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

Iowa’s Title V agencies will continue to leverage partnership with community programs to assure increased rates of developmental screening. Particular focus will remain with IDEA Part C and Iowa’s 1st Five Initiative for this effort.

The 1st Five Healthy Mental Development Initiative engages primary care clinics and providers to support healthy mental development for all children ages birth to five years. Primary care clinics and providers are supported to ensure the three levels of developmental care through Iowa Medicaid’s Early and Periodic Screening Diagnostic and Treatment (EPSDT) benefit. This includes developmental surveillance and standardized developmental screenings at well-child exams within the medical home.

With Iowa’s change to a revised set of Collaborative Service Areas, Iowa is taking steps to place greater emphasis on the primary care role in increasing rates of standardized developmental screening as the direct service to assure that Title V resources are used only for gap filling when necessary for screening. Title V agencies will shift more attention to Public Health Services and Systems and Enabling Services.

Title V agencies will continue to work with Iowa’s Area Education Agencies which deliver IDEA Part C Services (called Early ACCESS). When referred children from birth to age three do not meet eligibility requirements for Early ACCESS, Title V will provide developmental follow-up services as needed to assure each child is connected to services. As appropriate, the Title V screening center will include developmental screening as part of the follow-up. This will mainly occur when the referred child does not have access to a medical home and will not be able to receive a well-child visit at a primary care clinic in a timely manner.

1st Five has enhanced the tools and strategies available to local contractors to assist them in their work with primary care practices. FFY 23 will be the first year that a fully redeveloped set of guidance documents is available for this purpose. It includes a new structure for working with practices called “Levels of Engagement” along with specific guidance regarding surveillance and screening, infrastructure development and developmental support services.

During FFY22, 1st Five state consultants began an enhanced process of working with local contractors by conducting quarterly (or more often) virtual check-in workshops. This allows local contractors to set informal progress milestones and receive specific coaching and technical assistance toward those aspirations. Iowa will continue this process in FFY23. The Collaborative Service Area structure will reduce the number of individual contractors, allowing for state consultants to focus more time with each contractor’s 1st Five Site Coordinator. Coupled with the enhanced guidance documents and strategies, we are hopeful that impact on this NPM 6 will be realized.

Local 1st Five Site Coordinators outreach to primary care practices to encourage their consistent and universal use of standardized developmental screening tools. Outreach may include, but is not limited to individualized on-site or virtual training, personal contacts and meetings. Newsletters, mass emails and other generalized outreach is also used. Beginning in the summer of 2022, local sites will subcontract with a local primary care physician to offer peer consultation for other primary care physicians and their colleagues. When this local support is not feasible, peer consultants will be available via a state contract as has been the case since the inception of the 1st Five initiative.

A new performance measure in contracts with local 1st Five sites in FFY23 will focus on assuring that sites make and maintain contact with referred children’s parents/caregivers. This will be tracked in the Referral Outcome responses in the Referral Activities recorded in the signifycommunity™ data system.

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

OHDS staff will address NPM 13B through the I-Smile™ program. The I-Smile™ program's primary goal is to connect children and families with dental, medical, and community resources. OHDS staff provide oversight and policy development of I-Smile™. There will be some program changes in FFY23 and OHDS staff will assure that all local staff involved with I-Smile™ is trained and understand any new requirements and policies. OHDS staff will hold quarterly I-Smile™ Coordinator meetings to ensure program consistency, develop leadership skills, discuss new opportunities, and promote current standards and procedures. Meetings will include continuing education on current oral health topics and provide an open forum for sharing best practices and successes between the coordinators. These meetings will also address current issues brought forward by OHDS staff and I-Smile™ Coordinators (e.g. Silver Diamine Fluoride (SDF) usage, rural health clinics access). OHDS staff will have site visits with each CAH contractor to discuss I-Smile™ work plans, review data, and troubleshoot concerns; staff will also participate in yearly chart audits, to ensure contractors are documenting client information and services accurately and to ensure the agency is prepared if they were to receive a Medicaid audit. OHDS staff will continue to meet quarterly with the oral health epidemiologist to discuss agency-specific data, including any racial/ethnic disparities identified.

OHDS will maintain its stock of promotional materials that can be used by contractors for children and families. OHDS staff will continue to manage the I-Smile™ Facebook page, targeting parents/guardians with information and education about good oral health for children as well as during pregnancy. For quality assurance, one OHDS staff member will be the Facebook lead to ensure information is posted and appropriate. The I-Smile™ website will be maintained and updated as needed, including educational material for families and professionals. OHDS staff will continue to use QR codes on promotional materials to ease access to resources.

