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© 2015 National Conference of State Legislatures The Bright Futures Guidelines: Improving Children’s Health SEPTEMBER 2015 Strong States, Strong Nation BY TAHRA JOHNSON “Legislators want to be sure that our children’s health programs are effective. As we designed and implement hawk-i, it has been important for us to incorporate guide- lines, such as Bright Futures, that emphasize coordinated care, family involvement and support for practitioners.“ —Senator Amanda Ragan, Assistant Senate Majority Leader, Iowa State governments provide health coverage for mil- lions of children through their Medicaid and Children’s Health Insurance Programs (CHIP). Providing cost-effec- tive screening and treatment services saves states money and promotes healthy children. Infant, children and adolescent health needs include well-child visits, vaccinations and developmental screen- ings. Well-child visits offer an important opportunity for physicians to identify and treat problems earlier, yet only about 31 percent of children between 10 months and age 5 received recommended developmental screenings during these visits in 2011-2012. 1 In 2013, 91 percent of in- sured children regularly saw their pediatrician, compared to 68 percent of uninsured children. 2 States have explored strategies to most effectively use these doctor-patient visits, which reach most children. Among the strategies, a program called Bright Futures offers a blueprint for phy- sicians to follow as they administer key social, behavioral and developmental screenings. Detecting and preventing problems early can avert the need for later, more expen- sive treatment for identified conditions. Bright Futures also recognizes the critical role of families in promoting children’s health as partners in their care. 3 “Bright Futures is a national health promotion and disease prevention initiative that addresses children’s health needs in the context of family and community. In addition to use in pediatric practice, many states implement Bright Futures principles, guidelines and tools to strengthen the connections between state and local programs, pediatric primary care, families, and local communities.” 4 —American Academy of Pediatrics The Bright Futures Guidelines: Improving Children’s Health

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© 2015 National Conference of State Legislatures The Bright Futures Guidelines: Improving Children’s Health

SEPTEMBER 2015

Strong States, Strong Nation

BY TAHRA JOHNSON

“Legislators want to be sure that our children’s health programs are effective. As we designed and implement hawk-i, it has been important for us to incorporate guide-lines, such as Bright Futures, that emphasize coordinated care, family involvement and support for practitioners.“

—Senator Amanda Ragan, Assistant Senate Majority Leader, Iowa

State governments provide health coverage for mil-lions of children through their Medicaid and Children’s Health Insurance Programs (CHIP). Providing cost-effec-tive screening and treatment services saves states money and promotes healthy children.

Infant, children and adolescent health needs include well-child visits, vaccinations and developmental screen-ings. Well-child visits offer an important opportunity for physicians to identify and treat problems earlier, yet only about 31 percent of children between 10 months and age 5 received recommended developmental screenings during these visits in 2011-2012.1 In 2013, 91 percent of in-

sured children regularly saw their pediatrician, compared to 68 percent of uninsured children.2 States have explored strategies to most effectively use these doctor-patient visits, which reach most children. Among the strategies, a program called Bright Futures offers a blueprint for phy-sicians to follow as they administer key social, behavioral and developmental screenings. Detecting and preventing problems early can avert the need for later, more expen-sive treatment for identified conditions. Bright Futures also recognizes the critical role of families in promoting children’s health as partners in their care.3

“Bright Futures is a national health promotion and disease prevention initiative that addresses children’s health needs in the context of family and community. In addition to use in pediatric practice, many states implement Bright Futures principles, guidelines and tools to strengthen the connections between state and local programs, pediatric primary care, families, and local communities.” 4

—American Academy of Pediatrics

The Bright Futures Guidelines: Improving Children’s Health

2 | The Bright Futures Guidelines: Improving Children’s Health © 2015 National Conference of State Legislatures

The federal Health Resources and Services Administra-tion (HRSA) initially established Bright Futures in 1990 to improve the standard of care for children and adolescents. Since 2002, the American Academy of Pediatrics (AAP) has overseen development and dissemination of these guide-lines. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents provides pediatric care providers and families with tools for evidence-based care for children from birth to age 21. The Bright Futures guide-lines are of interest to state and local governments because they can help improve children’s health and may provide a return on state investment in health care costs. The Afford-able Care Act (ACA) requires private health insurance plans to cover Bright Futures screenings and services. Most state Medicaid agencies also incorporate these guidelines into children’s preventive services.

