Enhancing State Measurement for Early Childhood Preventive and Developmental Services

1
Enhancing State Measurement for Early Childhood
Preventive and Developmental Services
Brett Brown, PhD Holly Grason, MA Catherine
Hess, MSW Edward Schor, MD Gillian Silver, MPH
Karen VanLandeghem, MPH

• Association of Maternal and Child Health Programs
  2004 Annual MeetingSkills Building Session
  A2Saturday, February 28, 20041200 330 p.m.

2
Measuring to Improve Child Health and Development

• Edward L. Schor, MD
• Program Director
• Child Development and Preventive Care
• The Commonwealth Fund
• February 28, 2004

3
Health is a state of complete physical, mental
and social well-being and not merely the absence
of disease or infirmity.
Constitution of the W.H.O.
1948 a mentally or physically disabled child
should enjoy a full and decent life, in
conditions which ensure dignity, promote
self-reliance, and facilitate the childs active
participation in the community.
Convention on the Rights of the Child, U.N. 1989
4
Children will receive the nutrition, physical
activity experiences, and health care needed to
arrive at school with healthy minds and bodies
1st
National Education Goal 1990 the right to grow
is universally assured through attention to the
comprehensive physical, psychological and social
needs of the MCH population.
Vision, MCHB
1999
5
Human Potential
Risk Factors
Protective Factors
6
CONTRIBUTORS TO CHILD HEALTH PROMOTING AND HEALTH
RISK BEHAVIORS
FAMILY
PEERS
COMMUNITY, SCHOOLS, MEDIA
7
Childrens Early Reading and Mathematics
Performance By Mothers Education 1998-2000
Scale Score
Reading
Mathematics
100
80
Bachelors degree
Some college
60
High school diploma
40
Less than high school
20
0
Kindergarten
Kindergarten
1st grade
1st grade
US Department of Education, National Center for
Education Statistics, The condition of education
2003, NCES 2003-067, Washington, DC US
Government Printing Office, 2003
8
The ABCs of Developmental Services

• Screen families and children
• Educate parents (anticipatory guidance)
• Treat children and counsel parents
• Make referrals and coordinate care

9
Low-Income Childrens Risk for Developmental,
Behavioral or Social Delays
10
Pediatrician Recognition of Developmental and
Behavioral Problems
Percent of Children
PERCENT
Lavigne et al. Pediatrics 199391(3)649-55
Costello et al. Pediatrics. 198882415-424
11
Infants and Toddlers Receiving Early Intervention
Services from States
Highest Percentage Served Hawaii 7.70 Massachu
setts 5.15 New York 3.68 Lowest
Percentage Served Georgia 0.96 Virginia 1.1
2 Alabama/Louisiana/Nevada 1.13 National
Mean 1.99
12
Commonwealth Fund Program Goal

• To assure that appropriate developmental
• and preventive child health services are
• available to all families, especially those
• with young children and low income.

13
The Commonwealth Fund Program Strategies

• Promote adoption of quality standards and quality
  measurement
• Identify and promote the adoption of effective
  practices, models and tools
• Promote policy change and facilitate adequate
  reimbursement

14
Benefits of Setting Goals and Measuring
Performance

• Target own efforts
• Gain resources and support
• Engage partners

15
Past Measurement Successes

• Healthy People
• Immunization goals
• Infant mortality reduction
• Health disparities

16
Health care should be

• Safe
• Effective
• Patient-centered
• Timely
• Efficient
• Equitable

Crossing the Quality Chasm A New Health System
for the 21st Century, IOM 2001
17
should move forward expeditiously with the
establishment of monitoring and tracking
processes for use in evaluating the progress of
the health system in pursuit of the above-cited
aims.
Crossing the Quality Chasm A New Health System
for the 21st Century, IOM 2001
18
The Early Childhood Initiative LandscapeKaren
VanLandeghem, MPH
19
The Early Childhood Initiative Landscape

• Comprehensive and diverse
• Multidisciplinary (e.g., health, education, child
  care, mental health, social services)
• Initiatives focused expressly on early childhood
  (e.g., ABCD)
• Established initiatives with linkages to early
  childhood (e.g., Healthy Child Care America)
• Initiatives covering sectors other than health
  (e.g., BUILD, SRII)

