Developmental Specialists in Pediatric Practices: Perspectives of Clinicians and Staff

As part of the Healthy Steps for Young Children initiative, 15 pediatric practices across the country incorporated early child development specialists into their teams; these "Healthy Steps Specialists" meet with families in offices and conduct home visits, address behavioral concerns, and make referrals. A survey of clinicians and staff at the 15 practices finds that the specialists have become well integrated into pediatric practice, are a trusted source of information, and are being consulted for a variety of developmental concerns. The specialists typically have backgrounds in pediatric nursing, child development, social work, or counseling.

An article based on the survey, Developmental Specialists in Pediatric Practices: Perspectives of Clinicians and Staff (Ambulatory Pediatrics, Nov./Dec. 2003), by C. S. Minkovitz and colleagues at the John Hopkins Bloomberg School of Public Health, examines how the introduction of Healthy Steps Specialists and enhanced developmental services has affected clinical teams. All members of pediatric practices--including physicians and nurse practitioners, nurses and other clinical workers, and clerical and administrative staff--were surveyed before the introduction of Healthy Steps Specialists and then 30 months later. Survey respondents reported on barriers to providing well-child care, visit length, and their perceptions of the quality of care they provide.

For the Healthy Steps evaluation, about 400 newborns were assigned to intervention and control groups at six randomization design (RND) sites. Children in the control group had no contact with Healthy Steps Specialists and their families did not receive Healthy Steps materials. Circumstances prevented randomization at the other sites, but up to 200 children were assigned to control and intervention practices and followed from birth to age 3 for nine quasi-experimental (QE) sites.

Barriers to Care
The researchers found that a number of commonly cited barriers to providing well-child care persisted over the study period. At baseline, from one of three (31.6%-QE intervention) to more than half (52.6%-QE control) of clinicians reported that limited staff was a barrier to delivering high-quality services. Similar percentages of clinicians reported problems with managed care organizations or Medicaid reimbursement, and somewhat higher numbers reported that lack of time was a barrier (42% of QE control respondents and 53.1% of RND respondents).

At the QE sites, the percentages of clinicians reporting such barriers did not change significantly over time, and there were no statistically significant differences between the intervention and control groups. At the RND sites, clinicians were three times as likely to report that lack of time was a barrier to care after 30 months, but no significant changes were reported in other areas.

Time Spent in Well-Child Visits
Clinicians reported that, at baseline, well-child visits took an average of 25.1 minutes at intervention practices and 21.6 minutes at control practices. After 30 months had passed, average visit length at QE control sites declined to 17.8 minutes, while there was no change at QE intervention sites. At baseline at the RND sites, clinicians reported 22.4 minute average visits; after 30 months, the reported visit length had declined to 18.6 minutes for intervention families and 19.4 minutes for control families. The authors conclude that the introduction of Healthy Steps Specialists and services did not affect the length of visits at the 15 practices.

Topics Discussed with Parents
The majority of clinicians reported that they discussed the importance of routines with families, and about half reported that they discussed risk topics with them. At the QE sites, there were not significant changes over time on these measures. At RND sites, fewer clinicians said that they discussed routines with intervention families, while more clinicians reported discussing this issue with control families. The authors suggest that clinicians may have been relying on Healthy Steps Specialists to provide this information to the intervention families.

Satisfaction in Meeting Parents' Needs
Clinicians at the QE intervention sites and at RND sites were significantly more likely to report being very satisfied with clinical staff's ability to meet the needs of intervention parents after 30 months than they were at baseline—a finding that, the authors suggest, could be due to the additional resources and organized approach to care provided by Healthy Steps. Clinicians were less satisfied with their ability to meet developmental and behavioral needs of children in the control group, with no significant changes reported over time.

Perception of Specialists' Roles
The vast majority of clinicians and staff serving intervention families acknowledged the benefits of Healthy Steps Specialists (see table). Surveyed after 30 months at the QE sites, all clinicians and clinical staff (100%) and most non-clinical staff (86.5%) agreed or strongly agreed that the specialists talked to parents about their child's behavior or development, demonstrated activities and provided them with information, and gave them with emotional support. Further investigation showed that, as clinicians worked with the specialists over time, their acknowledgment of the specialists' services grew and they became more satisfied with the care being provided to families by their clinical staff. Clinicians' perceptions of the specialists were most positive, followed in declining order by clinical staff and then by non-clinical staff.

In general, clinicians and practice staff viewed the activities of the specialists as an effective way to focus attention on behavioral and developmental needs. The authors note that, at baseline, they found inherent variability among pediatric practices in terms of barriers to care, visit length, and satisfaction levels. This survey underscores the complexity of organizational change within clinical settings, and the importance of including perspectives of all staff members, as well as clinicians, in future quality improvement efforts.