NPM 6: Percent of children, ages 9 through 71 months, receiving a developmental screening using a parent-completed screening tool

 

Each of Iowa’s 23 Title V Child and Adolescent Health (CAH) contract agencies are approved Medicaid Screening Centers. They are enrolled with the IME and two MCOs operating in Iowa are (Amerigroup and Iowa Total Care). Developmental screenings and emotional/behavioral assessments are provided by CAH agencies using the ASQ and ASQ:SE tools. Contract agencies are able to receive payment from the IME for services provided for Medicaid fee‐for‐service clients and from the Medicaid MCO for children enrolled in an MCO.

 

The FFY 2021 Request for Application will require all CAH applicants to continue to develop plans to address NPM #6. Agencies will continue coordinating developmental screening with local providers such as child care providers, home visiting programs, and primary care practitioners to assess need, assure access, and avoid duplication; collaborating with early care and education providers that encourage developmental screening; and educating families on the importance of developmental screening at recommended age intervals. Moreover, IDPH will contract with an outside entity to do a state-wide environmental scan to assure coordination of the provision of developmental screens and social/emotional assessments. It will assist in identifying where screening/assessment occurs and the tools used within the following environments: child care providers, home-visiting programs, primary care providers, CCNC, ECI, MIECHV and Head Start.

 

Agencies will continue to educate parents on their child’s developmental milestones and promote and utilize the toll-free central referral line and/or website for the Iowa Support Network (www.iafamilysupportnetwork.org) to provide resources to  parents. Promoting developmental screening will continue to be a part of the age‐specific informing scripts. Agencies will ensure that age appropriate developmental screening is provided by trained staff, results are communicated with primary care practitioners, and related education and follow‐up services are provided.

 

In FFY2021, Title V agencies will be asked to engage with the Children’s Behavioral Health Coordinator in their  Children’s Mental Health System Region in system building to advance universal, periodic behavioral health screening and assessments, education, prevention and access to mental health consultation services in collaboration with the Children’s Mental Health Systems Region covering all counties their service area. Detecting early signs of mental health conditions in children, will circumvent issues later.  If children can be referred to mental health professionals (counselors, therapists, psychologists, etc) earlier in life, long-term benefits will result.

 

Title V agencies will also be asked to write to one of the priority populations in the FFY 2021 RFA. This includes- African Americans/Black American, Alaska Native/Native Americans, Asian/Pacific Islanders, Fathers, Hispanic/Latinx, Immigrants/Refugees, LGBTQ+ and Persons with Disabilities.  Other populations may be addressed in addition to the priority populations, based on the service area (e.g. Amish, families involved with the correctional system, children in foster care).  This includes building partnerships with alliances who support one or all of these priority populations.  It can include joining the Refugee and Immigrant Alliance in a local community, educating and training local public health staff on annual cultural competency training that serves one of these populations.

 

Partnerships will continue with 1st Five, early care and education programs, home visiting (MIECHV), family support and CHSC to promote developmental screening. BFH monthly meetings with Iowa Medicaid staff provided an avenue to discuss contracting, coding, and billing issues pertaining to developmental services.

 

BFH staff continue to meet with MIECHV program staff to discuss opportunities for collaboration including coordination of developmental screening promoted by CAH, 1st Five, and home visiting programs and the need to avoid duplication. Since 2015, BFH staff have participated on a state-wide (stakeholder) Leadership Team coordinated by Iowa Children’s Justice to address the impact of substance use/abuse on pregnant women, infants, and children. Promoting children’s healthy growth and development is an inherent component of this work. Aggregated data reports of results of ASQ and ASQ:SE screening provided by Title V CAH contract agencies have been of particular interest to this workgroup.

 

At the state level, IDPH will continue to provide technical assistance where needed particularly to agencies (providing direct services) who will be providing ongoing developing screening (ASQ) and emotional /behavioral assessments (ASQ-SE) to infants and toddlers ages 0-3 years found not be eligible for Early ACCESS services. The state will continue to enhance our partnership with our other Title V partner (CHSC) Child Health Specialty Clinics from the University of Iowa Stead Family Children’s Hospital; serving those children with special healthcare needs.

 

IDPH will begin exploring more resources for Title V agencies specifically around culturally appropriate developmental screening tools for parents and children of different cultures and backgrounds. In addition, the state will explore the abundant parental apps to assist parents in their child’s development.

