CHILD HEALTH DOMAIN
Nebraska Application for the 2023-2024 Year
In this section, Nebraska MCH Title V describes planned activities in the Child Health Domain for the period October 1, 202023 to September 30, 2024. This represents the fourth year of activity in the Title V five-year needs assessment cycle for 2020-2025. The numerical sequence of headings used to organize the narrative below correspond to the narrative guidance for the Annual Report year as found on page 43 of the Title V Maternal and Child Health Services Block Grant to States Program: Guidance and Forms for the Title V Application/Annual Report, OMB Number 0915-0172, Expiration Date 1/31/2024.
The Nebraska Priorities in the Child Health Domain with 2023-2024 NPM, SPM, and ESM statements are as follows:
- Priority: Child Abuse Prevention
SPM: The rate of substantiated reports of child abuse and neglect per 1,000 children ages 1-9 years
ESM: None
- Priority: Access to Preventive Oral Health Care Services
NPM: Percent of children ages 1-17 years with a preventive dental visit in the past year
- Description of Planned Activities
OVERVIEW OF THE CHILD HEALTH DOMAIN
Systems Partners
Nebraskans care about child wellbeing, and there are several strong systems-level efforts led by state organizations and foundations to improve child and family services and outcomes. First Five Nebraska, the Nebraska Children and Families Foundation (NCFF), and the Buffett Early Childhood Institute at the University of Nebraska-Lincoln all bring strong infrastructure and policy-building assets to helping Nebraska families succeed. Title V MCH has collaborative relationships with all, and partners with NCFF on a variety of activities. NCFF is the lead agency for the Bring Up Nebraska effort, which in turn heavily supports the infrastructure of community collaboratives across the state. In addition to these well-established organizations, Nebraska participates in a Preschool Development Grant, and First Five Nebraska leads a Pritzger Prenatal to Three project. Title V and N-MIECHV have both actively participated in the development of the state plan under the Family First Prevention Services Act which includes home visiting services for families at-risk of involvement in the child welfare system. Additionally, Title V participates on the Child Abuse Prevention Fund Board, on workgroups focused on Preventing Child Maltreatment Deaths, and ensures Child Welfare representation on the Child Maternal Death Review Team. This is an example of the Nebraska Department of Health & Human Services (DHHS) approach to integrated service delivery in health and human services that has grown collaborative opportunities for Title V and related programs to participate in discussion and planning for alternative interventions for families and children at risk of involvement in the child welfare system.
Title V Children’s Health
After the departure of the School Health Program Manager in 2022, Title V’s MCH Program restructured the position to broadly support children’s health. For Title V this is an important opportunity to focus priorities and determine the right mix of resources for ongoing efforts. As the new staff person in this position builds capacity, they will have an opportunity to participate in development of this role. This position will support the systems- and state-level collaborations that have built a comprehensive system of child and family supports and services.
Children’s Hospital & Medical Center
Children’s Hospital & Medical Center is expanding their footprint in Nebraska. They have numerous clinical service locations, clinics, and referral networks across Nebraska, as well as community-based and school health services, providing child psychiatry and consultation services via telehealth statewide.
In 2021-2022, the Nebraska’s Children’s Hospital & Medical Center partnered with the Nebraska Department of Education to expand and embrace comprehensive and coordinated school health programs to provide additional expertise and staff support. The School Health Nurse Consultant position moved from the Nebraska Department of Health & Human Services Maternal & Child Health (MCH) Program to Children’s Hospital & Medical Center. The MCH Program and Title V maintain robust connections and collaborations with the staff who are supporting Nebraska school health services.
Priority: Child Abuse Prevention
2023-2024 Objectives and Proposed Strategies
Objective CH4a: By 2025, reduce rate of substantiated child abuse or neglect by: supporting prevention, early identification, and early intervention strategies; and investigating disproportionality of children and families involved with the Child Welfare Agency
Strategy CH4a (1): The Nebraska MIECHV program will expand evidence-based home visiting services targeted to Nebraska families at-risk for child abuse and neglect in collaboration with DHHS Division of Children and Family Services
Strategy CH4a (2): Title V staff will continue collaboration with the Division of Children and Family Services (DCFS) in the Thriving Families, Safer Children workgroup, Child Abuse Prevention Fund Board, Plan to Prevent Child Maltreatment Deaths workgroup, Prenatal Plans of Safe Care, and Bring Up Nebraska initiatives co-led by DCFS and Nebraska Children and Families Foundation
Discussion of Activities for this Objective – Relevance to Identified Priority
N-MIECHV Expansion
For the past few years, the N-MIECHV program, housed in the Division of Public Health, has worked in a formal collaborative partnership with the Division of Children & Family Services (DCFS) to implement Family First Prevention Services Act (FFPSA) services, primarily through the Child Welfare Protocol of Healthy Families America model of home visiting. Additionally, starting in 2020, DCFS allocated funds from the Temporary Assistance for Needy Families (TANF) program for the expansion of HFA evidence-based home visiting programs across the state.
