Beyond Medical Care:
An Integrated, PreventionOriented Child Health System
February 2011
Debbie I. Chang, MPH
Vice President, Policy & Prevention
What is Nemours?
 Operating foundation dedicated to children's health & health
care
 Integrated health system with a continuum of care including:
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Clinical treatment
Health promotion and prevention services, including community-based
Research
Education
Policy and advocacy
 Alfred I. duPont Hospital for Children and outpatient facilities in
the Delaware Valley
 Specialty care services in Northern/Central Florida; building
new state-of-the-art Children’s Hospital near Orlando
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Nemours Health and Prevention Services
 In 2003, Nemours redefined its approach to address health
as well as health care.
 NHPS focuses on child health promotion & disease
prevention to address root causes of health problems.
– First initiative is preventing childhood obesity
 NHPS complements and expands the reach of clinicians by
providing a broader, community-based perspective.
 NHPS target population includes all 228,000 children in
Delaware as compared to the 50,000 children who use the
Nemours pediatric care system.
The Current System
 Many of our children’s programs were designed decades
ago to treat infectious disease; they are not fully capable of
addressing current threats such as:
– Obesity
– Chronic diseases
– Mental illness
 Our existing children’s system is:
– Highly fragmented
– Highly complex for families, providers and administrators
– Financed by multiple public and private categorical funding
streams that perpetuate silos in the system
A Comprehensive Approach
 Numerous reports suggest that health care alone is not
sufficient to promote healthy child development.
– Child health and well-being are influenced by multiple factors.
 A comprehensive approach is needed that integrates and
coordinates across health, education and human services
 This comprehensive approach should consider:
– The health and well-being of the whole child including the child’s
physical environment and social service needs; and
– The child’s needs over the long-term
Critical Components of an Integrated Health System
That Can Address Public Health Needs
1.Oriented toward health and address social
determinants of health
2.Fosters health promotion and disease prevention at
individual and population level
3.Incorporates public health, health care, and public and
private sector
4.Inclusive of the unique expertise of partners including
those not traditionally associated with health
5.Continuously measures and improving the health
outcomes
6.Built on key health system capabilities, including a
electronic medical records; appropriate mix of health
professionals; and flexible, sustainable financing.
Source: The Commonwealth Fund, June/July 2009
Promoting Health and Prevention
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
Nemours Continuum of Care: Childhood Obesity Example
Community,
environmental
supports,
policies, etc.
for healthy
lifestyles
Community
services
Primary care
prevention,
early id and
management
of at risk and
less complex
cases
Health Promotion and Prevention
Services
Medical
management
of complicated
patients
Inpatient
services
including
surgery
Specialty Outpatient and Inpatient
Diagnostic and Treatment Services
Primary Care Practices
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Concept – Integrated Health System
Source: Hassink, Werk, June 2008
What does a System Committed to
Prevention Look Like?
 A prevention-oriented child health system builds
upon, and extends beyond, traditional prevention
in primary care to look at the population level
 Strategy makes use of socio-ecological model,
looks beyond the individual to examine a range of
other factors that affect health outcomes at multiple levels
 Spreading policy and practice changes:
– Population health-focused model: Defined program goals around reducing prevalence
of overweight and obesity
– Strategies in multiple sectors: Exposure to consistent healthy choices/environments for
behavior change, all around 5-2-1-Almost None prescription
– Strategic partnerships: Greatest potential impact, authority to make policy and practice
changes, ability to leverage resources
– Knowledge mobilization: Providing evidence-based materials and tools
– Social marketing: Creating and accelerating social policy and behavior changes
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The Model: Working with Over 200 Community
Partners
Changing the health status
and well-being of the most
children possible through
the deployment of
evidence based policies
and practices. Seeking the
highest sustainable impact
with the most efficient use
of resources.
