The Affiliate Evaluation
Final Report
Prepared by:
The Women’s & Children’s Health Policy Center
Johns Hopkins University
Bloomberg School of Public Health
November 2003
The Affiliate Evaluation
Final Report
 Johns Hopkins Bloomberg School of Public Health
Authors:
Tess Miller, Bernard Guyer, David Bishai, Diane Burkom, Becky
Clark, Allison Cosslett, Janice Genevro, Holly Grason,William Hou,
Nancy Hughart, Alison Snow Jones, Cynthia Minkovitz, Heather
Rutz, Daniel Scharfstein, Heather Stacy, Donna Strobino, Eleanor
Szanton, and Chao Tang.
Editor:
Janice Genevro
Contact:
Kamila Mistry
Project Director
Bloomberg School of Public Health
Johns Hopkins University
624 N. Broadway, Room 195
Baltimore, MD 21205
410-955-8694
[email protected]
Healthy Steps for Young Children is a program of The Commonwealth Fund
in collaboration with Boston University School of Medicine,
and local funders and health care providers across the nation.
Healthy Steps is co-sponsored by the American Academy of Pediatrics.
The Healthy Steps affiliate evaluation was carried out with grants from
The Atlantic Philanthropies, The Robert Wood Johnson Foundation and local funders.
The views presented here are those of the authors.
Table of Contents
Acknowledgments ................................................................................................................................ i
Executive Summary............................................................................................................................. ii
Introduction........................................................................................................................................... 1
What is Healthy Steps?....................................................................................................................... 1
How was Healthy Steps Evaluated? ................................................................................................ 2
Who Participated in the Affiliate Evaluation?............................................................................... 4
Pediatric Practices .................................................................................................................. 4
Families ..................................................................................................................................... 5
How was Healthy Steps Implemented at Affiliate Sites? ............................................................ 7
Integrating the HS Specialist into the Practice ............................................................... 7
Implementing the Healthy Steps Services ........................................................................ 8
What Services did HS Specialists Provide to Affiliate Families?.............................................. 12
What Services did Affiliate Families Report Receiving? ............................................................ 15
In What Ways Did Healthy Steps Add Value to Standard Pediatric Care at Affiliate Sites?
.................................................................................................................................................................. 17
Enhanced Relationships ........................................................................................................ 17
Increased Parent Satisfaction with Care ........................................................................... 18
Increased Provider Satisfaction........................................................................................... 19
Improved Teamwork and Practice Environment ........................................................... 19
Positive Parenting Practices and Improved Child Outcomes ...................................... 20
What Did We Learn from the Affiliate Evaluation?.................................................................... 26
What is happening at Affiliate Sites Now?..................................................................................... 28
Appendix I – Methodology ................................................................................................................ 30
Appendix II – Selected Outcomes .................................................................................................... 47
Acknowledgments
We wish to thank Margaret E. Mahoney, Karen Davis, Kathryn Taaffe McLearn, Edward
Schor, and members of the Healthy Steps National Advisory Committee for their guidance,
advice and support. We also are grateful to Michael Barth at ICF Consulting for his
tireless leadership and to his staff, Juliet Konvisser, Philip Rizzi, Cynthia Hansel, Nita
Hassan, Samantha Gill and Sara Rogers. The affiliate evaluation has greatly benefited from
the close collaboration of Barry Zuckerman, Margot Kaplan-Sanoff, Steven Parker, Andrea
Bernard and Tracy Magee at the Boston University School of Medicine.
Funding for the Affiliate evaluation was made possible through the generous support of The
Atlantic Philanthropies, The Robert Wood Johnson Foundation, and the following local
funders: Brown Foundation; The Chicago Community Trust; Children’s Trust Fund of
Texas; The Duke Endowment; Harris Foundation; Hogg Foundation for Mental Health; The
Houston Endowment; John D. and Catherine T. MacArthur Foundation; Kansas Health
Foundation; Michael Reese Health Trust; Prince Charitable Trusts; Rockwell Fund, Inc.; San
Antonio Metropolitan Health Department; Texas Children’s Hospital; W.P. and H.B. White
Foundation; Washington Square Health Foundation. The views presented here are those of
the authors and not necessarily those of the financial supporters, or their directors, officers
or staff.
The following members of the evaluation team at Johns Hopkins led by Bernard Guyer
assisted in the affiliate evaluation: Mary Benedict; Allison Cosslett; Brandy Fauntleroy;
Janice Genevro; Holly Grason; Nancy Hughart; William Hou; Ashraful Huq; Avanti
Johnson, Alison Snow Jones; Armenta Jones; Pat Lanocha; Tess Miller; Cynthia Minkovitz;
Lexie Motyl; Stephanie Neal, Becky Newcomer; Laura Pagels, Heather Rutz; Daniel
Scharfstein; Jane Schlegel; Heather Stacy; Brenda Sterling; Lavonne Sumler; Kristie Susco;
Donna Strobino; Eleanor Szanton; Chao Tang; and Marsha Young. In addition, Diane
Burkom, Helen Gordon and the interviewing staff of Battelle Centers for Public Health
Research and Evaluation conducted the parent telephone interview. Jean Su and her staff at
SOSIO, Incorporated provided data entry for the evaluation. Thank you all for your hard
work and dedication.
We are grateful to the Healthy Steps Specialists, lead physicians, administrators, and staff
at each of the sites for their devotion to the program, their commitment to the evaluation,
and their hard work to ensure that both succeeded. Their names are listed below.
Lead Physicians, Administrators and Others: Anita Berry; Mary Martha Bledsoe Felkner;
Julia Bowers-McLain; Mohammad Chaudhary; Glenna Dawson; Jan Drutz; Fernando
Guerra; Cynthia Henderson; Molly Jacob; Crystal Mobley; Jane Moss; Jerry Neiderman;
Karen Nonhof; Isabelle Patton; Consuelo Sandoval; Penny Schwab; Silvana Shilapochnik;
Daniel Treviño; Juan Vargas; Darlene Victorson; and Gail Wilson.
Healthy Steps Specialists: Catalina Ariza; JoAnn Allen; Melanie August; Juanita Brown;
Jennifer Dubrow; Rosa Fernandez; Patricia Garza; Kris Hawkins; Elaine Nishioka; Janie
Ochoa; Esther Oppliger; Sabrina Provine; Veronica Serano; and Claudia Yañez.
Finally, we wish to thank all the families who generously gave of their time. Without them,
our work would not have been possible.
Executive Summary
This report focuses on the evaluation of the Healthy Steps for Young Children program at six
affiliate sites1. Affiliate sites were selected based on the same criteria as national evaluation sites
except they did not have a comparison population. They implemented the Healthy Steps program
fully, offering the same program as the national sites. Six sites, comprising seven primary pediatric
practices, participated in the affiliate evaluation.
On average, mothers participating in the affiliate evaluation tended to be young (more than one half
were less than 25 years old), with limited education (45% had not graduated from high school), of
Hispanic origin (56% reported they were of Hispanic origin) and poor (for 54% of the families,
maternity care was paid for by Medicaid). They differed from the families in the national evaluation
in terms of these demographic characteristics.
The full Healthy Steps program was implemented at all affiliate sites. All affiliate sites hired two HS
Specialists and delivered the package of Healthy Steps services from the time the first family was
enrolled into the program. There were some barriers encountered in implementation as well as
variability in the programs.
Results from both providers and parents indicated that affiliate families received Healthy Steps
services in addition to routine pediatric primary care. According to the Healthy Steps Specialists,
the average family who participated in the program at least 15 months received a variety of services
from their Specialist:
7 office visits
2 home visits
6 telephone calls
2 other contacts such as mailings.
The average family did not attend a parent group. Only 20% of families attended at least one parent
group during the program.
Child development was universally discussed with families, and other important topic areas such as
nutrition, child health, injury prevention, family support and maternal health were addressed with a
large proportion of families. Families with higher incomes and older, better educated and first-time
mothers appeared to receive more Healthy Steps services than their counterparts, but the differences
between groups were small.
These results are particularly noteworthy because five of the six affiliate sites served low-income,
transient populations at high risk for poor outcomes. Initially, there was doubt whether Healthy
Steps could even be implemented at these sites. Not only did these sites successfully implement the
program, but they also delivered developmental services to populations that are traditionally
difficult to reach and to engage in health care programs.
Healthy Steps added value to the primary pediatric health care delivered at affiliate sites. It
enhanced the relationship between the family and the practice. The key to the program was the
1
Three other affiliate sites participated in Healthy Steps. Two sites implemented variations of the Healthy
Steps program and evaluated their programs: one site included a prenatal component; another offered
telephone counseling in lieu of enhanced well child visits. Each utilized a randomized, case/control design for
their evaluation. A third site participated in a local evaluation.
relationship that developed between the family and the HS Specialist. This relationship, and the
additional services provided, seems to account for increased parents’ satisfaction with the care they
received. According to all the evaluation data, affiliate families—whether at high or low risk, new
parents or more experienced, young or older mothers—were highly satisfied with the program.
In addition, based on surveys conducted with health care providers at start-up and 30 months into
the program, Healthy Steps appeared to have improved the satisfaction of pediatricians and nurse
practitioners with the care they provided. All those in the practice who worked with the HS
Specialist acknowledged the benefits that this new professional brought to the practice. Overall
teamwork improved over the course of the program. Increased satisfaction occurred among health
care professionals that work with at-risk populations. Again, this is particularly noteworthy as
these providers are traditionally at higher risk of job dissatisfaction and turnover.
The level of positive parenting practices was high among affiliate families. The majority of families
reported using safety devices, establishing routines and talking to and playing with their child.
There was some evidence to suggest that Healthy Steps improved parents’ use of the health care
system for their children. A greater percentage of HS affiliate children than children who received
care at the practice prior to HS were given a Denver Developmental Screening Tool (DDST) by 12
months and made age-appropriate well child visits. At several sites, more affiliate children were fully
immunized at 12 months of age than were children who received care at the practice prior to HS.
Results from the affiliate evaluation reinforced the results of the national evaluation. Healthy Steps
was well implemented. The key to the program seemed to be the relationship that developed
between the HS Specialist and families, which in turn strengthened the relationship of the family
with their primary care provider and ultimately the practice overall. Healthy Steps improved
clinicians’ and families’ satisfaction with pediatric care. The program increased the amount of
preventive health care children received. Most important, the invaluable contribution of the
affiliation evaluation is that it demonstrated that Healthy Steps could be successfully implemented
with a low income, high risk population as well as in a high income population.
