Virgin Islands CDC EHDI GRANT (2001)

GRANT ABSTRACT

MATERNAL AND CHILD HEALTH IMPROVEMENT PROJECTS FOR CHILDREN WITH SPECIAL HEALTH CARE NEEDS

Project Title: V.I. Universal Newborn Hearing Screening and Intervention
Project Number: CFDA #93.251
Project Director: Mavis L. Matthew, MD, MPH Phone (340) 713-9924
Fax: (340) 713-9928 E-mail: vimchstx@viaccess.net
Organization Name: Maternal Child Health & Children With Special Health Care Needs Program
Address:
V.I. Department of Health
3012 Vitraco Mall, Estate Golden Rock
St. Croix, U.S. Virgin Islands, 00820
Contact Person: C. Patricia Penn Phone (340) 776-3580
Fax: (340) 774-8633 E-Mail: CPPenn_mch@worldnet.att.net
Project Period: 4 years
From: 8/1/01 - 3/30/05

1. Organizational Setting: The Department of Health (VIDOH) is the single state agency in the Virgin Islands responsible for administering the Title V program, Maternal Child Health and Children With Special Health Care Needs (MCH&CSHCN). The proposed Universal Newborn Hearing Screening and Intervention (UNHSI) Program will be implemented in collaboration with the Part C (IDEA) Early Intervention Program for Infants and Toddlers and the Newborn Genetic / Metabolic Screening Program under the direction of the MCH & CSHCN Territorial Program Director.

2. Purpose: The primary purpose of the project is to plan, develop and fully implement a territory wide UNHSI Program by the end of Year 4 that will screen 95% of newborns before hospital discharge. The project will enable the MCH & CSHCN Program to ensure that all newborns identified with a significant hearing impairment / loss receive appropriate follow-up testing, referral for audiological diagnosis and early intervention / family support services by six months of age. The UNHSI Progam will ensure that early identification and intervention are standard medical practice for newborns in the territory identified with significant hearing loss.

3. Challenges: There are two government-operated hospitals in the territory, Juan F. Luis Hospital on St. Croix and Roy L. Schneider Hospital on St. Thomas. Newborn hearing screening was initiated at both hospitals in 1999. There are approximately 1800 births annually in the territory including home births. Presently approximately 60% of newborns are screened before hospital discharge. The fail / refer rate is approximately 30%. Initial screening is performed by Staff Audiologists (2). Newborn screening technicians will be required to provide coverage during evening, weekend and holiday hours for each hospital and the island of St. John, which has the highest home birth rate.

4.Goals and Objectives: The goals of the UNHSI will ensure that: 1) all newborns are screened for hearing impairment before hospital discharge or by one month of age; 2) referred for audiologic evaluation by three months of age and 3) are enrolled in early intervention / family support services by six months of age. These goals mirror national UNHS goals and MCHB milestones related to screening, follow-up, clinical assessment and intervention.

Primary objectives of the proposed project are to ensure: newborn hearing technicians are recruited and trained to ensure availability of screening; all infants referred for follow-up receive timely evaluation and diagnostic services; families of infants identified with hearing impairment / loss receive appropriate information and support through the diagnostic process; 100% of infants identified with hearing loss are connected to a medical home; development of a plan for screening infants who are home birthed; establishment of a UNHSI Advisory Council to advise and assist in the implementation of screening.

6. Evaluation: The newborn hearing screening database will be utilized to provide monthly and quarterly reports regarding status of screening. The reports will include data on percentage of newborns screened before hospital discharge or one month of age; percentage of newborns referred for follow-up; age at follow-up; diagnosis and referral to early intervention; and tracking and contact of parents for infants lost to follow-up. Surveys of hospital and newborn screening personnel will be used to measure project effectiveness and efficiency. Families will be requested to complete satisfaction surveys.

7. Text of Annotation: The V.I. Universal Hearing Screening and Intervention Project will be fully implemented by March 2005. The purpose of this project is to improve the number of newborns receiving hearing screening at birth and referred for appropriate diagnostic and early intervention / family support services. The project will provide training for technician screeners to increase availability of screening. Parents and pediatricians / primary care providers will be contacted to ensure that a medical home is established for every infant diagnosed with a hearing impairment / loss.

