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

2. Objectives Past: Healthy Steps Background and Outcomes Present:Healthy Steps Fresno Outcomes Future: Adaptation, Change and Flexibility

3. Phase 1 – Evaluation (15 + 9 sites) 1995 Phase 2 – Sustainability and Dissemination  10 of 24 sustained (42%)  9 of 24 with significant spin-off  35 new sites since end of the evaluation 2003 Total Current Sites: 45  17 in Residency Training  20 in Planning or Discussion Evolution of Healthy Steps

4. Why Healthy Steps? MCB.AB.UIMCH 4-21-2005

5. 1975: The “new morbidity” recognized in Pediatrics 1993: "After infancy, children in the United States are more likely to die from injuries of violence and suicide than from infectious disease.” PEDIATRICS Vol. 92 No. 5 November 1993 Beginning Healthy Steps

6. 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

7. Many Mothers Not Breastfeeding 33% did not breastfeed 13% 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.

8. 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.

9. 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.

10. 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

11. 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

12. Margaret E. Mahoney of the Commonwealth Fund: “Healthy Steps represents a change in health care” Changing Health Care What is Healthy Steps?

13. 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 Families Clinical 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

14. 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.

15. Quality of Care: 4 Domains Effectiveness Patient-centeredness Timeliness Efficiency 1.7 times more likely to receive care through 20 months of age

16. Outcomes Breastfeeding Feeding Reading Harsh and Abusive Parenting E/R Usage

17. 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.

18. 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)

19. Reading 22% higher for showing picture books daily Minovitz. JAMA, December 17, 2003—Vol 290, No. 23 (3081 – 3091)

20. 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)

21. E/R Usage Not significant for National Study What about Fresno?

22. “I think Healthy Steps can help us do better what we already do.”

23. 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

24. Fresno Pediatric: RESIDENTS 350 pediatricians since 1947 Over 60% stay in the Central Valley Over 40% stay in Fresno Today: 30

25. Healthy Steps Fresno: 2003-2006 Grant: $453,490 3 years 220 kids ≈40 residents

26. Cost? $933/year@162 families $402/year@463 families Fresno? $682/year@220 families –Plus 43 residents trained

27. 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)

28. 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 Families Clinical 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)

29. Prenatal Home Visit

30. Did it Work? Evaluation Plan: –For Residents and for families and children CSUF Students: Comparison Group Dr. Kathleen Ramos, Ph.D. California State University, Fresno

31. Healthy Steps Fresno: Resident Outcomes Yearly pre and post survey Resident rotation evaluations

32. 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

33. Survey Results…so far Administered 4 times with one beginning and ending pair: 1.Instrument is reliable: alpha=.93 2.Scores increase with years in residency 3.Scores jump the most after the Developmental and Behavioral rotation 4.Pre and Post = significant increase in scores

34. But, is this Healthy Steps? We cannot say…

35. Children’s Hospital Social Work Elementary School Experience Children’s Hospital Psychology Developmental Pediatrics TOTAL AVERAGE Diagnostic Center Behavior Clinic Regional Center HEALTHY STEPS

36. Healthy Steps Fresno: Patient and Family Outcomes Breastfeeding Feeding Reading Harsh and Abusive Parenting Father Involvement E/R Usage

37. 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.

38. 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.

39. Reading 50% increase in Moms and Dads reading to baby more than once per day

40. Harsh and Abusive Parenting Moms more often offer explanations to children and less often use harsh parenting (threaten, yell, slap, spank) Relative Risk Reduction

41. 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.

42. E/R Usage Less likely to visit the ED (0% vs 28% of toddlers) Any Questions before we move on?

43. Healthy Steps Results Elizabeth and Her Baby

44. 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

45. Detection Rates Without ToolsWith 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

46. Future Healthy Steps: Adaptation, Change and Flexibility The Prius Model From: THE CADILLAC MODEL To:

47. Healthy Steps Key Points Into the Future: Flexible  Component selection:  Essential: Developmental Screening, Home Visits, Developmental Info. Line and Healthy Steps Materials  Intensity: Can vary from site to site Venues  Private practice  Hospital clinics and FQHCs  Residency Training  Public Health MCB.AB.UIMCH 4-21-2005

48. 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 Pediatrics and Family Medicine The Prius Model

49. Community Expansion Support Proposal: Healthy Steps Fresno and California Healthy Steps: Family-Centered Primary Care 2007 Conference

50. 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