Presentation is loading. Please wait.

Presentation is loading. Please wait.

Life Course Health Development: A Transformative Framework To Improve Children’s Health Neal Halfon, MD, MPH UCLA Schools of Public Health, Medicine, Public.

Similar presentations


Presentation on theme: "Life Course Health Development: A Transformative Framework To Improve Children’s Health Neal Halfon, MD, MPH UCLA Schools of Public Health, Medicine, Public."— Presentation transcript:

1 Life Course Health Development: A Transformative Framework To Improve Children’s Health
Neal Halfon, MD, MPH UCLA Schools of Public Health, Medicine, Public Affairs UCLA Center for Healthier Children, Families and Communities National Center for Infancy & Early Childhood Health Policy MCHB-AIM Child & Adolescent Policy Support Center CityMatCH ’08, Albuquerque September 21, 2008

2 Goals of this Presentation
To review the evidence, importance and potential impact of the developmental origins of health and disease To consider the strategic role that the emerging Life Course Health Development approach can play in Advancing a progression Health Policy Agenda Enabling significant Health Systems Reform in the US

3 Take home Points: Power of LCHD
Life Course Health Development (LCHD) is different than a life course approach LCHD –integrating framework Connecting the disparate parts of MCH Connecting MCH to rest of health and human development Leverages MCH and Positions and Prioritizes MCH policy Provides a new Operating Logic for Transforming the Health System Powerful analytic model for solving MCH problems

4 From Lifespan to LCHD Lifespan models – connect the dots- linking early life to later life Life stage models – periods of psychological development Life-course models – are concerned with patterns and pathways that connect the dots between early and later life Life Course Health Development models- Connect the dots Describe the pathways or heath trajectories Address the mechanisms that determine or influence health trajectories

5 Reasons to link Health and Human Development across the life span
Health policy needs to better reflect our knowledge of what influences health development across the life course The converging goals of medicine and public health requires a framework that can integrate personal and population health production models The dynamics of “health production” need to be understood in era of genomics driven medicine The developmental origins of disparities need to be better understood

6

7 LCHD Where We Have Been

8 Life expectancy in years
Figure 22. Life expectancy at birth and at 65 years of age by sex: United States, 100 NOTE: See Data Table for data points graphed and additional notes. Females 80 SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System. Life Expectancy at birth Males 60 Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2004 Life expectancy in years 40 Females Life expectancy at 65 years 20 Males 1901 1910 1920 1930 1940 1950 1960 1970 1980 1990 2001 Year

9 Health / functional Status
Life Span Health Span Health / functional Status Performance Span 0 years 20 years 80 years

10 Social/Nutritional/Epidemiological/ Developmental Shift
Social Conditions dramatically changes over this time period Nature, Array, and Prevalence of Risk, Protective and Health Promoting factors Nutritional Conditions change- high sugar, high fat diets Types, prevalence, distribution of acute and chronic disease changes dramatically Developmental expectancies change Capacity of Medical Care to intervene, modify risk and treat disease

11 The Evolving Health Care System
The First Era (Yesterday) The Second Era (Today) The Third Era (Tomorrow) Focused on acute and infectious disease Germ Theory Medical Care Insurance-based financing Reducing Deaths Increasing focus on chronic disease Multiple Risk Factors Chronic Disease Mgmt & Prevention Pre-paid benefits Prolonging Disability free Life Increasing focus on achieving optimal health status Complex Causal Pathways Investing in population-based prevention Producing Optimal Health for All Each era of health and health care represent major cultural shifts -each has it own logic, values, service delivery algorithms, system specification base on what the system is trying to achieve Fight against disease- infectious disease, war on cancer and heart disease was not about waging health like all cultural evolution- algorithms become more complex, broader, deeper and more functional ( finance algorithms, transportation algorithms, energy production) Progress from one to the next represent quantum leaps forward where discovery necessitates new designs to produce new functionality Structure of Scientific revolution – the imperative to shift often results when the friction under the old regime too great, run out of room, We have all the elements of the paradigm shift Orderly and planned or chaotic and reactive Drip Incrementalism, gradual evolution doesn’t get you there – jolt, leap forward, new design, Looking back at transition to First era- Flexner, 2nd era- science, MediCare, HMO, Part of why Blue Sky Project was launched was not just because US health system is not performing up to snuff, and National Health Care Reform might be back on the table- ( HI is back on the table) but because new knowledge, new contexts are requiring that health algorithms be changed, upgraded, and transformed This is happening all over the world Health care operating systems are being upgraded and transformed to take advantage of new information, new health producing networks and to integrate and optimize health producing capacity of new technologies New operating system (rather than patching the old system) and new algorithms Come Back to what I mean Health System 1.0 Health System 2.0 Health System 3.0

