AMCHP 2006 ANNUAL CONFERENCE
EARLY CHILDHOOD: BUILDING THE FOUNDATION FOR LIFELONG HEALTH
March 4-8, 2006
MICHAEL CALIGUIRI: Today's session is model programs for mental health for young children. If you're not supposed to be here, stay anyways. Firstly, I'll introduce myself. My name is Michael Caliguiri. My background is undergraduate and graduate degrees in child development from the University of Pittsburgh. I've served in various human service capacities, including child welfare, treatment foster care and now in maternal child health for Healthy Start Incorporated, both of Pittsburgh and Fayette County projects. Pittsburgh being the home of the Super Bowl champions, by the way.
On my right is my most favorite colleague, Erica Dorsett. She's a clinical coordinator for Healthy Start, five plus years of experience in nursing and health and human services. She received her master's degree in nursing from the University of Pittsburgh as a clinical nurse specialist. She currently holds the position of Clinical Coordinator for both the Pittsburgh, Allegheny County and Fayette Healthy Start programs.
On my right newest colleague is Mary Beth Jackson. Mary Beth Jackson graduated from Eastern Kentucky University with a Bachelor's degree in child and family studies. In 2002 Mary Beth came to state government to further her career goals to help young children in Kentucky as an early childhood mental health program administrator she's gone through the process of developing the state program, monitoring field staff, keeping abreast of current best practice, and maintaining well trained staff to carry out the mission of the program.
Her role as the early Childhood Promotions Section Supervisor allows her to expand her knowledge base and strategize numerous ways to sustain programs and attain goals while not taking from the most needy individuals in the state, the young children.
I'd like to introduce you to Jessica. Jessica came to us as a 24‑year‑old African American. She presented with her 12th pregnancy. Ten of the past 12 have had poor outcomes. She's had miscarriages ectopic pregnancies and one infant death she still struggles with. She was diagnosed at 16 with bipolar disorder and she's had inconsistent treatment at best.
She's had domestic violence relationships in the past, and she currently is involved ‑‑ she currently was involved in a domestic violence relationship. She even attempted suicide by trying to take her boyfriend's prescription medicine.
She has tenuous housing but did manage to get her GED. Jessica is a Healthy Start participant, and Jessica is somewhat typical for us.
Just to give you a brief history, Healthy Start was a program launched in 1991 by the Health Resources and Services administration of the U.S. Public Health Service. The problems were the African American babies are more than twice likely to die before their first birthday than white babies. They're nearly five times more likely to die from prematurity than white babies. And the women, children and families experience overall racial health disparities with access and delivery of basic healthcare.
So why did they pick Healthy Start? The purpose was to demonstrate innovative ways to reduce the infant mortality in some of the areas with the highest infant mortality rates in the country.
Pittsburgh, in 1991, had an infant mortality rate of almost 25 per 1,000. That rate rivaled and sometimes surpassed third world countries.
The mission of the current Healthy Start project as it stands now is to focus on the reduction of infant mortality and low birth weight babies in southwestern PA in such a way to make valuable use of its resources preserve flexibility and offer seamless services, and I think what the most important part of the mission is that we talk with the entire family. It's a holistic approach.
There are 15 original sites in 1991, of course Pittsburgh being one of them, unfortunately. We were also Pennsylvania was also the only state to have two projects. There was one also in Philadelphia. Their infant mortality rates made them eligible as well.
The original goal was to reduce infant mortality rates by 50%. Pittsburgh was the only project to actually accomplish that goal. However, the problem still exists for us in Pittsburgh, in Philadelphia and across the country.
Health and social disparities for African American mothers, infants and children still existed two to three times that of the white population in Pittsburgh and Allegheny county. So where the infant mortality rate may be seven for whites, it's still at 14 and 15 for African Americans.
Consider this, and take into account that Pittsburgh has some of the most renowned medical services available. Pittsburgh has been ranked number one in maternal smoking, on at least two occasions and I believe the most recent being 2003/2004. And 25% of births to African American mothers in 2000 and 2002 in Pennsylvania.
African Americans in the Healthy Start project area obtained prenatal care at a significantly lower rate. That 81% as compared to 92% for whites in those years as well.
When we look at depression, in our project area, up to 45% of our women who were screened tested positive. It's double the rate for all persons serviced by our health choices managed care organization in Pennsylvania.
Depression is considered to be the most important mediator of mother/infant interaction. Lowers the rates of positive behaviors in infants of depressed mothers. Mothers display decreased eye gaze during feeding. Less playfulness and less reciprocity. Other maternal mental health disorders can lead to insecure attachment.
So what does a typical woman who is in our program Allegheny county, typically 23 years old, African American. Never married. Enrolled in Medicaid, without a high school education. Smokes and unemployed or has never ever even been in the labor force. Typically had two or more children and previously experienced a minimum one poor pregnancy outcome.
