Transforming the Child Health System: Moving from Child Health 2.0 to 3.0

1
Transforming the Child Health System Moving
from Child Health 2.0 to 3.0

• Neal Halfon, M.D., M.P.H
• UCLA Schools of Public Health, Medicine, Public
  Affairs
• UCLA Center for Healthier Children Families
  Communities
• National Center for Infancy and Early Childhood
  Health Policy
• September 26, 2008
• Colorado Coalition for Medically Underserved
• Aurora Colorado

2
Conclusions

• Child Health and Health Care System needs to move
  from version 2.0 to 3.0
• This requires a major change in the operating
  system
• This will also require new and more integrated
  policy framework that is capable of supporting
• New and more integrated delivery platforms
• Newly aligned (cross-sector) service delivery
  pathways
• More coordinated, integrated and long-term
  funding, data collection, and

3
Conclusions

• Transformation of Child Health and Health Care
  System will be accomplished through
• Collaborative Innovation
• Collective Invention
• The Transformation process will require
• Rebalancing, re-aligning, re-engineering and
  re-financing existing services ( 2.0 to 3.0)
• New partnerships,
• New Communication Strategy
• Framing the Problems and Solutions as Systems and
  not Service issues

4
Policy/Political Context

• Health Care Reform
• Incremental Changes vs. Transformation

5
Health Reform

• Health Reform will emerge as major domestic
  policy issue in 2009
• Cost, quality, access and disparities problems
• Health Insecurity
• Inefficient System
• Most expensive system
• Worse outcomes
• Economic Costs are not sustainable (micro/macro)
• Inconvenient Truth about Health Care
• The system needs to change

6
Child Health 2.0 to 3.0 The questions

• Why transform the child health system?
• What kinds of reforms are necessary?
• What logic should guide this transformation?
• What changes need to be made?
• What the future system could look like?
• What will take to get there?

7
Historical Context

• 3 Eras of Health Care

8
Three Eras of Health Care

• 1st Era - 1750 -1950 - Infections
• 2nd Era - 1950-2010 Chronic Disease
• 3rd Era - 2010-Future Health for All

9
1st Era of Modern Health1750-1950

• Life expectancy of 47 years in 1900
• 1900-1950 life expectancy increases 21 years
• Dfn Health as the Absence of Disease
• Mechanism Infections/ Contact/ Single cause
• Approach Medical Treatment Public
  Health-Safety
• Finance Insured Loss Program Grants
• Delivery Mode Clinic, Practice Hospital,
  Public Health Department
• Goal Reducing deaths

10
2nd Era of Modern Health Care1950-2000

• Life expectancy increases from 67 to 78 years
• Health as Absence of Disease, Disability and
  Dysfunction
• Mechanism Multiple risk factors, Behaviors,
  Lifestyle
• Approach Chronic disease management, disease
  prevention, community care
• Finance Pre-paid health benefits
• Delivery Mode Health Maintenance Organization
• Goal Prolonging Life

11
Life Span
Health Span
Health / functional Status
Performance Span
0 years
20 years
80 years
12
3rd Era of Modern Health Care2008 -?

• Life expectancy 78gtgtgtgt85
• Health as positive capacity to achieve lifes
  goals
• Mechanism developmental processes, social
  networks, psychosocial relations, gene
  environment transactions across the life span
• Disparities Developmental programming,
  cumulative, pathways
• Approach Life Course Health Management and
  Health promotion
• Finance Investment in health capital
• Delivery Mode Health Development Org. run by
  Health Outcomes Trust
• Goal Health for all

13
Disease Progression
1 current practice 2 current capability 3
future capability
1
Symptoms
Cost
3
2
Years
Source Snyderman R. AAP presidential address
the AAP and the transformation of medicine.
Journal of Clinical Investigation.
2004114(8)1169-1173 (suppl)
14
Paradigm Shift
Source Snyderman R. AAP presidential address
the AAP and the transformation of medicine.
Journal of Clinical Investigation.
2004114(8)1169-1173 (suppl)
15
Personalized and Predictive

