States find ways to support early childhood development services

Research over the last 10 years has clearly demonstrated the impact that the early years have on a child’s development, health, readiness to learn, and potential for success in later years, all of which have public policy and fiscal impacts for states and communities.

Consequently, there is great interest in finding the most efficient and effective ways to deliver services that support early development of children.

The need is especially great for children of low-income families. Studies suggest these children face disparities that compromise their health and development.

State Medicaid Early Periodic Screening, Diagnosis, and Treatment (EPSDT) programs provide coverage for a comprehensive set of preventive services designed to ensure healthy growth and development. Medicaid programs could collaborate with other state efforts to provide coordinated developmental services as part of the comprehensive quality health care delivered to children through Medicaid.

To pilot such collaborative efforts, in 1999 the New York City-based Commonwealth Fund launched its Assuring Better Child Health and Development (ABCD) program, an initiative to strengthen the capacity of the health system to support the early development of children from low-income families. The Commonwealth Fund provided a grant to the National Academy for State Health Policy (NASHP) in Portland, ME, to work with four states (North Carolina, Utah, Vermont, and Washington) to look at various ways to better deliver early childhood development services.

In a progress report, NASHP says that although the states have similar objectives, they have developed individual approaches. (To see state objectives, click here.) Some launched statewide projects, while others worked at the county level. Some introduced new services; others focused on collaboration among agencies or integration of existing services into a new delivery system.

Deborah Curtis, NASHP project director, tells State Health Watch that although agencies and staff recognize the importance of developmental screening through EPSDT, it hasn’t always performed as it should. Much of the problem, she says, relates to reimbursement issues for pediatric practices.

The importance of the pilot programs is they approach early childhood development from a health perspective and build bridges between agencies with the goals of helping low-income children get a good start, Ms. Curtis says. With the four demonstration states entering the three-year program’s final year, she says they are creating a toolkit for other states.

There also have been preliminary discussions with officials from the Commonwealth Fund about what the next step should be, since the organization is committed to making additional investments in early childhood development.

Targeted case management

Julie Olson, public health program manager For the Utah Health Department in Salt Lake City, tells SHW the state wanted to restructure its flagging home-visit program and bring more services into the Medicaid funding stream.

"Working with ABCD also made sense in terms of our Medicaid goal to increase the number of well-child visits," she says. "We were doing what we could but not making a lot of progress."

Utah, which also is heavily involved in the American Academy of Pediatrics medical home program, decided to use its Commonwealth Fund grant primarily for a targeted case management effort to identify needs and get people access to the services.

"The program has worked very well," Ms. Olson reports. "The biggest stumbling block has been money because Utah, like other states, is suffering from budget problems."

To overcome the budget problem, it has worked through county agencies to put up the money and has logged an increase in home visits. Utah decided to use the grant money to establish the program but not to provide direct services because it didn’t want to terminate services at the end of the grant period.

"We’re now looking for a way to keep the registered nurses who provide technical assistance to the county health departments," Ms. Olson says.

The department has outlined objective measures for use in evaluating program success, such as an increase in the number of children receiving more than one well-child visit and an increase in the immunization rate.

"It helped in the beginning to have the Commonwealth Fund champion this cause," Ms. Olson says. "It will be good if other states can have such support when they try to replicate the ABCD programs. And the grant money was very important. One thing we learned is that it’s critical for state Medicaid programs to work in conjunction with other state public health programs in a collaborative effort."

In North Carolina, which already has local community-based systems of care that bring together physicians, public health agencies, and social service agencies, the state wanted to use the ABCD grant to build the Medicaid capacity for child development services, working through physician offices at the time of well-child visits.

The pilot program now works through six pediatric and family practices in one health plan. Actual mechanics differ at each practice and were worked out in consultation with the person who runs the office, according to ABCD project coordinator Sherry Hay in the Office of Research Demonstrations and Rural Health Development in Raleigh.

