Rick Brandt-Kreutz, LCSW August 10, 2006 2006 State First 5 Summit South Lake Tahoe, California Healthy Steps: Past, Present and Future.

Rick Brandt-Kreutz, LCSWAugust 10, 2006

2006 State First 5 SummitSouth Lake Tahoe, California

Healthy Steps:Past, Present and Future

Objectives

Past: Healthy Steps Background and Outcomes

Present: Healthy Steps Fresno Outcomes

Future: Adaptation, Change and Flexibility

• Phase 1 – Evaluation (15 + 9 sites) 1995• Phase 2 – Sustainability and

Dissemination10 of 24 sustained (42%)9 of 24 with significant spin-off35 new sites since end of the

evaluation 2003• Total Current Sites: 45

17 in Residency Training20 in Planning or Discussion

Evolution of Healthy Steps

Why Healthy Steps?

MCB.AB.UIMCH 4-21-2005

• 1975: The “new morbidity” recognized in Pediatrics

• 1993:"After infancy, children in the United

States are more likely to die frominjuries of violence and suicide than

from infectious disease.”

PEDIATRICS Vol. 92 No. 5 November 1993

Beginning Healthy Steps

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% did not breastfeed13% 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.

• 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

Parents Want Help With Development

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

Margaret E. Mahoney of the Commonwealth Fund:

“Healthy Steps represents a change in health care”

Changing Health Care

What is 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

Healthy Steps

FamiliesClinical Team

+Healthy Steps

Specialist (HSS)

* JAMA 12/17/03

• Focuses on Behavior and Development

• Nurtures Families

• Provides Important Information Parents Want and Need

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

Quality Enhancement in Primary Care for Children 0 to 3

MCB.AB.UIMCH 4-21-2005

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

Relative Risk Reduction

• 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)

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)

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

Healthy Steps

FamiliesClinical Team

+Healthy Steps

Specialist (HSS)

• Focuses on Behavior and Development

• Nurtures Families

• Provides Important Information Parents Want and Need

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

Quality Enhancement in Primary Care for Children 0 to 3

MCB.AB.UIMCH 4-21-2005

JAMA, December 17, 2003—Vol 290, No. 23 (3081 – 3091)

Prenatal Home Visit

Did it Work?

• Evaluation Plan:– For Residents and for families and

children

• CSUF Students: Comparison GroupDr. Kathleen Ramos, Ph.D.

California State University, Fresno

Healthy Steps Fresno:Resident Outcomes

•Yearly pre and post survey•Resident rotation evaluations

With regard to infants and toddlers (ages 0-3):

• Frequency

• Competence

– Answer questions– Initiate discussion– Use screening– Obtain history– Identify problems– Recommend

intervention

Resident Survey

Survey Results…so far

Administered 4 times with one beginning and ending pair:

1. Instrument is reliable: alpha=.932. Scores increase with years in residency3. Scores jump the most after the

Developmental and Behavioral rotation4. 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)

5.2

4.9

4.8

4.5

4.4

3.9

3.8

3.7

3.5

1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6

1

RO

TA

TIO

N S

IT

ES

Poor Excellent

Children’s Hospital Social Work

Elementary School Experience

Children’s Hospital Psychology

Developmental Pediatrics

TOTAL AVERAGE

Diagnostic Center

Behavior Clinic

Regional Center

HEALTHY STEPS

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 RatesWithout Tools With

Tools• 30% of

developmental disabilities identified

(Palfrey et al. JPEDS. 1994; 111:651-655)

• 20% of mental health problems identified

(Lavigne et al. Pediatr. 1993; 91:649-655)

• 70-80% with developmental disabilities correctly identified

(Squires et al., JDBP 1996; 17:420-427)

• 80-90% with mental health problems identified

(Sturner, JDBP 1991; 12:51-64)

Anita Berry MSN, CNP/APN

Future Healthy Steps: Adaptation, Change and

Flexibility

The Prius Model

From:

THE CADILLAC MODEL

To:

Healthy Steps Key Points Into the Future:

• FlexibleComponent selection:

Essential: Developmental Screening, Home Visits, Developmental Info. Line and Healthy Steps Materials

Intensity: Can vary from site to site• Venues

Private practiceHospital clinics and FQHCsResidency TrainingPublic Health

MCB.AB.UIMCH 4-21-2005

• 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

Healthy Steps Pediatricsand Family Medicine

The Prius Model

• Community Expansion Support• Proposal:

Healthy Steps Fresno and California

Healthy Steps:Family-Centered Primary

Care

2007 Conference

http://www.fresno.ucsf.edu/pediatrics/program_info.htm

Fresno, California

supported by a grant from First 5 Fresno

Check out our website:

Thank you for your time

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.