Transcript Slide 1

Healthy Steps: From Idea to
Innovation and
Beyond
Margot Kaplan-Sanoff, Ed.D.
Associate Professor of Pediatrics, BUSM
National Program Officer, Healthy Steps
September 16, 2010
Initial Assumptions of
Healthy Steps
 Primary care pediatrics can be a point of entry into services
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for families with infants and young children
Primary care can be a relationship-based practice
Child development information and family support can be
infused into well child visits: Cross walked with Bright Futures
Developmental and behavioral concerns are the new
morbidity for primary care pediatrics: Cross walked with Bright
Futures
Requirements from AAP keep increasing: car seat safety; bike
helmets; etc and……
Pediatric clinicians cannot do all this alone: they need another
professional to work as part of a team
Relationships are the key to
development
Between
parents and children
Between parents/grandparents
Between parents and clinicians
Between families and the practice
 Healthy Steps emphasizes a close relationship between
health care professionals and parents in addressing the
physical, emotional, and intellectual growth and
development of children from birth to age three.
Components of Healthy Steps
 Enhanced well child care with new team member:
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Healthy Steps Specialist
Reach Out and Read
Teachable moments
 Home visits by Healthy Steps Specialist
 Child development telephone information line
 Developmental screening for child and for family risk
factors
 Linkages to community resources
 Written materials emphasizing prevention
 Parent groups
Roles of Healthy Steps
Specialist
1. Establish a therapeutic relationship with
family and practice
2. Conduct home visits
3. Conduct developmental-behavioral screening
for child and for family risk factors
4. Staff child development information telephone line
5. Provide written materials emphasizing prevention
6. Ensure access and successful referrals to
community resources
7. Conduct parent groups
Diversity Of Sites
• Community Health Centers
• Federally Qualified Health Centers
• Private practices
• Hospital-based clinics
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NICU
Mobile clinic
• Residency Training Programs
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Academic Health Centers
Hospital-based training programs
Residency training rotations sites
Healthy Steps for Young Children:
Quality Enhancement in Pediatrics and
Family Medicine
Outcomes
• Moms match behaviors to
children’s development
Healthy
Steps
Cross-walked with
Bright Futures
• Moms openly discuss
feelings of sadness
2,021 families in HS;
1,716 in comparison
• Infants sleep on back
Cost $400-800/family
Minkovitz CS, et al
JAMA. 2003;290:3081-3091
• Moms use less physical
punishment
• Greater compliance with
immunization schedule
• Parents and physicians
more satisfied with care
Impact of Healthy Steps on
Maternal Depression
Among HS mothers who had experienced
sadness, reported depressive symptoms, or
limited their activities because of feeling
anxious or depressed:
1.6 times were more likely to report
that they had discussed feeling sad
with someone in the practice
.
Impact of Healthy Steps on
Parenting Behavior
 Greater knowledge of infant development, better
recognition of appropriate discipline and
increased satisfaction with pediatric care among
parents who received Healthy Steps services;
and
 The rate of disengagement from the HMO was
75 percent lower among families enrolled in
Healthy Steps during the prenatal period.
Johnston, B., et. al. “Expanding Developmental and Behavioral Services for
Newborns in Primary Care.” American Journal Preventive Medicine, 26(4), May
2004.
Healthy Steps IS Quality
Improvement
IOM-AHRQ Dimensions of Quality
Effectiveness
 Patient-Centeredness
 Timeliness
 Efficiency
 Equity
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Minkovitz CS, et al
JAMA. 2003;290:3081-3091
Healthy Steps: Long term
outcomes at 5 1/2 years
 Parents reporting more child behavioral issues to
clinician
 Parents less likely to use severe punishment
 Parents receiving anticipatory guidance
 Greater parental satisfaction with practice
 Children experiencing continuity within same
practice
 Children reading more
C. Minkowitz, et. al., Pediatrics, 2007
Source: C. Minkovitz, et al., Pediatrics,
Sept 2007
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Healthy Steps EvaluationWord on the Street
Editorial by Halfon and Inkelas in JAMA 2003:
“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.”
Lessons Learned
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Pediatrics is a window of opportunity, especially for
families with new babies
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Enormous reach and power of pediatric visits: Pediatrics is a
non-stigmatizing and universal environment
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Pediatricians are often the only professionals to interact with
the family around this new baby: Accessibility, timing &
frequency of visits
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Pediatrics can be a vehicle for real change: High trust factor
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Pediatricians have the power to:
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support parents in their child rearing
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validate parents’ ideas and concerns
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change parental behavior
The Elephant in the Room: Barriers
to Expansion of Healthy Steps
 Reimbursement for HSS
 Reimbursement for HSS
 Reimbursement for HSS
 Changes to staffing patterns and practices
 Scheduling challenges
 Record keeping challenges
 Space constraints
 Flow
Adaptations to Healthy
Steps
 Using public health nurses to deliver Healthy
Steps in rural communities
 Highly successful residency training strategy
 Using specially trained Healthy Families home
visitors to link families with primary care and to
serve as their Healthy Steps Specialist
 Use HS as platform for additional services:
Fussy Baby Program; Project Solve for
addressing maternal depression
And now for something
completely different…
Healthy Steps as
a strategy to
ensure school
readiness and
eliminate the
achievement gap
for Boston’s
youngest children
Thrive in Five: Boston’s
Promise to its Children
Health care, early intervention and other systems that
serve young children will succeed in earlier detection and
more effective responses to barriers to child development
and school readiness, including earlier detection of family
and environmental conditions that can create “toxic
stress” in young children.
LAUNCH-Linking Actions for
Unmet Needs in Children's Health
 Uses primary care as a point of entry into the
city-wide system of care for young children (08) and their families
 Family Partners and Early Childhood Mental
Health Clinicians team with PCP to ensure
children are receiving all the benefits and
developmental services needed to ensure
school readiness
 Funded by Substance Abuse and Mental Health
Services Administration (SAMHSA)
Dulce – Developmental
Understanding and Legal
Collaboration for Everyone
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 Healthy Steps model combined
with Medical Legal Partnership to
serve families with infants birth to
6 months during primary care visits
 Goal – prevent child abuse
 Serves as a platform for additional
services: Fussy Baby; Project
Solve for maternal depression
 Funded by Center for the Study of
Social Policy (CSSP)
Healthy Steps as a Model for
Patient Centered Medical Homes
 Personal physician - provides first contact,
continuous and comprehensive care
 Physician directed practice – the personal
physician leads a team of individuals at the
practice level who collectively take
responsibility for the ongoing care of patients.
 Whole person orientation – the personal
physician is responsible for providing for all the
patient’s health care needs
Healthy Steps as a model for
Patient Centered Medical Homes
 Care is coordinated across all elements of the
complex health care system) and the patient’s
community
 Quality and safety are hallmarks of the
medical home
 Enhanced access to care is available through
systems such as open scheduling, expanded
hours and new options for communication
between patients, their personal physician, and
practice staff.
Healthy Steps = PCMH
 Focus on patient-centered care and
relationship-based practice
 Delivered by a multidisciplinary team
 Success in improving quality of care
 Increase in patient and clinician satisfaction
Health care reform seeks to make major
changes to practice patterns while increasing
prevention and the provision of primary care