AMCHP 2006 ANNUAL CONFERENCE
EARLY CHILDHOOD: BUILDING THE FOUNDATION FOR LIFELONG HEALTH
March 4-8, 2006
PHYLLIS STUBBS-WYNN: Dr. Aronson founded and directs the early childhood education linkage system, or Healthy Child Care Pennsylvania. This is a program of the Pennsylvania chapter of the American Academy of Pediatrics that promotes health and safety in early childhood education and child care programs.
For nearly two decades Dr. Aronson has offered the column called Ask Dr. Sue, in Exchange, which is a national magazine for child care directors and early childhood leaders. For those of you who know Dr. Aronson, you know I'm leaving out a lot of important information about her career in pediatrics, as well as her leadership in Healthy Child Care America. She's given me the permission to do so in the interest of time. Dr. Sue.
SUE ARONSON: Thanks. Actually, I just didn't give her permission, I asked her, please, give us the time. Because I think it is important for us to interact in this session, and to have you feel that you go home with some things you can actually do.
You'll notice at your places you have these handouts, and in the handout the first page is sort of a synopsis of key slides from my presentation.
And death by PowerPoint is definitely a hazard in these conferences, so I'm hoping that we'll be able to interact a little bit as we go along.
My responsibility, in talking with you today, is about the second objective in this panel, and it's about linking children in child care with their medical homes. And the focus I am hoping you will take home is that there are some tools, and one of them is this online tracking tool that is available to help bring the early education professionals and health professionals together to work on assuring that children have preventive health care.
But let's look a little bit first at the medical home issue, and let me go back -- looks like I'm going the wrong direction, here.
Here. What is a medical home? Well, a medical home -- let me just ask you, how many of you think of the concept of medical home all the time? All right. Well, there's another whole session this afternoon on medical home, somewhat of a linker here. A medical home is an approach, and it's the idealized making sure you have people linked with a place that they can get the things that they need, that's a home, a place they can get -- if you don't show up, they will be looking for you. That's the basically the concept in a nutshell. And the characteristics are listed there.
Now, preventive care today is really about health professionals who work in offices and tell people what they're supposed to get. They set up appointments for them, tell them when to return, and give them -- sometimes they give them a copy of a complex schedule that the parent can rarely understand that the health professional often has trouble implementing. And fail to use recall reminder systems; very few preventive, pediatric preventive care facilities actually use effective recall reminders, because they have no financial incentive to do it. Unlike dentists and veterinarians, who do an excellent job of sending out notices when it's time to come back. Even oncologists do a better job than most pediatric sources.
So it's about this sort of a tug and pull, trying to get them to come back, keep appointments, and hope that things will work.
But we have these different worlds where families function. And in fact, they function more in the educational world than they do in the health professional world. We have shared goals with educators. Our goals are mutually to make sure that children are well, that we promote wellbeing, that we prevent harm, and that we collaborate with families and other sources of support for families to make sure that we optimize the development of children and the support from their families. And we work with policymakers and advocates. But we look at it from different vantage points. We tend to view this whole issue as something which is uniquely turf of the health professionals, or uniquely turf of the educators, without thinking about how to work together.
Now, you have already been introduced multiple times to the primary reference, Caring for our Children, the National Health and Safety Performance Standards for out of home child care. Phyllis mentioned it, I'm showing it here. How many of you actually have a hard copy of this in your office or at your desk?
Okay, those out of who did not raise your hands, I assume it's because you're internet savvy and you're easily able to get it off the internet by just going to the National Resource Center for Health and Safety. There are multiple avenues you can access to get there, but it is available at the National Resource Center. Just simply www -- sorry, no www, it's just HTTP. NRC.UCHSC -- University of Colorado Health Sciences Center, dot, edu. And out of that set of standards, the evidence based consensus documents, have been pulled a number of subset documents that focus on a particular topic. And these have been printed off as separate sets.
So there are separate sets on a variety of topics, and one of them is on promoting a medical home. And you will find this subset on the web now. And Laura, where are you to hold up your copy? Laura has a hard copy in her hand, if you like hard copy it will be printed out and available shortly, but you can always get it off the web.
Now, the table of contents gives you a sense of what standards have been included, they've been sort of taken out of the set. And I have the web resource there on the screen, so if you didn't get it from my saying to you, you can copy it off the screen now. Where you can get all of these standards, and these subset of standards as well. And you can also do the comparison that Pat talked about, of how the -- what the state regulations have, that's also on that same website.
