Executive Summary
Healthy Steps: The First Three Years
Healthy Steps: The First Three Years
Executive Summary
Women’s and Children’s Health Policy Center
Department of Population and Family Health Sciences
Johns Hopkins Bloomberg School of Public Health
February 28, 2003
Executive Summary
Healthy Steps: The First Three Years
HEALTHY STEPS: THE FIRST THREE YEARS
The Healthy Steps for Young Children program began in
1995 as a new approach to primary health care for young
children, birth to age three. The program was intended to
enhance early pediatric care by incorporating preventive
developmental and behavioral services as part of a
comprehensive, whole-child, whole-family model of health
care and to help provide mothers and fathers with the
child rearing information and guidance they seek. It was
specifically designed to promote improvements in:
The clinical capacity and effectiveness of pediatric
primary care to better meet the needs of families
with young children;
The knowledge, skills and confidence of mothers
and fathers in their childrearing abilities; and
The health and development of young children.
Initially provided in 24 practices, Healthy Steps has now
been offered in more than 47 sites, and thousands of
children and families have received home visits and other
services through the program. It has resulted in
measurable benefits – in developmental screenings for
young children, child and parent safety measures, more
immunizations, and access to special services within and
outside of the pediatric practice.
This progress occurred during challenging times in
American health care with increasing health care costs,
decreases in health care coverage, and tightening of
private, state and federal budgets. This has been
particularly true recently as resources have been shifting
from human services to other priorities including national
security and public safety. Despite this climate, both new
practices and existing practices continue to seek ways to
implement Healthy Steps.
The Healthy Steps Program and Evaluation
Healthy Steps broke new ground both in its approach and
in the range of families served. It emphasized normal
child development in primary health care by adding
specialists in child development – nurses, social workers,
or in some instances, experts from the child development
field – to 24 practice sites throughout the United States
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Healthy Steps: The First Three Years
that were selected for the program. The sites included
HMO practices, hospital clinics and private practices.
These child development specialists, called Healthy Steps
Specialists, expanded the traditional services offered in
pediatric and family practices to include:
Enhanced well child visits, conducted jointly or
sequentially by the clinician and Healthy Steps
Specialist;
Home visits;
A child development telephone information line;
Child development and family health checkups
with developmental screening;
Written materials for parents that emphasize
prevention and health promotion;
Parent groups offering social support and
interactive learning; and
Linkages to community resources.
Through the Healthy Steps Specialists and these expanded
services, Healthy Steps provided mothers and fathers with
authoritative information and opportunities to consult a
trusted source on concerns regarding child health,
behavior and development. It was designed to benefit all
families – not just vulnerable subgroups. More than 4,000
families of many ethnic backgrounds across the
socioeconomic spectrum received Healthy Steps services.
Fifteen of the original 24 sites were included in an
independent program evaluation (see box). The evaluation
was charged with assessing the process, outcomes, costs,
and sustainability of the program. This executive
summary focuses on the five areas covered in the
evaluation: changing pediatric practice; quality of care;
parent and child outcomes; program costs; and
sustainability.
Changing Pediatric Practice
The Healthy Steps program was designed to change
pediatric practice. The processes used to select the
participating practices, to train staff, to foster and support
teamwork, to monitor implementation, and to provide
operational support were concentrated and sustained
throughout the program demonstration period. The
intervention was fully implemented from the beginning
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Healthy Steps: The First Three Years
and resulted in improvements in the pediatric care
delivered – even by practices observed to be of very high
quality prior to the program’s start.
Physicians reported that Healthy Steps facilitated a team
approach, increased their understanding of family’s needs,
and allowed a greater focus on child development and
preventive care. Both clinicians and administrators viewed
Healthy Steps as a valuable service that helped keep
families in their practices and promoted regular
attendance for well child checkups.
One hallmark of the program was the relationship that the
Healthy Steps Specialist developed with families. This
relationship made it possible to provide enhanced services
and strengthened the bond between families and the
practice. Healthy Steps Specialists located in sites with
residency training programs also promoted education
about child development and family psychosocial issues.
