Overview and context for new domain-specific priority needs

The top-ranking issues during the 2020 Needs Assessment impacting the Child Health domain were reducing violence and injury and ensuring that all children are screened for a broad range of developmental needs and receive early intervention. To address these issues, Title V strategies in the 2021-2025 State Action Plan align with the following Population Priorities:

• Promote healthy development and family resilience through policies and practices rooted in core principles of development
• Reduce child injury and violence

To strengthen the systems and upstream factors that impact the above Child Health Population Priorities, Title V will also implement strategies in alignment with the following Systems Priorities:

• Partner with families, youth, and communities at all levels of systems change
• Ensure equitable access to quality, coordinated care and supportive services

In alignment with the above Priority Needs, Louisiana Title V selected the following Child Health National Performance Measure for the FFY 2021-2025 cycle:

• NPM 6: Developmental Screening: Early identification and treatment of developmental issues can have life-long impacts on a child. Louisiana’s rates of developmental screenings are significantly lower than the national average. Over the last several years, Louisiana Title V has made strategic investments in staffing and programming to improve the state’s developmental screening rates and subsequent connections to care. Title V will build upon successful activities from the previous cycle and introduce new strategies to improve statewide rates of developmental screening.

Summary of Title V Efforts and Alignment with Child Health Priorities

Population Priority: Promote healthy child development and family resilience through policies and practices rooted in core principles of development.

Provide home-based developmental screening and early intervention support: In FFY 2021, BFH will continue to serve as the state’s 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 Louisiana, the MIECHV program includes two of the nationally recognized, evidence-based home visiting models--Nurse-Family Partnership (NFP) 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 NFP 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. In FFY 2021, Title V Developmental Screening Initiative will also support the integration of autism screenings throughout all MIECHV teams.

Title V will also continue to fund LA MIECHV’s dedicated Infant and Early Childhood Mental Health (IECMH) Team, which consists of licensed mental health providers embedded in each of the 19 home visiting teams across the state. Through consultation, the IECMH Specialists will continue to work with home visitors to support families and strengthen parents’ efforts to nurture their child’s social and emotional development. They will also work with home visitors to identify emerging problems in parent-child relationships, navigate mental health concerns in the family, and provide resources and referrals for additional support.

Promoting Developmental Monitoring with Learn the Signs. Act Early (LTSAE). In FFY 2021, Louisiana will continue work to improve early identification of children with autism and other developmental disabilities by creating materials to engage parents in developmental monitoring. In FFY 2020, Louisiana added two new deputy ambassadors to the LTSAE team - one for health and one for education. The first project, which began in FFY 2020, is a joint collaboration of co-branded LTSAE materials with Louisiana Department of Health (LDH) and Louisiana Department of Education (LDOE) logos, as well as the logo for each parish school system. Each checklist or brochure contains all three logos and the contact information for two key resources: EarlySteps (early intervention: birth to 3) and Child Find (3-21 years). In FFY 2021, all 64 parishes will have the co-branded, customized LTSAE materials information available.

Population Priority: Reduce Child Injury and Violence

Monitor and analyze trends in child injury and violence: In FFY 2021, Title V will support part of an injury epidemiologist in their work with the Department of Children and Families (DCFS). Child welfare victim and perpetrator data have been linked with health system data and vital records.  Analytics will facilitate more comprehensive predictive analytic topics such as relationships between repeated allegations, substance use and mental illness and perpetration of child abuse and neglect (CAN), and outcomes for substance exposed newborns. 

Support Regional and State Child Death Review (CDR): In FFY 2021, Title V will continue to fund mortality review staff and provide infrastructure support to the local and state CDR panels. A focus for the 2021-2025 cycle will be supporting the movement of CDR recommendations to action. Title V staff will work with members on the local and State CDR panels and partners to support new and ongoing policy efforts, including those related to the prevention of abusive head trauma (including shaken baby), safe sleep, child passenger safety, self-harm prevention, and drowning prevention.

Collaborate with Emergency Medical Services for Children (EMSC): In FFY 2021, Title V will continue to provide infrastructure support to EMSC and actively seek additional areas of collaboration to reduce the impact of child injury. The EMSC Program Manager participated in the Title V State Action Planning sessions and will continue to play a lead role in the Child Safety Learning Collaborative (CSLC), which is described in more detail in the adolescent health domain.  