We use this as a detail sheet for how we categorize moms in high risk. I'm not going to read through them, but in addition to all of these, they're most likely to be poor. And the outcomes associated with poverty of biological effects related to malnutrition, iron deficiency, jeopardize brain development, low birth weight and obviously infant mortality. And developing fetuses have a higher risk for congenital malformations. Race is related to low birth weight through its association with poverty.
For substance abuse, we have lifestyle issues which lead to inconsistent care giving environment. High risk for child abuse and neglect and mothers may experience physical and sexual violence in their own lives.
So what's a typical child for us look like? They're most likely to be poor and prematurely or preterm before 37 weeks. Experience some form of physical cognitive or social developmental delay, and not up‑to‑date on immunizations, and they frequently require medical monitoring.
These are some of the high risk categories, the low birth weight, the delays and medical congenital anomalies, failure to thrive and multiple acute infections.
You can see the impacts of that are that 1.7% of our children were born very low birth weight. We've had almost 11% preterm and 13% of our infants born require some kind of NICU admission.
So if we put it altogether, where we stand in 2006 and as we move forward, it's the infant mortality rates still remain high for African Americans, SIDS chances increase especially considering the high rates of smoking. We have tremendous amount of developmental delays. Bonding and attachment difficulties, which down the road could lead to child abuse and neglect. Failure to thrive. And we have frequent and expensive Medicare. I mean overall the poor long‑term outcomes for children are exorbitant.
So I want to give ‑‑ my purpose in the program is to go through and give you some programmatic strategies to deal with these issues. None are listed in order of performance. I really couldn't categorize them that way but we'll go through and hopefully I'll be able to give you some skills for your programs.
I do want to mention you that Pittsburgh is called the City of Bridges. And just to show that in Pittsburgh, traveling across one bridge puts you in a totally different community with totally different values, practices and beliefs. And you'll see as we go through where community‑based design. So we're required by the federal government to maintain a consortium of individuals and organizations. There are gatekeepers to the community. They tell us what the real world practice is, problems and needs are. And they guide the implementation of our services.
We spend quite a bit of time on keeping our community knowledgeable. Since they're going to be our gatekeepers and tell us what's going on, we also want to equip them with the skills to be able to provide applicable guidance to the participants in these communities.
You can see there's quite a few and we take them very seriously and our community is quite receptive to engaging in these health education activities.
One of our primary through our mission statement, one of the primary systems we engage in is a holistic or family‑centered approach. That includes grandparents, siblings, foster parents, strengthening really the entire family. But I'd like to take the time to stress the involvement of fathers and male caregivers, which is a wonderful component in our program. Brazleton and Kramer said: Despite grade advances, the forces that have historically excluded fathers are still strong. Based on cultural recognition, a father's natural ambivalence and their own powerful doubts of about being able to be protective and nuturant. And I think that's the natural ambivalence is a perception of the community at large. That's for you to determine to be true or untrue.
As far as their own doubts, particularly for the case of fathers they lack a steady male mentor figure as children themselves that's the case for most men enrolled in the male Healthy Start initiative program. The purpose of the male initiative program is to inform male partners and spouses of how influential they are to the outcome of pregnancy and the ongoing health and well‑being of their babies. Father's male care giver they receive the identical services of the enrolled women including health education on maternal health principles as well as care coordination and screening for behavioral and mental health problems.
Here's a good shot, I guess what I would ask you is this the typical father in your community. For Healthy Start men, this is not a typical picture for us, this is what we strive toward.
The typical father in Healthy Start is 22 years old, unmarried, unemployed, tenth grade education, needs housing and has no health insurance coverage. He's likely had fathered two or more children to different moms. Fathers as male caregivers more likely use tobacco, alcohol and drugs to cope with psychosocial stressors. Considering 32% of the births in Allegheny county were to unmarried women. Nationwide 24 million live absent to their biological father.
And again I would stress that most of these men have not had a father or male care giver in their lives as they came along. The negative impacts of not having a father involved in the up bringing of the child is that they're absent on average at least two to three times more likely to be poor, to use drugs, to experience educational health emotional and behavioral problems and to be victims of child abuse and engage in criminal behavior.
Whereas the positive impacts of having a father involved are that they're significantly more likely to do well in school. They have healthy self‑esteem. They exhibit empathy and pro social behavior and they avoid high risk behavior such as drug use truancy and criminal activity and for more facts you can go on to the national fatherhood initiative, father facts.
Another part of our program I wanted to take some time on is collaborations. That would be local, state and federal collaborations. To effectively target and manage large population relationships with leaders in every field and at every level must be formed. Just to highlight a few of these are the program participants and the faith‑based communities. They're of particular importance to us because they're enmeshed in the cultures and unique insight on how best to provide the needed services and oftentimes the members in our community will seek out faith‑based options if available.
