Report: Adolescent:
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 including connections with Vermont’s school health services and their school systems. This partnership allows the advancement of 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 coordinate closely under interagency agreements with DCF and VT’s 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, 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 (through the creation of an Annual Reinvestment Plan). Annual reinvestment planning encourages the use of the Health Department’s annual School Nurse Report and Youth Risk Behavior Survey data. 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 to connect at risk kids with dental services in a dental home and other efforts related to the 802 Smiles Network’s different tiers ; establishing, maintaining, and implementing WSCC teams 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 Title V efforts and promotes the administration of Medicaid while reducing barriers to access and use of services. The SSNC aligns the Standards of Practice: School Health Services Manual with current school nursing best practice and concepts of the National Association of School Nurses’ Framework for 21st Century School Nursing Practice to provide technical assistance on school health services, and related policies and procedures. The SSNC maintains and updates the new school nurse online orientation, which is required by the Agency of Education for school nurse licensing, in collaboration with the School Nurse Advisory Committee. The SSNC is also engaged with the work of the National Association of State School Nurse Consultants, and the Vermont State School Nurses' Association.
The SSNC chairs the School Nurse Advisory Committee, whose tasks include continuous improvement and revision of the Standards of Practice: School Health Services Manual, the online new school nurse orientation, implementation of the Essential School Health Services model, and school nurse workforce development Content in the Manual is validated and verified through expert, legal, and MCH leadership review. The work of the School Nurse Advisory Committee guides school nurse practice within Vermont to ensure all school-aged children and youth receive the recommended, age-appropriate care, as described by Bright Futures, and that chronic health conditions are managed effectively for the best possible outcomes. The School Nurse Advisory Committee is comprised of school nurses from different locations around the state, the president of the Vermont State School Nurses Association, an appointed professional from the Agency of Education, an APRN that specializes in children and families, and the SSNC. The committee regularly connects with various subject matter experts and leaders in the state to discuss content areas related to their specialty. The School Nurse Advisory Committee continues to look for parent and student input to assist in the development and revision of resources and tools for school nurses throughout the state. We plan to reach out to partners such as 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.
Over the past year, several MCH staff collaborated, coordinated, and assisted with Vermont State School Nurses’ Association sponsored school nurse town hall meetings. These meetings provided opportunities to support school nurses, who were important partners in the COVID-19 pandemic response, by ensuring they had the most current information (even when information changed frequently), respond to their questions and concerns, and gather input for future considerations in the pandemic response and the related materials created in partnership with the Agency of Education, the Department of Children and Families, the Health Department, and others.
The Health Department School Liaisons (Public Health Nurses in each of the 12 Offices of the VDH Offices of Local Health) work with the SSNC, school nurses, and other school staff to assist families in obtaining health insurance and to encourage them to access medical and dental homes for regular preventive care or to address potential special health needs through engagement of our school and community partners (not direct service to the public) using a population-based approach. 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 providers and can assist with addressing issues that may impact coordination or communication between school nurses and local practices. These relationships were formed, reestablished, enhanced, or reinvigorated during the last year, as schools and providers provided support and leadership locally to further our ongoing efforts at the Health Department and with the Schools and Childcare Branch of our Health Operations Center (HOC) for the pandemic response work.
Due to substantial disruption of in-person school from the COVID-19 pandemic, the Health Department (specifically including members of the MCH division and Health Surveillance), Agency of Education, members of the pediatric infectious disease community, and other State and community partners worked to create evidenced based guidance for the 20-21 school year. MCH leadership and the Schools and Childcare Branch is very proud of our efforts to support access to in-person education for children and youth. MCH’s relationship with the provider and education communities facilitated connections which ensured evidence-based guidance was in place so that students could access their education and other needed services best provided in-person. The School Liaisons were in an excellent position to promote vital connections between medical homes and schools to plan for in-person classes in the fall, while supporting a new or reinvigorated interest in the role of the school physician in providing consultation or education for operationalizing local school reopening. The liaison’s long history of promoting this type of relationship will continue to be very helpful moving forward. As the impact of COVID-19 cases and information about the virus evolved, MCH served as a key partner to help update school (and out of school time care) guidance. The Schools and Childcare branch helped to clarify guidance, answer tough questions, and connect with Health Department and Agency of Education partners to get clarification or aid in decision making as needed. The Schools and Childcare branch answered calls and emails from the public and other State partners and helped provide clinical guidance and consultation. When a case of COVID-19 impacted a school, we provided guidance and supported outbreak prevention response work. Through targeted, evidence-based work, the Health Department effectively minimized the impact of COVID-19 cases on in-person education (and extracurricular experiences), helped to ensure schools remained open, and minimal transmission of COVID-19 cases in schools.