System Priority: Partner with families, youth, and communities at all levels of systems change

Support State Young Child Wellness Collaborative (SYCWC): In FFY 2021, the ECSS Manager will continue to support the SYCWC work to drive shared priority-setting and strategic planning across the continuum of supports and services within Louisiana’s Early Childhood System. During the FFY 2021-2025 cycle, the SYCWC will support and further statewide efforts to improve developmental outcomes for children, considering all areas of development, as well as the major factors that work together to influence developmental outcomes. Areas of focus for FFY 2021 include:

• promoting family engagement in Louisiana’s Early Childhood System;
• supporting the sustainability and growth of essential early childhood supports and services in Louisiana; and
• increasing alignment and strengthening linkages between supports and services across the Early Childhood System in order to create seamless transitions and coordination for families.

System Priority: Ensure equitable access to quality, coordinated care and supportive services

Implement agency-wide early childhood system (ECS) strategy: A core strategy to address both population priority needs is to support the development and implementation of a shared, agency-wide early childhood agenda for a comprehensive early childhood system. Over the past several years, staff from various offices across LDH 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.

More recently, the work has turned to the challenge of developing a cohesive shared agenda that encompasses approaches that can be brought to scale and sustainably funded. In January 2020, the LDH staff workgroup developed a Developmental Health Strategic Plan that outlines priority opportunities to strengthen universal promotion, targeted prevention, and intervention for families and young children in Louisiana. The Title V-funded ECSS Manager has been charged with coordinating implementation of the plan and shepherding LDH towards a shared agency-wide early childhood agenda for a comprehensive early childhood system.

The comprehensive early childhood system as outlined in the strategic plan consists of three levels:

• Universal Promotion, which encompasses 1) early identification of risk through developmental screening, and 2) promotion of healthy development
• Targeted Prevention, which focuses on early response to identified risk
• Intervention, which focuses on specialty support and care to mitigate risk

Most of the Title V strategies to improve young child health will fall within this ECS Strategy framework in the Universal Promotion and Targeted Prevention levels.

Ensure early identification of risk through developmental screening: At the universal promotion level, the ECS Strategy envisions that every young child in Louisiana is screened for developmental milestones and environmental factors in multiple developmental domains at appropriate intervals using validated screening tools. During the 2016-2020 cycle, Title V laid the groundwork to support adoption of high-quality developmental screening, especially through leading a cross-agency partnership to develop the Louisiana Developmental Screening Guidelines, and working with Medicaid to advance supportive policy changes. During the 2021-2025 cycle, Title V will build upon successful strategies and lessons learned from the last cycle and expand the scope of the BFH Developmental Screening Initiative. 

Update the Louisiana Developmental Screening Guidelines (LDSG). Beginning in FFY 2020 and concluding in FFY 2021, BFH and the SYCWC will review the current Louisiana Developmental Screening Guidelines (LDSG) and determine if changes are needed to the current guidelines based on recent scientific and policy evidence for best-practice. The initial LDSG were initiated in 2015 and presented in 2016, so after four years of use and potential developments in the scientific and policy literature, the BFH Developmental Screening Coordinator will convene a project workgroup to update the guidelines to match with best practices and evidence. BFH will then support the documentation and communication of the updated version of Louisiana Developmental Screening Guidelines.

Provider Training and Technical Assistance (TA): A key strategy to implement the LDSG and support broad adoption of high-quality developmental screening is to leverage well-child visits to screen infants and young children for general and social-emotional development, as well as maternal depression and other social determinants of health. Since the LDSG are voluntary, an approach to promote uptake across the state is providing technical assistance to providers on both developmental screening and care coordination. Additionally, evidence from other states that have improved their developmental screening rates demonstrate that TA should be available to physicians as part of a quality improvement initiative to integrate best-practice screening into their practices and follow up with effective referrals and care coordination. In FFY 2021, Title V will continue to expand and improve upon the provider developmental screening TA project and will incorporate lessons learned through the evaluation of the pilot project described in the 2019 report. The results will be used to refine the practice-level direct TA as well as a “train the trainer” model for MCO quality teams. Additionally, mental health consultants supporting pediatric primary care providers will also support providers in administering validated screening tools, particularly for maternal depression and social-emotional development.

Collaborate with Medicaid: The Title V Developmental Screening workgroup will continue to work with Medicaid to explore policy opportunities that promote implementation and measurement of developmental screening in primary care, such as turning on the appropriate Current Procedural Terminology (CPT) codes with associated reimbursement outside of the existing bundled payments for well-child visits. Developmental screening was selected as an incentivized quality measure for the MCO contracts starting in 2020, creating an opportunity for MCOs to work with providers to improve screening rates over the next three years. In order to support comprehensive screening using validated tools at recommended intervals, BFH has proposed that CPT codes for general development, autism, maternal depression, social determinants of health, and social-emotional development be adopted with nominal reimbursement and regular chart audits to ensure usage of appropriate tools.

