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SPECIAL ARTICLE |
* Department of Pediatrics, Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts
ICF Consulting, Fairfax, Virginia
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ABSTRACT |
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 TOP ABSTRACT BACKGROUNDTHE DEVELOPMENT OF HEALTHY...EVALUATIONTHE FUTURE OF HEALTHY...REFERENCES |
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The original HS cohort consisted of 15 pediatric practices in a variety of settings (private practices, health centers, pediatric training programs). Evaluated for the effects of HS on their family were 3737 intervention and comparison families. HS families received significantly more preventive and developmental services, compared to families in the control group. HS families were also less likely to be dissatisfied with their pediatric primary care. Additionally, HS had a positive impact on parenting in many areas including adherence to health visits, nutritional practices, developmental stimulation, appropriate disciplinary techniques, and correct sleeping position. Other outcome measures (such as initiation or duration of breastfeeding, child development knowledge, sense of competence, and reports of child language development at 2 years of age) did not differ between intervention and comparison group.
Compared to other early childhood intervention efforts, HS offers a comparable positive impact on parenting at a relatively inexpensive cost: an estimated $400 per family per year (compared to $4500 from Early Head Start). Approximately 3 years after the evaluation of HS ended, 10 of the original 24 sites are still in operation, and an additional 24 sites have started up. Although funding and reimbursement remain an important barrier, continued growth of HS suggests an abiding interest in this approach to expand and enhance preventive and developmental care in pediatric primary care.
Key Words: pediatric prevention • developmental services • parenting
Abbreviations: HSS, Healthy Steps specialist
Healthy Steps represents a significant innovation in the way pediatric primary care can be delivered. Its goal is to enhance and expand preventive pediatrics around developmental, behavioral, and psychosocial issues for families with children 0 to 3 years old and to enhance compliance with the American Academy of Pediatrics Health Supervision Guidelines1 and Bright Futures.2 Although there are many components of Healthy Steps designed to achieve this goal, most important is the addition of a professional, the Healthy Steps specialist (HSS), to the pediatric team. The goal of this article is to inform the pediatric community about this ongoing effort, including its background, implementation, results of an outcome evaluation, and future plans.
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BACKGROUND |
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TOPABSTRACTBACKGROUNDTHE DEVELOPMENT OF HEALTHY...EVALUATIONTHE FUTURE OF HEALTHY...REFERENCES |
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The Current State of Parenting
The increased number of working mothers with infants and family economic concerns present a special stress on families. At the same time, extended family and neighborhood support for young parents around child rearing has declined over the past decades. Parents have been left to seek more information and support from pediatricians, family physicians and other child experts, parenting magazines, television, and, most recently, the Internet. The Commonwealth Fund survey of parents with young children identified many unmet needs and concerns of parents.3 For example, 4 of 5 parents surveyed expressed a need for more information and support on common child-rearing issues such as sleep issues, responding to crying, toilet training, discipline, and how to "encourage children to learn." Although the vast majority expressed satisfaction with their pediatric clinician, most parents felt that additional services such as home visits by a nurse or a special telephone advice line would be useful. Approximately half of the parents said they were having difficulty coping, and 40% said that they felt frustrated by the child's behavior or that their child "got on their nerves" at least once a day. Not surprisingly, parents in the study were also more likely to report negative disciplinary practices such as spanking, hitting, and yelling.
Another survey conducted by Zero to Three4 found that parents and other adults had, to some extent, limited or inappropriate understanding of young children based on their developmental stages. Specifically, 2 important child-development concepts are not well understood by parents: 1) more than half thought that the more caregivers a child has before the age of 3, the better the child will be at adapting and coping with change and 2) that the more stimulation a infant receives, the better. Neither is true. Infants need continuity with a limited number of caregivers to develop relationships, and too much stimulation can be overwhelming. Finally, parents did not fully understand the connections between healthy child development and their own parenting practices.
Beyond basic child rearing, many parents express feeling insecure and worried about just how to raise their children in a world that little resembles that of their own childhood.4,5 Should they try to raise a child who is friendly and cooperative, or should their focus be on fostering academic skills such as early reading? What should they make of their toddler's unwillingness to share toys? Which is more important, cognitive or emotional development?