.
Introduction
The purpose of this report is to summarize the results of the evaluation of the Healthy Steps for
Young Children program at affiliate sites. Affiliate sites were selected based on the same criteria as
national sites except they did not have a comparison population. They implemented the Healthy
Steps program fully, offering the same program as the national sites.
The 6-site affiliate evaluation involved 1,103 families, followed from the birth of their child until
he/she turned 3 years old. The report is a synopsis of the findings from a variety of sources—key
informants, primary care providers and parents, and from a variety of instruments—in-depth
interviews, telephone interviews, medical record abstraction. The report has been written so that it
is accessible and informative for multiple audiences. We refer readers who would like more indepth information to the two appendices. Appendix I includes a discussion of the methodology used
to conduct the affiliate evaluation. Appendix II includes results for selected outcomes.
What is Healthy Steps?
The Healthy Steps for Young Children Program (Healthy Steps) offers a new approach to
traditional primary pediatric care for children from birth to age three. By expanding the traditional
focus of primary pediatric care to more fully include development and behavior and by fostering a
closer partnership between health care professionals and parents, Healthy Steps provides a familycentered approach in caring for the whole child. In its demonstration phase, the program was a
universal intervention offered to all families, not only those at high risk of poor outcomes.
The concept and design of Healthy Steps were influenced by advances in research on brain
development, contemporary parenting practices, demographic trends in the United States, and
changes in the health care industry. Recent research on brain development has emphasized the
importance of children’s earliest years. Negative or inadequate developmental experiences,
especially within the first 18 months of life, may lead to cognitive deficits. Alternatively, the impact
of positive experiences during this time can be long-lasting.2,3 Although the importance of the first
three years of life in terms of healthy development has become increasingly clear, a survey
conducted by The Commonwealth Fund revealed that parents in the United States do not
necessarily know the best way to promote their child’s development and they are not receiving this
information from their health care providers.4 At the same time, parents’ needs for additional
support may be increasing because of changing demographic trends among American families, such
as the increasing number of single-parent households, households in which both parents are in the
labor force and increasing number of families whose native language is not English. Finally,
changes in the health care sector have increased market competition. Some health economists
suggest that in order to remain competitive, pediatric practices and managed care plans must offer
services that not only attract new families but keep families satisfied with the care they receive so
they stay at the practice or within the health plan.
Healthy Steps was designed by a multidisciplinary team at Boston University School of Medicine.
As originally implemented, Healthy Steps consisted of a package of services. These services
included:
Carnegie Task Force on Meeting the Needs of Young Children. Starting points: meeting the needs of our youngest children.
New York: Carnegie Corporation of New York; 1994.
3 Green M, ed. Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents. Arlington, VA: National
Center for Education in Maternal and Child Health; 1994.
4 Young KT, Davis K, and Schoen C. The Commonwealth Fund Survey of Parents with Young Children. New York, NY: The
Commonwealth Fund; 1996.
2
enhanced strategies in well child care such as: linked or joint well child visits with a
pediatrician, family physician, nurse practitioner and a child development specialist and the
“Reach Out And Read” program;
home visits;
telephone support for developmental and behavioral information;
child development and family health check-ups;
written materials for parents that emphasized prevention and health promotion including a
Child Health and Development Record and LinkLetters, age-appropriate newsletters sent to
parents in anticipation of each well child visit;
parent groups; and
linkages to community resources.
The cornerstone of the program was the addition of a new health care provider, the Healthy Steps
Specialist (HS Specialist), into the pediatric practice. The HS Specialist, who may have been a nurse,
a pediatric nurse practitioner, an early childhood educator, social worker or other professional,
brought a focus on expertise in early childhood development into the pediatric practice and oversaw
the delivery of the Healthy Steps services. For more information on the design of the program,
please see Zuckerman, 19975 and Sanoff-Kaplan, 20016.
Healthy Steps began in 1995 and was originally implemented at 24 sites around the country. The
Commonwealth Fund provided initial funding for the program in conjunction with approximately
60 local funders. The National Program Office at ICF Consulting, Inc provided overall technical
and administrative support. Healthy Steps was co-sponsored by the American Academy of
Pediatrics.
How was Healthy Steps Evaluated?
The affiliate evaluation was part of a comprehensive evaluation of Healthy Steps. For details on the
National Evaluation, see Healthy Steps: The First Three Years.7
Six sites participated in the affiliate evaluation. Affiliate sites were selected to participate in Healthy
Steps based on the same requirements as the national sites except they did not have a comparison
population. The affiliate sites implemented the Healthy Steps program fully, offering the same
program as the sites in the national evaluation. Like the national evaluation sites, they enrolled two
hundred intervention families and hired two HS Specialists, each to work with 100 families.
Staff at the affiliate sites received the same training, technical assistance calls and monitoring site
visits as the national evaluation sites. Ongoing training was an essential part of the Healthy Steps
program. Key personnel from each affiliate site participated in three annual Healthy Steps Training
Institutes at Boston University School of Medicine. In addition, before enrollment began, the lead
physician and other staff met with a member of the evaluation team to walk through the
implementation process at their site. Each site received a monitoring site visit within six months of
start-up. HS Specialists participated in monthly technical assistance calls with staff from Boston
University and other HS Specialists. Throughout the program, sites had access to staff at the
5 Zuckerman B and Parker S. Teachable moments: making the most out of the office visit. Contemporary Pediatrics. 1997;
14(2): 20-25.
6 Kaplan-Sanoff M. Healthy Steps: delivering developmental services for young children through pediatric primary care.
Infant & Young Children. 2001; 13(3): 69-79.
7
Guyer et al. (2003). Healthy Steps: The First Three Years. Nancy Hughart and Janice Genevro, Eds. Women’s and
Children’s Health Policy Center, Department of Population and Family Health Sciences, Johns Hopkins Bloomberg School
of Public Health. Baltimore, MD.
National Program Office, The Commonwealth Fund, Boston University and Johns Hopkins
University.
Because affiliate sites did not have a comparison population, the affiliate evaluation was descriptive
in nature. It described the characteristics of the affiliate sites and their patient populations, the
process of implementing Healthy Steps and to a limited degree, the impact of Healthy Steps on
providers, parents, and children. The four objectives of the affiliate evaluation were:
To describe the degree to which children and families at Healthy Steps affiliate sites
received Healthy Steps services.
To describe parents' knowledge, attitudes, and behaviors regarding their parenting
practices, learning-enhancing activities, and health services utilization patterns.
To assess the effect of Healthy Steps on providers' knowledge, attitudes, and
practices related to the content of pediatric care and the Healthy Steps components.
To determine the cost of Healthy Steps at affiliate sites.
Healthy Steps at affiliate sites was delivered through a pediatric practice. We anticipated, therefore,
that the addition of the program would influence the practice and clinicians as well as the pediatric
services provided (Figure 1). We also expected that Healthy Steps program activities would have a
direct effect on the parent by increasing his/her knowledge of child development and sense of
competence and satisfaction as a parent, and by affecting his/her parenting practices, such as early
literacy and safety practices. Finally, we anticipated that improvements in child outcomes would
result indirectly from the impact of the program on the parent or possibly directly from the impact
of program activities on the child.
Figure 1
Conceptual Model for Evaluating Healthy Steps
Healthy Steps
Practice & Provider Changes
Availability of HS Services
Receipt of HS Services
Changes in Parents’
Knowledge & Beliefs
Changes in Parents’
Practices
Improved Child Outcome
A detailed description of methods used to evaluate the program at affiliate sites is presented in Appendix I.
Who Participated in the Affiliate Evaluation?
Pediatric Practices
Six sites, comprising seven primary pediatric practices, participated in the affiliate evaluation (Table
1). The seven participating practices represented a mix of organizational types including two group
practices, a hospital-based clinic, a community based clinic, two hospital-based residency training
pediatric clinics, and a group practice in partnership with the local health department. Most
pediatric practices were of moderate size, employing 3-10 clinicians. Most had contractual
arrangements with more than one type of managed care organization: three reported arrangements
with preferred provider organizations, two with independent practice associations and four with
HMOs.
Table 1.
Healthy Steps Affiliate Evaluation Sites (in alphabetical
order)
Advocate Health Center at Bethany Hospital
Eastover Pediatrics
Healthy Steps de San Antonio
Ravenswood Hospital Colonel Stanley R. McNeil Pediatric Clinic
Ravenswood Hospital Maternal/Family Health Center
Residents’ Primary Care Group, Texas Children's Hospital
United Mexican-American Ministries Health Clinic
Chicago, IL
Charlotte, NC
San Antonio,
TX
Chicago, IL
Houston, TX
Garden City, KS
During the course of the Healthy Steps program, affiliate practices changed. For some, these
changes were quite dramatic. Three sites reported changes in ownership during this time. Over half
of the practices (57%) reported changes in management or administrative personnel in the practice
or home institution. Although the retention rate of medical providers was high (89%), fewer than
half of the nursing staff and clerical/administrative staff that were at the practice at start-up were
still there at 30 months (46% and 44% respectively). As one HS Specialist commented, “Staff
turnover is epidemic.”
A measure of site stability based on key informants’ reports of the major administrative, financing,
and staffing changes that had occurred at the site during the program indicated that all affiliate sites
experienced some change while implementing Healthy Steps. The most stable site, which was rated
2.2 on a scale of 1 (most stable) to 5 (least stable), replaced the primary pediatric provider, HS
Specialist (after 6 months) and administrative coordinator, and moved to a different building during
the course of Healthy Steps. Key informants from the least stable site, rated 4.2, reported the
following: “Administrative coordinator left, not yet replaced;” “Major staff turnover;” “Clinic may close or be
consolidated;” “Everything [is] up in the air.”
In addition to these changes in personnel and/or infrastructure, several practices experienced
changes in their client base during the course of the program. Three practices reported a 10% or
greater increase in clients insured by managed care. One practice reported at least a 10% decrease in
the number of clients insured through public programs such as Medicaid. Two practices reported
that the ethnic mix of their clients changed substantially during implementation of the program. At
two sites, the number of clients served increased by 10% or more.
Families
In total, 1,103 families enrolled in the affiliate evaluation. On average, mothers participating in the
affiliate evaluation tended to be young (over 50% were less than 25 years old), with limited
education (45% percent had not graduated from high school). About half of the mothers described
their race as White; over half reported that they were Hispanic. Slightly more than half of mothers
(54%) were married at the time of their enrollment in the affiliate evaluation. However, more than
two thirds of mothers reported that they were living with the baby’s father.
