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Service Delivery Innovation Profile

Practice-Based Teams of Clinicians and Development Experts Enhance Access to Care and Improve Parenting Skills and Knowledge Among Children and Their Families


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Snapshot

Summary

Healthy Steps for Young Children (Healthy Steps) is a national initiative that encourages the use of pediatric/family clinician-child development specialist teams in health care settings to promote the use of timely preventive care; parent information and support; and other interventions to address the physical, emotional, and intellectual development of children from birth to age 3. Although Healthy Steps was created for children of all ethnicities and income levels, many health care settings in low-income and minority communities have adopted this model. The program increased parent and clinician satisfaction, continuity of care, the likelihood of parents sharing concerns about their child's development, receipt of timely developmental screening, and access to well-child visits and vaccinations at participating sites; it also reduced the use of severe punishments by parents. Positive benefits were found to be sustained through age 5½ years.

Evidence Rating (What is this?)

Moderate: The evidence provided is the result of a 15-site national evaluation, consisting of 5,565 children and their parents (intervention and control) enrolled at birth and followed for 3 years. A quasi-experimental design and a comparison location were used at nine of the sites. The evidence also includes a second national evaluation, following participating and nonparticipating families until children reached the age of 5½ years.
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Developing Organizations

Boston University School of Medicine; The Commonwealth Fund
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Date First Implemented

1994
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Patient Population

Vulnerable Populations > Children; Impoverished; Age > Infant (1-23 months); Newborn (0-1 month); Preschooler (2-5 years)end pp

Problem Addressed

The quality of health care provided for children during the first 3 years of life in the United States is becoming a growing concern. Limitations have been noted in both developmental and behavioral services provided to young children, specifically as they relate to recommended and actual care.1,2
  • Deficiencies in quality of care for children: There is growing evidence that children receive preventive services at a low rate, that persistent disparities in health status are prevalent, and that children of ethnic and racial minorities and children in low-income families lack access to a usual source of care.1
  • Limited time with physician: Even when these children are able to access care, physicians seldom have time to fully understand and address their needs. A general survey of parents of 2,068 children (age 4 months to 35 months) found that 34 percent did not believe their child's clinician always took time to understand their child's needs. In a survey of parents of 1,900 children 4 years and younger who were enrolled in Medicaid, only 40 percent of parents reported that their child's physician asked parents if they had any concerns about the child's development and well-being.1

What They Did

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Description of the Innovative Activity

Healthy Steps is a national initiative that uses pediatric/family clinician-child development specialist teams in health care settings to promote the use of timely preventive care; parent information and support; and other interventions to address the physical, emotional, and intellectual development of children from birth to age 3. Any primary care or family practice can implement the program, which can be developed using existing staff (if available) or new hires. Key elements of the program are described below:
  • Composition of the Healthy Steps team: The team consists of a pediatrician, family medicine physician, or pediatric nurse practitioner and a professional who has been trained in child development. The child development expert, referred to as a "Healthy Steps Specialist," is typically an early childhood specialist, early interventionist, nurse, mental health professional, or social worker with experience in the field of child and family development.
  • Enhanced well-child care and routine child development/family health checkups: The team conducts well-child appointments that include a physical examination; developmental checkup; a review of family health risks, such as maternal depression, household smoking, substance abuse, and domestic violence; and a review of family protective factors, such as social connections and parental resilience. They also conduct regular checkups that are designed to detect the early signs of developmental or behavioral problems, using a temperament scale at 4 months, a developmental screening tool (Ages and Stages Questionnaire or Parents Evaluation of Developmental Status) every 6 months from age 6 months to 3 years, and a test to identify autism spectrum disorders (Modified Checklist for Autism in Toddlers) at 18 to 24 months. At all appointments, the Healthy Steps teams are trained to take advantage of "teachable moments" to help mothers and fathers observe and understand their child's temperament and development. Early literacy activities are also provided as part of the Reach Out and Read program. During these appointments, they also answer any questions parents may have about their child's developmental stages.
  • Child development telephone information line: This service complements a practice's medical information/emergency line by providing parents with access to Healthy Steps Specialists, whom they can ask about day-to-day concerns, such as breastfeeding, a baby's crying, or a toddler's temper tantrum. Families can connect with Healthy Steps Specialists and receive responses via phone, pager, email, or text depending upon their preference.
  • Home visits: The team conducts home visits periodically during a child's development in order to create a more comfortable environment for mothers, fathers, extended family, and children, allowing them to more easily voice concerns about behavioral and developmental issues. The initial newborn home visit focuses on general health, nutrition, breastfeeding, sleep, and strategies for comforting babies. As the child grows, these visits focus on safety issues; dealing with toddler autonomy; and management of behavioral and developmental concerns, such as limit setting, early learning and stimulation, eating, and toilet training.
  • Educational materials emphasizing prevention: Parents receive a variety of prevention-themed educational materials, available in both English and Spanish, including prompt sheets, check sheets, a health and development record, and other handouts.
  • Parent support groups: These gatherings are held at the health care setting or in collaboration with local parenting groups. Facilitated by Healthy Steps Specialists, the meetings offer parents social support as well as interactive learning sessions and practice in problem solving. Group meetings often focus on specific issues, such as learning infant massage or cardiopulmonary resuscitation.
  • Links to community resources: Parents have access to a book or an online listserv developed by the practice that lists available community resources, including child care programs, libraries, play groups, substance abuse and counseling services (including those with information on issues related to domestic violence), and housing assistance. In addition, parent-to-parent bulletin boards are set up at Healthy Steps practices; these bulletin boards contain a variety of information, including information on child care resources and opportunities to purchase used baby clothing and equipment. Participating practices also publish newsletters that provide information on new research or guidelines for infant care.