12 2004 National Research Council and Institute of Medicine Report

13 IOM/NRC Definition of Children’s Health (2004)
“Children’s health is the extent to which individual children or groups of children are able or enabled to (a) develop and realize their potential, (b) satisfy their needs, and (c) develop the capacities that allow them to interact successfully with their biological, physical, and social environments.” From Children’s Health, the Nation’s Wealth, National Academies Press, 2004.

14 LCHD Defines Health as a developmental process
Builds upon Ecological and Transactional models of Life Span Development Utilizes a rapidly Expanding Evidence Base Life Course Chronic Disease Epidemiology Neurobiology Early Intervention Research Economics of Human Capital Formation Gene-Environment/ Social Epidemiology

15 Health as a Developmental Process
Health is a developmental process Health develops across the life course Health development can be represented by health trajectories Critical/ Sensitive periods Gene - Environment – Interaction have different impacts during different periods Macro and Micro pathways delineate how toxic environments and risky families get under the skin

16 How Risk Reduction and Health Promotion Strategies
influence Health Development 20 Health Development 40 60 80 Age (Years) HP RR Risk Reduction Strategies Health Promotion Strategies RR Risk Factors Optimal Trajectory Trajectory Without RR and HP Strategies Protective Factors HP FIGURE 4: This figure illustrates how risk reduction strategies can mitigate the influence of risk factors on the developmental trajectory, and how health promotion strategies can simultaneously support and optimize the developmental trajectory. In the absence of effective risk reduction and health promotion, the developmental trajectory will be sub-optimal (dotted curve). From: Halfon, N., M. Inkelas, and M. Hochstein The Health Development Organization: An Organizational Approach to Achieving Child Health Development. The Milbank Quarterly 78(3):

17 Fig. From: Lamberts SWJ, van den Beld AW, van der lely A. The endocrinology of aging. Science. 1997;278:

18 From: Kuh D, Ben-Shlomo Y
From: Kuh D, Ben-Shlomo Y. A life course approach to chronic disease epidemiology. New York: Oxford University Press

19 Health Development Trajectories
Strategies to Improve Health Development Trajectories Back to Overall Model Poverty Lack of health services Family Discord Age 6 mo mo mo mo yrs yrs Ready to learn Pre-school “Healthy” Trajectory Health Services Appropriate Discipline Reading to child “At Risk” Trajectory Parent education Emotional Health Literacy “Delayed/Disordered ” Trajectory Birth Early Infancy Late Infancy Early Toddler Late Toddler Early Preschool Late Preschool Graphic Concept Adapted form Neal Halfon , UCLA

20 Risk and protective factors
Risk Factors Child Family Community School Protective Factors Child Family Community School Outcome Negative vulnerability Positive resilience

21 LCHD Connecting the Dots

22 Adverse childhood events and adult depression
Odds Ratio Adverse Events Chapman et al, 2004

23 Adverse childhood events and adult ischemic heart disease
Odds Ratio Adverse Events Dong et al, 2004

24 Adverse childhood events and adult substance abuse
% % Dube et al, Dube et al, 2005 Self-Report: Alcoholism Self-Report: Illicit Drug Use

25 Actionable Mechanisms for Intervention
LCHD Actionable Mechanisms for Intervention

26 Cumulative, Programming and Pathway Mechanisms Influence LCHD
Three basic mechanisms influence LCHD Cumulative - additive effect of multiple risks and protective factors, weathering Programming - time specific influence of stimulus or insult during a critical or sensitive period on selection, adaptation, compensatory processes Pathways-chains of (eco-culturally constructed) linked exposures that create a constrained conduit of gene-environment transactions

