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
•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
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• Cooking Matters suite of courses
– kids, teens, families, adults
• Tours & demos
• Just Say Yes
• Nutrition Basics Workshops
• Fruit Bowl
CH Nutrition Education Programs
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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!!
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““
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!