Approximately 40% of families enrolled in the affiliate evaluation were first-time parents. For more
than half of the families (54%), maternity care was paid for by Medicaid, with 25% of families
utilizing private insurance to cover the maternity care expenses. More than half of families reported
receiving assistance from the Women, Infants and Children (WIC) program during pregnancy.
Almost one quarter of families received food stamps during pregnancy.
Table 2 provides a comparison of the families enrolled in the affiliate evaluation with families
enrolled in the national evaluation of Healthy Steps and with all families in the United States who
had a baby in 1997. On average, mothers participating in the affiliate evaluation tended to be
younger, less well educated and poorer than mothers in the national evaluation. In addition, more
mothers of Hispanic origin participated in the affiliate evaluation than in the national evaluation.
Almost 60% of affiliate families had selected their pediatric practice prior to the birth of their infant;
however, only 20% of families had actually visited the practice before the baby’s birth. The most
frequently cited means through which families knew of the pediatric practice was that they had
taken other children there, or they learned about the practice from a prenatal care provider or a
friend. The two most frequently endorsed reasons for choosing the practice were that the practice
provided good care and that the practice had been recommended.
Table 2.
Comparison of Families Enrolled in the Healthy Steps Affiliate Evaluation,
National Evaluation and US Births in 1997
Mother’s Age at Child’s Birth
19 years or less
20-24 years
25-29 years
30-34 years
35 years or older
Mother’s RaceB
White
African-American/Black
Asian/Native American
Other
Mother’s Ethnic OriginC
Hispanic
Mother’s Educational Level at Child’s Birth
11 years or less
High School Graduate
Some College
College Graduate or more
Mother’s Marital Status
Married
Method
of
Payment
for
Pregnancy/DeliveryD
Medicaid
Baby’s Birth Order
First
Baby’s Birth Weight
Low, < 2500 grams
Affiliate
EvaluationA
(n=1,096)
%
National
EvaluationA
(n=5,563)
%
US Births ’97
(3,880,894)
%
23.5
28.4
22.2
17.2
8.7
13.6
23.6
27.4
22.8
12.6
12.7
24.3
27.6
22.8
12.6
49.7
22.5
1.3
26.5
57.9
24.4
4.5
13.2
79.2
15.4
5.4
0.0
56.4
20.2
18.3
45.8
22.2
16.3
15.3
17.9
26.7
28.8
26.6
22.1
32.9
22.2
22.8
53.6
64.2
67.6
53.5
31.8
33.6
41.2
46.4
40.8
5.0
6.6
7.8
AData for up to 4% of respondents in the HS affiliate & national evaluation samples may be missing from the variables. These
missing data were excluded from the denominator for purposes of calculating percentages.
BFor mother’s race, many in the ‘other’ group for the Healthy Steps Evaluation sample are women of Hispanic origin, most of
whom are also likely to be white.
C
Percentage of Hispanic births may be under-estimated for 1997 U.S. Live Births.
D
The national U.S. birth data for Medicaid coverage are for women on Medicaid 1991 through 1995 at delivery.
How was Healthy Steps Implemented at the Affiliate Sites?
At start-up, key informants including the head of pediatrics, lead HS pediatrician, site administrator,
Healthy Steps Specialist and the lead funder generally were very enthusiastic about having the
opportunity to participate in Healthy Steps. Many indicated that the Healthy Steps program would
give them an opportunity to provide families with the type of comprehensive services they had
hoped to offer. Although many described the decision to participate in the program as “top down,”
they did not feel that the program had been imposed on them, largely because they felt that if they
had entertained serious reservations about the program, it would not have been implemented at
their site.
Concerns about buy-in from medical and administrative staff varied among key informants.
Respondents from sites serving more “high risk” families expressed minimal reservations about buyin on the basis of the anticipated value the program would bring to their families. Respondents at
residency training programs expressed optimism that introducing Healthy Steps as part of residents’
learning experiences would lead residents to view Healthy Steps as the expected standard of
practice. Some respondents also indicated that the firm commitment of upper-level management to
the implementation of HS enhanced the buy-in of medical and administrative staff. As a group, HS
Specialists expressed the most concern about buy-in on the part of others. Their concern may have
been due in part to the fact that Healthy Steps was the reason they joined the practice and the focus
of their job.
Barriers to implementing the program reported at start-up included: identifying and remodeling
space for the HS Specialists, concerns about the length of time that joint or linked visits would
require of families and other scheduling issues, and difficulties with the lines of authority and the
responsibilities of team members.
For some sites, scheduling issues continued throughout the program. As one HS Specialist told the
evaluators, “Scheduling went from written to computerized system. I don’t have access to the system, no
password even. [The] receptionist who has been at [the] practice forever [is] not eager to help. [I] could not
tell if HS child [was] coming, if HS child [was] seeing the right physicians…” HS Specialists at two sites
indicated that space remained a challenge throughout the implementation of the program. Other
administrative issues noted at 30 months into the program included the need for additional
administrative and bilingual services, and staff turnover.
Integrating the HS Specialist into the Practice
The cornerstone of the program was the HS Specialist. HS Specialists were asked how well they
thought they, as professionals with a focus on child development, had been integrated into the
pediatric practice. The vast majority of their responses were positive. One HS Specialist summed
up feelings expressed by many:
“It took a while with some of the MDs but they really respect my expertise and use it. MDs that never
gave me the time of day, now ask for advice. [They] tell non-HS families to call me.”
Most Specialists mentioned that integration into the practice took time. Like this respondent, many
Specialists seemed to equate integration with being asked to consult with non-Healthy Steps
families, being given time to do their job, and being trusted and treated with respect by other
providers in the practice. Only two HS Specialists interviewed felt they had not been integrated into
the practice. Although they felt that providers appreciated their services, they did not feel like part
of the practice.
When asked the same question about integration of the HS Specialist, the four lead physicians and
five site administrators who responded were extremely positive. One lead physician went so far as
to say “integration has been seamless.”
We also asked the HS Specialists if they felt that their role had changed over time, from start up to
30 months after the program began. Six said no, seven said yes. Among those who said they felt
their role had changed, there was considerable variation in the reasons identified for the changes.
Some felt that their role changed as Healthy Steps children aged or the program expanded. One
Specialist mentioned that her role evolved to become a case manager. Another said it changed to
include new duties such as interpreter. Several Specialists indicated that their role in the practice
changed as they became more confident.
When asked about the structure of the HS Specialist role, two Specialists said it was fairly well
structured as it was. Other Specialists (8) indicated that the role did not need restructuring but
rather they would recommend additional training or support for the Specialist. Interestingly, there
was little consensus on the ideal training or background for a HS Specialist among both HS
Specialists and lead physicians. Respondents suggested backgrounds in nursing, social work and
child development. The type of professional they recommended might have been influenced by the
populations they served. For example, at a site that served middle- to high-income families, all
respondents thought that the HS Specialist should be a nurse or nurse practitioner. At one of the
sites that served low-income families, all respondents recommended training or a background in
social work.
We also asked site administrators and lead physicians if they felt the role of the Healthy Steps
Specialist had changed over time. Two site administrators said no: “What [the] Healthy Steps
Specialist came in to do, she did.” The other four site administrators and all five lead physicians said
yes, although how they felt the role had changed varied. Like the HS Specialists, some attributed
changes in the role to the age of the children or program expansion. However, most of their
comments reflected their belief that the role changed in a positive way as the HS Specialists became
more integrated into the practice, more confident in the role, and as the role became more defined.
As one site administrator noted, “The role became more defined. [the] program recognized more [what
the] HS Specialist could do. [The] program had flexibility to make the role work.”
Implementing the Healthy Steps Services
In addition to the HS Specialist, the Healthy Steps program featured a package of services to expand
pediatric care. A brief description of each service follows. In addition, we summarize the
implementation of each service in terms of its fidelity to program protocols based on information
provided by the HS Specialists and lead physicians.
Enhanced Strategies of Pediatric Care: Program strategies to enhance pediatric care included
extended well child visits conducted jointly or sequentially by a pediatrician, family physician or
nurse practitioner and the HS Specialist; child development assessment tools,8 anticipatory guidance,
teachable moments, linkages with OB care, counseling about breastfeeding, the Reach Out And Read
(ROR) program, and referrals for maternal depression, smoking, family violence or substance abuse.
Most respondents from affiliate sites reported implementing the enhanced strategies. All affiliate
sites implemented jointed or linked visits with physicians/nurse practitioners and HS Specialists.
The HS Specialist met with the family at the office either at the same time as the pediatric clinician
8
For the purposes of the evaluation, child development and family health check-ups were included under
enhanced strategies of pediatric care.
(joint visit) or immediately before or after (linked visit). Informants at three sites reported modifying
the format.
Six developmental assessment tools were used to measure child development and family health.
These were: the Brazelton Neonatal Behavioral Assessment Scale (NBAS); the BABES behavior
checklist; the Denver II Developmental Screening Test (DDST); the Temperament Questionnaire; a
Family History; and the MacArthur Communicative Development Inventory (MacArthur).
According to key informants, the BABES, DDST and Temperament Questionnaire were
implemented without modifications at all affiliate sites. Informants at three sites noted modifications
to the NBAS and the MacArthur. Two sites modified the Family History.
All informants said they utilized anticipatory guidance and teachable moments. Respondents at all
but one site said they implemented counseling about breastfeeding without modification. Nearly all
sites had linkages with OB care, although several modified the linkage protocol and one
discontinued it. The Reach Out And Read Program (ROR; www.reachoutandread.org), which
fostered reading to children by providing books to families, was very well received and fully
implemented at all sites beginning with the six-month well child visit.
Home Visits: Home visits gave the HS Specialists a chance to build a supportive relationship with
families, use or create “teachable moments,” conduct developmental assessments, and gain insight
into how the child’s home environment could foster or impede his/her growth and development.
The recommended home visiting schedule included 6 visits in total: three during the child’s first
year at 3-5 days, 9 months and 12 months; and visits at 18, 24, and 30 months.
All affiliate sites implemented home visits during all three years of the program. Three sites
modified the schedule of home visits during the first year. Two sites eliminated the 9-month visit
because this visit was too difficult to schedule and complete before the 12-month visit. Informants
at one site extended the timing of the first home visit to the first 30 days. Informants at only one
site reported modifying the schedule during the second year. There were no reported modifications
to the home visiting schedule for the third year.