JHU WCHPC February 28, 2004
20
Common Elements of Early Childhood Development
Initiatives

• Early Care and Education
• Family/Caregiver Education
• Family/Caregiver Support
• Health Care/Medical Home
• Provider Training and Education
• Quality Standards and Measurement
• School Readiness
• Social and Emotional Development/Mental Health

JHU WCHPC February 28, 2004
21
Common Elements of Selected National Early
Childhood Initiatives
22
What are we trying to measure?Examples of core
components

• Health Care (e.g., content and quality of
  anticipatory guidance, medical home, well-child
  care, child development screenings and
  assessments)
• Early Care and Education (e.g., quality of child
  care)
• Education/School Readiness (e.g., social and
  emotional development)
• Mental Health Care (e.g., access and referrals to
  behavioral health care services)

JHU WCHPC February 28, 2004
23
Example of a Health System Measurement
Initiative The Promoting Healthy Development
Survey (PHDS)

• Seven quality measure scores for health plans
• Anticipatory guidance from providers
• Anticipatory guidance information from health
  plan
• Follow-up for at-risk children
• Assessment of psychosocial well-being and safety
• Assessment of smoking, drug and alcohol use in
  the family
• Family-centered care
• Helpfulness and effect of provider information
• Source Bethell C, Peck C, and Schor E.
  Assessing Health System Provision of Well-Child
  Care The Promoting Healthy Development Survey.
  2001, Pediatrics.

JHU WCHPC February 28, 2004
24
Examples of PHDS Application

• Complements EPSDT reporting
• Strengthens purchasing and contracting
• Strengthens implementation of child development
  services in state agency systems
• Enhanced reporting forms
• Referral services
• Coverage of developmental screening
• Source Bethell C, Peck C, and Schor E.
  Assessing Health System Provision of Well-Child
  Care The Promoting Healthy Development Survey,
  2001, Pediatrics.

JHU WCHPC February 28, 2004
25
Importance of Identifying a Conceptual Framework
for Early Childhood Measurement

• Serves as a tool and roadmap for organizing
  thinking and work.
• Helps formulate the goal(s), focus, and content
  of and strategies for measurement.
• Can help crystallize application of findings.
• Identifies inputs and outputs to the
  measurement process.
• Can range from simple to more complex models.
• Frameworks are an enduring way of specifying
  what should be measured while allowing for
  variation in how it is measured over time. (IOM
  Quality Report, 2001)

JHU WCHPC February 28, 2004
26
Example of a Framework Used in Assessing Health
Care Quality

• Structure-Process-Outcome Model for Assessing
  the Quality of Care
• Structure The attributes of the setting in which
  care occurs
• Process The content of care
• Outcomes The end results of care
• Source Donabedian, 1962, 1980.

JHU WCHPC February 28, 2004
27
Early Child Well-being Indicators Tools and
Approaches

• Brett Brown
• Child Trends

28
How are Social Indicators Used?

• Education
• Needs assessment and monitoring
• Goals-tracking
• Accountability
• Reflective practice
• Evaluation of policies and programs

29
Choosing Indicators

• Consult research
• Consult experts
• Consult the stakeholders
• Consult the data resources

30
Design and Dissemination

• Identify audiences and their needs
• Identify budget constraints
• Design accordingly
•  

31
Contributors to Early Childhood Development and
School Readiness
Parenting Supports
Family Economic and Social Characteristics
Parent-Child Interactions and Relationships
Family Supports
Family Composition and Organization
Family Functioning/ Harmony
Health Supports
Child and Family Health
Early Care and Education Supports
Acknowledgement Zaslow, M., Halle, T., Johnson,
R., Bridges, L., Guzman, L., Pitzer, L.,
Calkins, J. (2003). First Steps and Further
Steps Early outcomes and lessons learned from
South Carolina's school readiness initiative
1999-2002 program evaluation report (prepared for
the state of South Carolina). Washington, DC
Child Trends.
32
Selected Federal Data Resources on Early Child
Development and Health

