2017 Primary Care Symposium

PEDIATRIC WELLNESS

2

Pediatric Wellness

Moderator: Celina Ramsey, MShc

Panelists:

Ginny Mantello, MD

Fern Aaron Zagor, LCSW, ACSW

Teré Dickson, MD, MPH

Maggie Meehan MA MPH RDN

Working Together on Child Well-Being

Ginny Mantello, MD

Director, Health and Wellness

Office of the Staten Island Borough President

What is Child Well-Being?

“Child well-being, as a multidimensional and a holistic

approach, provides a contextual understanding of a child in

different domains such as health, material well-being,

education, conditions of housing and environment, and

interpersonal relations.

The child well-being approach puts the quality of life and

happiness of the child in the forefront and aims at increasing

the capabilities of the child in accordance with the basic

indicators in each domain.”

(UNICEF)

Contributing Factors

CHILD WELL-BEING

Personal life

Safety and physical status

Behavior Problems

Confidence

Competence

Positive identity

Intellectual development

Healthy Diet

Empathy

Physical development

Contribution

Civic life

Character

Connections

Social competencies

Positive Values

Educational/ intellectual

School Engagement

Suicide

Depression

Substance Use

Why is well-being useful for public health? Well-being integrates physical, mental and emotional health

as well as social determinants, resulting in more holistic

approaches to disease prevention and health promotion

Well-being is a valid population outcome measure beyond

morbidity, mortality and economic status

Well-being is an outcome meaningful to the public

Well-being is associated with – self perceived health,

longevity, healthy behaviors, social connectedness,

productivity, decrease mental and physical illness

Well-being can provide a common metric to shape and

compare effects of different policies and to track disease

prevention and health promotion

SHARED MEASUREMENT

Mutually

Reinforcing

Activities

BACKBONE ORGANIZATION

CONTINUOUS COMMUNICATION

Many cross sector coalitions working

together to address well being of

children and families using a

collective impact model

Child Well-Being Continuum

SI Perinatal Network

Perinatal-2 years

SI Alliance for North Shore Children and Families

0-8 years

Child Wellness Initiative

5-14 years

SI Asthma Coalition

0-17 years

TYSA

12-25 years

Staten Island Perinatal Network

Organizational Framework

GOAL: By 2020, create lasting improvements in the health and well-being of babies and families on Staten Island, with a specific focus on those neighborhoods and population groups experiencing the worst perinatal outcomes

Staten Island Alliance for North

Shore Children and Families

Organizational Framework

How does SI Alliance for NSCF define child well-

being?

Staten Island Child Wellness

Initiative

Overarching Goal of CWI

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By 2026, bring 80% of SI children through 8th grade to a healthy

weight by addressing:

Access and opportunities for physical activities

Availability and affordability of fresh, healthy food

Community-wide partnerships that shape children’s home,

school, recreational, and healthcare environments

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Staten Island Asthma Coalition

Organizational Framework:

DATA WORKGROUP

Work Groups

Schools/ After Schools/ Community

Goals: • Strengthen school-based

asthma care and education

• Strengthen coordination with clinical and community services

Overarching goal: By 2020, all children with asthma lead full active lives with minimal symptoms and 25% reduction in unnecessary ED visits, hospitalization and school absences.

Clinical

Goals:• Improve clinical practice by

using evidence based strategies and data to assessand drive improvement

• Strengthen partnership between clinical and community partners (non-clinical and CBOs)

• Share data around key asthma performance metrics

Care Coordination/ Environment

Goals: • Provide self-management

support

• Ensure coordination of care among providers

• Reduce environmental triggers in the home

Tackling Youth Substance Abuse (TYSA)

TYSA aims to decrease use of alcohol and prescription drugs, and to increase healthy choices among SI youth and young adults

Guiding Principles

Population-Level Impact

Structural Changes

Data-Driven

Research-Driven Strategies

TYSA StructureSteering Committee

Alcohol

AdvisoryOpioid

Social

Norms

Policy &

Advocacy

Borough Hall

School Based

Substance Use

Taskforce

Continuum

of CareYouth

• External groups w/ TYSA participation

• Backbone + relevant reps from WGs or SC

• Group led by TYSA backbone, with relevant

reps from WGs or SC

BA

CK

BO

NE

YPD

Youth

First pilot

Executive

Committee

Data• Reviews new substance abuse related

research and targets WG strategies

Heroin

Overdose

Response

Initiative

DSRIP

BHIP

School

Based

Youth

WINSPerinatal

Network

What role can clinicians play?

