The Snohomish Health District (SHD) serves one of the most populous counties in Washington State with over 800,000 residents. Snohomish County lies North of King County and South of Skagit County. People of color make up 29% of the county’s population. Approximately 20% of Snohomish County families speak a language other than English at home, and in 2017, 8.8% of residents and over 11% of children were living under the Federal Poverty Level.

SHD’s Child Care Health Outreach Program (CCHOP) is a multidisciplinary team of health professionals - including a public health nurse, environmental health specialist, nutritionist and behavioral health specialist - that has provided health and safety services to child care providers in Snohomish County for over 20 years. This multi-disciplinary team approach is only similarly modeled in 3 other counties in Washington State and broadens the reach and impact of our work as child care health consultants providing communicable disease response in a pandemic.

 One of the pivotal ways SHD’s CCHOP responded to the COVID-19 pandemic was by creating an online training course to disseminate accurate COVID-19 guidance practices for child care providers caring for children in Washington State. The course provides upstream prevention strategies for controlling the spread of the virus in a child care environment. The course was launched May 29, 2020 and has since had 2,166 users. Child care providers from over 35 counties in Washington State have completed this course with a total of 1,129 users in counties outside of Snohomish County as of September 2020. Child care providers are offered one in-service credit for taking the course, contributing to their annual in-service credit requirements. Due to partnership with the American Academy of Pediatrics Washington Chapter (WCAAP), this course is being offered free of charge for all child care providers in our state. We are acutely aware of the health inequities in our community which motivated us to offer a free course at the state-wide level, ensuring financial or geographic barriers did not prohibit providers from accessing the course. 

SHD’s CCHOP is committed to upstream prevention of health and safety concerns, such as disease spread mitigation of SARS-CoV-2. The imperative to provide accurate information in the wake of a pandemic cannot be overstated. The learning course supports this goal of preventing disease spread and outbreaks in child care facilities. CCHOP health and safety classes have been offered for over 20 years and are a go-to source for learning and in-service credit by child care providers. It is through this platform that the COVID-19 course has been launched. CCHOP has leaned on its community partners to help share this course opportunity with as many child care providers as possible. The longstanding relationships CCHOP has with child care providers and community partners has aided our ability to provide COVID-19 best practices as trusted health and safety professionals in our community and state at large. 

On January 21st, 2020, the Centers for Disease Control announced a Snohomish County man to be the first positive COVID-19 case in the United States. As the virus spread and the pandemic evolved, SHD's CCHOP saw the need to quickly disseminate accurate information, given the abundance of information circulating in the news and on social media, much not from reputable sources. The COVID-19 learning course was an effective and innovative approach to quickly disseminate information to a large number of child care providers needing COVID-19 guidance and best practices, all with the goal of maintaining safe centers and curbing the spread of the virus in child care facilities. SHD's CCHOP is committed to upstream prevention of health and safety concerns, such as disease spread mitigation of SARS-CoV-2. The need for accurate information in response to the COVID-19 outbreak was the catalyst for this course, and supports the goal of disease spread prevention and response in the early learning environment.

More than ever, a stable and safe place for kids to be while parents and caregivers are at work is important for the mental, physical, and emotional health of our children. Child care remains a critical place for children to thrive, grow and develop. Offering safe and quality child care and early learning environments in the midst of the COVID-19 pandemic is vital to our community. With over 5,550 child care facilities in Washington State (as of 2018) including 506 licensed child care facilities in Snohomish County, we knew the broad scope of this task and what it would take to meet the needs of this community. Given the need for child care facilities to remain open as businesses supporting essential workers and the complexity of maintaining COVID-19 protocols in centers where young children congregate, the challenge --  along with the need for subject-matter expertice and guidance -- was apparent. With some facilities temporarily closing in phase 1, phase 2 saw additional child care facilities reopening and the need for consulting and communicable disease prevention and guidance expanded with this increase in operating facilities. Ensuring that child care providers have the resources they need to maintain the high level of quality care in their facilities is imperative to keeping our children and community safe. We believe the COVID-19 class has played a vital role in advocating for these outcomes. 

Another way our practice has shown itself innovative is through the modification of course content as the needs and situation of the pandemic evolve. Due to the decreasing number of children receiving preventative well child visits and immunizations during the COVID-19 pandemic, SHD responded by updating the course content to emphasize the importance of a medical home and a primary care provider, while reminding caregivers and families that clinics have made changes to ensure children are safe as they seek medical care during the pandemic. Child care providers are also reminded of their unique position to advocate for children not already linked with these vital services. When it comes to immunization rates, the course speaks to the steep drop in immunization rates seen in 2020 which leaves children vulnerable to preventable diseases. Once again, child care providers are reminded of their strong voice for supporting the immunization rates that protect children from illness. And as COVID-19 guidance and recommendations change as we learn more about the virus, the course is updated to reflect accurate information.

