Title: Enhancing State Measurement for Early Childhood Preventive and Developmental Services
1Enhancing State Measurement for Early Childhood
Preventive and Developmental Services
Brett Brown, PhD Holly Grason, MA Catherine
Hess, MSW Edward Schor, MD Gillian Silver, MPH
Karen VanLandeghem, MPH
- Association of Maternal and Child Health Programs
2004 Annual MeetingSkills Building Session
A2Saturday, February 28, 20041200 330 p.m.
2Measuring to Improve Child Health and Development
- Edward L. Schor, MD
- Program Director
- Child Development and Preventive Care
- The Commonwealth Fund
- February 28, 2004
3Health is a state of complete physical, mental
and social well-being and not merely the absence
of disease or infirmity.
Constitution of the W.H.O.
1948 a mentally or physically disabled child
should enjoy a full and decent life, in
conditions which ensure dignity, promote
self-reliance, and facilitate the childs active
participation in the community.
Convention on the Rights of the Child, U.N. 1989
4 Children will receive the nutrition, physical
activity experiences, and health care needed to
arrive at school with healthy minds and bodies
1st
National Education Goal 1990 the right to grow
is universally assured through attention to the
comprehensive physical, psychological and social
needs of the MCH population.
Vision, MCHB
1999
5Human Potential
Risk Factors
Protective Factors
6CONTRIBUTORS TO CHILD HEALTH PROMOTING AND HEALTH
RISK BEHAVIORS
FAMILY
PEERS
COMMUNITY, SCHOOLS, MEDIA
7Childrens Early Reading and Mathematics
Performance By Mothers Education 1998-2000
Scale Score
Reading
Mathematics
100
80
Bachelors degree
Some college
60
High school diploma
40
Less than high school
20
0
Kindergarten
Kindergarten
1st grade
1st grade
US Department of Education, National Center for
Education Statistics, The condition of education
2003, NCES 2003-067, Washington, DC US
Government Printing Office, 2003
8The ABCs of Developmental Services
- Screen families and children
- Educate parents (anticipatory guidance)
- Treat children and counsel parents
- Make referrals and coordinate care
9Low-Income Childrens Risk for Developmental,
Behavioral or Social Delays
10Pediatrician Recognition of Developmental and
Behavioral Problems
Percent of Children
PERCENT
Lavigne et al. Pediatrics 199391(3)649-55
Costello et al. Pediatrics. 198882415-424
11Infants and Toddlers Receiving Early Intervention
Services from States
Highest Percentage Served Hawaii 7.70 Massachu
setts 5.15 New York 3.68 Lowest
Percentage Served Georgia 0.96 Virginia 1.1
2 Alabama/Louisiana/Nevada 1.13 National
Mean 1.99
12Commonwealth Fund Program Goal
- To assure that appropriate developmental
- and preventive child health services are
- available to all families, especially those
- with young children and low income.
13 The Commonwealth Fund Program Strategies
- Promote adoption of quality standards and quality
measurement - Identify and promote the adoption of effective
practices, models and tools - Promote policy change and facilitate adequate
reimbursement
14Benefits of Setting Goals and Measuring
Performance
- Target own efforts
- Gain resources and support
- Engage partners
15Past Measurement Successes
- Healthy People
- Immunization goals
- Infant mortality reduction
- Health disparities
16Health care should be
- Safe
- Effective
- Patient-centered
- Timely
- Efficient
- Equitable
Crossing the Quality Chasm A New Health System
for the 21st Century, IOM 2001
17should move forward expeditiously with the
establishment of monitoring and tracking
processes for use in evaluating the progress of
the health system in pursuit of the above-cited
aims.
