Overview of Child Health Strategies for FFY 2020

In FFY 2020, Louisiana Title V will continue work to strengthen the detection of health problems, and work through partnerships to address factors related to social and environmental forces affecting health. In alignment with the state priority need to advance understanding of drivers of disparities in MCH and CYSHCN outcomes and boldly work toward equity, new strategies have been developed to address developmental screening and early intervention disparities with two underserved patient groups – children and parents who are deaf or hard of hearing, and children and families of color. In addition to continuing to focus on advancing early developmental screening and intervention systems, Title V approaches to improve Child Health outcomes include strategies to enhance social and behavioral supports as well as system-level strategies to promote local level capacity to promote and protect health and well-being of children, caregivers and families.

Planned Title V Strategies and Alignment with Priority Needs

Priority Need: Bolster local level capacity to promote and protect health and well-being of children, caregivers and families.

Comprehensive System of Care for Early Childhood Proposal: Over the past several years, the SYCWC and Title V workgroups have been instrumental in convening cross-cutting teams to develop policy briefs and proposals in particular related to developmental screening, mental health, and more recently home visiting, primary care, care coordination, and developmental health supports. This work has laid the foundation of preparedness for tangible policy proposals to be advanced formally and informally through Title V staff and partnership activities.

A focus for FFY 2020 will be to support state and local collaboration towards the development of a comprehensive system of care for young children and their families. This focus has emerged out of the work of the SYCWC to create a defined early childhood state policy agenda drawing on BFH’s participation in technical assistance from Zero to Three, consultation with Johnson Consulting Group related to Medicaid financing of early childhood supports and services, and a call-to-action from the Governor’s Children’s Cabinet requesting that LDH develop a proposal for a Comprehensive System of Care for Early Childhood.

In an effort led by the Title V Director and the BFH Infant Mental Health Manager, a team drafted a proposal that outlines a regional network of supports and services to prevent mental health problems and treat mental health disorders. The proposal, when finalized, will be presented to the Children’s Cabinet Advisory Board, which is the body responsible for developing policy, program, and budget recommendations to the Governor’s Children’s Cabinet.

In addition to state-level work toward a more cohesive early childhood system, within BFH, the organizational strategic planning process has illuminated the opportunity and need to align program efforts more powerfully at the local level. Historically, there were myriad individual programs and activities that are each administered separately from the state-level BFH central office - a vestige of programs being funded and managed separately rather than as a cohesive strategy. In FFY 2019, Louisiana’s Title V program created a new Family and Community Systems team that structurally and strategically aligns many of the child and family system efforts including various mental health consultation efforts to primary care, home visiting, and early intervention; regional family support and coaching home visiting teams; the developmental screening, care coordination and medical home initiatives; and resources and supports for CYSHCN including children who are deaf, deaf-blind, or hard of hearing. The vision for FFY 2020 is that the Title V program staff and the SYCWC partners will identify the core components of an early childhood system that should be in every region of the state, and initiate a systematic plan, region by region, to achieve it.

Early Childhood Systems Strategy Manager: In addition to the strategic reorganization of BFH, the Early Childhood Systems Strategy Manager role, created in FFY 2019, will help coordinate efforts within BFH and with partner agencies to collaborate toward a comprehensive early childhood system. In FFY 2020, the ECSS Manager will work internally alongside the Title V Strategy Manager, the Supportive Services Project and Strategy Manager, and the Data to Action Team to create a 2020 Early Childhood Risk and Reach report in parallel with the Title V and MIECHV Needs Assessments. This report, first published in 2010, presents parish-level data on risk factors for children’s development, as well as the reach of various state-funded early childhood programs. The goal of the report is to inform policy and funding decisions in regards to supports and services for young children and their families.

Externally, the ECSS Manager will continue to work to improve coordination and collaboration with other state agencies that serve young children, particularly by leading the SYCWC efforts. In FFY 2019, the ECSS Manager built stronger working relationships with LDOE Early Education staff to facilitate meaningful collaborative work. Building on the collaboration opportunities identified in FFY 2019, in FFY 2020 the ECSS manager, alongside other BFH early childhood staff, will work with partners at LDOE to improve early identification practices and coordinate early identification and intervention data across systems, facilitate collaboration at the local level between Ready Start Networks and regional BFH staff, and create stronger referral pathways between programs run by different agencies.

State Young Child Wellness Collaborative: Through the SYCWC, BFH has been working with external partners to map Louisiana’s ECS, including non-traditional partners who have not historically been included in larger systems-level conversations. By highlighting some of the gaps in who is invited to have a voice in the work, this mapping exercise marks the early stages of developing a Collective Impact approach to better support Louisiana’s children and families. The SYCWC is exploring the possibility of group Collective Impact training to provide structure for the systems building, strengthening, and coordination work they are currently engaged in. As attention nationally and locally turn toward Collective Impact, the thoughtful development of this foundational framework will be essential to sustained future success.