• Pro-Active Genetics (NY Times 1/17/08)
• Discovery of Prostate Cancer risk Polymorphism
• 5-HTTLPR
• Cross over effect of short allele homozygous
  individuals
• Stressful early family environment and depression
• Caspi et al Science 2003, Taylor Biol. Psychiatry
  2006
• Supportive Family Environment and protective
  effect on depression
• Taylor et al Biol. Psychiatry 2006
• Anticipatory Guidance Rx

16
Risk Assessment for Prospective Health
Risk assessment decision support
Late chronic
Symptoms
Cost
Early chronic
Low risk
High risk
Years
Wellness education and Internet and health
provider guided planning for all
Wellness education and Internet and health
provider guided planning for all
Individual-focused integrated provider systems.
Focus on quality of life and palliation at
appropriate late stages
Source Snyderman R. AAP presidential address
the AAP and the transformation of medicine.
Journal of Clinical Investigation.
2004114(8)1169-1173 (suppl)
17
The Evolving Health Care System
The First Era (Yesterday)

• Focused on acute and infectious disease
• Germ Theory
• Medical Care
• Insurance-based financing
• Reducing Deaths

• Increasing focus on chronic disease
• Multiple Risk Factors
• Chronic Disease Mgmt Prevention
• Pre-paid benefits
• Prolonging Disability free Life

• Increasing focus on achieving optimal health
  status
• Complex Causal Pathways
• Investing in population-based prevention
• Producing Optimal Health for All

Health System 2.0
Health System 1.0
Health System 3.0
18
Why Transform the Child Health System?

• Children are not as healthy as we think
• Changing parameters of what healthy development
  means
• Children are not as healthy as they could, should
  and ought to be
• Current system is poorly performing
• We have the capacity to do much better

19
What do we know about Childrens Health

• Science of Human Health Development

20
LCHD

• Defines Health as a developmental process
• Builds upon Ecological and Transactional models
  of Life Span Development
• Utilizes a rapidly Expanding Evidence Base
• Life Course Chronic Disease Epidemiology
• Neurobiology
• Early Intervention Research
• Economics of Human Capital Formation
• Gene-Environment/ Social Epidemiology

21
From Lifespan to LCHD

• Lifespan models connect the dots- linking early
  life to later life
• Health Care 1.0
• Life-course models are concerned with patterns
  and pathways that connect the dots between early
  and later life
• Health Care 2.0
• Life Course Health Development models-
• Connect the dots
• Describe the pathways or heath trajectories
• Explain the mechanisms that determine or
  influence health trajectories
• Health Care 3.0

22
2004 National Research Council and Institute of
Medicine Report
23
IOM/NRC Definition of Childrens Health (2004)

• Childrens 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.
• From Childrens Health, the Nations Wealth,
  National Academies Press, 2004.

24
Health

• Health is developmental
• Health develops across the life course
• Health development can be represented by health
  trajectories
• Critical/ Sensitive periods
• Gene - Environment Interaction have different
  impacts during different periods
• Macro and Micro pathways delineate how toxic
  environments and risky families get under the skin

25
How Risk Reduction and Health Promotion
Strategies influence Health Development
FIGURE 4 This figure illustrates how risk
reduction strategies can mitigate the influence
of risk factors on the developmental trajectory,
and how health promotion strategies can
simultaneously support and optimize the
developmental trajectory. In the absence of
effective risk reduction and health promotion,
the developmental trajectory will be sub-optimal
(dotted curve). From Halfon, N., M. Inkelas,
and M. Hochstein. 2000. The Health Development
Organization An Organizational Approach to
Achieving Child Health Development. The Milbank
Quarterly 78(3)447-497.
26
Fig.
From Lamberts SWJ, van den Beld AW, van der lely
A. The endocrinology of aging. Science.
1997278419-424.
27
From Kuh D, Ben-Shlomo Y. A life course approach
to chronic disease epidemiology. New York Oxford
University Press. 1997.
28
Strategies to Improve Health Development
Trajectories
Back to Overall Model
Healthy Trajectory
At Risk Trajectory
Delayed/Disordered Trajectory
Graphic Concept Adapted form Neal Halfon , UCLA
29
Cumulative, Programming and Pathway Mechanisms
Influence LCHD