Child Development Telephone Line: The child development “warm line,” was originally designed
as a separate Healthy Steps telephone line with specified call-in hours for parents to ask
developmental and behavioral questions about their child outside of office and home visits and
parent groups. However, this protocol was revised so that participating sites did not have to have a
separate, designated line or a specified time for calls. As revised, all affiliate sites implemented this
component.
Written Materials for Parents: HS Specialists and lead physicians were asked about the
implementation of written materials at their site. These included: LinkLetters, age-appropriate
newsletters mailed to the family before each scheduled well child appointment; Parent Prompt
Sheets, given to parents at check-in for well child visits suggested questions to ask the pediatric
team; and the Child Health and Development Record, provided to parents at the beginning of the
program to record their child’s growth and development, immunizations and illnesses. All written
materials were available in English and Spanish. According to the key informants, LinkLetters, and
the Child Health and Development Record were fully implemented at all sites. The Parent Prompt
Sheets were modified and/or discontinued at almost all of the sites (5).
Parent Groups: Parent support groups were included as part of the program so that parents with
children of similar ages or interests could exchange information and address issues of mutual
concern. This element was included in the package of services to reinforce information parents
received at office and home visits, and to potentially reduce the isolation that many parents feel in
raising a young child. The number and timing of parent groups was to be based on parents’ needs.
The protocol allowed for the groups to be discontinued if there was insufficient interest.
The implementation of parent groups at affiliate sites varied more than any other component of the
program. No sites had weekly parent groups; few sites had monthly parents groups. Two sites
discontinued the parent groups altogether. Providers at affiliate sites went to great lengths to boost
attendance at these groups, including scheduling groups at night or on the weekends, offering
incentives to attend, and throwing birthday parties for the children with an “education” focus.
Interestingly, the reasons sites struggled to offer parent groups varied, as captured by these two
comments from HS Specialists:
“[We are] trying very hard to have monthly parent groups. Groups we have had really made a
difference. Different way to engage families. Make connections with other parents. Not an easy
component to establish here. Lack of resources for extra help with child care. Very, very important
component. Always had good attendance. Logistics [are] the problem.”
“[We had a] rough time with parent groups, no one would show up. Culturally this population [is] not
used to groups, [they have] lots of kids, no transportation, [their] husband works 2 or 3 jobs.”
Linkages to Community Resources: These linkages were designed to help parents gain access to
resources, services, and information available in their communities. Each practice was to make a
binder listing community resources such as childcare, parent/play groups, educational activities and
referral and treatment programs. Sites were also to design and maintain a parent-to-parent bulletin
board. According to the key informants, four sites modified the book of community resources; one
site modified the parent-to-parent bulletin board and one site discontinued it.
Lead physicians and HS Specialists were asked to rank six9 Healthy Steps services in terms of their
value to families. In addition, lead physicians were given one additional component to rank, that
being the role of the HS Specialists. All of the lead physicians who responded ranked the role of the
Healthy Steps Specialist as the most valuable component of the Healthy Steps Program.
Not surprisingly, enhanced strategies, linked or joint office visits, and home visits were ranked as
most valuable to families by most informants. After the HS Specialists, these services were most
often listed by providers as being particularly well received. They were also the services parents
seemed to use the most. Of the enhanced strategies, developmental assessments (in particular the
NBAS and DDST), parent handouts, and Reach Out And Read received positive mention from
nearly all respondents, not just those who ranked the services. Linked or joint office visits also were
seen as quite valuable. However, not all providers appreciated the linked or joint visits; some
providers did not like or want the HS Specialist in the exam room with them. Further, several
respondents noted that linked or joint office visits took more time than a regular visit. One comment
by a site administrator illustrates the difficulty associated with introducing linked or joint office
visits into the practice, but also the great value she felt they added to pediatric care:
“…Very new to doctors to let someone in the exam room, especially someone who speaks to them, talks
to mom and expects to be listened to. Growth in perception by physicians. HS Specialist gives doctor
synopsis of family—what services they have used, what they have talked about. Mom happy because
someone [is] there speaking up for her. Everyone’s need is met. Good communicating going on.
Ultimately good for the child.”
9
For the purposes of the evaluation, child development and family health check-ups were included under
enhanced strategies of pediatric care.
Several informants mentioned the value of home visits, although these were not as uniformly
popular as enhanced strategies and linked or joint office visits. Only one HS Specialist ranked home
visits as the service most valuable to families. Many respondents, like these HS Specialists, had
positive things to say about the home visits:
“Home visits help solidify our relationship. I’m in their territory. I’ve made the effort to go to their
home.”
“Kids are so different at home. [They’re] not scared to death. I’ve enjoyed them. At home parents
[are] more relaxed, ask questions they wouldn’t in the office—[there’s] no time, [they’re] too
anxious.”
Many informants saw home visits as being of great value to providers because of the information the
HS Specialist learned about the child’s environment and family’s dynamics and brought back to the
providers, “…what we can report back to doctors after home visit. For example, why medication is
unobtainable, why child is not walking…They [doctors] now have more understanding of [the] whole family
and how [the] family is doing.”
Perhaps home visits would have been ranked higher if families had been more receptive to the visits.
One HS Specialist who ranked home visits as the least valuable service to families commented, “3040% [of families] didn’t want a home visit. Passive ‘no’s. Some say, ‘don’t come, [it’s] not safe, elevators
don’t work,’ etc..”
Based on the problems with implementation, it was not surprising that many informants rated the
parent groups and community linkages as the least valuable services to families. When asked what
parts of Healthy Steps did not work well or seemed to make no difference, ten HS Specialists, five
lead physicians and two site administrators said parent groups. As one site administrator lamented,
“The parent groups have not succeeded. Barriers but lack of value on the part of parents. We tried everything.
[We] can’t figure out why they don’t come.” Most respondents added the caveat, however, that parent
groups were valuable for the parents who attended.
Community linkages were also not a highly ranked component of Healthy Steps. One informant
said, “We used our parent-to-parent bulletin board but parents didn’t. I think the placement of the board was
the reason – at the back of the clinic [parents] don’t go by it.”
Three of the HS Specialists ranked the telephone line as the component of Healthy Steps that was
least valuable to families. Generally, the idea of having a “warm line” or someone to call with nonmedical, behavioral or developmental questions was well received. In accordance with revised
program protocols, many of the sites did not have a designated telephone line. This may explain its
low ranking for at least one of the Specialists, who commented, “The only component which was
unsuccessful was the child development line; only because families use our direct phone numbers to call
whenever they have questions. They are not limited to call at a specific time.” However, another Specialist
who ranked it the least valuable component noted, “The telephone line averages 9 calls [per] month.
[Parents] continue to call [the] nursing line.” The other HS Specialist at that site mentioned in her
interview that the “[The telephone line is] a wonderful resource, critical [the] first few months, as kids got
older, parents didn’t utilize it.”
What Services did HS Specialists Provide to Affiliate Families?
The HS Specialists’ logs of contacts with affiliate families provided insight into what actually
happened between the HS Specialist and the family. HS Specialists were asked to document every
contact they had with the family including home visits, office visits, telephone calls from or to
families, parent groups, mailings or other contacts. Information requested about each contact
included: the date of the contact, whether the contact was completed or not, the person(s) contacted,
and actual subjects discussed with the person(s) during the contact. Up to 15 individual topics could
be recorded by the HS Specialist for any one encounter with a family.
Total Contacts. Fifteen HS Specialists recorded a total of 16,470 completed contacts with affiliate
families during the first 32 months of the program. Office visits accounted for 44% of all contacts.
Telephone contacts were the next largest proportion of contacts (26%). Telephone contacts
included calls made to the designated “warm line,” but because not all sites had a dedicated warm
line, we included all telephone contacts reported in the logs. Calls may have been initiated either by
the family or by the HS Specialist. The telephone contacts could have been substantive in terms of
topics discussed, or could have been for the purposes of making appointments or confirming
appointments. Home visits with families accounted for 15% of the total number of contacts. Parent
groups comprised 4% of the overall number of encounters, and other contacts (such as mail contacts
regarding appointments or to send information, or encounters in other places such as the hospital)
accounted for 11% of total contacts.
Of the 16,470 total contacts, 11,508 (70%) took place during the period from birth to 14 months to
capture the 12-month well child visit. Approximately 5,000 contacts were made when the children
were 15 to 32 months of age. As expected, the HS Specialists had more contacts with families
during the first year of life than the second and third years; however, the pattern of contacts was
consistent over the two time periods. At each time period, office visits accounted for the largest
proportion of contacts, followed by telephone contacts and home visits. Parent groups accounted
for the fewest contacts at both time periods.
Person(s) Involved in the Contact. Of all 16,470 contacts with data identifying the person(s)
involved in the contact (3% were missing this information):
68% were made with the mother alone; 2% were with the father alone.
24% were made with either both parents, or with one parent and another relative such
as a grandparent or a sibling of the child.
6% were either made with a non-relative, generally a babysitter or a professional with
whom the HS Specialist had spoken on behalf of the family, or the contact person(s) was
unknown.
Handouts and Referrals.
A handout was given or mailed to the family at 64% of all contacts, excluding telephone
contacts.
A referral was made at 8% of the contacts.
Over 40% of referrals were to a medical provider; referrals to community agencies or
unspecified agencies or providers represented the remainder. Referrals to community
agencies were made for supplies such as breast pumps or baby supplies, and for WIC
services, financial assistance, housing assistance, or occasionally other community or
counseling resources.
Attempted Contacts. In addition to the completed contacts, HS Specialists recorded 1,832
attempted contacts with families. Most consisted of attempts to reach the family by telephone,
although occasionally a family would be a no show for a scheduled home visit. These attempted
contacts provide some measure of the additional time and effort expended by HS Specialists to track
families and provide quality services to them.
All subsequent results are presented as a percentage of families having a contact or discussing a
particular topic with the HS Specialist. During the first time period this included 1,102 families.
For the second time period, we limited the sample to those 783 families who had a contact with the
HS Specialist at 15 months or later.
During the first 32 months of life:
99% of families had at least one office visit with their HS Specialist.
84% of families had at least one telephone contact
81% had at least one home visit
20% attended a parent group.
On average, a HS Specialist saw each affiliate family in the office 5 times during the first 14 months
and two times from 15 to 32 months. This level of office contacts during the first year approached
the recommended well child visit schedule of the American Academy of Pediatrics. The Academy
recommends 6-8 visits during the first year of life.10 These results suggest that HS Specialists
attended most, if not all, of a child’s well child visits during the first year of life. The level of office
contacts during the second to third years, on average 2.2 visits, is lower than the 4 recommended
visits during this period. However, we may not have captured the third year visit at 36 months for
many families.