The SYCWC also created three workgroups devoted to specific priorities of the group in FFY 2019, as a result of survey feedback from meeting attendees. The workgroups are focused on family engagement, early and accurate identification, and data sharing and system integration. These workgroups will continue to meet in FFY 2020 between SYCWC meetings to advance the collaborative work on these topics, reporting back to the general group and soliciting feedback on findings and work products. This work structure will be monitored for sustainability, productivity, and engagement.

Priority Need: Ensuring high performing essential maternal and child health screening and surveillance systems in Louisiana

Screening Systems:

Implementation of LDSG: FFY 2020 will continue to see the broad dissemination of the Louisiana Developmental Screening Guidelines (LDSG)--a culmination of four years of work creating the guidelines, developing an implementation plan,  piloting and evaluating technical assistance. The majority of tools and materials will have been created and evaluated, opening up the developmental screening workforce capacity to focus on outreach and technical assistance. Title V promotion of evidence-based developmental screening practices will be measured through ESM 6.2 (# of medical residents receiving developmental, social/emotional and environmental screening trainings), ESM 6.3 (# of developmental screening and surveillance presentations at RIWs), and ESM 6.4 (# of developmental screening and surveillance outreach publications and presentations). Progress on increasing the number of providers implementing the developmental screening guidelines will be measured at the end of the fiscal year with the biennial provider survey, which will help inform efforts going forward.

Developmental screening in pediatric primary care is a critical component of MCH screening and surveillance systems. The LDSG provide comprehensive recommendations to primary care physicians across the state, including high-quality, validated screening tools as well as enhancing on periodicity schedules provided by the Bright Futures guidelines from the AAP.

Provider Training and TA: Since the LDSG are voluntary, a key strategy in promoting uptake across the state is providing technical assistance to providers on both developmental screening and care coordination. The MCH Workforce Development Center technical assistance project resulted in the creation of a library of tools and materials that enable the provision of multiple modes of assistance – ranging from in person, to over the phone, to sending materials and resources via email. This flexibility is important for engaging with busy primary care clinics who have different levels of professional capacity as well as current practices and understanding regarding developmental screening and surveillance.

The technical assistance work at this stage will be informed by lessons learned from the pilot phase in Region 4 and the pilot evaluation, and the lessons learned through Project LAUNCH and ECCS Impact. It will be continually expanded across the state, adding new regions of focus on an approximately biannual basis. This pace of expansion is informed by experiences from the pilot project – given the voluntary nature of the screening guidelines and the lack of additional funding for providers, effective outreach and securing buy-in from physicians and clinic managers takes time. However, as the project continues and the process is streamlined, provision of technical assistance will become increasingly efficient, and we hope to exceed this objective. Furthermore, if Medicaid policy changes to incentivize developmental screening, the pace of this expansion may increase and outreach strategies may shift.

Training pediatric residents, delivering presentations biannually at Children’s Special Health Services (CSHS) Resource Information Workshops (RIW), and delivering outreach publications and presentations will continue on par with previous years.

Collaborate with Medicaid: The Title V Developmental Screening work group will continue to work with Medicaid to explore policy opportunities that promote implementation and measurement of developmental screening in primary care, such as turning on the appropriate CPT codes with associated reimbursement outside of the existing bundled payments for well-child visits. Developmental screening may also be adopted by Louisiana Medicaid as a Quality Measure that MCOs would have to report on, which would incentivize MCOs to work with the DS workgroup to promote developmental screening among their providers.

Early Childhood Integrated Data System: A critical systems-level objective is to create a tracking system for developmental screening, referral, and follow-up that can be utilized across multiple professional fields, including primary care, early care and education, and early intervention. Implementing such a system will streamline the process for families, improve communication among different types of providers, prevent unnecessary duplication of screening, and ensure that referrals and follow-ups are made in a timely manner.

The efforts to develop an early childhood integrated data system should ramp up in the coming year. Research has begun to identify various models for this data system, and representatives from states who have implemented different models have been contacted for discussion. Qualitative data derived from SYCWC system mapping in FFY 2019 will provide a basis for understanding the desired functionality of such a system in Louisiana, and stakeholder input will be continually sought as the specifics of the plan come together. There will be additional capacity for this work from the data sharing and system integration workgroup of the SYCWC. Identifying a funding source for creating and maintaining this system will be a high priority for the work group.

