Healthy Steps For Young Children Research Articles

The Need for New Cost Measures in Pediatric Value-Based Payment

* Abbreviations: APM — : alternative payment model InCK — : Integrated Care for Kids TCOC — : total cost of care Value-based payment reform is gaining momentum as health care stakeholders seek to reduce costs and improve quality. Reforms have not been evenly distributed, with most alternative payment models (APMs) being focused on adults. The relative lack of child-focused APMs represents a missed opportunity. Early life interventions can improve children’s cognitive and behavioral development, resulting in reduced costs over a lifetime; however, such interventions require new financing models to be sustainable.1 The Center for Medicare and Medicaid Innovation’s recent Integrated Care for Kids (InCK) Model, which requires APM development to support the integration of health care and other family-serving sectors, offers new momentum for child-focused payment reform.2 To capitalize on the reform opportunities, new cost measures for APMs are needed that better capture the value of children’s healthy development and promote greater investment for preventive interventions during this critical life stage. Cost measures play a vital role alongside quality measures in shaping the incentives within an APM. Cost-of-care measures capture the total spending on health care services for a specific duration of time, population, or care setting. APMs use cost measures to ensure that the total amount paid out is not more than what would otherwise be spent absent the APM. For example, the total cost of care (TCOC) captures the total spending for a patient population over a certain duration … Address correspondence to Nathaniel Z. Counts, JD, Mental Health America, 500 Montgomery St, Suite 820, Alexandria, VA 22314. E-mail: ncounts{at}mhanational.org

Postpartum Depression Screening, Referral, and Follow-Up in Pediatric Primary Care: The HealthySteps Effect

BACKGROUND: Postpartum depression (PPD) is estimated to affect up to 20% of new mothers each year. Screening for PPD in the pediatric care setting provides an opportunity for dialogue and referral to treatment, and studies indicate that physician follow up improves maternal outcomes for PPD. HealthySteps for Young Children (HS) is a ZERO TO THREE national initiative supporting integrated pediatric care during the first three years of life. HS embeds an early childhood development specialist, the HealthySteps Specialist (HSS), into the care team. The HSS provides anticipatory guidance and …

Redesigning Health Care Practices to Address Childhood Poverty

Child poverty in the United States is widespread and has serious negative effects on the health and well-being of children throughout their life course. Child health providers are considering ways to redesign their practices in order to mitigate the negative effects of poverty on children and support the efforts of families to lift themselves out of poverty. To do so, practices need to adopt effective methods to identify poverty-related social determinants of health and provide effective interventions to address them. Identification of needs can be accomplished with a variety of established screening tools. Interventions may include resource directories, best maintained in collaboration with local/regional public health, community, and/or professional organizations; programs embedded in the practice (eg, Reach Out and Read, Healthy Steps for Young Children, Medical-Legal Partnership, Health Leads); and collaboration with home visiting programs. Changes to health care financing are needed to support the delivery of these enhanced services, and active advocacy by child health providers continues to be important in effecting change. We highlight the ongoing work of the Health Care Delivery Subcommittee of the Academic Pediatric Association Task Force on Child Poverty in defining the ways in which child health care practice can be adapted to improve the approach to addressing child poverty.

What we talked about at the pediatrician's office: Exploring differences between healthy steps and traditional pediatric primary care visits.

Healthy Steps for Young Children (HS) is a program designed to enhance pediatric primary care experiences for children birth to 3 years and their families by pairing a developmental specialist with a pediatric provider during well-child visits. This study examined the impact of HS on content discussed during well-child visits by providers, HS Specialists, and families. The impact of HS on pediatric outcomes, including timeliness of well-child visits and immunizations, also was examined. Using retrospective medical review, records of 40 children enrolled in HS were compared with records of 36 demographically matched controls. A developmental topics checklist was used to analyze content of well-child visits. Attendance at well-child visits, receipt of immunizations, and healthcare utilization also was evaluated. Important developmental topics were discussed more often during well-child visits of children enrolled in HS than for children who were not enrolled. Children enrolled in HS received timelier well-child visits and immunizations. No differences between groups were found in the number of sick or emergency room visits. Integrating HS Specialists into pediatric primary care well-child visits allows for discussion of important developmental topics while also impacting pediatric health outcomes.