Additionally, the litany of potential new threats to children's well-being seems to be expanding (such as media violence and sexual content, community and domestic violence, sex, mothers' early return to work, the adverse effects of less-than-high-quality child care, and the threats of living in unhealthy home or community environments). As society grapples with new values and new challenges to children and the media and the Internet present an increasing array of "experts" to advise parents (each with a different message and a different agenda), it is a small wonder that many mothers and fathers have become confused and would like to utilize their pediatric clinicians to help them make sense of the cacophony of mixed messages they are receiving from more sources than in the past.5
Better Understanding of Brain Development and the Importance of School Readiness
New technologies have provided an understanding of brain development in children that emphasizes, to a degree not recognized previously by many, the importance of experiences in the first decade of life. To summarize: to a significant degree, the structure (architecture) of the adult brain is etched by early experiences. Studies (eg, positron emission tomographic scans, magnetic resonance imaging, and counting synaptic density in pathologic specimens) have demonstrated that the full complement of neurons (
100 billion) is formed before the third trimester of gestation. The synapses between these neurons, on the other hand, form largely after birth and are the result of an exquisitely complex interaction of genetic controls and environmental input. The power of environmental factors to promote both the development and "pruning" of synaptic location and density had been previously underestimated.6 Additionally, emerging research has outlined how cortisol, in response to stress, modifies neural connections needed for learning.7–11 Even depression among mothers can alter the electroencephalogram of infants.12 It has been this emerging understanding of the importance of the child's experience for early brain development that has fueled newer federal efforts such as Early Head Start as well as 2 White House conferences and numerous state initiatives to promote early childhood development and school readiness.
The Importance of Parental, Especially Maternal, Health on Children's Health and Development
Advances in scientific knowledge have highlighted the importance of maternal health (not limited to health during pregnancy) on children's health and development. Parental mental health problems, especially alcoholism, substance abuse, and/or depression, are associated with childhood behavior and learning problems and childhood injuries.13,14 Parental cigarette smoking (prenatally or after birth) can be associated with respiratory, learning, and behavior problems and an increased likelihood of the child smoking during adolescence.15 Unsafe parental sex, for example, may lead to human immunodeficiency virus or other sexually transmitted diseases in newborns. Unplanned, unwanted pregnancy can be associated with child abuse and behavior problems.16 The development of effective treatments17,18 for many of these parental problems requires new strategies, especially by pediatric practices, and measures to ensure that parents have access to health care for the benefit of their own and their children's health.
Quality of Care
More recently, the Institute of Medicine report titled Crossing the Quality Chasm 2001 emphasized the importance of quality health care.19 This presents a special challenge for pediatric care, for which, historically, quality indicators have been limited to compliance with the periodicity schedule of visits and immunizations. However, many studies of delivering developmental screening, individual anticipatory guidance items, or a combination of preventive services has demonstrated significant deficits in quality or "opportunities for improvement."20–22 Significant barriers to enhancing the quality of care include staff time constraints, lack of reimbursement, and inadequate training of physicians. For example, a recent study indicated that it is not feasible, because of the amount of time required, to deliver all preventive services recommended by the US Preventive Services Task Force.23
Intervention in Early Childhood Can Matter
Information continues to accumulate about the efficacy of intervention efforts to improve parenting and promote children's development. The results of many published interventions demonstrate positive changes in child development as a result of early intervention, including and perhaps most important an altered developmental pathway that leads to greater completion of school, decreased use of special education services, and, still later, fewer arrests, episodes of running away, sex partners, and alcohol consumption in at-risk populations.24–28 Based on these data, pediatricians have been challenged to adapt some of these strategies and efforts to the pediatric practice, thereby augmenting other community-based efforts to promote the health and development of young children.
It was in this context that Margaret E. Mahoney, then president of the Commonwealth Fund, decided to operationalize her long-held vision that pediatric practices could make more of a difference in the lives of children by better supporting the mothers and fathers of young children. She initiated Healthy Steps as a large-scale, innovative, pediatric-based effort to help mothers and fathers raise happy, healthy, successful, and productive children. We translated her challenge into promoting maternal/paternal-child interaction and social-emotional development in the context of pediatric primary care basing the approach, in part, on our previous work at Boston Medical Center.14,29–33
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THE DEVELOPMENT OF HEALTHY STEPS |
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TOPABSTRACTBACKGROUNDTHE DEVELOPMENT OF HEALTHY...EVALUATIONTHE FUTURE OF HEALTHY...REFERENCES |
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To meet these goals, traditional services offered in a pediatric and family practice are expanded in a Healthy Steps practice to include:
Enhanced well-child visits with a pediatric clinician and an HSS allow for more time to be spent with families. For example, the HSS might spend 15 to 30 minutes after the pediatric clinician has finished with the examination to further explore salient developmental, behavioral, or psychosocial issues, or the HSS might choose to offer a home visit to further the work started in the office.
