CHILD DOMAIN

Nebraska Application for the 2020-2021 Year

 

In this section, Nebraska MCH Title V describes activities of the upcoming year, October 1, 2020 to September 30, 2021 for the Child Domain.  Also discussed is the relevance of the activities and ESMs to priorities, as well as any updates in the priorities, evidence-based or evidence informed strategies, and performance measures. The numerical sequence of headings used below references the narrative format found on pages 35-36 of the Title V MCH Services Block Grant to States Program: Guidance and Forms for the Title V Application/Annual Report, Eighth Edition.

As a result of the 2020 MCH Needs Assessment, the Nebraska Priorities in the Child Health Domain are:

 

• Child Abuse Prevention.

SPM: The rate of substantiated reports of child abuse and neglect per 1,000 children age 1-9 years.

 

• Access to Preventive Oral Healthcare Services.

NPM: Percent of children age 1-17 years with a preventive dental visit in the past year.

ESM: The number of sites participating in the Nebraska Early Dental Health Starter kits program.

 

1. Description of Planned Activities

Overview of this domain:

Stakeholders and advocates prioritized two topics in the Child Health Domain for 2020-2025.   The first, Child Abuse and Neglect, was described in the stakeholders’ Issue Brief as a priority of life course significance, with negative and long lasting effects on physical and mental health and wellbeing. Stakeholders identified relationships between risk for abuse and neglect, and subsequent child welfare system involvement, with poverty and parental substance use. The Issue Brief noted several important prevention-oriented approaches in Nebraska, including through the Family First Prevention Services Act, Prevent Child Abuse Nebraska, Bring Up Nebraska, and N-MIECHV Home Visiting (Healthy Families America). Stakeholders indicated there are ways Title V could work to amplify any or all of these efforts and groups.  

 

For the priority, Access to Preventive Oral Healthcare Services, stakeholders reported tooth decay as the most common childhood chronic disease in the U.S., and tied poor oral health of children to low school attendance, difficulty learning, concentrating, and socializing, as well as increasing lifetime risk of malnutrition, diabetes, heart disease, stroke, and oral cancer.  The Issue Brief for this priority identifies access issues stemming both from workforce shortages, and economic barriers preventing low-income families from accessing dental health care. For effective interventions, stakeholders were strongly in favor of continued collaborations between state and local public health and the Office of Oral Health, working particularly with Nebraska’s Public Health Dental Hygienists and Community Health Workers to promote basic preventive oral health and distribute supplies to children and families in the form of Dental Health Starter Kit.

 

For the 2020-2025 Needs Assessment, Title V worked with the Nebraska Association of Local Health Directors to bring forward a summary of current priorities identified through the Community Health Needs Assessment and Community Health Improvement Plans that local public health departments regularly undertake in their respective jurisdictions.  This summary allowed stakeholders to consider degree of alignment with local priorities when determining which issues should be included in Title V’s final list of priorities for the upcoming five year period.

 

One local health department identifies Violence and Injury Prevention among Adolescents and Children in current priorities. There were no local public health department priorities named that seemed to align with improved access to oral healthcare for children.  However, multiple national and state level organizations have identified both child abuse/neglect prevention and oral health as priorities, providing a strong framework of alignment for stakeholders and Title V.  

 

Consumer Engagement in this domain:

In review and public comment on the proposed Nebraska 2020-2025 priorities, respondents were asked about their concerns for the child population.  Nine comments focused on exposure of children to violence and neglect. Two comments included dental health care. 

 

When asked about the types of work the Title V block grant should be supporting in the Child domain, there were a couple of comments about oral health and safety.  In addition, stakeholders advocated for supports for healthy development, including screening; support for afterschool and extracurricular programs; mental health services; free, safe childcare; and supports for food and rent resources. 

 

Also in the public comment period, Title V asked for comments regarding proposed objectives and strategies aligned with each priority.  Results are as follows:

 

• On the priority of Child Abuse and Neglect, 51 individuals were in favor of the objective and strategies; 11 were opposed; 7 had no opinion.  Several comments were received:
  • “I like the plan for the child abuse/neglect system.”
  • “One really needs to look at the child abuse aspect at all ages and mental/behavioral health needs.  It’s just as frustrating to deal with an infant and young child with special needs as it is a youth.”
  • “N-MIECHV partners (Healthy Families America Programs) have a Child Welfare Protocol in place that connects home visiting staff directly to CPS case workers.  Tribal partnership is being considered.”
  • “Voices for Children and other groups have highlighted the disproportionate representation of children with special healthcare needs in our foster care system. Is it because there is a lack of family support programs in our state?  Are there things we can put in place to avoid this placement?  Title V needs to make sure voices of CYSHCN and their families have representation as Children and Family Services create a plan.”

