linkages: south carolina pediatric medical home and home visting
DESCRIPTION
F. Rushton presentation given at the 2012 South Carolina Home Visiting SummitTRANSCRIPT
Hawaii
Young Children Not Succeeding in School(Characteristics of Ages 0 – 3, Subsequently Retained or BB on PACT)
(%) Not Succeeding High Risk Group (%) of 1995-96
Birth Cohort
53% Abused, Neglected, or in Fostercare 3%
52% Very Low Birthweight (under 1500 grams) 1.4%
48% Lower Educated Mother (under 12 grades) 25%
45% TANF 17%
43% LBW (1500 - 2000 grams) 1.8%
43% Teen Mother (under 18) 8%
42% Food Stamps 32%
37% Mother (age 18 - 20) 17%
36% LBW (2000 - 2500 grams) 6%
Low Risk Group16% Higher Educated Mother (more than HS) 34%
Source: ORS Data Warehouse files from DHEC Vital Records and DSS linked to SDE PACT data.
The Role of Preschool Home-VisitingPrograms in Improving Children’s
Developmental and Health Outcomes
Child health and developmental outcomes depend to a large extent on the capabilitiesof families to provide a nurturing, safe environment for their infants andyoung children. Unfortunately, many families have insufficient knowledge aboutparenting skills and an inadequate support system of friends, extended family, orprofessionals to help with or advise them regarding child rearing. Home-visitingprograms offer a mechanism for ensuring that at-risk families have social support,linkage with public and private community services, and ongoing health, developmental, and safety education. When these services are part of a system ofhigh-quality well-child care linked or integrated with the pediatric medical home,they have the potential to mitigate health and developmental outcome disparities.This statement reviews the history of home visiting in the United States andreaffirms the support of the American Academy of Pediatrics for home-basedparenting education and support. Pediatrics 2009;123:598–603
Do we know if Home Visiting is effective?:
• Unfortunately, many of the early programs, including Hawaii Health Start, have had difficulty documenting efficacy when taken to scale.
• Not all home visiting programs are alike• Programs that show greater adherence to standards are
more likely to be effective• Programs staffed with nursing professionals more likely to
be successful.• ??Successful program build on the development of a
trusting relationship between the home visitor and parents over time.
Benefits of Home Visiting
• Improve parenting skills and the quality of the home environment
• Ameliorate several child behavioral problems
• Improve intellectual development, especially with low birth weight
• Enhance maternal life course
• Detect post partum depression
• Positive impact on maternal child attachment
• Enhance social supports for mothers
• Improve breastfeeding rates
Some characteristics of successful home visiting
• Focused on socially deprived mothers• Professional or nurse trained home visitor• Focused on low birth weight or premature
babies• Provide services of long duration and great
intensity• Focused on families with many risk factors
Linking home visiting to the pediatric medical home
• Because of increasing complexity of pediatric morbidity, movement towards team based care
• Home visitors could be critical members of these teams and augment pediatric medical home
• Partner ships with pediatricians working in the home setting to provide essential education and supportive services to at-risk children and families
• Improving adherence to medical preventive and treatment regimens
Home Visiting Affordable Care Act
• Early Head Start (EHS) – Home Visiting Option• Family Check-Up (FCU)• Healthy Families America (HFA)• Healthy Steps (HS) for Young Children• Home Instruction Program for Preschool Youngsters
(HIPPY)• Nurse-Family Partnership (NFP)• Parents as Teachers (PAT)• Early Intervention Program for Adolescent Mothers (EIP)• Child FIRST
Nurse-Family Partnership (NFP)Nurse-Family Partnership (NFP) targets first-time, low-income mothers and their children. Mothers must be enrolled in services by the 28th week of pregnancy, and services conclude when the child turns two years of age. Home visits provided by nurses seek to promote maternal and child health, children’s development, and parental economic self-sufficiency. For more information: Nurse-Family Partnership National Service Office1900 Grant Street, Suite 400Denver, CO 80203Phone: 866-864-5226Fax: 303-327-4260E-mail: [email protected]: http://www.nursefamilypartnership.org
Parents as Teachers (PAT)
