E-Update, April 9, 2007

Healthy Steps for Young Children^SM

E-UPDATE

April 2007 Issue
(Printable Version)

Stories

Vital Research on Maternal Depression
CDC Evaluation Praises Healthy Steps at Swope Health Care
New Healthy Steps Sites
Parental Satisfaction with Pediatrics Practice Leads to Increased Immunizations
Healthy Steps Dissemination and Sustainability—Not Too Bad!!
Healthy Steps Releases Multimedia Kit—DVD/CD-ROM Edition

Vital Research on Maternal Depression

Healthy Steps screens for maternal depression, a serious condition that is harmful to the baby and the mother if not treated. Data from the Healthy Steps National Evaluation has found that, among mothers with toddlers, those with depressive symptoms were less likely to implement safety and child development practices (e.g., using electric outlet covers and following daily routines) and more likely to use harsh discipline with their children. Author Kathryn Taaffe McLearn and colleagues conclude, in Pediatrics, that “providing periodic depressive symptom screening of the mothers of young patients has the potential to improve clinician capacity to provide timely and tailored anticipatory guidance about important parenting practices, as well as to make appropriate referrals.” (See McLearn, K. T., et al., “The Timing of Maternal Depressive Symptoms and Mothers’ Parenting Practices with Young Children: Implications for Pediatric Practice,” Pediatrics, July 2006, 118 (1): 207-216; e174-e182.)

The same issue of Pediatrics offers an evidence-based, relatively speedy way to screen mothers for depression. Using a simple, two-question screening tool developed by the U.S. Preventive Services Task Force, Dartmouth Medical School Professor Ardis L. Olson, MD, and colleagues found that pediatric practices were able to screen mothers in 70 percent of well-child visits. Six percent of mothers scored as being at risk for a major depressive disorder. Pediatrician actions included referral, counseling, and monitoring. The authors conclude that screening of mothers by pediatric practices is feasible, effective, and does not impose heavy time-burdens on practices. The screening tool, together with its introductory information, is below. (See Olson, A. L., et al., “Brief Maternal Depression Screening at Well-Child Visits,” Pediatrics, July 2006, 118 (1):207-216.)

Screening Form

Depression is a common but treatable illness that occurs more often among parents. Many people who suffer don’t realize they have a medical disease and could benefit from treatment.

The U.S. Preventive Services Task Force recommended that all adults be checked for depression when they see a doctor. Parents of children who are cared for in this practice may see us more often than any other health care provider. The Task Force is considered the authority on preventive health care and we believe it is wise to follow their advice. It’s our job because, if a parent is depressed, their child is affected. The child does better if the parent gets help.

For this reason, please take a minute to respond to the two statements below. We’ll then take a look at your responses together during this visit.

Over the past two weeks, you have felt down, depressed, or hopeless (true or false). If true, have you felt this way for (several days, more than half the days, or nearly every day)?

Over the past two weeks, you have felt little interest or pleasure in doing things (true or false).

CDC Evaluation Praises Healthy Steps at Swope Health Care

The U.S. Centers for Disease Control and Prevention (CDC) is evaluating the implementation of Healthy Steps at Swope Health Services, a Federally Qualified Health Center in Kansas City, Missouri. The evaluation focuses on Swope’s efforts in pediatric screening and intervention. Goals relate to children’s timely receipt of EPSDT and developmental screening, referral in the case of an identified delay, and screening of mothers for maternal depression by two months postpartum. CDC’s findings give Swope—and Healthy Steps—a reason to be proud.

Over the first year of implementation, 83% of children received a timely EPSDT, a number depressed by the low level at program start. For the last quarter, the figure is 96%. Among those children not current, 98% received an EPSDT over the year, with 100% in the last quarter, showing the success of Swope’s focus on identifying and treating children who have not received quality care.
Of children showing a delay of some sort in the screening visit, 98% are referred (100% in the last two quarters).
100% of mothers bringing an infant for an EPSDT visit receive a maternal depression screen. This is a happy result in light of the previous piece on maternal depression.

Congratulations to Swope Health Services for its focus on quality care for young children and their parents!

New Healthy Steps Sites

Healthy Steps welcomes three new sites. Two training programs for residents are University of California at San Francisco-Fresno Family Medicine and Children’s Mercy Hospital, of Kansas City, Missouri, Pediatrics . The Healthy Steps site at the Cleveland County Health Department in Norman, Oklahoma, is being led by Chris Jarko, a great source of pride since Chris was formerly a Healthy Steps Specialist in Mesa, Arizona, and took Healthy Steps with her to Oklahoma! (See below for more on how Healthy Steps continues to increase its growth and penetration across the United States.)