In order to target underserved communities, we have offered this course free of charge to all child care providers in Washington State and have widely broadcasted the availability of this course through early learning networks such as licensors and early learning coalitions to ensure all providers have access to this course. In early 2019, CCHOP moved from a distant learning or in-person learning format to an online learning format. This online learning format has enormously aided our ability to address the need for virtual, broad and quick distribution of information during the COVID-19 pandemic.

To sustain our practice, SHD staff outside of CCHOP were recruited and have contributed enormously to sustaining this course. An SHD Maternal and Child Health public health nurse has assisted with grading of the written response question of the course. The final exam is graded electronically to minimize staff labor, but a written response is required for in-service credit. Additionally, SHD's communication department supported the creation of an electronic flyer (see "supporting documents") which has been essential for quick and efficient dissemination of the course.

The need for evidence-based information to be circulated in our community and among child care providers is imperative. Within CCHOP, a public health nurse and environmental health specialist have generated and maintain course content to support best practices. Course content includes how the virus spreads and methods of control, guidelines for limiting exposure in child care centers, review of up-to-date guidance for engaging in regular daily child care activities while practicing physical distancing and sanitation, what to do if there is a case of COVID-19 associated with a child care, and COVID-19 resources. All this information represents evidence-based practices outlined by Washington State Department of Health, the Snohomish Health District, Centers for Disease Control, and other reputable resources. 

CCHOP has continually pursued its mission to lead in upstream promotion of healthy early childhood development through collaborative population-based interventions that support and educate the child care community. This project is one example of the efforts made by our team to foster this mission. Our goals from the onset of the pandemic were to share COVID-19 disease prevention strategies and recommendations with as many state child care facilities as possible. We partnered with WCAAP, the Coalition for Safety and Health in Early Learning, and a variety of local and state community partners in order to launch and disseminate this course. In fact, a coalition of state leaders determined that the highest need in the early learning environment during the COVID-19 pandemic was to offer child care providers credible, evidence-based information on providing care safely during these unprecedented times. A planning committee was formed to identify the scope of work and funding needed to make this a reality.

WCAAP has played a pivotal role in making this project financially sustainable. With an increased number of users taking this course due to this funding, we expanded our advertising of the course to ensure as many providers had access to this resource. We invited several of our community partners -- including state licensors, the Snohomish County Early Learning Coalition, Early Achievers, Schools Out Washington, neighboring local health jurisdictions, and the Department of Children, Youth and Families (DCYF) -  to share the free COVID-19 class with their partners and providers via a flyer produced by SHD's communication team. 

The value of strong relationships between SHD and child care providers or community partners cannot be understated. As trust is strengthened among partners, ongoing communication has allowed for the wide-spread distribution of this learning resource. Trusting relationships are the foundation for positive change and effective collaboration, and the decades-long relationships SHD (with CCHOP) has with Snohomish County and Washington State partners has been pivotal for sustained implementation of this project. Through our focus on building relationships, CCHOP engages and works with early learning partners, child care providers, pediatricians and families in our community. Throughout the pandemic, CCHOP has shown its commitment to the community, guiding countless child care providers and partners on COVID-19 response protocols for facilities via phone consultations, email correspondence, newsletters and health alerts. CCHOP's COVID-19 guidance and support has contributed immeasurably to our successful COVID-19 response during a most unprecedented year. 

Examples of our community commitment are seen in how we partner with child care facilities to address the unique health, safety and child development questions or concerns of providers and affirm efforts being made to protect and promote the health and well-being of children in our community. We work alongside community members and partners to identify strengths, needs and next steps that align with best practices. CCHOP conducts hundreds of health consultations with child care providers each year on a variety of health and safety-related topics. An internal study of CCOHP’s effectiveness demonstrated 94% of child care centers markedly improved health and safety practices as well as physical environments after receiving consultation. In October 2002, CCHOP received an award from the Washington State Association of Local and Public Health Officials for “developing innovative and effective programs and representing outstanding contributions to public health.” These are examples and indicators of CCHOP's efficacy as health and safety experts leading our state and community in communicable disease response within the early learrning environment. We stand with child care providers and community partners, valuing their role in the community, while recognizing our need to work together to support the greatest good of individuals and Washington State at large.  

For decades, SHD has shown its commitment to community stakeholder collaboration. SHD participates in local and statewide coalitions and consortiums, distributes and receives a variety of newsletters aimed at addressing publich health issues, and leads efforts to collaborate and link partners for expansion and advancement of positive publich health outcomes. SHD also administers Maternal and Child Health (MCH) programs such as CCHOP, Children and Youth with Special Health Care Needs, Universal Developmental Screening and Trauma and Resilience. These programs are guided with an equity lens that recognize the health disparities vulnerable populations face. SHD has partnered with Therapeutic Health Services to support pregnant women and mothers struggling with mental illnesses and/or substance misuse to build positive parenting skills. We have worked with Program for Early Parenting Support, Cocoon House and Crossroads Alternative High School to support at-risk youth mothers receiving parenting support. Through our Trauma and Resilience program, we facilitate the Neuroscience, Epigenetics, ACEs – Adverse Childhood Experiences – & Resilience (NEAR) Collaborative. With SHD’s MCH leadership, the NEAR Collaborative boasts successful community entry and engagement with the Compact of Free Association (COFA) Pacific Islander Community and has begun building a relationship with the Communities of Color Coalition (C3) as well as the Snohomish County Latino Coalition. In 2018 and 2019, the NEAR Collaborative supported event programming for the COFA Islander Health Fair, where in 2019, over 200 people accessed services such as health insurance navigation, health screening, and mobile dental treatment. SHD is rooted in the community, provides statewide leadership, and is committed to partnerships and programs that address health equity in our community. 