Context of the Innovation

Healthy Steps for Young Children is a national initiative that is set in a variety of health care settings, including physicians' offices, federally qualified health centers, and hospital-based clinics. It was developed to be flexible enough to serve families from all demographics. The program was started by The Commonwealth Fund, a private foundation whose main focus is on the promotion of a high-performing health care system that achieves better access, improved quality, and greater efficiency. The Commonwealth Fund is particularly interested in improving the health care system for the Nation's most vulnerable populations, including low-income individuals, the uninsured, minority Americans, young children, and elderly adults. The organization supports improvements in the health care system by supplying grants to improve health care practice and policy, and by providing funds for independent research on health care issues. Inspired by the desire to apply new scientific discoveries regarding child behavior and development to medical practices, Commonwealth Fund leaders launched Healthy Steps in 1994. In 1995, the Commonwealth Fund provided a substantial grant to the Division of Developmental and Behavioral Pediatrics at Boston University School of Medicine to design and implement training and materials for the Healthy Steps program. Boston University School of Medicine is now the site of the National Office for Healthy Steps.

Did It Work?

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Results

A national evaluation of the Healthy Steps program, conducted at 15 of the initial 24 sites by the Women's and Children's Health Policy Center of the Johns Hopkins Bloomberg School of Public Health, found that the program improved parenting and enhanced preventive care, created high physician satisfaction, and resulted in enduring benefits for children. Comparisons were made over a 3-year period with a group of comparable families who did not participate in the program. A followup study of past program participants found that positive benefits were sustained through age 5½.
  • Improved parenting and enhanced preventive care: Families involved in Healthy Steps were more likely than nonparticipating families to do the following:
    • Raise concerns: Participating parents were more likely to share their concerns about a variety of issues, such as the importance of routines, discipline, language development, child's temperament, and sleeping patterns.
    • Place infants on their back to sleep: Participating parents also were more likely to follow instructions about placing infants on their back to sleep, thus reducing the risk of sudden infant death syndrome (SIDS). The study found the chance of placing babies on their stomachs to sleep was 24 percent lower among participating mothers.
    • Receive timely well-child visits and vaccinations: Healthy Steps children were 1.4 times more likely to receive age-appropriate vaccinations at least through age 2 and were 1.5 to 2.4 times more likely (depending on age at visit) to continue receiving well-child care at the practice during the 3-year evaluation period.
  • High physician satisfaction: Participating physician practices expressed high levels of satisfaction with the program, viewing it as a valuable service that helps keep families in their practices.
  • Facilitation of medical resident knowledge development: Medical residents who participated in Healthy Steps during their primary care rotations rated their knowledge in child development and family support as extremely high.
  • Enduring benefits: A second national evaluation, conducted by the same Johns Hopkins University team, found that the benefits persist long after children "graduate" from the program at age 3. This study, which followed participating and nonparticipating families until children reached the age of 5½ years, found the following among participants:
    • Higher levels of satisfaction among parents with their child's health care
    • Increased odds that parents will report a child’s serious behavioral issue to the pediatrician
    • A greater likelihood that the child's parents will receive education on what to expect during their infant's or child's current and approaching stage of development
    • A greater likelihood that parents read books with their child
    • Reduced odds of parents using severe discipline, such as spanking with an object or slapping in the face
    • Increased likelihood that the child still receives care in the same pediatric practice, thus ensuring continuity of care

