Project DULCE Implementation Manual
A.
Evaluation Summary
Project DULCE introduces a Strengthening Families intervention model into the
pediatric primary care setting at Boston Medical Center through the Patient
Centered Medical Home. The DULCE intervention partners with parents to learn
about and adapt to their newborns with the dual goals of improving child
development and reducing maltreatment. Caretakers and parents of newborns
are recruited in the primary care pediatric clinic at Boston Medical Center when
they come for one of their new baby’s first visits. As soon as the consent process
is completed, the family is randomly assigned to either the intervention or control
group. Families in the control group receive an informational session on safe
sleep and safe transportation, with an option of receiving either a portable crib or
car seat. Families in the intervention group are assigned a DULCE Family
Specialist who works and partners with the family during the first six months of
the baby’s life. The DULCE Family Specialist provides families with support for
unmet legal needs and provides information on child development and family
support. Recruitment was universal – offered to all families with newborns – so
there was no stigma attached to participating. Families meet with the DULCE
Family Specialist at all routine visits, and for home visits and telephone check-ins
depending on the needs of the family – working with families to empower them to
solve their own problems. At six months, the DULCE Family Specialist
transitions care to the primary care team of pediatrician and nurse and any other
ongoing services at Boston Medical Center or in the family’s neighborhood, as
necessary.
The intervention component adapts and combines elements of two existing
programs: Healthy Steps and Medical-Legal Partnership | Boston (MLP|Boston).
The evidence-based Healthy Steps program adds a professional with knowledge
of child development to a child's pediatric primary care team to support optimal
parenting through knowledge, modeling, ongoing support, referrals (when
needed), optional home visits and a telephone phone line. MLP|Boston supports
families by providing legal advice, consultations, and representation to address
their civil legal needs. The DULCE Family Specialist is trained by MLP|Boston to
identify legal and social needs that may affect a child's health and development
and to take action either by helping the family advocate for themselves, or by
referring them to an appropriate public health, legal, or social service agency or
resource (including MLP|Boston).
A community component is added through the active participation of a number of
programs: Boston’s Thrive in Five (school readiness initiative), the
Massachusetts Children’s Trust Fund, the Massachusetts Department of
Children and Families, the Massachusetts Department of Public Health and the
Boston Public Health Commission, all of whom collaborate with DULCE formally
and informally.
Evaluation of Implementation
Evaluation Summary
© 2013 Project DULCE / Boston Medical Center
66
Project DULCE Implementation Manual
Following are the major finding of the DULCE research and demonstration
project:
1. A Strengthening Families–based intervention can be implemented in pediatric
primary care. We were able to implement DULCE in the context of a busy
primary care environment. Based on the report of the cross-site evaluation team,
as well as our own experience in discussions with providers, it appears that the
healthcare provider team overwhelmingly supported the introduction of the
DULCE intervention.
Our own research data shows that 92% of families received some intervention,
while half (52.5%) of them accepted the offer of a home visit. Families received a
median of 14 contacts with the Family Specialist, for a total of five hours of
contact time. The length of the doctor’s office portion of the intervention (one
hour per visit) was slightly below the average visit length (one hour seven
minutes), demonstrating that the presence of the Family Specialist did not disturb
the practice.
2. Compared to controls, research subjects had significantly more success in
obtaining concrete supports. On both baseline and it’s month surveys, there
were no differences in awareness of the types of assistance available. However,
at six months, participants in the intervention group received assistance with
food, housing, and utilities at significantly higher rates than the controls,
demonstrating that it was the effectiveness of the Family Specialist intervention
that directly led to improved access to concrete supports.
3. Compared to controls, research subjects engaged in the patient centered
medical home at a higher rate. We used receipt of six-month immunizations as
an indicator of primary care engagement; research subjects were less likely to be
delinquent with immunizations.
4. The common evaluation measures designed to demonstrate increased parent
knowledge of child development did not show any significant results. This may
been due to measurement challenges. However, our research subjects appeared
to have trend towards fewer emergency department visits for issues related to
misunderstandings of child development – particularly infant crying.
5. Project DULCE Family Specialists successfully identified high risk outliers who
received more intensive support and linkage with outside agencies.
6. Finally, the study design used an active control. Control group families were
exposed to an intervention designed by a public health commission to improve
safe sleep practices. Our results demonstrate that this was effective, an
important result on its own.
Evaluation of Implementation
Evaluation Summary
© 2013 Project DULCE / Boston Medical Center
67