Parental Satisfaction with Pediatrics Practice Leads to Increased Immunizations

The importance of children being up to date on their immunizations is well known and the subject of great effort. Analysis of Healthy Steps evaluation data by researchers at Johns Hopkins Bloomberg School of Public Health shows a “simple” way to increase the chances children will get their shots—provide services that increase parental satisfaction. The Healthy Steps evaluation results reported in JAMA in 2003 showed that Healthy Steps does so and meets this and other Institute of Medicine criteria for a high quality medical practice. Johns Hopkins' latest analysis of the Healthy Steps data shows that children whose parents reported only fair or poor satisfaction with care (4%) had a reduced chance of receiving age-appropriate vaccinations. Even after adjusting for the independent effects on children’s immunizations of sociodemographic and maternal health factors, the effect of satisfaction persists. It appears that children of low-satisfaction parents go the pediatrician less often. The Johns Hopkins team concludes that quality assurance activities should assess parental satisfaction as part of any effort to increase immunizations. (See Schempf, A. H., et al., “Parental Satisfaction with Early Pediatric Care and Immunization of Young Children: The Mediating Role of Age-Appropriate Well-Child Care Utilization.” Archives of Pediatric and Adolescent Medicine, 2007; 161:50-6.)

Healthy Steps Dissemination and Sustainability—Not Too Bad!!

The history of Healthy Steps for Young Children, brief as it is, is beginning to tell a story of dissemination and sustainability that we think merits a bit longer article than is normal for this space. Healthy Steps began serving families in 1996 with 24 sites in a structured evaluation phase. Subsequent to the evaluation phase, which ended in 2001, an additional 41 pediatric and family medicine practices adopted Healthy Steps as a way to enhance the quality of the health care provided to young children and their parents. Over this period we have learned important lessons about how to fund and sustain Healthy Steps. First, the facts: of the original 24 evaluation sites, eight currently provide Healthy Steps services (and nine others have been associated with a significant change in practice or a spin-off). Of the 41 new sites, 40 continue to operate. Of the 48 sites currently operating, 19 are in residency training programs. Within the next several months we expect six new sites to begin operations.

How are these sites funded? The typical funding cycle begins with start-up funding from philanthropy or, in a few states and localities such as California, which has First Five program funds, by a state or local government program. Sometimes the original funder will continue and even expand funding. Often, because of the impressive record of Healthy Steps in the community and the significant highly favorable outcomes research on Healthy Steps, the site is able to obtain funding from other philanthropies, the state, and/or, most interestingly, self-funding. The latter is, of course, a major example of program sustainability. Examples of various funding methods:

The Healthy Steps site in Allentown, Pennsylvania, (which began operations in September 1996 as the pilot site for the national evaluation) now markets Healthy Steps services to first-time pregnant women through Ob-Gyn offices in its multi-practice group. Over the five years of doing so, the practice has increased its enrollment of new pediatric patients by about one-third. The added revenue from the additional patients funds the Healthy Steps Specialist and other program costs.
The California First Five program currently funds four Healthy Steps sites, two of which (Fresno and Oakland) are expanding. In addition, First Five Sacramento provides the Healthy Steps Child Health and Development Record to Sacramento County families as part of their Kit for New Parents. The North Carolina Smart Start program has funded the site in Lumberton since 1999. The Dade County, Florida, Children’s Trust Fund funds the Miami Beach Community Health Center (one of several FQHC’s participating in Healthy Steps) and recently asked for proposals to expand Healthy Steps. As additional states and localities develop child health programs and funding mechanisms such as the ones just noted, these should prove fertile ground for growing Healthy Steps sites. (In November 2006, for example, Arizona passed legislation for an 80 cents per pack cigarette tax to fund a children’s trust fund.)
In the long run, widespread adoption of Healthy Steps would be greatly facilitated if practices could simply bill traditional payers for Healthy Steps services. There has been some progress in this area. CPT Codes 96110 and 96111 now have the potential to permit reimbursement for developmental screening and, while hardly widespread, some payers have provided reimbursement to practices using these codes. The State of Illinois’ Medicaid program encourages pediatric practices to offer regular screening for maternal depression, providing reimbursement. (See www.edopc.org for information on reimbursement for both developmental and depression screening in Illinois.)
State Medicaid programs in North Carolina and Iowa have at times provided grants to Healthy Steps practices. Using Administrative Claiming Fund balances, states may provide funding for Medicaid providers to offer services that are broadly included in the state plan, while not directly reimbursed.
At present, 14 of the 48 operating Healthy Steps sites are funded by the health care organization of which they are a part. These health care organizations are funding Healthy Steps because they want to provide high quality pediatric care with appropriate attention to behavior and development. They have noted the greater satisfaction of both patients and clinicians and the outcomes that follow Healthy Steps. Once the great benefits of providing Healthy Steps are seen, it is difficult for providers to end such quality care, even given the added cost and the difficulty of gaining reimbursement. Examples include the pediatrics residency training program at the University of North Carolina—Chapel Hill; Lifetime Health, part of BCBS of Rochester, New York; and the Revere Clinic of Massachusetts General Hospital, all of which fund Healthy Steps costs from general funds, as well as ABC-Family Pediatrics in Allentown (noted above).