The number of office visits with a HS Specialist varied greatly from family to family. HS Specialists
reported a range of 0 to 16 office visits per family during the first time period and 0 to 12 visits
during the second time period.
During the first year, the average affiliate family received or made 3 phone calls to a HS Specialist.
During the second to third years, the average family made or received less than two calls. Again,
there was considerable variation among families. HS Specialists made up to 40 phone contacts with
one family from birth to 14 months and up to 23 calls with one family during the period from15 to
32 months.
On average, HS Specialists made one home visit per family during both time periods. However, the
Healthy Steps protocols specified that each family receive 3 home visits in the first year and 3 in the
second and third years. It also was recommended that the first home visit be as early as possible,
preferably within the first 2 weeks of the baby’s life. Slightly fewer than half of the families who had
a home visit within the first year had it within the first 2 weeks of life; nearly 60% had it within the
first two months of life. The timing of the first home visit varied across sites in part due to different
enrollment patterns. Some sites enrolled families only in the office (rather than in the hospital and
the office), and that may have prevented home visiting within the first two weeks of the baby’s life.
Further, as reported by a key informant, one site modified the timing of the first home visit to take
place within the first 30 days of life.
Slightly over half of the affiliate families (52%) had a home visit between 8 - 12 months of life and
half had a visit between 15 to 32 months. Although we cannot tell from these data whether the
family refused the home visit or the Healthy Steps Specialist failed to offer it, it would appear that
both the total number and timing of the home visits did not meet the recommended schedule.
The average affiliate family did not attend a parent group during either time period. During both
periods, affiliate families received, on average, one mailing or one contact in a setting other than the
pediatric practice.
10
Recommendations for Preventive Pediatric Health Care, http://www.aap.org/policy/re9939.html
All sites experienced a marked decrease in the average number of total contacts from the first to the
second time period. However, there was variation by site in the average number of contacts, from a
low of slightly over 12 contacts per family to a high of over 23 contacts. The greatest variability
among sites was in the mean number of home visits and telephone contacts.
In addition to providing information on the nature of the contact in the logs, the HS Specialists also
recorded the topics that were discussed at each contact. We categorized the individual topics
recorded into six broad areas: promoting development, nutrition, promoting health, providing
family support, injury prevention, and maternal health.
There were differences between the two time periods in topics discussed. During the first year, HS
Specialists reported that they discussed promoting the child’s development with nearly all families
(99.5%). Maternal health was the least frequently discussed issue of the six broad areas. Although
HS Specialists continued to discuss development with the majority of parents during the second
time period, they discussed nutrition, child’s health, and injury prevention with far fewer families.
Because we do not know who initiated the discussions, we cannot tell if parents had fewer questions
regarding these topics during the second time period or if HS Specialists failed to introduce them.
We explored the potential relationship of the educational background of HS Specialists and the
topics discussed with families. However, due to the limited sample (for example, only one HS
Specialist had a background in social work), our findings are not conclusive. Further, as noted
previously, the logs of contacts did not indicate who initiated the discussion of the topics logged by
the HS Specialists. Nevertheless, the patterns that emerged suggest that HS Specialists with a
background in nursing discussed promoting development with a smaller number of families and
discussed family support and maternal health with a greater number of families than did HS
Specialists with a background in education, child development, or social work.
Similarly, we examined the pattern of family characteristics, such as household income, and the
number of contacts and the topics discussed. Because approximately 11% of affiliate families were
missing data on their household income, caution is merited in interpreting these results due to the
potential bias from excluding these families. In general, findings suggest that high-income families
(those with an annual household income of $40,000 or more) had more overall contacts and were
more likely to discuss five topic areas with the HS Specialist than low-income families. It is
important to note that regardless of a family’s income, nearly all families had at least one office visit
and discussed promoting development with their HS Specialist.
Patterns in the number and type of contacts varied for mothers with different educational
backgrounds. Use of office visits and telephone contacts was similar across education groups
(defined as less than high school graduate, high school graduate, some college, and college
graduate). Mothers who had some college experience appeared to use the parent groups and home
visits more than mothers with both lower and higher educational attainment. In terms of the topics
discussed, promoting development was discussed with all mothers. However, a greater percentage of
mothers who had graduated from college discussed the remaining five topic areas compared to
mothers with lower educational levels.
A greater number of first-time mothers received a home visit, telephone contact, or participated in a
parent group than second- or greater-time mothers. Similarly, a slightly larger proportion of firsttime mothers discussed the major topic areas with their HS Specialist (except promoting
development and promoting health topics, for which there was no real difference).
These results support other evidence that Healthy Steps was well implemented at affiliate sites. The
HS Specialists attended nearly all affiliate families’ well child visits. Although the average number
of home visits per family fell short of the recommended level, we cannot tell if this was due in part to
families’ refusals to participate. Findings from the logs of contacts suggest that the HS Specialists
discussed development with nearly all affiliate families. Finally, there is evidence to suggest that HS
Specialists’ achieved the goal of universality; that is, they delivered services to all families, not only
those considered at social or medical risk.
What Services did Affiliate Families Report Receiving?
Half way through the Healthy Steps program, when their children were approximately 18 months
old, affiliate families were asked to participate in a telephone interview. The telephone interview
updated demographic information on the family. It also contained questions about parenting
practices related to the child’s nutrition, development, safety, and health care utilization. In
addition, parents were asked to comment on Healthy Steps services they had received from their
practice and their satisfaction with these services.
When considering results from these interviews, it is important to keep in mind that a number of
families did not complete this interview. Of the 1,103 affiliate families originally enrolled in the
Healthy Steps program, 30% were not eligible to participate in this telephone survey, the majority
because they had moved out of the area. Of the 784 families eligible to participate: 636 families
(81%) completed an interview; 141 (18%) could not be located; only 7 eligible families (< 1%)
refused to be interviewed. Thus, only 58% of the original families enrolled in the affiliate evaluation
completed a telephone interview. Families who were not eligible to participate in the interview or
who did not complete the interview differed from eligible families who completed an interview. A
significantly greater percentage of mothers who completed the interview at 18 months were older,
better educated and married than mothers who were not eligible to be interviewed or who did not
complete an interview. A greater percentage of White mothers completed an interview, while fewer
African-American mothers did. Families who completed an interview tended to be wealthier than
families who did not, as measured by the percentages of fathers employed outside the home and the
method of payment for pregnancy and delivery expenses. These differences may bias the
interpretation of the results.
The vast majority of interviewed families reported receiving enhanced well child visits (100%), home
visits (91%), LinkLetters and other handouts (97%), and the Child Health and Development Record
(96%). Well over half (67%) of interviewed families said they used the telephone line for
developmental and behavioral concerns. Only 39% of interviewed parents said they attended a
parent group. The relatively low attendance at parent groups reported by parents corresponds to
the reports from the key informants and HS Specialists’ logs of contacts.
Nearly all affiliate families interviewed (91%) reported receiving a home visit by the time their child
reached 18 months old. In related questions, we asked if they had received a home visit from
someone at the practice or from another agency. Eighty-seven percent of interviewed parents said
they received a home visit from someone at the practice; 22% reported receiving a visit from another
agency. On average, affiliate families said they received 2.3 home visits during this period. This
closely matched the Healthy Steps Specialists’ report of an average of 2.7 home visits per family
during this same period (birth to 18 months). Although this number is lower than the 4 prescribed
Healthy Steps visits for this period, as we learned from the key informants, two affiliate sites decided
to eliminate the 9-month home visit as it occurred too close to the 12-month visit (a change that was
permitted by program management). In addition, many affiliate sites serve very transient, inner-city
populations, which created additional challenges to setting up home visits. Further, 40% of families
interviewed reported receiving 3 or more home visits during this period. Interestingly, both parents
and Healthy Steps Specialists reported that the number of home visits per family during this period
ranged from 1 to 24. Three percent of affiliate families reported having received seven or more
home visits during this period.
The 18-month telephone interview did not ask parents if they discussed developmental or behavioral
topics with their HS Specialists, but rather asked if anyone at the practice has talked to you or given you
information on selected topics. After 18 months in the program, the vast majority of affiliate families
interviewed reported receiving information on: home safety (94%); child development (91%); car
seats (86%); routines (86%); and discipline (81%). Fewer parents reported receiving information on:
sleep problems (74%); language development (74%); child independence (61%); sibling rivalry; (42%)
and toilet training (41%).
In What Ways Did Healthy Steps Add Value to Standard
Pediatric Care at Affiliate Sites?
Enhanced Relationships
Healthy Steps built relationships – between the HS Specialists and families, between the primary
care provider and families, between the practice itself and families, and among the team of providers
in the practice. However, the key to the program appeared to be the relationship that developed
between the HS Specialist and the family. As one HS Specialist commented,
“[I] help parents feel like someone at the practice cares. Parents have so many questions. Now, they
have time, an avenue and comfort level in asking. Someone at the clinic has time for them…I’m here.
The connection has made a difference”.
As this Specialist noted, she had the time to devote to establishing meaningful relationships with the
families she served. As one Specialist simply said, “I had the luxury of time.” It appeared to be the
intensity and quality of this relationship that made it so important. Trust developed between the
HS Specialist and the family.
“[At the] 30-month [home] visits, I’m spending 2 hours. [We have] deep conversations about their
future. They are concerned about me….what’s going to happen to me when the program ends. For
some, Healthy Steps has really meant a lot. We’ve developed a tight relationship. They know I worry
about them. I tell them, ‘you can do this’. I feel like I’m the only one telling them that they can do
something”.
Other providers in the practice recognized this. As two lead physicians noted,
“[The] strong relationship of [the] family with [the] HS Specialist is the primary motivating factor
to make things happen”.
“[The HS Specialists] determine things we don’t about families. [They] have time to follow up—
whether aspects of care, can’t say, some issues I don’t even discuss with patients anymore. I trust the
HS Specialists to do it. Time savings for me. Frustration savings for me. [The] doctor doesn’t
know everything.”
This relationship in turn strengthened the relationship of the family with their primary care
provider and ultimately the practice overall. As one site administrator noted,
“HS improves delivery and utilization of health care information. The families trust [the] HS
Specialists, will keep in touch with them and tell them things. Physicians and staff appreciate this.
It’s the relationship with [the] HS Specialist that causes these improvements”.