Crossing the Quality Chasm A New Health System
for the 21st Century, IOM 2001
18The Early Childhood Initiative LandscapeKaren
VanLandeghem, MPH
19The Early Childhood Initiative Landscape
- Comprehensive and diverse
- Multidisciplinary (e.g., health, education, child
care, mental health, social services) - Initiatives focused expressly on early childhood
(e.g., ABCD) - Established initiatives with linkages to early
childhood (e.g., Healthy Child Care America) - Initiatives covering sectors other than health
(e.g., BUILD, SRII)
JHU WCHPC February 28, 2004
20Common Elements of Early Childhood Development
Initiatives
- Early Care and Education
- Family/Caregiver Education
- Family/Caregiver Support
- Health Care/Medical Home
- Provider Training and Education
- Quality Standards and Measurement
- School Readiness
- Social and Emotional Development/Mental Health
JHU WCHPC February 28, 2004
21Common Elements of Selected National Early
Childhood Initiatives
22What are we trying to measure?Examples of core
components
- Health Care (e.g., content and quality of
anticipatory guidance, medical home, well-child
care, child development screenings and
assessments) - Early Care and Education (e.g., quality of child
care) - Education/School Readiness (e.g., social and
emotional development) - Mental Health Care (e.g., access and referrals to
behavioral health care services)
JHU WCHPC February 28, 2004
23Example of a Health System Measurement
Initiative The Promoting Healthy Development
Survey (PHDS)
- Seven quality measure scores for health plans
- Anticipatory guidance from providers
- Anticipatory guidance information from health
plan - Follow-up for at-risk children
- Assessment of psychosocial well-being and safety
- Assessment of smoking, drug and alcohol use in
the family - Family-centered care
- Helpfulness and effect of provider information
- Source Bethell C, Peck C, and Schor E.
Assessing Health System Provision of Well-Child
Care The Promoting Healthy Development Survey.
2001, Pediatrics.
JHU WCHPC February 28, 2004
24Examples of PHDS Application
- Complements EPSDT reporting
- Strengthens purchasing and contracting
- Strengthens implementation of child development
services in state agency systems - Enhanced reporting forms
- Referral services
- Coverage of developmental screening
- Source Bethell C, Peck C, and Schor E.
Assessing Health System Provision of Well-Child
Care The Promoting Healthy Development Survey,
2001, Pediatrics.
JHU WCHPC February 28, 2004
25Importance of Identifying a Conceptual Framework
for Early Childhood Measurement
- Serves as a tool and roadmap for organizing
thinking and work. - Helps formulate the goal(s), focus, and content
of and strategies for measurement. - Can help crystallize application of findings.
- Identifies inputs and outputs to the
measurement process. - Can range from simple to more complex models.
- Frameworks are an enduring way of specifying
what should be measured while allowing for
variation in how it is measured over time. (IOM
Quality Report, 2001)
JHU WCHPC February 28, 2004
26Example of a Framework Used in Assessing Health
Care Quality
- Structure-Process-Outcome Model for Assessing
the Quality of Care - Structure The attributes of the setting in which
care occurs - Process The content of care
- Outcomes The end results of care
- Source Donabedian, 1962, 1980.
JHU WCHPC February 28, 2004
27Early Child Well-being Indicators Tools and
Approaches
28How are Social Indicators Used?
- Education
- Needs assessment and monitoring
- Goals-tracking
- Accountability
- Reflective practice
- Evaluation of policies and programs
29Choosing Indicators
- Consult research
- Consult experts
- Consult the stakeholders
- Consult the data resources
30Design and Dissemination
- Identify audiences and their needs
- Identify budget constraints
- Design accordingly
- Â
31Contributors to Early Childhood Development and
School Readiness
Parenting Supports
Family Economic and Social Characteristics
Parent-Child Interactions and Relationships
Family Supports
Family Composition and Organization
Family Functioning/ Harmony
Health Supports
Child and Family Health
Early Care and Education Supports
Acknowledgement Zaslow, M., Halle, T., Johnson,
R., Bridges, L., Guzman, L., Pitzer, L.,
Calkins, J. (2003). First Steps and Further
Steps Early outcomes and lessons learned from
South Carolina's school readiness initiative
1999-2002 program evaluation report (prepared for
the state of South Carolina). Washington, DC
Child Trends.
