The Early Learning
Challenge
in North Carolina
January 23, 2014
Marshall Tyson, MPH
NC Division of Public Health
Oscar Fleming, MSPH
National Implementation Research Network
Jeannine Sato
Center for Child and Family Health
NC Early Childhood Advisory Council
Race to the Top--Early Learning
Challenge (ELC) Grant Program
 Joint program
 US Dept. of Health and Human Services
 US Dept. of Education
 37 applicants; 9 states selected, including NC
 NC’s award: $69,991,121.00
 4-year grants—Jan. 1, 2012–Dec. 31, 2015
NC Early Childhood Advisory Council
ELC Focus
 Bold action to improve early
learning and development
 Supports states that
demonstrate “commitment
and capacity to build a
statewide system that raises
the quality of early learning
and development programs
so that all children receive
the support they need to
enter kindergarten ready
to succeed.”
NC Early Childhood Advisory Council
NC’s Implementation Strategy
 Lead Agency: Early Childhood Advisory Council—responsible for
overall coordination and specific projects
 Participating State Agencies—responsible for specific projects:
 Division of Child Development and Early Education
 Division of Public Health
 Department of Public Instruction, Office of Early Learning
 Contracts and MOUs with other state and local agencies and
organizations, such as NC Partnership for Children and the
National Implementation Research Network, FPG, UNC-CH
NC Early Childhood Advisory Council
NC’s Plan:
Four Areas of Focus
 Strengthen the state’s early childhood system and build its
capacity to foster positive outcomes for young children
 Enhance the quality of programs to serve young children and
their families and improve access to high-quality programs
 Strengthen the early childhood workforce to increase staff and
system effectiveness and sustain change
 Target high-intensity supports and community infrastructurebuilding efforts to turn around poor outcomes for young
children in the state’s highest-need counties (Transformation
Zone)
NC Early Childhood Advisory Council
NC’s Plan:
Transformation Zone Strategy
• Focus intensive effort in selected high-need counties
in northeastern North Carolina
• Increase capacity for effective collaboration and
implementation to gain desired and sustainable
results
• Provide comprehensive set of services and supports
offered when and where needed—existing services
and selected additional services (e.g., Family
Strengthening services)
NC Early Childhood Advisory Council
NC’s Plan:
Transformation Zone Strategy
• Help achieve dramatically improved outcomes for all
young children
• Lessons learned through concentrated approach used
to
 hone early childhood strategies
 improve outcomes for young children across the
state
NC Early Childhood Advisory Council
NC’s Transformation Zone
• 17 northeastern Tier 1 counties eligible
CAM-CURRITUCK
ALLEGATES
NORTHWARREN
DEN
HERTGHANY SURRY STOKES ROCKING-CASWELL
PERAMPTON
PERSONGRAN-VANCE
PASQUOFORD
HALIFAX
HAM
WATAUGA WILKES
QUIMANS
CHO- TANK
VILLE
YADKIN FORSYTH
ORANGE
BERTIE
MITCHELL
FRANKLIN
GUILFORD
AVERY
WAN
YANNASH EDGECALDWELLALEXALADURHAM
DAVIE
MADISON CEY
WASHANDERIREDELL
DAVIDMANCE
MARTIN
COMBE
TYRELL DARE
WAKE
INGTON
WILSON
SON RANDOLPHCHATHAM
BUN- McDowellBURKE CATAWBA
HAYBEAUPITT
ROWAN
SWAIN WOOD COMBE
HYDE
JOHNSTON
FORT
LINCOLN
GREENE
RUTHERLEE
GRAHAM
HENDERCABARRUS
JACKWAYNE
FORD CLEVE- GASTON
HARNETT
MONTTRANLENOIR
MOORE
SON POLK
STANLY
CHEROKEE MACON SON
CRAVEN PAMLAND
GOMERY
MECKLENSYLVANIA
CLAY
BURG
LICO
JONES
SAMPSON
CUMBERRICHHOKE
DUPLIN
UNION ANSON
LAND
MONDSCOTCARTERET
ONSLOW
LAND
ROBESON BLADEN
PENDER
ASHE
NEW
HANOVER
BRUNSWICK
COLUMBUS
• After exploration and RFA process, 4 counties selected:
Beaufort
Chowan
Bertie
Hyde
NC Early Childhood Advisory Council
NC’s Transformation Zone
Three streams of work in Northeast
• Statewide projects
• Transformation Zone projects and activities (4 counties)
• Additional work in 15 surrounding counties
 13 counties which were eligible through the grant
 Nash and Pitt--closely linked to those 13 counties; home to
many services
Division of Public Health
projects
 Family strengthening
 Family Connects
 Triple P (Positive Parenting Program)
NC Early Childhood Advisory Council
Family Connects
(A.k.a. NorthEast Connects
Family Connects
 Oscar Fleming
 Use of implementation science principles
 Jeannine Sato
 Replicating the Durham Connects model as
Family Connects in the TZ
NC Early Childhood Advisory Council
An Overview of the
Active Implementation
Frameworks
Applied
Implementation
Science
State Health Directors Conference
January 23rd, 2014
Oscar Fleming
National Implementation
Research Network
FPG Child Development Institute
University of North Carolina at
Chapel Hill
Agenda
• Introduction/Purpose
• Why Focus on Implementation? (5)
• What are the Active Implementation Frameworks
(15)
• Fidelity and Outcomes
Why Focus on Implementation?
