North Carolina’s Medicaid both pays for maternal depression screening (MDS) as part of well-child visits, and also offers support to providers to promote effective MDS and response to positive screens. This support includes clear guidance about conducting screening and referring the parent and child to appropriate services, resources for identifying services for the parent and dyad, learning communities for providers, and data to help the provider self-monitor the delivery of MDS. In addition, North Carolina provides access to case-management for very young children whose mothers are experiencing depression. The organization responsible for Medicaid service delivery in North Carolina, Community Care of North Carolina (CCNC), has developed a suite of policies and supports that help ensure the well-being and healthy development of infants and young children who are at-risk due to maternal depression.
A comprehensive maternal depression toolkit for screening, referral, and follow-up gives providers easy access to key resources, including background on the value of maternal depression screening; guidance on screening tools, an algorithm for deciding when and how to respond to elevated scores, and information on management and treatment options, and guidance on provider-to-provider communications about results. The toolkit highlights the need for referral of the parent and child to relationship-based dyadic treatment and to a care coordination program called CC4C (discussed below). In addition, guidance stresses the need for follow-up social-emotional screening of the child, in response to a positive parent screen.
North Carolina Medicaid helps providers improve their practices related to maternal depression screening and response in several ways. In addition to the toolkit, CCNC can provide pediatricians with materials they can use to complete a course on maternal depression and receive maintenance of certification (MOC) credit. The course covers screening policies and procedures, the negative impacts of maternal depression on the infant, and referral practices for the mother and the mother-infant dyad. Another critical support provided by CCNC is feedback to providers. Each quarter, providers receive their MDS rates so that they know their performance on this indicator. The system’s quality improvement specialists also visit practices and can help providers increase their rates by encouraging their use of the toolkit and maternal depression MOC course, and providing individualized assistance.
North Carolina Medicaid pays for up to four maternal depression screenings in the child’s first year, conducted during well-child visits. Providers bill for the screenings under the child’s Medicaid.
Monitoring and Evaluation
This suite of supports for MDS has produced high rates of screening in North Carolina. In a 14-month period ending in March 2018, MDS ranged from 72 percent to 87 percent across providers. As of the first quarter of 2019, 43 percent of mothers of 6 month olds had received at least one maternal depression screen, an increase from 38 percent in the fourth quarter of 2018.
CC4C is a case-management program for children birth to five years who are experiencing risk factors for poor health outcomes and who require health and related services beyond those required by most typically developing children. Children whose mothers are experiencing maternal depression are eligible for CC4C services. Other children who can participate in CC4C include children with behavioral and mental health conditions, children in very low income households with continuous chaos, including parent substance abuse, children in foster care, and children experiencing abuse or neglect. CC4C serves close to 10 percent of Medicaid eligible children age 0 to 5 years in North Carolina.
Enrolled children receive services in a medical home. Case managers, who are nurses or social workers, conduct an assessment of family needs with The Life Skills Progression. This tool measures the adequacy of support systems, parent education and employment, health care, mental health and substance use, and access to basic needs. Results guide efforts to secure assistance for families to meet a wide range of needs to help reduce family stress and ensure that children’s health and mental health needs are met. Case managers connect with families through home-visits, phone calls, and visits with families to the pediatrician.
A CC4C workgroup meets monthly to help guide the work of the program. Members are representatives of the NC Division of Medical Assistance, Division of Public Health Early Intervention, the physician community, and local health departments.
CC4C is financed through Medicaid and Title V (Maternal and Child Health Services Block Grant Program). Each public health department receives a “per month per member” payment based on the county population of 0-5 year olds; this payment covers full-time staff of CC4C in each county.
Monitoring and evaluation
North Carolina is currently transitioning to managed care. The NC Department of Health and Human Services has developed a plan for maintaining the core activities of CC4C. During a two-year transition period, a clinical leadership team will develop quality measures for case-management that will be carried out in managed care organizations and existing entities that operate CC4C.
Positive Parenting Program (Triple P) is an evidence-based program that teaches parents of children from birth to age 17 strategies to promote social competence and self-regulation in children. Triple P consists of five tiers, with two universal tiers designed for all parents and three tiers of targeted supports for families with greater needs. Level 1 is a community-wide media campaign. Levels 2 through 5 can be delivered in group formats, and levels 4 and 5 can be delivered individually. Triple P can be delivered in a number of settings, including the home, community agencies, healthcare settings, schools, and online. This profile provides a description of Triple P as it is being implemented state-wide in North Carolina. The state-wide profile is followed by a description of how Triple P is being delivered to families with children birth to age 5 in Mecklenburg County along with a Triple-P-based program (PECE) for staff in early care and education programs.
