Cynthia S. Minkovitz, N. Hughart, R.N., M.P.H., D. Strobino, Ph.D. et al.
"A Practice-Based Intervention to Enhance Quality of Care in the First 3 Years of Life," C. S. Minkovitz, M.D., M.P.P, N. Hughart, R.N., M.P.H., D. Strobino, Ph.D. et al., JAMA 290 (December 2003): 30813091
The nation's first, large clinical trial designed to improve delivery of developmental and behavioral services to young children has improved quality of care, enhanced communications between pediatricians and parents, and helped children receive appropriate preventive services, according to a national evaluation of the Healthy Steps for Young Children Program supported by The Commonwealth Fund.
In A Practice-Based Intervention to Enhance Quality of Care in the First 3 Years of Life (JAMA, Dec. 17), researchers at the Johns Hopkins Bloomberg School of Public Health report that physician practices with childhood developmental specialists on staff showed "significant improvements" in parental satisfaction with the services they received; timelier preventive care such as immunizations; and receipt of more developmental services. In fact, Healthy Steps families were found to be four to 20 times more likely to receive developmentally oriented care than families not in the program.
The study, conducted when children were 30 to 33 months old, corroborates the findings of an earlier evaluation of Healthy Steps undertaken when its participants were 2 to 4 months old (Minkovitz et al., 2001). Healthy Steps was developed with funding from The Commonwealth Fund, the Robert Wood Johnson Foundation, and more than 100 funding partners.
Why Healthy Steps?
Deficiencies in American children's health care are known to be common. These include low rates of preventive service delivery as well as inadequate attention to behavioral and developmental problems. With respect to child development and behavior during the first three years of life, the disparity between recommended services and the ones actually delivered has been particularly wide.
The Healthy Steps Approach
Healthy Steps' key proposition is that deficiencies in children's health care, particularly those centered on early childhood development and behavior, can be remedied at the ideal sites for care delivery—the pediatric practices—with changes to practice organization, staffing, and procedures. Healthy Steps added two nurses, nurse practitioners, early childhood educators, or social workers (all with training and experience in child development and each carrying a caseload of approximately 100 families) to the staffs of 15 pediatric practices in 14 states. "Healthy Steps is unique among early child interventions in that it was based in pediatric practices, took a 'universal' approach to addressing families' needs, and introduced a new developmental specialist into pediatric practices," say the authors. By a host of widely accepted criteria of health care quality, the successes among the groups who received the attention of the Healthy Steps Specialists were substantial.
Applying the Healthy Steps Method
For the study's intervention groups (of the 5,565 originally enrolled families, the JAMA article reports results for 2,021 in the intervention groups and 1,716 in the control groups), the Healthy Steps Specialists met with physicians and parents during office visits, made home visits, staffed call-in child-development phone lines to answer parents' questions, performed developmental assessments, provided written materials for parents that emphasized prevention and health promotion, helped to organize parent groups where support and learning could occur, and provided some targeted referrals to community resources. Three annual training sessions enhanced the skills of the Healthy Steps Specialists.
Healthy Steps sought to improve four particular domains of health care quality: effectiveness, patient-centeredness, timeliness, and efficiency. Some examples of the criteria for each domain are: