Calvin Sia

Evaluation of Hawaii's Healthy Start Program

Hawaiis Healthy Start Program (HSP) is designed to prevent child abuse and neglect and to promote child health and development in newborns of families at risk for poor child outcomes. The program operates statewide in Hawaii and has inspired national and international adaptations, including Healthy Families America. This article describes HSP, its ongoing evaluation study, and evaluation findings at the end of two of a planned three years of family program participation and follow-up. After two years of service provision to families, HSP was successful in linking families with pediatric medical care, improving maternal parenting efficacy, decreasing maternal parenting stress, promoting the use of nonviolent discipline, and decreasing injuries resulting from partner violence in the home. No overall positive program impact emerged after two years of service in terms of the adequacy of well-child health care; maternal life skills, mental health, social support, or substance use; child development; the childs home learning environment or parent-child interaction; pediatric health care use for illness or injury; or child maltreatment (according to maternal reports and child protective services reports). However, there were agency-specific positive program effects on several outcomes, including parent-child interaction, child development, maternal confidence in adult relationships, and partner violence. Significant differences were found in program implementation between the three administering agencies included in the evaluation. These differences had implications for family participation and involvement levels and, possibly, for outcomes achieved. The authors conclude that home visiting programs and evaluations should monitor program implementation for faithfulness to the program model, and should employ comparison groups to determine program impact.

Patient- and Family-Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multiple Systems

Understanding a care coordination framework, its functions, and its effects on children and families is critical for patients and families themselves, as well as for pediatricians, pediatric medical subspecialists/surgical specialists, and anyone providing services to children and families. Care coordination is an essential element of a transformed American health care delivery system that emphasizes optimal quality and cost outcomes, addresses family-centered care, and calls for partnership across various settings and communities. High-quality, cost-effective health care requires that the delivery system include elements for the provision of services supporting the coordination of care across settings and professionals. This requirement of supporting coordination of care is generally true for health systems providing care for all children and youth but especially for those with special health care needs. At the foundation of an efficient and effective system of care delivery is the patient-/family-centered medical home. From its inception, the medical home has had care coordination as a core element. In general, optimal outcomes for children and youth, especially those with special health care needs, require interfacing among multiple care systems and individuals, including the following: medical, social, and behavioral professionals; the educational system; payers; medical equipment providers; home care agencies; advocacy groups; needed supportive therapies/services; and families. Coordination of care across settings permits an integration of services that is centered on the comprehensive needs of the patient and family, leading to decreased health care costs, reduction in fragmented care, and improvement in the patient/family experience of care.

New workforce, practice, and payment reforms essential for improving access to pediatric subspecialty care within the medical home

T HE AVAILABILITY OF pediatric subspecialty care is critically important to the heal th and wel l being of infants, children, and adolescents. Moreover, timely collaboration with pediatric subspecialists is an essential element of the standard of care for children: the community-based medical home. The medical home model of care, with a generalist physician as the leader, has been shown to produce considerable economic and patient-level benefits. In this model, primary care practice teams coordinate all care for a patient, including subspecialty care. Unfortunately, lack of access to pediatric subspecialty care within the medical home has reached crisis proportions in the United States owing to several interrelated factors: an insufficient number of pediatric subspecialists, dramatically increasing demand for pediatric subspecialty care, a fragmented system of pediatric primary and specialty care, and inadequate f inancing of medical education and collaborative primary and specialty pediatric care through the medical home. In the United States, approximately 28 000 medical and surgical pediatric subspecialists serve 80 million children and youth. The ratio of board-certified pediatric subspecialists to children in each of the 31 specialties is hazardously low. Although the number of pediatric subspecialists has increased in the last decade, far too few physicians are being trained in nearly every pediatric subspecialty. For example, the American Board of Pediatrics reports that in 2007 there were only 19 first-year fellows in developmental behavioral pediatrics, 24 in adolescent medicine, and 26 in pediatric rheumatology. Compounding the pipeline problems are increasing retention difficulties, a growing retirement rate, the tendency of younger physicians to limit their hours of practice, and the overall shortage of physicians. Furthermore, as the elderly population grows, the availability of adult specialists, many of whom care for children in areas where pediatric subspecialists are unavailable, is eroding. In addition to the problem of a shrinking workforce, demand for pediatric subspecialty care has reached unprecedented levels. During the last few decades, the incidence and prevalence of certain chronic conditions, such as attention-deficit/ hyperactivity disorder, asthma, depression, and obesity, have dramatically increased. Furthermore, the survival of infants and children with complex, formerly fatal conditions has become commonplace. Advances in medical and surgical care, technology, and drugs have clearly created new benefits and stresses on our pediatric care delivery systems. Changes in families’ knowledge and preferences for referral to specialty care are resulting in higher rates of referrals to pediatric subspecialists. Also affecting higher rates of specialty referral is the lack of adequate primary care capacity, resulting in a reduced amount of time that physicians can devote to identifying and managing chronic conditions. Underlying these obvious supplyand-demand problems is the worsening fragmentation between primary and specialty pediatric care. Despite the supporting evidence, resources to enable primary care practices to provide this level of care are not generally available. Lack of recognition of the importance of the medical home as the base of care coordination from the standpoint of reimbursement along with the absence of organized and efficient systems for referral, consultation, and collaborative care at the community and regional levels result in worsening fragmentation. Fragmentation is also aggravated by the uneven geographic distribution of pediatric subspecialists, the everchanging insurance and health plan enrollment of families, and the shifting composition of plans’ provider networks. Inadequate financing of graduate medical education and the lack of financing for continuing medical education for primary care providers further compromises access to pediatric subspecialty care within the medical home. Because payment for graduate medical education is a function, in part, of the percent of inpatient days attributable to caring for Medicare patients, hospitals serving children are at a distinct disadvantage. While a separate graduate medical education program operates for children’s hospitals, it is subject to low annual appropriations. In addition, the graduate medical education program is structured to discourage subspecialty training in favor of primary care training by counting fellows in subspecialty training at lower levels than resident physicians in their initial specialty training. Moreover, no funding sources are available to support primary care providers who are interested in pursuing additional specialized training. Equally significant is inadequate third-party payment. Between one-third to one-half of all children (depending on their age) are insured by Medicaid or the State Children’s Health Insurance Program, and children with special