AMCHP 2006 ANNUAL CONFERENCE
EARLY CHILDHOOD: BUILDING THE FOUNDATION FOR LIFELONG HEALTH
March 4-8, 2006
BETH ZIMMERMAN: Thank you so much, I have to adjust. You have the short one up here now. It’s really a pleasure for me to be here because we’ve been working on Bright Futures evaluation activities as Chris mentioned for years, and in addition to the national process evaluation, we just completed the case studies so we’re really considering today to be our big launch. And I’ve put some reports in the back for you to see. They’re all on-line and I’ll give you the details here in a minute. And I would like to thank Chris and Ann Drum who have worked with us throughout at the MCHB as our project officers, as well as probably people in the room who’ve taken the time to share your Bright Futures stories with us, or be a part of our work group.
Okay, you can see I’m very good at the technology. Okay, this is a quick overview of the various things that we’ve done Chris mentioned. I won’t spend much time on this but we did spend a chunk of time looking at the national picture doing a process evaluation of Bright Futures. We did an extensive annotated bibliography so we could catalog the great massive materials that actually have been developed. Not only the ones that you may be familiar with, the big books over here, but there’s also been a lot produced at the State level and by other organizations. And actually I’ve pulled out what I think are some of the best and most easily accessible for you on the back of the yellow handout at the back of the room there. So I hope you’ll look at those. Oh, the dancing started again so we all have to--you don’t mind if I dance through, do you? We also worked with an evaluation work group throughout the process. They advised us, they gave us feedback and they did give us support for moving ahead with the case studies, which we did in 2005, and again welcome to our launch. And it’s been really nice to have the opportunity as we did that evaluation to have close connections with AAP. We did present to their work groups throughout the course so it’s kind of unique to have that opportunity when you’re looking back at something also to look forward. So that was really nice. And the findings from all this work that we’ve done are very interrelated so I’ll present them in a combined way for you. But I would like to just spend a minute talking about how we went about the process evaluation and an overview of the report. With regard to the methodology that we used, we used qualitative research methods, focusing primarily on key informants. And our goal in doing this was to focus in on the way that Bright Futures has diffused from the national level, to the state level, and the local level. So we honed in on people who had actively used Bright Futures. So this was not something where we said let’s talk to every pediatrician in the country, but we honed in on different people, and different areas to get a sense of that. We conducted three focus groups. We did one with pediatricians, one with pediatric nurse practioners, and also one with grantees of the Bureaus Healthy Tomorrows Program. And we looked at lots and lots of databases, and papers, and reports, and all of those good secondary data sources.
So what’s in the report? Really what it does is it tells you the Bright Futures story. Beginning back with that time line that Chris showed--most of that time. Talking about how it was conceived, what were the goals, how was it developed, who was involved, and taking you all the way up to 2002 when the AAP was funded. And I think that that historical perspective can be very helpful to people who are picking it up now and trying to move forward with it. The evaluation itself was structured around the five objectives that complement the goals that Chris talked about. They were developed at the beginning of the initiative, and that had to do with development of the philosophy and the materials, dissemination of those, training, partnerships, and evaluation. And in the report we provide sort of a progress on where we are for each of those.
Now what the report did very well is to support and confirm the major role that the public health system has had in utilizing Bright Futures. You are all over this report. Lots and lots of examples and snapshots of what people have done in the past and currently, in all sorts venues, in clinical practice, in training, policy, et cetera. And of course, being the kind of people we are who write these reports, we put together a lot of recommendations as well. If you want to get the report I encourage you to do so on our Web site. That is the address. Again please see the yellow sheet in the back for an overview of that and all the reports that are available. You will have your choice of downloading the 100 plus page report with every detail you would ever want to know or the executive summary.
So in addition to capturing the breadth of all the things that were going on around the country with Bright Futures, it also really highlighted and opportunity to go deeper and go in and look more closely at some of the States that seem to have a more active level of Bright Futures use, where they’ve used it more consistently, or more systematically in their efforts. So what we did is we moved ahead and did the case studies. This is the map Chris already told you, the States that we covered, again Maine, Virginia, South Carolina, Georgia, Louisiana and Washington. And again what we did is we talked to people again, got lots of key informants. We found a main contact in each state and they helped us to identify people at the State and local levels who we could talk with and we talked, and talked. We’ve spoken with clearly over 100 people throughout the course of the evaluation and the case studies. We like doing that.