Healthy Steps was a “real world” experiment, successfully
implemented in a time of resource constraints on practicebased care. The Healthy Steps practices experienced many
The Healthy Steps Evaluation
The final report describes results from the 15-site national evaluation. The
evaluation sample included 5,565 children and their parents (intervention
and control) enrolled at birth and followed for three years. At six sites,
newborns were assigned randomly to the intervention or control group; at
nine sites, a quasi-experimental design was used and a comparison location
for the Healthy Steps practice was selected.
The practices and families included in the evaluation shared some important
characteristics with all practices and families throughout the United States.
Participating sites represented a range of organizational practice settings.
Among them were community-based group practices, pediatric clinics
located within academic medical centers, and staff model managed care
organizations.
Two of the 15 sites also participated in an embedded, direct observation
study. The embedded study assessed the program’s effect on the home
environment, mother-child interaction, and child development.
Nine additional sites implemented Healthy Steps in the same way as the 15
national evaluation sites. They are referred to as affiliate sites. Six affiliate
sites were involved in a more limited evaluation. Findings from the affiliate
evaluation complement the larger evaluation. Results of the embedded study
and the affiliate evaluation also are summarized here. Two of the remaining
affiliate sites implemented their own formal evaluations, which are not yet
completed, and one affiliate site participated in a local evaluation.
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Executive Summary
Healthy Steps: The First Three Years
changes over time, including changes in practice
ownership, administration, and staffing. Despite these
barriers to delivering quality care, clinicians serving
Healthy Steps families at sites where the same clinicians
saw both intervention and control families were more
satisfied with their clinical staff’s ability to meet the
developmental and behavioral needs of children in the
Healthy Steps program.
Thirty months after beginning the program, clinicians
caring for both intervention and control families:
Had over 5 times the odds of being very satisfied
with the ability of their clinical staff (nurses, other
clinical staff, and Healthy Steps Specialists) to meet
the developmental and behavior needs of
intervention children than they were when the
program began. Their satisfaction with the care the
clinical staff without the HS Specialist provided to
control children did not change significantly.
The major challenges of Healthy Steps related primarily
to implementation. Healthy Steps required a
transformation in the way health care was implemented in
pediatric primary care practices. It changed the way in
which many staff – whether part of Healthy Steps or not –
related to the practice and to each other. In most cases,
implementing the program disrupted long established
procedures. Scheduling difficulties, record keeping
systems, space constraints, patient flow, and threats to the
roles of staff were some of the specific difficulties that were
handled, generally quite successfully, across practices.
Enhancing the Quality of Care
Healthy Steps was implemented during a time of growing
concern about the quality of health care in the United
States. A series of sentinel reports published by The
Institute of Medicine highlighted the overall poor quality
of care in the US and its negative consequences for
patients, families, clinicians, and the overall health care
delivery system (Institute of Medicine, 2001). At the same
time, national surveys of parents of young children
highlighted the fact that parents’ needs were not being
met with regard to helping them properly guide their
young children’s behavior and development (Young et al.,
1998; Halfon et al., 2000; Bethell et al., 2001). In
particular, parents reported that anticipatory guidance on
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Healthy Steps: The First Three Years
salient topics was not provided. In addition, their children
did not receive all appropriate well child care, including
recommended vaccinations and developmental screenings.
In contrast, Healthy Steps succeeded in enhancing the
quality of care. The degree to which Healthy Steps
achieved its goal of “increasing the capacity and
effectiveness of pediatric care” can be described by
highlighting results that are consistent with five of the six
key domains of quality described by the Institute of
Medicine (IOM): effectiveness; patient or familycenteredness; timeliness; efficiency; and equity.* A sixth
domain, safety, was not directly addressed by Healthy
Steps.
Effectiveness
Families in the intervention group, across all 15 sites,
received enhanced pediatric and developmental services in
far greater percentages than did families in the control
group.†
The odds that intervention families would receive the
following services increased:
20 times for receiving 4 or more of the Healthy
Steps services;
16 times for a home visit;
10 times for discussing 6 or more age-appropriate
topics with someone from the pediatric practice;
8 times for receiving a developmental assessment;
4 times for receiving information on community
resources; and
29 times for receiving books to read to their child.