OHDS staff work to ensure optimal oral health for underserved children and this depends upon the strength of partnerships, both at the state and local levels. OHDS staff will maintain important partnerships with entities such as WIC, 5-2-1-0 Healthy Choices Count!, Head Start, Healthy Child Care Iowa, Delta Dental of Iowa Foundation, Iowa Primary Care Association, Count the Kicks, Oral Health Iowa Coalition, and the University Of Iowa College Of Dentistry.

Another growing partnership is with Title X (within the Iowa Department of Public Health) seeking to educate adolescent families on the Human Papillomavirus (HPV) vaccine and oral health. I-Smile™ Coordinators will distribute education on HPV vaccines and oral cancer screenings - available on rack cards - at medical clinics, WIC, and dental offices. OHDS staff will assist Title X staff on a new grant to incorporate oral health with family planning. OHDS staff will meet with Title X staff quarterly to continue the partnership and determine next steps.

OHDS staff will maintain its strong partnerships with Iowa Medicaid Enterprises (IME) and the Prepaid Ambulatory Health Plan (PAHP) carriers for dental Medicaid in Iowa – Delta Dental of Iowa and Managed Care of North America – to ensure that rule and/or policy changes are made when needed for positive impact on families served by I-Smile™ and to troubleshoot any issues.  OHDS staff is part of the Oral Health Iowa coalition, which advocates for maintaining and strengthening  I-Smile™ and to increase dental Medicaid reimbursement. Additionally, the partnership with Cavity Free Iowa has demonstrated importance. This is a workgroup focused on increasing training for medical office staff to apply fluoride varnish for children at well-child exams. OHDS staff facilitate the workgroup meetings and activities; medical office training is provided by I-Smile™ Coordinators using materials developed by OHDS staff.

In FFY2023, there will be I-Smile™ program changes in the CAH contracts. For example, the required hours I-Smile™ Coordinators spend on activities to build local public health system capacity and to ensure enabling and population-based oral health services will be increased. Similar to previous years, each I-Smile™ Coordinator will develop one new local partnership with a business or organization, as well as improving and expanding partnerships with a minimum of four existing partners to benefit families served through I-Smile™. I-Smile™ Coordinators will make face-to-face outreach visits with all general and pediatric dental offices and family practice medical offices and/or pediatric medical offices within their service areas and provide training for medical office staff as requested. I-Smile™ Coordinators will also conduct oral health promotion about the importance of oral health for children and pregnant people along with the benefits of I-Smile™. Oral health promotion provides encouragement, creates awareness, and communicates health messages about the I-Smile™ program and the importance of optimal oral health for overall health. One initiative must promote the age 1 dental visit and another must use social media.

I-Smile™ Coordinators will train MCAH staff regarding oral health as it pertains to the informing process and care coordination. Dental care coordination includes assisting clients in finding a dentist and removing barriers to access, such as addressing their social determinants of health, helping with appointments, and setting up transportation and/or translator services. Training on the “informing” process assures competency of staff about the importance of routine preventive care and the dental benefits offered through Medicaid.

Data indicates that low-income children do not have adequate access to services from dentists. As a result, I-Smile™ programs will be required to provide gap-filling preventive services for children ages 0-2 years and also those in elementary schools with 40% or greater free/reduced lunch rate participation (as part of I-Smile™ @ School). In FFY23, a new I-Smile™ position will be required for CAH contractors – a Direct Dental Service Planner (DDSP). This position will focus on arranging direct dental services and may also provide direct services. The DDSP will assure all I-Smile™ @ School guidelines are followed and requirements are met. I-Smile™ programs will be required to offer SDF applications, in addition to screenings, fluoride varnish, and sealant applications. SDF is particularly beneficial for at-risk children seen in public health settings, who may have limited access to care. OHDS staff will work with I-Smile™ Coordinators to address barriers associated with use of SDF, make protocols, and assist with implementation questions.

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

The Title V Program continues to work with the IDPH Childhood Lead Poisoning Prevention Program (CLPPP) to determine the reasons for the decreases in blood lead testing for both one and two year olds for 2020.In recent years the Department has seen a decline in the rate of testing children for lead, especially amongst children under 3 years in age. Overall, 70.8% of Iowa’s children 1 year of age received a blood lead test from 2018-2020. However, more than 25% of Iowa’s counties have 60% or less of their 1 year old population with a documented blood lead test. There was a 12% decrease in blood lead testing from 2019-2020 for this age group. The number of Iowa’s children 2 years of age who received a blood lead test is significantly lower than their 1 year old counterparts. As of 2020, only 35.7% of 2 year old children received a blood lead test, which represents a decrease in coverage from 2019 (38.5%). Currently, both age groups fall below the Department’s goal of blood lead tests completed for 75% of Iowa’s 2 year old children.