Schools may choose to use the Bright Futures sports clearance well child form which was recently updated but not yet rolled out to schools due to other competing priorities as well as the ongoing impact of COVID-19 on the last two school years. The updated version better highlights the importance of annual well care and provides families with action steps they can take to access well care. Additionally, the Health Department (and Agency of Human Services as a whole) began to increase the emphasis on the use of “plain language” to improve how we message important health related information with the public this year. We would like to review the most current iteration of this document during the next grant period and update it using this plain language lens in partnership with VCHIP and the Primary Care Public Health Integration work group. We plan to work on roll out in the next school year.
Supporting youth during the COVID 19 pandemic has been a priority area and elevating youth voice has also been an important part of our work. VT RAYS is a specialty youth group focused on adolescent and young adult public health issues, with a particular interest for improving access and utilization of preventive health services. Under the leadership of the Youth Health Improvement Initiative at the Vermont Child Health Improvement Program (VCHIP), and in partnership with the Health Department, the RAYS have the unique ability to connect with primary care practices throughout Vermont to help identify adolescent health priority areas, increase engagement, and improve quality of youth services. Additionally, VCHIP provides opportunities to bring the youth perspective to other state partners and stakeholders, creating an impact at the policy level. In its current capacity, VCHIP continues to serve as a liaison between youth and the medical community, public health entities, and other state and/or national stakeholders. VCHIP faculty provide content expertise and facilitate integration of youth voice and experience. In an effort to improve sustainability, we have explored opportunities to collaborate with similar youth focused organizations including VT Afterschool. As leaders in facilitating youth groups and youth leadership trainings, VT Afterschool offers an opportunity to strengthen the impact of youth voice and help build youth leadership skills. VT Afterschool, VCHIP and MCH have met several times to discuss this future collaboration Over the last year we have solidified this collaboration with the introduction of a six-week youth advisory council effort focused on health equity in Vermont. Meetings will be held regularly this summer (2021) to discuss health equity, specifically as it relates to healthcare, third space, and mental health.
Our partners at VCHIP have been incredibly helpful with supporting a platform to keep primary care providers including pediatricians up to date on COVID-19 related information. Starting at beginning of the pandemic, VCHIP hosts 30-to-45-minute calls 3-4 days a week for providers. Calls were co-led by VCHIP and the MCH Director (who then became our division’s medical director) at the Health Department. Attendance frequently reached over 100 providers. This platform has provided a place for increased connectedness between public health and primary care during this crisis. Feedback from providers has frequently informed materials, impacted testing process and procedures, and provided important narrative for what is occurring on the frontlines in relation to the COVID-19 response in healthcare settings. We also see this increased connection as an opportunity to promote the role of the school physician as part of the local level supports needed for schools as they planned how to implement guidance for reopening, and supported efforts to promote the importance of vaccination for eligible youth 12 and over. Providers around the state hosted webinars for youth and families to answer questions about COVID-19 and the vaccine (in collaboration with the VT AAP chapter). We hope these relationships continue long after the pandemic as they are important for our efforts related to supporting the administration of Medicaid at the local level.
VCHIP continues to advance on improving adolescent preventive care and maintains an Adolescent and Young Adult Resources web page for primary care practices in support of youth-friendly services. They facilitate expert consultation around confidentiality and youth-friendly care and facilitated in-person trainings with an expert on the topic of confidentiality pre-pandemic. They worked with this national partner to disseminate a Vermont specific confidentiality toolkit for interpreting confidentiality laws impacting health care services for youth and young adults in Vermont. A youth’s understanding of confidentiality impacts youth access of primary care and improves the quality of their visits with providers.