N-MIECHV conducted an updated needs assessment in 2020 to identify the counties in Nebraska whose community data shows most “at risk” for child maltreatment due to factors such as the rates of poverty, teen pregnancy, and/or exposure to violence or substance abuse, among others. After community planning to identify appropriate organizations to provide home visiting services in each community, N-MIECHV will use braided funding to expand services across Nebraska via subawards. In 2023-2024, five new HFA programs, in identified priority counties that do not have existing services, will complete training and orientation, and start providing home visits. The 2020 needs assessment results ensure that N-MIECHV expansion will focus on communities with vulnerable pregnant and parenting families.
Child Welfare Disparities
The Child Abuse and Neglect Issue Brief created through the Title V Needs Assessment process clearly identified disparities between racial groups in NE when looking at alleged and substantiated child abuse and neglect rates. As a result, the Division of Children and Family Services (DCFS) committed to analyzing data to further describe existing disparities.
DCFS found that in certain locations across NE, American Indian/Alaska Native and multi-racial children have a rate of screened in reports at least twice that of White children. Nebraska Children and Families Foundation (NCFF) is leading programs intended to reduce unnecessary entry into the child welfare system, and they are reaching the populations most at risk of child abuse and neglect. Nebraska’s Community Response model is the backbone support element of a community-based prevention system and encompasses all individual-level strategies implemented across the life span. Community Response coordinates existing resources within a community to help children, young adults, and families address immediate needs, and increase promotive and protective factors long-term. Community Response is intended to prevent unnecessary entry into the child welfare system. A similar program, Alternative Response, is offered to lower risk families that have already entered the child welfare system.
In 2021-2022, American Indian/Alaska Native families were represented in the Community Response population at a higher percentage as compared to the Alternative Response population (5.3% vs 2%), with the same situation existing for Black families (19.3% vs 8.6%). Additionally, evaluation of the child well-being collaboratives has shown that people participating in Community Response made significant improvements in measured concrete support, social connections, hope, and resilience. Collaboration with NCFF, DCFS, and initiatives led by each group will continue in 2023-2024. During this reporting period, in the four communities with Thriving Families, Safer Children workgroups, DCFS will support trainings on implicit bias, review data disparities and focus on persons with lived experience with child abuse and neglect.
Driven by state legislation, LB 1173, Nebraska is engaged in a three branch initiative, working with a national consultant that is charged with recommending the framework for a child welfare system practice and finance model to improve outcomes for children and families and support wellbeing efforts across Nebraska. In 2023-2024, Title V and DCFS staff will review the developed framework and identify opportunities for Title V to support systems change.
Results of the 2023 Public Input Survey support the work described for this priority. One respondent commented, “These are great ideas. Additionally, it may help to look at ways to create community and relationships among parents whether through formal or informal supports. Isolation, mental health, and parent’s own lack of healing their own trauma doesn’t help with the reasons children are brought into the child welfare system.”
Priority: Access to Preventive Oral Health Care Services
2023-2024 Objectives and Proposed Strategies
Objective CH5a: By 2025, increase the percent of children ages 1 to 17 years who receive preventive oral health care services
Strategy CH5a (1): The Office of Oral Health will distribute dental health starter kits in the population and report evaluation measures of the project
Strategy CH5a (2): The DHHS Office of Oral Health and Dentistry (OOHD) will analyze data collected during the statewide Oral Health Survey
Strategy CH5a(3): Title V will fund and support community-based oral health care service delivery through subaward agreements.
Discussion of Activities for this Objective – Relevance to Identified Priority
Distributing Nebraska Early Dental Health Starter Kits to families of children birth to age five helps to educate these families not only about the importance of daily oral hygiene, but also provides examples of age-appropriate oral hygiene tools to use. Increased understanding of the need for preventive oral health care leads to guardians taking their children in for routine dental care and the establishment of a dental home. In addition, the Nebraska Early Dental Health Starter Kits contain a listing of Dental Public Health Clinics in Nebraska where families can access lower cost oral health care services. Kits are distributed by local partners, including but not limited to local and tribal health departments, Children’s Hospital & Medical Center, and the University of Nebraska Medical Center’s College of Dentistry. Title V will continue supporting this activity in the upcoming year.