32Selected Federal Data Resources on Early Child
Development and Health
- National Surveys
- National Household Education Survey (NHES)
- Early Childhood Longitudinal Studies (ECLS-K and
ECLS-B) - Panel Study of Income Dynamics Child
Development Supplement - National Health Interview Survey (NHIS)
- National Survey of Early Child Health (NSECH)
- National Health and Nutrition Examination Survey
(NHANES)
33Selected Federal Data Resources on Early Child
Development and Health
- State-Level Surveys
- National Survey of Children with Special Health
Care Needs (CSHCN) - National Survey of Childrens Health (out in
2004) - Pregnancy Risk Assessment Monitoring System
(PRAMS) - National Survey of American Families (NSAF)
(private) - Community-Level Data
- American Community Survey (Limited)
- Vital Statistics Birth and Death Data
34Consulting Experts/ Stakeholders
- Convened panel (academic, practice, funder)
- Prepared background materials
- Project goals
- Panel tasks
- List of indicators based on model/research
- All day meeting, followed by panel voting for the
final list of indicators. - Modification of final list based on data
availability
35Early Child Development in Social Context A
ChartbookChild Trends and Center for Child
Health Research Sponsored by The Commonwealth
Fund
- Socioemotional Development
- Intellectual Development
- Child Health
- Family Practices/Family Functioning
- Parental Health
- Health Care Receipt
- Early Child Care and Education
- Neighborhood Influences
- Demographics
36Quality of Health Care for Children and
Adolescents A Chartbook Sheila Leatherman and
Douglas McCarthySponsored by The Commonwealth
Fund
- Effectiveness
- Patient safety
- Access and timeliness
- Patient and family centeredness
- Disparities
- Capacity to improve
37Design and Dissemination of Chartbook
- Purpose Education
- Audience Early child health policymakers,
practitioners and parents - Design goals
- Hardcopy (and PDF)
- Easily digested
- Linked to practice
38Fine and Gross Motor Skills
Early Child Development in Social Context Child
Trends and Center for Child Health Research, 2004
- Why is this important?
- Childrens motor control and coordination can
have an important influence - on their cognitive and socioemotional
development, as well as their - academic achievement. Visual motor skills, such
as visual scanning, - discrimination, and memorization, are especially
important in acquiring - reading skills. Delays in motor development can
affect a childs performance - in school, and have been linked to lack of
concentration, behavior problems, - low self-esteem, and poor social confidence.
Problems in motor coordination - have been associated with loneliness and poor
peer interactions, especially - among young boys. Young children with low scores
on fine and gross motor - skills assessments are also at risk for later
developmental difficulties. - Assessments of fine motor skills are based on how
well children perform - tasks such as constructing forms with wooden
blocks, copying basic figures, - and drawing a person. Assessments of gross motor
skills would be based on - how well children perform actions such as
balancing on each foot, hopping - on each foot, skipping, and walking backwards in
a line. - What do the data show?
- Boys are more likely than girls to demonstrate
low levels of fine and gross motor skills. In
1998, for example, 31 percent of male
kindergartners received low scores on assessments
of fine motor skills, compared with 22 percent of
female kindergartners.
- Implications for Policymakers and Practitioners
- Early, accurate identification of fine and gross
motor skill deficiencies - is important, because early treatment can lead to
better developmental - outcomes. Health practitioners can become
familiar with local - childcare options in order to make better
recommendations for - programs to stimulate the development of fine and
gross motor skills. - In addition, practitioners can educate parents on
appropriate - developmental expectations for their children.
Clinicians can also - work with the children themselves, as well as
with parents, teachers, - therapists and other physicians, to identify
appropriate developmental - goals and treatments for children with motor
disabilities. According to - the American Academy of Pediatrics, policymakers
should consider - banning the manufacture and sale of infant
walkers because they fail - to help with infant motor development. Moreover,
they have been - found to be detrimental and dangerous.