Parents as Teachers (PAT) targets families from pregnancy to kindergarten entry of children. The program seeks to promote child development knowledge and to improve parenting practices of caregivers. The PAT model consists of four components: (1) one-on-one home visits, (2) group meetings, (3) developmental screenings for children, and (4) a resource network for families. Home visiting services can range in intensity, from weekly to monthly, as well as in duration. For more information: Parents as Teachers National Center, Inc.Attn: Public Information Specialist2228 Ball DriveSt. Louis, Mo. 63146Telephone: 314-432-4330 Toll-free telephone: 1-866-728-4968Fax: 314-432-8963 Website: www.parentsasteachers.org
Early Head Start (EHS) – Home Visiting Option
Early Head Start (EHS) is a child and family development program that targets low-income pregnant women and families with children ages birth to three years. EHS provides high-quality, flexible, and culturally competent child development and parent support services with an emphasis on the role of the parent as the child’s first and most important relationship. The goals of EHS are to promote healthy prenatal outcomes for pregnant women, to enhance the development of very young children, and to promote healthy family functioning. The Home Visiting Option offers and supports comprehensive services to children and their families through weekly home visits and group socialization experiences. The key focus of the Early Head Start Home Base program option includes: Health & Safety, Mental Health, Nutrition, Education, Special Education, Parent Involvement, and Social Services. For more information: Administration for Children and FamiliesOffice of Head Start (OHS)8th Floor Portal BuildingWashington, DC 20024Website: http://www.acf.hhs.gov/programs/ohs/
Healthy Steps (HS) for Young Children
Healthy Steps (HS) targets parents with children from birth to 3 years. Services are implemented by any pediatric or family health medicine practice. Healthy Steps focuses on building a close relationship between health care professionals and parents for the promotion of physical, emotional, and intellectual growth and development of infants and children. Through regular home visits and contact with a health professional, the program seeks to promote child development, promote school readiness, and improve positive parenting practices.
For more information: Margot Kaplan-SanoffHealthy Steps National DirectorVose Hall #419Boston University School of Medicine 72 East Concord StreetBoston, MA 02118Telephone: 617-414-4767Email: [email protected]: http://www.healthysteps.org
The Children's Center of Carolina Health Centers, Inc.113 Liner DriveGreenwood, SC 29646Phone: (864) 941-8105
Darlene Hood-JohnsonHealthy Steps [email protected]
Sally [email protected](864) 941-8105
Behavioral HealthServices
Pediatric
Medical Home Care
Evidence-basedHome VisitationServices
The Children’s
Center
The Children’s Center, Greenwood
Evidence-based Home Visitation
• Home visiting should not be delivered in isolation but as part of the continuum of care and network of health services for families with young children, beginning in pregnancy.
• A continuum of evidence-based early childhood home visitation provides the best fit for families and the most cost-effective services.
• Our continuum includes Nurse-Family Partnership, Healthy Families America/Parents as Teachers, and Healthy Steps for Young Children.
System improvements
• Provision of a continuum of services to provide the “best fit” for families.
• Increased access and decreased barriers to services
• Seamless team approach utilizing medical providers, home visitation providers and behavioral health providers. Families hear consistent messaging.
System improvements
• Shared use of electronic records for communication
• Improved family identification, engagement and retention.
• Use of a standardized screening and assessment process prenatally and at birth
• Quality improvement across services using PDSA format.•Improved referral pathways to additional community resources.
QTIP Example
Quality Indicator is number of children that kept at least six well child visits from birth to 15 months.
• TCC – all children 55.2% met the indicator• HS/HF children 72% met the indicator
• TCC – all children 77.6% with at least 5 visits• HS/HF children 100 % with at least 5
visits
Healthy Steps expands traditional clinical practice through the addition of Healthy Steps Specialists (HSS) who provide services that augment pediatric care by building parents’ knowledge about child development, and their confidence in actively participating with the pediatric team and in their child’s health care.
Enhanced Well Child Care
Usually completed at the Well Child Visit. HSS answer parents questions about developmental issues or problems and referred to the physician for medical issues.
Parents are given information on a variety of topics and when needed, given ideas/exercises to enhance developmental skills.