 

• On the priority of Access to Preventive Oral Healthcare, 54 individuals were in favor of the objectives and strategies; 7 opposed; 8 had no opinion.  Two comments were recorded:
  • “Some rural communities don’t have access to a dentist that accepts Medicaid. If families can’t afford the screenings, then they aren’t going to seek out assistance.”
  • “The initiative does not address access to quality pediatric dental providers including rural communities. The initiative does not address uninsured Nebraskans including women, men, and children.”

 

Collaborative Approaches in this domain:

 

In the area of Child Abuse and Neglect, Title V will in particular continue to engage with the Division of Children and Family Services (CFS), N-MIECHV, and Bring Up Nebraska, a collaborative group promoted by CFS (https://www.bringupnebraska.org/).  This particular relationship has proven very fruitful in growing and expanding home visiting as a prevention service that can be incorporated into child welfare response as an alternative support for families at risk of deeper more significant involvement in the child welfare system.  Also foundational to this relationship is the presence of a data sharing agreement between the relevant Divisions in DHHS that may provide a mechanism to better understand racial disproportionalities in child abuse and neglect allegations and substantiated cases.  

 

In the area of Access to Preventive Oral Healthcare Services, Nebraska benefits greatly from the leadership of a Public Health Dentist who has ignited a very dedicated staff and an engaged cadre of local health departments, as well as other partnerships including the University of Nebraska-Lincoln School of Dentistry in a much-enlivened public health dental program in Nebraska.  Title V is pleased to be a part of such an enthusiastic collaboration, working through an existing and ready statewide infrastructure to reach children and families with the supplies and education for dental health, as well as working in supportive roles with partners to conduct the upcoming statewide Open Mouth Survey of third-grade and Head Start children.

 

Priority:  Child Abuse Prevention

2020-2021 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.

 

Proposed Strategies: 

• Strategy CH4a (1): The Nebraska MIECHV program will expand evidence-based home visiting services Nebraska families at-risk for child abuse and neglect in a collaboration with DHHS Division of Children and Family Services.

 

• Strategy CH4a (2): MCH Epidemiology will work with the Division of Children and Family Services to analyze data and describe any existing disparities among Child Welfare involved families.

 

Discussion of Activities for this Priority.

 

In working toward expansion of N-MIECHV through collaboration with Children and Families Services, Title V is undertaking a bold vision of delivering preventive services directly to families who have come to the attention of the child welfare system, but are not yet formally involved.  This is a powerful opportunity to influence of lives of families that Title V has committed to, working with many partners and the myriad of various rules, procedures, and policies that need to be addressed.

 

In identifying an equity-focused topic the Division of Children and Family Services joins efforts across Title V programs to advance equity among MCH populations.  Similarly to the disparities identified in exclusionary discipline practices in Nebraska public schools described elsewhere in this application, disparities in child welfare and juvenile justice in the state underscore the disproportionality with which all these systems operate when it comes to minority children or children with disabilities.

 

Results-based Accountability (RBA) or evaluation framework for this Priority.

 

Results Based Accountability (RBA) measures Child Abuse Prevention
	Proposed 2020-2021
How much did we do?	How many new sites and families were added to N-MIECHV during the period?
How well did we do it?	Have points of disproportionality been identified through the CFS-MCH Epi collaboration?
Is anyone better off?	Do families enrolled through TANF expansion on N-MIECHV have the same rate of achievement on benchmarks compared with other N-MIECHV families?

 

Priority: Access to Preventive Oral Healthcare Services

2020-2021 Objectives and Proposed Strategies

 

Objective CH5a: By 2025, increase the percent of children age 1 to 17 years who receive preventive oral health care services.

 

• Strategy CH5a(1): The DHHS Office of Oral Health will identify needs for translation of existing health literate oral health education materials.

 

• Strategy CH5a(2): Title V will assist the Office of Oral Health in acquiring and distributing Dental Health Starter Kits in the population. The DHHS Office of Oral Health will report evaluation measures of the project.

 

• Strategy CH5a(3): The DHHS School Health Program and the Office of MCH Epidemiology will participate in the planning and implementation of the statewide Oral Health Survey.

 

Discussion of Activities for this Priority.

 

Many Title V stakeholders in Nebraska are passionate about access to oral health care for MCH populations, so it is exciting that this is once again a priority area for Title V.  As with the Child Abuse and Neglect Prevention priority, Title V is fortunate to have a dynamic partner with developed capacity to provide technical assistance, guide, and lead efforts in the Office of Oral Health.  Here, Title V seeks to support the work and reach already begun by the Office of Oral Health in the state’s public health dental clinics, including the important Open Mouth Survey of Third Grade and Head Start students in the state.

 

Results-based Accountability (RBA) or evaluation framework for this Priority.

