Future of Developmental Health Care in Pediatrics

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Future of DevelopmentalHealth Care in Pediatrics

• New Models
• Neal Halfon, MD, MPH
• Director, UCLA Center for Healthier Children,
  Families and Communities
• Professor of Pediatrics, Public Health, Public
  Health
• UCLA
• SDBP
• 2005 Annual Meeting

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Goals of Presentation

• To provide a rational for why pediatric health
  services must be transformed and improved
• To consider the implications for transforming and
  improving developmental health services in
  pediatric primary care
• To describe new models of organization and
  delivery of pediatric primary care services
• To consider strategies for improving how
  developmental health services are organized,
  financed and provided

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Forces Driving Change

• Poor Performing Systems, Poor Outcomes
• New ideas and concepts about child development
  and what's at stake
• Shifts in Demand
• Consumer demand - Autism, Einstein
• School district demand Increase School Readiness
  and Decrease Special Ed
• Business sector demand Educated Workforce

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Forces Driving Change

• New approaches- technology, measures,
  connectivity-opportunity to do more, better
• Policy Initiatives- SECCS, First 5,
• Economic and Moral Dilemma Do too little too
  late for many children with identifiable problems
  that would benefit from early intervention-
  benefit them and benefit us.

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Sub-optimal Child DevelopmentWhat is at Stake

• School failure and additional costs due to
  expenditures for second chance programs
• Special education
• Mental health, juvenile justice
• Diminished potential to form strong social and
  family relationships
• Long-term costs in social dependency
• Sub-optimal productivity-economic, social,
• Sub-optimal health

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Children Flying Under the Radartill School Entry

• Many Children are not receiving the pediatric
  health services they need and are entitled to
  receive
• Especially true for developmental services that
  are suppose to identify developmental
  disabilities and provide parents with information
  and children with interventions to optimize
  health development
• While the parents of children with learning
  disabilities identify their children at age 3-4,
  schools do not initiate interventions till age 8.

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Children Receiving EI, DD, Special Ed in Orange
County

• 3.2 0-5s CSHCN (ECENA 2001)
• 0.7 0-5s Early Start
• 1.9 0-5s Regional center
• 1.1 3-5s School District Special Ed.
• 9.8 K-12 Special Ed.

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Special Education Enrollment by Age and
Disability in Orange County (2002)
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Policy Strategy for Improving early childhood
health and development

• Policies that focus on treating established
  problems not sustainable - move to
  prevention/early intervention
• Evidence for the effectiveness of interventions
  that focus on a single issue or single risk
  factor is weak
• Risk factors and adverse outcomes cluster
  together more integrated interventions
  (services) have the potential to improve outcomes
  in multiple domains
• Need to shift service delivery away from narrow
  single issue programs towards Broadband
  services multi-sector, multi-agency,
  multi-level- integrated approach- focused on
  shifting population outcomes

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Ideas and Change Concepts

• Developmental health
• Developmental optimization
• Integrating Personal Population Health
  approaches

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2004 National Research Council andInstitute of
Medicine Report
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IOM/NRC Definition of ChildrensHealth (2004)

• Childrens health is the extent to which
• individual children or groups of children are
  able
• or enabled to (a) develop and realize their
• potential, (b) satisfy their needs, and (c)
• develop the capacities that allow them to
• interact successfully with their biological,
• physical, and social environments.
• From Childrens Health, the Nations Wealth,
• National Academies Press, 2004.

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From Maturational toTransactional Development

• Transactional Model
• Bi-directional gene-environment Interactions
• Continuous optimization process
• Promote optimal development
• Continuous surveillance of developmental
  competency
• Developmental Assets
• Early Intervention

• Maturational Model
• Unfolding of presetgenome
• Stages and milestones
• Prevent disabilities (chronic disease model)
• Screen for disabilities
• Deficit based/focus
• Hell grow out of it

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Strategies to ImproveSchool Readiness
Trajectories
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Risk and protective factors
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Ideas and Change Concepts

• Developmental health
• Developmental optimization
• Integrating Personal and Population Health
  Approaches

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Young Children at Risk
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Normal Development OutcomesAlong Four
Measurement Domains
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Development outcomes for a child with
cerebralpalsy. High cognitive and emotional
functioning areable to compensate for decreased
physical functioning.
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Development outcomes for a child with cerebral
palsy andlow compensatory outcomes in other
domains.Lack of protective factors reduces
overall functioning.
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Ideas and Change Concepts

• Developmental health
• Developmental optimization
• Integrating Personal Population Health
  approaches

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Population based Strategies forOptimizing Early
Child Health andDevelopment

• Optimizing early childhood health and brain
  development requires
• Integration of clinical, targeted prevention,
  universal and broader social interventions
• Curve shifting strategies that minimize risks and
  maximize protective factors are necessary
• Broadband policies that align levels of
  government and service delivery sectors (silos)
  within government in a common effort
• Place based programs that integrate early
  childhood services and program into a more
  integrated system of care providing the
  scaffolding that optimize developmental
  trajectories

