHIP; and the Vermont Medical Society.
As described throughout this report, a key partner across all population domains is the Vermont Child Health Improvement Program (VCHIP). VCHIP is a population-based child and adolescent health services research and quality improvement program of the UVM.
In addition, new partnerships as outlined above include the Youth Thrive Statewide Coordination Team, the Youth Services Advisory Council, Vermont After School Inc., and the newly formed VT 9 to 26 Coalition.
Vermont Raise Awareness for Youth Services (VT RAYS) is our youth health advisory council as mentioned in sections above.
Other partners in our adolescent work include: Planned Parenthood of Northern New England, the Vermont Network Against Domestic and Sexual Violence, Vermont Medicaid, the Agency of Education, the Department of Mental Health, Vermont State School Nurse Association, local schools and school boards, and a broad range of youth serving organizations.
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