Transcript Healthy Steps Program Outcome Assessment

Healthy Steps:
Past, Present and Future
Rick Brandt-Kreutz, LCSW
August 10, 2006
2006 State First 5 Summit
South Lake Tahoe, California
Objectives
Past:
Healthy Steps Background and
Outcomes
Present:
Healthy Steps Fresno Outcomes
Future:
Adaptation, Change and
Flexibility
Evolution of Healthy Steps
• Phase 1 – Evaluation (15 + 9 sites) 1995
• Phase 2 – Sustainability and Dissemination
10 of 24 sustained (42%)
9 of 24 with significant spin-off
35 new sites since end of the evaluation
2003
• Total Current Sites: 45
17 in Residency Training
 20 in Planning or Discussion
Why Healthy Steps?
Beginning Healthy Steps
• 1975:
The “new morbidity” recognized
in Pediatrics
• 1993:
"After infancy, children in the United
States are more likely to die from
injuries of violence and suicide than
from infectious disease.”
PEDIATRICS Vol. 92 No. 5 November 1993
Healthy Brains
• Significance of the environment in forming
babies brains
• Stress effects development
– Depressed mothers twice as likely to
become frustrated
• Recognition of the importance of school
readiness
PEDIATRICS 114:3 September, 2004
Many Mothers Not Breastfeeding
+
33%
13%
did not breastfeed
stopped after a month
=46% TOTAL
Young, KT, et al. Listening to Parents: A national Survey of
Parents with Young Children. Archives of Pediatric
Adolescent Medicine. 1998; 152: 255-262.
Parents Want Help With
Development
• 79% reported they could use more info in 1 of
6 areas
• 74% use books/magazines/videos
– 35% attended a class
• 23% talked with the doctor about learning and
discipline
Young, KT, et al. Listening to Parents: A national Survey of
Parents with Young Children. Archives of Pediatric
Adolescent Medicine. 1998; 152: 255-262.
Read With Your Child?
-
49% if learning IS discussed with the
MD/Nurse
37% if learning IS NOT discussed with
the MD/Nurse
= 12% Increase if the doctor or nurse
talks with the family
Young, KT, et al. Listening to Parents: A national Survey of
Parents with Young Children. Archives of Pediatric
Adolescent Medicine. 1998; 152: 255-262.
The Unique Influence of the
Primary Care Provider
• Who else sees 0-3 babies?
• High trust factor
• Timing and frequency of well-child visits
– Supportive, on-going relationship
– General and personalized relationship
Why Healthy Steps?
• Developmental and Behavioral Risks to Child
Health
• Parent-Child-Family Relationships are Key to
Child Health
• Primary Care Provider Has a Unique
Opportunity With Families
Changing Health Care
Margaret E. Mahoney of the Commonwealth
Fund:
“Healthy Steps represents a change in health
care”
What is Healthy Steps?
Quality Enhancement in Primary
Care for Children 0 to 3
Families
Clinical Team
+
Healthy Steps
Specialist
Healthy
(HSS)
Components:
• Enhanced Well Child Care
• Home Visits by HSS
Steps
Outcomes*
• Infants sleep on back
• Focuses on Behavior
and Development
• Nurtures Families
• Moms openly discuss
feelings of sadness
• Moms use less physical
punishment
• Provides Important • Moms match behaviors
Information Parents
to children’s
development
Want and Need
• Greater compliance
with immunization
schedule
• Telephone Information Line
• Developmental Screening
• Special Printed Material
• Parents and physicians
more satisfied with care
• Parent Groups
• Linkages to Community
Resources
• Reach Out and Read
MCB.AB.UIMCH 4-21-2005
* JAMA 12/17/03
National Evaluation
• 3 year project
• 5565 participants
• 6 randomization and 9 quasi-experimental
sites
• Also, the PREPARE program with Group
Health in Seattle
Minovitz. JAMA, December 17, 2003—Vol 290, No. 23 (3081 – 3091)
B.D. Johnston, et al., “Expanding Developmental and Behavioral Services
for Newborns in Primary Care.” AJPM, 26(4) May 2004.
Quality of Care: 4 Domains
•
•
•
•
Effectiveness
Patient-centeredness
Timeliness
Efficiency
1.7 times
more likely to
receive care
through 20
months of age
Outcomes
•
•
•
•
•
Breastfeeding
Feeding
Reading
Harsh and Abusive Parenting
E/R Usage
Breastfeeding
• Mothers who received Healthy Steps
prenatally or shortly after giving birth were
more likely to continue breastfeeding.