 

Results Based Accountability (RBA) measures Children’s Access to Preventive Oral Healthcare Services
	Proposed 2020-2021
How much did we do?	How many Dental Health Starter Kits were distributed by the Office of Oral Health in the period?
How well did we do it?	How many materials were newly translated?
Is anyone better off?	How many schools participated in the Oral Health Survey?  Are diverse children and underserved areas represented?

 

2. Describe alignment of Planned Activities with the priority needs.

 

Title V worked closely with program partners through the Needs Assessment and into planning the State Action Plan to identify planned activities.  Partners reviewed and approved objectives and strategies prior to finalizing this application.  The relationships that will drive activities in these two priorities of the Child Health Domain in the coming five-year period are mutually reinforcing.  The Division of Children and Family Services and the Office of Oral Health both express appreciation for the reinforcement and support provided by Title V.

 

3. Emerging or influential new priorities in this domain.

During the public comment period, respondents were invited to identify concerns about the Child domain in addition to the priorities presented.  Additional topics identified as concerns included:

• school disruption, and inadequate school environments to meet needs (5 comments);
• children missing developmental milestones (11 comments);
• nutrition including obesity and food insecurity (10 comments);
• adequate affordable childcare (5 comments); and
• access to health care and immunizations (7 comments). 

 

On the subject of COVID-19, Title V adapted the needs assessment process by inviting public input on the question: “How is the COVID-19 pandemic impacting each priority in your community?”

 

In response to the question on Child Abuse and Neglect, a total of forty-seven comments were received, virtually all expressing concern COVID-19 has been placing children at greater risk of abuse and neglect due to: parental stress (lack of resources, frustration, anxiety), lack of school oversight on the wellbeing of each child, isolation, and other barriers to identifying cases. It was the context of COVID stressors on families that gave rise to the strategy of reaching out to families with coping and referral resources at food distribution sites.

 

With regard to Access to Preventive Oral Healthcare, thirty-seven comments were received about impacts of COVID, the majority pointing to disrupted access to dentists and dental care.

 

4. Relevance of selected ESM for the selected NPM.  Describe the evidence base for the selected activities.

 

The NPM and ESM selected for the priority of Access to Preventive Oral Healthcare Services are as follows:

NPM: Percent of children age 1-17 years with a preventive dental visit in the past year.

ESM: The number of sites participating in the Nebraska Early Dental Health Starter kits program.

 

The ESM is relevant to the NPM in the respect that each Dental Health Starter kit includes a directory of Nebraska’s public health dental clinics.  The Starter kits also include basic age-appropriate dental health promotion materials, intended to cultivate awareness of preventive dental health behaviors, including good nutrition and periodically visiting a dentist.  Also included in the Starter kits is a flyer developed in a previous collaboration between Title V, Early Childhood Comprehensive Systems in Nebraska, and the Office of Oral Health, describing benefits to children and families of having a dental home.

 

5. Are Changes needed in established SPMs and SOMs?

 

The State Performance Measure selected for the 2020-2021 program period for the priority of Child Abuse Prevention is: the rate of substantiated reports of child abuse and neglect per 1,000 children age 1-9 years.

 

6. Notes on the five year action plan table for this domain.   

 

When stakeholders developed the issue brief for Child Abuse and Neglect they described a two-part future five years down the road if Title V were to engage with this priority in Nebraska.  First, both alleged and substantiated reports of child abuse and neglect would substantially decline.  Second, universal evidence-based home visiting services would be available to all families. When the public was invited to comment on the Title V action plan for 2020-2025, they were invited to comment on three strategies for the priority on Child Abuse and Neglect.  These are: expand evidence-based Home Visiting; Title V work with Children and Family Services to address racial disproportionality of children, youth, and families involved in the Child Welfare Agency; and collaborate with Bring Up Nebraska to address mental well-being and dealing with stress, at food distribution sites. The proposed 2020-2021 action plan for this priority reflects the first two of these.  The strategy to collaborate with Bring Up Nebraska is developmental in 2020-2021 and remains in the five-year action plan but not specified in 2020-2021.  

 

For the Issue Brief on Access to Preventive Oral Healthcare Services, stakeholders identified specific goals of sustaining the current nine Nebraska Teeth Forever (NTF) sites with public health dental services and expanding into more rural and underserved locations.  The disparities between rural and urban children in accessing preventive and treatment services should be addressed.  The statewide third grade oral health survey (to be conducted 2020-2023) should show improvement compared to the previous iteration of the survey. Public input was invited on the need for translation of preventive oral health materials into more languages in addition to English and Spanish; Developing, testing, implementing, and evaluating a plan for the distribution of the Dental Health Starter Kits; and Title V participation in the statewide Oral Health Survey of Third-Graders. The 2020-2021 action plan for this priority initiates all of these strategies.