“Children and families cannot benefit from
interventions they do not experience.”
RESEARCH
IMPLEMENTATION
PRACTICE
Active Implementation is defined as a specified
set of activities designed to put into practice an
activity or program of known dimensions.
Formula For Success
Effective
Interventions
Effective
Implementation
Socially
Significant
Outcomes
Enabling
Contexts
Active Implementation
Applied Implementation
Science
To effectively implement & realize the benefit of evidencebased and evidence-informed interventions, we need to
know:
• WHAT to do
What is the usable intervention or package of
strategies? (e.g. evidence-based home visitation programs)
• HOW to do it
Active and effective implementation and
sustainability frameworks (e.g. strategies build competencies and
create enabling contexts and conditions)
• WHO will do it
Organized, purposeful, & active implementation
support from linked implementation teams
Active Implementation
Frameworks: The “What”
The effective
interventions and
approaches that will
improve outcomes for
children, youth and
families.
Usable Intervention Criteria
Clear description of the program
Philosophy, values, principles (guidance)
Inclusion – exclusion criteria (beneficiaries)
Clear essential functions that define the
program (core components)
Operational definitions of essential functions
(practice profiles; do, say)
Practical performance assessment
Highly correlated with desired outcomes
Active Implementation
Frameworks:
Making It Happen
The “How”
• Implementation Drivers
result in competence and
sustainability
• Improvement cycles
support learning and change
at multiple levels
• Stage-related work
necessary for successful
change
Implementation Drivers
Reliable Benefits
Consistent Uses of Innovations
Performance Assessment
(Fidelity)
Systems
Intervention
Coaching
Training
Integrated &
Integrated
Compensatory &
Selection
Facilitative
Administration
Compensatory
Leadership Drivers
Technical
Adaptive
Decision Support
Data System
Improvement Cycles
Rapid cycle (PDSA) problem
solving
Shewhart (1931); Deming (1986)
Usability testing
Rubin (1994); Nielsen (2000)
Practice-policy communication
loop
Fixsen, Blase, Metz, & Van Dyke (2013)
Implementation Stages
Exploration
•
•
•
•
Assess needs
Examine
intervention
components
Consider
Implementation
Drivers
Assess fit
Installation
•
•
•
•
Acquire
Resources
Prepare
Organization
Prepare
Implementation
Drivers
Prepare staff
Initial
Implementation
•
•
•
•
2-4 Years
Strengthen
Implementation
Drivers
Manage change
Activate Data
Systems
Initiate
Improvement
Cycles
Full
Implementation
•
•
Monitor &
manage
Implementation
Drivers
Achieve and
improve Fidelity
and Outcomes
Active Implementation
Frameworks: The “Who”
Implementation Teams with specific
competencies “make it happen”
Minimum of three people with
expertise in:
Innovations
Implementation
Improvement Cycles
Organization change
Implementation Stages
• Why Teams?
– Letting it happen
• Diffusion; networking; communication
– Helping it happen
• Dissemination; manuals; websites
–Making it happen
• Purposeful and proactive use of
implementation practice and science
Based on Hall & Hord (1987); Greenhalgh, Robert, MacFarlane, Bate, & Kyriakidou (2004); Fixsen, Blase, Duda, Naoom, & Van
Dyke (2010)
Implementation Teams
Implementation Team
Simultaneous, Multi-Level Interventions
Practitioner/Staff Competence
Organization/Agency Supports
Management (leadership, policy)
Administration (HR, structure)
Supervision (nature, content)
State MCH/Title V Leadership
Federal and National Supports
The Frameworks in Action
• Eastern NC: Working with teams in
Chowan, Bertie, Beaufort, Hyde counties
• Purveyor Collaboration: Develop/enhance
usable intervention criteria
• State Agencies: Collaborative support for
implementation informed policy
A Final Word on Fidelity
• Achieving fidelity if a shared responsibility among Providers,
their Home Agency, and Program Purveyors, among others.