 

Title V Child and Adolescent Health (CAH) agencies will continue to reinforce the importance of developmental screening through the informing process for newly enrolled Medicaid families. Bureau of Family Health (BFH) will provide Title V CAH agencies with needed information and resources. Title V CAH agencies will continue to offer gap‐filling developmental screenings (Ages and Stages Questionnaire (ASQ)) and emotional‐behavioral screenings (Ages and Stages Questionnaire: Social‐ Emotional (ASQ:SE)). Some local agencies also administer the Modified Checklist for Autism in Toddlers (M-CHAT) for toddlers between 16 and 30 months of age.

 

Iowa’s 1st Five program engages healthcare providers in supporting the use of developmental surveillance and standardized developmental screening tools. A partnership between providers and 1st Five staff is established for developmental support services (an enhanced form of referral and follow up services). 1st Five is funded through a state appropriation and was built upon Iowa’s Title V infrastructure at the local level.

 

Local 1st Five site coordinators will work on outreach to primary care practices to encourage their consistent and universal use of screening tools. Outreach may include, but is not limited to, newsletters, trainings, and personal contacts through phone, email and meetings. Local 1st Five site coordinators will work with 1st Five Medical Consultants on providing developmental screening trainings to office staff and engaged healthcare partners.

 

Contracts with local 1st Five sites will build on the recent performance measure to increase the percentage of referrals that follow results of a standardized developmental screen.  The measure will continue to tier the expectations so that lower performing sites will need to make greater progress to achieve the measure.

 

1st Five’s IDPH staffing has increased, adding a staff member with more direct experience working with care coordination and services for families.  Through this staffing, technical assistance for local sites will include enhanced assistance with planning, preparation, and skill-building to better prepare local staff for providing developmental support services and documenting services. 1st Five also expects continued improvements and enhancements to training and support for 1st Five site coordinators for their work with primary care practices.

 

NPM 13: B) Percent of infants and children, ages 1 through 17 years, who had a preventive dental visit in the last year

 

I-Smile™ is the oral health component of Iowa’s Title V Maternal, Child, and Adolescent Health (MCAH) program. Staff with the Iowa Department of Public Health’s Bureau of Oral and Health Delivery Systems (OHDS) manages I-Smile™, which includes I-Smile™ @ School (school-based sealant program). I-Smile™ connects children, pregnant women, and families with dental, medical, and community resources to ensure a lifetime of health and wellness. OHDS staff provide oversight and technical assistance for I-Smile™. Each Child and Adolescent Health contractor is required to have a dental hygienist who serves as the local I-Smile™ Coordinator. OHDS and I-Smile™ Coordinators have a strong relationship and strive to improve the oral health of Iowans. I-Smile™ Coordinators must spend at least 20 hours a week on public health services and systems-building and enabling services.

 

OHDS staff use data to determine focus areas within I-Smile™. Data sources include the MCAH data system, Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Dental Services Reports, and oral health screening surveys.  Data is analyzed by the bureau’s epidemiology consultant, who also facilitates quarterly quality assurance reviews of MCAH data with OHDS consultants to identify service gaps, data entry errors, and troubleshoot areas of concerns. Similarly, local I-Smile™ activities are determined using a needs assessment, updated each year using community data and information from the MCAH service area.

 

OHDS staff will hold quarterly I-Smile™ Coordinator trainings, to ensure program consistency, share best practices, develop leadership skills, and promote current standards and procedures. These training often include continuing education on current oral health topics and an open forum for sharing from the I-Smile™ Coordinators. OHDS staff will make a site visit to each contractor to discuss local work plans, review data, and troubleshoot concerns. OHDS staff will also participate in yearly chart audits to ensure documentation of services is accurate and provide technical assistance to each contractor.

 

Assuring good oral health for underserved children and pregnant women relies upon the strength of partnerships, both at the state and local levels. OHDS staff will maintain important partnerships with entities such as WIC and the 5210 project, Head Start, Healthy Child Care Iowa, Delta Dental of Iowa Foundation, Iowa Primary Care Association, Iowa Medicaid Enterprise, and the University of Iowa College of Dentistry. Partnership activities in FY21 will include training of local WIC staff; networking meetings with Head Start health Coordinators; providing support to sealant programs that are not administered by MCAH contractors, to assure maximum benefit for children statewide; and collaborating on oral health promotion campaigns, such as “Rethink Your Drink”. Next year, OHDS plans to work with a new partner, Count the Kicks, to incorporate oral health into its program, which uses best practices and evidence-based strategies to save babies and prevent stillbirths. OHDS staff will provide assistance to Count the Kicks regarding oral health education and resources to keep moms and babies healthy. I-Smile™ Coordinators will work to educate and distribute Count the Kicks educational materials while doing outreach to medical and dental offices.