* The Institute of Medicine Report defines six specific aims for improvement: 1)
effectiveness: providing services that are consistent with current scientific knowledge; 2)
patient centeredness: improving families’ experiences seeking care for their children and
developing effective partnerships with clinicians and pediatric practices; 3) timeliness:
obtaining needed care and avoiding unnecessary delays; 4) efficiency: health care services
delivered in such as way as to avoid waste, such as frequent changes in practice; 5)
equity: not varying in quality because of personal characteristics, including
socioeconomic status; 6) safety: not directly addressed within the Healthy Steps
Program): avoiding injuries to patients from care that is intended to help.
†Analyses reported in the executive summary account for baseline characteristics and
the fact that families within sites tend to be more similar to one another than they are to
families at other sites. Results reported are statistically significant. Unless otherwise
indicated, outcomes were measured when children were 30-33 months of age.
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Executive Summary
Healthy Steps: The First Three Years
Patient and Family Centeredness
Healthy Steps successfully strengthened relationships
between families and their pediatric practice, providing
them with an additional source of support from Healthy
Steps Specialists, clinicians, and practice staff. Intervention
families were significantly more likely to rely on someone
at the practice for developmental advice and to be satisfied
with the care they received.
Intervention families had:
2 times the odds of reporting that someone at the
practice went out of the way for them;
63% to 33% lower odds (depending on the aspect of
care) of being dissatisfied with the care they
received from their child’s physician or nurse
practitioners;
More than 1.5 times the odds of saying they would
rely on someone in the practice for advice about
their baby’s speech rather than a relative, a friend,
or another source.‡
Timeliness
Despite high baseline levels of well child care utilization
and immunization among all children in the Healthy Steps
evaluation, intervention children were significantly more
likely to attend age-appropriate well child visits and to be
immunized on time.
The odds that HS intervention children would receive the
following services increased:
1.5 to 2.4 times (depending on the age at visit) for
receiving age- appropriate well-child care;
1.4 to 1.6 times (depending on the vaccine dose) for
receiving age-appropriate vaccination; and
1.4 times for being up-to-date on their vaccinations
by 2 years of age.
This outcome was measured when children were 6 months of age and 12 months of
age.
‡
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Executive Summary
Healthy Steps: The First Three Years
Efficiency
One aspect of efficiency evaluated was whether families
used the Healthy Steps practice differently, captured as the
date of the last visit recorded in the medical record.
Intervention children had:
1.8 times the odds of continuing to receive care at
the practice through at least 20 months of age.
The greater percentage of families having recent visits
indicates that Healthy Steps increased the length of time
that children continuously used the practice for their care.
It is likely that this increased continuity contributed to
improvements in the timeliness of well child care and
vaccinations, receipt of developmental assessments, and
receipt of Healthy Steps core services.
No differences in health status and health care utilization
measures for acute care were noted—including mothers’
perceptions of their child’s health, injuries requiring
medical treatment, overall emergency department use, and
hospitalizations. The exception was that intervention
children were less likely to be seen for their injuries in the
emergency department. This finding may represent less
severe injuries, or more likely, differences in how the
practices approached injury care.
Equity
Healthy Steps promoted equitable delivery of services to
families, consistent with its goal of universality. Families
in the intervention group, regardless of income or the age
of the baby’s mother, received services in far greater
percentages than did families in the control group. At
baseline, higher income families and older mothers
received fewer services; Healthy Steps brought them from
very low levels to levels that were comparable to other
groups. Contrary to expectations, few differences were
found between first-time and second or greater-time
mothers in receipt of services, satisfaction with care, or
other outcomes. These findings suggest that families of
all income groups and levels of experience appreciated
these services and found them helpful.
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Executive Summary
Healthy Steps: The First Three Years
Improving Parent and Child Outcomes
Compared with other programs aimed at changing parent
and child outcomes, Healthy Steps was a program of
relatively “modest” intensity. The average family made
nine well child visits and received fewer than two home
visits within their child’s first two and a half years.
Nonetheless, the evidence suggests that Healthy Steps
contributed to establishing a firm foundation for the
children’s healthy growth and development, setting
parents on a trajectory of good parenting practices.
Parenting Practices
Significant program effects were found regarding specific
parenting practices that promote the health and
development of infants.
