AMCHP 2006 ANNUAL CONFERENCE
EARLY CHILDHOOD: BUILDING THE FOUNDATION FOR LIFELONG HEALTH
March 4-8, 2006
CHRIS DEGRAW: My name is Chris DeGraw. I am a pediatrician and I work at the Maternal and Child Health Bureau. I work specifically in the division of research training and education, but I’m also Project Officer for two cooperative agreements that the Bureau has with the American Academy of Pediatrics for the implementation of Bright Futures initiative.
I’m joined today by two colleagues, Paula Duncan and Beth Zimmerman, who are going to be helping me out. But first I’m also, I guess by default, the moderator for this panel as well, and they gave me a little cheat sheet of what a moderator is supposed to do. Make any housekeeping announcements and I wasn’t told of any, so if anybody knows of any housekeeping announcements to make. You probably hopefully by the second day know where the bathrooms are. And that’s primarily it. There are handouts and evaluation forms at the back of the room and I’m asked to remind you to please fill out the evaluations and I guess you can leave them on the back table. Oh, no, our (inaudible) representative here will collect them.
Today we’re going to talk about using Bright Futures to Promote Child Health in Clinical and Public Health Settings. I think that this is a real exciting opportunity for us who’ve been involved with Bright Futures, because the public health arena is an area, I think, that’s really ripe for using Bright Futures to help you folks do your jobs, and that’s really what we want to address today and get some input from you.
I’m joined today, as I mentioned, by Beth Zimmerman and Paula Duncan. Beth is the Director of Health Promotion at Health Systems Research, Inc. in Washington, D.C., where she’s worked since 1993. She’s served as a Project Director for the Bright Futures evaluation activities that HSR has been carrying out for the Bureau over the last several years, since 2002 specifically. Including the National Bright Futures Process Evaluation and the Bright Futures Public Health Case Studies that have just been released and we’re going tell you a lot more about today.
Dr. Paula Duncan is Professor of Pediatrics, and works at the Vermont Child Health Improvement Program, otherwise known as VCHIP, in the Department of Pediatrics at the University of Vermont School of Medicine in Burlington. Before assuming her position with VCHIP, Dr. Duncan was the Principal Assistant to the Secretary of the Agency in Human Services, and the Maternal and Child Health Director for the state of Vermont. Dr. Duncan is currently working with Pediatric and Family Medicine practices in Vermont for three quality improvement initiatives. Youth Preventive Services, Children in Youth and Foster Care, and Developmental Services for Children Birth through Five. The Developmental Services Project is funded by the Commonwealth Fund, and is being done in partnership with the Center for Children’s Healthcare Improvement at the University of North Carolina in Chapel Hill, who have also--both of those entities have been partners with us in some of our Bright Futures activities that you’ll hear about today. Nationally Paula is the Chair of the Bright Futures Implementation Advisory Committee and as such is one of the overall leaders of the Bright Futures Initiative that’s now housed at the American Academy of Pediatrics.
So why are we doing a Bright Futures workshop at AMCHP? I think a lot of people sort of have a misperception or a preconceived notion that Bright Futures is primarily a clinical thing. That it’s really something for the pediatricians and other health care professionals. But in actuality you folks, you public health people, were among the early adopters of Bright Futures. You saw the value of it. Saw how it could be applicable to your work in health promotion and prevention, and really picked up the ball and ran with it. And we’re going to hear about some of those efforts today.
We want to share with you all some of the Bright Futures activities that have been going on. I think a lot of people--Bright Futures has been around so long that people kind of have a nodding acquaintance with it if they haven’t really used it, and sort of a vague idea about what it is and know that it’s out there. But we really--this has been an exciting time over the last few years for Bright Futures. Lot’s of new things going on and we want to share some of those, a selected group of those things, because we can’t cover it all today, but hopefully it’ll whet your appetite for more. And most importantly we need your input to assist us and our partners in helping you implement Bright Futures to meet the health promotion and preventative service activities that you do in your own states and localities. Bright Futures has always been about partnerships. Our partners in implementation are the staff that work on Bright Futures are there to help broker some of these partnerships, to help, to listen very carefully to what the field needs and wants, and to help figure out how to do those things that will help you. So we really want to leave some substantial time at the end of this to start a dialogue that I hope will be ongoing between us and you, between the Bright Futures staff, and the leaders, and you folks, and at other venues over the next few years.