- Implications for Parents
- Practice is critical for children to improve
their fine and gross motor - skills. At appropriate ages, parents can give
their young children toys
DRAFT DRAFT DRAFT DRAFT DRAFT
39DRAFT DRAFT DRAFT DRAFT DRAFT
40Measurement in Context of Title V Program
Planning and Partnerships
- Lessons Learned and in Process
- Catherine Hess, MSW
41Measurement in Context Of...
- Title V Performance Measurement System
- State Indicators Partnerships
- Child Well Being
- School Readiness
- Public- Private Healthcare Quality Partnerships
- Federal- State Partnerships
- Medicaid and SCHIP
- Title V/SECCs
JHU WCHPC February 28, 2004
42Integrating Early Childhood Measurement with
Title V
JHU WCHPC February 28, 2004
43Integrating Early Childhood Measurement with
Title V
- What early childhood outcomes are you trying to
affect? What are the baselines and variations by
subgroups? (needs and strengths in health
status) - What does research/best practice say works in
influencing those outcomes? What partners are
needed? - What is in place now, where are the gaps? (needs
and strengths in health system capacity)
JHU WCHPC February 28, 2004
44Integrating Early Childhood Measurement with
Title V
- What will you change or develop to build on early
childhood system strengths and address needs?
(Program and Resource Allocation) - What are immediate and longer term measures of
success? (performance and outcomes measures) - How will you work with partners to monitor and
interpret measures, stay abreast of emerging
research, adjust program strategies and resource
allocation?
JHU WCHPC February 28, 2004
45Advancing State Child Indicators Initiatives
- HHS (ASPE/ACF) and Packard Foundation
- Promote state efforts to monitor child health and
well being in era of shifting policy - 14 states from 1998 to 2000 participated
- Workshops, meetings, publications to 2001
- http//aspe.hhs.gov/hsp/cyp/child-ind98/
JHU WCHPC February 28, 2004
46Advancing State Child Indicators Initiatives
- Alaska
- California
- Delaware
- Florida
- Georgia
- Hawaii
- Maine
- Maryland
- Minnesota
- New York
- Rhode Island
- Utah
- Vermont
- West Virginia
JHU WCHPC February 28, 2004
47Advancing State Child Indicators Initiatives
Lessons
- Cross agency collaboration critical
- Outcomes many can rally around,understand
- School readiness fits these criteria
- Central/governor office lead helps, with
grassroots, community partnerships critical - Cross agency can finance new data collection
JHU WCHPC February 28, 2004
48Advancing State Child Indicators Initiatives
Lessons
- Data drivers policy priorities, audience, data
availability and strongest predictors - Communities need ownership
- Need measures reflecting diversity
- Need high quality data available for years
- Clear interpretation over time
JHU WCHPC February 28, 2004
49School Readiness Indicators Initiative
- Packard, Kauffman and Ford Foundations
- RI Kids Count with 17 states
- Multi-agency senior policy and data staff
- National meetings, Residency Roundtables
- www.gettingready.org
JHU WCHPC February 28, 2004
50School Readiness Indicators Initiative
- Arizona
- Arkansas
- California
- Colorado
- Connecticut
- Kansas
- Kentucky
- Maine
- Massachusetts
- Missouri
- New Hampshire
- New Jersey
- Ohio
- Rhode Island
- Vermont Virginia
- Wisconsin
JHU WCHPC February 28, 2004
51School Readiness Indicators Initiative
- Change agenda in states and communities
- Developing child outcome and systems indicators
birth -gt 4th grade reading test - Measurable indicators tracked over time
- Adopted by govt., reported to citizens
- Stimulate policy and program change
JHU WCHPC February 28, 2004
52School Readiness IndicatorsEmerging List for
Physical Health
- adequate prenatal care
- low birthweight
- uninsured children
- immunizations at kindergarten entry
- developmental screening at age 3
- hearing/vision screenings
- elevated blood lead levels
- CSHCN or disabilities
- births to teens
JHU WCHPC February 28, 2004
53Massachusetts School Readiness Indicators Project
(SRIP)
54Massachusetts SRIP
- Governors State Commission on School Readiness