▶ Join the clinical teams of large coalitions to formulate and recommend evidence-based practices and strategies

▶ Increase referrals to Care Management and Health Home services

▶ Support linkages between the clinicians and CBO’s by increasing referrals to CBO partners

▶ Partner with school and afterschool programs ▶ Incorporate social determinants into clinical

assessments▶ Have more of a presence at community events

THANK YOU!

Services for Children in aChanging Health Care Environment

December 2, 2017

SIPPS Conference: Primary Care SymposiumFern Aaron Zagor, LCSW, ACSW

President and CEO

Staten Island Mental Health Society

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Agenda

New York State Initiatives• Pediatric Value Based Payment Strategy

• First 1000 Days Initiative

• Draft Transition Plan for the Children’s Medicaid System Transformation

Pediatric Value Based PaymentVBP Workgroup - Children’s Advisory Group

• Value-Based Payment –Bringing Children to the Forefront

• Delivery system and payment reform efforts to date generally focused on adults, and more specifically high-cost, high-need adults

• ‘Value’ for children is very different from adults, especially given that children and adult health differ dramatically: Dollars, Diagnoses, Dependency, Developmental Stages, Diversity

• New York Medicaid is leading and moving quickly: All Albany Ready –Pilot collaboration with Albany Promise on pediatric primary care and kindergarten readiness

• NYS Medicaid VBP Roadmap -Children’s VBP Subcommittee and Clinical Advisory Group

Children’s Advisory Group Process and Outcomes

• Conducted 5 in-person meetings and held 2 webinars between October 20, 2016 and July 10, 2017.

• Final report issued on September 18 with 3 core “products”• Conceptual framework intended to guide the State’s future

deliberations about VBP for children

• Draft recommendations pertaining to a child-specific VBP model, measures, and future work focused on children with complex needs

• Measures set that could be applied to VBP arrangements for children in 2018 and proposed expansion of some maternity measures for other VBP arrangements beginning in 2019.

Value Statement – Not Just Little AdultsA North Star Framework

• “Focusing on healthy growth and development of children will improve their quality of life. Children require a VBP approach that acknowledges the specific needs attendant to each developmental stage and the unique opportunity to improve health and life trajectories, as well as the near-term improvements that are possible from direct health interventions. Support and recognition of families and caregivers are central to improving children’s lives.”

• Recognition of importance of social determinants of health

Example of MeasuresCategory I (13 measures)• Adolescent Well-care visit rate

• Assessment and counseling of adolescents on sexual activity, tobacco use, alcohol and drug use, depression.

• BMI assessment and counseling

• Child immunization status, age 2

• Children ages 2 – 20 having annual dental visits

• Chlamydia screening women ages 16 – 21

• Asthma admission rate

• Follow-up care for children prescribed Rx for ADHA

Examples Category 2 • Screening for reduced visual acuity and referral for children

• Maternal depression screen done during child’s first 6 months

• Developmental screening using standardized tool, first 36 months

Maternity Measures for Child Health• Infants exclusively fed with breast milk in hospital

• Live births less than 2500 grams

• Timeliness and frequency of prenatal and postpartum care visits

• Women provided most or moderately effective methods of contraceptive care within 3 to 60 days of delivery

• Behavioral Risk assessment for pregnant women

Next Steps

•Recommendations submitted to MRT

•Reviews at all levels

•Submission to CMS for approval

•Annual updates and reviews to VBP Roadmap

•Children’s CAG will continue to meet

First 1000 Days Initiative

Jason Helgerson, Medicaid Director, NYS DOHChad Shearer and Suzanne Brundage, United Hospital Fund

Medicaid and Kids

The Charge of the Group

Final 10 – State Share, Subject to Available Funding.

