Communities of Practice Project: The
Key Elements of Sustainability
New Federal Opportunities for Promoting
Child Health and Well-Being
Charles Bruner, Director
Child and Family Policy Center, BUILD Initiative
Newark, DE -- July 20, 2010
New Federal Opportunities: A
Narrative for Action
1. Healthy child development is multidimensional.
2. Health practitioners are the “first contact” with young
3. Exemplary strategies exist that address the
multidimensionality of child health.
4. Federal health provisions offer the opportunity to
address children’s healthy development.
5. States and communities must be intentional and
creative to take advantage of these federal
6. Those who know best are in this room (but cannot do
it alone).
1. Healthy Child Development is
Child 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.
-- National Research Council and the Institute of Medicine. 2004. Children’s
Health, the Nation’s Wealth: Assessing and Improving Child Health.
social determinants of health
life course model of healthy child development
health equity
2. Health Practitioners are the “First
Contact” with Young Children.
% of All Children Involved
in Following Services
Health Care
Visit (0-5)
Formal Child
Head Start
Part B of IDEA Part C of IDEA
3. Exemplary Strategies Address the
Multidimensionality of Child Health ...
Assuring Better Child
Health & Development
Help Me Grow
… in the Following Ways.
Pediatric Practitioner
Care Coordination
• ecological assessment and
•from referral to scheduling and
• developmental screening
• recognizing and responding to
social determinants
• professional service responses
• social connections and community
Part C
g Education
Parent of
4. Federal Health Provisions Offer the
Opportunity to Address Children’s Healthy
• CHIPRA Provisions
– Expanded funding and options to states
– Child health quality outcomes development and demonstration grants
• PPACA Provisions
– Coverage for preventive care and well-child care based upon
recognized HRSA standards (Bright Futures)
– Maternal, infant, and early childhood home visitation program
– CMS healthcare innovation zones
– Prevention and public health fund
– Community transformation grants
– Community health teams to support patient-centered medical homes &
primary care extension program
– Spending for community health centers
+ CCAC in Head Start Reauthorization, Promise Neighborhoods, etc.
5. States and Communities Must Be
Intentional and Creative to Take
Advantage of Federal Provisions.
• Includes but is more than health IT, quality
outcomes, and medical records
• Includes but is more than reimbursement and
screening tools
• Includes but is more than clinical/medical
• Is more than but includes children in
achieving health cost, quality, and
accountable care goals
6. Those Who Know Best Are in
This Room (But Cannot Do It Alone).
• Identification of own needs and opportunities
in the context of federal activities
• Access to detailed information about
• Partnerships with state and community
• Compelling messages to key stakeholders
and decision-makers
Additional Resources from CFPC
• Healthy Child Storybook
• Journal of Pediatrics Commentary
• Children’s Healthy Development Model
Contact Information
Child & Family Policy Center
and the
The BUILD Initiative
505 5th Avenue, Suite 404
Des Moines, IA 50309
Voices for America’s Children
1000 Vermont Street, NW
Suite 700
Washington, DC 20005
Additional Slides Outlining
Outcomes, Exemplary Programs,
and Strategies
Source: Healthy Child Storybook
Outcomes of Well-Child Care During the First Five Years of Life
Domain of Well-Child Care
Outcome at School Entry
Child Physical Health and Development
Child Emotional, Social, and Cognitive
• All developmental delays recognized and treated (emotional, social, cognitive,
• Child has good self-esteem
• Child recognizes relationship between letters and sounds
• Child has adaptive skills and positive social behaviors with peers and adults
Family Capacity and Functioning
• Parents knowledgeable about child’s physical health status and needs
• Warning signs of child abuse and neglect detected
• Parents feel valued and supported as their child’s primary caregiver and function in
partnership with the child health care provider
• Maternal depression, family violence, and family substance abuse detected and referral
• Parents understand and area able to fully use well-child care services
• Parents read regularly to the child
• Parents knowledgeable and skilled to anticipate and meet a child’s developmental needs
• Parents have access to consistent sources of emotional support
• Parents linked to all appropriate community services
All vision problems detected and corrected optimally
All hearing problems detected and managed
Management plans in place for all chronic health problems
Immunization complete for age
All congenital anomalies/birth defects detected
All lead poisoning detected
All children free from exposure to tobacco smoke
Good nutritional habits and no obesity; attained appropriate growth and good health
All dental caries treated
Live and travel in physically safe environments
Note: regular font bullets are those outcomes for which child health care providers should be held accountable for achieving. Italicized bullets are those
outcomes to which child health care providers should contribute by educating parents, identifying potential strengths and problems and making appropriate
referrals, but for which they are not independently responsible.
Bright Futures
Bright Futures approach: Health supervision that promotes
physical, emotional, intellectual, and social health through a
developmental perspective involving health supervision guidelines,
training, and support for practitioners, families, and public health
Bright Futures impacts: Research of state efforts to incorporate
Bright Futures into practice have shown:
 Success in strengthening pediatric practice in using health
supervision guidelines when champions are enlisted and
training and resources provided to support that incorporation
into practice
 Improvements in identification, response, and family
involvement in addressing child health and development
concerns identified through health supervision
 Improved coordination across health, education, and human
services in meeting “whole child” concerns
Help Me Grow
Help Me Grow approach: Practitioner training to conduct whole
child “developmental surveillance” during child health visits, with
care coordinators following up with families to identify professional
and community resources to address child needs and schedule
appointments and visits, and community health liaisons identifying
and working with community resources.