The timeline for designing a tracking system to monitor timely referral and follow-up for children with a positive developmental screen has been extended from its original target by two years, to be completed at the end of FFY 2020. The time frame for this objective remains ambitious, given the current issues with screening data availability and the recent strengthening of BFH’s partnership with LDOE. However, BFH will work diligently to achieve meaningful buy-in from partners and determine the appropriate model and functionality that fits the needs of providers and families in Louisiana.

Developmental Monitoring Pilot:  To promote family engagement in the early identification process, a focus on developmental monitoring will be continued in FFY 2020. The Developmental Screening Coordinator was selected as the Learn the Signs. Act Early. Ambassador to Louisiana in FFY 2019, which is a program designed to enhance parental engagement in developmental monitoring by creating a library of eye-catching informational materials specifically designed for parents. The existing work plan for disseminating these materials includes integration into the developmental screening/care coordination technical assistance package administered to primary care providers, as well as integration within Louisiana MIECHV. In FFY 2020, the Act Early Ambassador will continue to strengthen integration into pediatric primary care, as well as integration into early care and education programs. There will also be a specific focus with outreach to fathers of young children, who are rarely intentionally engaged in early childhood efforts by state-funded programs.

Surveillance Systems:

Regional and State Child Death Review (CDR): The local and state-level reviews have resulted in recommendations for interventions related to the investigation and prevention of sleep-related, motor vehicle crash, drowning, homicide, and suicide deaths. During the 2019 state legislative session, BFH provided research, data (including CDR findings), and talking points for recent successful legislative effort to improve the child passenger safety law – one of most protective in the country. BFH was also awarded a grant from U.S. Consumer Product Safety Commission (CPSC) that aims to reduce deaths and injuries from drowning and drain entrapment incidents in pools and spas. Panel members on the local and State CDR panels will continue to work with partners to move recommendations to actions including ongoing policy efforts related to the prevention of abusive head trauma (including shaken baby), safe sleep, child passenger safety, and pursuing additional prevention resources for drowning prevention.

Injury Surveillance and Child Abuse and Neglect (CAN): In the coming year, Title V will support part of the new injury epidemiologist in their work with DCFS. Child welfare victim and perpetrator data have been linked with health system data and vital records.  Analytics will facilitate more comprehensive predictive analytic topics such as relationships between repeated allegations, substance use and mental illness and perpetration of CAN, and outcomes for substance exposed newborns.  An emerging area of emphasis for injury surveillance is assessing the shared risk and protective factors (SRPF) for the multiple forms of violence. In FFY 2019, BFH established the Injury-Free Louisiana (IFLA) Academy training series to teach local providers about the public health approach, primary prevention, and SRPF. In 2019, along with other violence prevention partners, BFH conducted the first academy in Southeast Louisiana and is now assisting multi-disciplinary teams in building evidence based interventions to address violence – primarily child abuse and neglect, sexual violence, youth violence and suicide. BFH has also applied for funding to expand the IFLA academy models with opioid prevention partners within OPH. 

Priority Need: To advance understanding of drivers of disparities in MCH and CYSHCN outcomes and boldly work toward equity.

Research and Develop Developmental Screening Equity Strategy:  One important priority for this year will be refining the materials and communication strategies to remove barriers to effective early identification and reduce disparities for underserved populations. One key population that is currently experiencing barriers to preventive care are children and their families who are deaf or hard of hearing.1 After the Louisiana Commission for the Deaf came under BFH administration it became clear that this group’s specific challenges and needs had not been adequately taken into account in the creation and implementation of the LDSG. Children who are deaf or hard-of-hearing have higher levels of developmental delay and disability than hearing children,2 and systems are not centered on a strengths-based orientation for language acquisition, and thus it is critical that our early identification policies are inclusive of these children.

The first step toward achieving this objective is researching best practices around developmental screening for children and families who are deaf or hard of hearing. A summary of this research will be presented both to the Developmental Screening Workgroup of the SYCWC, as well as the Early Hearing Detection and Intervention (EHDI) learning community, which includes the Executive Director of the Louisiana Commission for the Deaf. Feedback on the research will be gathered from these stakeholders, and a plan will be developed from the feedback to inform the work going forward. Concurrent and complementary to this effort, Louisiana Title V will provide support staff to coordinate the LEAD-K (Language Equality and Acquisition for Deaf Kids) task force that was created as a result of legislation passed in the 2018 Louisiana Regular Session. This task force is charged with developing a framework for assessing children who are deaf or hard of hearing to determine language skills and ensure kindergarten readiness.

Another important priority going forward is working deliberately to reduce racial disparities in early identification and intervention. Reducing these disparities will require more than encouraging doctors to provide universal screening. Implicit biases among providers at every level of the early intervention system, cultural beliefs and norms related to the health care system, and personal experiences all affect the behavior of both parents and providers, which affects the quality of care children receive, and ultimately their health outcomes.