Federal Share not included.

Children’s Medicaid Transition PlanThe 1115 Waiver• Children’s Transition Deliverables and Dates: Transition 1915(c) Children’s

Waivers to Health Home • July 1, 2018 • Align Children’s Home and Community Based Services for Level of Care

Population • July 1, 2018 • Children’s Behavioral Health Benefits Transition to Managed Care • July 1, 2018 • Foster Care Population Transitions to Managed Care January 1, 2019 • Expansion of Children’s HCBS for Community Eligible and Family of One

Level of Need Population January 1, 2019

The GOAL is to…Get children back on their developmental trajectory:

• Identify needs early

• Maintain the child at home with support and services

• Maintain the child in the community, in least restrictive settings

• Prevent longer term need for higher end services

Focus on recovery and

building resilience!

Proposed New Medicaid State Plan Services

• Crisis Intervention

• Community Psychiatric Supports and Treatment (CPST)

• Other Licensed Practitioner

• Psychosocial Rehabilitation Services

• Family Peer Support Services

• Youth Peer Advocacy and Training

Health Home Care ManagementHome and Community Based Services • Accessibility Modification

• Adaptive and Assistive Equipment

• Caregiver/Family Supports and Services

• Community Self-Advocacy Training, and Support

• Habilitation

• Non- Medical Transportation

• Palliative Care

• Prevocational Services

• Respite

• Supported Employment

• Financial Management and Customized Goods and Services

CANS (Child and Adolescent Needs and Strengths Assessment)

• John Lyons, PhD, author (www.praedfoundation.org) of the CANS

• A multi-purpose tool to support decision making, including level of care and service planning, to facilitate quality improvement initiatives, and to allow for the monitoring of outcomes of services.

• Developed from a communication perspective so as to facilitate the linkage between the assessment process and the design of individualized service plans including the application of evidence-based practices.

Role of the Independent Entity

• New Entity

• Work with MMCO to develop HH and HCBS Plan of Care

• Verify Eligibility for children who meet at-risk Level of Need

criteria for Medicaid and Home and Community Based

Services as a “Family of One.”

• Eligibility based on Level of Need not 3 of slots.

April 27, 2015 22

Thank You!

• Feel free to contact me:

•Fern Zagor, President/CEO

•Staten Island Mental Health Society

• fzagor@simhs.org

•718-442-2225, x321

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EAST HARLEM ASTHMA CENTER FOR EXCELLENCE

(EHACE)Teré Dickson, MD, MPH

Clinical Director, Asthma Initiatives

Outline

• Prevalence of asthma and racial/neighborhood disparities in New York City

• EHACE model approach to comprehensive asthma care

• Overview of the East Harlem Asthma Center of Excellence – Asthma Counselor Program (EHACE) and outcomes

In 2015, 13% of New York City children had asthma but children of color were disproportionally affected

Prevalence of asthma among children ages 0 to 12 by race/ethnicity,

New York City, 2015

4%

10%

15%

22%

0% 5% 10% 15% 20% 25%

White

Asian

Latino*

Black

*White, Black, and Asian and Pacific Islander race categories exclude Latino ethnicity. Latino includes Hispanic or Latino of any race.

