1/13/2015 1 Building Health in Home Visiting Colleen Kraft, M.D., FAAP Associate Professor of Pediatrics, University of Cincinnati School of Medicine Medical Director, Health Network at Cincinnati Children’s, Cincinnati Children’s Hospital EarlyExperiencesareCrucial • Byage3,80%ofsynapticconnectionsarealreadymade • Bytheseconddecadeoflifegrowthlevelsoffandpruningbegins • Increasedexperiencesdefinethewiringofaninfant’sbrain 3 Human Brain at Birth 6 Years Old 14 Years Old
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Building Health in Home Visiting
Colleen Kraft, M.D., FAAPAssociate Professor of Pediatrics, University of Cincinnati
School of Medicine Medical Director, Health Network at Cincinnati Children’s,
Cincinnati Children’s Hospital
Early Experiences are Crucial
• By age 3, 80% of synaptic connections are already made
• By the second decade of life growth levels off and pruning begins
• Increased experiences define the wiring of an infant’s brain
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Human Brain
at Birth6 Years
Old14 Years
Old
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Eco-Bio-DevelopmentalModel of Human Health and Disease
BiologyPhysiologic Adaptations
and Disruptions
Life Course Science
The Basic
Science ofPediatrics
EcologyBecomes biology,
And together they drive development across the lifespan
Critical Concept
The Science of Early Brain and
Child Development
Epigenetics Physiology of Stress Neuroscience
Education Health Economics
One Science – Many ImplicationsThe critical challenge now is to translate
game-changing advances in developmental scienceinto effective policies and practices for families w/ children
to improve education, health and lifelong productivity
Critical Concept
For young children, Caregivers create the environment for brain
development!
• Caregivers can turn off physiologic stress response by addressing physiologic and safety needs
• Turns off the physiologic stress response by promoting healthy relationships and attachment
• Notes and encourages foundational coping skills as they emerge
Early Childhood professionals are ideally placed!• Promote this sort of “Purposeful” Parenting• Advocate for a public health approach to address toxic stress
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Carilion Clinic-Aetna Partnership
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Carilion Clinic
ACO
Carilion Clinic
Physicians
Private Practice Physicians
Update: 12/08/2011
Virginia Medicaid Regions
Family-Centered Medical Home
Child and Family
Developmental Services
Home-visitingnetwork
Early Intervention
Child CareResource &ReferralAgency
Early HeadStart& HeadStart
Early ChildMental Health Services
Prevention,BuildingHealth
Acute Care
Chronic Care
Developmental Services
Parenting Support
Lactation Support
Vulnerable children and families
Medically Complex Children
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Medical Home: Pediatric “Extensive” Care
Child and Family
Shared In‐basket with
EHRHealth
Concierge; Screening, risk id
Medical or social needs, refer to CHIPCYSHCN,
refer to CCC , Special Families
Anticipatory Guidance
reinforced in‐home
Oral Health Ed,
Fluoride, dev scr
Home Visiting Partners for Higher Risk Families
• Child Health Investment Partnership of the Roanoke Valley
• Home Visiting with a Health Focus
– Parents As Teachers
– Oral Health
– Asthma Management
– Pregnant Moms
– Behavioral Health
Who are the Home Visitors?
• Team Care– Each team has one RN
– Three “family intervention specialists”• AAS trained
• Trained in Evidence-based model (Parents As Teachers)
• Often from community being served
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Care Management Design
• Home Visiting Contract– Paid per member/per month
• “High Touch”, in-person, in-home
• Data Collected in home– HEDIS metrics
– Health Outcomes
– Reduced costs
Routine Medical/Social Screening
• Screening, Risk Stratification, Communication– Personnel dedicated to this position (health
concierge)
– Ability to connect more important than education
– Could be a family partner
– Becomes a “point of contact” for the practice
– Can sign up families for text4baby and healthychild.org “push” notifications, select blogs, Facebook groups
– Can facilitate appointments or point-of-care referral14
Safe Environment for Every Kid
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Early Childhood support/guidance
• Parents as Teachers
– Parent/Child curriculum
– Frequent Developmental Screening
• Safety
– Sleeping
– Car seats
– Home safety
• Anticipatory Guidance
– Relevance in home setting
Oral Health and Fluoride Varnish
• Begin with a Grin!
Asthma Case Management
• Assess environment, modifications
• Smoking cessation
• Observe inhaler use
• Asthma control assessment
• Asthma action plan and education
• Transportation to visit
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Behavioral Health
• Prenatal to age 7
• Perinatal/postpartum depression screening
• Connection to services for parents and children at‐risk and diagnosed
• Transportation to visits
Results
100% families receive early childhood education
90% 2yr olds UTD on well visits and immunizations
100% children are screened for lead, Hgb, development
100% children have a Dental Home
66% of children have had a dental visit by age 3
97% have had an oral health assessment and fluoride
varnish
145 children in program 2011‐2012
84% well controlled
84% minimal inhaler use
90% decrease in ED visits
82% decrease in school absence due to asthma
HV/MH Integration in Cincinnati
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DRAFTWhat A Well‐Trained Clinic Will Detect
Maslow’s Hierarchy of Needs
Hunger; homelessness; denial or delay of benefits;
utility shut offs
Domestic violence; mental health issues; inadequate education
services
Overwhelmed new parents; lack of
parenting role models
Unemployment; lack of high school degree; ex‐offender reentry