Policy and Practice
Change Agenda
that evidence the
usefulness of
to build and
sustain the
Healthy
Children
Community
Infrastructure
Capacity
that support
supports
that leads to
Behavior
Change
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Going to Where the Children Are With 5-2-1Almost None
 Together We Can Make Delaware’s
Kids the Healthiest in the Nation
– Kids Can’t Do It Alone
– 5-2-1-Almost None
 Integrated into all 4 sectors
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Community
School
Child Care
Primary Care
– Helping accelerate policy
and practice changes
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360o of Child Health Promotion
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Progress Results at the Population Level
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Results from the 2008 DSCH, compared to the 2006 DSCH, suggest that the
prevalence of overweight and obesity has leveled off for children ages 2 -17
years in Delaware
– Overweight remained unchanged at 17%
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Evidence indicates the prevalence of obesity and overweight has leveled
off in all Delaware counties and within subpopulations
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Disparities still remain among racial groups
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Nemours’ initiative is on track to achieve its 2015 goal for some
populations
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School Sector Interventions
 Strengthened and implemented wellness policies
– Impact: 90,180 children per year (2006-present)
 Learning Collaborative
– Impact: 90,180 children per year (2007-present)
– Provide assistance with the implementation of
wellness policies (goals, action plans) and HB 471
– Tools, training, technical assistance
 Implemented HB 372: FITNESSGRAM®
– Impact: 30,000 children (2006-present)
– Assessment of fitness measured in grades 4, 7,9
– BMI data optional by school
 Implemented HB 471: 150 minutes of physical education/activity
– Impact: 26,112 children
– Pilot from 2007-2009
 Implementation of CATCH in elementary/middle/charter
– Impact: 43,213 children (2005-present)
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Child Care Interventions
 Statewide regulatory change
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Impact 54,000 children (2007-present)
Reduce sedentary behavior, promote health eating/physica activity
Child and Adult Care Food Program (CACFP)
Office of Child Care Licensing (OCCL)
 Learning collaborative
– Impact 2,750 children (2008-2009)
– Translate policy into practice and support implementation
 Training around Healthy Habits for Life (HHFL), CACFP
– Impact 20,000 HHFL children/ 24,000 CACFP children (2007-present)
 Child care technical assistance pilot program
– Impact 775 children (2006-2008)
 University of Delaware’s Institute for Excellence in Early Childhood
– Impact to be determined; up to 54,000 children (2010-future)
– Continue learning collaborative
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Primary Care Interventions
 Implementation of Expert Committee Recommendations on assessment,
prevention, and treatment of childhood overweight
– Impact 207,000 children (2007-present)
– Used by primary care providers, DE AAP, Medical Society of Delaware, Delaware
Academy of Family Physicians
 Learning collaborative
– Impact to be determined; up to 33,000 children (2010-future)
– Provide tools, training, technical assistance for the implementation of Expert Committee
Recommendations
 Nemours primary care strategy
– Impact 50,000 children (2008-present)
– Measuring BMI, identification of childhood
overweight, counseling on healthy lifestyles
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Primary Care Results
 Commitments from medical community to promote the Expert
Committee Recommendations
 Prevention and health promotion built into Nemours Electronic Medical
Record (EMR)
– Nemours’ provider classification of BMI during well child visits doubled,
49% (2007) to 94% (2008)
– Nemours’ providers offer lifestyle counseling to 95% of all patients
(almost double the national reported rate of 54.5%)
 Delaware Primary Care Quality Improvement Initiative
19 multidisciplinary primary care teams achieved high results:
– 98.2% of providers classified BMI or weight-for-length in 2009 (83% in 2007)
– 88.6% of providers provided counseling on healthy lifestyles in 2009 (72.7% in 2007)
– 88.1% of providers developed a care plan and family-management goals with
obese/overweight patients who were ready to change in 2009 (74.2% in 2007)
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Key Principles
• Comprehensive, integrated systems for children are
guided by the following principles:
– Focus on child well-being outcomes and intervene early to prevent problems;
– Coordination of programs and connection of services so that program silos are
eliminated and children are better served;
– Reach children where they live, learn and play; and
– Acknowledge that infrastructure and systems development are essential
elements of a comprehensive children’s system.
Debbie I. Chang, MPH
Vice President of Policy and Prevention
Nemours
252 Chapman Road, Christiana Building, Suite 200, Newark, DE 19702
(p) 302.444.9127 (e) dchang@nemours.org