Another site administrator exclaimed during her interview, “Kids, 2 year olds, know their doctor, call
them by name”. A lead physician summarized the thoughts of several lead physicians,
“…They [The HS Specialists] bring the families closer to the office by allowing a greater degree of
comfort—[in] asking questions or asking for help with services and they give them [families] better
accessibility to the office and resources.”
Increased Parent Satisfaction with Care
Affiliate families appeared to be highly satisfied with the care they received as part of the Healthy
Steps program, even if we assume some bias in these reports as “dissatisfied” parents may not have
completed an interview. Nearly all families interviewed (97%) would recommend their primary
pediatric practice to a friend. In addition, 66% of interviewed families rated the health care at their
practice as excellent and an additional 29% said it was good.
Nearly all families interviewed (92%) said they knew their HS Specialist. In general, 84% of
interviewed families found the HS Specialist to be very helpful; only 4% found the HS Specialist to be
somewhat or not at all helpful. Families were also asked to indicate their satisfaction with a variety of
attributes of the HS Specialist ranging from “Friendliness” to “Amount of Time Spent with the HS
Specialist.” Over 80% of families reported being very satisfied with each attribute of the HS Specialist.
In fact, in terms of these attributes, families were more satisfied with their HS Specialist than with
their doctor or nurse practitioner.
When asked if “Someone at the Practice Went Out of Way to Help Them,” 72% of affiliate mothers
responded it was their HS Specialist. Only 19% of families reported that their physician went out of
his/her way to help them. An even smaller percentage said their nurse or nurse practitioner went
out of his/her way (10% and 8% respectively). Twelve percent of families reported it was the
receptionist who went out of his/her way to help them.
We asked parents how helpful they found the Healthy Steps services they had received. Responses
were overwhelmingly positive. The Healthy Steps service that parents found to be most helpful was
the enhanced well child visits. Seventy-one percent of interviewed families who had enhanced well
child visits found them to be very helpful, 25% found these visits to be helpful, and only 4% found
them to be somewhat helpful or not helpful at all. Although over half (56%) of the families who
attended a parent group found them to be very helpful, this service was clearly the least helpful from
the perspective of parents: seventeen percent of families who had attended a parent group said they
were only somewhat helpful or not helpful at all.
We also asked how useful affiliate families felt the developmental and behavioral information was
that they received from the practice. The vast majority of families who received information on
child development (88%), home safety (88%), child independence (86%), routines (84%), language
(83%), toilet training (81%), car seats (81%), discipline (79%) and sleep problems (77%) found it to be
very useful. The least useful information parents received had to do with sibling rivalry; 8% of
families who received information on this topic said it was not useful at all.
Affiliate families’ overall satisfaction with the care they received from the Healthy Steps program
also is evident from the amount of money they would be willing to spend out-of-pocket to continue
to receive the Healthy Steps program for another year. Thirty-one percent of interviewed families
reported that they would spend $125 or more to continue to receive Healthy Steps services.
Another 17% said they would pay $100 to $125 for the services. Only 2% of affiliate families
indicated that they would not pay anything or did not know how much they would pay to continue
to receive Healthy Steps services. These results become more meaningful when put in the context
of the economic situation of these families: 64% of interviewed families participated in WIC; 18%
received AFDC/Welfare11; 23% qualified for food stamps; and 38% of the toddlers at affiliate sites
were covered by Medicaid. One hundred dollars or more per year would represent a significant
financial investment for many affiliate families.
11
Although AFDC was replaced by TANF in 1996, it was identified in the survey as AFDC/Welfare.
Reports from the key informants support what the parents told us. All key informants said that
Healthy Steps benefited families, and that the families loved the program. They received virtually
no negative feedback from families.
Increased Provider Satisfaction
In general, all providers and non-clinical staff in the pediatric practice who worked with the HS
Specialists acknowledged the benefits that this new professional brought to the practice and to
families. Generally, physicians and nurse practitioners had more favorable perceptions of the role of
the HS Specialist than other clinicians and staff. In addition, their perceptions improved over time.
For example, at start-up, 43% of physicians and nurse practitioners strongly agreed that the HS
Specialist talked to parents about their child’s behavior and development,12 compared to 85% at 30
months. Their perceptions regarding whether the HS Specialists discussed temperament, sleep
problems or both of these issues with parents also significantly increased with time (29% at start-up
vs. 82% at 30 months). There were no statistically significant changes over time in the perceptions
of nurses and other clinical staff.
Clinicians’ satisfaction with the quality of care provided at the site also generally improved over the
life of the program. At 30 months, slightly over half of the physicians and nurse practitioners (52%)
reported being very satisfied with the clinical support staff’s ability “to meet parents’ needs regarding
their child’s development” versus 22% at start-up. This is most likely due to the addition of the HS
Specialist to the practice. In an interesting contrast, nurses and other clinical staff were less satisfied
than physicians and nurse practitioners with their ability to meet the needs of parents regarding
their children’s development. In fact, their satisfaction appeared to decline over time, although the
decline was not statistically significant.
Of all the primary care providers surveyed, the HS Specialists were the most satisfied with the
ability of the clinical support staff to meet the needs of parents. As was the case with the physicians
and nurse practitioners, they were more likely to report being very satisfied at 30 months; however,
this difference was not statistically significant. Their comparatively high level of satisfaction with
the clinical support staff’s ability to meet parents’ needs regarding their children’s development may
be due to the fact that they were included in this group.
Improved Teamwork & Practice Environment
Establishing a team approach to the delivery of primary pediatric care was one of the foundations of
the Healthy Steps program. Overall, teamwork improved over the course of the program. At 30months, 67% of the HS Specialists who responded (8) said that there was a team approach to clinical
care at their practice; that is, providers shared responsibility for the clinical components of the visit.
Of the HS Specialists who said there was a team approach, 60% reported that there had been
significant changes in the way their team worked together over the course of Healthy Steps.
Another indication of team functioning was the quality of the relationship between the HS Specialist
and other providers and staff. We asked the HS Specialists to rate their overall relationship with
other providers and staff at the practice on a scale of 1, very good to 5, very poor. Generally, responses
were positive: 90% of HS Specialists interviewed said their overall relationship with physicians in
12
Talking to parents about their child’s behavior and development included: encouraging parents to talk about problems
they or their young child were experiencing; listening carefully to what parents said about their child; giving parents
advice about solving problems that they were having at home with their child; giving parents help understanding their
child’s growth and development; and checking the progress of their child.
the practice was positive. Seventy-three percent reported a positive relationship with the nurses,
75% with the Office Administrator. HS Specialists had a less positive relationship with the lead
physician, with only 67% reporting this relationship as positive.
We also asked all pediatricians and nurse practitioners and nurses and other clinical staff at each site
how well they worked as a team during well child visits both at start-up and after Healthy Steps had
been implemented for 30 months. Teamwork generally increased over time at the affiliate sites; at
30 months, many more providers responded that they often or always worked as a team. For
example, at start-up, 38% of physicians and nurse practitioners said they rarely or never worked as a
team; 30 months into the program, only 14% felt that way.
According to the key informants, the overall practice environment generally improved from start-up
to 30 months into the program. By practice environment, we meant the extent to which conflicts
were resolved fairly, other team members were consulted when appropriate in meeting the needs of
families, information was shared in a timely manner, and the opinions of others were considered in
making decisions. At start-up, 50% of the HS Specialists, 40% of lead physicians and 83% of site
administrators said the practice environment was very good or good. When asked about the practice
environment at 30 months, all lead physicians and site Administrators rated it very good or good. At
30 months, 63% of HS Specialists said the practice environment was very good or good, 37% of HS
Specialists said it was okay, poor, or very poor. These differences in perceptions of the practice
environment may be due to the fact that the lead physicians and site administrators had better
defined roles within the practice than the HS Specialists or the fact that Healthy Steps was just one
aspect of their job and may have involved a small number of their patients. HS Specialists devoted
all their time to Healthy Steps and may have had different expectations of how the program should
work within the practice environment. Furthermore, the two periods, start-up and 30 months,
represented times of transition for the HS Specialists. At start-up, they had just entered a new
position; at 30 month their job status could have been uncertain.
This is not to say, however, that HS Specialists were unhappy with their jobs. The vast majority of
Specialists said they loved their jobs. “It’s a great job and I can smile….something I’ve done may impact
them [families] for the rest of their lives. Makes me feel important too.” “I’m grateful everyday that I have
this job.” “I can’t go back to normal life. I cannot have a normal job.”
These findings from the key informants and the providers surveyed suggest that the relationship
among providers improved between start-up and 30 months into the program. As one HS Specialist
noted, “Gradually, as we saw Healthy Steps benefit our families, we learned to co-exist, rely on and trust each
other as a team within the framework of the practice.”
Positive Parenting Practices and Improved Child Outcomes
Feeding Practices
Well over half (64%) of affiliate mothers reported ever breasting feeding their child; at 18 months,
7% were still breastfeeding. Of the women who reported that they breastfed their child, 64%
supplemented with formula. Among select groups of mothers, there was statistically significant
variation in their reports at 18 months of ever having breastfed their child. For example, slightly
over half (52%) of teenage mothers interviewed (mothers who were 19 years old or younger at their
child’s birth) reported ever breastfeeding their child compared to 67% of older mothers. Fewer low
income mothers, that is, mothers with annual household incomes of less than $25,000, ever breastfed
their baby as compared to higher income mothers (52% vs. 79%). First-time mothers and working
mothers did not differ significantly from their counterparts in terms of ever having breastfed their
children. When looking at the results for these subgroups it is important to keep in mind the
potential biases in the data. These include, but are not limited to, the differences between the
affiliate families who completed an 18-month telephone interview and those who did not, as well as
the number of respondents who did not know or refused to report their annual income. These
respondents have been eliminated from the analyses.
From the self-administered questionnaire at six months, we learned that most of the families who
were interviewed had introduced solid foods at 13-16 weeks (39%) or at 17 weeks or later (36%).
Approximately three percent of families had given their child solid food by one month, which is not
recommended.
Safety Practices
In general, the use of safety devices was quite high among affiliate families. Nearly all affiliate
families interviewed at 18 months (94%) said that they always or almost always used a car seat for
their toddler. Most families (97%) placed the car seat in the back seat of their car. Although 2% said
they put their car seat in the front seat (which is generally not advised), we did not ask for the type
of vehicle. If these families owned trucks, putting the car seat in the front seat would be appropriate.