The ACA also requires all group health plans, health in-surance plans offered in the exchanges, and all non-grand-fathered plans outside the exchanges to cover all preventive services recommended for children in the Bright Futures periodicity schedule at each visit without cost sharing.5

The ACA requires health plans to cover, at no cost, a range of well-visit services, including immunizations, preventive care and screenings.6 The requirement does not apply to

Medicaid plans; however, many state Medicaid programs use Bright Futures as the standard of care and cover the recommended preventive services.

Bright Futures Guidelines Promote:• Child Development• Mental Health• Healthy Weight• Healthy Nutrition• Physical Activity• Oral Health• Family Support • Healthy Sexual Development • Safety and Injury Prevention• Community Relationships and Resources

To help insurers, regulators, lawmakers and other stake-holders better understand the preventive care screenings and services recommended at each Bright Futures pre-ventive care visit, the American Academy of Pediatrics has created Achieving Bright Futures (www.aap.org/Achieving-BrightFutures). This series of documents provides detailed information—including recommended services, the appro-

© 2015 National Conference of State Legislatures The Bright Futures Guidelines: Improving Children’s Health | 3

priate billing codes used for these services and additional recommendations—for each Bright Futures visit. Achieving Bright Futures can help stakeholders gain a better under-standing of the Bright Futures periodicity schedule recom-mendations.

How States Are Using Bright FuturesStates use Bright Futures guidelines to strengthen chil-

dren’s health programs and policies. Policymakers in both the legislative and executive branches of state govern-ment have used Bright Futures guidelines to design public policies and programs. For example, at least 25 states re-quire physicians to use—and reimburse them for using—Bright Futures guidelines for Medicaid’s benefit package of services for children, the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program. Other states require providers to follow Bright Futures’ recommenda-tions for school physicals. According to the Washington State Institute for Public Policy, approximately 21 state EPSDT programs cover the recommended 30-month visit (which was added in 2008), and approximately 40 states cover annual visits for older children.

Washington The Washington State Department of Health partnered

with the University of Washington (UW) in 2000 to develop pilot projects to improve children’s health. This relationship created an opportunity for UW to incorporate Bright Fu-tures into its training programs and curriculum for nursing, medical and other health professional training programs.8 Washington includes Bright Futures as a part of the Title V (federal Maternal and Child Health Services block grant) needs assessment measures for the state.9

The Department of Health, in conjunction with pediat-ric providers, also used Bright Futures to improve the EPS-DT services for young children (birth to age 5), covering most well-child visits. In 2012, the Washington Legislature directed the Washington State Institute for Public Policy to assess the costs and benefits of implementing the Bright Futures guidelines, specifically well-child visits at age 30 months; annual instead of biennial visits for children over age 6; developmental screens at 9, 18 and 24-30 months; and autism screens at 18 and 24 months.

Prevalence of Developmental or Behavioral Disabilities in the United States

• According to a Policylab study conducted by the Children’s Hospital of Philadelphia, between 10 percent and 13 percent of infants and toddlers experience developmental delays.10

• The CDC indicates that approximately one in 68 children has been identified with Autism Spectrum Disorder. 11

According to the Senate Bill Report 5317, the research indicates that fewer than half of children with develop-mental delays are identified before they start school, and roughly half of children with autism spectrum disor-der are diagnosed only after they enter school. By then, significant delays may have occurred and opportunities for treatment may have been missed.12 As a result of the study, lawmakers passed a bill in 2015 (Wash. H 1365/ Wash. S 5317), signed by the governor in June, to require universal screening and provider payment for autism and developmental delays for children in Medicaid programs; these were not previously covered in the state’s EPSDT program.13

