Rick Brandt-Kreutz, LCSW

1
Healthy StepsPast, Present and Future

• Rick Brandt-Kreutz, LCSW
• August 10, 2006
• 2006 State First 5 Summit
• South Lake Tahoe, California

2
Objectives

• Past Healthy Steps Background and Outcomes
• Present Healthy Steps Fresno Outcomes
• Future Adaptation, Change and Flexibility

3
Evolution of Healthy Steps

• Phase 1 Evaluation (15 9 sites) 1995
• Phase 2 Sustainability and Dissemination
• 10 of 24 sustained (42)
• 9 of 24 with significant spin-off
• 35 new sites since end of the evaluation 2003
• Total Current Sites 45
• 17 in Residency Training
• 20 in Planning or Discussion

4
Why Healthy Steps?
MCB.AB.UIMCH 4-21-2005
5
Beginning Healthy Steps

• 1975 The new morbidity recognized in
  Pediatrics
• 1993
• "After infancy, children in the United
• States are more likely to die from
• injuries of violence and suicide than
• from infectious disease.
• PEDIATRICS Vol. 92 No. 5 November 1993

6
Healthy Brains

• Significance of the environment in forming babies
  brains
• Stress effects development
• Depressed mothers twice as likely to become
  frustrated
• Recognition of the importance of school readiness

PEDIATRICS 1143 September, 2004
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Many Mothers Not Breastfeeding

• 33 did not breastfeed
• 13 stopped after a month
• 46 TOTAL

Young, KT, et al. Listening to Parents A
national Survey of Parents with Young Children.
Archives of Pediatric Adolescent Medicine. 1998
152 255-262.
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Parents Want Help With Development

• 79 reported they could use more info in 1 of 6
  areas
• 74 use books/magazines/videos
• 35 attended a class
• 23 talked with the doctor about learning and
  discipline

Young, KT, et al. Listening to Parents A
national Survey of Parents with Young Children.
Archives of Pediatric Adolescent Medicine. 1998
152 255-262.
9
Read With Your Child?

• 49 if learning IS discussed with the MD/Nurse
• 37 if learning IS NOT discussed with the
  MD/Nurse

-
12 Increase if the doctor or nurse talks
with the family
Young, KT, et al. Listening to Parents A
national Survey of Parents with Young Children.
Archives of Pediatric Adolescent Medicine. 1998
152 255-262.
10
The Unique Influence of the Primary Care Provider

• Who else sees 0-3 babies?
• High trust factor
• Timing and frequency of well-child visits
• Supportive, on-going relationship
• General and personalized relationship

11
Why Healthy Steps?

• Developmental and Behavioral Risks to Child
  Health
• Parent-Child-Family Relationships are Key to
  Child Health
• Primary Care Provider Has a Unique Opportunity
  With Families

12
Changing Health Care

• Margaret E. Mahoney of the Commonwealth Fund
• Healthy Steps represents a change in health care

What is Healthy Steps?
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Quality Enhancement in Primary Care for Children
0 to 3
Families
Clinical Team Healthy Steps Specialist (HSS)

• Outcomes
• Infants sleep on back
• Moms openly discuss feelings of sadness
• Moms use less physical punishment
• Moms match behaviors to childrens development
• Greater compliance with immunization schedule
• Parents and physicians more satisfied with care

• Focuses on Behavior and Development
• Nurtures Families
• Provides Important Information Parents Want and
  Need

• Components
• Enhanced Well Child Care
• Home Visits by HSS
• Telephone Information Line
• Developmental Screening
• Special Printed Material
• Parent Groups
• Linkages to Community Resources
• Reach Out and Read

JAMA 12/17/03
MCB.AB.UIMCH 4-21-2005
14
National Evaluation

• 3 year project
• 5565 participants
• 6 randomization and 9 quasi-experimental sites
• Also, the PREPARE program with Group Health in
  Seattle

Minovitz. JAMA, December 17, 2003Vol 290, No. 23
(3081 3091) B.D. Johnston, et al., Expanding
Developmental and Behavioral Services for
Newborns in Primary Care. AJPM, 26(4) May 2004.
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Quality of Care 4 Domains

• Effectiveness
• Patient-centeredness
• Timeliness
• Efficiency

1.7 times more likely to receive care through 20
months of age
16
Outcomes

• Breastfeeding
• Feeding
• Reading
• Harsh and Abusive Parenting
• E/R Usage

17
Breastfeeding

• Mothers who received Healthy Steps prenatally or
  shortly after giving birth were more likely to
  continue breastfeeding.