8. Key Words: Universal Newborn Hearing Screening, Early Intervention

GRANT NARRATIVE

1. Purpose of the Project

1.1 Description of the problem and magnitude of the taskThe Virgin Islands Department of Health (VIDOH), Maternal Child Health & Children With Special Health Care Needs Program (MCH&CSHCN), is applying for funding of this proposal to establish and fully implement a UNSHI Program that will provide screening, identification of hearing impairment / loss and enrollment into early intervention / family support services. The expected outcome of this project is to improve the communicative, cognitive and social outcomes of children with hearing impairment / loss. Guidelines issued by the American Academy of Pediatrics (AAP) and the Joint Committee on Infant Hearing (JCIH) will be used to form the basis for developing performance measures and monitoring and evaluation of the project's impact.

Significant bilateral hearing loss is present in approximately 1 to 3 births per 1000 newborn infants in the well baby nursery population, and in 2 to 4 in the NICU population (Source: AAP Task Force on Newborn & Infant Hearing). Undetected hearing loss can lead to significant delays in speech, language, social, emotional and academic development. National data indicates that without a newborn hearing screening system in place many of these infants would not be identified until as late as two to three years of age. By identification of hearing loss in the newborn period, families can be referred immediately for appropriate and effective treatment.

The VIDOH is committed to addressing the Healthy People 2010 national objectives to reduce significant hearing impairment. The MCH & CSHCN program currently implements a newborn hearing screening program in accordance with Maternal Child Health Bureau (MCHB) Performance Measure # 10 to reduce the morbidity associated with hearing impairment through early detection. The target goal of the MCH & CSHCN Program is to increase to 95 percent the proportion of newborns that are screened for hearing loss by one month of age, receive diagnostic evaluation by three months and enrolled in appropriate intervention services by six months by the end Year 4. Implementation of a data management system will assure standardized, accurate reporting of screening results.

1.2 Rationale and evidence supporting the proposed intervention

There are significant challenges associated with the development and implementation of this system. Newborn screening and reporting of data is not mandated by law in the Virgin Islands. Genetic and metabolic screening is routine standards of care for all live births admitted to the nursery. Hearing screening is standard of care at the Juan F. Luis Hospital on the island of St. Croix, however, screening is not a standard of medical care or a standing physician order at the Roy L. Schneider Hospital on the island of St. Thomas and parental consent is obtained for initial screening in the nursery by the audiologist (Attachment F). Development and implementation of protocols that address timely notification to parents of newborns missed in the nursery; infants who are home birthed and are not screened; confirmatory testing for newborns who fail the initial screening within one month of age; availability of newborn screening technicians and collection and reporting of data is a priority of the proposed project.

Collaborative efforts with appropriate hospital administrative, medical and nursing personnel will be undertaken as part of this effort to address and resolve these issues. Additionally, a formalized data collection, surveillance and tracking system to monitor the actual number of infants screened or referred for diagnostic evaluation, the number identified with hearing impairment and those missed or lost to follow-up will be required.

There are approximately 1800 births annually. There are two government-operated hospitals one each on St. Thomas and St.Croix. Most births occur in the hospitals (99%) with the remainder being home births. Currently, approximately 60 percent of newborns at both hospitals are screened by otoacoustic emission (OAE) before discharge. An estimated 30 percent of these fail the initial screening and are referred for retesting. Those infants who do not pass OAE retesting are referred for audiological evaluation by automated brainstem response (ABR). The Virgin Islands has a significant percentage of high-risk infants with 8-9 percent of live births being of low birth weight. The Virgin Islands currently does not have a birth defects registry or electronic birth records. This inability to link and / or share birth records contributes to inadequate data collected relative to the number of live births.

Genetic and metabolic newborn screening has been implemented successfully in the territory since 1987. The MCH & CSHCN Program has applied for funding from the CDC Cooperative Agreement for Early Hearing Detection and Intervention. The proposed funding will provide the capacity for developing a tracking and surveillance system for hearing screening through integration with the existing database newborn screening database. The proposed MCHB funding would add resources necessary to build capacity and strengthen the infrastructure to implement an effective program. This includes support personnel to carry out all proposed grant activities; dissemination of educational materials to all stakeholders; and training / in-service for appropriate hospital personnel, physicians, parents, and community based partners.