The odds that intervention mothers would perform the
following practices were:
24% lower for placing their newborns on their
stomachs to sleep, thereby reducing the risk of
sudden infant death syndrome (SIDS);
22% lower for giving their newborns water;§
16% lower for introducing cereal by 2-4 months of
age;
22% higher for showing picture books to their
infants every day; and
24% higher for playing with their infant every day.
Differences also were found in mothers’ self-reported
responses to their toddler’s misbehaviors. Mothers who
received Healthy Steps services were less likely to use
harsh punishment.
The odds that intervention mothers would report use of
harsh punishment were:
30% lower for reporting that they used severe physical
discipline with their child----slapped their child in the
face or spanked him/her with a belt or other object;
and
Water is not recommended in early infancy due to the need for caloric intake as well as
the risk to infants of water intoxication.
§
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Executive Summary
Healthy Steps: The First Three Years
22% lower for relying on other harsh strategies.
These included yelling, threatening, slapping their
child’s hands, or spanking with their hand.
Amidst generally high use of safety practices, no
significant differences between the intervention and
control groups were found in toddler safety practices. In
addition, the program did not affect the initiation or
continuation of breastfeeding. In this case, it may be that
the Healthy Steps Specialists’ contacts with families came
too late to influence the mothers’ decisions regarding
breast-feeding.
Maternal
Interests
Sensitivity
to
Child’s
Behavior
and
Healthy Steps mothers interacted more positively with
their toddlers than control mothers.
In the embedded observation study, intervention mothers:
Were more likely to match their behavior to their
child’s developmental level, interests, and
capabilities when playing with their toddlers.
Further, intervention mothers and their children:
Showed more sensitivity to each other’s cues
during a teaching activity.
Maternal Perceptions of Child Behavior
Mothers’ perceptions of their children’s emotional and
behavioral problems fell within the normal range for
reported behaviors.
However, intervention mothers:
Were more likely than control mothers to report
aggressive behaviors and sleep problems in their
children.
This could be because Healthy Steps children actually had
more behavioral/emotional problems than children in the
control group. A more likely explanation is that Healthy
Steps affected how mothers perceived their child’s
behavior (and misbehavior) and possibly increased their
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Executive Summary
Healthy Steps: The First Three Years
level of comfort in discussing their child’s behavior with
others.
Mother’s Discussion of Sadness
Although no differences in the prevalence of depressive
symptoms were noted there were differences in mothers’
reported discussion of their own emotional states.
Among mothers in the intervention group who had
experienced sadness, reported depressive symptoms, or
limited their activities because of feeling anxious or
depressed, we found:
1.6 times the odds of reporting that they had
discussed feeling sad with someone in the pediatric
practice.
Other Parent and Child Outcomes
No effects were found in measures of mothers’ child
development knowledge, mothers’ daily stress, parenting
sense of competence, mothers’ reports of their behaviors
related to nurturing and expectations of children, or
reports of children’s language development at age two.
These results are generally consistent with findings from
other interventions targeted toward parents; that is,
significant effects tend to be observed in parenting
outcomes and fewer in child outcomes, particularly in the
short term.
Program Costs and Benefits
In year 2000 dollars, the cost of offering ongoing Healthy
Steps services was estimated at $933 per family per year in
the evaluation model where caseload (162 families) and
case mix were dictated by pre-determined research
conditions. In a fully implemented Healthy Steps program
serving children across the zero to three age range, the
cost could be reduced to $402 per family per year (serving
463 families).
The benefits of Healthy Steps fall into three categories:
Short term benefits that can be monetized;
Short term benefits that cannot be monetized; and
Potential long term benefits.
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Executive Summary
Healthy Steps: The First Three Years
In the first category are benefits associated with reduced
potential SIDS mortality, improved immunization rates,
parental satisfaction with care, and practice retention.
While valuation is complex and uncertain, when
monetized using conventional techniques, these benefits
would likely fall in a range of approximately $100 to $317
per family per year.
The evaluation found beneficial behavioral changes in
certain other categories where sufficient literature does
not exist connecting these changes to monetizable
outcomes. They included: improvement in the overall
quality of primary pediatric care; reduction in use of severe
physical discipline by parents; increased provision of
developmental assessments to young children; and
increased assistance to mothers exhibiting depressive
symptoms.
