Today’s Situation
Helping Parents Raise
Happy, Healthy, Productive Children
Parents today are trying to raise healthy
kids in a world much different from the
one in which they grew up.
It’s hard for moms and dads to stay on
top of what their kids, do, see and eat.
And there is little support to prepare
them to go out into the world and
succeed.
A Proposal to Give Families a BetterPerforming System for Their Children
Debbie I. Chang, MPH
Put into place a generation ago, America is living with 40-year old
programs and policies that are not fully capable of addressing today’s real
and growing risks – obesity, mental illness, chronic disease.
It’s time for a change.
Senior Vice President and Executive Director
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How did we get here?
What is at stake?
While America invests in education, welfare
and health for kids, the functions are largely
a patchwork of disconnected programs that
are out of date and incomplete
Children live with antiquated programs
that were designed when infectious
disease posed a widespread health
threat
We need a child health system
designed for the way kids today live
and grow – a coordinated approach
that addresses the health and wellbeing of the whole child.
These threats are:
Modern epidemics such as
obesity and diabetes have
lifelong health consequences
and present significant costs
to the economy
We are raising a generation of
children who for the first time in
our history will be less healthy
than their parents and
live shorter lives
• Largely preventable
• Often the result of
child’s physical and
social environment
They are rooted in the
way children live, learn
and play and
can be fixed.
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Focusing on Desired Outcomes
The Challenges Children Face are Real
•
The United States must make adequate investments in services
that families need, but spending more does not mean getting more.
•
It is time to better use the resources we have to get a greater
return on investment – better outcomes and healthier children.
o
The U.S. health system spends more on health care than any other
country in the world, yet ranks 37th in performance.
…And they are different. Children are not simply small adults – Just
downsizing adult-sized health and social programs ignores the problems
kids face today including:
America spends 95 percent of health dollars on medical care and only 5
percent on promoting health and prevention. The imbalance hits children the
hardest because the most fundamental purpose of health care for children is
to promote healthy development.
Administration and delivery of child health programs at all levels is often
ineffective, uncoordinated and incomplete. Programs vary widely across
states with little accountability for quality at any level.
Being healthy
Quality and access to services reflect significant disparities in geographical,
racial, ethnic and socioeconomic status.
Staying safe
A Focus on
Desired Outcomes
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Enjoying and achieving
The incidence and types of chronic disease in children have both
dramatically increased and changed over the past four decades.
Contributing to society
Achieving economic wellbeing
5
Nearly 9 million children are uninsured. For millions more insurance is
sporadic, unstable and often inadequate because benefits fail to focus
on prevention and promoting good health.
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How Do We Begin to Change?
Broaden the Definition of Health
A scientific consensus is emerging that views health not as
something set at birth but rather as a state that develops over time
as a child interacts with the physical and social environment.
•
Broaden the definition of health
•
Build on what works
A 2004 Institute of Medicine study, Children’s Health the
Nation’s Wealth, focuses on outcomes and provides a solid
scientific basis for action. It says that children’s health should
be defined based on whether they can:
Realize their potential
Satisfy their needs
Develop the capacities to allow them to interact successfully
with their biological, physical and social environment
America needs a children’s health system that incorporates the IOM’s
broader health definition, addresses growing public health threats, focuses
on prevention and promoting health and development and keeps pace
with the latest scientific advances.
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Nemours Integrated Child Health System
Example: Nemours Integrated Child
Health System
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•
Nemours is a non-profit organization dedicated to children's health
& health care.
•
Operates Alfred I. duPont Hospital for Children and outpatient
facilities in the Delaware valley and specialty care services in
Northern/Central Florida. Building new state of the art Children’s
Hospital in Orlando.
•
In 2003, Nemours redefined its approach to ensure maximum
impact: health as well as health care.
•
Nemours Health and Prevention Services (NHPS) focuses on child
health promotion & disease prevention to address root causes of
health problems.
o First initiative is preventing childhood obesity
•
NHPS complements and expands the reach of clinicians by
providing a broader, community-based approach.
•
NHPS target population started with children in Delaware. Using
lessons learned from Delaware, planning is underway for possible
initiatives in North Central Florida.
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Promoting Health and Prevention
Conceptual Model: Key Influences on Children’s Health
ƒ A healthy child includes a
balance of physical,
emotional, cognitive & social
well-being.
ƒPetals represent
determinants of health as well
as leverage points for
improving health.
