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Linkages: South Carolina Pediatric Medical Home and Home Visting

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F. Rushton presentation given at the 2012 South Carolina Home Visiting Summit

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Linkages: South Carolina Pediatric Medical Home and Home Visting

  1. 1. Home VisitingThe Pediatrician’s Viewpoint Francis E. Rushton, M.D. frushton@aap.net
  2. 2. Hawaii
  3. 3. Young Children Not Succeeding in School (Characteristics of Ages 0 – 3, Subsequently Retained or BB on PACT) (%) Not (%) of 1995-96 Succeeding High Risk Group 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 Group 16% Higher Educated Mother (more than HS) 34%Source: ORS Data Warehouse files from DHEC Vital Records and DSS linked to SDE PACT data.
  4. 4. The Role of Preschool Home-Visiting Programs in Improving Children’sDevelopmental and Health OutcomesChild 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
  5. 5. 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.
  6. 6. Benefits of Home Visiting• Improve parenting skills • Detect post partum and the quality of the depression home environment • Positive impact on• Ameliorate several child maternal child behavioral problems attachment• Improve intellectual • Enhance social supports development, especially for mothers with low birth weight • Improve breastfeeding• Enhance maternal life rates course
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10. Nurse-Family Partnership (NFP)Nurse-Family Partnership (NFP) targets first-time, low-income mothersand their children. Mothers must be enrolled in services by the 28thweek of pregnancy, and services conclude when the child turns twoyears of age. Home visits provided by nurses seek to promote maternaland 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: info@nursefamilypartnership.orgWebsite: http://www.nursefamilypartnership.org
  11. 11. Parents as Teachers (PAT)Parents as Teachers (PAT) targets families from pregnancy to kindergarten entry of children. Theprogram seeks to promote child development knowledge and to improve parenting practices ofcaregivers. 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 visitingservices 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: 314-432-4330Toll-free telephone: 1-866-728-4968Fax: 314-432-8963Website: www.parentsasteachers.org
  12. 12. Early Head Start (EHS) – Home Visiting OptionEarly Head Start (EHS) is a child and family development program that targets low-income pregnantwomen and families with children ages birth to three years. EHS provides high-quality, flexible, andculturally competent child development and parent support services with an emphasis on the role ofthe parent as the child’s first and most important relationship. The goals of EHS are to promote healthyprenatal outcomes for pregnant women, to enhance the development of very young children, and topromote healthy family functioning. The Home Visiting Option offers and supports comprehensiveservices 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, MentalHealth, 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/
  13. 13. Healthy Steps (HS) for Young Children For more information:Healthy Steps (HS) targets parentswith children from birth to 3 Margot Kaplan-Sanoff Healthy Steps National Directoryears. Services are implemented by Vose Hall #419any pediatric or family health Boston University School of Medicinemedicine practice. Healthy Steps 72 East Concord Street Boston, MA 02118focuses on building a close Telephone: 617-414-4767relationship between health care Email: sanoff@bu.eduprofessionals and parents for the Website: http://www.healthysteps.orgpromotion of physical, emotional, and The Childrens Center of Carolina Health Centers, Inc.intellectual growth and development 113 Liner Drive Greenwood, SC 29646of infants and children. Through Phone: (864) 941-8105regular home visits and contact with Darlene Hood-Johnsona health professional, the program Healthy Steps Specialist 864-330-8236seeks to promote child development, dhoodjohnson@greenwoodchildren.orgpromote school readiness, and Sally Baggettimprove positive parenting practices. sbaggett@greenwoodchildren.org (864) 941-8105
  14. 14. The Children’s Center, Greenwood Evidence-based Home Visitation The Children’s Pediatric Center Medical Home Services Care Behavioral Health Services
  15. 15. 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.
  16. 16. 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.
  17. 17. 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.
  18. 18. 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
  19. 19. 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.
  20. 20. Enhanced Well Child CareUsually 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.
  21. 21. 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.
  22. 22. Links to community resourcesHealthy Steps maintains a book of communityresources that includes information on childcare programs, libraries, as well as onprograms for substance abuse, counseling,domestic stress, and housing.
  23. 23. Well Baby Plus: Collaborative Approach to the Parent Child Relationship
  24. 24. 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
  25. 25. 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
  26. 26. 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)
  27. 27. 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.
  28. 28. Completed all Well Child Visits• Children in the WB+ 70% intervention group 60% (65%) were more likely 50% than comparison group 40% (37%) children to attend 30% WB+ all scheduled well-child 20% Control visits 10% 0%• ( p= 0.006) Completed Well Baby Visits
  29. 29. Immunization UTD as recorded in Patient Chart • 92% of WB+ children95 were fully immunized90 vs. 78% of comparison children (p= 0.01)85 WB+80 Control7570
  30. 30. Trend towards Lower ER Utilization • Well Baby Plus children1.6 showed a trend towards1.4 lower ED usage with an1.2 average of 1.0 visit vs. 1 1.45 visits in the control0.8 WB+ population (p=0.18) Control0.6 • Not statistically0.4 significant0.2 0
  31. 31. Well Baby Plus families were significantly morelikely to report their visits helped them become better parents100 90 • WB+ : 94% reported 80 70 that well child visits 60 WB+ were helpful 50 40 Control • Comparison: 76% 30 reported that well 20 10 child visits were 0 helpful • p= 0.04
  32. 32. Family Spacing: Well Baby Plus Mothers more likely to be using birth control30 • WB+: 25/41 using25 birth control (61%)20 WB+ • Comparison:15 Control 17/43 using birth10 control (40%) 5 • p = 0.03 0 bc no bc
  33. 33. When child was 15 months, parentsrecalled their clinician had discussed: •WB+:90 •P: Poisoning : 65% (p=0.003),80 •D: Discip.:69% p<0.001),7060 •L: Literacy: 87% p=0.16) N: Nutrition: 8%(p=0.17) T: Toi-50 WB+ train:35%(p=0.01)40 Control • Control Group:30 • P: Poisoning: 41%, D:20 Discipline: 31% L:Literacy: 75%10 N: Nutrition: 78% T:Toilet-0 Training 12% P D L N T
  34. 34. Impact on Obesity?: Were Well BabyPlus patients less like to be obese at 15 months of age?25 • WB+20 – weights> 90 percentile: 8% – Average 50 percentile15 WB+ • Control Group – weights>90 percentile: 24%10 Compari – Average 55 percentile son – p=0.035 – This difference disappeared0 when Weight vs. Height Wt. Wt/Ht percentiles used (p=.3) >90 >90
  35. 35. 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