So with regard to the findings, which I’d like to go into now, I’ve structured them around these three major questions. Why Bright Futures? What is it about Bright Futures that entices people to want to look further and use it? Who uses Bright Futures and how do they do that? So when we asked people why they use Bright Futures these are the reasons they commonly sited. You’ve got lots of them here. The fact that it is supported by so many different professional associations is something that people mention a lot, because especially when you’re in a policy-making environment you don’t want to start from ground zero with that. You want to start with something that already has a lot of support, and Bright Futures does. It’s also updated regularly. Obviously the AAP has invested an enormous amount of effort and that’s very appealing. In addition to being attractive, the comprehensiveness of the resources was certainly highlighted because people said, “You know in many cases there’s nothing as comprehensive on these particular topics for child health so it’s a wonderful resource.” And the State Health Department people in particular liked that Bright Futures is easy to work with people from a really broad variety of backgrounds, and disciplines, and agencies. So that’s very nice for getting people together and the fact that it’s organized around developmental periods is also very good. If you want to match it with EPSDT, right there with you. And it also helps provide consistency of messages across these providers and over the age spectrum of children. And when you look at the examples of how Bright Futures is used, which we’re going to do in a minute, you’ll see that people use Bright Futures because it helps them in some way to address an issue, a need, or a problem that they have. And the other thing that you hear is this notion of fit.
That Bright Futures reflects the philosophy and the values of the people who pick it up. For example, it’s obviously got a big focus on prevention that fits very nicely with public health departments. It’s a good complement for moving that agenda forward. But we did hear that from people beyond the public health setting as well. The pediatrician picks it up. It’s because they like how it fits with their style. Now in terms of who is using it, again just want to go back to what was envisioned at the beginning. It was a very broad audience that was intended for Bright Futures, providers, families, and communities. Kind of sweep everybody in on there. And we did find, in fact, that lots of different people do use Bright Futures in many different venues, and that would probably include people you’d think of normally as well as some you might not. Child health professionals are the primary target audience. Public health folks you guys are there. Among the child health professionals we did see some variation. Where we saw a lot of use in particular was pediatric nurse practitioners. Probably not really surprising. But we saw lots of other people in there, the home visitors, the schools, the community organizations.
So how is Bright Futures used? And in particular I want, because of the audience where we are here, how is Bright Futures used in public health? You can see it’s not neat, there’s a lot going on. Chris talked about that. We have activities related to policy planning, and education, and family empowerment, and standards development. All sorts of things that make it not really a very packaged story, but that’s really okay because I think it’s entirely consistent with how Bright Futures was developed and how it was put out there. They developed all this stuff, it was widely disseminated, and it has been picked up in a whole range of venues for all different audiences. And so we use this patchwork vision here, because I think that really does reflect it.
So I want to provide you with some more examples. Get into the richness of this how and that patchwork. And one of the major areas that we saw was policy development and planning. Bright Futures has been used as a guide for developing policies and plans that have to do with quality of care for children and health improvement. And in a few States, these are some examples from our case studies, we saw that the States found that their child health indicators were not necessarily what they would like them to be and so they undertook a comprehensive effort to address them and Bright Futures was used as part of that. For example, in Louisiana, they responded to some poor health indicators by doing some training of a broad variety of health professionals in interviewing skills, and using anticipatory guidance so that they could hopefully head off some of the problems that they were seeing. Georgia integrated Bright Futures into its EPSDT Program primarily as a quality improvement and monitoring initiative. In particular to respond to the Medicaid requirement that is part of well-child exams parents should be getting anticipatory guidance and Bright Futures provides a very nice framework for delivering that guidance. Many, many States have used Bright Futures as a standard of care. We saw a lot of examples in the process evaluation and numerous in the case studies as well. And one example of that is Maine, which has adopted Bright Futures as a standard for its public insurance programs, Medicaid and SCHIP. And they have used it to develop policies and clinical forms that constitute what is a well-child exam and what will be reimbursed for a well-child exam. And the providers who use these special clinical forms that they developed based on Bright Futures are reimbursed at an enhanced rate, which has lead to, not surprisingly, good use of the forms.