Traditional Medical Model
Expanded Approach
Rigid adherence to biomedical
view of health
Incorporate a multifaceted
view of health
Chronic disease prevention
and management
Focused primarily on acute
episodic illness
Focus on Individuals
Focus on communities/
populations
Cure as uncompromised goal
Prevention as a primary goal
Focus on disease
Focus on health
A child’s interaction with, and the effects of, these influences vary over
time and are often dependent upon age and developmental stage.
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12
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Linking Early Learning and Health
Nemours Continuum of Care: Childhood Obesity Example
Community,
environmental
supports,
policies, etc.
for healthy
lifestyles
Primary care
prevention,
early id and
management
of at risk and
less complex
cases
Community
services
Medical
management
of complicated
patients
•
Every young child’s developing mind is connected
to a developing body
•
High quality early childhood programs help
children develop strong emotional, social and
academic skills
Good nutrition supports not only the physical, but
also the cognitive development of children
Scientists are investigating precisely how physical
activity affects young children’s cognitive
progress
o
Inpatient
services
including
surgery
•
Health Promotion and Prevention
Services
Specialty Outpatient and Inpatient
Diagnostic and Treatment Services
•
Primary Care Practices
All aspects of children’s development are linked
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Investing in Preschoolers yields largest returns
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Build on What Works
While not perfect, the health and social supports
available for today’s seniors provide an example of a
comprehensive, coordinated approach to addressing a
large population group
Similar to the commitment made to our seniors, we need to make
children a higher national priority. This proposal would create a system
that is designed to meet the unique needs of children.
The proposal would better coordinate health care, education, child care
and wellness in a way that supports the growth and development of all
children. This means:
‡ Every child in America has meaningful health coverage;
‡ The children’s health system has an updated infrastructure with a 24/7
focus on policies and programs that are responsive to parents; and
‡ The health and well-being of children are among the nation’s top
priorities.
There is no need to start from scratch. We must build on pieces of the
system that work and change what doesn’t.
Heckman, J. (2006). Skill Formation and the Economics of Investing in Disadvantaged Children.” Science.
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Three Point Plan for Better Child Health
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Point 1: Provide Meaningful Health Coverage
Public and private sectors and families must assume
responsibility in providing and securing health coverage
for children.
Meaningful
Health
Coverage
•
•
Systemic changes
in children’s
programs
Provide education and support to parents to ensure that
their children receive age appropriate services addressing
their physical, cognitive, emotional and social needs. This
includes oral health, nutrition services and vision screening.
Children are
a top national
priority
This proposal outlines an infrastructure that can have a 24/7 focus on the
policies and programs parents need to raise healthy, happy, productive
children.
The whole effort is tailor-made for American innovation and ingenuity
o
o
It requires looking at existing models, research and resources and applying them
to today’s needs.
It is a way to piece together fractured programs where accountability lies in many
different places.
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Federal law should be amended to assure that:
• All children would have either public or private health coverage that
guarantees uninterrupted care and affordable enrollment through a highly
accessible system.
• Appropriate reimbursement for services that reflects a developmental
standard of child health and wellness.
• Supplemental health and development services would be available for those
with or at risk for special health care needs.
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Point 2: Systemic Changes for Children
•
•
•
There are a variety of mechanisms to
transform the child health system.
This proposal outlines potential changes at
the federal, state and local levels.
In addition, recommendations are included
for involving parents and families in the
policy-making process.
Create a National Child Advisory Committee
The U.S. Congress would charter an independent National Child
Health Investment Advisory Committee to:
Serve as the central hub for creating a measurement and outcomes matrix for all
child health programs and then evaluate those programs
Set national goals and progress milestones that will be monitored and updated as
needed.
Recommend a comprehensive health and development benefit package that would
include developmentally appropriate services
Develop an outcomes-driven child health and development agenda including
recommendations for programs and financing
Make recommendations for ensuring coordination and integration of key child health
and development programs across and within federal departments
Charge an independent research group, such as the IOM, to systematically analyze
and report on various components of the child health system over five years.
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Assure Accountability & Coordination of Services
Accountability will be shared among federal, state and local
levels and families and based on coordination, integration,
management and planning.