UNHS was implemented in 1999 in response to the need to identify children with hearing loss at an earlier age. Data from the Part C Early Intervention Program reported that six children were served between 1996 and 2000 with hearing impairment requiring habilitative intervention. In 1999, a survey of 696 families of children with special health care needs was conducted. Of the 395 families surveyed on the island district of St. Thomas, 8% reported hearing impairment as the major diagnostic criteria for seeking services.

1.3 Anticipated benefits

The anticipated benefits of the proposed project are: 1) all newborns in the territory including those birthed at home will receive screening for hearing loss before hospital discharge or by one month of age; 2) 100% of infants who have screened positive for hearing loss receive audiologic evaluation and diagnosis by three months and enrollment into early intervention by six months of age; 3) all infants diagnosed with a hearing impairment / loss are connected with a medical home; and 4) 100% of infants and their families will be linked with coordinated, culturally competent, family centered care. These activities together will ensure that children are developmentally, academically and socially ready to enter school.

The Department of Health is the single state agency in the Virgin Islands responsible for administering the Maternal Child Health and Children With Special Health Care Needs Program (MCH&CSHCN) pursuant to Title 19, Chapter 7, and Section 151 of the Virgin Islands Code. (ATTACHMENT E) The Maternal and Child Health Block Grant is authorized by Title V of the Social Security Act, as amended by the Omnibus Budget Reconciliation Act of 1989, Public Law 101-239. The Director of the MCH & CSHCN Program will have general oversight of the project.

The mission of the MCH & CSHCN Program is to promote quality health care for women, children, and families and assure access to services for all children, particularly high risk and special needs groups, through planning and coordination of comprehensive health services. Administration of newborn screening is facilitated by the unique organization of hospital services in the Virgin Islands. There are only two government-operated hospitals, the Governor Juan F. Luis Hospital on St. Croix, and the Roy L. Schneider Hospital on St. Thomas, which serve as the birthing facilities for the territory. A Level II nursery, each staffed with a Neonatologist, is established on both islands. Newborns requiring specialized care are transferred to Puerto Rico or the U.S. mainland. Home births are most common on the island of St. John, where boat transport is required to nearby St. Thomas.

Currently there is no legislative statute that governs newborn hearing or metabolic screening in the territory. Policy oversight is maintained at the level of the hospitals governing boards, which oversee all hospital-based services.

The Title V MCH & CSHCN Program will administer the UNHSI grant. All newborn screening activities are carried out under the auspices of the Title V Block Grant. The Director of the Newborn Genetic / Metabolic Screening and Sickle Hemoglobinopathy will serve as Project Coordinator along with Staff Audiologists (2) who will function as technical consultants. Existing office space in the MCH & CSHCN administrative office will be utilized. Project staff will work with hospitals to assure availability of screening; appropriate follow-up and treatment for identified infants. Additionally, CSHCN will collaborate with Part C to assure coordination of services with the infant's medical home.

A Memorandum of Agreement (MOA) was executed in July 1999 between the MCH & CSHCN and Part C Early Intervention Program. Organizationally, both programs are within the Division of MCH & CSHCN presently headed by the Acting Commissioner of Health / Director, MCH & CSHCN Program. Other programs within the division work together to provide preventive and primary care services for women, children and infants that will improve health outcomes. The programs are: Adolescent Health & Abstinence Education; Integrated & Coordinated Sickle Hemoglobinopathy Program; Part C (IDEA); Family Planning and the Supplemental Nutrition Program for Women & Children (WIC). Monthly divisional meetings are held with the program directors to promote communication, coordination, resource sharing, program monitoring and outreach services.

The MOA was developed as a mechanism to ensure the fair administration, supervision and implementation of UNHS. The MCH & CSHCN Program is responsible for provision of newborn screening activities, ABR testing, diagnostic and consultation services, provision of hearing aids and assistive technology and serve as the medical home for children with special health care needs. The Part C Program provides retesting of infants who fail the newborn screening and early intervention services.

The Children With Special Health Care Needs (CSHCN) component provides access to care coordination services for children with chronic or disabling conditions and diagnostic and consultative pediatric specialty care.

An Advisory Council is being established for the MCH & CSHCN UNHS program and will consist of representatives from hospitals, Part C (IDEA program, parents of hearing impaired children, Head Start, community based organizations, advocacy groups, and providers in order to ensure integration and systems development. The Council will consist of 15 members representing all four islands and will meet quarterly. Tasks of this council will include: assistance with development of guidelines to ensure an effective screening, diagnosis and intervention program; and a public awareness initiative related to the importance of early detection of hearing loss.