So the goals of our workshop today are to discuss how Bright Futures can help you promote the health of infants, children, and adolescents in your states and communities. I’m going to talk a little bit about Bright Futures. Where we’ve been, where we are now, and where we’re going with the Bright Futures initiative, at least from the Bureau’s perspective. Beth is going to start talking to you specifically about Bright Futures and public health. As I mentioned before we carried out an evaluation of the process evaluation of the initiative as a whole over the last few years, and some specific activities related to state implementation. And these are sort of our first tentative steps into laying the groundwork for hopefully an ongoing effort in terms of implementation of Bright Futures in the public health. Paula is going to then talk about Bright Futures for quality improvement in the clinical setting, and that has been a real exciting initiative over the last couple of years, and we’ll hear a lot more about that and how it can be applicable to the public health duties as well. And then finally, a discussion with you folks to find out what you need from Bright Futures that will help you do your job.
So where have we been with Bright Futures? This is a timeline. It’s in your packets so I’m not going to over it in detail, but Bright Futures started around 1990 as an initiative that was spearheaded by the MCHB and the Medicaid Bureau. It started off with a series of conversations over a period of time between MCH Bureau staff, some state MCH folks, and folks at the Medicaid Bureau too. Identified a need--that was sort of a period--the 80’s were the period when the so-called “new morbidities” were being discussed a lot and defined. Really taking a hard look at pediatric health care practice and what its needs were and how it had evolved over the previous century. Folks thought that there was really time to really rethink well-child care, health promotion, primary prevention, and think through by taking into account the psycho-social and other morbidities and the resources available that could be employed to address those in a new sort of way, and that’s what lead to Bright Futures.
It was carried out initially over the first about 12 years of the effort through a cooperative agreement that the Bureau had with the National Center for Education and Maternal Child Health. It started out as a--it kind of evolved, it wasn’t a well--the future of Bright Futures as I understand it, and I was somewhat involved with it in the beginning, wasn’t totally planned out or charted ahead of time. It really evolved and one thing built on another. The idea was to come up with some guidelines for health supervision or well-child care that could be applicable in the clinical setting and other settings as well. Four expert panels were pulled together nationally to address issues in infancy, early childhood, middle childhood, and adolescence. And after working for two or three years, came up with the first edition of the Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents in 1994. This sort of started things off with various partnerships and production of other materials, including the Bright Futures and Practice series, which those evolved kind of informally and certain disciplines decided that there needed to be more in-depth information available in certain areas than could be provided in the Bright Futures Guidelines publications which is already really long and had a lot of materials. So the first out of the block were the oral health folks, the dentists with Bright Futures in Practice: Oral Health. I find that to be one of the more interesting things that the dental community really were the early adopters of Bright Futures and really saw the potential there, and they continue to be. That lead to Bright Futures in Practice: Nutrition, Physical Activity, and then much more recently the Bright Futures in Practice: Mental Health, which I think is a sentinel event in the evolution of Bright Futures because it was more than just a manual of information with the Bright Futures Mental Health. It was the first stab at trying to do a tool book to give folks the actual tools they needed to implement some of these things that the book or the publication was saying should be done. There have been other efforts at tools throughout the way in terms of the Pocket Guides for the various volumes, some encounter forms for health professionals and for families around well-child care, but the Bright Futures in Practice: Mental Health was the first time to really systematically try to come up with a set of tools that would be useful for implementation.
Around the turn of the century, around 2001-2002, we had an open competition to let the cooperative agreements that would implement Bright Futures. We envisioned it as a Bright Futures education center that would carry out the work of the publications, and materials, and dissemination, and building partnerships. And a Bright Futures Pediatric implementation project that would really focus in on sort of the implementation in the clinical setting, because, as a matter-of-fact, that had kind of lagged behind. It had the uptake in the clinical setting for Bright Futures hadn’t been quite what I think the founders envisioned so we thought there needed to be a more intense effort in that domain. Well, low and behold, the AAP successfully competed for both of those cooperative agreements. I think at the time we kind of wondered how that was going to play out. You know the mumblings were that oh well, now it’s going to be all clinical because it’s the AAP in charge and we’ve been delighted in the way things have played out over the last four years. There’s been a real synergy between the two projects. The Academy and the staff have been great and have really carried on the spirit of Bright--the interdisciplinary spirit of Bright Futures, the emphasis on public health as well as clinical and on family, so it’s really done well.