Although two thirds of interviewed families said their car seat was easy to use, 15% said it was
somewhat easy, and nearly 10% said it was somewhat hard or hard to use their car seat.
During the 18-month telephone interview, 90% of families said they had a working smoke detector
in their home. Of those families living in homes with more than one story, 90% said they had a
working smoke detector on each floor. Although most families had a working smoke detector,
families varied in how often they checked the batteries. Of the families who said their smoke
detectors were battery-operated, 20% said they never check the batteries or they check them once a
year or less. One quarter of families said they checked the batteries once a month. Significantly
fewer low income mothers, (i.e., mothers in households with an annual income of $25,000 or less)
than higher income mothers reported having a working smoke detector at 18 months (89% vs. 98%).
Although the 18-month telephone interview did not include questions regarding other safety
practices, we were able to look at trends in the use of two other safety devices using data from
parent questionnaires completed at visits to the Healthy Steps practice. These safety devices are
cabinet locks and electrical outlet covers. The trends were consistent with what we would expect;
as children grew and became more mobile, more families installed electrical covers and cabinet locks.
By 18 months, 81% of affiliate families reported having electrical covers installed in their home; 56%
said they had cabinet locks. According to the Healthy Steps protocols, the HS Specialist was to
conduct a safety home visit at 9 months. Therefore, it is encouraging that these levels increased
after six months.
Early Reading Practices
Early reading was an important component of the Healthy Steps program. Beginning with the 6month well child visit, the child’s primary care provider gave each child a book as part of the Reach
Out And Read program.
The probability that an affiliate mother and father showed or read books to their child every day
increased over time. By 24 months, 57% of affiliate mothers reported showing or reading books to
their child every day; 49% of affiliate fathers did. We would expect, as children got older, more
parents would show or read books to them every day. These results closely matched those from the
18-month telephone interview. At that time, nearly 60% of mothers said they read to their child at
least once a day. They reported that 38% of fathers were showing books or reading to their child
every day. It is not surprising that more mothers showed or read books to their child every day as
the vast majority of mothers said they were the child’s primary care giver (e.g., 83% at the 18 month
telephone interview).
There were significant differences in reading practices noted among specific groups of families. Half
of low income mothers said they showed a book or read to their child every day compared to 80% of
higher income mothers. Similarly, fewer teen mothers reported showing a book or reading to their
child every day compared to older mothers (51% vs. 61%). However, a greater number of first-time
mothers compared to more experienced mothers reported that they show or read a book to their
child every day (65% vs. 54%). First-time mothers may have more time to spend with their children
than mothers who are balancing their time between two or more children.
Nearly half of affiliate families interviewed (47%) said they had 20 or more books for their toddler.
Approximately 2% of families said they did not own any books for their toddler; 30% reported
owning fewer than 10 books. Again, there were significant differences among specific groups of
families. Far fewer low income and teenage mothers said they owned 20 or more books for their
toddler than higher income or older mothers. Approximately one third of low income families (32%)
said they owned 20 or more books, compared to 85% of high income families. Similarly, 31% of
teenage mothers interviewed said they owned 20 or more books for their toddler compared to 52%
of older moms.
Early Language Development
Nearly all mothers interviewed at 18 months said they often or always talk to their child while they
work around the house. Less than 1% said they rarely or never talk to their child.
We asked affiliate families whom they would ask if they had a question about their child’s speech.
The percentage of affiliate families that said they would ask someone at the child’s pediatric practice
increased over time from 73% at 6 months to 80% at 18 months.
We also assessed children’s language development using The MacArthur Communicative
Development Inventories/Word & Sentences. The CDI-WS is designed to measure language
development in children 16 through 30 months of age. It was incorporated into the selfadministered parent questionnaire at 24 months with permission from the author. Specific measures
and results for affiliate children are described below. Of the 547 affiliate families who visited the
practice between 23 and 26 months of age, 341 (62.3%) completed the CDI-WS. Of these 246
(72.1%) completed the English language version and 95 (27.9%) completed the Spanish Language
version.
Mean Vocabulary Score (English-Language version only): One hundred words comprise the
MacArthur CDI-WS Short Form A vocabulary checklist. This checklist is intended to measure
vocabulary production. Table 3 shows the mean vocabulary scores by age in months for boys and
girls between 23 months and 26 months of age in the Healthy Steps affiliate evaluation sample.
Within each age group, the mean scores for girls at affiliate sites were higher than for boys, which is
consistent with the findings of other research on vocabulary development (not shown). Scores for
both boys and girls tended to increase with age.
Combining Words: Parents were asked whether their child had begun to combine words; responses
included: not yet, sometimes, or often. The two latter categories were combined to indicate that the
child had begun to combine words. There was a slight but consistent trend similar to that for
vocabulary scores with greater percentages of girls than boys in each age group combining words
(not shown). However the percentages for all age groups were high: 98% of 23 month olds, 89% of
24 month olds and 93% of 25 month olds were combining words according to their parents. These
percentages were higher than the percentage of children in the Pittsburgh studies who reportedly
combined words at the same ages (83%, 84% and 85%, respectively) but were lower than the
children in the CDI Normative sample (92%, 92% 100%).
Sentence Complexity: In the sentence complexity section of the CDI-WS, parents were asked to
choose from each of 37 pairs of more or less complex phrases. They could select either phrase or
neither one. For each of the 37 items, we assigned a score of zero if the parent checked the less
complex phrase or left that item blank and a score of one if the parent checked the more complex
alternative. Table 3 shows the results for sentence complexity. Here the trends described above are
even clearer, with scores higher for girls than for boys (not shown) and scores for both groups
increasing with age.
Mean Length of the Longest Sentence: The mean length of the longest sentence spoken by the
child is reported in Table 3. In this section parents were asked to list three of the longest sentences
they have heard their child speak. The number of morphemes in each sentence was counted
following instructions in the MacArthur CDI training manual.13 A morpheme is a linguistic unit
that contains no smaller meaningful parts, e.g., birthday or doggie. For forms completed in Spanish,
words were counted rather than morphemes. We then calculated the mean of the three longest
sentences; if fewer than three sentences were listed, the mean length of utterance was based on the
sentence(s) recorded. Again, girls seem to be using longer sentences sooner than boys, but the
length of sentence spoken did not vary across the age groups.
Overall, these results for Healthy Steps children at the affiliate sites are consistent with observed
differences between boys and girls at these ages. It is not clear how to interpret the absolute scores
for these children, which tended to be lower overall than were those for children in the CDI
norming sample, a sample comprised of mostly white, middle class families (Table 3). Whether
these lower scores reflect underreporting by parents and/or deficient language skills is not known.
Interestingly, absolute scores for affiliate children tended to be slightly higher than were those for
children in the Pittsburgh study, an inner-city, mostly African-American sample (Table 3). More
research is needed to understand how to interpret the results accurately and usefully in terms of the
socio-economic characteristics of these families. Further, the limited sample size may bias the
interpretation of results. We know, for example, that families that completed the CDI differed
significantly from families that did not in ways that may affect results.
Table 3.
MacArthur Communicative Development Inventories (CDI) Scores among
Affiliate Children and Two Other Samples
Age in Months
23
Mean (SD)
Mean Vocabulary Production (0 – 100)
CDI Norming Study
50.9 (21.7)
Healthy Steps Affiliate
46.3 (24.1)
Sentence complexity
CDI Norming Study
10.5 (10.2)
Pittsburgh Study
9.2 (8.3)
Healthy Steps Affiliate
9.3 (10.1)
Mean sentence length
CDI Norming Study
4.7 (2.2)
24
Mean (SD)
25
Mean (SD)
58.7 (24.5)
50.1 (22.3)
72.2 (19.8)
57.5 (22.9)
9.1 (9.6)
10.2 (8.7)
9.1 (9.3)
11.4 (10.2)
9.8 (8.5)
11.9 (11.0)
4.7 (2.7)
5.5 (2.7)
13 Fenson L et al. The MacArthur Communicative Development Inventories: User’s guide and technical manual. San Diego, CA: Singular
Publishing Group. 1994.
Pittsburgh Study
Healthy Steps Affiliate
3.5 (1.9)
3.8 (1.9)
3.8 (1.9)
4.4 (3.8)
3.9 (1.9)
4.4 (2.1)
Fenson L et al. (1994). The MacArthur Communicative Development Inventories: User’s guide and technical
manual. San Diego, CA: Singular Publishing Group, p 43.
Source for CDI Norming Study: CDI Norming Study: Renda C (1996). MacArthur Communicative
Development Inventories, Short Form Versions: A Norming Study, A Thesis Presented to the Faculty of San
Diego State University and Fenson et al. Measuring variability in early child language: Don’t shoot the
messenger. Child Development. 2000; 71 (2): 323-328. Portions of the table in Fenson et al were adapted
from Feldman et al. [see below].
Source for Pittsburgh Study: Feldman et al. (2000). Measurement properties of the MacArthur
Communicative Development Inventories at Ages One and Two Years. Child Development; 71 (2):310-322.
Routines
The majority of affiliate families interviewed at 18 months reported setting routines for their child.
For example, 81% said they usually have mealtime at the same time each day, 73% reported a set
time for naps, and 75% said their child went to bed at the same time each night. There were,
however, a few variations among selected groups of families. A smaller percentage of low income
and teen mothers said that bedtime for their child was usually the same time every day than their
counterparts (70% vs. 89% and 66% vs. 79%, respectively).
Health Care Seeking Behaviors for their Child
Preventive Care
Medical record reviews were conducted for all children enrolled in the affiliate evaluation and for a
retrospective sample of children. Since affiliate sites did not have a control or comparison population,
a retrospective sample was one way to approximate a comparison population. The retrospective
sample consisted of 100 children who received care at the practice approximately 1 year prior to the
Healthy Steps program. Children were selected for the retrospective sample based on the same
criterion as the Healthy Steps sample; that is, they had to have made a visit to the pediatric practice
within the first 28 days of life.
For each visit, the reviewer recorded the following information: the date of visit, type of visit, and
whether the visit was kept; the child’s height and weight; whether the child received any
immunizations or developmental assessments at the visit and if so, what kind(s); and finally, whether
the child was referred for any services and if so, what kind and for what reason. All visits in the
child’s medical record were abstracted from birth until 14 months. We extended the abstraction
through 14 months in an attempt to capture the child’s one-year well child visit.