There were two nationwide issues that impacted the blood lead testing rates of children. The first issue was the COVID-19 pandemic and the difficulty in getting routine medical care during this time and then difficulty in doing catch-up routine care once healthcare practices and public health began to re-open doors. The second issue was the recall and subsequent lack of availability of the LeadCare II testing kits by Magellan. Many of the Title V CAH contracting agencies that performed lead testing utilized these tests and there was a lapse of testing due to available supply and pivoting to a different method of testing. In 2021 a deep dive into 2019 and 2020 data was done by CAH staff in collaboration with IDPH CLPPP staff. Several areas of focus for future work were found, including targeted race/ethnicity in testing and targeted testing efforts for specific counties in Iowa where rates are low and specific types of communities (I.e., micropolitan and rural communities).

In 2023, the CAH Program released a competitive Request for Proposals (RFP) to select new community-based contractors to provide public health services at the community level for Child & Adolescent services. This RFP includes blood lead testing services for children. Through this application process state Title V staff are able to evaluate the applicant's ability to provide quality services for children in the state. Through a deep data dive, it was learned that 8 of Iowa’s 99 counties have higher than average rates of children in Title V’s Health Equity priority populations, which include Hispanic/Latinx and African American, Black or African, without blood lead tests. Staff are exploring ways to target these identified priority populations, including requiring contract agencies in these 8 counties to focus lead testing efforts on these specific populations. Title V staff will continue to work at the state level to identify and eliminate barriers to testing.  Additionally, when looking at the state geographically, there is a discrepancy between counties of residence and blood lead testing at both 1 and 2 years of age. Therefore, through the RFP process a requirement for applicants to provide blood lead testing to 1 year old children in 64 of our 99 counties which had less than the state goal of 75% of children residing in the county with a blood lead test, and for 2 year old children 57 of our 99 counties who had less than the state goal of 40% of children residing in the county with a blood lead test. Title V believes by targeting priority populations and requiring blood lead testing for 1 and 2 year olds in more than half of our counties Iowa will be able to expand testing post-COVID-19 and get more children tested at the proper ages and intervals.  Additionally, the RFP requires applicants to set both single year and 5 year goals for both 1 and 2 year old children to increase blood lead testing in their service area. These goals will allow staff to more closely measure each agency’s impact on the blood lead testing of children in their area.

Finally, the CAH Program will continue to work collaboratively with the IDPH Children’s Lead Prevention Program. The two programs continue to work to determine data sharing and meaningful use of the data collected, targeted interventions for populations, and improved testing strategies for Iowa’s children.

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

Iowa has 3,999 regulated child care programs. The COVID-19 pandemic has greatly impacted the need for child care nurse consultant (CCNC) services, increasing the percentage of early care and education (ECE) programs contacting their local CCNC for guidance and services over the past two years. Iowa’s Emergency Preparedness Plan for Child Care includes Healthy Child Care Iowa (HCCI) state staff and local CCNCs assisting in communicable disease response. Iowa’s COVID-19 guidance for child care has been a collaborative effort between the Iowa Department of Public Health and Iowa Department of Human Services. Local CCNCs have provided assistance to ECE programs regarding COVID-19 health and safety policies; managing positive cases, exposures and outbreaks; and improving quality.

Although COVID-19 cases have decreased in Iowa, requests for CCNC services have continued as many ECE programs who may not have accessed services in the past, have now established a strong partnership with their local CCNC and see the value of the services provided.

Research indicates that CCNCs support healthy and safe early care and education settings and protect and promote the healthy growth and development of children and their families. In Iowa, CCNC services are non-regulatory so 100% of programs receiving services may not be an achievable goal. However this rate will continue to increase due to Iowa’s new quality rating system (Iowa Quality For Kids - IQ4K). IQ4K has a continuous quality improvement approach incorporating a focus on health and safety. CCNC services are a requirement for ECE programs applying for IQ4K starting at a level 2.

HCCI state staff will continue to promote 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 limited CCNC coverage, and facilitating meetings with local stakeholders (including Early Childhood Iowa areas) for supports and funding of local CCNC services.

HCCI has and will continue to incorporate health equity language into the CCNC Role Guidance. Health equity is embedded in the Iowa Training Project for Child Care Nurse Consultants (ITPCCNC). ITPCCNC is the required initial training for nurses employed as CCNCs.

HCCI has worked to incorporate the 10 Essential Public Health Services into our HCCI state structure. Staff will continue to assess and ensure these are being utilized when making programmatic decisions.

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 ECI, DHS, MCAH and other partners. HCCI will continue to collaborate with DHS for gap filling support of local CCNC services.

Local CCNC services will be evaluated by state HCCI staff for program fidelity including annual inter-rater reliability visits utilizing the Health and Safety Checklist assessment tool. Fidelity with the tool will be at 90% or higher.

