For the 2022 application year, the Guam Title V Program children’s health will strengthen emotional, physical, and social services to achieve equitable and optimal development for children in Guam. Key activities include the early identification and treatment of developmental delays and improving access to high-quality preventive health services, including oral health services.  

Guam’s plan to address Oral Health will be to distribute the Bright Futures Pocket Guide, a resource for all health professionals (medical and dental) that discusses oral health and dental care aspects for pregnant and post-partum women and infants, children, and adolescents. The guide highlights the need for early dental visits (within 6 months of the eruption of the first tooth and no later than age 12 months) and aspects for subsequent dental visits, assessment of caries risk, education on factors to reduce risk of early childhood caries, appropriate oral health interview questions, and anticipatory guidance/education at each stage for the above populations. The pocket guide information supports provider referral or provision of appropriate preventive dental services.

Providing comprehensive care that improves mother and child's overall health and well-being is MCH’s greatest objective. Oral health is a vital component in meeting this objective. Largely preventable, tooth decay remains the most common chronic disease of children aged 6 to 11 and adolescents aged 12 to 19.  Children with poor oral health may experience difficulties with learning, poor school attendance, or have problems with creating socialization skills. They may also be more likely to have more significant adult health problems than those adult health problems than those with better childhood oral health experiences.

Medicaid covers dental services for all enrolled children as part of a comprehensive set of benefits referred to as the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. States submit annual reports to CMS describing the percentage of children enrolled in Medicaid, their eligibility for the EPSDT benefit, and the various health and oral health services received during the year.

Form CMS-416: Annual EPSDT Participation Report is a database that tracks the number of individuals eligible for EPSDT, the expected number of screenings, the total screens conducted, and the number receiving services or treatment as a result of screening. Unfortunately, the EPSDT dataset has a significant limitation in that the data track healthcare visits and use that indicator as a proxy for actual screenings. Guam Title V will continue to work with the EPDST to provide data on oral health visits.

Like many states, Guam also has a shortage of providers willing to treat Medicaid clients. Moreover, Guam does not have a school of dentistry. Only programs for dental hygienists and dental assistants are available in the states.

The Guam Web IZ tracks children island-wide from birth to age eighteen, as reported by providers enrolled in the Guam Vaccine for Children Program. Guam Web IZ captures vaccines throughout the lifespan. Guam Web IZ enables providers to report electronically, reducing data entry and enabling Guam Web IZ to capture timely data on children up through age eighteen and beyond.

Pediatric outpatient visits and routine childhood vaccination have declined substantially during the COVID-19 pandemic, leaving children and communities at risk for outbreaks of vaccine-preventable diseases. With the decrease in childhood immunizations, Guam has established a new State Performance Measure “By 2025, increase the percentage of all children 19 to 36 months of age who have completed recommended vaccines to 90%”.

In FY 22, Guam will monitor vaccination rates closely and work with partners on outreach and sharing of best practices to increase vaccination rates. The Guam Immunization Program has supported providers to remind parents that vaccinations are safe and important; Posting on the DPHSS social media sites to promote vaccine catch up; Continuing to onboard providers with Guam Web IZ; Sharing AAP and CDC messaging/webinars/resources on routine catch up; and having an Immunization Workgroup of various stakeholder discussing opportunities to reach parents where they are, reminding parents to take kids to the pediatrician, and providing immunizations in non-clinical settings to catch up children on routine immunizations. The Guam MCH Program is a member of the Immunization Workgroup and will continue collaborating with the Guam Immunization Program to promote timely vaccinations.

Program Bisita, Guam’s home visiting program, will continue to support NPM 6 (percent of children, ages 9 through 35 months, who received a developmental screening using a parent-completed screening tool in the past year).  The strategies implemented will provide support and ongoing professional development of Ages & Stages Questionnaire (ASQ) trainers to ensure a trained workforce and support families involved in the home visiting program to complete a developmental screening

Guam MCH will continue participating in the Guam Early Learning Council and leverage all existing screening and follow-up efforts to coordinate and align public health with early learning systems.  The purpose of this work is to align strategies to ensure that each child’s needs are identified, referrals to needed services are made and completed, services are not duplicated, and the messages that families hear are clear, aligned, and consistently reinforced to ensure that children and their families thrive.

The Guam Title V Program will work with staff from EPDST on 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.

In FFY 2022, BFHNS will continue to serve as the lead agency for MIECHV, offering no-cost, voluntary family support and coaching services to improve the health and well-being of pregnant women and parenting families with young children. In Guam, the MIECHV program includes two nationally recognized, evidence-based home visiting models—Healthy Families America (HFA) and Parents as Teachers (PAT).  Families are matched with registered nurses or parent educators who provide personalized education, guidance, and support to meet each family’s individual needs and empower them to reach their goals.

In both the HFA and PAT models, the home visitors provide health and developmental screenings for children, maternal mental health screenings, assistance with goal setting and life skills development, parenting guidance on a variety of topics, and connections to resources that help families meet their needs and reach their goals.

Implement agency-wide early childhood system (ECS) strategy: A core strategy to address both population priority needs is to support developing and implementing a shared, agency-wide early childhood agenda for a comprehensive early childhood system. Over the past several years, staff from various offices across Guam have been working together to coordinate efforts on shared priorities around young children’s development, particularly social, emotional development, and mental health. The vision of the comprehensive ECS Strategy is that children and families will be able to access locally available, coordinated, and comprehensive support across systems, spanning the full spectrum of early childhood social, emotional, and behavioral health, from wellness promotion to targeted prevention to treatment.