Within our practice, the same commitment to ensuring equitable access to health information and services is evident. Since CCHOP's launch of the COVID-19 class, the course has been offered free of charge with an in-service credit to all child care providers in Washington State. From the beginning, it was vital to our team to ensure all providers had access to COVID-19 best practices. Partnership with WCAAP allowed us to increase user participation in the course and continue offering the course for free, further addressing health inequities in our community. These are examples of just some of the benefits that have come about as we have partnered with community stakeholders in this practice. 

CCHOP, within SHD, has innovatively and adaptively generated a COVID-19 course for child care providers to address an unprecidented and ever evolving pandemic. Child care providers in Washington State have been significantly impacted by the pandemic, and we are the first in the state to offer a training course such as this to address a great need for COVID-19 education and response. As far as we are aware, we are still the sole providers of a training course addressing this population and need, and the course continues to be offered to all counties in Washington State, not only our own local health jurisdiction.

Quality improvement is vital to the success and sustainability of any practice. For our project, steps have routinely been taken to adopt changes that make the COVID-19 learning course more sustainable, to ensure program tasks unrelated to the practice are adequately maintained, and to prioritize efforts are made to reduce inequitable health outcomes. 

To address sustainability, partnership with WCAAP has allowed for this course to be offered free of charge to child care providers in our state. It was imperative to our team to offer a free course such that financial limitations would not prohibit providers from taking this course. In the wake of the pandemic, child care providers have faced reduced tuition revenue with increasing costs related to cleaning demands and supplies. In addition, COVID-19 guidance recommends smaller class sizes for facilities, increasing staffing needs. And in the event of a COVID-19 outbreak in a facility or insufficient staffing to keep the facility open, child care providers are faced with another financial obsticle to overcome. These financial burdens, the risk of some facilities having to permanently close, and the desire to minimize any financial or practical barries that would prevent child care providers from accessing the course, are reasons it was a priority for our team to offer the COVID-19 class free of charge.

Sustainability was also pursued through SHD's reallocation of staffing and resources, as previously mentioned, to ensure this project would thrive in the midst of an arduous pandemic while also allowing non-COVID program activities to continue without negative impact. 

To address health equities, CCHOP conducts regular reports to assess priority needs within our community and the state at large. As of 2018, approximately 93% of child care providers in Washington State speak English, with 38% bilingual or multilingual providers. 7% of child care providers do not speak English and predominately reside in Central and Eastern Washington. They account for 2% of overall child care capacity. At this time, the COVID-19 class is available in English and we are looking at ways to offer the course in other languages to address the 7% of child care providers in Washington State that do not speak English. The online learning courses are self-paced, allowing providers to access the training course at a time that is convenient for them and supports more providers accessing the material. The online learning format ensures that physical distance is not a barrier for providers to access an in-person learning course. It also ensures the safety of SHD staff and providers to maintain a remote learning environment throughout a pandemic. 

We have learned that online learning courses offered with in-service credit are efficient and effective modes of transmitting reputable information to a broad audience. The public health impacts of this practice are substantial, with disease prevention at the forefront of these efforts. In fact, CCHOP was birthed out of a need identified within SHD to curb and prevent communicable disease outbreaks presenting within child care facilities. As a result, CCHOP is critically positioned to not only provide needed guidance for early learning providers experiencing disease outbreak or other health and safety concerns, but to provide upstream disease prevention and health and safety promotion, working for the well-being of our community today and tomorrow.  

In closing, we are grateful for the opportunity given by of National Association of County and City Health Officials (NACCHO) to apply for the 2021 Innovative Practice Award. We greatly value NACCHO’s efforts to advance the public health impact in communities by advocating for the 3000 local health departments in our nation. We are incredibly thankful for the community partnerships that have made our project what it is. As it has been said from the beginning, “we are in this together,” and together, a project like the COVID-19 learning course for child care providers has seen widespread impact as a result of public health professionals and early learning partners coming together for the well-being of our state and communities. We would be amiss to not mention the tireless work of other local health departments doing innovative work in our country in response to the pandemic. For these groups, we are also proud and grateful. 

Given the Child Care Health Outreach Program’s innovative COVID-19 learning course, partnerships, and commitment to quality improvement as leaders of health in our state, we are proud of this project and are grateful for being given the opportunity to be considered as an Innovative Practice. The long-term benefits of public health as well as advancements made in the name of fighting the COVID-19 pandemic will be attributed to the collaboration of these partnering groups that align science with opportunity to empower local health departments and generate life-long community impacts. 

Sincerely, 

The Child Care Health Outreach Program