WHY HEALTHY STEPS?

1. PARTNERSHIPS TO IMPROVE QUALITY IN PEDIATRIC CARE: HEALTHY STEPS FOR YOUNG CHILDRENMICHAEL C. BARTH, PhDANITA BERRY, MSN, CNP/APN

2. WHY HEALTHY STEPS? • Nearly half of parents desire more information about how to raise their children • Children thrive in a nurturing environment • Why shouldn’t ALL children live in one? • All children see a pediatrician or family physician sometime in the early years • SOLUTION: provide child development services as an integral part of pediatric care

3. TOPICS • Overview of Healthy Steps • Quality • Evaluations of Healthy Steps • Partnerships in Healthy Steps • Methods to improve statewide delivery of preventive health and developmental services

4. Quality Enhancement in Pediatrics and Family Medicine for Children 0 to 3 Families • Outcomes* • Infants sleep on back • Moms openly discuss feelings of sadness • Moms use less physical punishment • Moms match behaviors to children’s development • Greater compliance with immunization schedule • Parents and physicians more satisfied with care Clinical Team + Healthy Steps Specialist (HSS) • Focuses on Behavior and Development • Nurtures Families • Provides Important Information Parents Want and Need Healthy Steps • Components: • Enhanced Well Child Care • Home Visits by HSS • Telephone Information Line • Developmental Screening • Special Printed Material • Parent Groups • Linkages to Community Resources • Reach Out and Read * JAMA 12/17/03

5. Healthy Steps IS Quality Improvement • IOM-AHRQ Dimensions of Quality • Effectiveness • Patient-Centeredness • Timeliness • Efficiency • Equity • Safety Source: Minkovitz et al (2003) “A practice-based intervention to enhance quality of care in the first three years of life: Results from The Healthy Steps for Young Children Program.” JAMA, 290, 3081-3091.

6. Markers of Quality Pediatric Preventive Health Care • Receipt of recommended preventive health care visits • Receipt of continuous care. • Up to date on all recommended immunizations • Medical home • Anticipatory guidance for parents (i.e. sleeping routines, toilet training, development)

7. Evolution of Healthy Steps • Phase 1 – Evaluation (15 + 9 sites) • Phase 2 – Sustainability and Dissemination • 8 of 24 sustained • 9 of 24 with significant spin-off • 50 new sites • Total Current Sites: 58 • Six Sites in Pipeline

8. Diversity of Healthy Steps Sites • Community Health Centers (8) • Private practices (12) • Hospital-based and other clinics (18) • Mobile clinic • NICU • Public Health Organizations • Residency Training Programs (20) • Hospital-based training programs • Residency training rotations sites • Academic Health Centers

9. Healthy Steps for Young Children: Evidence-Based • KEY FINDINGS FROM NATIONAL EVALUATION • Use of positive health practices • Discuss feelings of depression with practice • Use less harsh/physical punishment • Increased continuity of care/immunizations • High patient and clinician satisfaction

10. Healthy Steps for Young Children: Evidence-Based (2) • HEALTHY STEPS BENEFITS SUSTAINED to age 5 ½: • Parental satisfaction • Parent reporting child’s behavioral issue to clinician • Parents less likely to use severe punishment • Children receiving anticipatory guidance • Continuity within same practice • Children reading more

11. Healthy Steps for Young Children: Evidence-Based (3) JAMA EDITORIAL : “What is important about Healthy Steps…is that it provides important evidence that by changing the structure and process of pediatric care, one can significantly improve performance in the delivery of pediatric developmental services.”

12. CDC EVALUATION OF HEALTHY STEPS AT SWOPE HEALTH SERVICES • Over the first year of implementation, 83% of children received a timely EPSDT, a number depressed by the low level at program start. For the last quarter, the figure is 96%. Among those children not current, 98% received an EPSDT over the year, with 100% in the last quarter, showing the success of Swope’s focus on identifying and treating children who have not received quality care. • Of children showing a delay of some sort in the screening visit, 98% are referred (100% in the last two quarters). • 100% of mothers bringing an infant for an EPSDT visit receive a maternal depression screen. This is a happy result in light of the previous piece on maternal depression.