As previously mentioned, the UNHSI Program will be located within the MCH & CSHCN administrative office. The Project Coordinator and Title V Staff Audiologists (2) and Speech Pathologist will provide coordination, follow-up and evaluation services on an in-kind. Technical assistance for integration of the database and subsequent staff training will be provided by a Database Consultant on a contractual basis.

Part C (IDEA) Program staff and care coordinators will work with the Project Coordinator to ensure that infants and families are receiving appropriate services.

The proposed UNHSI project will have available the existing equipment used to conduct newborn hearing screening. This consists of two Otodynamics Echoport IIL0288 OAE Screeners and one Auditory Brainstem Evoked Response machine (ABR ). Presently, infants from St. Thomas travel to St. Croix or Puerto Rico for ABR testing. Expenses for this travel and audiological diagnostic services are provided by the Title V Block Grant or Part C as payer of last resort for parents who are uninsured or unable to pay. Supplies for testing are provided by the Part C Program as well as maintenance of the OAE's.

The proposed UNSHI project will have access to the newly acquired software that has been purchased for the newborn genetic/metabolic screening program. This is an Access database, which will allow easy integration of newborn hearing screening data.

The UNSHI project will also have access to the VIDOH's Information Management System that was implemented in the MCH & CSHCN clinics in May 2000. Data will be available on all children with hearing disorders territory-wide.

The University of the Virgin Islands University Affiliated Program (VIUAP) provides inter-disciplinary training to health professionals who work with children with developmental disabilities including physicians, nurses, physical and occupational therapists, social workers and other allied health professionals. The VIUAP has been designated as the lead agency for Assistive Technology responsible for developing an interagency plan of systems change and advocacy activities, designed to develop and implement a consumer responsive territory-wide program of technology related assistance for individuals with disabilities of all ages.

The target population for the proposed project is all newborns in the territory including home births and newborns that pass initial screening but have high risk factors for progressive hearing loss. The project in collaboration with the Part C Early Intervention Program will provide follow-up, care coordination and intervention services for all infants identified with hearing loss and their families.

Additional populations for training and support services are families of infants identified with significant hearing impairment / loss; audiologists; educators; pediatricians/primary care providers and all care coordinators providing service to this population. This on-going training will address the lack of awareness regarding the implications of hearing loss in the health care community and the community at large.

Cultural, language and socio-economic barriers exist in serving ethnic minorities, particularly the growing Latino population of the territory. Bilingual, culturally competent providers will be required to provide translation, educational and care coordination services. Availability of educational literature in Spanish and French Creole will assist families in understanding the need for hearing screening and identification of hearing loss at an early age. Appropriate educational material that has been developed to help parents and inform the public will be obtained from the National Center on Hearing Assessment and Management (NCHAM) and the Center for Early Intervention Professionals in Hearing Impairment at the University of North Carolina.

Difficulty in contacting families and failure to return for rescreening after hospital discharge is a major concern. This will be addressed through immediate contact of the family after discharge by phone and / or mail and a referral for a home visit by a MCH & CSHCN nurse as required.

Coordination with the Office of Vital Statistics will be utilized as a safety net to identify home births as well as collaboration with private and public sector physicians.

Experience to date indicates that the primary need in the Virgin Islands is infrastructure development to assist with the planning and full implementation of newborn hearing screening and data management. Screening needs to be expanded to include evenings, weekends and holidays to ensure maximum availability. With the recruitment and hiring of newborn screening technicians, the project will complement on-going efforts of the MCH & CSHCN and Part C Programs as direct service providers and care coordinators respectively. Purchase of ABR equipment for St. Thomas will assure easier access to audiological evaluation and diagnosis by three months of age. As previously mentioned, standardized protocols and guidelines to encompass all nationally recommended procedures screening, referral, evaluation, diagnosis and intervention activities need to be developed.

Integration of hearing screening with the existing newborn genetic / metabolic screening database is crucial for tracking, surveillance and quality assurance.

Using the information collected by the Audiologist on St. Croix from January 1999 - May 2001 it was determined that 1088 newborns were screened at the Juan F. Luis Hospital before discharge. (Attachment G) Of these, four were identified with hearing loss and referred to audiologic diagnosis and early intervention services. These results correlate with AAP and JCIH statements on the incidence of 1-3 per 1000 live births of significant hearing loss in newborns.