Sources: Child Health, Emotional Wellness and Development Survey (CHEWDS) 2015;

NYC Prevalence

Asthma disparities in NYC are not limited to morbidity

39

11

41 2

0

10

20

30

40

Black Latino White Asian Not Stated /Unknown

Num

ber

of

Death

s

N=57

Asthma-related deaths among children ages 1 to 14 by

race/ethnicity, New York City, 2010-2014

Source: New York City Department of Health and Mental Hygiene. Epiquery: NYC Interactive Health Data System. Epiquery: NYC

Interactive Health Data System - Death/Mortality Data 2010-14. [5/1/2017]. nyc.gov/health/epiquery52

Asthma disparities are also evident across neighborhoods in NYC

Source: New York State Department of Health, Statewide Planning and Research Cooperative System (SPARCS), 2008 (Data

Update: June 2015)

Rate (per 10,000 residents)

1.3 to < 13

Asthma Hospitalizations (Children 5 to 14 Yrs Old, 2014)

13 to < 28

28 to < 43

43 to < 58

58 to 104.9

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Asthma-related hospitalizations among children ages 5-14

During that time, East Harlem had the highest rates in NYC for:

Asthma-related

emergency department visits

among children ages 5-14

Source: New York State Department of Health, Statewide Planning and Research Cooperative System (SPARCS), 2008 (Data Update: June 2015)

In 2008, NYC made a commitment to serving children with asthma in East Harlem through the East Harlem Asthma Center of Excellence (EHACE)

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18% of homes had 3 or more

maintenance deficiencies

1 out of 2 homes

had cockroaches

Only 8% of housing stock was owner occupied

(3rd lowest in NYC)

Source: New York State Department of Health, Statewide Planning and Research Cooperative System (SPARCS), 2008 (Data Update: June 2015) and the Furman Center for Real Estate & Urban Policy

Children in East Harlem also experience many social inequities (2008)

Nearly half (45%) of children under

the age of 5 lived in poverty

56

Case Management

Education and

Outreach

EHACE: Multicomponent Asthma Model

EHACE: Place-based approach

Self Referral

Schools / Daycares

Community Programs

Physicians&

FQHCs

Asthma Clinics

Emergency Department

Inpatient

58

Epi Data Brief

•Go to NYC.gov

•Search “Epi Data Brief”

59

Among 2016 graduates, asthma symptoms decreased significantly from baseline to program completion

3.4

2.2 2.2

1.41.7

2.9

1.8

0.8

0.1

0.5

0

1

2

3

4

Baseline 3 Months 6 Months 9 Months Final Session*

Days with Symptoms

Nights with Symptoms

N=45

*Final session is typically 12 months after enrollment.

Day symptoms – Days with coughing, wheezing, shortness of breath or tightness in the chest in past 2 weeks

Night Symptoms - Nights with awakenings because of coughing, wheezing, shortness of breath or tightness in the chest in the past 4

weeks

Source: EHACE Asthma Counselor Program data, 2016 60

Among our graduates, emergency department visits and hospitalizations due to asthma decreased significantly

*Final session is typically 12 months after enrollment

Source: EHACE Asthma Counselor Program data, 2016

66

10

29

5

0

10

20

30

40

50

60

70

Emergency department visits Hospitalizations

12 month period prior to enrollment

12 month period prior to graduation

N=45

61

In East Harlem, asthma-related emergency department rates among children 0-4 declined from 2008 to 2014

1 – East Harlem

3 – Hunts Point / Mott

Haven

4– Crotona / Tremont

2 – High Bridge /

Morrisania

5 – Central Harlem

2 – Hunts Point / Mott

Haven

1 – High Bridge /

Morrisania

3 – Crotona / Tremont

5 – East Harlem

6 – Central Harlem

2008 2014

Source: New York State Department of Health, Statewide Planning and Research Cooperative System (SPARCS), 2008 & 2014 (Data Update: June 2015)

Neighborhood ranking of asthma-related emergency department rates among children ages 0-4, 2008 & 2014

62

In East Harlem, asthma-related hospitalization rates among children 5-14 declined from 2008 to 2014

1 – East Harlem

2 – Hunts Point / Mott Haven

3– Fordham / Bronx Park

4 – Williamsburg / Bushwick

5 – Central Harlem

1 – Hunts Point / Mott Haven

2 – Fordham / Bronx Park

4 – East Harlem

8 – Central Harlem

12 – Williamsburg / Bushwick

2008 2014

Source: New York State Department of Health, Statewide Planning and Research Cooperative System (SPARCS), 2008 & 2014 (Data Update: June 2015)

Neighborhood ranking of asthma-related hospitalization rates

among children ages 5-14, 2008 & 2014

63

East Harlem Asthma Center for Excellence

161-169 E. 110th StBetween Lexington and

3rd AveManhattan, NY 10029

646-682-2100

65

Nutrition Education on Staten IslandMaggie Meehan MA MPH RDN

Director, Nutrition Education

City Harvest, Inc.