MCH partnered 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. PATCH materials were purchased but are not yet distributed. Due to competing priorities and the end of in person classes during the winter/spring of the 19-20 school key VDH personnel’s deployment to support Schools and Childcare Branch HOC pandemic response duties, we have not recruited high school sites to participate in using the curriculum yet. We plan to revisit recruitment in the next school year. COVID-19 response and recovery efforts were the main priority during the previous school year.
In addition to improving adolescent well care visits, Vermont aims to promote healthy behaviors among youth through an empowerment model. Vermont MCH joined with other organizations in partnering 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 priority strengths and areas of concern they identified at their retreat, 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. UP for Learning adapted what was normally a day long in-person training into virtual training ensuring students were still able to access and participate in this important program during the 20/21 school year. Additionally, Getting to ‘Y’ was added to AMCHP’s Innovation Station Evidence Based Best Practice Database last year, and the Health Department will now consider Getting to ‘Y’ an evidence-based practice. UP for Learning and the Health Department were scheduled to present on this innovative program at last year’s AMCHP conference which was delayed due to the pandemic. We did present the same content in August for a virtual version of the conference which was well attended and received. Additionally, UP for Learning youth and adults joined AMCHP as co-presenters at the Adolescent Health Initiative’s 2021 Conference on Adolescent Health.
We nurtured a new partnership between Up for Leaning and the Vermont Network Against Domestic and Sexual Violence, supported by a CDC grant administered by MCH that focused on the primary prevention of sexual violence. Up for Learning collaborated with the VT Network to plan and lead a learning series to support participating organizations to sharpen their lens and build a toolkit for youth-adult partnership to amplify youth voice & agency in learning and decision making. This powerful strategy strengthens the social and emotional fabric of organizations and communities, enhances motivation and engagement, and ensures equity. Essential questions addressed as part of the series included: Why does youth voice and agency matter? What does youth voice and agency look and sound like? What conceptual framework will help me better understand and build youth voice and agency in my organization or community? And, how will I further develop a sense of shared responsibility in learning and decision making in my organization or community? Youth adult partnerships build on the strengths of each group to create more effective outcomes. These partnerships have also been shown to support positive youth development and resiliency and decrease risky behaviors in youth.
During the planning phase for Vermont’s 2020-2024 CDC/RPE grant program, sub-recipient organizations recruited cohorts of youth to partner with organizations in their sexual violence prevention efforts. UP for Learning facilitated an online Youth-Adult Partnership Learning Series to build a foundation of knowledge and skills for these partnerships. UP for Learning is currently facilitating a four-session online planning process where youth-adult teams are working together to learn and plan for the sexual violence prevention efforts the teams will implement during the grant period. Youth co-lead all sessions with staff from Up for Learning.
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.
The abrupt ending of in-person education in 19-20 and the ongoing school precautions in 20-21 school years due to the COVID-19 pandemic caused schools to adjust their expectations and outcomes for activities related to these two programs (Getting to Y and M3). The UP team rapidly prototyped resources to meet the needs arising in the field. Resources were created with the understanding that they could be used during remote learning and could also be adapted for in-person learning. UP for Learning continued to hold regular meetings with teams using Zoom and Google Meets. UP for Learning adapted and responded to individual teams' needs and designed training and support to meet these needs. A sense of the adaptation and work required during the pandemic can gleaned in the GTY 2020-2021 Newsletter.
Weekly newsletters have become essential communications for UP during COVID-19. From communicating how we are responding as an organization to sharing resources for engaging youth, we have found that these have been well received from our partners and supporters. Resources from UP have been shared with a larger audience and we are able to provide relevant and engaging resources for our educational community. Resources include:
- UP’s Remote Advisory Resource: Structures and Routines for Virtual Advisories
- UP’s Ideas to Support Remote Dialogue/Connections/Engagement
- UP and Shelburne Farm’s Cultivating Pathways to Sustainability Project-Based Resource for Learnings and Educators to support distance learning.