B.D. Johnston, et al., Expanding Developmental
and Behavioral Services for Newborns in Primary
Care. AJPM, 26(4) May 2004.
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Feeding

• Healthy Steps babies are 22 less likely to have
  water and 16 lower for introducing cereal and
  other foods introduced early (2-4 months)

Minovitz. JAMA, December 17, 2003Vol 290, No. 23
(3081 3091)
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Reading

• 22 higher for showing picture books daily

Minovitz. JAMA, December 17, 2003Vol 290, No. 23
(3081 3091)
20
Harsh and Abusive Parenting

• 30 lower use of severe physical punishment
  (slapped in face, spanked with belt or other
  object)
• 22 lower for relying on other harsh strategies
  (yelling, threatening, slapping hand, spanking
  with hand)

Relative Risk Reduction
Minovitz. JAMA, December 17, 2003Vol 290, No. 23
(3081 3091)
21
E/R Usage

• Not significant for National Study

What about Fresno?
22
I think Healthy Steps can help us do better what
we already do.
23
The Childrens Health Center PATIENTS

• 30,000 visits, 9,000 patients per year
• 3,500 0-3 year olds (40)
• 97 MediCal or no insurance
• 80 Hispanic
• About half speak only Spanish

24
Fresno Pediatric RESIDENTS

• 350 pediatricians since 1947
• Over 60 stay in the Central Valley
• Over 40 stay in Fresno
• Today 30

25
Healthy Steps Fresno2003-2006

• Grant 453,490
• 3 years
• 220 kids
• 40 residents

26
Cost?

• 933/year_at_162 families
• 402/year_at_463 families
• Fresno?
• 682/year_at_220 families
• Plus 43 residents trained

27
Cost Comparison?

• Head Start--4500 per family per year
• Infant Health and Development Program--10,000
  per family per year

JAMA, December 17, 2003Vol 290, No. 23 (3081
3091)
28
Quality Enhancement in Primary Care for Children
0 to 3
Families
Clinical Team Healthy Steps Specialist (HSS)

• Outcomes
• Infants sleep on back
• Moms openly discuss feelings of sadness
• Moms use less physical punishment
• Moms match behaviors to childrens development
• Greater compliance with immunization schedule
• Parents and physicians more satisfied with care

• Focuses on Behavior and Development
• Nurtures Families
• Provides Important Information Parents Want and
  Need

• Components
• Enhanced Well Child Care
• Home Visits by HSS
• Telephone Information Line
• Developmental Screening
• Special Printed Material
• Parent Groups
• Linkages to Community Resources
• Reach Out and Read

JAMA, December 17, 2003Vol 290, No. 23 (3081
3091)
MCB.AB.UIMCH 4-21-2005
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Prenatal Home Visit
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Did it Work?

• Evaluation Plan
• For Residents and for families and children
• CSUF Students Comparison Group

Dr. Kathleen Ramos, Ph.D. California State
University, Fresno
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Healthy Steps FresnoResident Outcomes

• Yearly pre and post survey
• Resident rotation evaluations

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With regard to infants and toddlers (ages 0-3)
Resident Survey

• Answer questions
• Initiate discussion
• Use screening
• Obtain history
• Identify problems
• Recommend intervention

• Frequency
• Competence

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Survey Resultsso far

• Administered 4 times with one beginning and
  ending pair
• Instrument is reliable alpha.93
• Scores increase with years in residency
• Scores jump the most after the Developmental and
  Behavioral rotation
• Pre and Post significant increase in scores