Another key strategy has been the emphasis on the use of teachable moments33 by the pediatric team. Teachable moments involve using experiences and questions that occur in the context of the visit to provide an opportunity for discussion, the exploration of parental feelings, modeling positive interactions, reframing negative parental attributions about their child, and providing specific information. A teachable moment capitalizes on the parent's immediate issues and concerns, when there is an increased desire to learn, rather than a preset list of anticipatory guidance issues, which may or may not coincide with parental priorities. Many teachable moments occur in response to a parent's questions but can also be found in the child's office behavior or in responses to written materials such as prompt sheets. Teachable moments provide a clinically effective and efficient approach to anticipatory guidance so that parents can prevent problems.
The family health check-ups emphasize a 2-generation approach to health care, attempting to identify parental depression, family violence, drug and alcohol use, and cigarette smoking in a more systematic way. Two new information sheets (available at www.healthysteps.org) were developed. The first, called a Link Letter, is sent to parents before each pediatric visit to describe the content and focus of that visit, emphasizing emerging developmental issues. The second is a prompt sheet (adapted from work done by Carol Lannon, MD), which is given to parents at the time of the visit. It contains common questions pertinent at each age involving safety, nutrition, child development, etc. The goal of these 2 written materials is to promote parental participation in the visit and make information-gathering more efficient.
Implementation of Healthy Steps
A National Advisory Committee consisting of 15 members including pediatricians and others with related scientific clinical, policy, and business expertise was appointed to provide oversight and leadership. A special funding strategy involving a national foundation (the Commonwealth Fund) and local funders was developed to support and implement the Healthy Steps model. Typically, the local funder (eg, a community foundation) would identify a pediatric practice with potential interest in implementing Healthy Steps. The national Healthy Steps program staff investigated the interest and quality of the practice as well as its ability to meet the data collection, sample size, and control/comparison-group requirements of the rigorous evaluation outcomes. Site visits were conducted to ensure adequacy of sites to participate in the program and evaluation. Sites were required to anticipate a patient base of 200 newborns within a 6- to 9-month period and be able to provide a random-assignment control group or comparison site.
Fifteen sites were chosen to participate in the national evaluation. Sites not chosen for the national evaluation were supported to become "affiliate sites" (data not included in outcome evaluation), of which there were 9 (6 of these sites implemented Healthy Steps but did not include a comparison group for their evaluation, 2 implemented controlled evaluations, and 1 implemented a local evaluation). Sites started providing services between 1996 and 1998, and the evaluation data collection at the last site was concluded in 2001.
Training in Healthy Steps
Healthy Steps staff (lead pediatric clinician and other pediatric clinicians who would be seeing Healthy Steps families, HSSs, lead practice administrator, and other office staff when available) participated in a 3- to 5-day intensive training sponsored by the multidisciplinary training team at Boston University School of Medicine. The training institute carefully infused team-building and organizational strategies into discussions of child and family behavior and development, using case-based approaches to help practices develop their implementation strategies and learn techniques for better teamwork between the HSS and pediatric clinicians.
With support from the Gerber and Harris Foundations, a training videotape was made to improve clinicians' observational skills of children's behavior, developmental competencies, and parent-child interaction. The training tape, along with a training manual, Strategies for Change: Child Development in Primary Care for Young Children, was designed to help the pediatric practice to individualize the care of each child, to focus on the whole child and the whole family, and to help clinicians and families build a supportive relationship. Group technical assistance addressing implementation strategies, best practices, etc was provided by monthly telephone conference calls with Boston University School of Medicine staff from the time of initiation of the project to the end. Members of the Healthy Steps administrative and training staff conducted quality-improvement site visits at 6 and 18 months after initiation.
