2023 Community Benefit Reporting

Once every three years, we conduct a Community Health Needs Assessment (CHNA) in compliance with requirements in the Affordable Care Act. The CHNA allows us to obtain a comprehensive data set on the health status, behaviors and needs of children in our community, which for this assessment includes the three counties in the state of Delaware (New Castle, Kent and Sussex). This data set allows us to develop a focused plan to address community health needs. We began this process in 2012–2013 and continued with new CHNAs in 2016 and 2019. This report details the most recent CHNA conducted in 2022, which identifies where we will be focusing our efforts through the delivery of pediatric healthcare services from 2023-2025.

Nemours Children’s Hospital, Delaware 2022 Community Health Needs Assessment (PDFs)

• 2022 Full Assessment
• Delaware Valley Implementation Plan (2023–2025)
• 2023 Progress Report

Unmet Community Health Needs

As required by House Substitute 1 for House Bill 326 and as reported by our 2022 CHNA key findings, unmet community health needs include:

Income and Poverty

Income and poverty vary greatly across our priority communities, with Wilmington and Dover residents being most affected. While these areas show the highest need, other parts of Delaware also experience significant challenges.

Residents of Dover have the highest percentage of children living in poverty, with 40.1% of children affected. This is significantly higher than the statewide percentage of 17.2% for Delaware. Additionally, Wilmington reported the lowest median household income of $45,139, which is notably lower than Delaware's overall median household income of $69,100. These statistics are based on data from the American Community Survey covering the years 2016 to 2020.

Youth Activities and Opportunities

The top priority area under the Social Determinants of Health (SDOH) is youth activities and opportunities. Data from the 2019 National Survey of Children’s Health indicates that 75.2% of Delaware children aged 6 to 17 years participated in organized activities outside of school, which is slightly lower than the national average of 77.5%.

Affordable Housing and Food Insecurity

Alongside issues related to income and poverty, food insecurity and housing concerns were significant issues identified by the survey participants. Delaware has not achieved the Healthy People 2030 objective of reducing household food insecurity to 0%.

The rising cost of housing was noted not only by the prioritization of housing as a top concern, but also by the data. According to the American Community Survey 2016–2020, more than half of renters in Dover (58.4%) and Wilmington (53.1%) spent 30% or more of their household income on rent as compared to less than half in Delaware (49.2%). Homeownership, or lack thereof, was also a concern in Wilmington with a smaller percentage of housing units occupied by homeowners (43.8%) as compared to Delaware overall (71.4%).

Crime and Neighborhood Safety

Issues of crime and safety are of particular concern across the state. The concerns were supported by quantitative data collected from the FBI Uniform Crime Report, showing a violent crime rate in pockets of the state that is more than three times higher than state and national averages. According to the 2019 data, the violent crime rate in Wilmington was 1,590.6 per 100,000 population as compared to 431.9 per 100,000 in Delaware overall.

Mental Health and Trauma

Mental health, including access to mental health services, continues to be a top concern among community members. These concerns were also validated by quantitative data collected. Mental health and trauma are and will remain a top priority for program and policy work across Nemours due to visibility from the CHNA efforts in 2016 and 2019.

Education

Access to affordable quality education was ranked as the fourth priority area that emerged under SDOH. According to the 2018 edition of the Quality Counts report, Delaware spends less on public education than nearby states, and also had lower outcomes. Only 29.5% of students in Delaware are at or above the National Association of Educational Procurement’s (NAEP) 8th grade math proficiency level, and just 31.1% are at or above the NAEP 8th grade reading proficiency level — compared to 46.2% and 40.6%, respectively, in neighboring New Jersey. In addition, while 60% of the Delaware adult population has earned at least some postsecondary education, only 41% of Delaware’s adult population has received a two-year, four-year or graduate degree. National data from the Bureau of Labor Statistics show lower levels of educational attainment are correlated with lower earnings and higher unemployment rates — which is linked to adverse health outcomes across the lifespan.