• If the goal is worth achieving its worth spending time to build
the required infrastructure
• Programs like Connects that have evidence, well defined
core components and operationalized essential functions
make your work easier, if not easy, and significantly increase
your chances for Socially Significant Outcomes.
Thank You!
For More Information
Oscar Fleming, MSPH
– 919-962-7193
– oscar.fleming@unc.edu
Frank Porter Graham Child Development Institute
University of North Carolina
Chapel Hill, NC
http://nirn.fpg.unc.edu/
www.scalingup.org
www.implementationconference.org
Implementation Science
Implementation
Research:
A Synthesis of
the Literature
Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M. & Wallace, F. (2005).
Implementation Research: A Synthesis of the Literature. Tampa, FL: University of
South Florida, Louis de la Parte Florida Mental Health Institute, The National
Implementation Research Network (FMHI Publication #231).
HTTP://NIRN.FPG.UNC.EDU
©Copyright Dean Fixsen and Karen Blase
This content is licensed under Creative Commons license CC BYNC-ND, Attribution-NonCommercial-NoDerivs. You are free to
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conditions: Attribution — You must attribute the work in the
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http://creativecommons.org/licenses/by-nc-nd/3.0
The “CONNECTS” Home
Visiting Model
Improving Child
Well-Being by
bridging new
parent needs
with community
resources.
Growing Healthy Babies
Evidence-based Universal Home
Visits for Parents of Newborns
NC DPH January 23, 2014
Why Universal?
Newborn nurse
home visits
should be
normalized,
much the way
prenatal care
has become the
standard of
care.” – Dr.
Robert Murphy,
CCFH
•
•
•
•
Public health approach improves community health
No stigma
All parents have needs (94% in research)
Short term triage (gateway) to more intensive services.
The Connects model
Feedback loop between hospitals, doctors, service
agencies to strengthen community system of care.
What we do
All areas
correlate to
empirically
based risks
for child
abuse.
Nurses:
• assess
• quantify
needs
• resolve or
• refer
• follow up
Who’s Involved?
NC Early Childhood
Advisory Council
FACT:
99% of
mothers
surveyed say
their DC visit
was helpful to
them and their
baby.
Local leaders
How is it Funded?
•
•
•
•
State and federal grants
Private foundations
Medicaid reimbursement (in some cases)
Local government funds
Who are Stakeholders?
•
•
•
•
Health departments
Hospitals
Primary care providers
Social service agencies
Impact Evaluation Results
Randomized Controlled Trial at age 6-month (in-home interview results):
•
More community connections
•
More mother-reported positive parenting behaviors
•
Higher quality mother-infant relationship
•
Higher quality home environment
•
Higher quality child care usage
•
Less clinical anxiety for mother
Age 12-month administrative hospital record reviews:
•
85% fewer hospital overnights
•
50% less total infant emergency medical care
Mean Cumulative Number of Emergency Care Episodes
Birth - 24-Months
3
Cumulative Emergency Care Episdoes
2.5
2
1.5
Total ED Visits: Control Families
Total ED Visits: DC Families
1
0.5
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Child Age in Months
•
37% less infant emergency medical care through 24-month
•
Significant decrease from 0-12 months; decrease sustained through 24months
Rural Replication
•
•
•
•
•
•
•
Race to the Top Early Learning Challenge
Multiple interventions in Transformation Zone
~ 800 births
High poverty
High unemployment
5 birth main hospitals, some out of county
Diversity among counties (not within)
The Connects Offering
• Universal home visits
= no stigma
• A triage system for
entire community
• A way to strengthen
system of care
• Technical support
and certification for
high fidelity, to
replicate outcomes
Model Requirements
• Universal reach, RN staff
• Partnered hiring, training & fidelity checks with
Connects for certification
• Adherence to the model (documentation and
performance measures)
• Exclusivity in program staffing, salary and work
assignments
• A regional/team approach to cover population
What next?
• Connects is ideal for:
–
–
–
–
–
Expand public health gateway
Strengthen systems of care
Track and ID service gaps and usage
Reduce child abuse
Save infant ER costs
• Tool kit for adoption/sustainability plan
• Lessons learned during replication
• Goal to serve families & replicate outcome results
Jeannine Sato
Program Director
j.sato@duke.edu
919-668-3295
www.durhamconnects.org
Questions?