We also around that time decided it was about time to take a look at Bright Futures from an evaluation standpoint. Of course everybody wants an evaluation of everything and Bright Futures hadn’t really been looked at critically in any way, and at the very least I think the evaluation was helpful to the Bureau in that it sort of helped us look back and take stock where we’d been and what some of the challenges were, what some of the real positive things were about Bright Futures and helped us with our thinking of where to go in the future. And we need all of your help to help us continue that. And then we also, as the evaluation kind of evolved, really decided that the information that was coming out of the evaluation with regard to public health was really interesting stuff, and that there was an opportunity for us to really lay the ground work for some public health implementation efforts by documenting what had gone on in at least a handful of states regarding the use of Bright Futures. We’d always heard the anecdotes at meetings and oh yeah, Bright Futures they’re doing lots of good things in Washington State, or wherever. And so that kind of perpetuated and everybody would talk about the great things that they were doing, but nobody really knew for sure in detail, except probably the people in those states. So we really wanted to take the time to document those good things, because I think that’s really the best way that we can learn from each other.
So what is Bright Futures? Well, it’s a lot of different things to a lot of different people. It’s certainly a set of very nice materials that are well produced. The National Center did a great job on the materials in production and have been well received. But it doesn’t really tell us what Bright Futures is. This is a quote from Dr. Maury Green who’s a Pediatrician at Indiana University and one of the fathers of Behavioral Pediatrics, and who is the first Chair of the Bright Futures Steering Committee starting back in 1990, and the co-editor of the first two editions of the Bright Futures: Guidelines. And he said that “Bright Futures is based on that belief that the new morbidity requires a new and contextual health supervision. One that attends to the strengths and risk factors of families and communities, as well as individual children.” And I think this captures some of the spirit of Bright Futures and has some really key points that have continued to inform the development of Bright Futures through the years. One, the contextual aspects of health supervision, it’s not just the doctor or the nurse doing the well-child anticipatory guidance in the office, but to the kid and the family. But that there’s a whole context that the child brings to the situation, of family and community, and there’s a whole context that health supervision can be done within not just the clinical setting, but within the home of course, and the school, and through other public health efforts, and the community at large.
Some other key points I think Maury makes are attention to the strengths, that we’re not just about risk reduction. I mean in public health that’s the first thing that you talk about, when you reading about public health is the risk factors and what not. But Bright Futures tries to look at the strengths as well as the risks, and address those and incorporate those and build upon them with regard to prevention. Families always a key aspect to Bright Futures, and I think that’s kind of paralleled efforts in the public health community, and the Bureau over the last 15 or 20 years about really seeing families in a different way. Seeing families as partners in their children’s health care, not just as sort of the passive recipients of the medical community’s information. And the last point that Maury makes that I think important is the idea of community. That it takes more than any one of us, or any certain discipline, to really be effective with regard to promoting health and preventing morbidities in infants, children, and adolescents. It takes a whole raft of us. It takes the public health community. It takes the clinical community. It takes the visiting nurses. It takes the schools. It takes the families. So those points have really guided the Bright Futures over the years.
I think it’s also helpful to look at the original Bright Futures goals. First to promote desired social, developmental, and health outcomes of infants, children, and adolescents. To enhance health care professional’s knowledge, skills, and practice of developmentally appropriate health care in the context of family and community. To increase family knowledge, skills, and participation in health promoting and prevention activities. And to foster partnerships between families, health professionals, and communities to promote the health of children. And I think these four goals are as applicable now and will be as applicable in 10 years from now as they were 10 years ago. I think this conference has--as I’ve sat through the various sessions of this conference it’s really reaffirmed to me how much we’re--we all have the same goals. You know this conference has been focused on mostly birth to pre-school, but we all have the same goals. We all have--Bright Futures I think can help us, one, sort of identify those goals. Can help us have similar expectations across our disciplines and our domains of what we want to get out of health promotion and prevention. And I think it was some folks in Washington State that described Bright Futures utility for them as providing a common language around children’s health promotion and preventive needs so that health care professionals of various disciplines, educators, public health folks, families have a common language to talk about these issues and that way we can all move forward together. But that still doesn’t tell us what Bright Futures is and I think we found that out very explicitly when the new project advisory committee, when the AAP took over Bright Futures activities several years ago, met for the first time. Large room, people representing a lot of different federal agencies, and organizations, and professional disciplines, and family members. And so we were trying to come up with a statement of really what is Bright Futures, because it became very evident that everybody had a little bit different idea and it wasn’t an easy or necessarily a pleasant task, and Betsy was there, Paula was there. It was kind of tough because everybody did have their own sort of preconceived ideas. So we sort of hashed out this statement, which again is not perfect but I think it does kind of get at the gist of things. “Bright Futures is a set of principles, strategies, and tools that are theory based, evidence driven, and systems oriented that can be used to improve the health and well-being of all children through culturally appropriate interventions that address the current and emerging health promotion needs at the policy, community, health systems, and family levels.” A lot in there, probably something for everybody, but I think it does go a way’s towards capturing the spirit of what Bright Futures is.