Integrating Bright Futures into policies and plans that live on is a strategy that a lot of States are using to try to infuse Bright Futures into the State environment and the plans that guide them. In Washington they recently adopted a Title V performance measure specifically about use of Bright Futures in a variety of settings. In Virginia, Bright Futures is all over their Healthy people 2010 plan as well as a variety of other plans, not only within the health department but also in other agencies. And South Carolina used Bright Futures kind of behind the scenes, but to really shape new policies that were developed for school based dental health programs.
So education and training of health and related professionals, another major theme. In the national evaluation we found that pediatric nurse practitioners are using them a lot. I skipped ahead. On this slide, excuse me, what it emphasizes that public health has taken a major role in using Bright Futures to train a whole variety of health professionals. Not surprisingly public health nurses are the core of that, in particular school nurses as well, but not at all limited to those. We have private providers, childcare, home visitors, lots and lots of training efforts that the public health departments have led. Georgia, for example, has been doing a series of forums bringing together a real cross section of providers who work with high risk families to help get them better skilled and trained and how to deal with some of the really difficult psycho-social and mental health issues that they are finding in the families that they are working with. And Bright Futures is being used as a forum for how they can think about those things. This goes on to the issue of integrating Bright Futures into the health professionals training program. This was a very big finding from all of the work that we’ve done.
People are more likely to use something that they were trained in school with. And from the national level I started to say a moment ago, the pediatric nurse practitioners have integrated it very widely into their programs. Their association, NAPNAP, told us that all 87 of their training programs have integrated it into their curricula and thus the finding that we found when we met with different groups of people pediatric nurse practitioners were very likely to use it in practice. In the case study States we did find some movement in this area. For example in Washington, the health department there contracts with the University of Washington to play a leading role in the State’s Bright Futures efforts, and one of the real benefits of that is that they have schools of public health, and nursing, and dentistry and other things, so that they’ve been able to facilitate those relationships and also integrate Bright Futures into the curricula there. We saw other examples as well. In addition to those school-based efforts, we also have seen some Web based efforts. Chris just mentioned the new training programs that Virginia has developed in partnership with a lot of other groups, including the State AAP chapter, to reach out to a broad variety of practioners. And the Bureau has also funded Children’s Hospital Boston in Harvard to develop another training program that’s particularly geared towards pediatric residents and other folks in training.
Bright Futures focus on the family and community also makes it a really good framework for doing that kind of outreach as well. And we saw a couple of major categories. Provider-client encounters. You know you’ve got the clinical ones between clinical providers who may be using Bright Futures and working with families. We also saw a lot of home visitors using it, so that was another direct sort of provider-client encounter where Bright Futures seems to be widely appreciated and used.
There are some broader communications efforts for families. For example in South Carolina they’ve initiated a Happy First Birthday campaign. And the goal is to try to encourage families to get their infants, or by their first birthday, into a dentist are really trying to promote the concept of oral health care for young children, pre-schoolers, and school children. Partnerships with community organizations is also another outgrowth of that reflection and the focus of Bright Futures on the community. Lots of schools. One really interesting and unusual example we found in Virginia was the Richmond Children’s Museum, which saw Bright Futures as fitting within their mission of treating the child holistically. What does the child need and what do the care providers need? And they sponsored some training programs and put the Bright Futures material in their resource center, and even participated on the Bright Futures Virginia steering committee.
In clinical practice, this is something that Paula is going to spend some more time on, but just to highlight quickly some of the things we found in our evaluation. Lots of work by clinical settings, public and private, to restructure clinical forms that are focused on anticipatory guidance and providing some more standardization across the visits and across providers. And a side benefit of doing those clinical forms that way is that people seem to be documenting things a little better, which helps with your insurance reimbursement needs. You know, what did I do last time? It helps you there. Comprehensiveness I mentioned again earlier. If a provider does not have particular expertise in an area such as mental health, Bright Futures can be something that they can go and look to and figure out what to do next.
