Healthy Kids Express Screening and Immunization Program

Healthy Kids Express Screening and Immunizations (HKES&I) program is a mobile clinic for children ages 1-18 years old in St. Louis City and surrounding counties. HKES&I is a site-based program, partnering with local school districts, day care centers, and Head Start programs. This program provides free health screenings to children in underserved populations, making sure to screen those grade levels that are required by law to have screening performed. Since 2000, Healthy Kids Express has provided height and weight checks, immunizations, and screenings for hearing, vision, anemia, blood lead, glucose, and cholesterol to more than 150,000 children.

To be considered for services, community sites must complete an online application. Applications are prioritized by income level of zip code in which the site resides, distance to health centers, site capacity for addressing needs, and special healthcare needs of children at the site. Throughout their operation, HKES&I seeks to implement best practices by following evidence-based practices.

HKES&I provides medical interpretation, by certified interpreters, for children and families with low English proficiency during the consent process, the screening/procedure, and during follow-up services. Families are provided written educational materials in their preferred language. Staff are educated at regular intervals on the cultural differences of the populations they serve to ensure cultural competency. All of these evidence-based practices are in line with US Department of Health and Human Services CLAS standards (US Department of Health and Human Services, Office of Minority Health). This has allowed the program to create partnerships with agencies and schools that serve Limited English Proficiency children and families, including refugee children needing to follow a catch-up vaccine schedule to become eligible to attend school.

When performing vision screenings, HKES&I implements evidence-based practices by including the components of a Comprehensive Vision Screening System. These actions follow the recommendations of the National Expert Panel of the National Center for Children's Vision and Eye Health when screening preschool aged children (Cotter, Cyert, Miller & Quinn, 2015):
- using recommended screening equipment
- having all written material reviewed by Health Literacy of Missouri, to make written material easy to understand
- sharing written and verbal results with parents that include follow-up actions
- including a list of local providers where follow-up can be obtained
- monitoring and reporting the follow up actions taken by the parents who have failed a screen
- having a fast track system in place to allow children with unequal pupil size or gaze for an immediate appointment with the local hospital ophthalmology department
- providing annual competency training and skills to its staff on the equipment used

A policy statement on instrument-based vision screening was released in 2012 by the American Academy of Pediatrics, with the sponsorship of the American Academy of Ophthalmology, the American Association for Pediatric Ophthalmology and Strabismus, and the American Association of Certified Orthoptists, stating "Instrument-based screening is quick, requires minimal cooperation of the child, and is especially useful in the preverbal, preliterate, or developmentally delayed child."

Children younger than 4 years can benefit from instrument-based screening, and visual acuity testing can be used reliably in older children (Miller & Lessin, 2012). HKES&I uses an automated instrument-based vision screener called the SPOT vision screener. This instrument allows increased accuracy in screens for the younger age while facilitating the screening of additional eye abnormalities which are not identified with vision charts, such as astigmatism (blurred vision), anisometropia (unequal refractive power), strabismus (eye misalignment), and anisocoria (unequal refractive power). HKES&I has another best practice in place; when a child can't be screened with the SPOT, or if the SPOT malfunctions, HKE implements a backup system by having the child test using a visual acuity test. This allows every child an attempt to be screened.

HKES&I ensures staff competencies by mandating staff perform annual competency skills on each piece of equipment used. Though it is not required by law to be an RN to perform these screens, HKES&I team has a large nursing staff with training to recognize problems such as abuse or neglect that go above and beyond the health screening. When children receive screenings through HKES&I program and a problem is identified, HKES&I nurses and social workers work in partnership with school nurses to monitor outcomes measures. They record the follow-up with the child's parent/guardian to help them identify the needed course of action and help them schedule a provider where possible.

References:
US Department of Health and Human Services, Office of Minority Health. (n.d). The National CLAS Standards. Retrieved December 17, 2015 from Think Cultural Health: https://www.thinkculturalhealth.hhs.gov/Content/clas.asp

Cotter, C., Cyert, L., Miller, J., Quinn, G. (2015). Vision Screening for Children 36 to <72 Months: Recommended Practices. Optometry and Vision Science, 6-16.

Miller, J., Lessin, H. (2012). Instrument-based Pediatric Vision Screening Policy Statement. Pediatrics, 983-6.

The mission of HKES&I is to increase access to needed healthcare for children. This is accomplished through the goal of identifying children who need further follow-up, particularly for hearing and vision problems, and to connect them to those services.

Healthy Kids Express Screening and Immunization program is successful in providing evidence based care to low-income populations and for connecting those identified with screening needs to needed follow-up care.

Since 2000, Healthy Kids Express has provided height and weight checks, immunizations, and screenings for hearing, vision, anemia, blood lead, glucose, and cholesterol to more than 150,000 children.

From June 2014 to May 2015, HKES&I provided services to 14,107 children. This included providing 450 immunizations, 8,343 vision screenings, and 2,767 hearing screenings. The median household income was $36,994 for zip codes where services were provided.

During this same time period, 1,238 children failed a hearing (126) or vision (1,112) exam with a high enough acuity to require follow-up. HKE social workers along with school and community partners completed follow-up with parents/guardians. Follow-up for vision and hearing screening results in a positive outcome when a parent/guardian has scheduled an exam for the child with an appropriate provider or it has been determined through an exam that no further services are necessary. A positive outcome for blood work includes providing the parent/guardian with education and resources to follow-up with their Primary Care Provider. Reasons follow-up may not end in a positive outcome include not being able to contact the parent/guardian due to wrong or missing information or the parent/guardian refusing assistance. 66% of hearing follow-up cases had a positive outcome and 68% of vision cases had a positive outcome. Social workers followed up 572 children who completed a vision exam by a vision provider, and found that 91% of needed glasses and obtained them. This is attributed to the accuracy of our screening process. 79% of the 69 children identified as having low hemoglobin and 91% of the 101 children identified as having high blood lead received a positive outcome from follow-up with HKES&I staff nurses.

HKES&I continues to keep up with new and emerging evidence such as proactively seeking ways to implement meningococcal vaccination recently required for school attendance for eighth graders in Missouri for the 2016-17 school year.