City Harvest

66

Overview of City Harvest

• Food distribution in all five boroughs through

agencies & soup kitchens

• Healthy Neighborhoods Initiative – one neighborhood

in each borough

67 Graphics

City Harvest’s Healthy Neighborhoods

Washington Heights

North Shore Staten Island

South Bronx

.

Northwest Queens

.

Bedford-Stuyvesant

68

Food Insecurity & Poverty on SI – 2015

Feeding America’s Map the Meal Gap/USDA Economic Research Service:

• 9.4% / 44,500 people are food insecure• 17% / 18,130 children are food insecure

Hunger Free NYC:

• 14.5% poverty rate (61% increase in last 6 years)• 33.33% of food pantries & soup kitchens responding

to survey do not have enough food to meet current need

69

• Cooking Matters suite of courses

– kids, teens, families, adults

• Tours & demos

• Just Say Yes

• Nutrition Basics Workshops

• Fruit Bowl

CH Nutrition Education Programs

70

CM Curricula

Adults*

EXTRA for Wellness

Families*

EXTRA for Diabetes

Cooking Matters at the Store for

Adults*

Cooking Matters at the Store for WIC Parents*

Parents*

71

Nutrition Educator: Bianca Palumbo

Bianca provides nutrition education at sites across

SI for 3 agencies: City Harvest, SIPPS, and DOH

What makes SI special?

72

1. Staten Island Head Start

2. Port Richmond Day Nursery

3. Creative Learning Clubhouse

4. Friends of Crown Heights (@ Stapleton Houses)

5. The Children Center CSI

Eat Well Play Hard, DOH

73

Nutrition Workshop/ Classes

1. Camelot Counseling Center

2. Archcare

3. Community Health Center Richmond

4. JCC @ I.S 49

5. P.S 78

6. Stapleton Senior Center

7. WIC – Bay Street and SIUH sites

8. SIUH

9. Beacon Christian Community Health Center

74

Continued 10.Port Richmond HS

11.CYO

12.Dr. Thomas

13.CYO Senior Center

14.Pride Center

15.Joseph House

16.City Harvest Mobile Markets

75

1:1 Patient Counseling

1. Comprehensive Pediatrics- 77

2. EG HealthCare- 70

3. Dr. Pelina- 25

4. Dr. Thomas- 20

Approx Total = 200 Patients

76

CH Recommend-ations forPediatrics Practices

✓ 6-week 1:1 counseling program

✓ 6-week Cooking Matters for Families course – most intensive

✓ 1-10 Just Say Yes activities

✓ Pop-tours in waiting room

✓ Supermarket tours

✓ Fruit & Veggie Prescription Program at City Harvest Mobile Markets

77

Clinics give at-risk patients referral cards for free fruits and vegetables at City Harvest Mobile Markets

City Harvest Referral Program

78

Train the Teacher

In partnership with Jody Stoll of SIPCW and

Stephanie Caloir of the DOE, we are developing a

Train the Teacher workshop as a first step in

bringing the Cooking Matters for Kids program to

5th grade classrooms in partnering schools.

These are schools with gardens – providing future

opportunities for additional programming.

In the works!!

79

““

79

I’m not so concerned about the number on the scale. I feel like I’m starting to become aware and able to make better decisions about food and exercise. I feel confident this can lead to a healthy life.

Child after losing only a small amount

of weight

Comprehensive Pediatrics

Content Slides

80

Thank you.

81

Questions and AnswersTHANK YOU FOR ATTENDING!