13. Healthy Steps Materials and Resources • Training and Technical Assistance Institute, Dept. of Pediatrics, Boston U. School of Medicine • Variety of materials in English and Spanish • Healthy Steps Interactive Multimedia Training and Resource Kit—DVD and CD-ROM

14. HEALTHY STEPS PARTNERSHIPS • Conceived as joint effort of health care and philanthropy • Growth and evolution of Healthy Steps continued partnership focus

15. REQUIRMENTS OF A PARTNERSHIP • Overlapping goals • Mutual respect • Need for a partner • Willingness to invest • Trust

16. NEW HEALTHY STEPS PARTNERSHIPS • Head Start and Early Head Start • Parents As Teachers • Public Health Nursing • Maternal and Child Health Bureau Regional Nurse Managers • Department of Human Services Programs • Safe from the Start Program • Child Care Resource and Referral Nurses • Family Case Managers • Federally Qualified Health Centers • Child and Family Connection – Early Intervention staff • Healthy Families Illinois • All Our Kids: Birth to Three Network • Illinois ABCD II • Perinatal Depression Collaborative with UIC and ENH

17. “A picture is worth a thousand words”

18. System of Primary Care for 0 to 5 Year Olds - Services include: Early Intervention Services Public Health Nurses Child Care 0 to 5 Year Olds, Their Family, and Pediatric Primary Care Providers Special Education Services Preventive Service Programs Parent Educational Services Parent Support Services Other Community Services

19. Enhancing Developmentally Oriented Primary Care (EDOPC)Overall Goal To improve the delivery and financing of preventive health and developmental services in primary health care settings for Illinois children under the age of three and to align goals of physicians and parents around high quality health care.

20. EDOPC Topics and ToolsGauging A Child’s Development • Developmental Screening & Referral Ages and Stages Questionnaire (ASQ) Parents Evaluation of Developmental Status (PEDS) Parents Observation of Infants and Toddlers (POINT) • Social Emotional Development: Screening Strategies for Primary Care Physicians Ages and Stages Questionnaire-Social Emotional (ASQ:SE) • Early Autism Detection and Referral Modified CHecklist for Autism in Toddlers (M-CHAT)

21. EDOPC Topics and ToolsFamily Factors Effecting Children • Identifying Postpartum Depression during the Well-Child Visit: Resources for Screening, Referral, and Treatment Edinburgh Postnatal Depression Scale (EPDS) Patient Health Questionnaire 9 (PHQ-9) • Domestic Violence Effects on Children: Detection, Screening and Referral in Primary Care HITS Scale (Hurts Insults Threatens Screams)

22. EDOPC Training 2005-2007 accomplishments • On-site training • 336 on-site presentations on the targeted screening/referral topics some sites full Healthy Steps training • 173 practices x 3 providers per practice (average) x 523 children per provider (average) equals 271,437 estimated children/families • 2873 health professionals (unduplicated) including 825 physicians, 69 nurse practitioners, 24 physician assistants and 1955 nurses and other health professionals • 11 education teleconferences and 47 grand rounds were held

23. Evaluation – Community Referrals Prior to the intervention none of the EDOPC sites were able to identify three community referral resources By the end of 2006, 90% of sites were able to identify three community referral resources

24. American Academy of Pediatrics Bright Futures Revision Project National Academy for State Health Policy ABCD II Project Annual Meetings Website Development National Association of Pediatric Nurse Practitioners Annual Conferences Medical Home and EDOPC Developmental and Social Emotional Early Childhood Mental Health Chair Autism Awareness National Initiative for Child Healthcare Quality Implementation in Residency Programs Pediatric Academic Society Poster Presentation by University of Chicago Resident Research, 2007 Annual Conference, Toronto Zero To Three Conference Presentation (PAC member) 2006 Presentation 2007 Poster Presentation 2007 Association of Maternal and Child Health Programs Annual Conference presentation Developmental and Behavioral Pediatrics Conference Annual Conference presentation March of Dimes Conference Annual Conference Requests from other states for guidance Arizona Ohio – 3 day Healthy Steps training Iowa California – 3 day Healthy Steps training Wisconsin EDOPC Healthy StepsNational Impact

25. Key Policy Achievements • Revised Medicaid Provider Handbook • Clarified unbundling for well-child visit • Added reimbursement for perinatal depression screening as a billable risk assessment • Clarified child as automatically eligible for early intervention services if primary caregiver has been diagnosed with a severe mental disorder, including maternal depression • Clarified that children birth through three are eligible to receive Early Intervention services if their only delay is social-emotional • Clarified Family Case Management protocol to require objective developmental screening • Expanded allowable screening tools for local health departments to include ASQ and ASQ:SE • Successfully advocated for $2 million in increased funding for children’s mental health services in 2006 legislative session • Work with legislative leaders on two key bills in 2007 legislative session: Perinatal Depression Screening and Social Worker Reimbursement

26. Additional Information AnitaBerry MSN, CNP/APN Director, Healthy Steps for Young Children Program Advocate Health Care Phone 847-384-3313 anita.berry@advocatehealth.com www.advocatehealth.com go to Baby Advocate Enhancing Developmentally Oriented Primary Care (EDOPC) www.edopc.org Healthy Steps for Young Children Program www.healthysteps.org

27. …and we are making a difference.

28. Questions?