and SRIP paved the way - Interest in whether current programs/resources
working and whether sufficient - Coordinated by the Executive Office of HHS and
the Office of Child Care Services - Six other state agencies, Head Start, United Way
and Kids Count involved
JHU WCHPC February 28, 2004
55Massachusetts SRIP
- Developed definition of School Readiness
- Childs physical, emotional, cognitive, social
- Families, schools and communities
- Developed list of indicators by using
- research and information from other states
- Commission findings
- Rxes and TA from RI KidsCount SRIP
JHU WCHPC February 28, 2004
56Massachusetts SRIP
- Started with approx. 90 indicators, using
consensus process got to about 50 fairly easily,
40s down harder - After more than a years work, now 30 indicators
- 10 indicators can be measured right now
- 10 can only be partially measured
- 10 are critical but currently cannot be measured
JHU WCHPC February 28, 2004
57Massachusetts SRIP
- Physical Health Indicators
- Prenatal Care
- Teen Births
- Hunger
- Health Insurance
- Well Child Visits
- Motor Skills
- Developmental and Mental Health Screening and
Services
JHU WCHPC February 28, 2004
58Massachusetts SRIP
- Next Steps
- Input from stakeholders-6 forums across state
- Develop communications strategy for school
readiness - Develop outreach materials for parents,
providers, policymakers, legislators
JHU WCHPC February 28, 2004
59Massachusetts SRIP and MCH Lessons
- Much of data currently collected from DPH
- Mechanism to educate/advocate for health
- Logical fit with Title V assessment/plans
- MCH contact Ron.Benham_at_state.ma.us
JHU WCHPC February 28, 2004
60Public-Private Partnerships to Measure Healthcare
Quality
- Key Framework Institute of Medicine
- Crossing the Quality Chasm
- Staying Healthy, Getting Better, Living with
Illness, Coping with End of Life - Beal (Pediatrics, Jan. 04) found
- 19 measure sets, 365 measures for childrens
quality - Few designed specifically for specific age ranges
- Largest getting better (40), staying
healthy(24)
JHU WCHPC February 28, 2004
61Public-Private Partnerships to Measure Healthcare
Quality
- National Quality Forum
- Fosters standard measures, adoption and use via
national, multiple stakeholder consensus - Workshop on Child Healthcare Quality Measurement
and Reporting, January 2004 - NACHRI, MOD, AHRQ, NICHQ, AAP involved
- Paper and action plan forthcoming
JHU WCHPC February 28, 2004
62Utah Health Partnerships
- Longstanding partnership b/t MCH and Medicaid,
within Dept. of Health - Collaborated on quality measures for plans
- Focus on CSHCN and EPSDT
- MCH and Medicaid staff do quality audits
- Added plan incentives for improvements
- EPSDT screening
- 2 year old immunizations
JHU WCHPC February 28, 2004
63Utah Health Partnerships
- Data warehouse- Medicaid claims, eligibility
data, vital records - Medicaid and MCH staff trained, have access to
data - Source of data for MCHBG, and for Medicaid and
MCH quality monitoring
JHU WCHPC February 28, 2004
64Utah Health Partnerships
- ABCD I - targeted case management for infants of
Medicaid women - Similar to MCH program for Prenatal-5
- Same outcome measures
- MCH does monitoring, TA for both
JHU WCHPC February 28, 2004
65Utah Health Partnerships
- ABCD II-Developed by/with Medicaid, MCH and
stakeholders, esp. pediatricians - Focus on improving developmental/mental health
screening of infants/toddlers/moms - LHDs to assist linking women to MH services
- Utah Pediatric Partnership to Improve Healthcare
Quality (UPIQ) -learning collaboratives
JHU WCHPC February 28, 2004
66Utah Health Partnerships
- UPIQ partners with Medicaid and MCH
- UT AAP
- HealthInsight-UT EQRO (PRO)
- University of UT
- Intermountain Health Care System (large MC)
- UPIQ chart audits with standard measures
- Example BMIs identified as needing improvement
one practice retooled computer system to calculate
JHU WCHPC February 28, 2004
67Utah Health Partnerships
- Lessons Learned
- MCHs relationship with physicians can help
engage them in partnership with Medicaid - Contracting with MCH for quality monitoring for