The OOHD recently completed a basic dental screening survey of Head Start and third graders across Nebraska and is analyzing the surveillance data. With the state survey completed, the Office of Oral Health and Dentistry will look at trends for the two age populations related to the number of children with caries experience, those who have received previous dental treatment, the urgency on needed dental treatment, and numbers of third grade children with sealants. Additionally, OOHD will report out results in a document drafted and disseminated to stakeholders and the public. This information will allow the OOHD to monitor where preventive services are provided across Nebraska and identify where adjustments to program activities need to be made. OOHD also uses this data when applying for additional funding to help support program activities.
One continuing challenge for Nebraska in this area is the shortage of dental health professionals across the state. This is not a new problem, and there has been significant effort to expand the available dental health workforce in rural areas, primarily using public health hygienists. Nebraska is unique in that a Public Health Authorization allows hygienists to offer preventive services without requiring a dentist on-site. Title V has supported the NDHHS Office of Oral Health and Dentistry in efforts to grow the capacity for public health hygienists across the state and will continue this support into the 2023-2024 year.
Since 2021, Title V has subawarded funds to Local Health Departments and community-based organizations for Child and Adolescent related Title V priorities. In 2023-2024, there will be three organizations engaged in oral health care service delivery through a Title V subaward. Title V will monitor progress in each community to assess if there are interventions that could be effectively scaled up for expanded reach.
Responses received from the 2023 Public Input Survey support community-based solutions (as currently provided through Title V subawards), and stress that the dearth of dentists statewide that take Medicaid is impacting the care families can access. Sixty percent of the responses to the 2023 Public Input Survey mention Medicaid as a determinant of health for children in need of oral health care services. One respondent wrote, “For Nebraskans with Medicaid, there are long wait times for oral health care leading to worsening oral health conditions and to an increase in the financial burden associated with the treatment of these conditions.” Another respondent wrote, “More needs to be done to address the lack of providers willing to take Medicaid related to reimbursement rates and timing – the infrastructure is there already, rather than increase new supports and programs, fund the ones that are there.” In response, Title V and the Office of Oral Health Dentistry will explore partnerships with Medicaid in 2023-2024.
- Alignment of planned activities with annual needs assessment updates
Priority: Child Abuse Prevention
Stakeholders in the 2020 Needs Assessment recognized not only the problem of child abuse, but the opportunities for prevention services embodied in the Family First Prevention Services Act, the collaborative Bring Up Nebraska effort, and evidence-based home visiting such as the Healthy Families America programs funded by N-MIECHV. Stakeholders advocated for universal home visiting services for all families, and in general increased family supports help children.
Alignment: Planned activities for 2023-2024 are aligned with the needs assessment findings and recommendations of stakeholders. Title V will continue collaborative relations with state and systems-level partners to support infrastructure development for expanding home visiting services statewide through N-MIECHV. The considerable interest among child advocates in the state as to data showing disparities (by race/ethnicity, gender, and/or geographic status) in child welfare involvement of families has been leveraged for continued efforts to reduce rates of child abuse/neglect.
There are no new findings to update the needs assessment in this priority area.
Priority: Access to Preventive Oral Health Care Services
When stakeholders selected this priority in 2020, they were well-aware that dental health issues are among the most chronic health problems for children. The Office of Oral Health at DHHS is an active partner with Title V in needs assessment activities. Stakeholders particularly pointed to the preservation, if not expansion, of public health dental services, particularly those available to children at school, and to low-income families, pointing to existing disparity between urban and rural access to dental services for children.
Alignment: Activities proposed for 2023-2024 are consistent with findings and recommendations of the Needs Assessment. The distribution of dental kits is a measure of reach in the population. There are no new findings to update the needs assessment in this priority area.
- Emerging new priorities taking precedence over the established priority needs
Mental and Behavioral Needs of Families and Children, with and without special health care needs
As discussed in other areas of this application, Title V, along with stakeholders and advocates statewide, are acutely aware of the many ways mental health issues are manifest in all MCH populations in Nebraska. The combination of social and health vulnerabilities existing prior to the onset of the pandemic with continued stressors felt by not only pandemic-related effects but additional challenges such as rising inflation have meant little relief for Nebraska families.
Title V MCH sees there is a role for the block grant to be a committed and invested asset for the state to meet these needs particularly focusing on the most disadvantaged and disproportionately affected families. This work does not displace the established priority needs, however, are noted as they will involve Title V MCH in the Child Health Domain in the coming year. Of note, during the public input process, this view was echoed by a Nebraska respondent, saying, “Not enough. You are forgetting the needs of parents of children with special health care needs/disabilities who have a high level of stress, and lack the respite needed in order to take a break and take care of themselves so they can care for their children.”