Help Me Grow impacts: Research has shown that Help Me Grow
dramatically increases identification of behavioral and
developmental concerns within the practitioner’s office and leads
to timely follow-up services, which include:
 Increased identification of developmental delays, parental
depression and stress, and other child developmental concerns
 Increased use of Part C (early intervention) services
 Improvement in child health and development reported in followup pediatric visits
Reach Out and Read
Reach Out and Read approach: Training to doctors and nurses to
make literacy promotion a standard part of pediatric care
(encouraging parents to read to children as part of well-child visits)
and proving the tools (a book at each visit) to do so
Reach Out and Read Impacts: Research has found that Reach
Out and Read:
 Increases parental reading to children in the home
 Improves children’s ability to express themselves verbally
 Increases children’s listening vocabularies
 Improves children’s preschool language scores
 Reduces the proportion of children with language delays that can
prevent them from succeeding in school
Assuring Better Child Health and
Development (ABCD)
Assuring Better Child Health and Development (ABCD) approach:
Collaborations across Medicaid, pediatric providers, Maternal and Child
Health, and Part C in developing strategies within Medicaid to improve
developmental screening of young children and actions to improve
healthy mental development.
Assuring Better Child Health and Development (ABCD) impacts:
Different states produced different gains in the identification and
treatment of developmental issues for young children, including:
 Increased identification of developmental delays and more timely
follow-up services under Part C of IDEA
 Earlier detection of autism and reduced time between identification
and initiation of services
 Identification of signs of maternal depression and follow-up services
to address this risk factor for healthy child development
 Increased provision of anticipatory guidance to parents on child
development and greater response to parental concerns raised
during well-child visits
Healthy Steps
for Young Children
Healthy Steps approach: Incorporating within pediatric and family
practice a Healthy Steps Specialist who provides additional links to
the family in promoting healthy and developmentally appropriate
practices in the home and ensuring early identification and
treatment of medical issues
Healthy Steps impacts: Research has found that Healthy Steps:
 Increases parental use of positive health practices, such as
ensuring infants sleep on their backs, receive all vaccinations,
and have injury prevention tools in their homes
 Improves interactions of parents with their toddlers, using more
positive and less harsh disciplinary practices and paying more
attention to their child’s behavioral clues
 Reduces toddler television viewing and improves child
expressive vocabulary
CenteringPregnancy approach: The goal of Centering groups is to
improve the overall health outcomes of mothers, babies, and new
families by adopting a group health model of care that emphasizes
care, honors the contribution of each member, and uses a facilitative
leadership style.
CenteringPregnancy impacts: Both participants and providers
report satisfaction with the Centering model. Research has shown a
series of improved outcomes for women and babies, including:
 reductions in emergency department visits by the third trimester
 reductions in low birth-weight births among preterm deliveries
 reductions in preterm births
Community Care of North Carolina/
Carolina ACCESS
CCNC/CA approach: Implementing a medical home model for
Medicaid and CHIP recipients, and providing care coordination to
ensure continuity and ease of medical care. The goal of the program
is to better address both medical and social determinants of child
CCNC/CA impacts: Research from the University of North
Carolina’s Sheps Center for Health Services Research of the asthma
and diabetes management initiatives has shown:
• improvement in child health outcomes, and
• significant cost savings from the program.
Research from the Mercer Human Resources Consulting group has
• increased use of primary and preventive services, and
• substantial savings to Medicaid in terms of reduced emergency
room use and hospitalizations.
Opportunities for Prevention,
Early Identification and Treatment
During Pediatric Visits
Issue or Concern
Healthy Development Impact
Nutrition and exercise
Obesity and diabetes
Exposure to second-hand smoke
SIDS, respiratory illness, asthma,
cognitive development, adult
cancer, heart problems
Maternal depression
Social/emotional development,
school success, safety
Oral health
Propensity for illness, pain, and
school success
Reading and school success
Early treatment leading to more
success and less disruption
American Academy of Pediatrics
Recommended Health Supervision Practices
Regarding the Prevention of Obesity
Identify and track patients at risk by virtue of family history, birth weight, or
socioeconomic, ethnic, cultural, or environmental factors.
Calculate and plot BMI (body mass index) once a year and use change in
BMI to identify rate of excessive weight gain relative to linear growth.
Encourage, support, and protect breast feeding.
Encourage parents and caregivers to promote healthy eating patterns by
offering nutritious snacks such as vegetables and fruits, low-fat dairy foods,
and whole grains.
Encourage children’s autonomy in self-regulation of food intake and setting
appropriate limits on choices; and modeling healthy food choices.
Routinely promote physical activity, including unstructured play at home, in
school, in child care settings, and throughout the community.
Recommend limitation of television and video time to a maximum of two
hours per day.
Limiting Child Exposure to Second-Hand
Smoke: Recommended Actions
• Routine queries about parental smoking and
exposure to second-hand smoke as part of wellchild visits
• Follow-up recommendations (anticipatory
guidance) regarding eliminating second-hand
smoke, through:
– Quitting
– Using nicotine replacement therapies
– Smoking only outside the home and
automobile and when not in the presence of
Maternal Depression
and Children’s Healthy Development
Recent findings on maternal depression and children’s
healthy development:
• Screening for maternal depression can be done
efficiently and effectively during well-child visits and
there is a good uptake by mothers on further
assessments and treatment, where those are
• Addressing and alleviating maternal depression
produces positive results for children, including:
improved social interactions, approaches to learning,
social and emotional physical health.
Vision Screening
• Half of low-income children have vision
problems that interfere with school
• Early vision screening and basic exercise
therapies can address vision problems
and lead to improved literacy and
educational success as well as general
healthy development.

communities of practice presentation heatlh