So in addition to the who, the why, and the how of Bright Futures when we did these case studies it also allowed us the opportunity to consider what might have been going on in these States that they use Bright Futures in a different way. And we came across a couple of factors that seem to come up repeatedly, not necessarily all at once in the same State, but you can see some of those here. The issues of Bright Futures Champions cannot be overstressed. These are people who understand Bright Futures, they believe in it, they can introduce it to other people, they can identify opportunities when it might help serve a need, or fulfill a need, or address a problem. And even one Bright Futures Champion can make a big difference if that person is well-positioned in a policy making position if they can help shape the content of staff training programs. We have seen that happen in South Carolina. In particular the Dental Director at the time knew about Bright Futures from something else and when he came in he really was able to use Bright Futures in a variety of ways to shape how the oral health programs were developed in the State, and those have really blossomed. Again that issue of fulfilling a need. And an environment that’s supportive of prevention, and of service integration. Those things will all facilitate the use of Bright Futures.
States also shared with us some of the challenges they face in maintaining, and sustaining, and growing their Bright Futures efforts. Things like engaging private providers, taking a policy and making it real in the practice setting, providing training over time, dealing with staff turnover, lots of challenges, more on the next page, but really we were able to identify a lot of strategies throughout our work for addressing these at least partially. And our report discusses--this is the synthesis of the case studies. Discusses all these challenges as well as multiple strategies for each of them, and I’ve highlighted some of them here. Dealing with staff turnover. It’s challenging when you’ve invested time and resources in telling somebody about Bright Futures and getting them up to speed on how to use it, but it can also provide an opportunity when things change and you’re bringing new staff in if you incorporate it into their staff orientation process, hand them a book, sets a really great stage for the kind of philosophy you’d like them to have in working in this position as a resource as they develop programs. And also some people who might have been there a long time might have felt like if you introduce something new that was not okay, this is an opportunity for change. And when people who know about Bright Futures leave and go somewhere else they can take it with them, they can become a new Champion if you will. These are some more challenges and strategies. Chris mentioned the how-to guide. This is something where, as Chris said, we tried to synthesize some of the lessons that we learned and turn it into something that was a little more practical in the way it’s structured. Structured around steps, and it provides guidance to an individual, or a community coalition, or a State health department, or other and just what things do you need to do, how can you move ahead to build awareness about it not only with yourself but others. How to introduce it; work it into policies, all those other things.
So some of the take away messages from all of our evaluation activities I think would be supporting the notion that many people in public health have that Bright Futures can be really helpful for a lot of the goals that we all share. Promoting interagency collaboration, improving consistency of messages, reducing some of that fragmentation that exists out there, getting more people and organizations involved in health promotion, schools, families, PTA, et cetera. Facilitating cross-disciplinary training. Bright Futures has been credited with helping to change the notion of what is child health. What should the framework be? From one that is more focused on a medical model to one that is more comprehensive, grounded around developmental periods, and consumer oriented. It was meant to and in many cases has been perceived as putting out a gold standard that we all can strive to achieve.
So the final thing I’d like to offer is just some thoughts from people we interviewed in the field about how what we’ve built so far might be taken to the next level if you will. At this point in the initiative there are certainly a good core of people with a good bit of experience under their belts about using Bright Futures in the real world. I think they’re very eager to be better connected with one another, so harnessing that knowledge and the resources and getting them into more of a network is something that we heard would be valuable. A real need for reducing the need to reinvent training materials at the State and local levels. There’s more and more thing being developed all the time. Something that could be available at the national level, building on those would be helpful to many people. Funding never hurts, you know make it a priority in funding opportunities. Some support for buying those materials is sorely needed. At the beginning Pfizer was a corporate sponsor and played a major role in getting free materials out to providers and families, and without that ongoing support that’s a challenge that does need to be addressed. And obviously with AAP’s pending publication of the third edition of Bright Futures which will integrate AAP’s health supervision standards, which have been separate. That’s been a barrier. Moving those together will really help to engage the providers. Again here’s all the reports. Please take a yellow handout at the back of the room and I look forward to hearing any thoughts you have at the discussion period. Thank you.