Evidence Rating (What is this?)

Moderate: The evidence provided is the result of a 15-site national evaluation, consisting of 5,565 children and their parents (intervention and control) enrolled at birth and followed for 3 years. A quasi-experimental design and a comparison location were used at nine of the sites. The evidence also includes a second national evaluation, following participating and nonparticipating families until children reached the age of 5½ years.

How They Did It

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Planning and Development Process

Key steps undertaken by The Commonwealth Fund in the planning and development of this program include the following:
  • Creation of Healthy Steps National Advisory Committee: This committee, which included members from a wide range of fields (including pediatrics, academia, business, public policy, and the media) provided ongoing strategic guidance to the program.
  • Development of program approach and curriculum: A multidisciplinary team at the Boston University School of Medicine defined the Healthy Steps approach and developed a curriculum to train medical teams across the United States. This team conceptualized the idea of adding Healthy Steps Specialists to the primary care team, allowing for an expansion of services available to families.
  • Development of partnerships: The program formed partnerships with funders and 24 pediatric and family practice sites across the United States. Participating sites included a variety of major health care delivery systems, such as group pediatric or family practices, primary care clinics in major academic medical centers, and managed care networks.
  • Plan for national evaluation: Program leaders asked a team from the Women's and Children's Health Policy Center of the Johns Hopkins Bloomberg School of Public Health to develop a plan for a national evaluation of the effectiveness of the program at 15 of the 24 participating sites.
  • Team training: Initially, a team from each of the 24 original sites, consisting of a lead pediatrician, an additional pediatric clinician, Healthy Steps Specialist, and practice manager, attended 3 days of intensive team training in Boston. Now, however, the Boston University team of Healthy Steps trainers travel to the new Healthy Steps sites and conduct training onsite to involve as many members of the health care practice as is possible, including receptionists, residents, and nurses. Additional/new staff can also receive training via the multimedia kit, which grants continuing medical education (CME) credits for completion of the material.

Resources Used and Skills Needed

  • Staffing: The Healthy Steps national program is supported by one full-time director who handles tasks such as new program development; collaborations with other programs in the Healthy Steps community; training of new teams, including tailoring training to the needs of the specific program and community; scheduling; and publication of materials. An individual Healthy Steps site can be started in any pediatric or family medicine practice. To become a Healthy Steps site, a health care clinician must be involved, and the site must be based in or linked to a primary health care practice. In addition to a physician or nurse practitioner in the program, key staff are the Healthy Steps Specialists, who can be new hires or existing staff nurses, child development specialists, or social workers. The number of specialists needed depends on the number of families served, the intensity of the intervention, the amount of administrative support provided, and the staffing mix used for the specialists. The typical caseload for a Healthy Steps Specialist ranges from 75 to 150 families, depending on the variables mentioned.
  • Costs: A majority of the cost of implementing Healthy Steps is represented by the cost of a Healthy Steps Specialist.
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Funding Sources

First Things First; The Children's Trust
As noted, the Commonwealth Fund provided a substantial grant to Boston University School of Medicine to design and implement training and materials for the Healthy Steps program.

Funding is the responsibility of the individual Healthy Steps sites, with most funds coming from local community or health care conversion foundations. Some sites have obtained funding from local health care or community organizations, while other sites have funded the program internally.