In 2017, North Carolina began the process of statewide implementation of Triple P. The partners in this effort include the state’s Department of Health and Human Services, Division of Social Services and Division of Public Health; The Duke Endowment; Triple P America; Frank Porter Graham Child Development Institute (FPG); and Prevent Child Abuse North Carolina.
In-person Triple P courses are offered in 48 of North Carolina’s 100 counties, with widespread implementation in approximately 36 of those counties. Originally counties could choose an age range to focus on (0-5, 0-8, or 0-17), but a commitment to serving the entire 0-17 age range has led to the scaling up of in-person course offerings for all age bands across the state. For parents unable to participate in person, Triple P is also available free online for all North Carolina parents.
For statewide implementation of Triple P, North Carolina counties have been grouped into 10 regional service coalitions, each led by a local implementing agency (LIA), typically a county public health department, and comprised of local family service agencies, schools, and organizations that deliver Triple P services. Each LIA is staffed with at least three full-time positions to coordinate and support community-wide implementation with fidelity to the Triple P model. These coordinators work with Triple P service providers in the area on implementation planning; outreach to parents and practitioners; practitioner training and fidelity support; and data collection and reporting.
Triple P coordinators also participate in the North Carolina Triple P State Learning Collaborative (SLC), supported by Triple P America and the North Carolina Triple P State Leadership Team. The SLC meets quarterly to engage in county-level peer support and improve Triple P across the state.
LIAs develop contracts with the Triple P providing agencies that cover the type and number of Triple P services to be delivered, and include a commitment on the part of agencies to collect and send data to the state, commit to delivering Triple P with fidelity, provide practitioner supports and conduct outreach. Individual counties have written agreements with between 10 and 40 agencies. A wide range of service agencies deliver Triple P, including schools, mental health agencies, faith-based organizations, health departments, and pediatric practices. LIAs and agencies work together to identify gaps in services (e.g., level 2 is well-covered, but there is unmet demand for level 4) and determine whether and how to expand.
Individual Triple P practitioners are trained in cohorts of 20, with each Triple P level and format having its own, evidenced-based training. During the early stages of scaling up it was easy to recruit individuals for training. Now, when new providers are often trained to maintain the workforce and make up for attrition, LIAs help bring together individuals from different regions to comprise a 20-person cohort. Individuals with a wide range of backgrounds participate in Triple P trainings, and include paraprofessionals, child care center directors, social workers, public health professionals, parent advocates, and nurses.
Varied strategies are used in outreach to families. Triple P Level 1 is a public awareness campaign focusing on positive parenting information and messages. In North Carolina, materials have included posters, brochures, flyers in medical waiting rooms, and a parent newsletter (left in grocery stores, school districts, local papers, yoga studios). Additional methods to inform parents about Triple P have included the use of Google AdWords, press releases, movie commercials, billboards, yard signs, and banners at public events. For more intensive Triple P levels (4 and 5), mental health and social services agencies often recruit from the families they are already serving.
FPG’s Implementation Capacity for Triple P (ICTP) project supports the scale-up of Triple P by providing training and technical assistance to Triple P coordinators, Triple P agency leaders, statewide funders and policymakers, and organizations in North Carolina. It has developed implementation support plans and quality improvement tools to assist communities during the implementation process.
Funding for LIA activities, including coordination, training, outreach, and materials, comes equally from the Division of Public Health (through federal Title V Maternal and Child Health Services Block Grant funds with a state match) and from the Division of Social Services (with a legislative appropriation as a line item in the child welfare budget). Total funding from these two sources is $4 million a year. The Duke Endowment funds the FPG Implementation Capacity for Triple P project. Funding for online Triple P totals $1.7 million and comes from the federal Maternal and Child Health Block Grant and state funding through DPH and DSS.
Triple P courses provided at the local level are funded through a variety of mechanisms. LIAs work with service providers to secure funding for Triple P courses, and a wide range of models are employed. Examples include Medicaid reimbursement, agencies covering the cost themselves, and charging course participants.
Evaluation and Monitoring
A meta-analysis of more than 100 studies of Triple P found positive effects on children’s social-emotional and behavioral outcomes and parenting practices, including for children from birth to five (for information on Triple P see parenting program research summary).
Local implementing agencies are responsible for coordinating the collection of administrative and monitoring data from Triple P providers in their region. (See the profile section on Mecklenburg County for examples of data collected.)
