1. Breena Holmes, MD  March 2017
Social Emotional Health of Children: Medical Home and Home Visiting Building Bright Futures State Advisory Council
Breena Holmes, MD  March 2017

2. LAUNCH (Linking Action for the Unmet Needs in Children’s Health)
Integration of behavioral health into primary care settings
Enhanced home visiting through increased focus on social and emotional well-being
Screening and assessment in a range of child- serving settings (Help Me Grow)
Mental health consultation in early care and education
Family strengthening and parenting skills training
Vermont Department of Health

3. Vermont Children Source: Johnson Group Consulting, Inc. 2014
Data from National Survey of Child Health and Medicaid data

4. Health Promotion in MCH: Bright Futures
Bright Futures is a national health promotion and disease prevention initiative that addresses children's health needs in the context of family and community. In addition to use in pediatric practice, Vermont implements Bright Futures principles, guidelines and tools to strengthen the connections between state and local programs, pediatric primary care, families, and local communities.
Bright Futures is the Vermont EPSDT Periodicity Schedule for children’s Medicaid

5. Health Promotion Themes, Fourth Edition
Healthy Development
Family Support
Mental Health and Emotional Well-Being
Nutritional Health
Physical Activity
Healthy Weight
Promoting Lifelong Health for Families and Communities
Oral Health
Healthy Sexuality
Safety and Injury Prevention
Promoting the Healthy and Safe Use of Social Media
Children and Youth with Special Health Care Needs

6. Promoting Lifelong Health
Since initial Guidelines, addressing the social components of child health has been a core component of the Bright Futures Guidelines: the environment in which children develop - family, extended family, neighborhood, community and culture - impact brain development, health and even genetics

8. Social-emotional Tell me about your child’s typical play.
Plays interactive games, eg, peek-a-boo, pat-a-cake
Imitates activities
Hands you a book when he wants to hear a story.
Does your child feel free to explore or stay very close to your side?
Waves bye-bye
Has a strong attachment with parent or significant caregiver
Shows distress on separation from parent

9. Medical Home – AAP definition
Accessible
Family-centered
Continuous
Comprehensive
Coordinated
Compassionate
Culturally effective 9

10. The Vermont Blueprint for Health is a vision, a plan and a statewide partnership to improve health and the health care system for Vermonters. The Blueprint is working to change health care to a system focused on preventing illness and complications, rather than reacting to health emergencies.
A foundation of medical homes and community health teams that can support coordinated care and linkages with a broad range of services
Multi Insurer Payment Reform that supports a foundation of medical homes and community health teams
A health information infrastructure that includes EMRs, hospital data sources, a health information exchange network, and a centralized registry
An evaluation infrastructure that uses routinely collected data to support services, guide quality improvement, and determine program impact

11. Care Coordination in Medical Home
DULCE (Developmental Understanding and Legal Collaboration for Everyone)
Most VT infants receive routine health care, which provides an extraordinary opportunity to reach infants and their families.
Lamoille County (PILOT) family specialist (FS) meets the family at every health visit for the first six months and offers support in person, through home and community visits, tele-phone, and texting.
JPB pilot at University Pediatrics through Help Me Grow
Screening for Social Determinants of Health to Mitigate Risks and Promote Protective Factors
Designated Agency staff located in primary care
Supported through DMH
15 sites around state
Blueprint
Community Health Teams and Care Coordination
Vermont Department of Health

12. ...is the health promotion/disease prevention part of the medical home
Bright Futures
...is the health promotion/disease prevention part of the medical home
At the heart of the medical home is the relationship between the clinician and the family or youth

13. Home Visiting
Home Visiting programs that help at-risk families provide young children with a healthy and nurturing environment have been shown to improve social, emotional, economic and health outcomes for both children and parents.
Research from multiple sources documents this point:
6. Vermont Nurse Family Partnership program data from standardized (PHQ-9 and EPDS) depression screening.
7. Sarah Avellar et al., Home Visiting Evidence of Effectiveness Review: Executive Summary, Washington, D.C. U.S. Department of Health and Human Services, Office of Policy, Research and Evaluation, September 2013, (Accessed January 2017)
8. Council on Child and Adolescent Health. The role of home-visitation programs in improving health outcomes for children and families. Pediatrics 101 (3) (1998): 598.
9. Ted R. Miller Nurse-Family Partnership Home Visitation: Costs, Outcomes, and Return on Investment. Pacific Institute for Research and Evaluation Report. (Accessed January 2017)
10. Lynn A. Karoly, M. Rebecca Kilburn & Jill Cannon Proven Benefits of Early Childhood Interventions, RAND Corporation Report. (Accessed January 2017)

