Can integrating child development specialists and enhanced services into pediatric practices improve care for young children and their families?

The Healthy Steps program integrates child development specialists into primary care along with other enhanced services to promote the physical, emotional, and intellectual development of young children. Families taking part in Healthy Steps were more likely to receive recommended preventive and developmental services and continuous, patient-centered care.

Why is this important?

Recent research has led to new appreciation for the importance of early life experience in shaping children's intellectual, emotional, and social development (NRC 2000). Yet changes in family and society are challenging parents and creating stresses that can harm children's life chances (Carnegie 1994).

Many parents say they want more information about child development from their health professional. Primary care appears to offer an excellent opportunity to support parents in creating the environment for favorable developmental outcomes, since most young children already have regular contact with a primary care practitioner for immunizations and other well-child care (AHRQ 2002; VanLandeghem et al. 2002).

Interventions

The Healthy Steps for Young Children program promotes a multidisciplinary model of pediatric care emphasizing "a close relationship between health care professionals and mothers and fathers in addressing the physical, emotional, and intellectual growth and development of children from birth to age three" (Healthy Steps 1999). The program was developed by The Commonwealth Fund and a team of experts at Boston University, with support from the Robert Wood Johnson Foundation and more than 100 funding partners. It was cosponsored by the American Academy of Pediatrics.Healthy Steps integrates a trained child development specialist (nurse, early childhood educator, or social worker with experience in child development) into primary care practices to enhance developmental services, including:

• enhanced well-child care,
• child development and family health checkups,
• home visits at critical developmental stages,
• telephone hotline for parents to discuss developmental concerns,
• parent support groups,
• written informational materials, and
• linkage to community resources.

The 15 primary care practices participating in a national evaluation of Healthy Steps received training manuals, videotapes, and technical assistance through biweekly teleconferences and annual training sessions (Zuckerman et al. 2004).

Findings

Young children (ages 30 to 33 months) enrolled in Healthy Steps at 15 primary care sites were more likely to receive age-appropriate well-child visits, developmental services, and immunizations compared with those receiving usual care at the same practices or at matched comparison sites. Parents of young children taking part in the Healthy Steps program were more likely than parents with usual care to report:

• receiving developmental information and services promoted by the program,
• being satisfied with support from the practice and communication with health professionals,
• engaging in nonphysical child discipline behaviors promoted by the program,
• discussing their own sadness with someone at the practice (among mothers at risk for depression), and
• maintaining continuity of care at the same practice after their child reached age 20 months (Minkowitz et al. 2003a).

Clinicians (physicians and nurse practitioners) at Healthy Steps sites reported greater satisfaction with their staff's ability to meet the developmental and behavioral needs of children, suggesting that they appreciated the role of Healthy Steps specialists (Minkovitz et al. 2003b). Clinicians' perceptions about quality of care improved the most among those in practices and clinics serving low-income families. These clinicians "also were more likely to strongly agree that they gave support to families and to be very satisfied with the ability of their clinical staff to meet the developmental needs of children" (McLearn et al. 2004).

Implications

Enhancing early child development services in primary care requires structural changes in practice. Given current health care market constraints, the authors conclude, "it is unlikely that physicians will be able to extend the length of visits or provide more direct services to families without relying on other professional staff" (Minkovitz et al. 2001). The Healthy Steps program represents a modest-intensity, universal approach to accomplishing this goal, with an incremental cost ranging from $402 to $933 per child per year.

Improvement Ideas and Resources

Additional resources are available from the Fund's Healthy Steps Web pages or the official Healthy Steps site.