Summary Focus: Violence Prevention and Food Insecurity

Given these identified needs, our two areas of focus will be violence prevention and food insecurity. In addition, Nemours will continue to support additional work under the Whole Child Health Model of Care, including making strides in behavioral health efforts such as integrating behavioral health care into the fabric of primary care across our health care system.

By concentrating our efforts on violence prevention, we aim to partner with other governmental and community stakeholders to strive to reduce the high rates of violent crime, particularly in areas like Wilmington where the rates are significantly above state and national averages. This will involve community engagement, educational programs and partnerships with local law enforcement to create safer neighborhoods for Delaware's children and families.

Addressing food insecurity is equally critical, especially as Delaware has yet to meet the Healthy People 2030 objectives. We will work on partnering initiatives that ensure consistent access to nutritious food for all families, thereby improving overall health outcomes and supporting the well-being of children who are most at risk.

Furthermore, our commitment to the Whole Child Health Model of Care will ensure that we are addressing the holistic needs of children. By integrating behavioral health care into primary care, we can provide comprehensive support that addresses both physical and mental health, fostering resilience and improving long-term outcomes for every child in our care.

As required by House Substitute 1 to House Bill 326, below are brief descriptions of programs Nemours has implemented, in addition to those outlined in our CHNA 2023 Progress Report to track and reduce health disparities. 

Asthma Home Visiting Program

With support from the Highmark Blue Cross Blue Shield Delaware BluePrints for the Community grants program, Nemours is implementing a community health worker home visiting program across the state focused on improving access to health care, clinical outcomes and stewardship of medical expenses for children with asthma. Any child with asthma being seen by Nemours primary care and enrolled in the Delaware Medicaid program is eligible to receive services. Since the program began in March 2024, it has enrolled 120 patients that have received approximately 250 home visits. Home visits include asthma self-management education, home environmental assessments and access to a variety of supplies such as air purifiers, mattress and pillow encasements, vacuums and cleaning materials. In the coming year, we will expand these efforts through additional funding from the Delaware Division of Public Health’s Advancing Health Equity in Asthma Control through EXHALE Strategies program.

Community Health Education

In 2023, Nemours established a Delaware-based Community Health Education (CHE) that would collaborate with community-based organizations to facilitate health education on a variety of topics important to the health and well-being of young people across the state. Our partners have included schools, libraries, community centers, Boys & Girls Clubs and many others. During 2024, the CHE team took part in more than 150 individual health education events attended by more than 8,000 participants. Event topics included asthma, healthy eating, living and relationships, human papillomavirus (HPV), hygiene, lactation and breastfeeding, mental health, opioid use, oral health, sports safety, substance use, vaping and other topics. These events are open to the public at no cost. We look forward to building on this success during 2025.

Infant Formula Resources

Infant formula is often a critical resource during the first year of a child’s life. It can also be one of the most expensive. To address this challenge, Nemours and numerous other organizations have partnered with the Office of the Lieutenant Governor to provide FDA-approved canisters of infant formula free of charge to any Delaware family with an infant up to 12 months. At this time, we are distributing the formula at our Jessup Street location. This service along with federal government programs including Women, Infants, and Children (WIC) and Supplemental Nutrition Assistance Program (SNAP) are essential strategies to reduce food insecurity among at-risk families in our state raising young children. 

Medical-Legal Partnership

Medical-legal partnership (MLP) is a novel intervention that partners health care providers with legal aid attorneys to recognize and address health-harming legal needs (HHLN). HHLN are social determinants of health (SDOH) such as housing conditions and food insecurity that contribute to disparities in health outcomes. The partnership involves a clinical team provider such as a physician or social worker recognizing a health harming legal need, referring the family to a legal aid attorney, legal intake and history gathering, and provision of a “dose” of legal intervention (includes such services as community referral, legal advice, letter on the family’s behalf or full court representation if needed). It not only helps address the SDOH that impact health disparities, but it also helps ensure equitable access to legal support services. There is a growing body of evidence supporting the positive legal, health and economic outcomes attributable to the improvement of HHLN through legal aid intervention.