 

OHDS staff will maintain strong partnerships with Iowa Medicaid Enterprises (IME) and the Dental Prepaid Pre-Ambulatory Health Plan (PAHP) carriers for Medicaid in Iowa – Delta Dental of Iowa and Managed Care of North America. Partners are discussing the potential for children to be covered by PAHP in the future and strategizing how to work together for the health of Iowa Medicaid members.

 

OHDS staff also facilitate advisory workgroups for I-Smile™ @ School and community water fluoridation (CWF). In addition to partners already mentioned, workgroup members include: Iowa State Education Association, Iowa School Nurse Organization, Iowa Department of Education, local MCAH contractor staff, American Water Works Association, Iowa Department of Natural Resources, Iowa Public Health Association, Iowa State Hygienic Lab, and Iowa Association of Water Agencies. Another important collaboration is Cavity Free Iowa, a workgroup focused on increasing training for medical office staff to apply fluoride varnish for children at well-child exams. Trainings are provided by I-Smile™ coordinators.

 

I-Smile™ Coordinators are also responsible for maintaining local partnerships. In FY21, I-Smile™ Coordinators are required to develop at least one new local partnership as well as improving and expanding partnerships with a minimum of four existing partners to benefit families served through I-Smile™. I-Smile™ Coordinators are holding medical/dental summits and facilitating and creating local coalitions to educate communities about oral health. Next year, I-Smile™ Coordinators will make face-to-face outreach visits with all general and pediatric dental offices within their service areas, outreach visits to family practice medical offices and/or pediatric medical offices, provide trainings for medical office staff as requested, and conduct oral health promotion at community events.

 

I-Smile™ Coordinators will train MCAH staff about oral health, ensuring staff is competent regarding oral health as it pertains to the informing process and care coordination; about oral health in accordance with the EPSDT periodicity schedule; and about proper techniques for direct preventive dental services (e.g., screenings, fluoride applications) and most current guidance for oral health education and anticipatory guidance. OHDS will maintain its stock of promotional materials that can be used for new moms as part of outreach to hospitals as well as for children and families. The I-Smile™ Facebook page will target parents/guardians with information and education about good oral health for children as well as during pregnancy.

 

I-Smile™ Coordinators will work with MCAH staff to continue focus on referrals to dentists and improved access to resources that address social determinants of health through individualized care coordination for those who need it. OHDS staff will offer technical assistance to MCAH contractors regarding best practices for providing care coordination. An online training is available for all local MCAH staff who provide care coordination, including information about proper documentation requirements. OHDS staff will work with Bureau of Family Health staff to assure proper documentation within the MCAH data system by completing service note review and working with Iowa Medicaid Enterprise to assure funding for dental care coordination is continued. In addition, the 2019 oral health survey of children at WIC found that children of minority racial groups are more likely to experience decay but not restorative dental treatment. OHDS staff are identifying outreach and care coordination plans to use with MCAH contractors that will help ensure minority populations receive the care needed.

 

Access to dentists for Iowa’s Medicaid-enrolled and under/uninsured families continues to be difficult. In 2019, 1,842 fewer Medicaid-enrolled children received care from a dentist than in 2018, demonstrating the need for MCAH contractors to continue to provide gap-filling preventive services. In FY21, dental hygienists and registered nurses will provide gap filling preventive services, such as dental screenings and fluoride varnish treatments at WIC clinics. Dental hygienists will also provide services as needed at child care centers, Head Start centers, and preschools. Dental hygienists will offer dental screenings, fluoride varnish applications, individual and classroom oral health education, and sealants to children in elementary schools with 40% or greater free/reduced lunch rates through the I-Smile™ @ School program. Oral health screenings are made available to maternal health clients during WIC clinics, and every client receives oral health education. Referrals and care coordination are provided as needed, following provision of all services.