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Optimizing Individual and PopulationHealthFour
Basic Strategies

• 1. Individual focus, diagnosis, treatment
• 2. Individual prevention and promotion
• 3. Targeted promotion and prevention
• 4. Universal curve shifting programs

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Interventions to OptimizeHealthy Development
Well-Being
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Optimizing Early Child Healthand Development

• Optimizing early childhood health and brain
  development requires
• Integration of clinical, targeted prevention,
  universal and broader social interventions
• Curve shifting strategies that minimize risks and
  maximize protective factors are necessary
• Place based programs that integrate early
  childhood services and program into a more
  integrated system of care providing the
  scaffolding that optimize developmental
  trajectories
• Broadband policies that align levels of
  government and service delivery sectors (silos)
  within government in a common effort

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Optimizing Early Child Healthand Development

• Optimizing early childhood health and brain
  development requires
• Integration of clinical, targeted prevention,
  universal and broader social interventions
• Curve shifting strategies that minimize risks and
  maximize protective factors are necessary
• Place based programs that integrate early
  childhood services and program into a more
  integrated system of care providing the
  scaffolding that optimize developmental
  trajectories
• Broadband Policies that align levels of
  government and service delivery sectors (silos)
  within government in a common effort

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National Early Childhood SystemBuilding
Initiatives

• England Sure Start
• 1998 national initiative to end child poverty
• Department of Health and Education along with
  Treasury
• 500 programs 2004, 1/3 of under fours living
  poverty,
• Australia-National Early Childhood Agenda
• Best Start Victoria, Platforms in Melbourne
• Families First- New South Wales
• Canada
• Better Beginnings Better Futures-Quebec
• Early Years- Ontario, Torontos First Duty,
• US
• State Early Childhood Comprehensive Systems
  Initiative
• Many State programsFirst 5

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State Early ChildhoodComprehensive Systems
Initiative

• Goal
• Plan for and build a more comprehensive and
  integrated system among the current uneven, and
  often ineffective, mix of services for young
  children.
• States Receive Funding for
• Two years of strategic planning
• Three years of implementation

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State Early ChildhoodComprehensive Systems
Initiative

• Five Components Improving and Integrating
  Programs and Services to form a System of Care
• Health Care- Medical Home for all children
• Early Care and Education
• Social/Emotional Health
• Parent Education
• Family Support

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New Models

• Delivery of developmental services

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A 2020 Vision of Pediatric CareStrategic Goals

• Automatic and affordable health insurance for all
  children and parents
• Comprehensive benefitspreventive care, medical
  care, dental care, mental health care,
  developmental services
• Medical home with a designated physician or
  pediatric nurse practitioner responsible for
  every child

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2020 Vision of Pediatric CareStrategic Goals
for the Medical Home

• Information and resources for parents and
  childcare providers
• Hubs of health development connectivity--
  automatic linkage to developmental services,
  early interventions, child care, and school-based
  services
• Use of information technology--reminders for
  visits, e-mail with pediatric clinician, parent
  information
• Commitment to quality improvement with measurable
  accountability

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Developmental Services

• Assessment Services
• Surveillance community wide approaches
• Screening- targeted or universal
• Assessments- focused on those who need it
• Anticipatory Guidance and Education
• Developmental Interventions
• Care Coordination

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New National Surveys for AssessingContent of
Health Supervision forU.S. Children under 3
Years of Age
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Factors Associated with provision
ofDevelopmental Services

• Physician/staff capacity
• Lack of non-physician to do DA
• Lack of training
• Unfamiliarity with DA instruments
• Office resources
• Time limitations
• Inadequate reimbursement
• Inability to bill and be reimbursed separately
• Unfamiliarity with CPT codes for DA
• Community resources
• Lack of developmental diagnostic/treatment
• services
• Lack of programs to refer to

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Targeted Initiatives

• Improving Pediatric Developmental Services to
  Optimize the Medical Home

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Innovations to Improve Delivery ofDevelopmental
Services and toCreate Medical Homes

• Practice redesign - Healthy Steps
• Improve Connectivity Help me Grow, CHADIS
• Improve Accountability - CAHMI PHD
• Improve Quality NICHQ, CCHQ
• Improve Systems- OC DS Pathways

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HS Specialist 7 Services

• Enhanced WC Care
• Home Visits
• Telephone Line
• Child Development
• Family Check-Ups
• Written Materials
• Parent Groups
• Linkages to Resources

2 HS Specialists/site (1 per 100 families)
A Physician-Developmental Specialist Partnership
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Innovations to Improve Delivery ofDevelopmental
Services andto Create Medical Homes

• Practice redesign - Healthy Steps
• Improve Connectivity Help Me Grow, CHADIS
• Improve Accountability - CAHMI PHD
• Improve Quality NICHQ, CCHQ
• Improve Systems- Orange County, Ca

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Help Me Grow- The Process

• Child Health Provider
• Language/Behavior/Parenting Concerns
• 1-800-Help Me Grow
• Referrals Language Eval Play and Support Groups
• Two Week Follow-Up Contact Enrolled
• Feedback to Child Health Provider