Healthy Steps for Young Children Program in Pediatric Residency Training: Impact on Primary Care Outcomes

Incorporating Healthy Steps for Young Children into pediatric practice has been shown to have positive effects for children and families. Although this model of care has also been integrated into several pediatric and family medicine training programs, published reports to date have focused only on residents' perceptions of their interactions with the model of care. In this study, we report the impact on primary care outcomes after integrating Healthy Steps for Young Children into residency training. Continuity of care, longitudinal care in the practice, quality of primary care services, and rates of behavioral, developmental, and psychosocial diagnoses were measured for 3 cohorts: (1) Healthy Steps-enrolled children, (2) non-Healthy Steps-enrolled children who were followed at the same site of care, and (3) non-Healthy Steps-enrolled children who were receiving primary care at a similar residency training site within the same training program. All data were extracted from patient charts at the 2 practice sites. Continuity of care was significantly better for Healthy Steps-enrolled children compared with non-Healthy Steps-enrolled children at the Healthy Steps site for both total visits and health maintenance visits. Longitudinal care and quality of primary care services did not differ within or between sites. The rates of documentation of behavioral, developmental, or psychosocial diagnoses did not differ between Healthy Steps-enrolled and non-Healthy Steps-enrolled children at the Healthy Steps for Young Children site but were significantly different between the Healthy Steps and the non-Healthy Steps for Young Children sites; the effect was driven wholly by differences in psychosocial diagnoses. Multiple indices that measure health service outcomes suggest benefits of incorporating Healthy Steps for Young Children into pediatric residency training. Most important, continuity of care in residents' practices significantly improved, as did the residents' documentation of psychosocial issues in children.

Healthy Steps for Young Children: Sustained Results at 5.5 Years

We sought to determine whether Healthy Steps for Young Children has sustained treatment effects at 5.5 years, given early findings demonstrating enhanced quality of care and improvements in selected parenting practices. Healthy Steps was a clinical trial that incorporated developmental specialists and enhanced developmental services into pediatric care in the first 3 years of life. A total of 5565 children were enrolled at birth and followed through 5.5 years. Healthy Steps was evaluated at 6 randomization and 9 quasi-experimental sites. Computer-assisted telephone interviews were conducted with mothers when Healthy Steps children were 5.5 years of age. Outcomes included experiences seeking care, parent response to child misbehavior, perception of child's behavior, and parenting practices to promote development and safety. Logistic regression was used to estimate overall effects of Healthy Steps, adjusting for site and baseline demographic characteristics. A total of 3165 (56.9%) families responded to interviews (usual care: n = 1441; Healthy Steps: n = 1724). Families that had received Healthy Steps services were more satisfied with care (agreed that pediatrician/nurse practitioner provided support, 82.0% vs 79.0%; odds ratio: 1.25 [95% confidence interval: 1.02-1.53]) and more likely to receive needed anticipatory guidance (54.9% vs 49.2%; odds ratio: 1.33 [95% confidence interval: 1.13-1.57]) (all P < .05). They also had increased odds of remaining at the original practice (65.1% vs 61.4%; odds ratio: 1.19 [95% confidence interval: 1.01-1.39]). Healthy Steps families reported reduced odds of using severe discipline (slap in face/spank with object, 10.1% vs 14.1%; odds ratio: 0.68 [95% confidence interval: 0.54-0.86]) and increased odds of often/almost always negotiating with their child (59.8% vs 56.3%; odds ratio: 1.20 [95% confidence interval: 1.03-1.39]). They had greater odds of reporting a clinical or borderline concern regarding their child's behavior (18.1% vs 14.8%; odds ratio: 1.35 [95% confidence interval: 1.10-1.64]) and their child reading books (59.4% vs 53.6%; odds ratio: 1.16 [95% confidence interval: 1.00-1.35]). There were no effects on safety practices. Sustained treatment effects, albeit modest, are consistent with early findings. Universal, practice-based interventions can enhance quality of care for families with young children and can improve selected parenting practices beyond the duration of the intervention.