• Three basic mechanisms influence LCHD
• Cumulative - additive effect of multiple risks
  and protective factors, weathering
• Programming - time specific influence of stimulus
  or insult during a critical or sensitive period
  on selection, adaptation, compensatory processes
• Pathways-chains of (eco-culturally constructed)
  linked exposures that create a constrained
  conduit of gene-environment transactions

30
Adverse childhood events and adult depression
Odds Ratio
Adverse Events
Chapman et al, 2004
31
Adverse childhood events and adult ischemic heart
disease
Odds Ratio
Adverse Events
Dong et al, 2004
32
Cumulative, Programming and Pathway Mechanisms
Influence LCHD

• Three basic mechanisms influence LCHD
• Cumulative - additive effect of multiple risks
  and protective factors, weathering
• Programming - time specific influence of stimulus
  or insult during a critical or sensitive period
  on selection, adaptation, compensatory processes
• Pathways- chains of (eco-culturally constructed)
  linked exposures that create a constrained
  conduit of gene-environment transactions

33
Poverty Child Health and Development
Parent- and Family-Level Predictors of Income
And Hardship ? Parent Work Status ? Job
Prestige ? Education Level ? Parent Marital
Status ? Race-Ethnicity
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LCHD Childhood Antecedents of later Childhood
and Adult Health
Early social and material deprivation (financial,
educational, environmental)
Prior poor health, fetal nutrition, case-mix
Immunologic physiologic moderators
Current poor health/ premature mortality
Prior poor physical activity
Current poor physical activity
Prior adverse behavior
Current adverse behavior
Current social and material deprivation
Source van de Mheen et al, IJE 1998
From Starfield 02/03
38
How are the Children?
39
Child Health System Past to Present

• Steady Progress in Childhood Morbidity for
  traditional medical conditions
• Many indicators show improvement
• Mortality, morbidity, trends improving
• Increasing Rates of chronic conditions,
  especially mental health, developmental and
  behavioral conditions, Obesity
• Increasing disparities

40
Source Wise PH. The transformation of child
health in the United States. Health Affairs.
23, No. 5 (2004) 9-25.
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Colorado (2007)

• Fewer woman smoking during pregnancy
• 1995-11.9 to 2005-7.5
• Early PNC no real change, below national
  average of 84
• LBW increased to 9.3 follows national trend of
  gtgt LBW, Premature births
• IZ- 83.4 of kids ( 16th in the nation)
• 14 of children w/o Health Insurance

Source Kids Count Colorado 20007
43
Changing Pattern of Childhood Morbidity

• Increase in chronic health problems (10-14)
• Greater recognition of mental health problems
  (15-20)
• Greater appreciation of role and impact of
  developmental health problems learning,
  language (10-17)

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Child Health USA 2006
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48
Children Youth at Risk
4-6 Severe Disabilities 12-16 Special
Health Care Needs 30-40 Behavioral, Mental
Health Learning Problems 50-60 Good Enough
What are thriving ? 30 ? 40 ? 50 ?
49
How well is the 2.0 Child Health System
Performing?
50
The existing child health service system

• Demand greater than services available
• Families have complex needs - often beyond
  capability of any single service
• Difficulty accessing services
• Socio-economic gradient of access
• Focus on treatment rather than prevention/early
  intervention
• Episodic contact
• Poor quality of Well Child Care

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The existing child health service system

• Fragmented service delivery
• Different sectors (health, public health,
  population health, civic)
• Different funding streams
• Different cultures
• Lack of co-ordination
• Narrow programmatic criteria for eligibility
• Variable understanding of child health issues
• Local community generally has limited
  accountability or responsibility