 

As part of a HRSA oral health workforce grant, OHDS staff will work with I-Smile™ Coordinators to incorporate silver diamine fluoride applications for children within preventive services offered at WIC. When applied to tooth decay, silver diamine fluoride stops the decay process. In addition to reducing bacterial infection, use of silver diamine fluoride stops cavities from getting larger and can sometimes prevent the need for a restoration. Another component of the HRSA workforce grant is to work with I-Smile™ Coordinators to facilitate community-driven approaches to recruit dentists to towns that may be experiencing or will soon experience a shortage of dentists.

 

The full impact of the COVID-19 pandemic on the I-Smile™ program is not yet known. OHDS staff anticipate changes to infection control requirements for dental services in the future and have also heard that more dental offices have already declined accepting any Medicaid referrals due to upcoming anticipated backlog of dental care.

 

SPM 2:  Percent of children ages 1 and 2, with a blood lead test in the past year

Historically, the Childhood Lead Poisoning Prevention Program (CLPPP) has measured testing rates by birth cohort at 0-6 years. Through a collaboration between Title V and CLPPP through involvement in the Maternal and Child Environmental Health Lead Poisoning Prevention Collaboration Innovation and Implementation Network (CoIIN), Title V and CLPPP have been sharing more annual testing rates per age.  Birth cohort information is typically close to 100% giving providers and stakeholders a false/inflated sense of testing. While most children will have a test by the time they are 6 years old, that does not mean they are being tested per recommendations. Annual testing rates per age really highlighted for Title V, the CLPPP, providers and stakeholders that Iowa is not testing children at two years of age as recommended and when they may be most at risk to exposure, developmentally.

With the state prioritizing blood lead testing of one and two year olds, increasing publicity of the need and partnerships with primary care providers, the rate should go up.  The CLPPP goal for blood lead testing of one and two year olds is 75%.  The goal is to maintain the current rate for one year olds at 78%, but to steadily increase the rate for two year olds over the next five years.

Some contributing factors to the current rate from surveying and meeting with primary care providers are the belief that a low test at one year of age is predictive of future tests being low, and hesitancy to test if parent states a test has already been done.

 

Each of Iowa’s 23 Title V Child and Adolescent Health (CAH) contract agencies are approved Medicaid Screening Centers. Blood Lead testing is an approved gap-filling Screening Center activity.  Contractors with counties that do not meet the goal for testing one year olds (75%) or with counties below the state average for number of two year olds tested (40%) will be required to provide testing for one and/or two year olds in the counties with low testing rates.

 

The FFY 2021 Request for Application will require all CAH contractors to develop plans to address SPM #2. Contractors will coordinate blood lead screening with primary care providers, local public health agencies, local CLPPPs and others providing blood lead testing in the community. CAH contractors will be conducting a environmental scans to assure coordination of the provision of blood lead testing to identify if and where the contractor should provide gap-filling screening and at what ages.

 

Contractors will educate parents on the importance of blood lead testing at appropriate intervals. Contractors providing blood lead testing must provide related education, anticipatory guidance and follow-up. Follow blood lead testing guidelines established by the IDPH Childhood Lead Poisoning Prevention Program. Provide results of all blood lead tests to the primary care provider, regardless of results. Provide all results to the IDPH Childhood Lead Poisoning Prevention Program.

 

Title V contractors are encouraged to partner with an agency or group serving one of the priority populations to promote blood lead testing in more culturally targeted ways. This includes: African Americans/Black/African, Alaska Native/Native Americans, Asian/Pacific Islanders, Fathers, Hispanic/Latinx, immigrants/Refugees, LGBTQ+ and Persons with Disabilities.  Other populations may be addressed in addition to the priority populations, based on the service area (e.g. Amish, families involved with the correctional system, children in foster care).

IDPH will provide training and resources to Title V agencies on blood lead testing guidelines, CLPPP and strategies for engaging health care providers and families. The Department has updated lead testing brochures and website information with 69,000 brochures being printed to support the new agency work FFY2021.

 

The Department will work with the University of Iowa through the EPSDT Training contract on a lead poisoning prevention initiative for increasing EPSDT lead screening compliance in response to the federal report on lack of testing in the Medicaid population in Iowa. This will include an EPSDT Newsletter article that is distributed to all primary care providers enrolled in Iowa Medicaid.