The process for achieving this objective closely mirrors that for children and families who are deaf or hard of hearing. The work will begin with a literature review of health disparities in early identification and intervention, as well as best practices for promoting equity in this field. These findings will be summarized and presented to the Young Child Wellness Collaborative Developmental Screening Workgroup, as well as the Health Equity Action Team (HEAT) at BFH, and feedback will be collected from these stakeholders to inform the work plan.

Priority Need: Improve social and behavioral health supports, with a focus on child and family well-being and resiliency

Priming Community and Decision-maker Awareness about the Lifelong Effects of Early Experiences: In FFY 2020, Louisiana will sustain efforts to build cohorts of informed champions who have a foundation of understanding of the significance of safe, stable, nurturing relationships and environments on the healthy development of young children. In the fall of 2019, a sixth ECPLI cohort will be launched, with support provided in part through Title V. In addition, Louisiana Title V will support the fifth and sixth cohorts of ACE Educators trained in the fall of 2019, and their associated local coalitions. The ACE Educator Program will monitor Educator capacity for audience engagement, use of trauma-informed language and presentation style, and scientific accuracy, and provide feedback and technical assistance as needed. The program will also host biannual Regional Support Meetings for Educators to discuss program updates, roll-out new presentation content and facilitate networking opportunities to maintain cohort cohesion. Future plans to train additional regional cohorts will follow in response to identified community readiness, interest and need.
 

Through membership and participation in the Louisiana ACE Initiative, the Louisiana ACE Educator Program collaborated with other child- and family-serving agencies to plan and host a statewide ACEs Summit in early 2019. Summit programming focused on dissemination of research conducted by the ACE Initiative to capture ACEs and resilience work being done throughout the state, community approaches to mitigation and prevention of childhood adversity, and special topics related to ACEs. The ACE Educator Program will provide similar collaborative support for future ACE Summits as funding is obtained. The program is also a key member of the Injury Free Louisiana (IFLA) workgroup, a collective of organizations working to prevent multiple forms of violence using the CDC Connecting The Dots shared risk and protective factors framework.

Family Coaching and Support through the Louisiana Maternal, Infant, Early Childhood Home Visiting Program (LA MIECHV Program): BFH will continue to oversee LA MIECHV as one of the anchor programs shaping the priorities and strategies of the Title V Program and the Bureau overall. In FFY 2020, Title V will continue as one of the funding streams supporting MIECHV services and the charge to contribute to the development of an early childhood comprehensive system.

Mental Health Consultation - Toward a Cohesive Regional Cross-Sector Model: Louisiana’s Title V program and partner, Tulane University, have been innovators in developing and scaling mental health consultation approaches in child- and family-focused services including home visiting, primary care, and early intervention.  In FFY 2020, Title V will continue its investment to sustain the MIECHV IMH Specialists that have been supported through MIECHV, the mental health consultants that piloted a cohesive region-based multi sector model through Project LAUNCH, as well as a new statewide initiative that provides telehealth psychiatric care consultation to perinatal providers.

Community and Family Level Intervention for Grief and Trauma: Support for Project LAST (Loss and Survival Team) in the greater New Orleans Area for children (0-17) and their families who have been impacted by a traumatic event or loss will be sustained in the coming funding period. While only serving the greater New Orleans area, this investment will be sustained because of the high incidence of community violence, and because this model of support is one that may ultimately be considered for expansion as a part of the Title V strategy to improve social and behavioral supports.

Priority Need: Actively and meaningfully engage youth and families, building local level leaders across the state.

CAATs: In FFY 2020, MIECHV Supervisors and MCH Coordinators will continue to lead quarterly regional Community Advisory and Action Team (CAAT) meetings. The CAAT meetings will provide a forum for diverse stakeholders to come together and develop community-driven solutions for issues affecting the health and well-being of children and families. In FFY 2020, BFH will continue to prioritize efforts to expand representation from all sectors (health, social services, early childhood education, etc.), increase family engagement, and provide support to MCH Coordinators and Nursing Supervisors around structuring and facilitating meetings.

In FFY 2020, increasing family representation will remain a priority across all CAAT teams. Now that the CAATs are more established in their respective communities, staff can focus on being more targeted and intentional about bringing families on board. Ideally, each CAAT will include previous clients and community champions from health, education, private businesses, local government, and faith-based organizations. The goal is to have each CAAT truly represent the wide variety of cultural, racial, experiential, and geographic backgrounds of participants supported through home visiting and collaborative partnerships in communities across the state.