Success is based on the number of children screened as a percentage of the total number of children coming in for well-child visits. Ms. Hay reports that under the old system, about 4% of the children received the developmental screening at the appropriate visit; under ABCD, it has grown to 24%.

"It’s not always easy to change behavior in physician practices," she says.

Ms. Hay and her colleagues are laying groundwork for keeping the program running after the ABCD grant is over and developing best practices that can be shared with other states.

"We see some windows opening, and think there are some ways we can keep going," she points out. "We were able to use the grant funds to hire an early intervention specialist and now are talking with the public health agency to see if the child service coordinators could take on some of this work."

The Vermont Department of Health in Burlington saw an opportunity to participate in the program, according to ABCD project director Susan Shepard, because more than half the families enrolled in the state Healthy Babies program declined or did not receive home visits, meaning that primary care interventions were not reaching their population target. They also found that they were reaching too few children in the important 1-5 age range.

"We saw that the home visit program was struggling to enroll and retain families, and wanted to develop other strategies that might work better," Ms. Shepard tells State Health Watch. "Our primary goal under the grant was to integrate the Healthy Babies and age 1-5 programs into a system of care from pregnancy through school age. We expanded the menu of service options in hopes of increasing engagement of families along the service continuum."

Resource materials for parents

A key element in the program is developing educational resource materials for parents. There are newsletters dealing with pregnancy and childhood development schedules, a web site, and group education programs through doctor offices, playgroups, Head Start, libraries, and child-care providers. The state group also conducted focus groups to find out why people don’t want to have home visits.

To provide a structure for the activities, they have adopted Touchpoints, a model for practitioners that emphasizes the building of supportive alliances between parents and health care professionals around key points in the development of young children. Touchpoints was developed by pediatrician T. Berry Brazelton, MD, of the Brazelton Institute in Boston.

Ms. Shepard says they are targeting high-risk groups such as teen parents, the homeless, and substance abusers. In developing collaborative efforts, they use staff whose skills match the identified needs and find reimbursement for the additional services.

Communication about family status has been a key element that led to a new form that replaced four old forms. To better describe the program, it has been renamed "Healthy Babies, Kids, and Families."

Evaluation of success has been through a comparison with Healthy Vermont 2010 goals and through a client satisfaction survey.

Ms. Shepard says she believes it is important for states wanting to replicate Vermont’s success to look at existing programs and identify where to make improvements, as well as looking at which partnerships work and which do not.

"Be sure you have an infrastructure that brings key stakeholders at the state level to the table and buying in," she says. "Develop collaborative partnerships and be sure you have sufficient resources to do what you want to do."

Multiple paths to success

Washington state strives to improve EPSDT outcomes by linking development health services for children and families, outreach to Medicaid families to ensure they receive EPSDT services, review and promotion of development screening tools, provider training, parent education, and improved EPSDT screening rates.

Ms. Curtis tells SHW that all four demonstrations have seen that effective communication of the results of a developmental screening is essential. While home visits can be an important strategy in identifying a child’s or family’s risk factors and concerns, service should be delivered with a sensitivity to the family’s circumstances and be responsive to each family’s particular needs. It is important to communicate the results of a home visit to the child’s providers so the findings can be used effectively.

Although parent health and well-being are integral to the healthy development of young children, limited resources and opportunities exist to provide consistent and continuous support and services to parents who lack health insurance. Curtis says mental health issues for mothers are particularly critical. The ABCD projects are developing multiple approaches for providing support to mothers and fathers through one-on-one consultation, group education, parent support groups, and educational materials.

Collaboration is the key to cost-effectively improving developmental services. Multiple agencies provide early childhood development services and coordination among them can be challenging. Finally, Ms. Curtis says, the financing of early childhood health and development services can be approached through modifications to existing reimbursement systems, incorporation of administrative and service functions into an existing infrastructure, addition of more resources, or the pooling of resources across agencies.

[Contact Ms. Curtis at (207) 874-6524, Ms. Olson at (801) 538-6303, Ms. Hay at (919) 715-1511, and Ms. Shepard at (802) 652-4174.]