Starting in 2022, First Lady Tracey Quillen Carney’s First Chance Delaware and Delaware Community Legal Aid, Inc (CLASI) received $250,000 from Casey Family Programs to establish a one-year pilot of neighborhood-focused civil legal aid services for families at the Nemours Children’s Health, Jessup Street location in partnership with the Stubbs Family Center, together comprising the “Wilmington Community of Hope.” That funding has since transitioned to Nemours investments to maintain a MLP between CLASI and our Jessup Street location, which provides free legal services to families impacted by health disparities and SDOH. Referrals to the MLP can be any family with a child under 21 years of age who receives primary care at Nemours Children’s Health, Jessup Street with income less than 200% of the federal poverty level and at least one HHLN on our screener.  

In 2025, we will be expanding legal services through our community health worker home visiting asthma program, our program for children with medical complexity and our primary care location at St. Francis Hospital. Nemours resources are also being invested to evaluate the impact of this program on SDOH and health outcomes. MLP also has important implications for recognizing patterns of social need in families impacted by health disparities and addressing these needs through legislative advocacy.

On-Demand Ear, Nose and Throat Program

The Oto on-demand program is a clinical project that aims to address disparities in access to care for routine pediatric otolaryngology (Ear, Nose & Throat/ENT) issues by leveraging a collaborative effort between general pediatrics and pediatric ENT. The program offers on-demand virtual services for appropriately selected patients and families dealing with recurrent otitis media (middle ear infections) and adenotonsillar disease (tonsillitis), which may require surgical intervention. We see families in conjunction with the referring pediatrician, who facilitates video otoscopic (examination of the ear canal, eardrum and middle ear) or oral cavity exams. This care model ensures timely access for underserved patient populations, eliminating the need for additional days off work or travel. Our goal is to expand this service to our pediatric practices in southern Delaware. This program is one of an increasing number of innovative care delivery initiatives developed by our clinical teams that seek to reduce the impact of health-related social needs, such as accessing reliable transportation.

School-Based Health 

Nemours operates 17 school-based health centers (SBHC) in elementary and middle schools across Delaware. With support from Colonial School District, Nemours launched its first SBHC during the 2021–22 school year. We have since expanded to Seaford School District and Christina School District. We provide a variety of services regardless of a family’s ability to pay, including well exams and sports physicals, sick visits, preventative health care including immunizations and health education, behavioral health counseling, nutrition counseling, and assistance applying for insurance programs and other health and social services. SBHCs are a supplementary care setting to primary care and play an important role facilitating services where children spend a large portion of their time, while reducing the need for school absences.

In addition, Nemours developed the Data Access for Student Health (D.A.S.H.) program in collaboration with Colonial School District, Delaware Health Information Network and The Data Service Center. With parental consent, D.A.S.H. facilitates the sharing of school attendance data with primary care providers across the state. For children who are part of our primary care network, Nemours receives alerts when students accrue a threshold of absences. Our care teams then contact the child’s parent and school to develop a holistic care plan that seeks to address root causes of absenteeism. Nemours plans to expand D.A.S.H. to additional school districts in 2025.

Social Needs Screening and Referral

Nemours has refined its strategies to make a positive impact on the social determinants of health (SDOH) and health-related social needs (HRSN) of its patients via a screening tool administered to Delaware primary care patients since 2020.  

While screening for social needs is a critical first step, the provisioning of resources and support to families is ever more important. Nemours has a multi-tiered approach providing support for needs from including providing printed resource lists and contact information during a visit to escalating the family for support from care coordination and social work. Most recently, Nemours developed a partnership with Delaware Helpline, Inc. (Delaware 211) in 2023 to expand the resources we have available. Families can receive a referral to resources available in their specific communities. For example, we may provide a referral to a food bank in their neighborhood if they express concern with the availability of food. In addition, Delaware 211 can notify Nemours if the family actually received the referred service and provide additional supports based on their interaction with each family. This work demonstrates how Nemours pairs its high-quality medical services with social support resources to holistically serve the needs of patient families.