Over the past several years, MCH has 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. Umatter YYA is carried out with the support of adult facilitators who work with youth and want support opportunities that teach skills that foster resilience and create norms for self-care and help-seeking in schools and community settings. Umatter YYA has a Youth Leadership Council that helps to plan and lead training events and advise on special projects and program design. Umatter YYA trains young people on personal skills such as strength and risk assessment, coping and stress management, recognizing warning signs of mental health distress, awareness of the importance of depression screens and well-care visits, and knowing how to get help. These young people become peer leaders and work with other youth to bolster these skills. They work together as a team to plan and implement a Community Action Project (CAP). CHL works with schools and community-based programs to identify young people to participate. Youth Leadership Council members and Adult Facilitators advise on curriculum design and all participants inform evaluation. Due to COVID they made several creative adaptations, including transitioning many of their materials into an online learning format, which has led to more options for programming and has increased reach.
The MCH Adolescent Health Unit team did not meet due to staff COVID-19 deployments. We will resume our meetings in the fall 2021 to identify priorities, assess the impact of COVID on our work and identify best next steps for our shared efforts related to adolescent health and wellbeing. A few examples of key topic areas are school health, injury prevention, Youth Thrive, adolescent well care visits, sexual and reproductive health, youth engagement and voice. In the past our unit has sought the expert insight of our partners 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. We look forward to reconnecting with these resources in the fall.
During the COVID-19 response this group played an important role in advising the Communications Team on topics related to adolescent health and the pandemic and provided guidance on messaging related to family stressors and coping, child abuse and neglect, domestic violence, mental health and suicide prevention, and health equity.
The Adolescent Health Unit started more intentional outreach to other divisions in the Health Department and to other departments across the Agency of Human Services. These included to the Department of Mental Health, and Division of Alcohol and Drug Abuse Prevention, and the Division of Health Promotion and Disease Prevention, namely the tobacco prevention team. These partnerships are critical to enhancing the coordination of our adolescent health efforts across our department and agency, especially related to mental health, suicide prevention, youth voice and engagement and substance use prevention. MCH also has representation on a vaping prevention workgroup that was established 2 years ago. While much of this has been paused due to COVID-19, there have still been several opportunities for collaboration related to proposal review processes for regional tobacco control coalitions and supporting linkages to community partners such as Outright VT and VT Afterschool to expand work related to tobacco prevention efforts.
The Division of MCH’s Personal Responsibility Education Program (PREP) works with high-risk youth ages 10 – 19 (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, and others. This work is overseen by the MCH Adolescent Health Program Manager, who also serves on several youth and young adult related statewide initiatives broadly related to youth development, including the Youth Thrive Statewide Coordination Team, and co-chairs 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.
The Adolescent and Reproductive Health Program Director and Adolescent Health Program Manager worked closely with the Agency of Education on an interagency workgroup per the request of the state legislature to improve and standardize sexual health education in Vermont schools. Several meetings were held, two of which included community stakeholders, to gather input to assess the needs and gaps related to sex ed in the state. A series of recommendations were formulated and presented to the legislature and now efforts are under way to implement the recommendations. This work has been somewhat slowed due the state’s COVID-19 response efforts, but it is ongoing.
For a fourth 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. This work was expanded in the reporting year to include training on substance use prevention for afterschool professionals, as well as several groups of medical residents at the University of Vermont School of Medicine.
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 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 Health Program Manager previously represented MCH on the Council and now serves as a Co-Chair.
The MCH collaboration with Vermont Afterschool Inc. continues and has expanded. 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 provide guidance on best practice approaches to out of school programming, performance measurement and stakeholder engagement, positive youth development, and communications/messaging.
Vermont Afterschool’s work under the CDC-funded Opioid Data to Action funding continues the work of the Youth and Community Health Coordinator and the Youth Voice Coordinator. MCH supports the Youth Voice Project, a data informed, community-led process of recognizing and building upon youth strengths and mitigating risk of substance use disorder and the work of Regional Youth Councils. Work for a Statewide Youth Council continues at the local level through which youth get to design, apply for, and manage their own wellness initiatives in their communities. The Director of Adolescent and Reproductive Health also served on a proposal review process led by VT Afterschool to fund summer programming expansion efforts focused on COVID recovery for children and youth.
The MCH Adolescent 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.
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, partnerships as outlined above include the Youth Thrive Statewide Coordination Team, the Youth Services Advisory Council, Vermont After School Inc., and the 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, Outright VT, Vermont Medicaid, the Agency of Education, the Department of Mental Health, Vermont State School Nurses’ Association, the Center for Health and Learning, local schools and school boards, and a broad range of youth serving organizations.
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