HRSA/MCHB 2005 FEDERAL/STATE PARTNERSHIP MEETING

PUBLIC HEALTH ACROSS THE LIFESPAN

Financing Early Childhood Health Systems

KAY JOHNSON: I always feel like I should be a little taller after one of those long introductions. I am delighted to be here. I am always happy to be at a Maternal and Child Health Bureau meeting because I know I am among friends and among colleagues and many of you have helped and formed the work here and the work that I do every day. I’m wearing at least three hats at this meeting so, it’s just me every time. Don’t worry about the titles on all of this. I want to set the context a little bit and I’m going to go through this a little bit fast. Lee Schorr has a wonderful slow speaking manner. I am really going to pick up the pace here. We are a little short on time.

But a lot of the data that I have here at the beginning you know and the fact that if we think about the children under age six, we have 42 percent of them living in low-income families. And if you look at the dark blue bars across the age span, you can see those are the poor children in the lighter blue bars, all of the low-income children with the near poor children up to 200 percent of poverty put in. And if you look birth to two and then three to four and even age five compared to the school age and adolescent children, you can see that the percentages decline, families often gain a little more income, work experience and so on, but for young children, poverty is really a reality and four out of 10 of them are poor. If you look by state, just giving a brief glance, you’ll be looking for your state, these are data from the current population survey. They represent combined 2003-2004 census data and the darker the color, the higher the percentage of children in poverty. I would also note to you that there isn’t a great deal of range here; that the best states are at 32 percent as compared to some a little over 40 percent. So, in every state the challenge of serving these low-income children and building systems that work for them is a challenge that Maternal and Child Health agencies face.

Phyllis mentioned Project Thrive. We are the policy center, but since we are located in something that’s already called a “center”, The National Center for Children and Poverty, we decided to give it a jazzy name and a fun logo. We said, you know, no more just another picture of a child on the cover. This little guy is our logo, so he’s going to help us shine a light on things, on complex systems and build things, and you should have a copy of a brochure about our strategy for work. This is established at the National Center for Children and Poverty and Phyllis has read to you what we hope to do and all of this. If you don’t know, and Lee Schorr mentioned Jane Knitzer who is now the director of the National Center for Children and Poverty, it’s been located since 1989 at Columbia at the School of Public Health. It is a public policy center in a think tank and it does a variety of work across a variety of issues.

The work at NCCP is very synergistic with what we’re hoping to do with Project Thrive. They are already synthesizing a lot of research related to early childhood policy. They have a Web site called “Research Connections” that’s really all about that. They have been doing a great deal to build cross-systems knowledge at the state level. If you haven’t used their data wizards and gone on and modeled your state and figured out how a variety of programs interact, I’d encourage you to do so. They work on identifying policy and practice solutions and promoting high quality policy research. There was a pink series of which this first one, “Making Dollars Follow Sense”, was one that I collaborated on, which was a set of case studies; seven examples of financing early childhood mental health, but it also goes through a range of other publications such as the "Dynamics of Child Care Subsidy Use."

Our mission is really to help you insure that young children and their families have access to integrated, high-quality health care, childcare and early learning, early intervention and parenting supports. And it’s a lot of words, but we mean to intentionally include each of those pieces. We want to work on those families that are affected by the highest risks, with you, those children with special health care needs, including those that have social-emotional and behavioral problems and trying to reduce disparities across there. What are we going to do? How are we going to do this? By providing information to you, by analyzing and synthesizing research and coming up with reports such as this one and the one that I’m going to talk about today called “Spending Smarter,” by creating peer-to-peer networks, conference calls, learning opportunities, ways to bring you as state policy leaders, together with researchers, with policy researchers, with advocates, to have that conversation and to provide you with hands-on or phone-on technical assistance as much as possible.

Finally, to facilitate policy linkages, both helping you at the state level figuring out community strategies, and making it at the national level. This is a lot of words on the page, but I did want to show you that in making a proposal to MCHB, we really were focused on saying how do we improve the policy and finance context in a way that helps you in the center area, improve child and family services across systems to improve outcomes, because we really don’t see this policy piece. It works through the strategies that you’re going to implement and your goals and trying to help you support, and we believe that all of this work together can then help and improve child health and development, reduce the stress on families, improve parenting, improve parent employment and perhaps some other things that you have on your agenda. On the left hand side, we hope to help you better use existing resources across programs and funding streams, improve coordination of eligibility and outreach processes as well as coordination in general, develop better mechanisms to integrate service systems and sustain them and to use cross-system approaches to serving and supporting families. I think very much in line with what many of you have been thinking about in your early childhood comprehensive systems work.