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Technology for enhancingConnectivity

• Promotes greater connectivity, communication,
  collaboration, and continuity
• Provides basis for greater service integration
  and alignment of services across sectors

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Technology Emerging Example

• Individual Practice-Based
• Technologies
• Telemedicine
• Rochester model
• CHADIS

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Innovations to Improve Delivery ofDevelopmental
Services andto Create Medical Homes

• Practice redesign - Healthy Steps
• Improve Connectivity Help Me Grow, CHADIS
• Improve Accountability - CAHMI PHD
• Improve Quality NICHQ CCHQ
• Improve Systems- Orange County, Ca

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Innovations to Improve Delivery ofDevelopmental
Services and to CreateMedical Homes

• Practice redesign - Healthy Steps
• Improve Connectivity - Child Serve
• Improve Accountability - CAHMI PHD
• Improve Quality NICHQ CCHQ
• Improve Systems- OC DS Pathways

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Improving AccountabilityDevelopmental Carefor
Young Children CAHMI PHD

• Seven Core Measures in the PHDS
• Anticipatory Guidance (Bright Futures and AAP
  Criteria)
• Getting Health Information
• Follow-Up for Children At Risk for
  Developmental/Behavioral Delays
• Assessment of Smoking, Alcohol or Other Substance
  Abuse
• Assessment of Well-Being and Safety in the Family
• Family Centered Care
• Helpfulness and Effect of Care Provided

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Performance in12 Managed Care OrganizationsWA
State, CA and Ohio

• Range
• Anticipatory Guidance 60.5-76.9
• Health Information 60.9-83.6
• Follow-Up for Children at Risk 35.5-65.7
• Assessment of Well-Being/Safety 15.2-34.6
• Assessment of Smoking, Drugs 43.1-65.9
• Family Centered Care 59.5-74.5

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Innovations to Improve Delivery ofDevelopmental
Services andto Create Medical Homes

• Practice redesign - Healthy Steps
• Improve Connectivity Help Me Grow
• Create Pathways- Denver System
• Improve Accountability - CAHMI PHD
• Improve Quality NICHQ, CCHQ
• Improve Systems- OC DS Pathways

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Re-engineering Strategies forDevelopmental
Service SystemChange

• Place-based Strategy
• Sector-based Strategy
• Innovation Strategy
• Finance Strategy

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Place Based Strategy

• Focus on the unique contextual needs and assets
  of particular community
• Build place based/ community specific service
  delivery pathways
• Integrate across sectors, phases of service
  delivery platforms
• Take advantage of school readiness sites, city
  and local community identity, expertise

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Sector Strategy

• Encourage Collaborative Learning and System
  Change within Sectors
• Pediatrics/child health sector
• Early care and education, community service
• IDEA funded DD and EI sector
• Business/ Payers of health care
• Build on Sector Strengths, common professional
  goals, finance goals,
• Focus on Building Capacity in each sector
• Knowledge, skills, tools, relationships,
  connections,

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Innovation Strategies

• Foster, Adopt and Adapt Innovations within
  communities and sectors
• Take advantage of sector, community, desires to
  change, improve
• Pediatric Sector
• Reach Out and Read in all practices
• PEDS in all child care centers
• Healthy Steps in training sites, Healthy Steps
  lite in clinics
• Maternal Depression screening with links to
  mental health services

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Finance Strategies

• Maximizing Federal and State public program
  revenues
• Leveraging existing resources across public and
  private sectors
• Matching strategies- donors, public programs
• Legislative, and administrative changes
• Develop new strategies
• WinWin partnerships with business

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Improving Early Childhood Health Care
Developmental Services

• Vision for what the early childhood health system
  will look like
• Strategic Communications re
• Development Health and School Readiness
• Medical Home
• Developmental Services
• Re-engineering current systems
• Connecting medical home and child care
• Improving capacity of medical home to provide
  developmental services

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Improving Early Childhood Health Care
Developmental Services

• Consider State or County-Wide Agenda Setting
  Strategy to
• Bring the various players in the health sector
  together
• Create a common vision about the importance of
  improving developmental services, service
  delivery pathways, and systems change strategies
• Consider a health care sector strategy focused on
  improving the development and function of medical
  homes

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Improving Early Childhood Health Care
Developmental Services

• Develop policy strategies that overcome barriers
  for fully functional medical homes
• Reimbursement and contracting changes to create
  incentives for the provision of developmental
  services
• Coding and reimbursement strategies
• Medicaid Contract language
• Quality measurement and monitoring strategies
  focused on provision of developmental services

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New Roles For Early ChildhoodAdvocates

• Transactionalist
• Curve shifters
• Pathway builders
• Innovators and system changers
• Sector Bridger's
• Conveners, collaborators, learners
• Community Capacity Enhancers
• Leverage financiers

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• UCLA Center for Healthier Children,
• Families and Communities
• National Center for Infancy and Early
• Childhood Health Policy

http.//healthychild.ucla.edu