VirginiaPolicymakers in Virginia have used Bright Futures

guidelines to set EPSDT program services in Medicaid and determine requirements for school physicals.14 Accord-ing to the Virginia Department of Health, many of Virgin-ia’s child health care policies are based on Bright Futures guidelines. The Virginia Department of Health partnered with James Madison University and AAP to create the ac-tive Healthy Futures VA website (www.healthyfuturesva.com/abouthf.html), an online version of Bright Futures. This website, which includes videos and health informa-tion, is targeted to families, community members, child

4 | The Bright Futures Guidelines: Improving Children’s Health © 2015 National Conference of State Legislatures

care providers and physicians, among others. The age specific topics include, but are not limited to: ∞ Newborn care∞ Parental support∞ Breastfeeding∞ School readiness∞ Home safety

IowaIowa’s Children’s Health Insurance Program (CHIP),

known as hawk-i, covers uninsured children of working families in Iowa. The program works on a sliding scale, where families may pay up to $40 for children’s health care coverage or up to $20 for dental-only coverage each month.15 The hawk-i governing board consists of four public members appointed by the governor, three direc-tors of state agencies and four ex-officio state legislators. Hawk-i supports the Bright Futures guidelines as the stan-dard of care.

Other State ExamplesMany other states have implemented Bright Futures in

a variety of ways, including the following examples.∞ The Illinois Chapter of the American Academy of

Pediatrics partnered with the Illinois Department of Healthcare and Family Services to promote Bright Fu-

tures as a standard of care in Illinois and to integrate the guidelines into state programs.16

∞ Maine conducted an assessment in 2012 to analyze the information systems, clinical workflow and data flow among health care providers, the public health depart-ment, and the state’s designated health information network and HealthInfoNet (HIN).17 MaineCare Services supported adoption of Bright Futures into electronic health records and offered technical assistance to help with the process. 18, 19

∞ In 2014, the Oregon Health Authority evaluated its ad-olescent well-care visits and found the percent of ado-lescents who had at least one well-care visit fell shy of the 2013 benchmark. Health Authority staff developed tips for improvement, one of which is to “incorporate teen-appropriate health education and health assess-ment tools which follow the Bright Future guidelines to optimize the reliability of care and the use of time.”20

∞ The District of Columbia has adopted a version of Bright Futures to guide the fundamental coverage in Medicaid’s EPSDT benefit.21 HealthCheck (www.dchealthcheck.net) provides information and materials for providers and government agencies that serve chil-dren and families.

Policy Options for State LegislatorsAs described above, several states have considered

various options to implement Bright Futures guidelines. For example, states:∞ Use the Bright Futures guidelines as the standard of

care as recognized by the state department of health.∞ Include the Bright Futures guidelines and tools in state-

run insurance plans or plans that are offered on the state exchange.

∞ Use the Bright Futures guidelines as a standard of care for the Medicaid Early and Periodic Screening, Diag-nostic, and Treatment (EPSDT) program.

∞ Use the Bright Futures Oral Health Risk Tool in Medic-aid dental services.

∞ Explore public-private partnerships to increase the use of Bright Futures in electronic health records.

Bright Futures guidelines recommend oral health risk assessments at the 6- and 9-month well-child visits. The American Academy of Pediatrics provides an Oral Health Risk Assessment Tool for Primary Care Providers to use until a dental home can be established for the child. (AAP)

Policymakers may also consider supporting specific principles of Bright Futures through legislation. For example:∞ AAP recommends exclusive breastfeeding for about

six months, followed by breastfeeding until at least 12 months of age in combination with introduction of

© 2015 National Conference of State Legislatures The Bright Futures Guidelines: Improving Children’s Health | 5

complementary foods to maximize benefits.22 Accord-ing to the U.S. Surgeon General, “For nearly all infants, breastfeeding is the best source of infant nutrition and immunologic protection, and it provides remarkable health benefits to mothers as well.”23

■ Many states have adopted legislation to reduce bar-riers to breastfeeding or support a woman’s decision to breastfeed. Twenty-nine states, the District of Co-lumbia and the U.S. Virgin Islands exempt breast-feeding from public indecency or indecent exposure laws. Laws in at least 25 states relate to breastfeed-ing in the workplace, typically requiring employers to provide time each day and adequate facilities for a breastfeeding employee.