9 Comprehensive, shared outcome and performance measures for tracking
progress across national, state and local programs and services
9 Consistent definition of comprehensive and developmentally appropriate
health services necessary to achieve desired outcomes
9 Common terms and definitions of fundamental concepts such as what
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Federal Structure Recommendations
National Child Health
Investment Advisory
Committee
Dept. of Health
and Human
Services
Deputy
Secretary for
Children
constitutes a covered service or permissible expenditure
9 Common, transparent, eligibility standards, reporting definitions and
shared electronic information systems
9 Coordinated quality improvement system with ongoing and rapid feedback
to all system stakeholders
9 Cross-cutting evaluation plan for monitoring system impact over time
9 Collection and timely reporting of population-based information on child
health and development
9 Process for ongoing feedback and involvement from all stakeholders
including youth, parents and family members
The state entities would develop programs consistent with the national children’s
system. They would be responsible and accountable for:
Demonstrating how their programs meet the needs of their communities
Special federal grants would be available to encourage innovative and
comprehensive approaches to improving child health and well-being
o
Employers
‡
Community-based organizations
‡
Local funders
‡
Parents
The Secretary would appoint a Deputy Secretary for Children to
oversee and coordinate all programs relating to children.
• Ensure coordination and integration of federal children’s programs
(i.e., Medicaid, SCHIP, Title V, Head Start, foster care, child care
and IDEA programs) using the budget project as leverage.
• Work to ensure parents can access appropriate services.
• Develop and implement an evaluation mechanism to measure
progress based on recommendations from the advisory committee.
• Recommend periodic changes in benefit structure to assure
appropriate services are available.
• Report regularly to the White House.
A $2 billion fund run by the Deputy Secretary for children would
ensure coordination and integration of children’s programs at the
federal, state and local levels and provide incentive grants to
encourage innovation at the state level
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• Plan, monitor and carry out the functions delegated by the state
accountability organization
• Ensure that families play an integral role in setting family
accountability measures and milestones
• Establish one or more “child and youth resource centers”
• Participate in state and national planning and implementation
efforts
Families would be involved in all aspects of policy making,
program design and implementation as well as setting and
monitoring milestones for accountability.
States would be provided with funds from the Trust Fund for Children to
establish partnerships with non traditional entities
‡
HHS would be accountable for overseeing implementation of the
advisory committee’s recommendations.
Would have authority across federal departments to ensure
coordination and integration of children’s programs.
Local governments would coordinate and integrate
approaches to improve child health and development:
The focus would be broader than medical care and would include the broad range of
determinants that affect child health
Planning, monitoring establishing policies and administering resources
•
Local and Family Accountability
As a condition of receiving federal health funding, each
governor would be required to establish an entity
responsible and accountable for all state policies and
services related to children and the youth.
o
•
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State Structure Recommendations
o
Trust
Fund for
Children
Authorize sufficient funds to carry out the establishment and
recommendations of the national advisory committee and the
coordination/integration of programs serving children
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Point 3: Make Children a Top Priority
•
•
•
•
Nemours Health & Prevention Services
A key to achieving these goals is elevating
children in our national priorities.
Some of the systemic changes (e.g., dep sec
position) will help raise the profile of children.
Transformational change will require political
leaders making children a top priority.
Parents, providers, advocates, elected officials
and others must join together to make these
changes in our child health system a reality.
•
•
•
NHPS believes that every child should
grow up healthy.
Our goal is a cultural change where each
sector of the community – public and
private – places the highest value on
health and well-being of all children.
We work in partnership with people and
organizations to develop and support
policies, practices and programs that
promote good health in children where
they live, learn and play.
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NHPS Intervention Strategy
NHPS Model: Over 200 Community Partners
Our goal is to
change the health
status and wellbeing of the most
children possible
through the
deployment of
evidence based
policies and
practices that will
have the highest
sustainable impact
with the most
efficient use of
resources
POPULATION
POPULATION BASED
BASED CHANGE
CHANGE for
for CHILDREN
CHILDREN
COMMUNITY
COMMUNITY &
& ORGANIZATIONAL
ORGANIZATIONAL CHANGE
CHANGE
RESULTING
RESULTING IN
IN SUSTAINABLE
SUSTAINABLE SYSTEMS
SYSTEMS &
& ENVIRONMENTS
ENVIRONMENTS
SCHOOL
SCHOOL
DISTRICT
DISTRICT
COMMUNITY
COMMUNITY
CHANGE
CHANGE AGENT
AGENT
PRIMARY
PRIMARY
CARE
CARE
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CHILD
CHILD
CARE
CARE
EVALUATION,
EVALUATION, KNOWLEDGE
KNOWLEDGE DISSEMINATION
DISSEMINATION &
& CAPACITY
CAPACITY BUILDING
BUILDING
for
for POLICY
POLICY &
& PRACTICE
PRACTICE CHANGE
CHANGE
Policy and Practice
Change Agenda
that evidence the
usefulness of
Healthy
Children
that support
supports
Behavior
Change
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NHPS Sectors
Content Areas
1) Healthy Eating &
Physical Activity
2) Emotional/
Behavioral Health
Policy and practice changes
afford the greatest potential
to transform the areas where
children live, learn, and play.
