1. The Early Learning Challenge in North Carolina January 23, 2014 Marshall Tyson, MPH NC Division of Public Health Oscar Fleming, MSPH National Implementation Research Network Jeannine Sato Center for Child and Family Health NC Early Childhood Advisory Council

2. Race to the Top--Early Learning Challenge (ELC) Grant Program Joint program US Dept. of Health and Human Services US Dept. of Education 37 applicants; 9 states selected, including NC NC’s award: $69,991,121.00 4-year grants—Jan. 1, 2012–Dec. 31, 2015 NC Early Childhood Advisory Council

3. ELC Focus Bold action to improve early learning and development Supports states that demonstrate “commitment and capacity to build a statewide system that raises the quality of early learning and development programs so that all children receive the support they need to enter kindergarten ready to succeed.” NC Early Childhood Advisory Council

4. NC’s Implementation Strategy Lead Agency: Early Childhood Advisory Council—responsible for overall coordination and specific projects Participating State Agencies—responsible for specific projects: Division of Child Development and Early Education Division of Public Health Department of Public Instruction, Office of Early Learning Contracts and MOUs with other state and local agencies and organizations, such as NC Partnership for Children and the National Implementation Research Network, FPG, UNC-CH NC Early Childhood Advisory Council

5. NC’s Plan: Four Areas of Focus Strengthen the state’s early childhood system and build its capacity to foster positive outcomes for young children Enhance the quality of programs to serve young children and their families and improve access to high-quality programs Strengthen the early childhood workforce to increase staff and system effectiveness and sustain change Target high-intensity supports and community infrastructure- building efforts to turn around poor outcomes for young children in the state’s highest-need counties (Transformation Zone) NC Early Childhood Advisory Council

6. NC’s Plan: Transformation Zone Strategy Focus intensive effort in selected high-need counties in northeastern North Carolina Increase capacity for effective collaboration and implementation to gain desired and sustainable results Provide comprehensive set of services and supports offered when and where needed—existing services and selected additional services (e.g., Family Strengthening services) NC Early Childhood Advisory Council

7. NC’s Plan: Transformation Zone Strategy Help achieve dramatically improved outcomes for all young children Lessons learned through concentrated approach used to  hone early childhood strategies  improve outcomes for young children across the state NC Early Childhood Advisory Council

8. NC’s Transformation Zone 17 northeastern Tier 1 counties eligible After exploration and RFA process, 4 counties selected: Beaufort Bertie Chowan Hyde NC Early Childhood Advisory Council

9. Three streams of work in Northeast Statewide projects Transformation Zone projects and activities (4 counties) Additional work in 15 surrounding counties  13 counties which were eligible through the grant  Nash and Pitt--closely linked to those 13 counties; home to many services NC’s Transformation Zone

10. Division of Public Health projects Family strengthening Family Connects Triple P (Positive Parenting Program) NC Early Childhood Advisory Council

11. Family Connects (A.k.a. NorthEast Connects

12. Family Connects Oscar Fleming Use of implementation science principles Jeannine Sato Replicating the Durham Connects model as Family Connects in the TZ NC Early Childhood Advisory Council

13. State Health Directors Conference January 23 rd, 2014 Applied Implementation Science Oscar Fleming National Implementation Research Network FPG Child Development Institute University of North Carolina at Chapel Hill An Overview of the Active Implementation Frameworks

14. Agenda Introduction/Purpose Why Focus on Implementation? (5) What are the Active Implementation Frameworks (15) Fidelity and Outcomes

15. Why Focus on Implementation? RESEARCH PRACTICE Active Implementation is defined as a specified set of activities designed to put into practice an activity or program of known dimensions. IMPLEMENTATION “Children and families cannot benefit from interventions they do not experience.”

16. Effective Interventions Effective Implementation Enabling Contexts Socially Significant Outcomes Formula For Success

17. Applied Implementation Science To effectively implement & realize the benefit of evidence- based and evidence-informed interventions, we need to know: WHAT to do What is the usable intervention or package of strategies? (e.g. evidence-based home visitation programs) HOW to do it Active and effective implementation and sustainability frameworks (e.g. strategies build competencies and create enabling contexts and conditions) WHO will do it Organized, purposeful, & active implementation support from linked implementation teams Active Implementation

18. Active Implementation Frameworks: The “What” The effective interventions and approaches that will improve outcomes for children, youth and families.

19. Clear description of the program Philosophy, values, principles (guidance) Inclusion – exclusion criteria (beneficiaries) Clear essential functions that define the program (core components) Operational definitions of essential functions (practice profiles; do, say) Practical performance assessment Highly correlated with desired outcomes Usable Intervention Criteria

20. Making It Happen Active Implementation Frameworks: The “How” Implementation Drivers result in competence and sustainability Improvement cycles support learning and change at multiple levels Stage-related work necessary for successful change

21. Implementation Drivers Performance Assessment (Fidelity) Coaching Training Selection Integrated & Compensatory Systems Intervention Facilitative Administration Decision Support Data System Adaptive Technical Competency Drivers Organization Drivers Leadership Drivers Consistent Uses of Innovations Reliable Benefits Integrated & Compensatory

22. Rapid cycle (PDSA) problem solving Shewhart (1931); Deming (1986) Usability testing Rubin (1994); Nielsen (2000) Practice-policy communication loop Fixsen, Blase, Metz, & Van Dyke (2013) Improvement Cycles