So what’s new? We have a new logo in the last couple of years. The old logo--nothing wrong with the old logo, in fact it was very nice. But I think the new logo signifies for a lot of us a new energy, a new commitment to Bright Futures. New activities. New partnerships. Really a new spirit, and certainly from the Bureau’s standpoint a continuing, on-going commitment to Bright Futures. I don’t think there’s an initiative at the Bureau that’s as long-standing as Bright Futures has been at the level of commitment, both financially and energy wise as anything. So the new logo captures some of the new spirit for us all.
There’s a new Web site for Bright Futures, www.brightfutures.aap.org, it’s a great Web site, I hope you’ve found it. If you haven’t please go look, it’s getting better all the time as we get more information from folks like you to share on the Web site. I think it really captures the spirit of what we’re trying to do with the implementation of Bright Futures and that it’s again not just focused on health care professionals and the clinical aspects of Bright Futures, though that’s certainly an important part. But they are also co-equally sections devoted to Bright Futures and families and communities, and Bright Futures for public health professionals. And we really want your help to help us make that, especially the public health part of the Bright Futures Web site, really responsive to your needs. One part of the Web site which is real exciting, and I think is getting--again getting better all and all and these case studies will help that even more, is identifying how people are using Bright Futures in the clinical setting, in the policy arena, in training of health care and other professionals, and in public health, and there’s some nice interactive click on “See What’s Going On in Your Area” and if you don’t see anything--we want to find out whatever is going on. Whether it’s a big State initiative or if it’s something that you--some useful way that you’ve incorporated Bright Futures in to your work we want to hear about it.
Again the Bright Futures Evaluation, Beth is going to talk about in more detail in a moment. It gives us a good assessment of where we’ve been, and a good starting point for looking ahead. The State Case Study is really one of the big messages that we want to get out to all of you here to day and to your colleagues. There are six case studies of State Bright Futures implementation efforts. I think when you take the time to read them you’ll see that one of the beauties of Bright Futures is that no one does it the same way, and no one sees the same things in Bright Futures and the utility can play out in a lot of different ways. And that’s, I think, a lesson for all of us who are working on Bright Futures is to really try to be responsive to the implementation needs of the folks out there, not try to be prescriptive. Some of the really wonderful things about Bright Futures have happened not spontaneously necessarily, but without being directed from some central source. We have case studies on South Carolina, Louisiana, Washington State, Maine, Virginia, and Georgia. And those are accessible either directly through HSR, and Beth will tell you about that Web site, or through the AAP Bright Futures Web site.
Our colleagues at HSR also sort of took the next step and did some synthesis and analysis of the case studies so that we can learn the lessons that they can teach us, and how we might be able to use them. And also put together sort of the first steps to a how-to guide for states and communities for using Bright Futures. More suggestions taken from the analysis of the case studies and from HSR’s extensive work with the states on other MCH issues. And I think it’s--you know we’re not saying this is the be all and end all, but this is our first efforts toward some tools that we hope will be useful to you.
The Bright Futures Training Intervention Project that Paula is going to talk about in some depth was a quality improvement strategy for the delivery of preventive care and developmental assessment in the clinical setting. It’s a co-funded or funded by the Commonwealth Fund, which is a major partner here, and with input from our HRSA projects, and the Academy, and the Center for Children’s Healthcare Improvement. And I’m not going to talk any more about that, we’ll let Paula do that.