- Relevance of ESM to selected NPM, changes in ESM
Priority: Access to Preventive Oral Health Care Services
NPM: Percent of children ages 1-17 years with a preventive dental visit in the past year.
ESM: The percentage of children in the Open Mouth survey from rural and underserved communities (new)
In April 2021, Nebraska was provided with the ESM Report from MCH Evidence Center for the state. The MCH Evidence Center assesses ESMs aligned to NPMs for the degree to which they are supported by evidence, and through the lens of Results-based Accountability. For the Child Health Domain, the number of sites participating in the dental kit project aligns with the Emerging MCH Best Practice strategy of Caregiver/Parent Education/Counseling. The ESM is an effective measure of reach, which could be strengthened by using a denominator (total # of relevant group addressed) to show percentage.
In addition to assigning ESM to at least one Priority in each Population Domain, corresponding to a selected NPM, Nebraska Title V uses Results-based Accountability Measures. Since 2015, Nebraska Title V has been writing and utilizing Results-base Accountability (RBA) measures to make annual impacts and achievements more discernable to front line staff and stakeholders. In addition, use of RBA often highlights inclusion and equity-focused efforts that have been transforming Title V work.
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Results Based Accountability (RBA) measures Priority: Child Abuse Prevention |
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Proposed for 2023-2024 |
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How much did we do? |
Strategy CH4a (1): How many new N-MIECHV families could local implementing agencies serve by Sept 2024 compared to May 2023?
Strategy CH4a (2): How many communities have Community Collaboratives supporting Community Response? |
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How well did we do it? |
Strategy CH4a (1): How many new local implementing agencies were trained and had capacity to serve home visiting clients by Sept 2024?
Strategy CH4a (1): How did communities with new N-MIECHV programs provide additional support for prevention and early identification/intervention strategies?
Strategy CH4a (2): Are ongoing initiatives assessing their impact on racial disparities in alleged and substantiated child abuse reports?
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Is anyone better off? |
Strategy CH4a (1): How many new N-MIECHV families did local implementing agencies serve by Sept 2024 compared to May 2023?
Strategy CH4a (2): How many people were served by Community Response and Alternative Response?
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Results Based Accountability (RBA) measures Priority: Access to Preventive Oral Health Care Services |
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Proposed for 2023-2024 |
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Strategy CH5a (1): How many dental kits were distributed?
Strategy CH5a (1): How many organizations are participating in distribution activities?
Strategy CH5a (2): How many partners received the results of the Oral Health survey? |
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How well did we do it? |
Strategy CH5a (1): Who received the dental kits? Did we partner with organizations that can reach the families who need it the most?
Strategy CH5a (2): What results came from the Oral Health survey data analysis? |
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Is anyone better off? |
Strategy CH5a (2): How do the findings of the Oral Health survey compare with the results of the previous study? |
- Are changes needed in the established SPMs and SOMs, if applicable
Priority: Child Abuse Prevention
SPM: The rate of substantiated reports of child abuse and neglect per 1,000 children ages 1-9 years
ESM: None
The SPM is aligned with the Priority, and further is copied almost exactly from the Issue Brief drafted by stakeholders during the Title V Needs Assessment. Stakeholders also expressed concern with perceived disproportionality reflected in child welfare cases, with minority families suspected to be disproportionately reported, and investigated, by child welfare authorities. Additional strategies in this area should include an equity lens to comprehensively address Child Abuse Prevention.
- Updates or changes to the Five-Year Action Plan Table
The effort to describe a five-year trajectory of planned and proposed activities is a new approach for Nebraska. The goal is to provide stakeholders regular information on the efforts of Title V in relation to Priority Statements, Objectives, and Strategies that is readily accessible and even engaging. A synopsis of the five-year action plans for this domain is shown in the tables below.
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Priority: Child Abuse Prevention 5-year Action Plan, 2020-2025 |
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Period |
Summary activities of the period |
Status 7/2023 |
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Year 1 |
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Year 2 |
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Year 3 |
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Year 4 |
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Year 5 |
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In the priority area of Child Abuse Prevention, with the data review complete the new strategy is to further evaluate the preventive model in NE and its ability to support vulnerable families. This work will be significantly enhanced if the submitted grant application is funded.
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Priority: Access to Preventive Oral Health Care Services 5-year Action Plan, 2020-2025 |
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Period |
Summary activities of the period |
Status 7/2023 |
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Year 1 |
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Year 2 |
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Year 3 |
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Year 4 |
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Year 5 |
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In the priority area of Access to Preventive Oral Health Care Services, the strategy to translate materials into other languages was completed. The Office of Oral Health determined there was not sufficient need to translate materials beyond English and Spanish.
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