Rick Brandt-Kreutz, LCSW August 10, 2006 2006 State First 5 Summit South Lake Tahoe, California...
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Transcript of Rick Brandt-Kreutz, LCSW August 10, 2006 2006 State First 5 Summit South Lake Tahoe, California...
Rick Brandt-Kreutz, LCSWAugust 10, 2006
2006 State First 5 SummitSouth Lake Tahoe, California
Healthy Steps:Past, Present and Future
Objectives
Past: Healthy Steps Background and Outcomes
Present: Healthy Steps Fresno Outcomes
Future: Adaptation, Change and Flexibility
• Phase 1 – Evaluation (15 + 9 sites) 1995• Phase 2 – Sustainability and
Dissemination10 of 24 sustained (42%)9 of 24 with significant spin-off35 new sites since end of the
evaluation 2003• Total Current Sites: 45
17 in Residency Training20 in Planning or Discussion
Evolution of Healthy Steps
• 1975: The “new morbidity” recognized in Pediatrics
• 1993:"After infancy, children in the United
States are more likely to die frominjuries of violence and suicide than
from infectious disease.”
PEDIATRICS Vol. 92 No. 5 November 1993
Beginning Healthy Steps
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
Many Mothers Not Breastfeeding
33% did not breastfeed13% 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.
• 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.
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.
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
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
Margaret E. Mahoney of the Commonwealth Fund:
“Healthy Steps represents a change in health care”
Changing Health Care
What is Healthy Steps?
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
FamiliesClinical 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
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.
Quality of Care: 4 Domains
• Effectiveness• Patient-centeredness• Timeliness• Efficiency
1.7 times more likely to receive care through 20 months of age
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.
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)
Reading
• 22% higher for showing picture books daily
Minovitz. JAMA, December 17, 2003—Vol 290, No. 23 (3081 – 3091)
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)
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
Fresno Pediatric: RESIDENTS
• 350 pediatricians since 1947
• Over 60% stay in the Central Valley
• Over 40% stay in Fresno
• Today: 30
Cost?
• $933/year@162 families• $402/year@463 families
Fresno?
• $682/year@220 families– Plus 43 residents trained
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)
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
FamiliesClinical 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)
Did it Work?
• Evaluation Plan:– For Residents and for families and
children
• CSUF Students: Comparison GroupDr. Kathleen Ramos, Ph.D.
California State University, Fresno
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
Survey Results…so far
Administered 4 times with one beginning and ending pair:
1. Instrument is reliable: alpha=.932. Scores increase with years in residency3. Scores jump the most after the
Developmental and Behavioral rotation4. Pre and Post = significant increase in
scores
Resident Ratings of Developmental and Behavioral Site Training
Sites
2004- 2006 (15 Residents)
5.2
4.9
4.8
4.5
4.4
3.9
3.8
3.7
3.5
1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6
1
RO
TA
TIO
N S
IT
ES
Poor Excellent
Children’s Hospital Social Work
Elementary School Experience
Children’s Hospital Psychology
Developmental Pediatrics
TOTAL AVERAGE
Diagnostic Center
Behavior Clinic
Regional Center
HEALTHY STEPS
Healthy Steps Fresno:Patient and Family
Outcomes
• Breastfeeding• Feeding• Reading• Harsh and Abusive Parenting• Father Involvement• E/R Usage
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.
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.
Harsh and Abusive Parenting
• Moms more often offer explanations to children and less often use harsh parenting (threaten, yell, slap, spank)
Relative Risk Reduction
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.
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
Detection RatesWithout Tools With
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
Future Healthy Steps: Adaptation, Change and
Flexibility
The Prius Model
From:
THE CADILLAC MODEL
To:
Healthy Steps Key Points Into the Future:
• FlexibleComponent selection:
Essential: Developmental Screening, Home Visits, Developmental Info. Line and Healthy Steps Materials
Intensity: Can vary from site to site• Venues
Private practiceHospital clinics and FQHCsResidency TrainingPublic Health
MCB.AB.UIMCH 4-21-2005
• 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 Pediatricsand Family Medicine
The Prius Model
• Community Expansion Support• Proposal:
Healthy Steps Fresno and California
Healthy Steps:Family-Centered Primary
Care
2007 Conference
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
REFERENCES American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family
Health. The New Morbidity Revisited: A Renewed Commitment to the Psychosocial Aspects of Pediatric Care. Pediatrics. 2001; 108.
American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health. The Pediatrician and the “The New Morbidity.” Pediatrics. Vol 92 No. 5 November 1993.
Blackwell DL, Tonthat L., National Center for Health Statistics. Summary Health Statistics for US Children: National Health Interview Survey, 1998. Tables 6 and 12, 2002.
Breunlin, Douglas C. et al. Pediatricians’ Perceptions of Their Behavioral and Developmental Training. Developmental and Behavioral Pediatrics, Vol. 11, No. 4, August 1990.
Christakis, Dimitri et al. Association of Lower Continuity of Care with greater risk of emergency department use and hospitalization in children. Pediatrics Vo. 103 No. 3 March 2001.
Guralnick, Michael J. Training Residents in Developmental Pediatrics: Results from a National Replication. Developmental and Behavioral Pediatrics, Vol. 8, No. 5, 1987.
Leatherman S., McCarthy D, the Commonwealth Fund. Quality of Health Care in the United States: A Chartbook. 2002. available at: http://www.cmwf.org/programs/pub_highlight.asp?id=736&pubid=520&CategoryID=3. Accessed September 20, 2004.