27 Cumulative SES (birth - 33 yrs) poor health, age 33
% fair/poor health best worst Lifetime SES score Source: Power et al, 1999

28 LCHD Programming

29

30

31 Life Course Chronic Disease Epidemiology: Barker Hypothesis
Affiliation: MRC Environmental epidemiology unit in South Hampton Design: Historical Cohort Key Finding: Fetal growth and development, and other factors, in first year(s) of life related to cardiovascular and other chronic disease in the fifth and sixth decade

32

33

34

35 Barker Hypothesis Birth Weight and Coronary Heart Disease
Age Adjusted Relative Risk Rich-Edwards 1997

36 Birthweight and CVD Outcomes Nurses’ Health Study
Curhan et al., Rich-Edwards et al.

37

38 Smoking During Pregnancy & Offspring Obesity
Odds Ratio .5 1 5 Combined Dubois, 2006 Chen, 2006 M Chen, 2006 F Al Mamun, 2006 Reilly, 2005 Oken, 2005 Adams, 2005 Whitaker, 2004 Wideroe, 2003 Toschke, 2003 Bergmann, 2003 von Kries, 2002 Toschke, 2002 Power, 2002 M Power, 2002 F Pooled AOR 1.46 (1.33, 1.59) Oken et al., unpublished

39

40 Odds ratio of obesity: breast versus formula fed
0.87 (95% CI 0.85, 0.89) Owen et al, Pediatrics , 2005 (From Gilman)

41 Programming leads to Latent Effects
LCHD Programming leads to Latent Effects Long time horizons between exposure and outcomes

42 Cumulative, Programming and Pathway Mechanisms Influence LCHD
Three basic mechanisms influence LCHD Cumulative - additive effect of multiple risks and protective factors, weathering Programming - time specific influence of stimulus or insult during a critical or sensitive period on selection, adaptation, compensatory processes Pathways- chains of (eco-culturally constructed) linked exposures that create a constrained conduit of gene-environment transactions

43 Child Social-Emotional
Poverty & ECD Parent Distress Behavior Investment Child Cognitive Development Physical Child Social-Emotional Family Income Poverty Financial Hardship Parent- and Family-Level Predictors of Income And Hardship  Parent Work Status  Job Prestige  Education Level  Parent Marital Status  Race-Ethnicity Neighborhood- and Community-Level Influences

44

45

46 Brains are built over time, a significant proportion is constructed during the early years of life, and the capacity for change decreases with age

47 LCHD: Childhood Antecedents of later Childhood and Adult Health
Early social and material deprivation (financial, educational, environmental) Prior poor health, fetal nutrition, case-mix Immunologic & physiologic moderators Current poor health/ premature mortality Prior poor physical activity Current poor physical activity Prior adverse behavior Current adverse behavior Source: van de Mheen H, Stronks K, Looman CW, Mackenbach JP. Does childhood socioeconomic status influence adult health through behavioural factors? Int J Epidemiol 1998; 27(3): Current social and material deprivation Source: van de Mheen et al, IJE 1998 From Starfield 02/03

48 LCHD: New Approaches to Old Problems

49 How are LCHD concepts being used
Health System Reform (US) Aday’s Reinventing Public Health Breslow’s 3rd Era of Health and Health Care Snyderman’s Future Medical/Health System analysis Health System Reform ( Intl) UK – Acheson Report, Sure Start, Health Development Agency Canada –CIAR, Major Measurement Strategy focused on curve shifting across the life course WHO- ECD initiative, Commission on Social Determinants of Health

50 Disease Progression 1 = current practice 2 = current capability 1
3 = future capability 1 Symptoms Cost 3 2 Years Source: Snyderman R. AAP presidential address: the AAP and the transformation of medicine. Journal of Clinical Investigation. 2004;114(8): (suppl)

51 Paradigm Shift Traditional medical evaluation and record
Prospective evaluation and record Chief complaint History of illness Past medical history Family history Social history Physical exam Diagnostic tests Assessment and plan Health profile summary Current (immediate) Health Status Health risk analysis Genetic Environmental Lifestyle 1-year health plan 5-year health plan Requires: Life Span Health Risk assessments Early detection Means for prevention/early intervention Individual health plan Effective Life course health delivery system Effective reimbursement Source: Snyderman R. AAP presidential address: the AAP and the transformation of medicine. Journal of Clinical Investigation. 2004;114(8): (suppl)

