Program Goals:

Children's success both in school and later in life depends on the quality of their early experiences and the ability of their parents and caretakers to anticipate and meet their developmental needs. Through regular contact with parents and young children, child health care providers can foster positive parenting behaviors to promote optimal development, identify children with or at risk for developmental problems, and initiate referral for intervention services when problems appear imminent.

The Commonwealth Fund's Child Development and Preventive Care Program seeks to encourage, support, and sustain improvements in preventive care for young children—particularly those services that address their cognitive, emotional, and social development. The program supports projects that:

• promote the establishment of standards of care and the use of these standards in quality measurement and monitoring;
• identify and disseminate models of pediatric practice that enhance the efficiency and effectiveness of care provided; and
• encourage policy reforms that remove barriers to quality care and align provider incentives with desired clinical practices.

The program is led by Vice President Edward Schor, M.D.

The Issues:

In the United States, the quality of preventive care—commonly referred to as well-child care—is highly variable. Research studies find that children attend only about half of the well-child visits recommended by national guidelines. And minority, uninsured, or economically disadvantaged parents are two to four times more likely than their white, insured, and more affluent counterparts to be dissatisfied with their children's care, especially care related to promoting growth and development. Nearly all parents report unmet needs for parenting guidance, education, or screening by a pediatric professional.

For their part, child health care professionals report many obstacles to providing quality well-child care: time constraints, low levels of reimbursement, lack of training in child development, and limited access to community support services for patients, as well as few external incentives. Taken together, these findings form a compelling case for reexamining the structure, content, and processes of pediatric care.

Recent Projects:

A High-Performing System for Well-Child Care. Several recent Fund projects provide guidance on how to redesign the structures and procedures of office practice. For one such project, David Bergman, M.D., of Stanford University, identified models that can contribute to the development of a high-performing system of preventive child health care and described innovative strategies for improving quality and efficiency in his Fund report, A High-Performing System for Well-Child Care: A Vision for the Future. This framework is now being implemented and evaluated at pilot practices in the Kaiser Permanante Colorado and Denver Health Plan health systems.

Assuring Better Child Health and Development. Through its Assuring Better Child Health and Development (ABCD) initiative, the Fund has had success in working directly with state Medicaid officials to adopt policies that support high-quality developmental services and in testing innovations in the delivery and reimbursement of care for low-income children. Building on earlier work with nine states, the ABCD initiative is now working with Medicaid programs in 19 additional states and territories, promoting the healthy mental development of young children by encouraging routine developmental and behavioral screening of young children and screening for parental depression. The ABCD projects are managed by Neva Kaye at the National Academy for State Health Policy, which provides technical assistance to the participating states and conveys lessons learned to policymakers and public health leaders across the nation.

Linking Families to Community Resources. In 2006, The Fund published the manual, How to Develop a Statewide System to Link Families with Community Resources: A Manual Based on Connecticut's "Help Me Grow" Initiative, by Paul Dworkin, M.D., of the Connecticut Children's Medical Center. Help Me Grow is a statewide referral and care coordination system that assists families and providers in identifying developmental concerns in young children and connects families to appropriate resources. A second phase of this project, now underway, will support efforts by Dr. Dworkin and his team to help five states replicate the Help Me Grow model.

Models of Statewide Collaboration. Recent experience demonstrates that creative reform of child health care policy and practice is likely to occur first among the states. The Vermont Child Health Improvement Program (VCHIP)—an exciting model of statewide collaboration—supports clinicians in their efforts to improve care by providing a centralized resource to guide and support quality improvement activities. With Fund support, VCHIP helped five other regions—in Kings County, Washington, Washington, D.C., and the states of Arizona, New York, and Rhode Island—develop improvement partnerships among state Medicaid programs, public health agencies, and local professional organizations. The improvement partnerships, which focused on strengthening the quality of developmental and preventive services for young children, proved successful, and this quality improvement model is now being implemented in five additional locations: Michigan, Minnesota, Ohio, Oklahoma and West Virginia. In this second phase of the project, staff are also creating a learning community of new and existing improvement partnerships and disseminating results nationwide.

Future Directions:

The Child Development and Preventive Care Program will continue to focus on improving preventive care for young children. Initiatives are underway to transform the practice of well-child care by developing new quality measures, engaging parents in redesigning care, and tailoring visits to the individual needs of a child and family. Encouraging states to adopt policies that promote structured screening and encouraging pediatric practices to make such screening routine continue to be major areas of focus.

The need for a comprehensive, freely available surveillance instrument to monitor young children's developmental and behavioral health has intensified, especially in Massachusetts, where a recent mandate requires child health care providers to conduct such surveillance at every well-child visit. With the advice of a team of experts, Ellen Perrin, M.D., and her colleagues at Tufts-New England Medical Center have begun to develop a Fund–supported conceptually and psychometrically appropriate instrument that will be in line with the American Academy of Pediatrics' recommended schedule for well-child care.

Current measures of well-child care focus primarily on whether visits occur at recommended intervals, rather than on the content or quality of those visits. Sarah Scholle, M.P.H., Dr.P.H., and a team of researchers at the National Committee for Quality Assurance (NCQA) have begun to develop a set of well-child care quality measures to gauge the extent and quality of developmental screening and assessment, anticipatory guidance, continuity of care, chronic condition management, and other critical aspects of preventive care.

Child health care providers find coordinating care to be a time-consuming and complicated service, for which they receive little or no reimbursement. Some states and communities are addressing this issue by creating systems of care coordination designed to support both families and practitioners. A new project will examine some of the most promising models in order to foster their dissemination and encourage continued innovation.

An anticipated new phase of ABCD work will build on the success of previous initiatives in promoting structured developmental screening in well-child care through practice and policy changes. ABCD III will focus on a related challenge: referring children for additional developmental services and integrating those services into ongoing care.

To apply for a grant from the Child Development and Preventive Care Program, visit the Applicant and Grantee Resources page.