Another one I wanted to point out was the health professionals. We take a lot of time in building networks with our local area health professionals concerning that we have a high number of hospitals and clinics in the center. But upon, from experience we found that it's often much too late to try to educate or teach health professionals who are currently practicing. So we've taken measures to get out into the universities and talk to pre-professionals and persons who are in training. We feel like it's going to make an outcome over the long haul and we've even seen the immediate impacts. We've gone as far to educate health professionals in Poland, Germany and Russia as well.
On the state level, the primary purpose of these state collaborations is to promote open communication and exchange of best practices. They allow us to become influential and promote policy and practice changes across the state. And obviously to influence some funding and sustainability efforts, one that we're most proud of is our Pennsylvania perinatal partnerships, which is a collaboration of the state and local Title Vs along with the six Healthy Start projects in the area.
At the federal level, these are some of your most important. I know on the bottom I had the big dollar signs and people were asked me if I really wanted to leave that in the slides. But building collaborations with legislators has been a key component for Healthy Start, both locally and federally. We've taken the necessary measures to actually invite local and state legislators to come to our place of business and develop presentations to them and have them create some buy‑in for them. The outcomes can be great. They can help sustain not only your program at home but if you're a national association, obviously they have influence as well. That's why I said think about what committees the legislators sit on. It will help, you one, develop your presentation and maybe allow you to ask for something that you needle.
A great example and one that I know we're most proud of is that we were able to enhance our health education efforts by getting a $10,000 grant to do a newsletter. It's been tremendously successful. We get a lot of positive feedback from our participants and community partners as well.
Build a referral network, speaks to itself. But we make our referrals with early intervention specialist, WIC, local and state health departments. Mental health, drug and alcohol treatment centers, family planning and child protection services.
The reason for doing such is that it increases the timeliness and accountability of available programs. Without both qualifications our at risk population is not ‑‑ they're unlikely to take advantage of the opportunities in the communities. So we're able to guide them quickly to access those services.
The outcomes are that we've had improvement in health disparities decreased rates in infant mortality. We have a very competent staff and professionals in our community at large. Early prenatal care is increased. And we've increased the coping skills and decreased crisis intervention needs of our participants.
Prevention principle. : This is actually a photograph of some early education as we like to call it. The early identification for us is primarily through targeted outreach and I have some of these little quips. But putting on your walking shoes. I mean that quite literally. Getting out walking talking in the communities. We hold forums in the communities that are relevant to the community, for example. Our men have a hard time accessing employment because of a criminal history. We pull together local leaders and legislators and they were able to help them with expungement of their criminal activities and push them towards employment.
Don't wait to educate. It's never too early to start preplanning. And we'll touch on that later myself and Erica. Get the word out. I mean that to the entire community. Including local businesses, hair salons, schools and even the local hang outs, that's again with your tennis shoes on and maybe a little logo shirt.
Pay It Forward. I don't know if anyone has seen the movie with Kevin Spacey and the kid who says I see dead people. But it's a fantastic movie, and we live on that philosophy. We educate our community and we ask them to promote our agency. If they believe in the program, they'll do it and they'll do it effectively. They're our biggest advocates when it comes to community services.
Food equals energy. It's important to give incentives or allow for incentives to have participation in your groups in the communities. We use a very small amount of money to feed a very large amount of people, and we've become very creative. It's something else we're very proud of as well. And finally talk the talk and walk the walk. This is critical. For us the at risk communities is used to being let down by providers and different agencies and leaders to be honest family members.
So if you say you're going to do it or if you're going to offer assistance, you gotta do it. Our experience, that's when we have the most satisfied customers.
And don't wait to educate. Erica will actually touch on this more in depth, but preplanning limits the likelihood that stress due to a lack of knowledge will influence how a situation is handled. And it's a person's ability to function productively, a person's ability to function productively is often measured by how they handle chaos over time and across situations.
So we often educate people about parenting or breast feeding early on in pregnancy. The same in postpartum, you know planning ahead what is your child going to look like at the age of one, what are the developmental milestones, when is it appropriate to start teaching potty training.
Much of what we do is done through home visiting, and the programs that include the prenatal and post natal visits and do this preplanning type philosophy have the ability to affect parenting behavior and parenting, safety, that can influence child abuse and neglect rates in your communities. Birth spacing and delinquency.
Being that I come from a child development child care school, I thought it was important to put in here about identifying a high quality child care provider. For most of our participants child care is provided through relatives. And it's important to educate and connect families with high quality care.
While it might be difficult to get someone to use a facility other than a family, the well‑being of a child long‑term is well documented. The Adsa Darren study is one I refer mostly but the outcomes by the age of 21 are higher IQ. Enrolled or graduated from a four‑year college and they've been gainfully employed.
