Children Get Better Care, Parent Satisfaction Improves When Physicians Have Developmental Specialists On Team, Says New JAMA Study

BALTIMORE, MD, December 16, 2003—The nation's first, large clinical trial designed to improve delivery of developmental and behavioral services to young children has improved quality of care, enhanced communications between pediatricians and parents, and helped children receive appropriate preventive services, according to a national evaluation of the program that appears in today's issue of the Journal of the American Medical Association. An evaluation of "Healthy Steps for Young Children" by researchers at the Johns Hopkins Bloomberg School of Public Health found physician practices with childhood developmental specialists on staff showed "significant improvements" in effectiveness, patient-centeredness, timeliness, and efficiency of care. These improvements included marked parental satisfaction with the services they received; timelier preventive care such as immunizations; and receipt of more developmental services. Healthy Steps was developed with funding from The Commonwealth Fund, a national foundation based in New York that supports research on health policy issues, with support from The Robert Wood Johnson Foundation and more than 100 funding partners. It is unique among childhood interventions because it is based in a medical setting, takes a universal approach to addressing families' needs, introduces a new developmental specialist into medical practice, and fosters a team-based approach to delivering patient care. Healthy Steps has been successfully implemented in pediatric and family medicine practices, hospital and community clinics, HMOs, and residency training programs. "For all children, not just those at high-risk, the quality of pediatric care in the first three years of life was dramatically improved because of this intervention," says lead evaluator Cynthia Minkovitz, MD, MPP, associate professor in the Department of Population and Family Health Sciences at Johns Hopkins. "In addition, it has produced more favorable disciplinary practices and helped parents better understand children's behavior and development," she says. Healthy Steps began in 1996. The program, now in 35 sites in 15 states, was launched by a national funding partnership to help pediatricians and family physicians better serve their patients and to encourage parental practices that help nurture emotional, behavioral and intellectual growth of children from birth to age 3. Commonwealth Fund-supported research and other surveys have shown that many parents want more guidance in early developmental issues such as toilet training and sleep management. Researchers note that many parents do not fully understand how their daily interactions with babies and toddlers affect development and learning. In turn, many clinicians are frustrated that they cannot offer the time required to help parents better understand how to care for their young children. "Healthy Steps was developed in response to the needs and expectations of parents, who say they want information on their children's development," says Karen Davis, president of The Commonwealth Fund, which is based in New York. "Too often these needs are not met by pediatric practices, resulting in missed opportunities to identify and address problems at an early stage. Healthy Steps is a way to provide these services as part of regular pediatric care for young children," she says. Under Healthy Steps, participating pediatric practices were able to hire and train two childhood development specialists (such as a nurse, a nurse practitioner, social worker, or early childhood educator), whose roles were to monitor behavioral development, promote good health practices, make home visits, and respond to parental concerns about infant and toddler development. Hopkins evaluators conducted a controlled clinical trial between 1996 and 2001 at 15 Healthy Steps practices across the United States. The evaluation followed 5,565 children enrolled in Healthy Steps at birth. Evaluators found that families participating in the program were more likely to:

• Discuss concerns with someone in the practice about a variety of issues such as the importance of routines, discipline, reading to children, language development, child's temperament, and sleeping patterns
• Be highly satisfied with care because someone in the practice went out of their way for them
• Receive timely well-child visits and vaccinations
• Remain at the practice for at least 20 months; children who received Healthy Steps also had increased odds of having a visit after 20 months.

In addition, evaluators found that parents who participated in the intervention were less likely to use severe discipline on their child, such as spanking with an object, yelling, or slapping in the face; and, mothers considered at high-risk for depression who participated in the Healthy Steps program were more likely to discuss their feelings of sadness with someone in the practice. "Having a developmental specialist as a team member should be a standard way of practice for pediatricians," says Barry Zuckerman, MD, Chief of the Pediatrics Department at Boston Medical Center. "The kinds of questions and concerns parents have need attention, but in a busy practice physicians must manage a variety of complex situations and do not have sufficient time during the visit," says Zuckerman, the architect of the Healthy Steps concept. "Physicians say they are more effective when they have a colleague with the necessary skills in behavior and development who can take the time to address parent's concerns," he adds. Although the developmental services that the program offers are generally not reimbursed by health insurers, many of the original Healthy Steps sites continue to offer these services and new practices are starting to do so regularly. Proponents say Healthy Steps services should be reimbursable by health insurers. An accompanying editorial on the program that appears in the same issue of JAMA says that the Healthy Steps evaluation "provides important evidence that by changing the structure and process of pediatric care, performance in the delivery of pediatric developmental services can be improved significantly." Neal Halfon, MD, MPH and Moira Inkelas, PhD, MPH, of the UCLA Center for Healthier Children, Families and Communities, say that "given the promising results of the Healthy Step evaluation and the emergence of other complementary interventions and approaches to improvements, it is important to consider a more integrated and population-based strategy to improving early childhood health." The federal Agency for Healthcare Research and Quality and The Commonwealth Fund are supporting an ongoing national evaluation of Healthy Steps as children reach 5.5 years of age. In 2003, The Robert Wood Johnson Foundation, provided funding to diffuse the Healthy Steps approach to more pediatric and family medicine practice sites.