53
How do we get the health system that children
need?

• Incremental vs. Transformational
• Reforms

54
Transforming the Child Health System New
Paradigm vs. Old System

• Child health system was designed for the first
  era of health care ( acute, infectious disease
  model)
• It was upgraded a bit for the 2nd era, with more
  regionalization, chronic disease care
• Ill equipped for this new era
• Under-performing
• Facing many new challenges

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Transformation Vision Strategic Goals

• Optimizing health for all children is best way to
  optimize health of entire population
• Informed by the life course health development
  (LCHD) paradigm
• Recognition of and responsive to the critical and
  sensitive periods of health development in
  childhood
• Heightened vulnerability and risk
• Origin of later health disparities
• Provide opportunity to enhance health
  trajectories
• Disadvantage during childhood is compounded,
  diminishing future prospects, by reducing child
  health potential

57
Child Health System Transformation Framework
58
Framework for Change in Operating Logic
59
NUMBER OF CHILDREN
FUNCTION
60
Universal Curve Shift
Low income
Median
High income
NUMBER OF CHILDREN
FUNCTION
VULNERABLE
61
Includes Physicians, dentists Schools Child Care
POLICY
COMMUNITY
NEIGHBORHOOD SERVICES
Education
FAMILY
CHILD
Child Health
Family Support
62
Child Health System Transformation Framework
63
Converging Service Sector Strategies to Create an
Early Childhood Integrated Service Delivery
Platform
Early Care Education
Medical Home
Deliberate Opportunities for Cognitive,
Physical, Social and Emotional Learning
On-going Assessment of Child Development
Training on Child Health and Development
Elicit Address Parent Concerns
Training on Maintaining a Safe and Healthy Early
Care Environment
Anticipatory Guidance
Preventive Health Care
Parent Education/Anticipatory Guidance
Acute and Chronic Health Care
Child Observation to identify possible
physical/emotional health problems
Integration with Community Resources for Referral
Linkage to Community Resources
Integrated Service Delivery Platform 3.0
Anticipatory Guidance from Pediatrician
Home Visiting
Positive Parent- Child Interactions
Housing Services
Anticipatory Guidance from ECE Provider
Adult Education
Child Birth Classes
Infant Mental Health Consulting in ECE Programs
Job Life Skills Training
Parenting Classes
Advice from Friends and Family
Marriage Family Counseling
Part C
Parenting Information from Media Sources
Case Management
Mental Health Socio-Emotional Development
Family Support
Parent Education
64
Pediatric Office 2.0
Preventive Care
Acute Care
Pediatric Office
Chronic Care
Developmental Services
65
18 month visit

• Pediatric Care 2.0
• C.D Disability
• Screen 4-6 w/ disability
• Screening tools Pathway
• Pediatric Office connected to Regional Center

• Pediatric Care 3.0
• Optimize Developmental Health
• I.D 30-40 developmental risk
• Screening tools Pathway
• Pediatric Office connected
• Child care
• Many other programs
• Coordination
• Regional center

66
DS Community Services Pathway
Evaluation (IDEA Sector
Screening Pediatric Services Sector
Surveillance Community Services and Resource
Sector
Assessment Peds/HPlan/PHSector
IDEA Regional Center for Developmental Disabilitie
s
Mid-Level Assessment Center
Preventive Care
Other Specialized Services
Acute Care
Developmental Services
Chronic Care
COORDINATION CENTER
Child Care/Family Resource Center
Program
Surveillance
Program
67
Optimal Health Development
Trajectory Optimizing Service Linkage Pathway
Lower Health Development Trajectory
Development
Pediatric Continuity
Network Connections
0
1
3
5
7
Years
68
Optimizing Trajectories Multisector Multilevel
Strategies
69
Child Health System Transformation Framework
70
Systematic Data CollectionFor tracking Health
Development Trajectories
Preschool Assessment
Pediatric Early Child Assessment
Health Development
Birth Certificate
School Readiness

• Physical Wellbeing motor devt
• Social emotional devt
• Approaches to learning
• Language devt
• Cognition general knowledge