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EVALUATION |
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TOPABSTRACTBACKGROUNDTHE DEVELOPMENT OF HEALTHY...EVALUATIONTHE FUTURE OF HEALTHY...REFERENCES |
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Methods
The Women's and Children's Health Policy Center of the Johns Hopkins Bloomberg School of Public Health conducted an independent evaluation of the effectiveness of Healthy Steps in improving outcomes for families with young children. Although a randomized, controlled trial was generally to be preferred, logistics and potential spill-over effects from the intervention to the control group made that problematic in some sites. The result was a mixed design that involved randomization in 6 sites in which it could be done feasibly (ie, families within the same practice randomized to a Healthy Steps model versus routine care) and a "quasi-experimental" design for the 9 other sites (ie, an entire practice provides Healthy Steps care and is compared with a separate but matched practice in the community that delivers their usual care).34
Results
HSSs kept logs of their contacts with families. These data demonstrate that services were fully implemented. Although there was variability among sites in the number of contacts, the average family who participated in the program to at least 15 months received the following services from the HSS: 9 office visits, 6 telephone calls, and 2 home visits. However, only 20% of families attended at least 1 parent group during the program.
Data on additional outcomes were collected by telephone interview with parents and show that Healthy Steps families received significantly more preventive and developmental services compared with families in the control group (see Table 1). 35 Not only did families receive more of the services, but Healthy Steps families were 2 times more likely to report that someone in the practice "went out of their way for them." Healthy Steps families were also less likely to be dissatisfied with the care they received from the child's physician or nurse practitioner.34
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Other measured outcomes showing no significant differences between the Healthy Steps and comparison groups include initiation or duration of breastfeeding, development knowledge, sense of competence, self-report of nurturing behavior and expectation of children, or reports of children's language development at 2 years of age.35 Mothers' use of safety practices was fairly high overall, and no differences were found between Healthy Steps and control parents at 3 years. Maternal reports of behavioral problems fell within the normal range for reported behaviors in both groups. Interestingly, Healthy Steps mothers were more likely than comparison mothers to report aggressive behaviors and sleep problems in their children, which could be because children in the Healthy Steps families actually have more behavioral problems, compared with children in the control group. A more likely explanation, however, is that the Healthy Steps group felt more comfortable in discussing a child's behavior, particularly negative behaviors, with the team in a Healthy Steps practice.
Cost
Compared with other early childhood interventions, Healthy Steps achieved a relatively comparable positive impact on parenting (less overall impact compared with Early Head Start but more short-term impact on parenting compared with nurse home visiting) with less cost because of a less-intense level of services.39,40 For example, Early Head Start provides daily to weekly contact with low-income families at a cost of approximately $4500 per year. The Elmira Nurse Home Visiting Intervention provided an average of 32 home visits from the fourth month of pregnancy through the child's second year at a cost of $6000 per year per family. These compare to Healthy Steps families who received 11 well-child visits, 2 home visits, and telephone access, costing approximately $900 per year during the evaluation. Postevaluation experience with a population whose size is not constrained by evaluation rules suggests that the cost of a comparable level of care per family per year is approximately $400. Perhaps it is the special attributes of the pediatric clinician-patient relationship that enhances the effectiveness of such interventions compared with similar strategies provided in other settings. Studies of early childhood interventions show more significant outcomes in later childhood that can result in savings on public expenditures, especially for high-risk children.28,40 Whether Healthy Steps will show a similar pattern will be known after future follow-up reports.
Limitations
A significant methodologic challenge to the study involved the increased cost and logistics of outcomes measured by direct observation, compared with less expensive parent report and medical record reviews. Concern was raised, for example, about the lack of sensitive instruments to assess social emotional development in very young children, especially by questionnaire. The compromise involved using parent report of this outcome measure, coupled with an "embedded study" that allowed for direct observation of parent-child interaction in 2 of the randomized sites.
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THE FUTURE OF HEALTHY STEPS |
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TOPABSTRACTBACKGROUNDTHE DEVELOPMENT OF HEALTHY...EVALUATIONTHE FUTURE OF HEALTHY...REFERENCES |
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What will it take to gain reimbursement for Healthy Steps? First, the societal concerns with the national issues discussed at the beginning of this article will have to rise in the national consciousness. Second, Healthy Steps has clear short-term benefits35 and, based on a significant amount of literature on the long-term benefits of early childhood interventions, the strong prospect of material, long-term benefits.28,39,40 At present, it will take pressure from parent-employees, the employers who pay the bulk of health care bills, and the Federal/State Medicaid program to force the health system to value long-term benefits.
New sites are considering our recommendation of an adapted version of Healthy Steps, which includes community outreach by the HSS. In this model, the HSS will continue to be based in the practice but will also provide outreach consultation and training to local Head Start, child care, and social service sites. The goal of this approach is to increase child-development expertise and capacity in community-based organizations and to foster the development of a system of developmental services or connectivity among many organizations serving young children and their parents. Additionally, a community-based component may be eligible for a variety of public funding streams as a means of supporting the HSS. In a similar vein, some communities are linking public health nurses and counselors to the medical practice system. Another adaptation to reduce costs is to train a current staff member to perform many but not all tasks of an HSS.
