Healthy Steps: A Case Study of Innovation in Pediatric Practice

Abstract

Healthy Steps (HS) represents a significant innovation in the way pediatric primary care can be delivered. Based on the standards and principles of Bright Futures and the American Academy of Pediatrics Health Supervision Guidelines, HS enhances and expands traditional pediatric care by including a child development specialist (Healthy Steps specialist) as part of the pediatric practice team. Services offered by this person, typically a nurse, early childhood educator, or social worker, include more time to spend discussing preventive issues during well-child visits, home visits, a telephone information line exclusively addressing developmental and behavioral concerns, new written materials, and more seamless linkages to community resources and parent support groups. The original HS cohort consisted of 15 pediatric practices in a variety of settings (private practices, health centers, pediatric training programs). Evaluated for the effects of HS on their family were 3737 intervention and comparison families. HS families received significantly more preventive and developmental services, compared to families in the control group. HS families were also less likely to be dissatisfied with their pediatric primary care. Additionally, HS had a positive impact on parenting in many areas including adherence to health visits, nutritional practices, developmental stimulation, appropriate disciplinary techniques, and correct sleeping position. Other outcome measures (such as initiation or duration of breastfeeding, child development knowledge, sense of competence, and reports of child language development at 2 years of age) did not differ between intervention and comparison group. Compared to other early childhood intervention efforts, HS offers a comparable positive impact on parenting at a relatively inexpensive cost: an estimated 400 dollars per family per year (compared to 4500 dollars from Early Head Start). Approximately 3 years after the evaluation of HS ended, 10 of the original 24 sites are still in operation, and an additional 24 sites have started up. Although funding and reimbursement remain an important barrier, continued growth of HS suggests an abiding interest in this approach to expand and enhance preventive and developmental care in pediatric primary care.

A Parent Coach Model for Well-Child Care Among Low-Income Children: A Randomized Controlled Trial

“…The role of the PC, however, is not to enhance WCC as currently provided by the pediatrician 43 but to instead serve as the primary provider of 7 We found a significant effect of the intervention on ED utilization, with a 52% reduction in the proportion of children with ≥2 ED visits, which would represent a substantial savings in costs over a large population of children. The rate of ED utilization in our control group is similar to national data, in which 15.3% of Medicaid-insured children aged <6 years made ≥2 ED visits in the previous 12 months.…”

Well-Child Care Clinical Practice Redesign for Serving Low-Income Children

“…10,30 Program costs, however, have limited its ability to be widely adopted. 31 Distinct from previous comprehensive models for redesigned WCC, the CABs had an explicit goal of decreasing reliance on physician time for routine WCC services while simultaneously providing more time for parents to discuss anticipatory guidance, psychosocial concerns, and developmental and behavioral concerns with a preventive care professional. The families served by these practices had multiple psychosocial needs often related to poverty, as well as numerous concerns regarding behavior and development.…”

The Role of Preschool Home-Visiting Programs in Improving Children's Developmental and Health Outcomes

“…43 The Commonwealth Fund's Healthy Steps intervention included home visiting by masters-level healthy development specialists with significant gains in the quality of well-child care, although the multifactorial nature of this intervention made it difficult to evaluate the effectiveness of the home-visiting component. [44][45][46] A South Carolina study showed that a program that linked school-based home visitors to group well-child visits resulted in greater retention of anticipatory guidance and improved satisfaction with care. 47 These initiatives provide a glimpse into the potential of linking home visitors with the pediatric medical home.…”