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 all serve the same population of young children in different capacities, but 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.

To address this issue, BFH has been working with staff from the Louisiana Department of Education to consider the potential functionality and parameters of a shared data exchange sharing systems that comply with HIPAA and FERPA. Additionally, the data sharing and system integration workgroup of the SYCWC researched various models for this data system, and the focus for FFY 2021 will be to identify a funding source for creating and maintaining the system. BFH will continue to work diligently to achieve meaningful buy-in from partners and determine the appropriate model and functionality that fits the needs of providers and families in Louisiana.

Support early response to identified risk: At the targeted prevention level, ECS Strategy envisions a statewide system of training, coaching, and consultation to obstetric, pediatric, and family medicine providers as well as for other child-serving workforces including early intervention providers and family support and coaching home visitors implementing evidence-based home visiting models.

Create a statewide system of mental health consultation. Child- and family-serving professionals such as obstetric, pediatric primary care providers, home visitors, and early intervention providers are in a prime position to promote early childhood and family well-being, identify risk factors early, provide front-line interventions for early mental health problems, and facilitate referrals to mental health professionals when necessary and possible. Lack of access to early childhood mental health providers contributes to families’ relying on their primary care provider (PCP) for evaluation and treatment of mental health concerns, especially in rural areas. Training, support, coaching and consultation to health, allied health, and public health professionals improves the reach of mental health expertise to families by increasing the confidence and comfort level of providers serving young children and their families who are at risk for or demonstrate early social-emotional difficulties and mental health concerns. Mental health consultation is effective in improving primary care capacity to ameliorate mental illness or conditions, which is an entitlement outlined in EPSDT (Early Periodic Screening, Diagnostic, and Treatment). Three consultation programs are currently supported in BFH:

• Following the successful implementation of Project LAUNCH (Linking Actions for Unmet Needs in Children’s Health, a SAMHSA-funded initiative that was completed in August 2018) in 3 parishes in LDH Region 4, mental health consultation service to primary care providers and EarlySteps providers was extended to all parishes in the region. Funding for this limited geographic area is temporarily being provided through Title V, but it is not resourced to reach the needed statewide scale.
• As described above, IEMCH consultation is integrated into Louisiana’s MIECHV program. This consultation has expanded to include all 19 family support and coaching teams, serving all 64 parishes in the state. Funding to sustain this is also being provided through The Title V Maternal Child Health Block Grant.
• Louisiana Mental Health Perinatal Partnership (LAMhPP) is a new HRSA-funded 5-year grant program aimed at providing mental health consultation to perinatal providers. Psychiatric phone consultation, phone resource and referral consultation, in-person and online training, and online resources are available statewide; in-office consultation is available in Region 4 and will be available in Region 8. 

These successful models of IECMH consultation were implemented with the intention of piloting approaches for a statewide system of remote education, support, and consultation, as well as on-the-ground support for implementation of practice-level changes. In FFY 2020, BFH hired a new Mental Health Strategy who will be responsible for identifying how these historical efforts could be harmonized and unified in order to prepare for a statewide system of remote consultation and targeted on-the-ground support in every region of the state. These services are currently funded by time-limited federal grants. Scaling training, clinical guidance, and resource-referral support (collectively, consultation) for perinatal and pediatric primary care providers is one of the most effective ways to improve family health in the current landscape. In FFY 2021, Title V Health System Strategy will conduct research to identify financing options to support a statewide system of consultation.

Expand access to evidence-based home visiting. Across the state, the two home visiting models supported by Louisiana MIECHV serve over 4,000 families each year. However, with approximately 60,000 births in the state each year, there is potentially significant unmet need during a critical window for mothers and young children. As a part of the LDH priority to promote maternal health and prevent complications, BFH proposes to pilot a complementary, less intensive home-visiting model that would allow Louisiana to lay the groundwork for universally-offered home-based support for individuals giving birth in Louisiana.

In FFY 2021, Title V Health System Strategy will conduct research to identify financing options for the pilot and long-term financing for evidence-based home visiting more generally. For almost 30 years, an increasing number of states have adopted strategies to use Medicaid funding to cover the cost of many Medicaid-coverable services provided by home visitors. Since Medicaid eligibility is a current requirement to receive MIECHV home visits, all clients currently served by MIECHV are eligible to receive Medicaid services. Allowing NFP nurses to bill Medicaid for eligible services (i.e. targeted case management) would provide a sustainable source of funding that would allow MIECHV to redirect more of its resources to expanding the reach of additional models that meet the needs of more Louisiana families.