Parental Satisfaction With Early Pediatric Care and Immunization of Young Children

To prospectively evaluate the impact of parental satisfaction on childhood immunization and the mediating role of age-appropriate well-child care. Secondary analyses of cohort data from the National Evaluation of Healthy Steps for Young Children. Data sources included an enrollment questionnaire, parent interview at 2 to 4 months, and medical records. Twenty-four pediatric practices across the United States. A total of 4896 (85%) of the initial 5565 enrolled families who were interviewed at 2 to 4 months and had abstracted medical records. Parental satisfaction with overall pediatric care assessed at 2 to 4 months as excellent, good, or fair/poor. Age-appropriate first dose of diphtheria-tetanus-pertussis; third dose of diphtheria-tetanus-pertussis; and measles, mumps, and rubella vaccinations; and up-to-date vaccinations at 24 months (4 diphtheria-tetanus-pertussis, 3 polio, and 1 measles, mumps, and rubella). The majority of parents were satisfied with their child's health care; only 4% rated overall care as fair or poor. Children whose parents reported fair/poor satisfaction with care had a reduced odds of receiving age-appropriate first dose of diphtheria-tetanus-pertussis vaccination (odds ratio, 0.43; 95% confidence interval, 0.28-0.67); third dose of diphtheria-tetanus-pertussis vaccination (odds ratio, 0.52; 95% confidence interval, 0.36-0.74); and measles, mumps, and rubella vaccination (odds ratio, 0.58; 95% confidence interval, 0.37-0.92); and of being up to date by 24 months (odds ratio, 0.65; 95% confidence interval, 0.43-0.99) compared with children whose parents reported excellent care, independent of sociodemographic and maternal health care utilization variables. The negative effect of fair/poor satisfaction on immunization was largely explained by reduced utilization of age-appropriate well-child care. Quality assurance activities that assess parental satisfaction with care may have added value in identifying children who are less likely to receive timely preventive services.

Maternal Depressive Symptoms at 2 to 4 Months Post Partum and Early Parenting Practices

To determine whether maternal depressive symptoms, reported when infants are 2 to 4 months old, are associated with mothers' early parenting practices. Secondary data analyses collected from the National Evaluation of Healthy Steps for Young Children. Data sources included newborn enrollment questionnaires and parent interviews when infants were 2 to 4 months old. Maternal depressive symptoms were assessed using the Center for Epidemiological Studies Depression Scale. Twenty-four pediatric practices across the United States. A total of 5565 families enrolled in Healthy Steps; 4874 mothers (88%) completed 2- to 4-month interviews and provided Center for Epidemiologic Studies Depression Scale data; 17.8% of mothers reported having depressive symptoms. Ten parenting practices assessed in 3 domains: safety (sleep position and lowering water temperature), feeding (cereal, water, or juice; continuing breastfeeding), and practices to promote child development (showing books, playing with infant, talking to infant, and following 2 or more routines). Mothers with and without depressive symptoms reported similar uses of safety and feeding practices. Mothers with depressive symptoms had reduced odds of continuing breastfeeding (adjusted odds ratio [AOR], 0.73; 95% confidence interval [CI], 0.61-0.88), showing books (AOR, 0.81; 95% CI, 0.68-0.97), playing with the infant (AOR, 0.70; 95% CI, 0.54-0.90), talking to the infant (AOR, 0.74; 95% CI, 0.63-0.86), and following routines (AOR, 0.61; 95% CI, 0.52-0.72). Maternal depressive symptoms are common in early infancy and contribute to unfavorable parenting practices.