■ Some states also support the Baby Friendly Hospital Initiative, launched in 1991 by UNICEF and the World Health Organization. It ensures that all maternity facil-ities, whether free-standing or in a hospital, become centers of breastfeeding support. Hospitals must demonstrate rigorous compliance to criteria in order to be awarded the title “Baby Friendly Hospital.”24

∞ The National Physical Activity Guidelines recommend that children participate in at least 60 minutes of phys-ical activity a day.25

■ Several states have adopted evidence-based pro-grams or policies to increase the time, space and resources allocated to physical activity. The Guide to Community Preventive Services, also known as The Community Guide, offers examples of ev-idence-based programs and policies to increase physical activity such as:■ Enhanced School-Based Physical Education.■ Creation of or Enhanced Access to Places for

Physical Activity with Informational Outreach, such as creating walking trails or shared use agreements that allow use of school facilities for community members.

∞ The Bright Futures guidelines recommend oral health coverage for children.

■ To address the low oral health participation rates in Medicaid, several states—including Connecticut, South Carolina, Tennessee and Virginia—have in-creased reimbursement rates for participating pro-viders. Other strategies for promoting participation in public programs include outreach to dental pro-viders, reduced administrative requirements and streamlined authorization.26

6 | The Bright Futures Guidelines: Improving Children’s Health © 2015 National Conference of State Legislatures

As policymakers consider the broad range of health policies in their state, they may want to explore oppor-tunities to improve children’s health through promotion of Bright Futures. Improving access to early childhood screenings, preventing and reducing chronic health con-ditions, and promoting wellness significantly affect the lives of children of all ages.

For more information regarding Bright Futures, see:∞ American Academy of Pediatrics (http://brightfutures.

aap.org) ∞ Association of State and Territorial Health Officials (www.

astho.org/Maternal-and-Child-Health/ Bright-Futures)

Resources for Families ∞ The Family Voices Bright Futures Pocket Guide: Raising

Healthy Infants, Children, and Adolescents (2nd Edi-tion) (www.fv-impact.org/publications/pocket-guide)

∞ The Child and Adolescent Health Measure Initiative Well Visit Planner (www.wellvisitplanner.org)

© 2015 National Conference of State Legislatures The Bright Futures Guidelines: Improving Children’s Health | 7

Notes

1. National Survey of Children’s Health, NSCH 2011/12, Data query

from the Child and Adolescent Health Measurement Initiative,

Data Resource Center for Child and Adolescent Health website

(Baltimore: The Johns Hopkins Bloomberg School of Public

Health, 2014), www.childhealthdata.org.

2. Child Trends,. Well-Child Visits. (Bethesda, Md.: Child Trends

Databank, 2014): www.childtrends.org/?indicators=well-child-

visits.

3. D. Denboba, M.G. McPherson, M.K. Kenney, B. Strickland, and P.W.

Newacheck, “Achieving family and provider partnerships for

children with special health care needs,” Pediatrics 118 (2006):

1607-1615.

4. American Academy of Pediatrics, Bright Futures (Chicago: AAP,

Oct. 16, 2014), http://brightfutures.aap.org.

5. The Patient Protection and Affordable Care Act, Sec. 2713,

Coverage of Preventive Services, www.gpo.gov/fdsys/pkg/

BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf.

6. Ibid., 1.

7. J. Bauer, Bright Futures Guidelines and Washington State Medical

Assistance Programs (Document 8. No. 13 – 01 – 3401r)

(Olympia: Washington State Institute for Public Policy, 2013),

www.wsipp.wa.gov/ReportFile/1123/Wsipp_Bright-Futures-

Guidelines-and-Washington-State-Medical-Assistance-

Programs-Revised_Full-Report.pdf).

8. Marisa Ferreira and Rebecca Ledsky, Washington’s Bright Futures

Story (Washington, D.C.: Health Systems Research, 2006),

http://altarum.org/sites/default/files/uploaded-publication-

files/06_project_report_hsr_bright_futures_wa.pdf.

9. Ibid., 8.

10. J. Kavanagh et al., An Integrated Approach to Supporting

Child Development (Philadelphia: Policy Lab, 2012), www.

coloradoabcd.org/files/5613/8117/9045/policylab_e2a_

summer2012_series.pdf.