• National Surveys
• National Household Education Survey (NHES)
• Early Childhood Longitudinal Studies (ECLS-K and
  ECLS-B)
• Panel Study of Income Dynamics Child
  Development Supplement
• National Health Interview Survey (NHIS)
• National Survey of Early Child Health (NSECH)
• National Health and Nutrition Examination Survey
  (NHANES)

33
Selected Federal Data Resources on Early Child
Development and Health

• State-Level Surveys
• National Survey of Children with Special Health
  Care Needs (CSHCN)
• National Survey of Childrens Health (out in
  2004)
• Pregnancy Risk Assessment Monitoring System
  (PRAMS)
• National Survey of American Families (NSAF)
  (private)
• Community-Level Data
• American Community Survey (Limited)
• Vital Statistics Birth and Death Data

34
Consulting Experts/ Stakeholders

• Convened panel (academic, practice, funder)
• Prepared background materials
• Project goals
• Panel tasks
• List of indicators based on model/research
• All day meeting, followed by panel voting for the
  final list of indicators.
• Modification of final list based on data
  availability

35
Early Child Development in Social Context A
ChartbookChild Trends and Center for Child
Health Research Sponsored by The Commonwealth
Fund

• Socioemotional Development
• Intellectual Development
• Child Health
• Family Practices/Family Functioning
• Parental Health
• Health Care Receipt
• Early Child Care and Education
• Neighborhood Influences
• Demographics

36
Quality of Health Care for Children and
Adolescents A Chartbook Sheila Leatherman and
Douglas McCarthySponsored by The Commonwealth
Fund

• Effectiveness
• Patient safety
• Access and timeliness
• Patient and family centeredness
• Disparities
• Capacity to improve

37
Design and Dissemination of Chartbook

• Purpose Education
• Audience Early child health policymakers,
  practitioners and parents
• Design goals
• Hardcopy (and PDF)
• Easily digested
• Linked to practice

38
Fine and Gross Motor Skills
Early Child Development in Social Context Child
Trends and Center for Child Health Research, 2004

• Why is this important?
• Childrens motor control and coordination can
  have an important influence
• on their cognitive and socioemotional
  development, as well as their
• academic achievement. Visual motor skills, such
  as visual scanning,
• discrimination, and memorization, are especially
  important in acquiring
• reading skills. Delays in motor development can
  affect a childs performance
• in school, and have been linked to lack of
  concentration, behavior problems,
• low self-esteem, and poor social confidence.
  Problems in motor coordination
• have been associated with loneliness and poor
  peer interactions, especially
• among young boys. Young children with low scores
  on fine and gross motor
• skills assessments are also at risk for later
  developmental difficulties.
• Assessments of fine motor skills are based on how
  well children perform
• tasks such as constructing forms with wooden
  blocks, copying basic figures,
• and drawing a person. Assessments of gross motor
  skills would be based on
• how well children perform actions such as
  balancing on each foot, hopping
• on each foot, skipping, and walking backwards in
  a line.
• What do the data show?
• Boys are more likely than girls to demonstrate
  low levels of fine and gross motor skills. In
  1998, for example, 31 percent of male
  kindergartners received low scores on assessments
  of fine motor skills, compared with 22 percent of
  female kindergartners.

• Implications for Policymakers and Practitioners
• Early, accurate identification of fine and gross
  motor skill deficiencies
• is important, because early treatment can lead to
  better developmental
• outcomes. Health practitioners can become
  familiar with local
• childcare options in order to make better
  recommendations for
• programs to stimulate the development of fine and
  gross motor skills.
• In addition, practitioners can educate parents on
  appropriate
• developmental expectations for their children.
  Clinicians can also
• work with the children themselves, as well as
  with parents, teachers,
• therapists and other physicians, to identify
  appropriate developmental
• goals and treatments for children with motor
  disabilities. According to
• the American Academy of Pediatrics, policymakers
  should consider
• banning the manufacture and sale of infant
  walkers because they fail
• to help with infant motor development. Moreover,
  they have been
• found to be detrimental and dangerous.
• Implications for Parents
• Practice is critical for children to improve
  their fine and gross motor
• skills. At appropriate ages, parents can give
  their young children toys

