+Transforming Partnerships: Integrating Public Health, Clinical Care and the Community for Young Children

Everything Matters for Babies Lauren Smith, MD, MPH September 2014

+Overview

n  Child well being

n  The case for prevention vs. remediation

n  Child development impact pyramid

n  Why we don’t do what the evidence tells us

n  What we can do about it

+ Where is the outrage?

4

Socioeconomic Factors

Changing the Context to make individuals’ default

decisions healthy

Long-lasting Protective Interventions

Clinical Interventions

Counseling & Education

Largest Impact

Smallest Impact

Examples

Poverty, education, housing, inequality

Immunizations, brief intervention, cessation treatment, colonoscopy Fluoridation, trans fat, smoke-free laws, tobacco tax

Rx for high blood pressure, high cholesterol, diabetes

Eat healthy, be physically active

CDC “Health Impact Pyramid” Shifting our Emphasis

CDC “Health Impact Pyramid” Shifting our Emphasis

+How child well-being is measured

Dimension Components

Material well-being

§  Monetary deprivation §  Material deprivation

Health & Safety §  Health at birth §  Preventive health services §  Childhood mortality

Education §  Participation in early childhood education §  Participation in further education §  % 15-19 yo not in education, employment

or training §  Scores in reading, math, science

Behaviors & Risks

§  Health behaviors §  Risk behaviors §  Exposure to violence

Housing & Environment

§  Housing – rooms per person, housing conditions

§  Environmental safety – air pollution, homicide

+UNICEF Child Deprivation Rate: Percentage of children lacking 2 or more ….

n  3 meals a day

n  At least 1 meal a day with meat, chicken, fish or vegetarian equivalent

n  Fresh fruits and vegetables everyday

n  Books suitable for child’s age, knowledge – not schoolbooks

n  Outdoor leisure equipment

n  Regular leisure activities

n  Indoor games

n  Money to participate in school trips/events

n  A quiet place with enough room and light to do homework

n  An internet connection

n  Some new clothes – not all second hand

n  2 pairs of properly fitting shoes

n  Opportunity to invite friends home to play and eat

n  Opportunity to celebrate special occasions – birthdays, religious events

+The US has a diagnosis

Cognitive dissonance:

n psychological conflict resulting from incongruous beliefs and attitudes held simultaneously

+A big disconnect

What we think:

n 40 % of Americans believe it is common to start poor, work hard and become rich.

What is true:

From Pew Charitable Trusts, Moving on Up, Nov 2013

43%

27%

17%

9% 4%

0%

10%

20%

30%

40%

50%

Bottom Quintile

4th Quintile Middle Quintile

2nd Quintile Top Quintile

70% of Americans born at the bottom never reach the middle

70% of Americans stay put

+What boosts the trajectory?

From Pew Charitable Trusts, Moving on Up, Nov 2013

55%

86%

28%

53%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Non-college graduate College graduate

Percentage of Americans who move up from bottom quintile

Any upward mobility from bottom quintile Upward mobility to at least middle quintile

+Prevention, not remediation

+Making the case for prevention vs. remediation

+Heckman Equation prosperity

n  Intelligence and social skills are developed at an early age and both are essential.

n  Early investment produces the greatest returns in human capital.

n  America’s advantage will come from helping the disadvantaged.

n  Quality economic returns come from quality investments in early childhood development.

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Socioeconomic Factors

Changing the Context to make individuals’ default

decisions promote healthy development

Long-lasting Protective Interventions

Clinical Interventions

Counseling & Education

Largest Impact

Smallest Impact

Examples

Poverty, education, housing, inequality

Early childhood education

Universal breakfast & lunch, universal pre-K

Charter schools

Special ed, grade retention

CDC “Health Impact Pyramid” Shifting our Emphasis

“Child Development Impact Pyramid” Shifting our Emphasis

+

If we know what to do, why don’t we do it?

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Barriers to implementation of evidence-based policy

n Rapid pace of decision making

n Validity of evidence vs. experience

n  Inadequate information vs. certainty

n Policy by anecdote

n Minefields in negotiating the political landscape

n Push-pull of information

n Time frame of impact

n Peril of intersectoral effects

+So what can we do?

