American Public Health Association THE URBAN INSTITUTE Developmental Content of Primary Care for Newly Insured Young Children in Los Angeles Embry Howell, Ph.D., Urban Institute Moira Inkelas, Ph.D., UCLA Patricia Barreto, M.D., UCLA Louise Palmer, M.A., Urban Institute Poster Presentation: American Public Health Association November 6, 2007

Background: Purpose of Los Angeles Healthy Kids Enhance outreach and enrollment for Medi-Cal, Healthy Families, and Healthy Kids Offer new insurance product, “Healthy Kids,” to children ineligible for Medi-Cal and Healthy Families Improve health service access and use

Evaluation of Los Angeles Healthy Kids Joint project of the Urban Institute, UCLA, USC, and Mathematica Policy Research Sponsored by First 5 Los Angeles Evaluation began in 2004 Multiple components Process analysis (focus groups/interviews) Process monitoring Client survey and analysis

Evaluation Questions What is the level and quality of developmental care provided to Healthy Kids enrollees? Does quality of preventive care increase after young children obtain health insurance? Does quality of care increase with time in the program?

Participant Survey Wave One: April – December, 2005 Wave Two: May, 2005 – January, 2006 Sample Size (Response Rate): Initial Sample: 1262 children ages 1-5 Interviewed in Wave One: 1087 (86%) Interviewed in both waves: 975 (77%) Most (88%) interviews in Spanish Descriptive Wave One results presented in October 2006 report, available on UI website (www.urban.org)

Survey Content Items from other child health insurance expansion evaluation surveys Items on developmental services taken from the Promoting Healthy Development Survey (Bethell, et al.) as used in the National Survey of Early Childhood Health

Components of Developmental Services Receiving developmental assessment Developmental surveillance (asking about parent concerns) to identify possible developmental problems Receiving health education/counseling on important topics (“Anticipatory Guidance”) Referral to specialty care and community-based resources for possible developmental problems

Developmental Content: Assessment During the past 6 months, did child’s providers tell you they were doing a developmental assessment? During the time period, did the providers have your child roll over, pick up blocks, etc.? Did the provider ask if your child did those things?

Developmental Content: Eliciting Parent Concerns Are you concerned a lot, a little, or not at all about any of the following:   How your child talks and makes speech sounds? How he/she understands what you say? How he/she uses his/her hands and fingers to do things? How he/she uses his/her arms and legs? How he/she behaves? How he/she gets along with others? How he/she is learning to do things for himself/herself? Your child’s feelings and moods? Whether your child can do what other children his/her age can do?

Developmental Content: Anticipatory Guidance During the past 6 months did your providers talk with you about: Helping kids grow and learn Behaviors Nutrition Guidance and Discipline Toilet training Making house safe Reading with child Child care WIC

Description of Study Cohorts: Characteristics at Baseline 1 2 3 4 5 Non-citizen Latino Asian Other Citizen Age Race/ Ethnicity Citizenship

Description of Study Cohorts: Characteristics at Baseline 0-1 2-3 4+ Parent/ spouse works full time Parent/ spouse works part time Neither works <100% of poverty >100% of poverty Parent’s Length of Time in LA County (years) Poverty Level Parents’ Employment

Rates of Developmental Concerns, and Parent-Provider Discussions of Concerns Ages 1-3 Age 4 Age 5 Provider Asked About Concerns If Concerned, Provider Gave Info. About Concern If No Info, Wished Provider Had Given Info. Developmental Concerns

Most Parent Developmental Concerns are in Emotions, Behavior, Speech

Regression-Adjusted % Parents w/ Dev. Concerns Rates of Developmental Concerns: Similar Before and After Coverage, and Between First and Second Year of Coverage One Year Later Regression-Adjusted % Parents w/ Dev. Concerns WAVE ONE WAVE TWO

With Developmental Assessment in Past 6 Months Rates of Developmental Assessment: Vary by Child’s Age and Type of Usual Source of Care Ages 1-3 Age 4 Age 5 Clinic Other With Developmental Assessment in Past 6 Months Usual Source of Care

Regression-Adjusted % w/Dev. Assessment Rates of Having Developmental Assessment: Increase with Coverage, No Difference Between First and Second Year of Coverage One Year Later Regression-Adjusted % w/Dev. Assessment WAVE ONE WAVE TWO ** Wave One Established greater than Wave One New (p<.05)

Rates of Anticipatory Guidance: Greater Coverage of Traditional than of Developmental Topics

Regression-Adjusted % w/guidance on 5+ topics Rates of Receiving Anticipatory Guidance on 5+ Key Topics: No Differences with Coverage, and Between First and Second Years of Coverage Regression-Adjusted % w/guidance on 5+ topics WAVE ONE WAVE TWO

Conclusions Many parents have concerns about their young child’s development Providers often do not ask about or address parent concerns, particularly for issues that involve: Parent-provider relationships, (i.e. less “traditional” pediatric topics such as behavior, emotions and communication) Referral resources Intensive/time consuming interventions

Conclusions Introducing new insurance coverage does not necessarily improve content of preventive/developmental services More needs to be done to improve the quality of early childhood preventive care, which is the majority of care for young children Improvements require: Provider training Greater cultural competency Systems of care that support early identification Greater capacity in early childhood specialized services (e.g., mental health)