Through the mail initiative program we were able to get into the schools and do some prevention planning. We did case management for the team fathers. We also did prevention services through, for middle school through high school students. Since 1999 over 5,000 elementary middle high school students were served and 23 schools and the curriculum was primarily around positive family, marriage and how to become a positive male figure. What's interesting about this is it actually had some outcomes that we weren't expecting. Some of the classroom results we got were there were 82% of the kids were more attentive in class. 90% showed improved grades and overall performance. 82% improved academically. 55% improved in controlling their anger in the classroom. And 45% displayed improved signs of respecting themselves and their classmates. It's going to be quite valuable.
We get advice from the experts. Evaluate the satisfaction and program and community participants. And to stick the quality improvement and control and protocols in time lines. I know it's very easy to get away from that when you're doing community based services, but it really is essential, and we'll keep you up‑to‑date on the trends of the communities that you serve.
You should make your findings available to your investors, which is your community, your participants, your local providers, provider agencies. And finally dig deeper for answers. Numbers are typically not enough. It's best to go back to the community with your initial figures and ask them to explain to you why things are going the way they are and the insight is invaluable.
Speak to cultural competency. I think this is a great picture. Reminds me of a (inaudible) on a golf course. But this is a community that we serve, and I put the picture up and followed it with the definitions of culture, and the reason was just to remind you that race and sex are not representative of culture. It's the values beliefs and practices that determine culture at differing levels. Again going back to Pittsburgh and the City of Bridges, our cultures and practices differ from literally neighborhood to neighborhood. We have 84 of them we serve.
Let the tech world be your guide. We found that management information systems can be critical as well. To best understand the various cultures, management information systems can be your biggest asset. They allow you to assess the ever‑changing demographics of the region. For instance we've had housing, public housing units close and close quickly. And we've had to track where they've moved to and how are we going to talk with them and how are we going to best serve them. We developed outcome based measurements from our management information systems, and we let data drive our services and vice versa.
Make the pieces if it the puzzle, a very culturally appropriate slide. You should think what should your personnel or teams look like. For us they're multi‑disciplinary. They consist of outreach workers, professionals and social workers, information systems and technology individuals, interns and volunteers. Over 82% and actually I believe that figure is out of date. It's almost 90% of our staff members actually reside within the targeted communities, especially with regard to our para professionals. It makes rapport much easier. Since they've been through much of the systems, they help navigate those systems for our participants. They're not afraid to push people towards independence and empowerment when some people need that kind of push. They give real world mentoring. Based on their own experiences.
And building blocks for programs. We use screenings and assessments and valuations to monitor the well‑being and plan next steps. We educate our parents, fathers, male caregivers, foster parents and grandparents and moms on infant behavior. We educate our staff and advocate for additional research. Just so you know what I'm saying actually has an impact on the community. I have quite a few accomplishments listed, but we've decreased the infant mortality rate to its lowest point in over 8 years to 7.2 per 1,000. 92% of our participants established a medical home. We've made tremendous strides just over a three‑year period, as you can see the number of African American women that receive prenatal care is up from 76% to 86.5%. And we've overly exceeded our goal in providing postpartum depression screening for women.
One of the things that we are also very proud of is that we have an 89% attendance rate for community consortium meetings, that's getting our volunteers to attend meeting, come up with strategy and actually educate us on how to provide services. And we take the same approaches. We make sure that we supplements available for them to eat. We call them nutritional supplements. We hold our meetings in the community so they're accessible. And relieves them of transportation whenever possible.
System impacts: We've enhanced public concerns about health disparities and infant mortality. We have improved conditions and circumstances for residents of Southwestern PA. We've improved the sensitivity of providers to cultural linguistic and gender needs.
Lessons learned: Normative cognition, emotional social development are more likely when we have these multi‑disciplinary community based services. Prevention principles in conjunction with early identification and education will promote your most optimal outcomes versus an intervention approach. And strengthening entire families, especially fathers are proven effective.
Healthy Start as designed and implemented is long‑term rather than short‑term. I think that's important to point out. There's no quick fixes in the communities that we all serve. And that we have shown that local communities with support develop and implement innovative approaches to reduce infant mortality.
And finally I guess you want to know about Jessica. Well, Jessica actually delivered prematurely. She had a five and a half pound baby girl. I am happy to say she's a whopping 27 pounds today. Jessica has been regularly attending group counseling and taking her medication with support from our behavioral health unit. She did end her violent relationship and she plans to not have any more kids in the near future.
And something that JoAnn our licensed social worker wanted me to point out she's going to receive her associate's degree this spring and looks like she's on a successful path. And so thank you. We'll move on to Erica Dorsett.