Now, the Pennsylvania chapter of the American Academy of Pediatrics is an awarding winning state chapter, about a little over 2,000 pediatricians, which has used approaches that have been adopted by many other states now. And it is an organization which is a wonderful home for individual pediatricians to gather up others who are interested in the same topic and move forward as a team of advocates, in link, in block step with other people in the community that have a common interest. Because the academy has the ear and the respect of many, many others in the state.
How many of you are working with your state chapter of the Academy of Pediatrics already? Hands high, real high. Okay, those of you who are not, I think you should find out what you are interested in that some folks in the academy might be interested in, because you can often get more done by marrying your interests together with the energies and interests of pediatricians in the community.
Now, what we did do was to develop -- one of the programs of the Pennsylvania chapter was this ECELS, Early Childhood Education Linkage System, which then became wrapped around in the Healthy Child Care America campaign at Healthy Child Care, Pennsylvania. And it is a program of the academy, it's 17 years old now. I'm no longer its director, actually, I have handed that off to someone else who does an able job of maintaining the program. But I am still its health advisor, pediatric advisor, along with several other pediatricians in the academy who advise the program on its function and regularly take part in carrying out its initiatives.
Now, many health issues in early childhood programs. You see a smattering of images here of things which are really relevant health issues. Eating, and both the preparation and the choice of food and the presentation of food, and how nutrition is handled in relation to activity. We are all into obesity prevention now. How babies are slept. And if you look carefully, you'll see they're not being slept well in that slide there. They're tummy sleeping, in the one on the right, and they're too close together, their cribs are too close together. How they're diapered. Here you see a child who is standing on a fecally contaminated surface that he's now going to trek around the room. How they wash their hands. And how they may have need for medication, as in the child in the lower picture who is using a spacer device because she has asthma.
There are many issues that actually require on-point observation, interaction, with early childhood professionals to make sure these are addressed appropriately.
But we are going to talk about one aspect that is a very important opportunity to link the practitioners of pediatric care and the practitioners of early childhood education, and that is the ensuring of preventive health care. Early education programs can be a safety net to ensure immunizations and screening by checking documentation and giving parents reminders. Because after all, they see families every day, unlike most of us health professionals who don't in fact get that opportunity.
Now, the educators' challenges in doing this are many. First place, they have lots of other things to do other than this. They're working on numeracy and literacy and a bunch of other things. And we give them complex screening schedules that we can hardly read and say you should make sure kids are up to date with this. We give them complex immunizations schedules. We have new vaccines and combinations. We say you need to have reminder and recall tools that you give to parents, but you figure out how to develop them. And then we have parent resistance. Parents who say I'm busy working, I can't necessarily get all this stuff done, and you're hassling me, who are you to hassle me? My pediatrician takes care of it, and if he doesn't take care of it, there's something wrong with him.
There's a lot of finger pointing, blaming, complaining, and not problem solving in this situation. And that never gets much done.
Health professional performance, though, does vary, and there are health professionals who for their own reasons decide not to give the preventive health schedule as it is recommended, and that makes it hard on everybody.
And when we -- let me see, I seem to be pressing the wrong arrow here. There are different state requirements for reporting. Because from one state to another, as Pat mentioned to you, you really have different requirements, and people get really confused with the national recommendations and what the state requires.
Well, here's a look at the AP schedule for preventive care. Obviously you can't read it from your seat, and let me tell you, when you're close it's not even that much easier. There's all these different marks and different symbols, and ifs, ands and buts, and footnotes. And then of course we have the current immunization schedule. Now, that's a little bit easier to read, because it has colors, but I didn't even put up on that slide the whole page of footnotes of ifs, ands and buts about that.
Healthy People 2010 gives us some specific guidelines about what we should be trying to accomplish. Achieving and maintaining immunization at 90 percent level at 19 to 35 months. Excuse me? What do you do with the kids who are younger than that, and the kids who are older? There's a measurement for a national benchmark. It's not very useful to people who have kids who are two, three, four months of age in their programs. And the 95 percent level, which is expected for children in child care at 19 to 35 months, that's a higher level because you have them captured there, you should be able to do a better job.
And of course, we have other screens we could work on, and one of the ones that appears in Healthy People 2010 is blood lead of zero percent target. Well, let me tell you, we should not be identifying lead risks in child care by looking for kids who have elevated blood levels. It would be much better for us to make sure that child care programs do not have lead risks in them. And lots of states do not such regulations.