52 Risk assessment decision support
Risk Assessment for Prospective Health Risk assessment decision support Symptoms Late chronic Cost Early chronic Low risk High risk Years Health Promoting Plan Risk modification Disease management Personalized health plan Wellness education and Internet and health provider guided planning for all Wellness education and Internet and health provider guided planning for all Individual-focused; integrated provider systems. Focus on quality of life and palliation at appropriate late stages Source: Snyderman R. AAP presidential address: the AAP and the transformation of medicine. Journal of Clinical Investigation. 2004;114(8): (suppl)

53

54 LCHD and Birth Outcomes
White Reproductive Potential African American Pregnancy Age

55 LCHD and Birth Outcomes
White Reproductive Potential African American Pregnancy Age

56 Life Course Health Development
White Poor Nutrition Stress Abuse Tobacco, Alcohol, Drugs Poverty Lack of Access to Health Care Exposure to Toxins African American Poor Birth Outcome Age 5 Puberty Pregnancy

57 LCHD: AA – White Birth outcomes
African American Primary Care for Children Early Intervention Prenatal Care Prenatal Care Internatal Care Primary Care for Women Poor Birth Outcome Age 5 Puberty Pregnancy

58 LCHD Framework: Service Delivery System Applications
Health Services Moving from health maintenance to health development organizations Integration strategies for newly engineered health systems Vertical – Primary, Secondary, Tertiary Horizontal – Biological, Behavioral, Social, Env. Longitudinal – Life-course/Lifespan

59 Source: Wise PH. “The transformation of child health in the United States.” Health Affairs. 23, No. 5 (2004): 9-25.

60

61 Changing Pattern of Childhood Morbidity
Increase in chronic health problems (10-14%) Greater recognition of mental health problems (15-20%) Greater appreciation of role and impact of developmental health problems – learning, language (10-17%)

62

63 Children & Youth at Risk
4-6% Severe Disabilities 12-16% Special Health Care Needs 30-40% Behavioral, Mental Health Learning Problems 50-60% Good Enough What % are thriving ? 30% ? 40% ? 50% ?

64 How well is the 2.0 Child Health System Performing?

65 The existing child health service system
Demand greater than services available Families have complex needs - often beyond capability of any single service Difficulty accessing services Socio-economic gradient of access Focus on treatment rather than prevention/early intervention Episodic contact Poor quality of Well Child Care

66 The existing child health service system
Fragmented service delivery Different sectors (health, public health, population health, civic) Different funding streams Different cultures Lack of co-ordination Narrow programmatic criteria for eligibility Variable understanding of child health issues Local community generally has limited accountability or responsibility

67 How do we get the health system that children need?
Incremental vs. Transformational Reforms

68 Transforming the Child Health System: New Paradigm vs. Old System
Child health system was designed for the first era of health care ( acute, infectious disease model) It was upgraded a bit for the 2nd era, with more regionalization, chronic disease care Ill equipped for this new era Under-performing Facing many new challenges

69 Child Health 3.0 : the New & Improved approach
Integrated and comprehensive approach - broadbanding of services to achieve curve shifting outcomes Greater flexibility of services and improved coordination at local community level Increased community and consumer participation Prevention, health promotion, early intervention, developmental optimization focus Focus on outcomes through improved systems performance Innovative funding and accountability arrangements

70

71 Transformation Framework
Components Current System 2.0 Transformed System 3.0 Change Strategies Logic Organization of Health Producing Sectors Organization & Delivery of Individual Care Medical Education & Workforce Market Funding Planning Regulation & Governance Performance Monitoring Systems change framework that incorporates a theory of change Components are the major components that make up our current system, and the design and  operational parameters that allow it to function Allows us to consider where we are at, what needs to change, and what we need to do/consider in order to make the kinds of changes that we think are necessary The framework is transformative and outcomes focused. It is not intended to be a full blueprint with details mapped out for every component. Rather, it includes the design principles and strategies necessary to set in motion fiscal and organizational changes that will be required to launch a transformed health system. The framework is open to, and we are actively soliciting further development of each of the components (Logic, System Organization, Service Delivery Organization, Workforce and training, Market, Funding, Planning, Regulation and Governance, Performance Monitoring). This framework and initiative will be built on expertise from different kinds of folks, not just the usual suspects. WE’RE ASKING A NEW SET OF QUESTIONS, OF NEW PEOPLE AND GETTING A NEW AND BETTER SET OF ANSWERS (E.G., IDeo, Google, David Fischer, etc.)