Healthy Steps parents receive a variety of handouts, specific to the age of their child.
Pride Cards, in conjunction with the Greenville Hospital System, are mailed directly to the parent at key developmental stages through age 5.
LINK Letters are mailed to parents prior to the Well Child visit. These inform the parent about what to expect at the visit, give parenting tips and tools, and act as a reminder of scheduled appointment. These are given to age 3.
Links to community resources
Healthy Steps maintains a book of community resources that includes information on child care programs, libraries, as well as on programs for substance abuse, counseling, domestic stress, and housing.
Well Baby Plus: Collaborative Approach to the Parent Child Relationship
Well Baby Plus intervention• Group well child visits staffed by a private pediatric
practice (8 clinicians), who provided other medical home services at their office. Group visits were scheduled using the AAP periodicity schedule
• Utilized a school-based home visitation program (“Parents as Teachers” curriculum). Home visitors provided assistance with coordination, appointment reminders, transportation and post visit reinforcement. Home visitors attended the group well visits.
• Visits were provided on a school site where other auxiliary services were present
Features of Well Baby Plus Evaluation Group
• 119 Families offered WB+
• 91 families enrolled• 70 families still engaged
at 15 months of age• 51 families completed
exit questionnaire• Lived east of Battery
Creek
Comparison Group Features• Received traditional
pediatric care within the medical home
• Lived west of Battery Creek
• Matched retrospectively one to one with WB+ patients by maternal age, marital status and SE stress (Orr SES)
Methods
• Outcomes were assessed at or near the child’s 15-month visit by parental questionnaire and review of the child’s medical records.
• Analysis used McNemars test for nominal data and paired t-test for continuous data.
Completed all Well Child Visits
• Children in the WB+ intervention group (65%) were more likely than comparison group (37%) children to attend all scheduled well-child visits
• ( p= 0.006) 0%
10%
20%
30%
40%
50%
60%
70%
CompletedWell Baby
Visits
WB+
Control
Immunization UTD as recorded in Patient Chart
70
75
80
85
90
95
WB+
Control
• 92% of WB+ children were fully immunized vs. 78% of comparison children (p= 0.01)
Trend towards Lower ER Utilization
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
WB+
Control
• Well Baby Plus children showed a trend towards lower ED usage with an average of 1.0 visit vs. 1.45 visits in the control population (p=0.18)
• Not statistically significant
Well Baby Plus families were significantly more likely to report their visits helped them become better
parents
0102030405060708090
100
WB+
Control
• WB+ : 94% reported that well child visits were helpful
• Comparison: 76% reported that well child visits were helpful
• p= 0.04
Family Spacing:Well Baby Plus Mothers more likely to be using birth control
0
5
10
15
20
25
30
bc no bc
WB+
Control
• WB+: 25/41 using birth control (61%)
• Comparison: 17/43 using birth control (40%)
• p = 0.03
When child was 15 months, parents recalled their clinician had discussed:
0
10
20
30
40
50
60
70
80
90
P D L N T
WB+
Control
• WB+: • P: Poisoning : 65% (p=0.003),
• D: Discip.:69% p<0.001), • L: Literacy: 87% p=0.16) N:
Nutrition: 8%(p=0.17) T: Toi-train:35%(p=0.01)
• Control Group: • P: Poisoning: 41%, D:
Discipline: 31% L:Literacy: 75% N: Nutrition: 78% T:Toilet-Training 12%
Impact on Obesity?: Were Well Baby Plus patients less like to be obese at 15 months of age?
0
5
10
15
20
25
Wt.>90
Wt/Ht>90
WB+
Comparison
• WB+– weights> 90 percentile: 8%– Average 50 percentile
• Control Group– weights>90 percentile: 24%– Average 55 percentile– p=0.03– This difference disappeared
when Weight vs. Height percentiles used (p=.3)
Conclusion
• South Carolina’s Children are failing to have satisfactory development at alarming levels
• Home visitation’s time has come. • Need to promote fidelity to proven home
visitation models• Link home visitation to other services such as
the pediatric medical home• Use the resources of the Affordable Care Act
and others to provide services