Finally, other studies that have followed children into
adulthood have shown that early childhood interventions
have the potential to provide significant benefits in
adulthood. These benefits tend to accrue outside the
health care field, in areas such as education, juvenile
justice, and employment. They include increased
socialization and enhanced cognitive skills and can
manifest themselves in increased employment, reduced
unemployment, and reduced receipt of welfare assistance.
Sustainability
Healthy Steps was implemented as a time-limited
demonstration program of one specific approach to
improving pediatric practice nationally. An important
factor in judging the overall success of the program is the
extent to which the pediatric practices involved in the 15site evaluation have continued with the innovations
introduced by Healthy Steps.
Approximately a year and a half after the demonstration
program ended at the 15 evaluation sites:
8 sites continued to employ at least one Healthy
Steps Specialist. Each of these eight practices
offered five or more Healthy Steps services. Four of
these eight sites had restricted the program to a
targeted group of families.
3 sites no longer employed a Healthy Steps
Specialist, but had sustained limited Healthy Steps
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Healthy Steps: The First Three Years
activities by referring parents to other providers
for selected Healthy Steps services and/or by
adopting the Healthy Steps philosophy in practice
routines.
4 sites had ceased Healthy Steps operations
entirely.
At two of the sites that provided minimal or no Healthy
Steps services, new Healthy Steps or Healthy Steps-like
practices had emerged in other locations nearby in the
host community.
The eight sustained programs shared some important
characteristics. In addition to the active original funders:
All 8 programs reported having at least one new
(during the evaluation period) source of financial
support;
6 of the 8 programs reported positive changes in
the practice environment;
4 had multiple leaders championing the program as
well as active local advisory committees; and
5 had adapted their programs and taken other
actions, early on, to sustain them. These steps
included both formal and informal “marketing” to
community groups, academic institutions, and
community coalitions; garnering transitional or
“bridge” funds; or developing internal cost
substitutions.
A national partnership—reflecting the combined efforts of
The Commonwealth Fund, a team of pediatric experts
from Boston University School of Medicine, the National
Program Office (ICF Consulting), and the National
Advisory Committee and the Local Funders Network—
played important roles at the level of the individual
Healthy Steps program demonstration sites ensuring
robust program implementation through training and
technical consultation and by encouraging initial
community “buy-in.”
The national partnership’s influence in diffusing the
Healthy Steps concept and program is evidenced in the
volume and array of emerging Healthy Steps-like practices
and processes. Five of the original nine Healthy Steps
affiliate sites continue to operate the program and four are
fostering new activities in public health agencies,
residency programs, and neonatal intensive care units.
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Executive Summary
Healthy Steps: The First Three Years
Twenty-one new practices and one statewide initiative
have adopted Healthy Steps of which eight are Healthy
Steps sites providing residency training programs. This
expansion has been achieved in the context of considerable
health systems change, increasing fiscal pressures on both
private sector medical institutions and public health
service programs, and major cost containment efforts on
the part of employers, health plans, and public grant and
insurance programs.
Summary
As a pediatric primary care intervention, Healthy Steps
was eminently successful. It demonstrated that the quality
of pediatric care can be improved so that the care young
children and their families receive is effective, patient- and
family-centered, timely, efficient, and equitable. The
program also showed that preventive and developmental
services can be effectively delivered in pediatric primary
care settings and that utilization of pediatric primary care,
immunization rates, and parents’ satisfaction with their
child's primary care can be improved. Healthy Steps added
to our body of knowledge indicating that physicians not
only are willing to engage in partnerships with nonphysicians, but also are satisfied with and appreciate the
value these new specialists bring to the practice and the
families they serve.
The evidence suggests that Healthy Steps contributed to
setting parents on a positive trajectory for several sentinel
parenting practices that are important to healthy child
growth and development.
Healthy Steps positively
affected infant sleep position and increased mother-child
activities (showing picture books and play). With respect
to discipline practices, Healthy Steps had a positive effect
on reducing parental use of harsh discipline strategies,
particularly severe physical discipline. Healthy Steps
parents also were found to interact more positively with
their young children, being more sensitive to their child's
cues.
In conclusion, Healthy Steps successfully redesigned
primary health care to refocus attention on preventive
services, child development, and effective parenting
practices. The Healthy Steps model has shown itself to
have significant benefits for children, families, and
pediatric care in the United States.
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