Child Public Health & Preventive Child Health Care

Child Public Health & Preventive Child Health Care Edward L. Schor, MD John C. MacQueen Lecture March 6, 2006 THE COMMONWEALTH FUND

Human Development Age Human Potential Risk Factors Protective Factors

“Policies that seek to remedy deficits incurred in early years are much more costly than early investments wisely made, and do not restore lost capacities even when large costs are incurred. The later in life we attempt to repair early deficits, the costlier the remediation becomes.”James J. Heckman, PhDNobel Laureate in Economics, 2000

Universal Preschool in California Benefit to Cost Ratio Benefit-cost ratio $1.95:$1 $4.21:$1 Karoly et al, Rand Review 2005

Home Visiting/Parent Education Benefit Cost Ratio Family TypeRatio Higher risk $5.70 : $1 Lower risk $1.26 : $1

“Families are the most central and enduring influence in children’s lives.” CHILD FAMILY COMMUNITY

Mother’s Education Affects School Readiness Skills of 3-5 Year Old Children Trends in the Well-Being of America’s Children and Youth, US DHHS, 2003

Parents’ Misconceptions of Young Children • 62% believe babies do not take in or react to the world around them until 2 months • 55% say a baby must be at least 3 months to sense their parent’s mood • Almost 40% believe a 12-month-old’s behavior can be based on revenge • 51% expect a 15-month-old to share

Parent-Child Relationships Affect Later Life Health Stewart-Brown, European J PH, 2005

Public Opinions About Childrearing Strongly Agree or Agree The job of parent is more difficult today than it used to be Parents today often feel uncertain about what is the right thing to do 87% 87%

Parents With Concerns About Their Children Ages 4-35 Months National Survey of Early Childhood Health, 2000

Parents Want More information On: McLearn et al, Arch Pediatr Adol Med 1998, vol. 152.

Well Child Care Affects Mother-Infant Relationships Scale Scores Casey & Whitt, 1980

Reach Out & Read • Serves 2.1 million children annually in health care settings • Changes parents attitudes about reading aloud • Improves children’s receptive and expressive language • Reduces language delays

Healthy Steps Parents Discipline More Appropriately

Reason for Visit to Pediatrician

Average Length of Preventive Care Total Time in Office (Minutes) Min. Average waiting time = 19.5 minutes AAP, PS#43, 2000

Parents with Concerns about Their Children’s Development Found Medical Professionals Helpful DB Bailey et al, 2004, Pediatrics 113:887-896

Missed Opportunities • 44-79% of parents report not discussing important child development topics with their pediatricians • About 57% of parents report receiving a developmental assessment of any kind • Parents concerns are often not elicited or addressed.

Well Child Care Referral & Care Coordination Anticipatory Guidance and Parent Education Developmental and Behavioral Assessment Developmental Services Medical History Physical Exam Sensory Screening Procedures Measurements Immunizations

Minutes of Anticipatory Guidance During Well Child Visits Goldstein, Dworkin & Bernstein, 1999

Pediatricians Always Counseling for Children 2-5 Years Galuska, et al. Pediatrics, 2002;109(5)e83

Actions Following Hearing Screening at Well Child Visits Halloran et al. Arch Ped Adol Med, 2005

Pediatrician Recognition of Developmental and Behavioral Problems Percent of Children Lavigne et al. Pediatrics 1993;91(3):649-55 Costello et al. Pediatrics. 1988;82:415-424

Services for Children <31 Months with or at Risk for Developmental Disabilities (N=3338) 1st Concern Diagnosis EI Referral IFSP X 0 2 4 6 8 10 12 14 16 Child’s Age (months) Bailey et al, Pediatrics 2004;113:887-896

Barriers to Developmental Assessment of Children 0-3 AAP, Periodic Survey of Fellows No.45, 2000

Child Health Care UtilizationMedical Expenditure Panel Study 2000 Annual Visits Ages of Children (Yrs)

Insurance Status and Age Affect Receipt of Any Well Child Care MEPS, 2000

Percent Compliance with Recommended Immunization and Preventive Care Schedule 0-23 Months 24-60 Months J Brown et al, 1993

Rethinking Well Child Care • Define desired outcomes • Revise schedule and content of care • Establish clinical standards of care • Individual content of care • Adopt office redesign models • Implement quality improvement processes • Improve education about preventive care • Align reimbursement with service

41,000 Pediatricians 9,600 Pediatric Community Practices (non-HMO) Average of 21 clinicians and support staff Clinician turnover 27% over 4 years Staff turnover 39% over 2 years

Self Motivation

Incentive

Threat!!

Partnership

System Change

National Partnerships: Shared Mission The mission of the Maternal and Child Health Bureau is to provide national leadership, in partnership with key stakeholders, to improve the physical and mental health, safety and well-being of maternal and child health populations…. The mission of the American Academy of Pediatrics is to attain optimal physical, mental, and social health and well-being for all infants, children and adolescents, and young adults.

Missing An Opportunity Local Child Health Care Practices State, County and City MCH Programs

MCH Approach to Services Direct Health Care Services Enabling Services Population-Based Services Infrastructure Building Services

Newborn metabolic screening Family-centered care Medical home Immunization Dental sealants Breast-feeding Newborn hearing screening First trimester prenatal care National Title V Performance Measures Dependent on Private Sector

Partnership for Preventive Care Pediatrics Direct Health Care Services Enabling Services Population-Based Services Infrastructure Building Services Child Public Health

Pediatrics and Public HealthSeparated by a Common Mission Primary care and local child public health: Formal relationship 4% Information relationship 58% No relationship 38% 90% of practices rarely or never made referrals to public health Iowa Department of Public Health

Partnering with Child Health Care Providers on Preventive Care • Form relationships locally with primary health care practices • Agree upon desired child health outcomes that people really care about • Identify complementary or shared roles • Be patient but persistent in building networks