Data from Health and Safety Checklist assessments of ECE programs by local CCNCs will be evaluated by state HCCI staff to assess training needs, resources, fact sheets, and to help drive the work of the CCNC in assessment items falling below national standards where quality improvement is needed.

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

Tooth decay, despite being highly preventable, is the most common chronic disease among children. Research indicates that when fluoride varnish is used early, it can reduce decay by 18-25% in children. The benefits of fluoride varnish for very young children may be demonstrated through Iowa’s surveillance data. Based on data showing that too few Medicaid-enrolled children ages 0-2 years see a dentist, I-Smile™ programs have been required to provide preventive services, including fluoride varnish applications, at WIC clinics since 2012. A 2019 survey of WIC children in Iowa found a 4% reduction in untreated decay compared to a 2010 survey.

The Bureau of Oral and Health Delivery Systems (OHDS) staff and I-Smile™ Coordinators will continue to seek ways to increase access to early preventive dental care for children, including use of fluoride varnish by medical providers. OHDS staff will lead the Cavity Free Iowa (CFI) initiative, a workgroup launched in 2017. Recognizing that young children often see their physician more routinely than a dentist, the goal of CFI is to increase the number of young children receiving preventive oral health services like fluoride varnish from their primary care physician. Using materials developed by OHDS staff, I-Smile™ Coordinators will continue to offer training to medical office staff on the benefits and how to apply fluoride varnish.  The medical providers will receive a certificate after training and a plaque after continued use of fluoride for patients. Over the next year, the CFI workgroup plans to add a CFI section to the I-Smile™ website, hosted by OHDS, to connect medical providers to I-Smile™ Coordinators for training. The website will also include specific education about oral health for medical practitioners. The central Iowa pediatrician who has championed CFI was chosen to continue to lead the One Hundred Million Mouths Project. He will continue providing training to medical students in Iowa about oral health and the benefits of fluoride for decay prevention, in hopes that the students will incorporate what they learn when they go into practice. An I-Smile™ Coordinator will assist with the training for medical students.

OHDS will continue to leverage its CFI partnerships in FFY2023. For example, Delta Dental of Iowa Foundation brings experience in public relations and marketing and will provide commemorative plaques and training certificates for medical offices trained by I-Smile™ Coordinators. OHDS staff will work with Medicaid’s Dental Program Managers to assure reimbursement to medical offices and troubleshoot any billing issues. OHDS staff will also continue to partner with the CFI pediatrician “champion” and a dentist from a central Iowa dental clinic for the underserved. This partnership works to increase participation in the CFI workgroup by connecting with colleagues and increase the use of physician applied fluoride varnish by helping medical clinics with technical assistance.

OHDS staff also will continue participation in the Oral Health Iowa coalition (OHI). The coalition formed to provide a unified advocacy voice regarding oral health of Iowans; two OHDS staff are on the coalition steering committee. OHI gives OHDS staff access to additional partners who support the goal of physicians incorporating oral health prevention during well-child visits.

As a result of OHDS staff advocating for an expansion of Iowa Medicaid's coverage for physician-applied fluoride to children through age 5 to coincide with Iowa’s EPSDT periodicity schedule, Medicaid adopted this policy in December 2021. OHDS staff will assure that flyers, training, and promotional materials are updated to reflect the change so that I-Smile™ Coordinators will have the materials when making required in-person outreach visits to all pediatric medical offices within their service area, emphasizing the importance of early and regular oral health care and parent education. The coordinators will also promote the ability to bill for fluoride varnish applications for children through the age of 59 months with medical clinics when doing their outreach.

Iowa has more than 200 Rural Health Clinics (RHCs). They are federally funded and must meet federal requirements, operating differently than medical clinics that are not designated as RHCs. For example, they receive cost-based reimbursement, similar to Federally Qualified Health Centers. It is more difficult to integrate use of fluoride varnish within a well-child visit at RHCs due to the cost-based reimbursement.  Because of Iowa’s large rural population, OHDS staff have met with the State Office of Rural Health staff and the Iowa Association of Rural Health Clinics to identify ways to add use of fluoride varnish applications in RHCs. The collaboration has led to addition of oral health questions on the yearly Iowa Association of Rural Health Clinics needs assessment. In 2023, OHDS staff will use the needs assessment information to determine the interest of Iowa's RHCs for oral health services, linking I-Smile™ Coordinators with those RHCs. OHDS staff will continue working through billing considerations and procedures needed for the RHCs and will seek the assistance of Cavity Free Iowa to determine opportunities to pilot use within selected RHCs.

OHDS staff submitted a HRSA Oral Health Workforce grant with a project period of September 2022 – August 2026. If funded, OHDs would develop a plan to incorporate public health dental hygienists in medical offices. This grant would lead to more medical/dental integration and increased opportunities to reach children ages 0-5 years with preventive dental care.