A formal needs assessment will be conducted to collect information that will assist in determination of unmet needs of families and providers. This information will also be used to identify gaps in services.

The V.I. Department of Health (VIDOH) has sole responsibility for screening, tracking and follow-up of newborns. The VIDOH and Title V MCH & CSHCN Program in collaboration with the State Systems Development Initiative (SSDI) have negotiated a Memorandum of Agreement for Data Sharing (MOA). This agreement of cooperative and mutual data sharing activities is anticipated to improve the delivery of coordinated health services within the VIDOH. (Attachment A).

Specific objectives relevant to surveillance and tracking activities of the EHDI program include: sharing of available data on the health needs and status of clients and target populations; coordination of future data gathering activities to the maximum extent possible; and sharing of technical assistance materials efforts relative to databases pertaining to client target populations. An Interagency Agreement with the Part C (IDEA) Program to collaborate resources including public awareness activities and screening also exists and is reviewed annually.

The agreement was developed as a mechanism to ensure the administration, supervision and implementation of the newborn hearing screening program. This agreement will be amended to include provision of early intervention services when required. (Attachment B) The newborn genetic / metabolic screening and Part C directors interact to share information pertinent to both programs. Organizationally, both programs are within the division of Maternal and Child Health, headed by the Acting Commissioner of Health / Director, MCH & CSHCN.

Other partners in the collaborative process will include: the newborn nurseries at Juan F. Luis and Roy L. Schneider Hospitals, V.I. Perinatal Partnership, WIC, Immunization Program; Head Start, CISS-Child Care Project, V.I. Find, VIUAP, V.I. Alliance for Primary Care, V.I. Advocacy Agency and Advocates for the Deaf Coalition.

The primary goal of the proposed UNHSI project mirrors the Healthy People 2010 Objective and the MCHB Performance Measure to reduce the morbidity associated with hearing impairment through early detection and intervention.

Goal 1: To provide newborn hearing screening services to all infants in the territory.

Objectives

1.1 Expand newborn hearing screening activities in both island hospitals to provide screening to at least 60% of newborns before hospital discharge by the end of Year 1, 80% by the end of Year 2, 95 % by the end of Years 3 and 4.

Objectives:

1.2 Promote screening for babies born at home. Increase the number of infants born at home who receive screening before one month of age.

1.3 Promote two step screening to complete re-screening before hospital discharge to reduce referrals and false positives.

1.4 Assure that at least 90% of newborns requiring a post discharge retest receive this service by one month of age through utilization of the tracking system to monitor receipt of service and results.

1.5 Provide training to appropriate staff and providers regarding hearing screening, diagnosis and intervention.

Goal 2: To develop a system that will ensure early diagnosis of infant hearing loss by six months of age.

Objectives

2.1 Assure that 100% of infants who fail the post discharge screen are referred for complete audiological diagnostic evaluation and assessment by three months of age.

2.2 Assure that 100% of infants diagnosed with hearing impairment or loss are enrolled in early intervention services and facilitate coordination with a medical home by six months of age.

2.3 Integrate the newborn hearing tracking system with the genetic and metabolic newborn screening database.

2.4 Train audiologists, public health nurses and other appropriate staff regarding procedures for linkage to a medical home and early intervention services.

2.5 Provide training for newborn screening technicians to expand hours of availability in the newborn nurseries.

2.6 Design and implement public awareness activities to increase and promote public awareness and understanding regarding the importance of early screening, detection and treatment of hearing loss.

9. Required resources

The VIDOH does not have the funds available to support full implementation of a UNHSI program that can assure screening, follow-up and intervention services for all infants.

Personnel: Additional staff is required in order to fully implement the EHDI program and assure availability of screening on a regular basis. Funding is requested for the following positions: Newborn Screening Technicians (.2FTE, 3 positions) and a Clerk Typist (1.0 FTE, 1 position). (Attachment J)

These positions are necessary to ensure that project goals and objectives will be achieved during the grant period. Of the three Newborn Screening Technicians, one will be a resident of the island of St. John. This will prevent additional travel and per diem expenses for a screener to travel to and from St. Thomas on a regular basis. The other two technicians will have responsibility for providing screening for the islands of St. Thomas and Water Island. Two positions for the island of St. Croix were requested in the CDC-EHDI, Tracking and Integration in the VI application.