Measure:

This prospective controlled trial was conducted at 15 pediatric practice sites (private group practices, community health centers, primary care clinics of academic medical centers, and staff-model HMOs) located in 14 states with enrollment staggered between September 1996 through November 1998. At each of six randomization sites, 400 newborns meeting enrollment criteria were randomized to intervention or control groups (the same clinicians cared for children in both groups). At each of nine quasi-experimental study sites, about 200 newborns were enrolled in an intervention practice and 200 at a matched comparison practice. Preventive and developmental services are recommended by the American Academy of Pediatrics (AAP 1997) and the national Bright Futures initiative (Green and Palfrey 2002). The immunization rate included four doses of diphtheria-tetanus-pertussis (DTP) vaccine, three doses of oral or inactivated poliovirus vaccine (OPV/IPV), and one dose of measles-mumps-rubella (MMR) vaccine (4:3:1 series), Combined results shown in the charts were significantly better for the intervention versus usual care in bivariate and multivariate analyses (Minkovitz et al. 2003a).

Limitations:

Families that participated in the interview may not be representative of the total enrolled population at study sites. Lack of observed treatment effects may be related to relatively high baseline levels of positive parenting practices reported by the sampled families in comparison to national estimates (Minkovitz et al. 2003a). Despite improvements in quality of care, the intervention was not associated with significant reductions in emergency room visits or hospitalizations. Although some early improvements in parenting practices were observed for children at ages two to four months (Minkovitz et al. 2001), there were no significant changes in parents' reported child safety and development practices (other than discipline) at ages 30 to 33 months (Minkovitz et al. 2003a).

Source:

Data were obtained from telephone interviews with parents when the child was ages 30 to 33 months (N=3,737 representing 67 percent of 5,565 enrolled families), enrollment forms, and a random sample of medical records at each practice. Results were analyzed and reported by researchers at the Johns Hopkins School of Public Health (Minkovitz et al. 2003a).

References:

* Indicates source of data used in the chart(s).AAP (American Academy of Pediatrics). 1997. Guidelines for Health Supervision III. Elk Grove, Ill.: American Academy of Pediatrics. AHRQ (Agency for Healthcare Research and Quality). 2002. Improving Early Childhood Development: Promising Strategies. User Liaison Program workshop brief, January 30–February 1, 2002. Rockville, Md.: U.S. Department of Health and Human Services. Carnegie (Carnegie Task Force on Meeting the Needs of Young Children). 1994.Starting Points: Meeting the Needs of Our Youngest Children. New York: Carnegie Corporation. Green, M., and J. S. Palfrey, Eds. 2002. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Arlington, Va.: National Center for Education in Maternal and Child Health. Healthy Steps. 1999. Frequently Asked Questions About Healthy Steps. New York, N.Y.: The Commonwealth Fund. McLearn, K. T., D. M. Strobino, N. Hughart et al. 2004. Developmental Services in Primary Care for Low-Income Children: Clinicians' Perceptions of the Healthy Steps for Young Children Program. Journal of Urban Health 81 (2): 206–21. Minkovitz, C., D. Strobino, N. Hughart et al. 2001. Early Effects of the Healthy Steps for Young Children Program. Archives of Pediatric and Adolescent Medicine 155 (4): 470–9. * Minkovitz, C. S., N. Hughart, D. Strobino et al. 2003a. A Practice-Based Intervention to Enhance Quality of Care in the First 3 Years of Life: The Healthy Steps for Young Children Program. Journal of the American Medical Association 290 (23): 3081–91. Minkovitz, C. S., D. Strobino, N. Hughart et al. 2003b. Developmental Specialists in Pediatric Practices: Perspectives of Clinicians and Staff. Ambulatory Pediatrics 3 (6): 295–303. NRC (National Research Council). 2000. From Neurons to Neighborhoods: The Science of Early Childhood Development. Washington, D.C.: National Academy Press. VanLandeghem, K., D. Curtis, and M. Abrams. 2002. Reasons and Strategies for Strengthening Childhood Development Services in the Healthcare System. New York, N.Y.: The Commonwealth Fund. Zuckerman, B., S. Parker, M. Kaplan-Sanoff et al. 2004. Healthy Steps: A Case Study of Innovation in Pediatric Practice. Pediatrics 114 (3): 820–6.