Healthy Steps Specialists participate in several visits per patient per year. When multiplied by the hundreds of families they serve during a year, the total number of interactions is large. Thus the compensation cost of the Healthy Steps Specialist is modest on a per patient-interaction basis. Some Healthy Steps practices report that the ability of the Healthy Steps Specialist to provide families with behavioral and developmental information and counseling frees physician time to see additional patients. Whatever the precise calculus for the practice, those who self-fund Healthy Steps have determined that the efforts of the Healthy Steps Specialist produce benefits at least commensurate with the salary and other costs.

The last funding example—self-funding—is perhaps the most encouraging. This is because it demonstrates the compelling nature of Healthy Steps that, in the face of the great challenges in funding preventive innovation in health care today, somehow motivates managers and clinicians to overcome sometimes daunting problems to sustain this innovation.

For outcomes findings based on controlled trials, see Minkovitz, C. S., et al., "A Practice-Based Intervention to Enhance Quality of Care in the First Three Years of Life: Results from the Healthy Steps for Young Children Program," Journal of the American Medical Association, December 2003, Vol. 290, No. 23, pp. 3081-3091; Halfon, N., Inkelas, M., "Optimizing the Health and Development of Children," Journal of the American Medical Association, December 2003, Vol. 290, No. 23, pp. 3136-3138; Johnston, B. D., et al., "Healthy Steps in an Integrated Delivery System: Child and Parent Outcomes at 30 Months," Archives of Pediatric & Adolescent Medicine, August 2006, Vol. 160, No. 8, pp. 793-800. For a list of the 27 peer reviewed journal articles based on Healthy Steps, go to www.healthysteps.org, Publications.

Healthy Steps Releases Multimedia Kit—DVD/CD-ROM Edition

Healthy Steps for Young Children is very pleased to announce the release of the Healthy Steps Interactive Multimedia Training & Resource Kit--DVD/CD-ROM Edition. The fully interactive CD-ROM will now be packaged with a single DVD that contains nine video segments, a revised printable user manual, and all information, including examination booklets, needed to receive Continuing Medical Education credits and Contact Hours for Nurses.

The Healthy Steps Interactive Multimedia Training & Resource Kit--DVD/CD-ROM Edition is available for $99, plus $8 shipping and handling. The original Healthy Steps Multimedia Kit, which contains nine separate videocassettes, a CD-ROM, a printed User Manual, and Continuing Education booklets for both physicians and nurses, continues to be available at a cost of $350, plus $12 shipping and handling. Additional DVDs and CD-ROMs are available to those who have purchased either the DVD/CD-ROM Edition or the original Kit. DVDs sell for $25, plus $5 shipping and handling per disk; CD-ROMs sell for $15, plus $5 shipping and handling per disk.

To order either the DVD/CD-ROM Edition or the original Kit (VHS/CD-ROM), or additional DVDs and CD-ROMs, go to https://co.clickandpledge.com/default.aspx?wid=18406. If you have any questions, or to inquire about quantity discounts, contact Lisa Zbar at the Independent Production Fund at (800) 727-2470 or by e-mail at info@ipfmedia.org. Call for quantity discounts.

For more details, go to www.healthysteps.org and click on the Multimedia Training Kit icon located in the lower-left corner of the page.

Boston University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Boston University School of Medicine designates this educational activity for a maximum of 18 AMA PRA Category 1 Credit(s)™. Advocate Health Care is an approved provider of continuing nursing education by the Illinois Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. Advocate Health Care designates this educational activity for 18.0 contact hours, for review of all nine video segments and CD-ROM units.

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