Equipment / Supplies: Portable OAE / ABR equipment (2) will be purchased. This will enable the screeners to confirm initial fail results and inform parents immediately of the importance of follow-up testing by three months of age. Two step screening will reduce referrals and false positive rates. Funds are requested for supplies required to carry out all project activities, postage, internet/network access and telephone.

Data System: Funds are requested for the purchase of writable CD-ROM's for storage of integrated newborn screening database. This method of data storage will prevent loss of data due to computer or drive failure.

Travel: Funds are requested to support staff off-island travel to attend one national meeting / workshop on newborn hearing screening per year and for one annual trip as stipulated in the grant guidance to Washington, DC for the Project Coordinator. Funds are also requested to assist with monthly inter-island travel for Project Coordinator and quarterly Advisory Council meetings.

Education / Training: Funds are requested to conduct a newborn hearing screening workshop for families and providers with the assistance of NCHAM or other technical assistance as recommended by MCHB. Funds are also requested to purchase and produce educational materials for families and providers, including translation services and conduct needs assessments.

Other: Funds are requested to support Advisory Council meetings and provide a sign language interpreter if required and incidentals.

The primary emphasis of the proposed activities of this project is to expand and improve the existing newborn hearing screening program. Linkage with the metabolic screening database will provide data on the status of hearing screening for each newborn. Parents of infants requiring initial or follow-up screening and referral can be contacted and appropriate services offered. The data management system will assure timely reporting as well as a mechanism to identify and collect data on newborns not screened before hospital discharge. The hospitals will be requested to provide data for infants that are discharged without an initial screen or a failed screen. This data will also be utilized to monitor screen, miss and refer rates.

The project will be developed and implemented in accordance with Joint Committee on Infant Hearing, American Academy of Pediatrics and CDC-EHDI guidelines to provide screening, referral, diagnostic and early intervention services for infants by six months of age for all infants identified with a significant hearing loss or impairment.

During Year 1 of the project, activities will focus on integration of newborn hearing screening with the metabolic screening in an Access database. Monthly and quarterly screening statistical reports will be generated to determine quality indicators such as: percentage of infants screened before discharge; percentage of infants who do not pass initial and are referred for further evaluation and percentage of infants who return and are referred for audiological and / or medical evaluation.

Development and implementation of standard protocols that address the three components of the UNHSI program; screening, identification and intervention will be accomplished during this project year with advice and direction from the Advisory Council.

Recruitment and training for newborn technician screeners to increase availability of screening during evening, weekend and holiday hours will be initiated during Year 1 and completed during Year 2. Technical assistance will be requested from the National Center for Hearing Assessment and Management (NCHAM) at Utah State University and the Title V Staff Audiologists to accomplish this training.

Parent and provider satisfaction surveys will be conducted during Years 2 and 4.

Assessment and evaluation of the project's effectiveness will be an ongoing process during the four years of the project. Criteria for measurement of the project's success will be taken from the JCIH (Attachment C) and AAP (Attachment D), and recommendations, guidelines and quality indicators for screening, confirmation of hearing loss and intervention.

The program will be monitored for number of live births, newborns screened and referred. Age at enrollment in early intervention and care coordination services; family satisfaction and documentation of developmentally appropriate skills in language and communication are some of the factors that will be used to determine effectiveness of the project.

During Year 2 & 3, quarterly and annual reports will be evaluated for areas that need improvement. This data will be shared with collaborating programs and providers.

By the end of Year 3, August 2004 a complete report to determine effectiveness of the project and achievement of goals and objectives.

Family, consumer and provider survey instruments will be distributed and evaluated to determine satisfaction with services provided by the program. These surveys will be conducted annually beginning in Year 2.

The Early Intervention Program will be responsible for reporting data of infants identified with hearing loss or impairment who were referred for services.

Data analysis will provide information on the overall effectiveness of the program in achieving the stated goals. Data generated will be reviewed by the Advisory Council and project staff to determine: compliance with screening. ; refusal rate; failure rate; false positive rate; number referred that returned for outpatient screening; number returning for diagnostic testing; number entering early intervention services and age; number passing initial screening with high risk factors for hearing loss; and number diagnosed with hearing loss or impairment.

This data will also be used to evaluate the need for additional training or technical assistance.