Teen Pregnancy Collaboration

Timely prenatal care is essential for the health of both the mother and the baby. It supports early detection and management of potential health issues, reduces the risk of complications and ensures better health outcomes. Several years ago, Nemours found that a significant number of its adolescent patients attending primary care sick visits were pregnant. We also determined that many of these patients did not have an established relationship with an obstetrics provider. As a result, Nemours now offers these patients a warm handoff to Christiana Care’s Healthy Beginning maternal health care program. We hope facilitating this connection promotes more coordinated care and healthier pregnancies while decreasing preventable emergency department use and infant mortality.

Nemours Children’s Reading BrightStart!

In January 2023, Reading BrightStart! re-energized our partnership with the United Way of Delaware and the Get Delaware Reading Campaign. More than 15 teachers from pre-K providers within New Castle County Head Start and Children and Families First were trained to implement the Level One curriculum in their classrooms in the spring of 2023. A staff member at Stubbs Early Learning Center also became a trainer to support usage of the Level Two curriculum in multiple classrooms at their school. Towards the end of 2023, yet another teacher training was conducted in Dover at Children and Families First to support classrooms utilizing the curriculum in spring 2024. 

In addition to the work with the United Way of Delaware, the Nemours Children’s BrightStart! became members of the DE Early Literacy Workgroup of the Delaware Readiness Team. This is a statewide initiative of volunteer-based teams that strengthens communities at a local level and helps children from birth through age eight get ready for school and life. We meet with the team monthly to stay abreast of work related to literacy in Delaware. 

Healthy Kids, Healthy Future Technical Assistance Program

Through the Healthy Kids, Healthy Future Technical Assistance Program (HKHF TAP) funded by a Cooperative Agreement with the Centers for Disease Control and Prevention, Nemours Children’s partnered with Rodel and the Delaware Readiness Teams to promote and align child health and wellness initiatives in Delaware from 2022–2024. Under this program, Rodel was awarded a total of $165,813 to lead these efforts. Rodel implemented a state action plan to promote healthy habits in Early Care and Education (ECE) settings and centered their efforts on the Delaware Readiness Teams’ focus areas of Healthy Children and Developmental Screening and Family Empowerment. Through HKHF TAP, Rodel completed the following activities:

• Rodel established a working group of around 60 state and local partners focused on healthy eating and physical activity and assessed healthy eating and physical activity resources in the state through a landscape assessment.
• Rodel hosted family and community events where they highlighted local resources to support health and wellness. Through these efforts, they organized two community health fairs, as well as several kindergarten readiness events and an early childhood literacy event in collaboration with the Nemours Children’s Reading BrightStart! team.
• In 2021, Delaware passed new early childhood legislation that focuses on healthy development and systems change, including requirements for developmental and lead screenings. Through HKHF TAP, Rodel supported implementation of the new statewide developmental screening initiative that went into effect on July 1, 2023, and integrated healthy eating and physical activity messaging into ECE trainer, provider and family resources and other materials. Rodel assembled and distributed approximately 350 developmental screening bags to provide families with a variety of materials needed to complete the screening questionnaire to assess their child’s growth and development.
• In 2023, Delaware built state-wide capacity for physical activity training for ECE providers through Nemours Children’s Physical Activity Learning Sessions (PALS), a training package for ECE and health training and technical assistance staff on best practices for physical activity. Seventeen (17) Individuals from the professional development organization in Delaware (DIEEC) and other organizations became trainers, and PALS is now integrated into Delaware’s professional development system. On June 1, 2024, Rodel hosted an in-person PALS training for ECE Providers. Attendees received training on the PALS curriculum and resources to support active play in their programs. Rodel planned to follow up with the ECE programs by asking them to complete a survey to see how the training and materials have supported increasing physical activity in their programs.
• Through HKHF TAP, Nemours Children’s offers an annual opportunity for states to participate in a curated, time-bound set of Springboard Opportunities. Over the last two years, Rodel has submitted a request on behalf of Delaware to participate in several Springboards, which include:
  • Early Childhood Outdoor Learning Environments Certificate Course provided by North Carolina State University; and
  • Gardening with Young Children Certificate Course provided by North Carolina State University; and
  • Health Equity Training and Technical Assistance provided by the Institute for Public Health Innovation.