Once Upon a Time in North Carolina: CHIP Health Services Initiative Funds Early Literacy Promotion as Part of Well-Child Care

In June 2019, as part of the Pediatrics Supporting Parents initiative, CSSP, Donna Cohen Ross, and Manatt Health released Fostering Social and Emotional Health through Pediatric Primary Care: A Blueprint for Leveraging Medicaid and CHIP to Finance Change. Designed as a practical guide for policymakers, program administrators, managed care plans, pediatric care providers, advocates, and others, the Blueprint features key strategies and tools for optimizing the use of Medicaid and the Children’s Health Insurance program (CHIP) to help ensure that the well-child pediatric health care delivered to young children promotes and strengthens early parent-caregiver relationships and healthy development that lead to school readiness and future success. Given that nearly half of young children in the U.S., and and more than half of children of color, are covered under Medicaid and CHIP, these programs have a central role to play in promoting equitable outcomes for all young children; supporting children, families, and pediatric care providers; and in sparking innovation in the field.  

Over the last 18 months, a workgroup of nine states—California, Kansas, Maine, Massachusetts, New York, Nevada, North Carolina, Virginia, and Wisconsin—used the Blueprint, their shared experience, and customized technical assistance to implement new Medicaid and CHIP policies and payment procedures. This blog series will share the successes and lessons from different states in the workgroup in hopes that more states will join them in leveraging Medicaid and CHIP financing to promote the social and emotional health of young children. We thank them for sharing their work and for their commitment to the healthy development of young children. First up in this series is the North Carolina story.

Once Upon a Time

So many well-loved stories of early childhood begin with the words “once upon a time” and go on to tell fairy tales of fantastic adventure. Here in North Carolina, we are excited to share our own early childhood story—one that is certainly adventurous and promises real benefits for young children and their caregivers.

Our story opens with the 2019 release of North Carolina’s Early Childhood Action Plan, devoted to ensuring that the state’s youngest children are “healthy, safe and nurtured, learning, and ready to succeed.” To advance this vision, the NC Department of Health and Human Services (NCDHHS) joined forces with early childhood experts, pediatric care providers, families, and many partners, to set objectives and identify smart, cross-sector, evidence-informed investments that can improve outcomes for young children. 

One such investment is Reach Out and Read, a national model endorsed by the American Academy of Pediatrics, that is an effective strategy for improving child health outcomes by incorporating early literacy promotion into primary health care. At every well-visit from infancy through age 5, a trained pediatric provider enters the exam room with a new, age- and culturally-appropriate book, which is used as a tool for assessing child development and modeling positive caregiver-child interactions. During the visit, the provider discusses the brain-building power of shared reading and offers caregivers guidance on incorporating this vital activity into the child’s routine to promote social and emotional health. The child takes the book home, enabling the family to follow the daily “prescription for reading” and build a literacy-rich environment at home.

Considering the growing public appreciation of the connection between early social and emotional health and school readiness, the time seemed ripe to support the expansion of Reach Out and Read throughout NC.

Our story continues with the need to find a flexible financing option to support this idea.  A promising opportunity soon materialized: NCDHHS and select partners were invited to join a philanthropic initiative, Pediatrics Supporting Parents, designed to help states leverage Medicaid and CHIP (called NC Health Choice in North Carolina) as financing mechanisms to transform pediatric primary care. One strategy—the Health Services Initiative—was identified as an option that could  help North Carolina expand Reach Out and Read by matching  a portion of state “non-coverage” expenditures with CHIP federal funds to implement child health improvement activities. We were encouraged by a similar effort in Oklahoma and hoped to build on their previous success.

Books? At a Time Like This?

And then, our state, along with the nation and the world, found ourselves facing an overriding obstacle: the COVID-19 pandemic and its economic fallout. Families, immersed in worry and financial uncertainty, were confronting unrelenting stress that could have enduring negative effects on their children’s health and development. At the same time, public health experts were expressing grave concerns about a dramatic decline in well-child visits and the racial inequities exposed by the COVID pandemic and what that could mean for routine immunizations and other preventive care. Was it wise to push forward? Books? At a time like this? 

Our state responded with a resounding “yes!” Promoting well-child care became paramount to making sure children receive all necessary preventive care to remain healthy, stay on-track developmentally, and receive appropriate immunizations. Additionally, at a time like this, parent-child rituals like reading aloud together would help foster feelings of safety and security, helping caregivers and children cope with adversity and build resilience. Moving ahead with the Health Services Initiative would be more important than ever.

Timing Couldn’t Be Better

Our team collaborated with Reach Out and Read on the development of a CHIP State Plan Amendment, making the case for expanding the model to all 100 North Carolina counties. Reach Out and Read will train 120 more health care providers to reach 30,000 additional children in a total of 380 clinical sites. All clinics will now begin Reach Out and Read at birth, adding 3-4 more visits before the traditional start of the program at 6 months of age, to get the full developmental advantage of the language-rich interactions that come with reading aloud each day. At the same time, we will focus on ensuring program quality and will measure health outcomes to show the direct impact of this work. The state received federal CMS approval in short order and we are well-positioned for the approximately $3.1 million Health Services Initiative to elevate the standard of pediatric primary care in North Carolina. In addition, under the Families First Coronavirus Response Act signed into law in March 2020, a temporary bump in the federal Medicaid matching rate, effective through the COVID-19 emergency period, will make it even t easier for North Carolina to make this investment.

Not “The End”

Familiar children’s stories conclude with the words “happily ever after,” but we are not at all ready to close the book on our budding partnership of policymakers, child advocates, and health care practitioners. It is not “The End” by a long shot; rather, we are marking a new beginning for improving care for all of North Carolina’s young children and their caregivers.

Ror Logo BlogTo hear more about how policymakers and practitioners collaborated to implement this innovative financing approach, listen in to a recent Reach Out and Read podcast as Dr. Mandy Cohen, Secretary of North Carolina Department of Health and Human Services and Dr. Elizabeth Erickson, Medical Director of Family Connect-Durham, discuss this accomplishment with host Dr. Dipesh Navsaria—himself a Reach Out and Read pediatrician and children’s librarian.

This blog was written by Emma Sandoe, PhD, Associate Director, Strategy and Planning, Division of Health Benefits, North Carolina Department of Health and Human Services and Anna Miller-Fitzwater, MD, MPH, FAAP, Clinical Assistant Professor, Department of Pediatrics, Wake Forest University School of Medicine, Medical Director of Reach Out and Read NC with Donna Cohen Ross, for the Pediatrics Supporting Parents TA Team. Image courtesy of Reach Out and Read.