So, on to the topic that I agreed to speak about today and at the end of our very short commercial for Project Thrive, we have a new report coming out and you should have some copies of the executive summary on your table. It’s called “Spending Smarter: A Funding Guide for Policy Makers to Promote Social-emotional Health and School Readiness.” What we’re really talking about in this report, and it should be up on the Web site, if not today, by the end of this week, is how to use federal programs and policies to do this work, particularly as it relates to financing. We approach this in the framework of thinking about three groups of children and a lot of people are thinking about this. This, in fact, is a framework we’ve adapted and been talking about, but which came from the Florida strategic plan, and credit to them for codifying this, if you will. At the Level 1 there are things that all children need. They need them to strengthen their caregiver skills in the families and the parents’ relationship with the children. There are things that at-risk children need; ways to intervene early with those having identified risks delays and disabilities and cannot wait until things become more serious, and a Level 3 group of children who have conditions that are diagnosed and ways to treat those children who have diagnosed problems and, when necessary, their families.

So the framework for spending smarter, we went through actually about 25 federal programs and tried to say, what are the ways in which this federal program could be used to finance early childhood system services and supports, and then what are the ways that these programs could be used in particular to reach the most vulnerable children and families? The framework that we’ve developed, the items I’m about to show you, have to do with the way that we sliced them and the knowledge that we gained. We identified things that could improve screening and diagnostic evaluation. We identified a set of financing to do more outreach and monitoring for high-risk children and their families. For “monitoring” you could almost insert the word “tracking”; it relates from things that you’re doing where there are integrated databases all the way to some other service coordination systems. We identified a set of funds that could improve access to appropriate services, resources to develop clear, functional eligibility definitions and apply them across systems, to enhance professional training and work force capacity and to strengthen the infrastructure in order to reduce policy and administrative barriers.

So, what you will find in this report when you read either the executive summary or the full report is a look at a cross section of programs thinking about these actual functional activities. It’s not bright and you may not be able to see this and this is a lot of words, but some of you have seen me use this slide before and it’s my way of going out, when I talk to people in the field, of saying, here is the way that I see the federal funding streams so that you have a health care financing stream with Medicaid, EPSDT and CHP. You have the Title V stream, particularly Children with Special Health Care Needs the CSHCNs and CYSHCNs. You have Community Mental Health Services and other Children’s Mental Health Services. You have here a set of child welfare and other Childcare and Early Education Programs and you have the IDEA funding streams. So what we really want to help think about is how do you leverage those federal dollars with state and local, public and private funds, and blend or braid funds to maximize resources. And what are the planning and administrative mechanisms that you’re using to finance services in an array of settings? And you can see this whole variety of settings here is from home visiting and pediatrician’s offices and Community Mental Health Centers and Community Health Centers and Childcare Centers’ Early Intervention Programs, all the way over to Family Resource Centers and Shelters, thinking about how those dollars actually reach in to the settings where families are served.

Now I just want to go through a small number of the programs and highlight some of the things that we’ve been talking about. In the Medicaid EPSDT arena, one of the top recommendations we make is that you recommend age appropriate screening and diagnostic tools in EPSDT. This is something that’s really been learned and tested in a number of states and is going on now in those states that have the Commonwealth ABCD II funding. If the state doesn’t recommend age appropriate screening and diagnostic tools, it leaves people open, busy providers, to having to make a lot of choices, to tracking down the research, to figuring out what are the best screening tools for an infant or a toddler versus a four year old versus an adolescent even. So thinking about ways, for example, that states can recommend three tools and then say, "If you’re a provider who has a validated screening tool that you want to use for your population, let us know." But, we must have the courage to go forth and make those recommendations and encourage the Medicaid agencies to do so as well.

Covering services delivered in a range of settings is something a small number of places are doing now, but in Vermont for example, we are paying for childcare consultation and individual assistance to children right in those childcare settings. Florida made progress in this arena by saying we don’t want every child who needs some kind of special support to be put in a day treatment program. We don’t want to spend all of our money on day treatment programs for children who should be quote “mainstreamed,” who should be in natural settings and children who could be better served in the childcare setting where they are. States are separating billing for developmental screening and diagnostic evaluation. There’s a lot of confusion about this in the Medicaid program because the Medicaid rules basically just talk about assessment, and making that distinction between the screening kind of assessment and the diagnostic evaluation kind of assessment and being able to finance that separately, has been proven effective in a few states and is increasingly being used.