When interpreting the results from the analyses of medical record data for affiliate children and
children in the retrospective sample, it is imperative that we consider how these two samples may
differ beyond the availability of the Healthy Steps program. We know, for example, that three of the
six sites involved in the affiliate evaluation experienced changes prior to the program (e.g., changes
in the state Medicaid program which affected enrollment eligibility and timing) or as a result of
implementing the program (e.g., moving to a new building in a different part of town to
accommodate the program). These included changes in the provider location, the provider type, and
the population served. Thus, caution is merited in interpreting results of the medical record
analyses as these changes could account for differences in health care utilization between the affiliate
children and children in the retrospective sample. Changes noted in health care utilization between
the two groups could also be due to changes in the community at large. Observed differences could,
however, be due to the Healthy Steps program.
Receipt of Developmental Assessments: At all affiliate sites but one, a statistically significant
greater percentage of affiliate children received at least one DDST developmental assessment within
the first year (14 months) compared to children who received care at the site one year prior to
Healthy Steps. In fact, at most sites, none of the children seen at the practice prior to Healthy Steps
received a DDST developmental assessment.
Age-Appropriate Well Child Visits: We looked at the percentage of children who received a well
child visit at 1, 2, 4, 6, 9, and 12 months of age. The time periods were based on the American
Academy of Pediatrics’ recommended schedule of well child visits for the first year of life. For a well
child visit to be considered age-appropriate, the visit had to occur within a window around each age.
For example, the six-month well child visit had to occur between 5 to 7 months. For each time
period, we had to determine which children were actively seeking health care from the provider or in
other words, who were “at risk” for a well child visit. We defined the eligible sample as children
who had made a visit to the practice, as recorded in their medical record, during or after the previous
age-appropriate well child visit window. For example, for a child to be eligible for the six-month
age-appropriate well child visit, s/he had to have made a well child visit after 3 months.
After the first well child visit at one month, a greater percentage of children participating in Healthy
Steps made their age-appropriate well child visits than children in the retrospective sample,
although these differences were not always statistically significant. For example, at 12 months, 80%
of Healthy Steps children received their well child visit compared to 70% of children receiving care
at the practice one year prior to Healthy Steps.
Up-to-Date Immunizations: We created a variable to reflect whether a child had received all
his/her recommended immunizations by 12 months. By definition, a child was up-to-date if by 12
months they had received 3 DTP vaccinations, 2 Polio vaccinations, 3 Hib vaccinations and 2 Hep-B
vaccinations. There is very limited evidence to suggest that Healthy Steps had an impact on
children’s immunization rates. Only two sites showed a statistically significant difference between
the HS children and the children in the retrospective sample in terms of their immunization rates.
The site where this difference was most apparent is one of the sites that experienced changes in the
provider or population served in order to implement Healthy Steps. Thus, these results cannot be
attributed to the Healthy Steps program with any certainty.
Further, at three of the sites, immunization rates may have already been so high as to prevent
improvement. This is often referred to as a ceiling effect. Once the immunization rate is very high
it is difficult to improve it, as the last 10% of children represent those who are most difficult to get
immunized.
At one site, a site that had no known changes prior to Healthy Steps, a statistically significantly
greater percentage of Healthy Steps children had their immunizations up-to-date at 12 months
compared to children who received care at the practice approximately one year prior to Healthy
Steps (57% vs. 42%, respectively). The immunization rates are, however, low at this site.
Acute Care
Emergency Department Visits: During the 18 month telephone interview, we asked parents if the
child had visited the emergency department (ED) or an urgent care center or had been hospitalized
since his/her birth. Nearly half of all affiliate families interviewed (44%) said their child had been to
the ED or urgent care center at least one time since his/her birth. According to parents, 54% of
these children had made only one visit to the ED or urgent care center during this period (range 110 visits). The top three reasons for visiting the emergency department were fever, ear infections,
and injuries.
Hospitalizations: Parents’ responses to the 18-month telephone interview indicated that from birth
to 18 months, 18% of children were admitted to the hospital. Three quarters of these children were
admitted only one time; the highest number of admissions for a single child was five. The three
most common causes of hospitalization reported by families were: fever, urinary tract infections, and
respiratory problems including respiratory distress, respiratory illness, respiratory syncytial virus,
pneumonia and asthma.
What Did We Learn from the Affiliate Evaluation?
In summary, the full Healthy Steps program was implemented at all affiliate sites. All affiliate sites
hired two HS Specialists and delivered the package of Healthy Steps services from the time the first
family was enrolled into the program. The ability of the sites to implement the program may have
been due to the fact that Healthy Steps was delivered through the existing health care system.
Ongoing training and support was an essential element of the Healthy Steps program that may have
contributed to the sites’ ability to fully implement the program. Successful implementation also may
be attributed to the moderate intensity of the Healthy Steps program, which made it feasible to
integrate with other services.
The pediatric health care professionals at affiliate sites were devoted to the program and worked
hard to overcome barriers to its implementation. They chose to participate in the program and
made a large commitment to participate in the evaluation. They were deeply invested in providing
high quality health care that they felt would benefit the families they served.
Results from both providers and parents indicated that affiliate families received Healthy Steps
services. According to the HS Specialists, the average family who participated in the program at
least 15 months received:
7 office visits with their Specialist— the HS Specialists attended most, if not all, of the child’s
well child visits during the first three years of life.
2 home visits from their Specialist—the level of home visiting was lower than the
recommended schedule, although these data do not indicate if a family refused a home visit(s)
or the HS Specialists failed to offer it.
6 telephone calls with their Specialist.
2 other contacts from their Specialist such as mailings.
The average family did not attend a parent group. Only 20% of families attended at least one parent
group during the program.
Child development was universally discussed with families, and other important topic areas such as
nutrition, child health, injury prevention, family support and maternal health were addressed with a
large proportion of families. Families with higher incomes and older, better educated and first-time
mothers appeared to receive more Healthy Steps services than their counterparts, but the differences
between groups were small.
These results are particularly noteworthy because five of the six affiliate sites served low-income,
transient populations at high risk for poor outcomes. Initially, there was doubt whether Healthy
Steps could even be implemented at these sites. Not only did these sites successfully implement the
program, but they also delivered developmental services to populations that are traditionally
difficult to reach and to engage in health care programs.
Healthy Steps added value to the primary pediatric health care delivered at affiliate sites. It
enhanced the relationship between the family and the practice. The key to the program appeared to
be the relationship that developed between the family and the HS Specialist. This relationship, and
the additional services provided, seemed to account for increased parents’ satisfaction with the care
they received. According to all our sources, affiliate families—whether at high or low risk, new
parents or more experienced, young or older mothers—were highly satisfied with the program.
In addition, the program appeared to have improved the satisfaction of primary health care
providers with the care they provided. All those in the practice who worked with the HS Specialists
acknowledged the benefits that this new professional brought to the practice. Overall teamwork
improved over the course of the program. Increased satisfaction occurred among those health care
professionals that work with at-risk populations.
The level of positive parenting practices was high among affiliate families. The majority of families
reported using safety devices, establishing routines and talking to and playing with their child.
There was some evidence to suggest that Healthy Steps improved parents’ use of the health care
system for their children. At some sites, a greater percentage of Healthy Steps children made ageappropriate well child visits and had their immunizations up-to-date by 12 months than children
who received care at the practice prior to Healthy Steps. These results could be due to: changes in
the provider or population; changes in the community at large; or the Healthy Steps program.
Lastly, most key informants spoke optimistically about the impact that Healthy Steps had on the
way pediatrics was practiced at their site and could have on pediatrics in general. All noted the
challenge of funding—finding a way to reimburse for the HS Specialists services or modifying the
program without compromising its effects.
“I think the HS model has a tremendous impact on the way pediatrics is practiced. I think the
providers have developed a new mindset toward developmental issues and provide more holistic care
for the family”
HS Specialist
“What I see happening through Healthy Steps [is] modeling to physicians how they can change their
practice or expand their scope. When you communicate with families in different ways—listening
skills being more in tune to what families have to say. [They] see the importance. Even if I was not
here, certain things would remain—already embedded in the practice. Once you change, start seeing
with different pair of eyes…”
HS Specialist
“Physicians see the benefit of Healthy Steps and are trying their best to do the same things with other
patients. [They] took their blinders off—bought into the program. That is outstanding.”
Site Administrator
“I learned a lot. Made me a lot more focused on development and behaviors. We focused on
communication skills too. I hope mine have improved as a result. This is standard—some of these
services are truly needed in order to practice successful pediatrics. This truly should be the standard
practice—not pie in the sky—how to do it. Healthy Steps can become ‘the standard’. The delivery of
the same services as outlined in Bright Futures. But no pediatrician can do all this. Healthy Steps
[is] a more crisp model. It has got a mechanism to deliver services. Won’t work without retraining
or retooling or some reimbursement above what it is.”
Lead physician
What is happening at Affiliate Sites Now?
At the time of this report, two of the six affiliate sites were still fully in operation and a third was
not due to the closure of the hospital in which it was located. Although most had modified Healthy
Steps as originally designed and evaluated, all operating sites continued to employ at least one HS
Specialist. A brief description of the activities at each site follows.
Charlotte, NC: After the period of the Affiliate evaluation, Healthy Steps was being provided to
families with children who have spent time in the neonatal intensive care unit and to families who
have adopted foreign-born children. The HS Specialist saw families at all well child visits and
conducts several home visits. This program recently ended.
Chicago, IL, Bethany at Advocate: Advocate Health Care system now uses HS Specialists at five
facilities and serves as a Chicago-wide resource for the program. Bethany now offers a prenatal
program and has established links with community organizations and the Department of Public
Health. HS Specialists from Bethany have taken Healthy Steps into the Cook County prison.
Chicago, IL, Ravenswood: Ravenswood Hospital was closed in 2002. However, the residency
training program has been moved to the University of Illinois, which hired the HS Specialist from
Ravenswood.
Garden City, KS: Staff incorporated HS components such as Reach Out And Read, lactation
consultation and play groups into the general clinic. Through a contract with Parents as Teachers,
HS Specialists make home visits to families at greatest need.
Houston, TX: The site secured funding from a local foundation. With this funding, HS Specialists
see families at well child visits and conduct a prenatal home visit. The practice has expanded the
program to age 5 to help prepare families for school. More than 50 residents continue to work with
the HS Specialists and the HS program.
San Antonio, TX: Using funding from the Texas Tobacco Settlement, the sponsor of this site
currently operates a case management program for teenage women with multiple pregnancies called
Healthy Mother/Healthy Families. It is a direct outgrowth of Healthy Steps.