Healthy Steps was chosen as one of the original evidence-based models of care eligible for funding under the Affordable Care Act Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program. Funding for MIECHV was available in all 50 states, including tribal communities and migrant programs (added January 2014).end fs

Adoption Considerations

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Getting Started with This Innovation

  • Establish the level of need: Assess the need for the program by examining the demographics of the patient population that is currently served. Healthy Steps was developed to be flexible enough to serve all families regardless of their income or education levels. However, the intensity of the intervention may vary according to the needs of the particular families served by the pediatric practice.
  • Initiate funding search early: Develop a long-term sustainability plan at the outset, including a consideration of long-term funding options. Consider whether the site qualifies for MIECHV funding or Substance Abuse and Mental Health Services Administration funding under the LAUNCH or MY CHILD initiatives.

Sustaining This Innovation

  • Form an advisory committee: Consider establishing an advisory committee that can help in different areas, particularly with fundraising.
  • Use existing program supports to help with the ongoing pursuit of funding: Continue to pursue ongoing funding sources. To that end, make use of the existing proposal template (available on the Healthy Steps Web site at http://healthysteps.org/) that can help in writing grant proposals, and refer to the Healthy Steps Reimbursement Toolkit for guidance, information, and useful tools to help navigate the often complex health care financing system. Additional billing options for home visits, parent groups, and child screening will depend on state requirements and the discipline of the Healthy Steps Specialist.

Spreading This Innovation

As of December 2013, there are 55 Healthy Steps sites operating across the country, with over 10 new sites being planned for 2014. Of the 55 sites, 20 are in residency training programs. A list of all the sites can be found at http://www.healthysteps.org.

In Arizona, First Things First, a statewide initiative funded through voter-enacted tobacco taxes, has dedicated a significant amount of funding to spreading Healthy Steps to approximately 10 new pediatric/family medicine sites across the state.

The Children's Trust of Florida has supported the development of seven sites in Miami-Dade County.

In 2014, over 11 new Healthy Steps Specialists will be hired and trained to implement Healthy Steps in all South Carolina Medical Schools and pediatric residency training programs throughout the state. In addition, the tribal community of Red Cliff, WI is adopting Healthy Steps using MIECHV funding.

More Information

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Contact the Innovator

Margot Kaplan-Sanoff, EdD
National Program Director, Healthy Steps
Associate Professor of Pediatrics
Boston Medical Center
Boston University School of Medicine
72 East Concord Street
Vose Hall 4th Floor, Room 419
Boston, MA 02118
Phone: (617) 414-4767
Fax: (617) 414-7915
E-mail: sanoff@bu.edu

Innovator Disclosures

Dr. Kaplan-Sanoff has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

The Healthy Steps for Young Children Web site is available at http://www.healthysteps.org.

Kaplan-Sanoff M, Talmi A, Augustyn M. Infusing mental health services into primary care for very young children and their families. Zero to Three Journal. 2012;33(2):73-7. Available at: http://www.nxtbook.com/nxtbooks/zerotothree/201211/index.php?startid=77#/72/OnePage.

Niederman LG, Schwartz A, Connell KJ, et al. Healthy Steps for Young Children program in pediatric residency training: impact on primary care outcomes. Pediatrics. 2007 Sep;120(3):e596-e603. [PubMed] Available at: http://pediatrics.aappublications.org/content/120/3/e596.full.

Minkovitz CS, Strobino D, Mistry KB, et al. Healthy Steps for Young Children: sustained results at 5.5 years. Pediatrics. 2007 Sep;120(3):e658-e668. [PubMed] Available at: http://pediatrics.aappublications.org/content/120/3/e658.full.

Footnotes

1 Minkovitz CS, Hughart N, Strobina D, et al. A practice-based intervention to enhance quality of care in the first three years of life: results from the Healthy Steps for Young Children Program. JAMA. 2003 Dec;290(23):3081-91. [PubMed] Available at: http://jama.ama-assn.org/cgi/content/full/290/23/3081.
2 Leatherman S, McCarthy D, The Commonwealth Fund. Quality of health care in the United States: a chartbook. 2002. Available at: http://www.commonwealthfund.org/publications/chartbooks/2002/apr
/quality-of-health-care-in-the-united-states--a-chartbook
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Original publication: July 07, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 16, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: December 19, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.