Validity of Maternal Report of Acute Health Care Use for Children Younger Than 3 Years

National household surveys often rely on parents' recall to assess children's use of health care services. However, little is known about the accuracy of parental reporting of hospitalizations and emergency department (ED) use. To assess the agreement between maternal reported and medical record acute health care data for children younger than 3 years and to determine if agreement between the 2 varies by maternal characteristics. Data were obtained from the national evaluation of the Healthy Steps for Young Children for 2937 families who completed parent interviews at 2 to 4 and 30 to 33 months and whose children's medical records were abstracted. Services assessed included hospitalizations and ED visits since birth (2-4 and 30-33 months) and in the last 12 months (30-33 months). Absolute and beyond chance agreements were calculated. Results were stratified by maternal age (<20, 20-29, or > or =30 years), parity (first-time, second-time, or greater mother), income (<20,000 dollars, 20,000 dollars-49,999 dollars, or > or =50,000 dollars), and the presence or absence of maternal depressive symptoms. Absolute agreement was high for hospitalizations (> or =90%) at both time points. It was high for ED use (>90%) only at 2 to 4 months. Beyond chance agreement was higher for hospitalizations than for ED use at 2 to 4 and 30 to 33 months. Beyond chance agreement declined with increased duration of recall and younger maternal age. No differences were found by other maternal characteristics. Mothers have good recall for acute health care events during the first 3 years of their children's lives. This finding suggests that mothers are a good source of information regarding children's acute health care use.

Maternal Depressive Symptoms and Children's Receipt of Health Care in the First 3 Years of Life

Maternal depression is widely recognized to negatively influence mother-child interactions and children's behavior and development, but little is known about its relation to children's receipt of health care. To determine if maternal depressive symptoms reported at 2 to 4 and 30 to 33 months postpartum are associated with children's receipt of acute and preventive health care services in the first 30 months. Cohort study of data collected prospectively as part of the National Evaluation of Healthy Steps for Young Children (HS). Data sources included medical records abstracted for the first 32 months, enrollment questionnaires, and parent interviews when children were 2 to 4 and 30 to 33 months old. Acute care use included hospitalizations and emergency department visits. Preventive care included well-child visits and vaccinations. Maternal depressive symptoms were assessed by using the Center for Epidemiologic Studies-Depression Scale. Generalized linear models (logistic regression for dichotomous outcomes and Poisson regression for count outcomes) were used to estimate the effect of maternal depressive symptoms on children's receipt of care. The models were adjusted for baseline demographic characteristics, child health status, participation in HS, and site of enrollment. Of the 5565 families enrolled in HS, 88% completed 2- to 4-month parent interviews, 67% completed 30- to 33-month parent interviews, and 96% had medical records abstracted. The percentages of mothers reporting depressive symptoms were 17.8% at 2 to 4 months, 15.5% at 30 to 33 months, and 6.4% at both. Children whose mothers had depressive symptoms at 2 to 4 months had increased use of acute care reported at 30 to 33 months including emergency department visits in the past year (odds ratio [OR]: 1.44; confidence interval [CI]: 1.17, 1.76). These children also had decreased receipt of preventive services including age-appropriate well-child visits (eg, at 12 months [OR: 0.80; CI: 0.67, 0.95]) and up-to-date vaccinations at 24 months for 4 doses of diphtheria, tetanus, pertussis, 3 doses of polio vaccine, and 1 dose of measles-mumps-rubella (OR: 0.79; CI: 0.68, 0.93). There was no association of maternal depressive symptoms at 30 to 33 months with children's preceding use of care. Maternal depressive symptoms in early infancy contribute to unfavorable patterns of health care seeking for children. Increased provider training for recognizing maternal depressive symptoms in office settings, more effective systems of referral, and development of partnerships between adult and pediatric providers could contribute to enhanced receipt of care among young children.