Well, in Pennsylvania in 2002-2003 we achieved a 72.5 percent level of children having received all their recommended vaccines for age. And that is a very interesting number, because any one vaccine was over 90 percent. So for any one vaccine, that over 90 percent of children got their vaccines. If you understand math and the possibilities that you may have combinations and permutations when you have so many vaccines, in fact only 72.5 percent of all the children had all of their recommended vaccines. And that's the number we really should be looking at.
Immunizations and screenings, only 25 percent were up to date for preventive care overall.
The message is go to your medical home and get what you need. And the way we can get that done is to make sure that educators are involved. Because when you involve educators -- and we know this for schools -- you get more kids what they need, because families care about keeping their kids in school much more than they care about going to the doctor's office. And so it works.
But how do we get that to work? Well, we have some tools to ensure preventive care. And the tools that we have are the child health assessment forms that every state has, has some kind of form that the providers use to get information. Of course, they don't know what to do with it, they stick it in a folder, and as long as they have a paper in a folder that's okay.
We have immunization dose counter tools that many states use, but they don't work very well. You can get one dose of a vaccine that is recommended for three doses under a year of age. If you get it after you're 12 months of age, one dose is okay. But if that one dose was when you were two months old, it's not okay. Dose counting doesn't really do the job for us, it's a proxy. And I've been involved in immunization dose counting tool development, and it was okay at the time, but it doesn't do the job.
We need something that's more sophisticated, has the rules built in, takes away those complex schedules from any of our responsibility, and lets the computer check the dates of service against the birth date of the child, and tells us whether the child is up to date.
And that's what Well Care Tracker is. So now I'm going to tell you a bit about Well Care Tracker. Note the website. How many of you know about Well Care Tracker already, have been on the website? High, I can't see your hands. Maybe there aren't many of you. Well, there aren't many of you. Well, then you'd better make note of the Well Care Tracker website because I want to be able to come back and know that you in fact have been there, and have looked at it.
It was developed by Sue Weinberg, a pediatrician in Pennsylvania, and by Jerry Aronson, who is a relatively of mine for 43 years. And we did this because we realized that we needed to do something to simplify this process of figuring out who needs what, and getting the ones who need something sent back to where they're supposed to get it.
So what we did is that we took the -- it was a piece of software that Stu had developed for the University of Pittsburgh and the Pittsburgh Health Department clinics to check on immunizations, and elaborated it into something that could be used by lay people. And developed it over a period of 10 years, and then implemented it for eight years using it as a checking tool for the licensing staff who were going out and checking on child care programs, who had a regulation that nobody was enforcing that said that children who were enrolled had to be up to date with their preventive health care.
Well, the licensing people didn't know how to look at those pieces of paper stuffed in folders, so they were never enforcing it. And what we got them to do is to pick up a sample of those records and send them in to a data processing person, who then entered it into the software, while we refined the software to the point where it could be used directly by child care providers. That was always our goal, was to get it so they could use it.
And also, to wait the time while child care providers became more computer-savvy and more of them had computers. And we have reached that time. In fact, whether they have it at home or they have it in the center, whether the kids are doing software programs on them during the day, or whether they're being used for administrative function primarily in the child care program, over 70 percent of child care providers now have access to the internet through computers. So -- and use it regularly.
So now, the time is now that this is really quite feasible. So we have eight years of data trends that were from the picking up of the data, and we developed this web-based application which allows people to not have to have software on their computer, they can use any computer they want, but to simply have access to the internet, and their data are stored in a secure place on the internet.
And the rules that are applied to their data are updated regularly by pediatricians who are privy to the current schedule. So that they're always being tested by the current rules every time the rules change.
Any PC connected to the internet, you can use this software, from anywhere you are. This is password protected and private so that the information is guarded against being abused. And this is what it looks like. This is the home page. If you go to www.WellCareTracker.org you'll see this home page. And over here, if you would like to play, you can enter the word "demo" and then the password actually automatically comes up, but it would be -- it's WCT, for using the demo on this page.
You'll notice that in addition to the demo opportunity, you can log in and go play on some of those sample pages with a sample set, which I'll show you. You'll also have some opportunities to get other things on this home page. You learn about ECELS, you also can take some training which will give you training credits in Pennsylvania by using Home Care Tracker. We have sample letters to doctors and to the parents to use to send home the data, about how to get the kids into medical homes and why they need something.
This is the data entry page. Most kids come into a health professional office, and typically they get multiple services. They get multiple vaccines, they get vision screening, hearing screening, whatever they get on a particular date. So the first entry is a date of service, and then by just tabbing over and hitting the space bar, you put checkmarks into the services that were provided on that day.