+A potential strategy – Collective Impact

“ Large-scale social change requires broad cross-sector coordination, yet the social sector remains focused on the isolated intervention of individual organizations.”

John Kania & Mark Kramer, Collective Impact, Stanford Social Innovation Review, Winter 2011

+Elements of Collective Impact

n  Common agenda – shared vision for change

n  Shared measurement systems – collecting data and measuring results on indicators at community level

n  Mutually reinforcing activities – coordination of differentiated activities

n  Continuous communication

n  Backbone support organizations

John Kania & Mark Kramer, Collective Impact, Stanford Social Innovation Review, Winter 2011

+ 19

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Investing in and Supporting Children and Families

+What supports cross-sector collaboration?

n Shared expectations of senior leadership and the public

n Mutual accountability across sectors

n Data sharing across sectors

n Seizing opportunities to build coordinated system of family support n New Title V block grant performance and outcome

measures

n Start with something!

+Accelerate achievement of results

n  Forge meaningful connections between educators, pediatricians and public health

n Early education and care n Incorporate population health promoting criteria

into licensure, inspections

n Clinical care n Use hospitals’ community investment to promote

public-private partnership & multi-stakeholder initiatives

n Connect with and participate in community level public health initiatives

+Answering the challenge

n Early Head Start

n Universal Pre-K and full day kindergarten

n Universal lunch and breakfast

n Coordinated afterschool programs

n Integration of WIC with community health centers and home visiting initiatives

n Nomination of physician, business and educator champions to bridge sector gaps

n Identification of contracting and procurement opportunities

+ 23

Home Visiting: a key piece of the puzzle of systems building for families

MA Home Visiting

Early Learning Challenge Grant Early Childhood

Data Systems

Early Childhood Subcommittee,

Youth Readiness Cabinet

+ 24

Shared Priorities Across State Agencies

Data systems

Coordinated approach to screening &

assessment

Cross training on child health, development,

family wellbeing

Shared standards

+Opportunities in Title V Block Grant: 3 tiered performance measures n National outcome measures

n  Infant mortality, preterm birth n  Prevalence of autism spectrum disorder, attention deficit

disorder, mental & behavioral conditions n  Prevalence of & systems of care for children with special health

care needs (CSHCN)

n National performance measures n  Maternal and women’s health n  Perinatal and infant health n  Child health – developmental screening, 9-71 months n  Adolescent health n  Life course n  CSHCN

n Structural process measures – not due until July 2016

+Consider a CoIIN for Early Childhood

n Collaborative Improvement and Innovation Network n  Multiple sectors, multiple key stakeholders

n  Federal, state, local, private partners

n  Focus on real-time data for meaningful results

n  Incorporate multiple types of tools

n  Quality improvement

n  Policy change

n  Regulation

n  Programs

n  Achieve results at scale and sustain them

+Who should come to the party?

n  Public health department n  WIC n  Early Intervention n  Children with special health

care needs n  School health n  Adolescent health n  Chronic disease and

prevention n  Substance abuse prevention

and treatment n  Violence and injury

prevention

n  Education department n  Head Start & Early Head

Start

n  Pre – K & Kindergarten

n  Special education

n  Counseling services

n  School nutrition

+

n  State, county & city government

n  Medicaid

n  Office of Equity or Minority Health

n  Social service agency

n  Housing agency

n  Legislative committees

n  Mayor’s office

n  Governor’s office

n  Regional federal staff

n  Provider and professional organizations

n  AAP

n  School nurses

n  National Conference of State Legislators

n  National Governors Association

n  Health Insurers

n  Foundations/Philanthropy

Who should come to the party?

+Who should come to the party?

n  Community based organizations

n  Business organizations

n  Cultural groups

n  Faith-based organizations

n  Refugee & immigrant health organizations

n  Parent-teacher associations

n  State/local initiatives n  Perinatal quality

collaboratives

n  National Governor’s Association Improving Birth Outcomes Learning Network

n  Home visiting initiatives ($106 M)

n  Healthy Start ($65 M)

+Together we are stronger

Public Health

Education

Clinical Care

Community

+

+“It always seems impossible until it is done.” Nelson Mandela

+

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