72 Transformation Framework
Components Current System 2.0 Transformed System 3.0 Change Strategies Logic ID and Tx Disease Episode LCHD-optimizing health trajectories Build LCHD prevention, promotion into the DNA of the System Organization of Health Producing Sectors Silos, Medical Care Dominates Integrated, Organization & Delivery of Individual Care Vertically Integrated, 1°, 2°, 3° care Vertically, Horizontally, and Longitudinal Integ. Market Embedded, Competition on Value Funding Pay for illness care Invest in health capital Performance Monitoring Individual quality, Systems Performance Measures- ind, pop, community Systems change framework that incorporates a theory of change Components are the major components that make up our current system, and the design and  operational parameters that allow it to function Allows us to consider where we are at, what needs to change, and what we need to do/consider in order to make the kinds of changes that we think are necessary The framework is transformative and outcomes focused. It is not intended to be a full blueprint with details mapped out for every component. Rather, it includes the design principles and strategies necessary to set in motion fiscal and organizational changes that will be required to launch a transformed health system. The framework is open to, and we are actively soliciting further development of each of the components (Logic, System Organization, Service Delivery Organization, Workforce and training, Market, Funding, Planning, Regulation and Governance, Performance Monitoring). SELL THE ENDOWMENT’S ROLE TCE has been visionary in recognizing the need for a more expansive kind of reform debate Opportunities (and/or crises?) will arise soon that create a window for these discussions and the need for a more developed plan (TCE is currently funding part of the R&D to facilitate our development of specific components of the plan) The basic concepts and framework for Blue Sky have a certain appeal and “stickiness” that have already taken root in some areas (e.g., chronic care, Delaware and OC early childhood systems, Kansas Health Authority, Arkansas Obesity effort, etc.), and that require health policy thought leaders and health program developers to consider these change strategies in their work. TCE Strategic plan recognizes that most innovations in health policy are likely to begin at the local level, and that the Blue Sky approach has value as a theme for all of your mission-driven activities.

73 FUNCTION Universal Curve Shift Targeted
Low income Median Targeted Interventions High income VULNERABLE DISABLED NUMBER OF CHILDREN FUNCTION Clinical/Individual Interventions

74 FUNCTION Universal Curve Shift NUMBER OF CHILDREN Low income Median
High income NUMBER OF CHILDREN FUNCTION VULNERABLE

75 Education Civic Society Family Support Child Health Targeted
Includes: Physicians, dentists Schools Child Care POLICY COMMUNITY NEIGHBORHOOD SERVICES Education FAMILY CHILD Universal Civic Society Targeted Clinical/Individual Family Support Child Health

76 Pediatric Office Pediatric Office 2.0 Parenting Support Early
Intervention Early Child Mental Health Services Preventive Care Acute Care Pediatric Office Home-visiting network Early HeadStart & HeadStart Developmental Services Chronic Care Child Care Resource & Referral Agency Developmental Services Lactation Support

77 18 month visit Pediatric Care 2.0 Pediatric Care 3.0 C.D – Disability
Screen 4-6 % w/ disability Screening tools & Pathway Pediatric Office connected to Regional Center Pediatric Care 3.0 Optimize Developmental Health I.D 30-40% developmental risk Screening tools & Pathway Pediatric Office connected: Child care Many other programs Coordination Regional center ++

78 DS Community Services Pathway
Evaluation (IDEA Sector Surveillance Community Services and Resource Sector Screening Pediatric Services Sector Assessment Peds/HPlan/ PHSector IDEA Regional Center for Developmental Disabilities Mid-Level Assessment Center Pediatric Office Preventive Care Other Specialized Services Acute Care Developmental Services Chronic Care COORDINATION CENTER Child Care/Family Resource Center Program Surveillance Program