B.D. Johnston, et al., “Expanding Developmental and Behavioral
Services for Newborns in Primary Care.” AJPM, 26(4) May 2004.
Feeding
• Healthy Steps babies are 22% less likely to
have water and 16% lower for introducing
cereal and other foods introduced early (2-4
months)
Minovitz. JAMA, December 17, 2003—Vol 290, No. 23 (3081 – 3091)
Reading
• 22% higher for showing picture books
daily
Minovitz. JAMA, December 17, 2003—Vol 290, No. 23 (3081 – 3091)
Harsh and Abusive
Parenting
• 30% lower use of severe physical punishment
(slapped in face, spanked with belt or other
object)
• 22% lower for relying on other harsh
strategies (yelling, threatening, slapping
hand, spanking with hand)
Relative Risk Reduction
Minovitz. JAMA, December 17, 2003—Vol 290, No. 23 (3081 – 3091)
E/R Usage
• Not significant for National Study
What about Fresno?
“I think Healthy Steps can help us do better
what we already do.”
The Children’s Health Center:
PATIENTS
• ≈30,000 visits,
9,000 patients per
year
– 3,500 0-3 year
olds (40%)
• 97% MediCal or no
insurance
• 80% Hispanic
– About half speak
only Spanish
Fresno Pediatric: RESIDENTS
• 350 pediatricians
since 1947
• Over 60% stay in
the Central Valley
• Over 40% stay in
Fresno
• Today: 30
Healthy Steps Fresno:
2003-2006
• Grant: $453,490
•3 years
• 220 kids
• ≈40 residents
Cost?
• $933/year@162 families
• $402/year@463 families
Fresno?
• $682/year@220 families
– Plus 43 residents trained
Cost Comparison?
• Head Start--$4500 per family per year
• Infant Health and Development Program-$10,000 per family per year
JAMA, December 17, 2003—Vol 290, No. 23 (3081 – 3091)
Quality Enhancement in Primary
Care for Children 0 to 3
Families
Clinical Team
+
Healthy Steps
Specialist
Healthy
(HSS)
Components:
• Enhanced Well Child Care
• Home Visits by HSS
Steps
Outcomes*
• Infants sleep on back
• Focuses on Behavior
and Development
• Nurtures Families
• Moms openly discuss
feelings of sadness
• Moms use less physical
punishment
• Provides Important • Moms match behaviors
Information Parents
to children’s
development
Want and Need
• Greater compliance
with immunization
schedule
• Telephone Information Line
• Developmental Screening
• Special Printed Material
• Parents and physicians
more satisfied with care
• Parent Groups
• Linkages to Community
Resources
• Reach Out and Read
JAMA, December 17, 2003—Vol 290, No. 23 (3081 – 3091)
MCB.AB.UIMCH 4-21-2005
Prenatal Home Visit
Did it Work?
• Evaluation Plan:
– For Residents and for families and children
• CSUF Students: Comparison Group
Dr. Kathleen Ramos, Ph.D.
California State University, Fresno
Healthy Steps Fresno:
Resident Outcomes
•Yearly pre and post survey
•Resident rotation evaluations
Resident Survey
With regard to infants and toddlers (ages 0-3):
• Frequency
• Competence
–
–
–
–
–
–
Answer questions
Initiate discussion
Use screening
Obtain history
Identify problems
Recommend
intervention
Survey Results…so far
Administered 4 times with one beginning and
ending pair:
1. Instrument is reliable: alpha=.93
2. Scores increase with years in residency
3. Scores jump the most after the
Developmental and Behavioral rotation
4. Pre and Post = significant increase in scores
But, is this Healthy Steps?
We cannot say…
Resident Ratings of Developmental and Behavioral Site Training
Sites
2004-2006 (15 Residents)
Children’s Hospital Social Work
3.5
ROTATION SITES
Elementary School Experience
3.7
Children’s Hospital Psychology
3.8
Developmental Pediatrics
3.9
TOTAL AVERAGE
1
Diagnostic Center
4.4
4.5
Behavior Clinic
4.8
Regional Center
4.9
HEALTHY STEPS
1
1.5
Poor
2
2.5
5.2
3
3.5
4
4.5
5
5.5
Excellent
6
Healthy Steps Fresno:
Patient and Family Outcomes
•
•
•
•
•
•
Breastfeeding
Feeding
Reading
Harsh and Abusive Parenting
Father Involvement
E/R Usage
Breastfeeding
• Healthy Steps babies are more likely
to be breastfed beyond 12 months
(33% HS versus 9% comparison)
– The longer baby’s are breastfed, the
less chance of being overweight
Harder, T et al. Duration of breastfeeding and risk of overweight:
a meta-analysis.Am J Epidemiol. 2005 Sep 1;162(5):397-403.