DRAFT DRAFT DRAFT DRAFT DRAFT
39
DRAFT DRAFT DRAFT DRAFT DRAFT
40
Measurement in Context of Title V Program
Planning and Partnerships

• Lessons Learned and in Process
• Catherine Hess, MSW

41
Measurement in Context Of...

• Title V Performance Measurement System
• State Indicators Partnerships
• Child Well Being
• School Readiness
• Public- Private Healthcare Quality Partnerships
• Federal- State Partnerships
• Medicaid and SCHIP
• Title V/SECCs

JHU WCHPC February 28, 2004
42
Integrating Early Childhood Measurement with
Title V
JHU WCHPC February 28, 2004
43
Integrating Early Childhood Measurement with
Title V

• What early childhood outcomes are you trying to
  affect? What are the baselines and variations by
  subgroups? (needs and strengths in health
  status)
• What does research/best practice say works in
  influencing those outcomes? What partners are
  needed?
• What is in place now, where are the gaps? (needs
  and strengths in health system capacity)

JHU WCHPC February 28, 2004
44
Integrating Early Childhood Measurement with
Title V

• What will you change or develop to build on early
  childhood system strengths and address needs?
  (Program and Resource Allocation)
• What are immediate and longer term measures of
  success? (performance and outcomes measures)
• How will you work with partners to monitor and
  interpret measures, stay abreast of emerging
  research, adjust program strategies and resource
  allocation?

JHU WCHPC February 28, 2004
45
Advancing State Child Indicators Initiatives

• HHS (ASPE/ACF) and Packard Foundation
• Promote state efforts to monitor child health and
  well being in era of shifting policy
• 14 states from 1998 to 2000 participated
• Workshops, meetings, publications to 2001
• http//aspe.hhs.gov/hsp/cyp/child-ind98/

JHU WCHPC February 28, 2004
46
Advancing State Child Indicators Initiatives

• Alaska
• California
• Delaware
• Florida
• Georgia
• Hawaii
• Maine

• Maryland
• Minnesota
• New York
• Rhode Island
• Utah
• Vermont
• West Virginia

JHU WCHPC February 28, 2004
47
Advancing State Child Indicators Initiatives
Lessons

• Cross agency collaboration critical
• Outcomes many can rally around,understand
• School readiness fits these criteria
• Central/governor office lead helps, with
  grassroots, community partnerships critical
• Cross agency can finance new data collection

JHU WCHPC February 28, 2004
48
Advancing State Child Indicators Initiatives
Lessons

• Data drivers policy priorities, audience, data
  availability and strongest predictors
• Communities need ownership
• Need measures reflecting diversity
• Need high quality data available for years
• Clear interpretation over time

JHU WCHPC February 28, 2004
49
School Readiness Indicators Initiative

• Packard, Kauffman and Ford Foundations
• RI Kids Count with 17 states
• Multi-agency senior policy and data staff
• National meetings, Residency Roundtables
• www.gettingready.org

JHU WCHPC February 28, 2004
50
School Readiness Indicators Initiative

• Arizona
• Arkansas
• California
• Colorado
• Connecticut
• Kansas
• Kentucky
• Maine

• Massachusetts
• Missouri
• New Hampshire
• New Jersey
• Ohio
• Rhode Island
• Vermont Virginia
• Wisconsin

JHU WCHPC February 28, 2004
51
School Readiness Indicators Initiative

• Change agenda in states and communities
• Developing child outcome and systems indicators
  birth -gt 4th grade reading test
• Measurable indicators tracked over time
• Adopted by govt., reported to citizens
• Stimulate policy and program change

JHU WCHPC February 28, 2004
52
School Readiness IndicatorsEmerging List for
Physical Health

• adequate prenatal care
• low birthweight
• uninsured children
• immunizations at kindergarten entry
• developmental screening at age 3
• hearing/vision screenings
• elevated blood lead levels
• CSHCN or disabilities
• births to teens

JHU WCHPC February 28, 2004
53
Massachusetts School Readiness Indicators Project
(SRIP)
54
Massachusetts SRIP

