From 50th in the Nation to a National Success. Delaware Improves Early Childhood Outcomes

healthy little girl
“We’re seeking a system transformation in early childhood,” says NICHQ's ECCS CoIIN Project Director Zhandra Levesque, MPH. “Improving screenings, especially in terms of referrals and follow-up, is one critical step towards achieving that goal."

Children should have a developmental screening at 9, 18 and 30 months of age, according to the American Academy of Pediatrics. These screenings prompt early diagnosis, helping ensure children with disabilities receive optimal care. Yet successful screenings rely on training screeners, supplying appropriate equipment, a plan to offset costs, outlets to raise awareness, and ensuring that referral and follow-up systems are available, among multiple other barriers unique to individual families and communities. Until each of these barriers are addressed, the more than 15 percent of children in the U.S. who have a developmental disability, such as hearing loss, ADHD or vision impairments, will continue to miss out on early screenings and referrals, losing their chance to benefit from the tools and resources that can help safeguard their future health.

Delaware understands this problem well. The 2007 National Survey of Children’s Health placed Delaware as last in the country for the percent of young children (between 10 months - 5 years) who received standardized developmental screenings during visits. This result pushed the state to make some profound changes.

“The 2007 rankings were a wake-up call that we needed to put screenings at the forefront to ensure that children are ready for school,” says Paulina Gyan, the Public Health Department project director for Delaware’s Early Childhood Comprehensive Services Impact (ECCS-I) program.

In 2009, Delaware’s legislature and the early childhood community, led by then Lieutenant Governor Matt Denn, signed a bill mandating insurance coverage for developmental screenings while appropriating funds to Delaware’s Division of Public Health to support the initiative.  

On the federal level, the Division of Public Health was awarded an ECCS grant in 2003 through 2013, and the ECCS-I in 2016. The federal grant is awarded by the Maternal and Child Health Bureau (MCHB), and provides funding and support for states to improve early childhood health systems of care. Delaware’s latest award falls under the NICHQ-led ECCS Collaborative Improvement and Innovation Network (ECCS CoIIN). Together, these state and federal efforts revolutionized early childhood care in Delaware.

“By 2012, we had gone from ranking 50th in the country to ranking 21st. We’re excited about this success but we’re not done improving,” says Gyan.

NICHQ’s ECCS CoIIN Project Director Zhandra Levesque, MPH, says Delaware’s efforts are important to other states too, who can model what’s worked. “They’ve established a really strong foundation for developmental screenings. Now it’s time to refine the process and build even more momentum around it. And importantly, this momentum can have a national impact. By looking at the improvement they have made over the past decade, we can pull out lessons-learned and key tactics to spread and scale among other states working to improve early childhood systems.”

Seek Funding for Online Screening Tools

Developmental screenings take time and cost money. Prior to 2007, if a physician wanted to offer a screening in Delaware, she needed to pay out of pocket for the tool and screening, while finding time to squeeze the screenings into a regular wellness check-up. Unsurprisingly, many physicians had difficulty doing so.

Delaware changed that by providing free access to a convenient online screening tool and state appropriated funding for technical assistance and training. Technical assistance included visits to participating practices to help physicians manage implementation. The screenings themselves more easily fit into the physician’s wellness check-up workflow, and the state provides reimbursement to offset the additional time spent on screenings. Now, with more physicians providing screenings, more children are benefiting.

Because screenings can be administered by non-medical personnel, Delaware can also offer screenings in new and other accessible locations, such as in early child care centers and in kindergarten, as well as through home visiting programs. Delaware’s early childhood community and the ECCS-I program are working in partnership to support these efforts by leveraging funding opportunities across the early childhood system. These opportunities include the Early Learning Challenge Grant (Race to The Top) and the Maternal, Infant and Early Childhood Home Visiting Program (MIECHV).

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Prioritize Timely Parent and Screener Support

Delaware has made provider and parent-support a priority by offering a centralized telephone access point. The call-line, Delaware 2-1-1, provides information and referral services that prevent barriers to health and social services. Families and providers view this call-line as an essential place to find information and resources about screening and follow-up resources.

“Linking families as well as childcare and healthcare providers with appropriate community resources assures children’s on-time development,” says Gyan. “Over and over providers tell us they do not know where the resources are and they are worried about making referrals. When they have a number to call, a burden is lifted and they are more likely to give the process a try.” Just as physicians receive individual support upon implementation, through Delaware STARS and recently, the ECCS CoIIN, childcare providers also receive training and support on optimizing screenings and interpreting results. Delaware also hosts a yearly workshop, originally intended for physicians but now targeting childcare providers as well. The workshop brings together screeners, physicians and early intervention programs so they can share their advice, experiences, resources and expertise.

Raise Public Awareness

Childcare and physician support can go a long way but screenings can’t happen unless the children are there to be screened. Parents may not understand the importance of developmental screenings; they may not know where to go; and they may find a difficult and complicated process discouraging. Delaware tries to make the process as easy as possible for parents, and looks for multiple outlets to educate and build awareness around why developmental screenings can change children’s lives.

“Parents want their children to thrive. If they know there is a tool that can help their children succeed, they will want access to it,” asserts Gyan. “And once parents start demanding these screenings for their children, the momentum will really start building.”

The state health department’s developmental screenings webpage has been essential for raising awareness. It helps parents find nearby screening locations and provides links to helpful resources, such as the Center for Disease Control’s developmental tracker. It also hosts print brochures that can be given out to families during home visits. These brochures are available for order on the website, at no cost, so that they can be easily disseminated by physicians and childcare providers. Finally, getting the message out through radio announcements and videos helps raise awareness among families who may not read a brochure or attend regular wellness check-ups.

Enhance Data Sharing Capacity

Building a system for sharing data is critical. “We have data that helps us understand more about our screening process, such as how many children are screened and how many physicians are participating; and we have data that tell us more about Delaware’s children, such as the breakdown of different developmental disability indicators and the number of high risk results,” says Gyan. “Having an accurate and comprehensive view of all of this information helps us decide our next steps and focus improvement efforts.”

Merging this data can be difficult though. Cross-sector collaboration is essential for success with early childhood programs, but it also means that data findings can sometimes be divided between participating partners. For example, in Delaware, the Public Health Department manages the data from home visiting programs and physician visits, while the Department of Education manages the data from the childcare providers.  

The Department of Education’s Office of Early Learning shares their data on a quarterly basis, so we do have a system of collaboration in place,” Gyan shares. “That said, we hope to continue to improve our data sharing capacity through ECCS. We plan to develop a robust public database that hosts all relevant variables in one place and makes it available to the full early childhood community, including the Department of Education, non-profits, Health Departments and any other group working towards improvement.”

Never Settle. Never Stop Improving

Like Levesque, Gyan is committed to continuing to build on Delaware’s momentum. “Data-sharing is just one place for improvement. There are still other system gaps,” she says. “Right now, we’re thinking a lot about equity and how to target vulnerable populations who may not have benefited from some of our earlier interventions. There are federally funded healthcare centers directed at vulnerable populations that are not yet doing screenings. We can change this.”

And with Delaware’s impressive improvement history, it seems likely that they will. In turn, the other 11 states participating in the ECCS CoIIN will study and learn from Delaware’s efforts, resulting in national momentum around developmental screenings.

“We’re seeking a system transformation in early childhood,” says Levesque. “Improving screenings, especially in terms of referrals and follow-up, is one critical step towards achieving that goal and supports one of ECCS CoIIN’s core drivers.  When we align this with other drivers, such as promoting family partnerships and addressing social determinants of health, we come closer to creating a truly effective and sustainable system.”