Narrowing the income gaps in preventive care for young children: families in healthy steps.

Persistent unmet preventive and developmental health care needs of children in low-income families are a national concern. Recently, there have been efforts to promote developmental services as part of primary care for all young children. However, there is limited research to determine whether the neediest families are well in universal interventions. In our study, we assessed if disparities persist in utilization of developmental services, well child care, and satisfaction with care among low-, middle-, and high-income families participating in Healthy Steps for Young Children. Healthy Steps is a national experiment that incorporated developmental services into primary care for children from birth to 3 years of age. In the United States, 15 pediatric practices participated in this prospective study. At birth, 2,963 children were enrolled between September 1996 and November 1998 and followed through 33 months of age. The utilization of developmental services, satisfaction with care, and receipt of age-appropriate well child visits were measured at 30-33 months and adjusted for demographic and economic covariates. We found that the adjusted odds of low-income families did not differ from high-income families in receipt of four or more Healthy Steps services, a home visit, or discussing five or more child rearing topics. Low- and middle-income families had reduced adjusted odds of receiving a developmental assessment and books to read. The adjusted odds of low- and middle-income families did not differ from high-income families in being very satisfied with care provided or receiving age-appropriate well child visits. A universal practice-based intervention such as Healthy Steps has the potential to reduce income disparities in the utilization of preventive services, timely well child care, and satisfaction with care.

Healthy Steps: Resident’s Perceptions

The objective of this study is to determine pediatric residents' perception of Healthy Steps for Young Children, Healthy Steps Iowa, and Healthy Steps specialists. Twenty-nine of 37 (78%) pediatric residents participated in this survey. The Healthy Steps specialists facilitated pediatric residents' learning of anticipatory guidance (69%), and assured the patients received information efficiently (69%). Sixty-two percent reported that the Healthy Steps specialists did not interfere with their relationship as the patient's primary care provider. Seventy-six percent would consider using Healthy Steps specialists in their future practice. Program improvement areas include improving clinic efficiency with the incorporation of Healthy Steps specialists; increasing the pediatric residents' awareness of family violence, mental illness, and substance abuse; and improving their method of referral to community contacts.

2003 C. Anderson Aldrich award lecture: enhancing developmental services in child health supervision--an idea whose time has truly arrived.

In 1938, in his famous Babies Are Human Beings , C. Anderson Aldrich was cautious in describing the feasibility of enhancing children's developmental potential: “Every human being, as he grows into childhood, must inevitably be hampered and opposed by the restrictions of his environment, and the best we can hope for is to modify somewhat the urgency of this conflict. The degree to which we are considerate of our baby's early needs, however, may be the measure of his later ability to feel secure in a world of change and to adapt himself to the necessities of circumstance.”1(p xi) Aldrich's contributions occurred at a crucial transitional period for child health. In the early 20th century, child health services were almost exclusively focused on the treatment of the sick child, with the modest exception of cursory examinations to detect signs of contagion, milk stations for feeding and weighing, and urban child health conferences for examining and later immunizing children. Subsequent control of infection through improved sanitation, public health measures, the introduction of antibiotic agents, and effective immunization profoundly influenced the scope of child health care, with the founding of the American Academy of Pediatrics in 1930 heralding a shift of emphasis to include health promotion and disease prevention.2 In 1944, Aldrich helped to pioneer this shift through the founding of the Rochester (Minnesota) Child Health Institute, devoted to research on the development of normal infants and children and to a program of delivering child health care to an entire community. Contemporary efforts to enhance the effectiveness of developmental services similarly occur within the context of a profound transition in children's health services. In the mid-1970s, the recognition of developmental, behavioral, and psychosocial problems as the “new morbidity” of pediatric practice by Haggerty et al3 reinforced an emphasis … Reprint requests to (P.H.D.) Connecticut Children's Medical Center, 282 Washington St, Hartford, CT 06106. E-mail: pdworki{at}ccmckids.org