Early Childhood Integrated Data System: An ongoing, 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. Primary care providers, early care and education providers, and early intervention providers serve the same young children differently. Still, they lack a standardized way to share information about the screening, referral, and intervention process. Without infrastructure for sharing information, children may fail to receive services they need, they may receive duplicative services from different providers, and families struggle to navigate the system. Implementing such a tracking 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 Guam Early Learning Council also implemented a 311-information hotline to be promoted by the members. The Neni (Chamorro for baby) 311 hotline is a centralized telephone access point to connect families with children to services and support for developmental, behavioral, and/or learning challenges. The Neni Directory lists all resources for Health, Family Support, and Education available for families and children birth through age 8. Pre-COVID-19, the NENI 3-1-1 warm line provided a mechanism for parents and caregivers to call for information on developmental screening, referrals for early childhood services, and family supports. Since the COVID-19 global pandemic began, the 311 line was used to provide information related to the coronavirus. The Guam PDG B-5 staff has been working with the Governor’s Office to include an option for families to call for information related to child development and -resources to support growth and learning.

Families need to know the importance of early care and education for young children and how it impacts school readiness. The lack of available programs to service the birth to three population impacts school readiness for children. Coupled with the lack of birth to three programs is the lack of online access for all early childhood programs and supports, especially access to appointments to avail services. The COVID-19 global pandemic has exacerbated the long wait times and/or inability to schedule appointments to get information about said services. For example, families who qualify for childcare subsidies must take leave from work or school to submit proof of eligibility monthly continually. The time off from work may result in lost wages for the parent.

While the ECCE programs have had a long-standing history of working collaboratively, there are still significant gaps in providing services and supports to children and families. The DPHSS has many programs under the Divisions of Public Health and Public Welfare that provide services and supports to children birth to five years and their families. There is a big disconnect among these programs. Improvements in awareness and communication would enable better collaboration within DPHSS. Eligibility for services from DPHSS programs should be streamlined and expanded to include all services available to families rather than having families go from one place to the next to avail of services they need. Stakeholders feel that when families apply for specific services and/or public assistance programs, they are also informed of other services for which they are eligible. For example, if a family applies for SNAP, they are also provided information about TANF, CCDF, WIC, etc.

While there are many programs and services available in Guam, there is still the issue of access and equity of services for our most vulnerable and underserved/underrepresented populations. One of the most significant systemic barriers to be examined is how information is disseminated to reach vulnerable populations.

Many programs do provide information and resources that have been translated into other languages. However, a vast majority of resources are not accessible to families because they are only available in English. Interpreters and translators are available and/or accessible in some programs, but not always for all languages.

Homeless families have the least access to services and supports. With no address or a reliable mode of communication, homeless families encounter missed opportunities for their children. Programs such as Project Bisita have attempted to provide home visiting services to homeless families but are often unable to locate these families after a few visits. Other vulnerable populations such as the FAS/FSM and Russian families also miss available services because the information is not easily accessible in their languages.

Children who are currently wards of the state and under the care of Child Protective Services housed in group care homes are not eligible for childcare subsidies. Since the same law governs group care homes also manages the center-based facilities, these children cannot be placed in center-based facilities because of how the Guam law is written. Changes will need to be made to the current law to make an exception for wards of the state.

Policies need to be developed to ensure that children with disabilities are not denied access to any services, including but not limited to childcare and other services and supports available to typically developing children. Parents have shared that they have been asked to leave or have been turned away from childcare centers because their child’s needs sometimes require one-on-one assistance. Childcare providers also need training programs to learn how to assist and support children with special needs. These providers also need to work more collaboratively with early childhood service providers and programs to identify children with special needs and provide intervention services.

Early childhood providers have voiced the need for training to support social, emotional wellness for themselves and the children for whom they care. They have also requested training on trauma-informed care and ongoing coaching and mentoring as the strategies are implemented.

Foster families lack a one-stop center for information and application of services for their foster children. The processes need to be streamlined as they must go to multiple places to ensure they receive the services and supports for their foster children.

The COVID-19 pandemic has magnified many of the issues parents, and caregivers face around receiving inadequate support. Many have lost their jobs or have been furloughed due to the closure of businesses, adding significant financial stressors to their plate. Others have had to significantly cut hours or quit their jobs to care for their children on a day-to-day basis. In addition to the multiple roles they filled before the pandemic, many parents/caregivers have had to take on the role of at-home educator or child care provider. Many formal and informal supports that families had before the pandemic were no longer accessible in the new era of physical distancing – leading to even greater feelings of isolation among parents and caregivers. For parents and caregivers of CYSHN, the pandemic has only magnified the lack of support and isolation that many were feeling.

Parents need a network of supportive relationships, strategies for coping with stress, resources, knowledge, and understanding child development. Unfortunately, a lack of these critical supports can cause otherwise well-intentioned parents to become overwhelmed and at times result in abuse or neglect. Parents and caregivers who have resources and support are more likely to provide safe and healthy homes for their children and families and reduce the need for out-of-home placement following confirmed instances of abuse or neglect.