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Healthy Steps: Past, Present and Future

Healthy Steps: Past, Present and Future. Rick Brandt-Kreutz, LCSW August 10, 2006 2006 State First 5 Summit South Lake Tahoe, California. Objectives. Past: Healthy Steps Background and Outcomes Present: Healthy Steps Fresno Outcomes Future: Adaptation, Change and Flexibility.

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Healthy Steps: Past, Present and Future

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

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

  3. Evolution of Healthy Steps • 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

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

  5. Beginning Healthy Steps • 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

  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. Parents Want Help With Development • 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 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. Changing Health Care Margaret E. Mahoney of the Commonwealth Fund: “Healthy Steps represents a change in health care” What is Healthy Steps?

  13. Healthy Steps Quality Enhancement in Primary Care for Children 0 to 3 Families Clinical Team + Healthy Steps Specialist (HSS) • 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 • Focuses on Behavior and Development • Nurtures Families • Provides Important Information Parents Want and Need • 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 * JAMA 12/17/03 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 • 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) Relative Risk Reduction 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. Healthy Steps Quality Enhancement in Primary Care for Children 0 to 3 Families Clinical Team + Healthy Steps Specialist (HSS) • 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 • Focuses on Behavior and Development • Nurtures Families • Provides Important Information Parents Want and Need • 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 JAMA, December 17, 2003—Vol 290, No. 23 (3081 – 3091) MCB.AB.UIMCH 4-21-2005

  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. Frequency Competence Answer questions Initiate discussion Use screening Obtain history Identify problems Recommend intervention Resident Survey With regard to infants and toddlers (ages 0-3):

  33. Survey Results…so far Administered 4 times with one beginning and ending pair: • Instrument is reliable: alpha=.93 • Scores increase with years in residency • Scores jump the most after the Developmental and Behavioral rotation • 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. 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) Detection RatesWithout Tools With Tools Anita Berry MSN, CNP/APN

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

  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. Healthy Steps Pediatricsand Family Medicine • 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 The Prius Model

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

  50. Check out our website: http://www.fresno.ucsf.edu/pediatrics/program_info.htm Thank you for your time Fresno, California supported by a grant from First 5 Fresno

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