Ultimately, they will enable
behavior changes that lead
to positive health outcomes
for children.
Community
Infrastructure
Capacity
that leads to
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Policy & Practice Changes Lead to Behavior Change
to build and
sustain the
1)
2)
3)
4)
Sectors
Childcare
Primary Care
School
Community
Outcomes
Impact on
Delaware
Children and
Communities
(Policy and
practice change)
Impacting the greatest number of
children in the shortest amount of time.
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Going to Where the Children Are With 5-2-1-Almost None
•
Example: Addressing obesity through child care policies
Together We Can Make Delaware’s
Kids the Healthiest in the Nation
o
o
Kids Can’t Do It Alone
5-2-1-Almost None
‡
•
Advocating for Child Nutrition Act Reauthorization
Participating in key coalitions to improve Child Nutrition
Act
Planning a national conference on child care
obesity prevention best practices for leaders in the
states.
Presenting the keynote address at the CACFP Leadership
conference
o
o
Integrated into all 4 sectors
ƒ
ƒ
ƒ
ƒ
o
Healthy Eating and Physical Activity
behavior change is the key outcome for
federal, state and local activity.
At the federal level, Nemours is:
•
Community
School
Child Care
Primary Care
o
o
Helping accelerate policy
and practice changes
A stronger federal act will support state
innovation and local practice change
•
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State policy changes in child care
Local level: changes for children in child care
•
ƒ State policy changes in support of
5-2-1-Almost None: 54,000 children
o
•
•
o
o
o
•
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Child and Adult Care Food Program
Interactive instruction for center directors to teach
child care providers to implement healthy eating
and physical activity best practices
Sesame Workshop Preschool Toolkit (3 - 5 year olds)
o
ƒDelaware passed a voluntary quality rating system that
includes provisions for health and emotional well-being
Child Care Directors collect baseline data on current state
of practices in their centers
Best Practices in Healthy Eating (CACFP Guidelines)
Child Care Collaborative DVDs
o
ƒChild and Adult Care Food Program (CACFP) adopted
policy changes for foods served in child care
ƒ OCCL is also requiring that all licensed child care
providers use the CACFP guidelines to provide
adequate nutrition
Nemours partnering with Sesame Workshop
Influencing practice change with concrete healthy eating and
physical activity lessons and activities
Distributed 705 kits that reach 13,000 children
Helps children develop positive associations with healthy foods and
physical activity
University of Delaware Toolkit (Infant – 2 year olds)
o
Influencing practice change with concrete healthy eating and
physical activity lessons and activities
REACH = 28 Centers serving 3,000 children
All centers have participated
in 4 learning sessions and
are implementing policy and
practices changes regarding
HEPA
Policy Change:
NHPS and the Delaware Child and
Adult Care Food Program collaborated
to co-author Best Practices for Healthy
Eating: A Guide to Help Children Grow
Up Healthy embodying the Nemours 52-1-Almost None message
o
o
•
Practice Change:
o
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Child Care Collaborative
REACH: 54,000 children in all licensed child care
o
NAPSACC
o
ƒOffice of Child Care Licensing (OCCL) regulations
updated - reducing screen time and increasing physical
activity - in licensed child care and family centers
•
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o
Best practices identified in the Guide
resulted in policy regulations
implemented this July. Guide endorsed
by the USDA.
o
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Imbedding moderate to
vigorous physical activity
into the day
Increasing fruits and
vegetables on the menus
Creating policies for
what parents and staff can
bring into the center (e.g.
no unhealthy fast food)
Increasing access to water
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Our Commitment to Tomorrow
Delaware Children Growing Up Healthy
ƒ Changes in federal, state and local policies and
practices, supported by targeted and strategic
activities, are making an impact on the lives of
Delaware’s children. More than 100,000 children are
growing up healthy due to Nemours:
Helping parents today raise healthy, happy and productive
children is the best chance we have to create a future generation
of healthy, happy, productive adults.
– 32,000 community encounters
– 76,400 school district encounters
Change will not happen overnight or in a vacuum. It requires
dedication among many and a focus on what works.
– 54,000 child care encounters
– 33,000 primary care encounters
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