We have the Bright Futures Oral Health Toolbox that was developed--it’s a new product developed by the National Maternal and Child Oral Health Resource Center and Georgetown. Katrina Holts specifically and her colleagues. And you can find out more about that on their Web site, which is listed in your hand out.
Our partners at Family Voices have been a key player in Bright Futures from the very beginning. Betsy Anderson, take a bow. As most of you I hope know by now, for the past several years they came out--they’ve had a Bright Futures Family Pocket Guide. Really kind of directed to families, and most recently a Spanish version of the Bright Futures Family Pocket Guide, and you can contact Family Voices and find out how to access those. Or nab Betsy after the presentation.
Our colleagues at the Virginia Department of Health have an exciting new product, a web based training course on promoting child and adolescent health Bright Futures and EPSDT. Cathy Bodkin, I don’t know whether--are you here? I guess she’s at another session today, but if you can corner her on your travels during the meeting she can tell you more about it, or you can go to their Web site, which is again at the bottom of the slide on your handout. Another example of partnerships, in this case a partnership between the Virginia Department of Health, the Virginia Commonwealth University, the Virginia Chapter of the AAP, and the Department of Medical Assistance Services. I live in Virginia so I can say it, but it’s not always known as the most progressive state in the union, but with regard to Bright Futures they’re doing some wonderful things.
And coming soon, well, hopefully all but the newest of you are acquainted with the Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents. Again, as I said before, it was first published in 1994, it’s gone through a couple of updates in the interim. It’s generally been well received, but coming soon is the new Bright Futures. Oh, when we transferred the slide it lost all my little spins and flashes and stuff. Too bad. Just blink a few times and you’ll see it. AAP has been spearheading this revision. I think we first thought it would be another update, but when the expert panels were formed about three or four years ago, and the steering committees met, and everybody kind of got into it the decision was made to do sort of a ground up rethinking of Bright Futures. To build on the strengths and counter some of the perceived weaknesses of the original Bright Futures: Guidelines and really try to come up with something that was ready for the--whatever you call this decade, the 2000’s. And really more responsive to the needs of the people we’re trying to help here. We really need your input into the Bright Futures: Guidelines. Like I said, four expert panels have been working literally it seems like night and day by monitoring the e-mails from all the list servers, but for the last couple of years. We’re down to the near final draft which is the finishing touches are going on. There’s going to be a web-based review of the Bright Futures final draft coming up in we’re hoping May. Over about a three-week period in May it’ll be on the web. We would love to have any or all of you review any or all of the draft. Your input can be critical in helping us make this something that really works for you and we hope that you’re interested enough to take some time to look at it. You can contact Bright Futures at aap.org, send them your contact information and they’ll get back to you at the time and tell you how to hook up to the Web site for the on-line review. So really take it home, tell your colleagues and solicit their input. We’d love to have you do it. For those of you who are in training programs I told the trainees this weekend--we had some of our trainees meeting, that I think it would be a great exercise for trainees to take a look too. Yes?
UNKNOWN SPEAKER: We all agree but just one question. In terms of programs that would have a number of staff that may or may not be interested in reviewing, would you rather they contact you as individuals or as program?
CHRIS DEGRAW: Jane do you have any preference? I don’t think it matters. I think you probably need one person’s contact information to be the person who can log in to get the thing, but if you want to do it as a group that would be ideal too.
JANE: If you do it as a group and you wanted us to know your names you could call me or you can e-mail in, but otherwise everybody will get their own log in I.D. So however you want to do it, just so we have your feedback.
CHRIS DEGRAW: Yeah, you can orchestrate it at your site however works for you, I think, just so we do have a point of contact in order to get the information.
UNKNOWN SPEAKER: Just as a follow up. Do you have a very broad idea of the amount of time it would take to review the document?
CHRIS DEGRAW: That’s a--no, I don’t, not having seen the final draft, though I know it is long and it will probably, if you’re going to look at the whole thing, which we would definitely encourage you to look at the whole thing, but at least enough that you understand the whole context before you hone in on one specific part, but Jane, I don’t know, what do you think?
JANE: No, that was the answer.
CHRIS DEGRAW: I think it’s probably would take a lengthy time to do a comprehensive review. Yeah.
JANE: And some people will only review certain sections, but as Chris said you’ll want to review the beginning part so you understand the context of it.
CHRIS DEGRAW: Okay, I’m going to turn this over to Beth Zimmerman now and she’ll talk about the work that they have been doing.