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

2. Initial Assumptions of Healthy Steps  Primary care pediatrics can be a point of entry into services 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

3. 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.

4. Components of Healthy Steps  Enhanced well child care with new team member: 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

5. 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

6. Diversity Of Sites Community Health Centers Federally Qualified Health Centers Private practices Hospital-based clinics NICU Mobile clinic Residency Training Programs  Academic Health Centers  Hospital-based training programs  Residency training rotations sites

7. Healthy Steps Minkovitz CS, et al JAMA. 2003;290:3081-3091 Outcomes Moms match behaviors to children’s development Moms openly discuss feelings of sadness Moms use less physical punishment Infants sleep on back Greater compliance with immunization schedule Parents and physicians more satisfied with care Healthy Steps for Young Children: Quality Enhancement in Pediatrics and Family Medicine 2,021 families in HS; 1,716 in comparison Cost $400-800/family Cross-walked with Bright Futures

8. 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

9. . 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.

10. Healthy Steps IS Quality Improvement IOM-AHRQ Dimensions of Quality  Effectiveness  Patient-Centeredness  Timeliness  Efficiency  Equity Minkovitz CS, et al JAMA. 2003;290:3081-3091

11. Source: C. Minkovitz, et al., Pediatrics, Sept 2007 11 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

12. Healthy Steps Evaluation- Word 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.”

13. Lessons Learned  Pediatrics is a window of opportunity, especially for families with new babies  Enormous reach and power of pediatric visits: Pediatrics is a non-stigmatizing and universal environment  Pediatricians are often the only professionals to interact with the family around this new baby: Accessibility, timing & frequency of visits  Pediatrics can be a vehicle for real change: High trust factor  Pediatricians have the power to: support parents in their child rearing validate parents’ ideas and concerns change parental behavior

14. The Elephant in the Room: Barriers to Expansion of Healthy Steps  Reimbursement for HSS  Changes to staffing patterns and practices  Scheduling challenges  Record keeping challenges  Space constraints  Flow

15. 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

16. 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

17. 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.

18. 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 (0- 8) 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)

19. Dulce – Developmental Understanding and Legal Collaboration for Everyone   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)

20. 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

21. 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.

22. 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