 

The Department will begin looking into priority population specific strategies for promoting lead testing, and family education. Additional strategies will be explored for assuring racial and ethnic demographic information is included in testing reporting from LPHAs, providers, and labs.

 

The Department will support the ongoing collaboration and coordination of programming between Title V and the Childhood Lead Poisoning Prevention Program. Department staff and local contractor participation in the Childhood Lead Advisory Workgroup. Department will support the signifyCommunity data feed of HHLPPSS lead testing data.

 

Title V staff will collaborate with different state programs and agencies to obtain increased access to data sources and strengthen partnerships to increase data sharing.

 

Title V staff will work collaboratively with Iowa Medicaid Enterprise and private insurers to promote appropriate reimbursement for blood lead screening for Child Health Screening Centers.

 

 

SPM 3:  Percent of early care and education programs that receive Child Care Nurse                                                                                                                                               Consultant services

 

Child Care Nurse Consultant (CCNC) services focus on health and safety in the early care and education (ECE) environment. In FY19, 96 out of the 99 counties in Iowa had access to local CCNC services with a 2% increase in the number of ECE programs receiving services. CCNC services are non-regulated and are optional for ECE providers in Iowa’s Quality Rating System (QRS). Often licensed centers request CCNC services for onsite health and safety visits, policy development and care planning for children with special health needs. Many home providers do not request CCNC services. In Iowa, approximately 30% of ECE providers participate in QRS and both homes and centers request CCNC services when applying for QRS levels 3, 4 and 5. This past year Iowa saw an increase in the number of ECE providers participating in QRS however the largest increase was in the number of providers entering the QRS system at a level 1 or 2. There was also an increase in the number of centers moving up in QRS levels 4 and 5; however, these centers would have probably already been receiving CCNC services for other requests.

 

Iowa will continue to see an increase in the number of ECE programs receiving CCNC services as statewide coverage is achieved, as CCNCs prioritize outreaching to home providers, and when Iowa’s new quality rating system (Iowa Quality For Kids - IQ4K) is released.  IQ4K will have a continuous quality improvement approach incorporating a focus on health and safety as well as medication administration.  CCNC services will be a requirement for both homes and centers in IQ4K starting at a level 2.

 

HCCI State staff will continue to help in the development of partnerships between Title V Child Health agencies and CCNC programs by providing annual local and statewide CCNC performance measure data to partners, outreaching to agencies with no or limited CCNC coverage and by facilitating meetings with local agencies and other local stakeholders (including Early Childhood Iowa areas) for statewide expansion of local CCNC services.

 

HCCI State staff will provide annual updates on CCNC services, performance measure data, and information on child care health/nurse consultation nationally and impact on quality child care to state Early Childhood Iowa (ECI) and DHS. HCCI will continue to collaborate with state ECI Professional Development and DHS for support of CCNC services. 

 

HCCI State staff will provide quarterly training to CCNCs on performance measure data collection. Data collection tools will be provided to CCNC agencies by HCCI for consistent/reliable collection and reporting.

 

CCNC agencies will be evaluated by State HCCI staff for program fidelity including a review of child care provider outreach activities, performance measure data collection methods, comparison of local data with statewide averages, and local partnerships/collaboration. HCCI CCNC TA Team will conduct annual fidelity visits with local CCNCs utilizing the Health and Safety Checklist assessment tool. Fidelity with the tool will be at 90% or higher.

 

Annual HCCI CCNC Program presentation by HCCI State staff to Early Childhood Iowa Area Directors. HCCI CCNC program updates will be included in MCAH regional meetings with an annual program overview including CCNC statewide performance data with Title V Child Health agencies.

 

SPM 5:  Percent of children 0-35 Months who have had fluoride varnish during a well visit with Physician/health care provider

 

Children are recommended to see a dentist before their first birthday. However, many dentists are not comfortable seeing children this young. Cavity Free Iowa is an initiative focused on increasing the number of children who receive preventive fluoride varnish at well-child medical appointments and dental referral. In 2019, 61% more Medicaid-enrolled children ages 0-3 years received a fluoride varnish application from a medical provider than in 2018. As more medical offices participate around the state, the number of children receiving fluoride varnish is expected to increase over the next 5 years and the National Outcome Measure (decay experience) to decline.