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But, is this Healthy Steps?
We cannot say
35
Childrens Hospital Social Work
Elementary School Experience
Childrens Hospital Psychology
Developmental Pediatrics
TOTAL AVERAGE
Diagnostic Center
Behavior Clinic
Regional Center
HEALTHY STEPS
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Healthy Steps FresnoPatient and Family Outcomes

• Breastfeeding
• Feeding
• Reading
• Harsh and Abusive Parenting
• Father Involvement
• E/R Usage

37
Breastfeeding

• Healthy Steps babies are more likely to be
  breastfed beyond 12 months (33 HS versus 9
  comparison)
• The longer babys are breastfed, the less chance
  of being overweight

Harder, T et al. Duration of breastfeeding and
risk of overweight a meta-analysis.Am J
Epidemiol. 2005 Sep 1162(5)397-403.
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Feeding

• Healthy Steps babies are less likely to have
  water (35 vs 75), cereal (7 vs 34), and other
  foods introduced early
• Early feeding habits effect chances of being
  overweight and Hispanics start foods earlier

Mennella JA. Feeding Infants and Toddlers Study
the types of foods fed to Hispanic infants and
toddlers. J Am Diet Assoc. 2006 Jan106(1 Suppl
1)S96-106.
39
Reading

• 50 increase in Moms and Dads reading to baby
  more than once per day

40
Harsh and Abusive Parenting

• Moms more often offer explanations to children
  and less often use harsh parenting (threaten,
  yell, slap, spank)

Relative Risk Reduction
41
Father Involvement

• Dads more involved in diapering (77 vs 60) and
  bathing (67 v 42) baby
• Dads read, play and sing more to their toddler
• Father play at 24 months related to peer
  competence, adaptive coping strategies at 16
  years old

Yogman,W. Kindlon, D. Pediatric Opportunities
with Fathers and Children. Pediatric Annals
271, January 199816-22.
42
E/R Usage

• Less likely to visit the ED (0 vs 28 of
  toddlers)

Any Questions before we move on?
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Healthy Steps Results

• Elizabeth and Her Baby

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Fresno Questions

• How could we identify and serve the children and
  families who need Healthy Steps more?
• Can our residents implement Healthy Steps in
  their future practice?
• How could we serve more kids? How can we SCREEN
  more children?

Every Child is a Healthy Steps Child
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Detection RatesWithout Tools With Tools

• 30 of developmental disabilities identified
• (Palfrey et al. JPEDS. 1994 111651-655)
• 20 of mental health problems identified
• (Lavigne et al. Pediatr. 1993 91649-655)

• 70-80 with developmental disabilities correctly
  identified
• (Squires et al., JDBP 1996 17420-427)
• 80-90 with mental health problems identified
• (Sturner, JDBP 1991 1251-64)

Anita Berry MSN, CNP/APN
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Future Healthy Steps Adaptation, Change and
Flexibility
From
THE CADILLAC MODEL
To
The Prius Model
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Healthy Steps Key Points Into the Future

• Flexible
• Component selection
• Essential Developmental Screening, Home Visits,
  Developmental Info. Line and Healthy Steps
  Materials
• Intensity Can vary from site to site
• Venues
• Private practice
• Hospital clinics and FQHCs
• Residency Training
• Public Health

MCB.AB.UIMCH 4-21-2005
48
Healthy Steps Pediatricsand Family Medicine

• Selective Prevention and Continuum of Care
• Using ASQ-SE and clinical observations to
  identify families for Healthy Steps services
• Universal screening for all patients
• Follow the resident and the residents patient
• Expanded to Family Community Medicine
• Healthy Steps Residency Institute October 24-26

The Prius Model
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Healthy Steps Fresno and California

• Community Expansion Support
• Proposal

Healthy Steps Family-Centered Primary Care 2007
Conference
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Check out our website
http//www.fresno.ucsf.edu/pediatric
s/program_info.htm
Thank you for your time
Fresno, California
supported by a grant from First 5 Fresno  
 
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