• Governors State Commission on School Readiness
  and SRIP paved the way
• Interest in whether current programs/resources
  working and whether sufficient
• Coordinated by the Executive Office of HHS and
  the Office of Child Care Services
• Six other state agencies, Head Start, United Way
  and Kids Count involved

JHU WCHPC February 28, 2004
55
Massachusetts SRIP

• Developed definition of School Readiness
• Childs physical, emotional, cognitive, social
• Families, schools and communities
• Developed list of indicators by using
• research and information from other states
• Commission findings
• Rxes and TA from RI KidsCount SRIP

JHU WCHPC February 28, 2004
56
Massachusetts SRIP

• Started with approx. 90 indicators, using
  consensus process got to about 50 fairly easily,
  40s down harder
• After more than a years work, now 30 indicators
  
• 10 indicators can be measured right now
• 10 can only be partially measured
• 10 are critical but currently cannot be measured

JHU WCHPC February 28, 2004
57
Massachusetts SRIP

• Physical Health Indicators
• Prenatal Care
• Teen Births
• Hunger
• Health Insurance
• Well Child Visits
• Motor Skills
• Developmental and Mental Health Screening and
  Services

JHU WCHPC February 28, 2004
58
Massachusetts SRIP

• Next Steps
• Input from stakeholders-6 forums across state
• Develop communications strategy for school
  readiness
• Develop outreach materials for parents,
  providers, policymakers, legislators

JHU WCHPC February 28, 2004
59
Massachusetts SRIP and MCH Lessons

• Much of data currently collected from DPH
• Mechanism to educate/advocate for health
• Logical fit with Title V assessment/plans
• MCH contact Ron.Benham_at_state.ma.us

JHU WCHPC February 28, 2004
60
Public-Private Partnerships to Measure Healthcare
Quality

• Key Framework Institute of Medicine
• Crossing the Quality Chasm
• Staying Healthy, Getting Better, Living with
  Illness, Coping with End of Life
• Beal (Pediatrics, Jan. 04) found
• 19 measure sets, 365 measures for childrens
  quality
• Few designed specifically for specific age ranges
• Largest getting better (40), staying
  healthy(24)

JHU WCHPC February 28, 2004
61
Public-Private Partnerships to Measure Healthcare
Quality

• National Quality Forum
• Fosters standard measures, adoption and use via
  national, multiple stakeholder consensus
• Workshop on Child Healthcare Quality Measurement
  and Reporting, January 2004
• NACHRI, MOD, AHRQ, NICHQ, AAP involved
• Paper and action plan forthcoming

JHU WCHPC February 28, 2004
62
Utah Health Partnerships

• Longstanding partnership b/t MCH and Medicaid,
  within Dept. of Health
• Collaborated on quality measures for plans
• Focus on CSHCN and EPSDT
• MCH and Medicaid staff do quality audits
• Added plan incentives for improvements
• EPSDT screening
• 2 year old immunizations

JHU WCHPC February 28, 2004
63
Utah Health Partnerships

• Data warehouse- Medicaid claims, eligibility
  data, vital records
• Medicaid and MCH staff trained, have access to
  data
• Source of data for MCHBG, and for Medicaid and
  MCH quality monitoring

JHU WCHPC February 28, 2004
64
Utah Health Partnerships

• ABCD I - targeted case management for infants of
  Medicaid women
• Similar to MCH program for Prenatal-5
• Same outcome measures
• MCH does monitoring, TA for both

JHU WCHPC February 28, 2004
65
Utah Health Partnerships

• ABCD II-Developed by/with Medicaid, MCH and
  stakeholders, esp. pediatricians
• Focus on improving developmental/mental health
  screening of infants/toddlers/moms
• LHDs to assist linking women to MH services
• Utah Pediatric Partnership to Improve Healthcare
  Quality (UPIQ) -learning collaboratives

JHU WCHPC February 28, 2004
66
Utah Health Partnerships

• UPIQ partners with Medicaid and MCH
• UT AAP
• HealthInsight-UT EQRO (PRO)
• University of UT
• Intermountain Health Care System (large MC)
• UPIQ chart audits with standard measures
• Example BMIs identified as needing improvement
  one practice retooled computer system to calculate