11. Centers for Disease Control and Prevention, “Prevalence of

Autism Spectrum Disorder Among Children Aged 8 Years.

Autism and Autism and Developmental Disabilities Monitoring

Network, 11 Sites, United States, 2010” MMWR 63, no. SS-0

(2014)): 1-21

12. Senate Bill 5317, http://lawfilesext.leg.wa.gov/biennium/2015-16/

Pdf/Bills/Session%20Laws/Senate/5317-S.SL.pdf

13. Ibid., 12.

14. Valerie Gwinner and Beth Zimmerman, Virginia’s Bright Futures

Story (Washington, D.C: Health Systems Research, 2006),

http://altarum.org/sites/default/files/uploaded-publication-

files/06_project_report_hsr_bright_futures_va.pdf.

15. Iowa Department of Human Services, Hawk-i: Healthy and

Well Kids in Iowa (Des Moines: Iowa Department of Human

Services, Jan. 31, 2013), www.hawk-i.org/en_US/index.html.

16. American Academy of Pediatrics, Illinois Chapter, Bright Futures

(Chicago: IACCP, March. 10, 2015), http://illinoisaap.org/

projects/bright-futures.

17. Martha Williamson et al., Maine’s Improving Health Outcomes for

Children: Bright Futures As-Is Assessment (Portland, Maine:

The Muskie School of Public Service. 2012), www.maine.gov/

dhhs/oms/pdfs_doc/ihoc/Bright_futures_As_Is_Assessment.

pdf.

18. Ibid., 17.

19. Maine Department of Health and Human Services, Incorporating

the Newest Version of the Bright Futures Toolkit into your

Electronic Health Record (Augusta: Maine Department of

Health and Human Services, Nov. 11, 2011), www.maine.gov/

dhhs/oms/headline_news_details.shtml?id=318765.

20. Oregon Health Authority, Adolescent Well Care Visits- Overview

(Salem: Oregon Health Authority, Dec. 2014), www.oregon.

gov/oha/analytics/CCOData/Adolescent%20Well%20Care%20

Visits%20Overview%20--%20revised%20Dec%202014.pdf.

21. National Academy for State Health Policy, Support to Providers

and Families (Washington, D.C.: NASHP, March 10, 2015), www.

nashp.org/epsdt/support-providers-families#sthash.BBAqYSct.

dpuf.

22. American Academy of Pediatrics, AAP Reaffirms Breastfeeding

Guidelines (Chicago: AAP, Feb. 27, 2012), www.aap.org/en-

us/about-the-aap/aap-press-room/Pages/AAP-Reaffirms-

Breastfeeding-Guidelines.aspx.

23. U.S. Department of Health and Human Services, The Surgeon

General’s Call to Action to Support Breastfeeding (Washington,

D.C.: U.S. Department of Health and Human Services, Office of

the Surgeon General; 2011).

24. UNICEF, The Baby-Friendly Hospital Initiative, www.unicef.org/

programme/breastfeeding/baby.htm.

25. U.S. Department of Health and Human Services, The Physical

Activity Guidelines (Washington, D.C.: U.S. DHHS, 2008),

www.health.gov/paguidelines/guidelines/chapter3.aspx.

26. Kristine Goodwin, Smart Investments in Children’s Health:

10 State Strategies (Denver: National Conference of State

Legislatures. 2014), www.ncsl.org/documents/health/

SmartInvestments914.pdf.

8 | The Bright Futures Guidelines: Improving Children’s Health © 2015 National Conference of State Legislatures

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UC4MC28038, Alliance for Innovation on Maternal and Child

Health, Expanding Access to Care for Maternal and Child Health Populations. This information or content and conclusions are those of the author and

should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

NCSL ContactTahra Johnson, MPH

[email protected]

William T. Pound, Executive Director7700 East First Place, Denver, Colorado 80230, 303-364-7700

444 North Capitol Street, N.W., Suite 515, Washington, D.C. 20001, 202-624-5400

www.ncsl.org

©2015 by the National Conference of State Legislatures. All rights reserved. ISBN 978-1-58024-774-0