Or if you prefer to use a cursor, which data processing people find takes more time, you can just put the cursor on the box, click on it, and put the checks in. And then re-checking, clicking on that box removes the check if you made a mistake. So it's very, very simple to enter in the data from a health record, it takes actually between two to four minutes per record to enter the dates of service that children have had for preventive care.
And it's less for younger children, and the most for the older children that have more services. Any questions about that data entry? Real simple.
And it takes -- question, yes.
UNIDENTIFIED SPEAKER: Sue, how does the child care professional know exactly what services?
SUSAN ARONSON: Because the forms that they get from the -- almost every state has forms that require documentation of immunization by date, and many states now have documentation of a health assessment and what services were provided on that date.
This doesn't say whether the services were normal or abnormal, this is checking whether the child got the things he was supposed to get.
UNIDENTIFIED SPEAKER: And who does the data entry? At the --
SUSAN ARONSON: Anybody really can, whom the child care provider decides to put on computer that has internet access. So in many child care programs that are using it -- you might ask how many are really using it, that's a pretty good question. We have about 350 centers in Pennsylvania now using it directly, it is taking them less than an hour to learn how to do it. We have Health Best, Health Best is my husband. And we get very few questions or calls, and he can monitor how they're using it to know whether they're having difficulty, and to see how well they're entering in their data.
So it can be an enlightened secretary, it can be -- sometimes it's a director who wants to do it all herself. Sometimes it's a health care professional, which we have very few that do; in fact, the health professional's time is not well used for this. It's better used with following up on the children who don't have what they need.
Well, this is what you get. What you get is -- I wish this were moved over just a little, but you can see you get the list of services, this is the list of services, and in red are highlighted the ones that are overdue.
And in yellow, behind but not due. We don't have any of this on John Bob Walton, who happens to be our sample child here. Remember him from Waltons fame? What's the name of that show again? It's something mountain. Anyway, it was an old television show. But John Bob Walton was one of the kids there. And currently due is in green. So this child has these services that he's overdue for, which has to do with history, physical, developmental, DTP, and I believe this is HiB, and he is currently due for vision and dental screening, by age. And those colors will change every day as the child becomes due for something. So you can enroll a child at the beginning of the year and be up to date for everything, but in three months, because he's grown older, he may now need some things. And it will show up as they choose that particular option to get that report.
And that report can be sent to a child's health professional who could say, well, yes, he did have it, I just didn't write it down on the form when I filled it out. Well, get it. It's your report. Or, hm, no, he slipped through the cracks, he didn't get it when he was in the office and we do need to do those things for him.
The child care provider also gets a report of all the children in the program, and it gives them a list of those things which are currently overdue for each of the children, and those things which will be overdue in three months, so you can give a little note to the parents and say your kids are going to need these things in the next three months, and they can schedule an appointment. Let’s not make it an emergency that you need a form filled out for your child care program.
So preventive care tomorrow, we hope, will include both the push and the pull. The community-based outreach, with child care and schools, for example, Well Care Tracker, vaccine registries can play a role in that. And the pull from the medical home, with insurance QA incentives, VFC programs, case management support, and those kinds of things that can be done in the health care setting. But we need both to get this job done.
So in summary, really, what we're trying to do is to strengthen the link between early education, child care, and medical pulls. And I like to think about the image of the bridge. We are in -- how many of us are health professionals in this room? Raise your hand.
Okay, how many of you are educators who are in the early education and child care oriented? Okay, there are some of you here.
You know, we work on different banks of the same stream. We have the health professionals working and doing their stuff over here, we have educators doing their stuff over here, and families keep flowing downstream. And we keep throwing our life buoys out from our shores, you know, trying to best give them and ensure they get what they need, that they don't drown, they're learning to swim okay, and they're going to get to their destination healthy and well.
What we have to do is build a bridge across the shores, so that we can work together to make sure we're most effectively helping those families who are flowing down the stream between us. And it really is important to strengthen those links and to recognize the burden that we impose on each other.
Early education professionals look at health professionals, say, you know, you're sitting in your office not doing your job. These kids are supposed to have these services, why are you asking us to check on them? You're the ones who are supposed to do it.
Well, we don't, health professionals, see families very frequently, and many of them don't even show up ever. For us to even begin to get them into our system, even if we had a system for reminding people.
So it isn't about complain and blame, it's about solving the problem. We need to get together and figure out what will work.