EDI Early Development Inventory
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Physical Health and Well-Being Percent students
in the bottom 10
73
Average Score on the Social Competence Subscale
of the EDI, 2003
From Hertzman
74
Early Development Instrument (EDI) score and
Risk 4 associated categories
26
From Hertzman
75
Master Contract
Child Health 3.0
ECH D VPN
Categorical Funding
Data share
Child Health 2.0
edcucation
family
Hea l t h
Framily Support
76
Conclusions

• Child Health and Health Care System needs to move
  from version 2.0 to 3.0
• This requires a major change in the operating
  system
• This will also require new and more integrated
  policy framework that is capable of supporting
• New and more integrated delivery platforms
• Newly aligned (cross-sector) service delivery
  pathways
• More coordinated, integrated and long-term
  funding, data collection, and

77
Conclusions

• Transformation of Child Health and Health Care
  System will be accomplished through
• Collaborative Innovation
• Collective Invention
• The Transformation process will require
• Rebalancing, re-aligning, re-engineering and
  re-financing existing services ( 2.0 to 3.0)
• New partnerships,
• New Communication Strategy
• Framing the Problems and Solutions as Systems and
  not Service issues

78
Conclusions

• Transforming the child health and health care
  system
• Non-linear
• Policy Jolts and Incremental Changes
• Innovations Within and Across Sectors

79
http//www.firstfocus.net/Download/BigIdeas.pdf
80
National Reform Proposal

• Meaningful Coverage to support health and
  development
• Creating a seamless system by linking up
  disparate programs, policy and accountability
• Making meeting the developmental health needs of
  all children a national priority

81
Meaningful Coverage

• Covers all children
• Covers the whole child
• Addresses a developmental standard of care
• Ensures that supplemental coverage is available
  for those with or at risk for special health care
  needs

82
Child Health System

• National Child Health Investment Advisory
  Committee
• Establish Child Health Outcome Priorities
• Determine the Benefit Package and Coverage
  options
• National Outcome Performance Standards for
  Children's Health
• Coordinate the performance and outcomes of
  Medicaid, SCHIP, Title V, Child Health Services
  Block and other programs

83
Child Health System

• System of Accountability and Coordination
• Share outcome and performance measures
• Common definitions and eligibility standards
• Cross cutting evaluation and performance
  monitoring
• Realign Federal Programs
• New Child Health Trust Fund
• State Child Health Trusts
• New Office for Child Health
• New Deputy Secretary for Child Health

84
Child Development and Well Being as National
Priority

• Significant structural changes in HHS
• High level leadership changes
• New Funding mechanisms and priorities
• Alignment of State and National Goals,
  Priorities, Measures, Accountability
• Communication, messaging and parental empowerment
  around their children's health

85
UCLA Center for Healthier Children,
Families and Communities National Center for
Infancy and Early Childhood Health Policy

• Http.//healthychild.ucla.edu

86
Early Childhood System Building Blocks
Desired Outcomes at School Entry
A.
Family Capacity and Function
Emotional / Social / Cognitive Development
Physical Health Development
Trajectory of Child Development and Family
Function
B.
C.
Child Health Services
87
Early Childhood System 2.0 Building Blocks
Desired Outcomes at School Entry
A.
Family Capacity and Function
Emotional / Social / Cognitive Development
Physical Health Development
B.
Universal Preschool
Head Start Family Literacy
Early HS
Family Resource Centers
C.
Early Care Education
Family Support Services
Child Health Services
88
Child Health Services Building Blocks
Desired Outcomes at School Entry
Family Capacity and Function
Emotional / Social / Cognitive Development
Physical Health Development
.
Child Health Services
89
Child Health Services Building Blocks
Desired Outcomes at School Entry
Family Capacity and Function
Emotional / Social / Cognitive Development
Physical Health Development
.
Child Health Services
90
Early Childhood System 3.0
Desired Outcomes at School Entry
Family Capacity and Function
Emotional / Social / Cognitive Development
Physical Health Development
.
Assessment
Health Center
Screening
ECE Center
Family Resource Center
Surveillance
Co-located or virtually connected service centers
creating new pathways