 

Tooth decay is the most common chronic disease in children, five time more common than asthma. Left untreated, children with active tooth decay may experience mouth pain, difficulty learning and concentrating, impaired eating leading to growth delays, and delayed speech development. Children see a physician up to 11 times by their third birthday, yet in 2018 only one in five children saw a dentist before turning 3. Recognizing the need to prevent dental disease, Iowa’s Medicaid program adopted a policy several years ago to reimburse physicians for application of topical fluoride varnish during well-child visits for children up to 36 months of age. And although I-Smile™ Coordinators have provided trainings for medical offices for many years on how to apply the fluoride, very few offices have incorporated the service as part of routine care. 

 

In 2017, the American Academy of Pediatrics /Bright Futures added fluoride varnish applications to their recommendations for all well child visits from age 6 months to 5 years.  In response, Iowa’s Early, Periodic, Screening, Diagnosis and Treatment (EPSDT) periodicity schedule was updated to reflect that change. A central Iowa pediatrician noticed the change in the periodicity schedule and began investigating how to incorporate use of fluoride varnish into his practice. The result became a collaboration between the Iowa Department of Public Health’s Bureau of Oral and Health Delivery Systems (OHDS), Delta Dental of Iowa Foundation, local I-Smile™ Coordinators, Medicaid, hospitals, dental clinics, and the interested pediatrician known today as Cavity Free Iowa (CFI). CFI is an initiative focused on increasing the number of children ages 0-35 months receiving preventive fluoride varnish applications in the primary care setting. Currently Medicaid-enrolled children have an easier time finding a primary care physician than a dentist that accepts their insurance.  Since low income children are more likely to suffer from dental decease, this initiative serves to improve this health disparity.  Initial implementation was in the Des Moines area and the project has expanded to target medical offices statewide. Thirty-two of Iowa’s 99 counties have medical practices participating in CFI.

 

Much of the success of CFI can be attributed to the pediatrician who has become a champion for the cause. Another key factor to the success of CFI has been the work of I-Smile™ Coordinators (working for Maternal, Child, and Adolescent Health contractors) who have provided trainings and follow up for medical office staff. In 2019, 61% more Medicaid-enrolled Iowa children (904) received a fluoride application from a physician’s office than in 2018 (562), likely due to the efforts of Cavity Free Iowa.

 

During FY21, I-Smile™ Coordinators are required to visit all pediatric medical offices to promote the age one dental visit; offer training on oral screenings and fluoride varnish applications; and provide oral health educational and promotional materials. (Coordinators will make visits to all family practice medical offices in counties with no pediatrician.) I-Smile™ Coordinators will provide onsite training (developed by OHDS staff) for offices interested in becoming a “Cavity Free Iowa” participant and assist with referrals to local dentists for care. OHDS staff is researching options to offer continuing education credits for medical staff who participate in the fluoride varnish training. 

 

OHDS staff will continue to facilitate quarterly Cavity Free Iowa workgroup meetings, bringing medical and dental stakeholders together to discuss how to grow the initiative and address barriers. In 2020, OHDS mailed letters to pediatric and general dentists describing Cavity Free Iowa, seeking the interest of dentists to accept referrals from local physicians and to refer children to a physician if they do not have one already. The letter also sought dentists to join the Cavity Free Iowa initiative. Similar letters will be mailed to pediatric and family practice physicians. Partnerships with workgroup members will continue in FY21 to leverage contributions. For example, Delta Dental of Iowa Foundation brings experience in public relations and marketing and provides commemorative plaques and training certificates for medical offices trained by I-Smile™ Coordinators. OHDS staff will work with Medicaid’s Dental Program Manager to assure reimbursement to medical offices and troubleshoot any billing issues.

 

OHDS staff will provide technical assistance for I-Smile™ Coordinators regarding planning of local medical-dental collaboration events. Two events are being planned by I-Smile™ Coordinators for Fall 2020 in eastern and central Iowa. OHDS staff and I-Smile™ Coordinators will also look at how to use local and state coalitions to enhance how oral health can be integrated within medical practice for the benefit of children and women of child-bearing age.

 

It is difficult to know how or if the COVID-19 pandemic will impact outreach visits to medical and dental offices and trainings for medical providers. During Spring of 2020, medical offices in Iowa have continued providing well-child visits, while dental offices have only been available for emergencies. This is an example of prime example of how young children may still obtain preventive dental care, even in a health crisis.