Michael C. Barth
M. C. Barth, Healthy Steps at 15: The Past and Future of an Innovative Preventive Care Model for Children, The Commonwealth Fund, December 2010.
The Commonwealth Fund started Healthy Steps for Young Children in 1995 to develop and test a model of preventive pediatric care for children from birth to age 3 that emphasized child behavior and development. In 1996, the Fund launched a three-year evaluation that included 15 sites in a controlled trial and another nine sites in separate evaluations. The results of these studies have been published in the Journal of the American Medical Association, Pediatrics, and other peer-reviewed journals.
In 2001, as the evaluation was wrapping up, it became clear that other pediatric care facilities wanted to offer Healthy Steps, so funders and managers opened participation to additional sites. The new sites were pediatric and family medicine practices, and Healthy Steps managers chose to offer the new sites flexibility to implement the model in ways that were most consistent with their existing practice methods, patient population, and resources. The number of participating sites grew to more than 60, but eventually some sites were unable to find continued funding and had to cease offering Healthy Steps. Today, 50 sites offer Healthy Steps, including pediatric and family medicine practices, Federally Qualified Health Centers (FQHCs), hospital-based clinics, and pediatric and family medicine residency training programs. Those sites that had to discontinue Healthy Steps are universally disappointed; most report that Healthy Steps had a concrete impact on their practice methods by focusing their efforts on child and family behavior and development.
Funding has been the primary difficulty with maintaining Healthy Steps implementations, as there is no steady source of government or other reimbursement for the new Healthy Steps staff. Currently, sites fund their Healthy Steps implementations with government (state or local) funds, grants from philanthropies, or internal funds. Facilities that use their own funds are referred to in this report as self-funded, and there are 19 such sites; these sites are able to provide a median of approximately $50,000 of the roughly $65,500 median annual cost of providing Healthy Steps (including one Healthy Steps Specialist). Leaders at the self-funded sites are aware of the sacrifices they must make in order to secure this funding, in some cases not being able to offer additional compensation for physicians or to hire additional support staff. Their actions clearly reflect their commitment to what they consider high-quality patient care. Other sites have found ways to bill for Healthy Steps in one way or another, using the CPT billing code for developmental screening, for example.
Several sites are funded by new municipal or state taxes. Residents of Dade County, Florida, voted for a property tax increase with revenues to be dedicated to children's programs. The tax first passed by a margin of two to one, but in the statutorily required revote after five years, 83 percent of voters supported the tax. The fact that this self-imposed property tax increase was so overwhelmingly supported during a steep recession is instructive in two ways. The vote suggests that when voters are assured as to how their tax dollars will be spent, they may not inherently be against new taxes, and it offers an idea for additional ways to fund programs for children.
Twenty of the current Healthy Steps sites operate in residency training programs. By providing Healthy Steps services to patients with the Healthy Steps Specialist to model proper use of anticipatory guidance, teachable moments, and developmental screening, a new generation of pediatricians and family physicians is being trained in quality, whole-family, whole-child pediatric care with a focus on behavior and development. Two of the current Healthy Steps training programs are directed by attending pediatricians who trained at Healthy Steps residencies themselves. These two programs are self-funded, which suggests they may be self-sustaining.
The Patient Protection and Affordable Care Act envisions a health care system with a focus on the patient-centered medical home, primary care, teamwork, and quality over volume, making Healthy Steps a natural fit. Indeed, any Healthy Steps site has a head start on becoming a patient-centered medical home, since the model entails both prevention and treatment and engages the whole family in the health of the child. Healthy Steps is based on changing or enhancing practice patterns in ways that already conform with health care reform. As implemented at the 17 currently participating safety-net organizations, Healthy Steps can serve as a model for shifting the current focus of treatment away from treating symptoms toward engaging patients, their families, and a whole care team in the well-being of the child and the family. Federal agencies could look to Healthy Steps when examining how to work a patient-centered, team-care approach into the new and expanding FQHCs provided for in reform legislation.
The patient-centered, team-oriented practice envisioned under reform will benefit greatly from physicians and other staff trained in the team-oriented methods of Healthy Steps, and in particular from the participation of the skilled Healthy Steps Specialists. Healthy Steps is already operating at residency training sites, and is prepared, with the Healthy Steps Training and Technical Assistance Team at Boston University School of Medicine, to expand its residency sites and begin turning out providers with experience in and a commitment to patient-centered, whole-family, team-based care.