79 Trajectory Optimizing Service Linkage Pathway
Optimal Health Development Trajectory Optimizing Service Linkage Pathway Tutor FRC PED SR FRC PED Lower Health Development Trajectory Development ROR FRC PED Pediatric Continuity NHV FRC PED Network Connections 1 3 5 7 Years

80 Optimizing Trajectories: Multisector Multilevel Strategies
Health Development Education Health Family support Child Family Neighborhood Services Community Policy Social Welfare 20 40 60 80 Age (Years)

81 Early Childhood System Building Blocks
Desired Outcomes at School Entry Emotional / Social / Cognitive Development Family Capacity and Function Physical Health & Development Trajectory of Child Development and Family Function Early Care and Education Programs B. Birth Early Infancy Late Infancy Early Toddler Late Toddler Early Preschool Late Preschool Age 6 mo 12 mo 18 mo mo yrs yrs Ready to learn “At Risk” Trajectory “Delayed/Disordered ” Trajectory “Healthy” Trajectory Family Support Services C. Child Health Services 81

82 Early Childhood System 2.0: Building Blocks
Desired Outcomes at School Entry Emotional / Social / Cognitive Development Family Capacity and Function Physical Health & Development B. Birth Early Infancy Late Infancy Early Toddler Late Toddler Early Preschool Late Preschool Age 6 mo 12 mo 18 mo mo yrs yrs Ready to learn “At Risk” Trajectory “Delayed/Disordered ” Trajectory “Healthy” Trajectory Universal Preschool Head Start & Family Literacy Early HS Family Resource Centers Universal Discretionary Categorical / Intensive Care Coordination C. Prt C (B-to-3) \CYSHCN Spec Ed Early Care & Education Family Support Services Developmental Services Medical Services Home Visiting Child Health Services Medical Home 82

83 Child Health Services Building Blocks
Desired Outcomes at School Entry Emotional / Social / Cognitive Development Family Capacity and Function Physical Health & Development Early Care and Education Programs . Family Support Services Child Health Services 83

84 Child Health Services Building Blocks
Desired Outcomes at School Entry Emotional / Social / Cognitive Development Family Capacity and Function Physical Health & Development . Early Care and Education Programs Family Support Services Child Health Services 84

85 Early Childhood System 3.0
Desired Outcomes at School Entry Emotional / Social / Cognitive Development Family Capacity and Function Physical Health & Development . Assessment Health Center Screening ECE Center Family Resource Center Surveillance Co-located or virtually connected service centers – creating new pathways 85

86 Systematic Data Collection For tracking Health Development Trajectories
Birth 1yr 4 ys 3 ys 2 ys Preschool Assessment Pediatric Early Child Assessment Birth Certificate School Readiness Physical Wellbeing & motor dev’t Social & emotional dev’t Approaches to learning Language dev’t Cognition & general knowledge

87 Big Idea – Forward looking Integrative Framework
What does LCHD New Synthesis Provide to the Discourse on Health System Reform? Big Idea – Forward looking Integrative Framework Connect up an increasingly balkanized field Reframe for health system reform goals Positions child/MCH in Vanguard of New Era in Health and Health Care Reform New Rational for current and future activities

88 Take home Points: Power of LCHD
Life Course Health Development (LCHD) is different than a life course approach LCHD –integrating framework Connecting the disparate parts of MCH Connecting MCH to rest of health and human development Leverages MCH and Positions and Prioritizes MCH policy Provides a new Operating Logic for Transforming the Health System Powerful analytic model for solving MCH problems

89 LCHD Framework: Think Different!
Developmentally - in order to optimize outcomes Population and upstream determinants of the outcomes that we want to achieve How to shift population risk curves and not just work at the individual level How to use alignment, connection, networking strategies to join up people, sectors, systems into a more functional approach - open source for a flatter health policy world How to change the culture of the system we work in To frame health in terms of its life long impacts

90 UCLA Center for Healthier Children, Families and Communities & National Center for Infancy and Early Childhood Health Policy AIM-MCHB Child and Adolescent Policy Support Center Http.//healthychild.ucla.edu


Download ppt "Life Course Health Development: A Transformative Framework To Improve Children’s Health Neal Halfon, MD, MPH UCLA Schools of Public Health, Medicine, Public."

Similar presentations


Ads by Google