JHU WCHPC February 28, 2004
67
Utah Health Partnerships

• Lessons Learned
• MCHs relationship with physicians can help
  engage them in partnership with Medicaid
• Contracting with MCH for quality monitoring for
  Medicaid avoids duplication
• MCH expertise in quality monitoring can assist in
  assuring services withstand federal scrutiny

JHU WCHPC February 28, 2004
68
Federal/State Partnerships CMS

• CMS Medicaid EPSDT 416 form
• revised 97 with state MCH/Medicaid input
• screening ratios by age groups
• UT requires plans to calculate ratios
• CMS contract with Medstat for advising on EPSDT
  encounter data

JHU WCHPC February 28, 2004
69
Federal/State Partnerships CMS

• CMS Performance Measurement Partnership Project
  with NASHP
• Collaboration for measures to meet federal
  requirements and engage stakeholders in QI
• 19 measures for Medicaid/SCHIP whittled down to 7
• Methods for measurement left to states
• First SCHIP reports with measures in Jan04

JHU WCHPC February 28, 2004
70
Federal/State Partnerships CMS

• CMS National Performance Measures Opportunity
  for Collaboration
• Well child visits in first 15 months
• Well child visits in 3rd, 4th and 6th years
• Use of appropriate meds for pediatric asthma
• Childrens access to primary care services
• Prenatal and postpartum care
• Comprehensive diabetes care
• Adult access to preventive/ambulatory services

JHU WCHPC February 28, 2004
71
Federal- State Partnerships Title V

• National indicators/measures for
• LBW/VLBW
• Immunizations
• Screening/well-child
• Health insurance coverage
• Hearing screening
• Oral health
• Teen births

JHU WCHPC February 28, 2004
72
Federal State Partnerships Title V

• State Performance measures to build on, commonly
  related to
• Parent smoking and drinking
• Blood lead levels
• Oral health
• Domestic violence
• Developmental screening and well-child
• Hearing screening

JHU WCHPC February 28, 2004
73
Federal State Partnerships Title V

• State V building/measuring partnerships
• CT-degree to which Title V funded programs
  screen, assess, refer and link to mental health
• DC, MS-Medicaid getting EPSDT screens
• KS- EPSDT screening ratio for infants
• MI- Medicaid 0-6 getting lead screening
• PA- children in center based child care getting
  vision screens

JHU WCHPC February 28, 2004
74
Federal State Partnerships Title V

• RI SECCS
• Successful Start Environmental Scan
• Title V Needs Assessment Coordinator joining team
  to promote coordination/integration
• MI SECCS
• Great Start Indicators in Context
• Timeline/process opportunities to integrate with
  Title V

JHU WCHPC February 28, 2004
75
Small Group Exercise

• Objectives
• To learn the multiple components needed to
  develop, in partnership with sectors or systems
  serving Title V populations, shared measures of
  early childhood health, preventive and
  developmental services
• To develop a strategy for joint or parallel
  application and use of measures by each partner
  in their needs assessment, performance
  measurement and planning processes

JHU WCHPC February 28, 2004
76
Directions

• Once divided into groups, each group will be
  assigned the sister agency or group with which
  they will partner
• Identify and/or develop three performance
  measures using the provided worksheet as a guide
• Develop strategies and plans for how and where
  this information would be used
• Report to the entire group on lessons learned in
  measure development, noting benefits and
  challenges of partnerships, and describing ideas
  discussed for use of the measures

JHU WCHPC February 28, 2004
77
Discussion Questions

• What unique strategies for measurement were
  identified by your group and how does this relate
  to your partner?
• What indicators did your group select for
  measurement and why?
• What challenges do these indicators present and
  what solutions did your group come up with to
  address these challenges?
• What applications did you propose for Title V
  needs assessment? Other purposes?

JHU WCHPC February 28, 2004
78
Overall Strategies for Success

• Be clear about your overall goals for
  measurement.
• Align related and realistic strategies to those
  goals.
• Be realistic about what measurement will or will
  not do.
• Involve key partners and stakeholders.
• Select a small group of clear and compelling
  indicators, and measure over time.

JHU WCHPC February 28, 2004