Medicaid avoids duplication - MCH expertise in quality monitoring can assist in
assuring services withstand federal scrutiny
JHU WCHPC February 28, 2004
68Federal/State Partnerships CMS
- CMS Medicaid EPSDT 416 form
- revised 97 with state MCH/Medicaid input
- screening ratios by age groups
- UT requires plans to calculate ratios
- CMS contract with Medstat for advising on EPSDT
encounter data
JHU WCHPC February 28, 2004
69Federal/State Partnerships CMS
- CMS Performance Measurement Partnership Project
with NASHP - Collaboration for measures to meet federal
requirements and engage stakeholders in QI - 19 measures for Medicaid/SCHIP whittled down to 7
- Methods for measurement left to states
- First SCHIP reports with measures in Jan04
JHU WCHPC February 28, 2004
70Federal/State Partnerships CMS
- CMS National Performance Measures Opportunity
for Collaboration - Well child visits in first 15 months
- Well child visits in 3rd, 4th and 6th years
- Use of appropriate meds for pediatric asthma
- Childrens access to primary care services
- Prenatal and postpartum care
- Comprehensive diabetes care
- Adult access to preventive/ambulatory services
JHU WCHPC February 28, 2004
71Federal- State Partnerships Title V
- National indicators/measures for
- LBW/VLBW
- Immunizations
- Screening/well-child
- Health insurance coverage
- Hearing screening
- Oral health
- Teen births
JHU WCHPC February 28, 2004
72Federal State Partnerships Title V
- State Performance measures to build on, commonly
related to - Parent smoking and drinking
- Blood lead levels
- Oral health
- Domestic violence
- Developmental screening and well-child
- Hearing screening
JHU WCHPC February 28, 2004
73Federal State Partnerships Title V
- State V building/measuring partnerships
- CT-degree to which Title V funded programs
screen, assess, refer and link to mental health - DC, MS-Medicaid getting EPSDT screens
- KS- EPSDT screening ratio for infants
- MI- Medicaid 0-6 getting lead screening
- PA- children in center based child care getting
vision screens
JHU WCHPC February 28, 2004
74Federal State Partnerships Title V
- RI SECCS
- Successful Start Environmental Scan
- Title V Needs Assessment Coordinator joining team
to promote coordination/integration - MI SECCS
- Great Start Indicators in Context
- Timeline/process opportunities to integrate with
Title V
JHU WCHPC February 28, 2004
75Small Group Exercise
- Objectives
- To learn the multiple components needed to
develop, in partnership with sectors or systems
serving Title V populations, shared measures of
early childhood health, preventive and
developmental services - To develop a strategy for joint or parallel
application and use of measures by each partner
in their needs assessment, performance
measurement and planning processes
JHU WCHPC February 28, 2004
76Directions
- Once divided into groups, each group will be
assigned the sister agency or group with which
they will partner - Identify and/or develop three performance
measures using the provided worksheet as a guide - Develop strategies and plans for how and where
this information would be used - Report to the entire group on lessons learned in
measure development, noting benefits and
challenges of partnerships, and describing ideas
discussed for use of the measures
JHU WCHPC February 28, 2004
77Discussion Questions
- What unique strategies for measurement were
identified by your group and how does this relate
to your partner? - What indicators did your group select for
measurement and why? - What challenges do these indicators present and
what solutions did your group come up with to
address these challenges? - What applications did you propose for Title V
needs assessment? Other purposes?
JHU WCHPC February 28, 2004
78Overall Strategies for Success
- Be clear about your overall goals for
measurement. - Align related and realistic strategies to those
goals. - Be realistic about what measurement will or will
not do. - Involve key partners and stakeholders.
- Select a small group of clear and compelling
indicators, and measure over time.
JHU WCHPC February 28, 2004