Feeding
• Healthy Steps babies are less likely to have
water (35% vs 75%), cereal (7% vs 34%),
and other foods introduced early
Early feeding habits effect chances of
being overweight and Hispanics start
foods earlier
Mennella JA. Feeding Infants and Toddlers Study: the types of
foods fed to Hispanic infants and toddlers. J Am Diet Assoc. 2006
Jan;106(1 Suppl 1):S96-106.
Reading
• 50% increase in Moms and Dads reading to
baby more than once per day
Harsh and Abusive
Parenting
• Moms more often offer explanations to
children and less often use harsh parenting
(threaten, yell, slap, spank)
Relative Risk Reduction
Father Involvement
• Dads more involved in diapering (77% vs
60%) and bathing (67% v 42%) baby
• Dads read, play and sing more to their
toddler
– Father play at 24 months related to peer
competence, adaptive coping strategies at 16
years old
Yogman,W.; Kindlon, D. Pediatric Opportunities with Fathers and
Children. Pediatric Annals 27:1, January 1998:16-22.
E/R Usage
• Less likely to visit the ED (0% vs 28% of
toddlers)
Any Questions before we move on?
Healthy Steps
Results
Elizabeth and Her Baby
Fresno Questions:
• How could we identify and serve the
children and families who need Healthy
Steps more?
• Can our residents implement Healthy
Steps in their future practice?
• How could we serve more kids? How can we
SCREEN more children?
Every Child is a Healthy Steps Child
Detection Rates
Without Tools
With Tools
• 30% of
developmental
disabilities
identified
• 70-80% with
developmental
disabilities correctly
identified
(Palfrey et al. JPEDS. 1994;
111:651-655)
• 20% of mental
health problems
identified
(Lavigne et al. Pediatr. 1993;
91:649-655)
(Squires et al., JDBP 1996;
17:420-427)
• 80-90% with mental
health problems
identified
(Sturner, JDBP 1991; 12:5164)
Anita Berry MSN, CNP/APN
Future Healthy Steps:
Adaptation, Change and Flexibility
From:
THE CADILLAC MODEL
To:
The Prius Model
Healthy Steps Key Points
Into the Future:
• Flexible
Component selection:
Essential: Developmental Screening,
Home Visits, Developmental Info.
Line and Healthy Steps Materials
Intensity: Can vary from site to site
• Venues
Private practice
Hospital clinics and FQHCs
Residency Training
Public Health
MCB.AB.UIMCH 4-21-2005
Healthy Steps Pediatrics
and Family Medicine
• Selective Prevention and Continuum of
Care:
– Using ASQ-SE and clinical observations to
identify families for Healthy Steps services
• Universal screening for all patients
• Follow the resident and the resident’s
patient
• Expanded to Family & Community Medicine
– Healthy Steps Residency Institute:
October 24-26
The Prius Model
Healthy Steps Fresno and
California
• Community Expansion Support
• Proposal:
Healthy Steps:
Family-Centered Primary Care
2007 Conference
Check out our website:
http://www.fresno.ucsf.edu/pediatrics/program_info.htm
Thank you for
your time
Fresno, California
supported by a grant from First 5 Fresno
REFERENCES
American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family
Health. The New Morbidity Revisited: A Renewed Commitment to the Psychosocial
Aspects of Pediatric Care. Pediatrics. 2001; 108.
American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family
Health. The Pediatrician and the “The New Morbidity.” Pediatrics. Vol 92 No. 5
November 1993.
Blackwell DL, Tonthat L., National Center for Health Statistics. Summary Health Statistics
for US Children: National Health Interview Survey, 1998. Tables 6 and 12, 2002.
Breunlin, Douglas C. et al. Pediatricians’ Perceptions of Their Behavioral and
Developmental Training. Developmental and Behavioral Pediatrics, Vol. 11, No. 4,
August 1990.
Christakis, Dimitri et al. Association of Lower Continuity of Care with greater risk of
emergency department use and hospitalization in children. Pediatrics Vo. 103 No. 3
March 2001.
Guralnick, Michael J. Training Residents in Developmental Pediatrics: Results from a
National Replication. Developmental and Behavioral Pediatrics, Vol. 8, No. 5, 1987.
Leatherman S., McCarthy D, the Commonwealth Fund. Quality of Health Care in the United
States: A Chartbook. 2002. available at:
http://www.cmwf.org/programs/pub_highlight.asp?id=736&pubid=520&CategoryID=3.
Accessed September 20, 2004.