FPG’s ICTP has also been responsible for evaluating the implementation of Triple P. An initial implementation evaluation, which included a qualitative component, focused on Cabarrus and Mecklenburg Counties from January 2014 through December 2015. ICTP conducted regional workshops to share lessons from the evaluation and support Triple P implementation across the state.
Findings from the evaluation identify a number of factors associated with counties’ successful implementation of Triple P. Agencies implementing Triple P were more likely to continue providing Triple P services during the study period when they had Triple P implementation teams of at least three members with adequate time and effort to support daily implementation and when they had more than one practitioner providing Triple P services. The evaluation also identified a need for increased use of best practices in both coaching for practitioners and fidelity assessment. The evaluation suggests use of these practices can increase the quality of delivery of Triple P services, as well as how often practitioners use Triple P with their clients. Supporting these findings on the importance of provider supports, a separate study of Triple P in seven North Carolina county or country clusters found that Triple P providers who attended peer support sessions used Triple P with more parents.
The FPG ICTP implementation evaluation also examined county-level child maltreatment indicators over time and found a two-year drop in the rate of substantiated child maltreatment reports for children birth to age 17 after Triple P practitioner training was initiated in Cabarrus County. FPG evaluators cautioned against drawing causal inferences from the outcome results since other factors may have contributed to the drop.
Another study of Triple P examined the relationship of child maltreatment indicators to state-funded implementation of Triple P in 34 of North Carolina’s 100 counties in 2012 and 2013. Comparing children birth to 18 in counties with and without Triple P implementation, findings for Triple P counties showed small but significantly greater reductions in investigated child maltreatment reports and foster care placements, but not emergency department visits for suspected child maltreatment.
The FPG ICTP also supports ongoing monitoring, which focuses on three outcomes in North Carolina counties scaling-up Triple P: substantiated child abuse and neglect, out-of-home foster care placements, and emergency department visits indicating child injury.
Mecklenburg County: Focus on Triple P for Birth to Five
In the past year more than 8,000 children age birth to five were served with Triple P in Mecklenburg, the state’s second most populous county. Nearly 4,000 children were served by Positive Early Childhood Education (PECE), an evidence-based program designed for ECE settings and introduced in Mecklenburg in 2019. PECE teaches ECE staff to use Triple P practices, and can be used in conjunction with Triple P parenting programs to provide consistent supports for children’s self-regulation and positive behavior across home and ECE settings. A total of 229 early care and education (ECE) classrooms in 28 child care facilities and 41 elementary school prekindergarten programs participated in PECE. In PECE settings, the ECE program director is trained in PECE and Triple P, while classroom staff take four online PECE modules and receive four hours of coaching. ECE programs conduct seminars with parents and refer parents with greater needs to Triple P level 3 classes.
Parents of an additional 4,800 children birth to five were served by traditional Triple P classes in the past year in community settings such as pediatric offices, churches, schools, mental health agencies, and libraries. Referrals to these classes come from child care centers, pediatric offices, public health agencies providing families with case management services, and the library system.
In cases where Triple P is delivered by a licensed clinician, level 2 can be billed to Medicaid as anticipatory guidance. Medicaid can also be billed for higher levels of Triple P if the child has a diagnosis. Stakeholders are working with the state Medicaid agency to allow trained providers who are not licensed clinicians (e.g., health educators) to bill Medicaid. Medicaid is also exploring CPT codes for Triple P-trained, licensed clinicians that would allow enhanced rates of reimbursement.
Mecklenburg County has around 500 trained Triple P providers, with 250 actively delivering Triple P. Fewer than half of Triple P providers are licensed clinicians. At lower levels, Triple P can be delivered by a variety of non-clinicians such as librarians, health educators, and non-clinical staff in pediatric settings. Training and post-training peer support for providers includes guidance about recognizing families’ needs for referrals to more intensive services, including higher levels of Triple P and parent mental health services.
Evaluation and monitoring
As part of PECE implementation, programs collect data on parent seminar participants, parent and teacher perceptions of home-school connections, and teacher perceptions of classroom climate. Parents and teachers are encouraged to submit a Strengths and Difficulties Questionnaire, which screens for children’s social-emotional problems. See above description of state-wide Triple P for information on evaluations.
Funding for Triple P training, support services, and systems coordination comes from Title V Maternal and Child Health funds, as well as an additional birth to five grant from the state’s Improving Community Outcomes for Maternal and Child Health initiative. (See description of state-wide financing, above, for other funding information.)
Special thanks to the following individuals for providing information for and reviewing this profile: Marian Earls, Director of Pediatric Programs, Community Care of North Carolina; Sara van Driel, Implementation Consultant, Triple P America; and Cathy Henderson, Health Manager, Mecklenburg County Public Health.