So to improve the preventive care status of children, which is necessary for them to be healthy and able to earn, and to achieve the Healthy People 2010 objectives for children, we need to work together. We need to build and maintain those bridges, and find practical ways that work within the worlds in which we operate. And that means we need to learn how to talk to each other, we need to learn how to open our lines of communication so we listen to each other.
And that means letting our gatekeepers, especially for health professionals, let educators through so that we can communicate. And child care child health consultants are a very important function for us. We have a minute or two for any questions that you might have about what I've shared with you. Anybody?
Nobody is going to ask me the key question? Yes, go ahead.
UNIDENTIFIED SPEAKER: So I was just thinking, like the Department of Ed and Department of Health can just decide to go in and start using this Well Care Tracker? They don't have to sign up?
SUSAN ARONSON: Oh, that's the key question.
UNIDENTIFIED SPEAKER: How do you get in on this?
SUSAN ARONSON: The way you get in on it is, first, it's being operated by the Pennsylvania chapter of the Academy of Pediatrics, and we're a nonprofit organization, and all we charge for this is what it costs us to maintain it. You go in and you sign up. A child care provider signs up and says I want to subscribe. The cost is $1.50 per child per year right now to maintain the service. That is the key question. It costs $25 to get two passwords programmed in. That's an initial start-up cost. But after that, you know, you've got -- if you've got a facility of 100 children, it costs you $150 for the year to use this service. It's not exactly an overwhelming cost for programs that are -- have that many children.
It's not a huge cost. It's what it cost us to maintain the server, and to keep Stuart Weinberg upgrading the rules. We just had a change the rules on vaccines, and influenza vaccine is now on there being tested. We are not testing -- looking at TB testing, but it is available for people to keep track of, because of course TB testing is not routine for every child, but only high risk circumstances. We are working with Head Start programs who actually want to be able to enter in flags for abnormal data, and we need a funding source to program that in right now, but that can be done. But it's $1.50 per child per year.
UNIDENTIFIED SPEAKER: It starts with your child care provider.
SUSAN ARONSON: It can start with a whole system. We have big systems like Goddard Schools, who decided to enroll all their schools. But generally speaking, they like to have their reports site-specific, they like to have a password and an aggregate report created for each individual site, so that's the unit on which we're working. But a whole system could enroll all their centers, a whole state could enroll. And we do have a couple states that have inquired about that. We do have other states using it, by the way, I just give you the figures for Pennsylvania users. Yes.
UNIDENTIFIED SPEAKER: Do you have family and child care providers enrolled?
SUSAN ARONSON: No, you have to have at least 25 children right now to use it, because it takes work for us to set up the passwords and kind of maintain it, and if you're only getting -- well, like 3 to 5 dollars, we just couldn't work with that kind of unit. So we had to figure a way to do that. However, systems of family child care are doing it, so that individual family child care providers are not entering the data, but --
UNIDENTIFIED SPEAKER: Like an association that had --
SUSAN ARONSON: Exactly.
UNIDENTIFIED SPEAKER: -- members could enroll?
SUSAN ARONSON: Exactly. We do have associations, and in fact they already were keeping health records for their child care providers. But it was too much for individual family providers who had six kids, and it wasn't very effective. So they were doing that on their behalf. Rosemary.
UNIDENTIFIED SPEAKER: Can the health care professional be the entry point for this, or does it have to be the child care provider?
SUSAN ARONSON: The child care provider is doing it and getting the report. Of course, this system was originally developed for a health care clinic. Stuart has done this for a number of different settings, including camps and primary care health clinics. But then they were reporting lot numbers of vaccines and other things in that system.
But this was set up for entry and for flags to be gleaned about when children are overdue. Because we didn't want to be chasing kids back for services when they were in fact going to get them on a routine schedule, anyway. So a child doesn't become flagged for overdue unless he's past the age at which he should have had that service. So a three year service can be provided anytime between the ages of three and four, he doesn't become overdue until he comes to four. That would be a different flag you'd put on it in a health care arena.
Any other questions? Yes.
UNIDENTIFIED SPEAKER: Are the standards that are incorporated in this Pennsylvania-specific, or are they --
SUSAN ARONSON: No, they're the national academy standards. And those states who are using different schedules, we tell them -- what you get is a report of what the child is due for by national recommendation. And if your state chooses to have lesser requirements, then you can ignore the fact that this child is actually due for something that's nationally recommended, but at least you'll know that you're ignoring it.