14. CIS/MCH Evidence Based Home Visiting Programs
Nurse Family Partnership
Maternal Early Childhood Sustained Home Visiting (MECSH)
Parents as Teachers (PAT)
Early Head Start
Specific Outcomes
Maternal Health
Child Health
Child Development and School Readiness
Reductions in child maltreatment
Reductions in Juvenile Delinquency, Family Violence, and Crime
Positive Parenting Practices
Family Economic Self-Sufficiency
Reductions in Child Maltreatment
Eligibility
Low income, first-time, pregnant women prior to 28 weeks gestation, through birth and infant/child up to 23 months
Pregnant women, through birth and infant/child up to 23 months
Parents and child. Birth-11 months, months, months, 48+months
Children under age 3 who are homeless or foster children
Pregnant women and children under age 3 from families who are on public assistance*
Community Providers
Non-profit Home Health Agencies
12/14 counties*
Non-profit Home Health Agencies and Parent Child Centers
8/14 counties*
Parent Child Centers
13/14 counties*
Community Action Agencies and School Districts
11/14 counties
Service Delivery
Registered nurses trained in NFP model, Nurses must have a Bachelor’s degree
Registered nurses trained in MECSH model, Nurses must have a Bachelor’s degree
Trained social worker or child development specialist; Masters prepared in most cases
Home visitors with minimum of Associates Degree. Some Bachelor’s Degree in Early Childhood Education or related field
*NFP has active clients in all 12/14 counties. MECSH has clients in 5/8 counties where nurses have received training and PAT has clients in 3/13 counties where staff have received training.
*Early Head Start Home Visiting Eligibility: 289 slots available in Vermont
Children under age 3 who are homeless or foster children;
Pregnant woman and children under age 3 from families who are on public assistance such Reach Up and Supplemental Security Income or from families who have incomes below 100 percent of the federal poverty guidelines ($24,600 for a Vermont family of four in 2017);
If higher priority pregnant women and children under age 3 are served, up to 35 percent of a program’s enrollment may be for pregnant women and children under age 3 from families who have incomes between 100 percent and 130 percent of the federal poverty guidelines ($24,600 and $31,980, respectively for a Vermont family of four in 2017);
Up to 10 percent of a EHS grantee’s enrollment can consist of children under age 3 irrespective of their family’s income if the children and their families would benefit from EHS. Often these spaces are served by young children with disabilities.
U.S. Department of Health and Human Services. (2017). Annual Update of the HHS Poverty Guidelines. Retrieved in February Available at

15. Benefits of Evidenced Based Home Visiting
Improved maternal and child health
Promotion of parent-child interactions and improved social readiness
Reduction in maltreatment
Reduction in family violence, juvenile delinquency and crime
Reduction in maternal tobacco use
Reduction in maternal behavioral impairment attributable to drug and alcohol abuse
Increased family economic self-sufficiency
Refer back to previous references.

16. Referral Data: NFP Program: 2012 - Present
Nurse home visitors have made over 27,000 separate referrals to hundreds of different government and community services
Average of 30+ referrals for each client, sometimes many individual referrals required before a client followed up
One nurse reported encouraging a client who smoked to call QUIT line on 50+ separate occasions
57% of referrals resulted in client receiving new services

17. Referral Data: NFP Program: 2012 - Present
Top ten referral types (in order of frequency):
Mental health services
WIC
Dental services
Ob/Gyn for prenatal care
Housing
Smoking cessation
TANF
Job training and employment
Pediatrician for well-child visits
Lactation counselor

18. Opportunities for Connection
Medical Home and Early Care and Education
Medical Home and Home Visiting
Home Visiting and Early Care and Education
Other opportunities?
Vermont Department of Health