23. Implementation Stages ExplorationInstallation Initial Implementation Full Implementation 2-4 Years Assess needs Examine intervention components Consider Implementation Drivers Assess fit Assess needs Examine intervention components Consider Implementation Drivers Assess fit Acquire Resources Prepare Organization Prepare Implementation Drivers Prepare staff Acquire Resources Prepare Organization Prepare Implementation Drivers Prepare staff Strengthen Implementation Drivers Manage change Activate Data Systems Initiate Improvement Cycles Strengthen Implementation Drivers Manage change Activate Data Systems Initiate Improvement Cycles Monitor & manage Implementation Drivers Achieve and improve Fidelity and Outcomes Monitor & manage Implementation Drivers Achieve and improve Fidelity and Outcomes

24. Implementation Teams with specific competencies “make it happen” Minimum of three people with expertise in: Innovations Implementation Improvement Cycles Organization change Active Implementation Frameworks: The “Who”

25. Why Teams? – Letting it happen Diffusion; networking; communication – Helping it happen Dissemination; manuals; websites – Making it happen Purposeful and proactive use of implementation practice and science Based on Hall & Hord (1987); Greenhalgh, Robert, MacFarlane, Bate, & Kyriakidou (2004); Fixsen, Blase, Duda, Naoom, & Van Dyke (2010) Implementation Stages

26. Organization/Agency Supports Management (leadership, policy) Administration (HR, structure) Supervision (nature, content) Practitioner/Staff Competence State MCH/Title V Leadership Implementation Team Simultaneous, Multi-Level Interventions Federal and National Supports Implementation Teams

27. The Frameworks in Action Eastern NC: Working with teams in Chowan, Bertie, Beaufort, Hyde counties Purveyor Collaboration: Develop/enhance usable intervention criteria State Agencies: Collaborative support for implementation informed policy

28. A Final Word on Fidelity Achieving fidelity if a shared responsibility among Providers, their Home Agency, and Program Purveyors, among others. If the goal is worth achieving its worth spending time to build the required infrastructure Programs like Connects that have evidence, well defined core components and operationalized essential functions make your work easier, if not easy, and significantly increase your chances for Socially Significant Outcomes.

29. Thank You!

30. Oscar Fleming, MSPH – 919-962-7193 – oscar.fleming@unc.edu Frank Porter Graham Child Development Institute University of North Carolina Chapel Hill, NC http://nirn.fpg.unc.edu/ www.scalingup.org www.implementationconference.org For More Information

31. HTTP://NIRN.FPG.UNC.EDU Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M. & Wallace, F. (2005). Implementation Research: A Synthesis of the Literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network (FMHI Publication #231). Implementation Research: A Synthesis of the Literature Implementation Science

32. ©Copyright Dean Fixsen and Karen Blase This content is licensed under Creative Commons license CC BY- NC-ND, Attribution-NonCommercial-NoDerivs. You are free to share, copy, distribute and transmit the work under the following conditions: Attribution — You must attribute the work in the manner specified by the author or licensor (but not in any way that suggests that they endorse you or your use of the work); Noncommercial — You may not use this work for commercial purposes; No Derivative Works — You may not alter or transform this work. Any of the above conditions can be waived if you get permission from the copyright holder. http://creativecommons.org/licenses/by-nc-nd/3.0

33. Evidence-based Universal Home Visits for Parents of Newborns NC DPH January 23, 2014 Improving Child Well-Being by bridging new parent needs with community resources. The “CONNECTS” Home Visiting Model Growing Healthy Babies

34. Why Universal? Public health approach improves community health No stigma All parents have needs (94% in research) Short term triage (gateway) to more intensive services. Newborn nurse home visits should be normalized, much the way prenatal care has become the standard of care.” – Dr. Robert Murphy, CCFH

35. The Connects model Feedback loop between hospitals, doctors, service agencies to strengthen community system of care.

36. What we do All areas correlate to empirically based risks for child abuse. Nurses: assess quantify needs resolve or refer follow up

37. Who’s Involved? NC Early Childhood Advisory Council Local leaders How is it Funded? State and federal grants Private foundations Medicaid reimbursement (in some cases) Local government funds Who are Stakeholders? Health departments Hospitals Primary care providers Social service agencies FACT: 99% of mothers surveyed say their DC visit was helpful to them and their baby.

38. Impact Evaluation Results Age 12-month administrative hospital record reviews: 85% fewer hospital overnights 50% less total infant emergency medical care Randomized Controlled Trial at age 6-month (in-home interview results): More community connections More mother-reported positive parenting behaviors Higher quality mother-infant relationship Higher quality home environment Higher quality child care usage Less clinical anxiety for mother

39. 37% less infant emergency medical care through 24-month Significant decrease from 0-12 months; decrease sustained through 24- months

40. Rural Replication Race to the Top Early Learning Challenge Multiple interventions in Transformation Zone ~ 800 births High poverty High unemployment 5 birth main hospitals, some out of county Diversity among counties (not within)

41. The Connects Offering Universal home visits = no stigma A triage system for entire community A way to strengthen system of care Technical support and certification for high fidelity, to replicate outcomes

42. Model Requirements Universal reach, RN staff Partnered hiring, training & fidelity checks with Connects for certification Adherence to the model (documentation and performance measures) Exclusivity in program staffing, salary and work assignments A regional/team approach to cover population

43. What next? Connects is ideal for: –Expand public health gateway –Strengthen systems of care –Track and ID service gaps and usage –Reduce child abuse –Save infant ER costs Tool kit for adoption/sustainability plan Lessons learned during replication Goal to serve families & replicate outcome results

44. Jeannine Sato Program Director j.sato@duke.edu j.sato@duke.edu 919-668-3295 www.durhamconnects.org

45. Questions?