The Healthy Steps approach has shown itself to be highly flexible and capable of adapting to a broad range of community needs, population groups, and staffing patterns (eg, training an existing staff member to perform the function of the HSS). Also, because of fiscal constraints, some practices have reduced the intensity of the program such as decreasing the number of home visits or Healthy Steps contacts at office visits. The use of Healthy Steps within pediatric residency programs has been a serendipitous result of the program, providing a way to meet residency board requirements for developmental and behavioral pediatrics. Healthy Steps has developed a training kit consisting of 9 videos and multimedia CD-ROM (available through www.healthysteps.org), the use of which brings continuing medical education credit, which replaces the need for 3- to 5-day intensive training, although 1- to 2-day training is recommended.
At the present time, $42 million has been invested to develop, implement, evaluate, and expand Healthy Steps to improve pediatric care and represents a specific approach to related pediatric initiatives such as the medical home, community pediatrics, and collaborative care. Additional areas of study include longer-term follow-up, cost-effectiveness, cost/benefit analysis, and identifying and refining essential components. We are optimistic that its ongoing expansion over the next decade will prove to be an efficacious and cost-effective approach to raising the level of quality of care that pediatricians and other child health professionals can offer to mothers and fathers of young children.
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ACKNOWLEDGMENTS |
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We thank the Commonwealth Fund for their leadership in Healthy Steps. We also thank the evaluation team from Johns Hopkins Bloomberg School of Public Health; our Boston University colleagues, Patricia Lawrence, PNP, Tracy McGee, PNP, and Andrea Bernard, MEd, who participated in training and technical assistance; and Kathryn Taaffe McLearn, PhD, the Healthy Steps specialists and physicians, other staff and local funders, and Ed Schor, MD, and Robert J. Haggerty, MD, for comments on previous drafts. We give special thanks to Margaret Mahoney for her vision and leadership. We also thank the 15 sites that were part of the Healthy Steps National Evaluation: ABC/Family Pediatricians; Inc/Lehigh Valley Hospital (Allentown, PA); Amarillo Area Health Care Specialists (Amarillo, TX); MGH Revere HealthCare Center/Partners HealthCare System, Inc (Boston, MA; comparison site at Somerville Pediatric Associates [Somerville, MA]); University of North Carolina at Chapel Hill Pediatric Clinic at the Ambulatory Care Center (Chapel Hill, NC; comparison site at University of Alabama Faculty Pediatrics and the Primary Care Clinic [Birmingham, AL]); General Pediatrics/Advocate Health Care/Good Samaritan Hospital (Chicago, IL; comparison site at Midwest Pediatrics, Ltd, Good Samaritan Medical Center [Naperville, IL]); Henry Ford Health System Detroit-Northwest Medical Center (Detroit, MI; comparison site at Henry Ford Hospital, Department of Pediatrics, K-13 Clinic [Detroit, MI]); Pediatric Associates of Florence/McLeod Regional Medical Center (Florence, SC); Western Colorado Pediatric Associates (Grand Junction, CO; comparison site at Pediatric Associates [Montrose, CO]); the University of Iowa Hospitals and Clinics (Iowa City, IO); KU Medwest/BlueCross/BlueShield of Kansas City (Kansas City, MO; comparison site at Independence Pediatrics [Independence, MO]); Wornall Medical Center (Kansas City, MO; comparison site at Englewood Medical Center of Medicine [Gladstone, MO]); New York Hospital-Cornell Medical Center (New York, NY; comparison site at Albert Einstein College of Medicine [New York, NY]); Children's Hospital of Pittsburgh (Pittsburgh, PA); Fort Bend Family Health Center, Inc. (Richmond, TX; comparison site at Good Neighbor Healthcare Center [Houston, TX]); and Kaiser Permanente, Bonita Medical Offices (San Diego, CA).
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FOOTNOTES |
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Address correspondence to Barry Zuckerman, MD, Department of Pediatrics, Boston Medical Center, 771 Albany St, Suite 3509, Boston, MA 02118. E-mail: barry.zuckerman{at}bmc.org
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REFERENCES |
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TOPABSTRACTBACKGROUNDTHE DEVELOPMENT OF HEALTHY...EVALUATIONTHE FUTURE OF HEALTHY...REFERENCES |
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