Reimbursing for parent child family therapy, this is another step that a small number of states are taking. Florida, most notably, actually changed its regulation and they have not broken the bank by doing so and the focus on that relationship based therapy and interventions, including the parents, makes a lot of sense, of course, when we’re talking about infants, toddlers and pre-schoolers. Some areas, San Francisco is a good example, are matching funds for Childcare Mental Health Consultation and many of you are looking at how to use appropriate diagnostic codes for young children, in particular the code set developed by zero to three called the DC:0-3. Most of you know the opportunities under Title V. I think using your CSHCN project grants as leverage and thinking about the definition of your Children with Special Health Care Needs, financing the things that are not covered by Medicaid, we really can use some more flexible funding around professional training, maternal depression and an array of other things. Are you thinking about social-emotional development in your concept of the medical home? Are you stressing the concept of early childhood development services in your concept of the medical home? It’s certainly part of what the Academy of Pediatrics intends. There are people here in this room who know much more about this than I do, but just as a reminder to all of us. And then, of course, promoting the use of Bright Futures guidelines both for the general health services as well as for the mental health services.

There are obviously other health programs. We make a couple of suggestions about CHP if you have a stand-alone CHP program. Covering services for social emotional needs and, in fact, in Arkansas they adopted a law, which required mental health parity rules for their separate CHP program. Using the Children’s Mental Health Grants to increase prevention of social-emotional disturbances--Vermont and Colorado are the two exemplary states in this area that asked for and got permission to waver from the traditional presentation of just treating severe emotional disturbances and in both of those states, I think the engagement of the advocacy community parent organizations in order to help them leverage more prevention money has been extremely important.

Using childcare funding, blending childcare quality funds to finance early childhood health and mental health consultation--this is going on; it’s particularly going on where people have blended functions into early childhood bureaus in their state government, but it’s going on elsewhere. Paying for improved caregiver skills to promote social-emotional and school readiness, using childcare development fund dollars to support training on social-emotional and school readiness and using available funds to insure that the highest risk children get high quality childcare. I had the honor of working with Sally Fogerty in a group of people in Massachusetts and when they really put their health, their education and their then childcare executives together from state government and had them listen and talk and learn, they looked at their system and found things that didn’t make sense and from the commissioner level down, made a whole series of changes. You can talk to Sally about the pros and cons of everything that resulted in that, but that kind of look made a huge difference in terms understanding how they could maximize the dollars that they had for reaching the highest risk children.

Special education funding is obviously a challenge in almost all states as the federal share drops and the state share for these kinds of entitlements has increased over the years, but we still need to do a better job at appropriate social-emotional screening and evaluation in Part C and thinking about the continuum of services and the transition between the Part C early intervention and the pre-school programs, as well as some states such as North Carolina thinking about how you build a continuum of services really from zero to five and maximizing and leveraging your state expenditures.

I want to talk particularly, we have listed in the report a number of opportunities using policies and programs for abused or neglected children, but I want to talk particularly about CAPTA for a moment. Can I see a show of hands of people who are thinking about the new CAPTA rules in their state? Oh, that’s great! So, many of you know about this. If you’ll bear with me, just to say to others that the Child Abuse Prevention and Treatment Act changed its rules two years ago and those rules now require referral and assessment of young children with confirmed abuse or neglect. In 2004, when I was speaking and visiting a lot of people about this, and listening, I heard three kinds of state responses: One is, we’re going to ignore this because we don’t know how to do it; number two is, we have submitted our plan to the feds and we’ll do it when we get around to it because all that the feds required was that we submit our plan, and three is we see this as an opportunity to do better integration for a group of very vulnerable children. I’m sure that array of states is represented still in this room. But, I really do see it as an opportunity; an opportunity to develop a more systematic approach, to promote collaboration between Title V agencies, child protection, child welfare agencies and Part C programs. It’s a window of opportunity for planning, for discussion and improving services.

Thinking about the responsiveness of Part C, both in terms of screening, but also who are the providers who are going to see those children identified. Some people are thinking about how do we not only include those with confirmed abuse or neglect, but also those young children who are witness to domestic violence and this is something I’ve been thinking about with people in San Diego and assuring that all children entering foster care get an evaluation--an increasing role in many areas for public health nurses. There are three kinds of public providers that I wanted to highlight, and not because there’s a whole pot of money waiting for you there to do things, but because we have service delivery systems that really are being used in some places better than others and I think could more consistently be used across the board.

In terms of Head Start, both better using the health and mental health consultants, people in Head Start sometimes say, you know, we have a mental health consultant and that person’s name is on paper, but we don’t really know how to use them effectively. And I think your agencies can help them figure out some of that through your early childhood comprehensive systems building. How to enhance and better use the skills of the parent involvement coordinators and the parent educators--aren’t they teachers and aren’t they modelers in all of those systems?

Looking at federally qualified health centers, they are providing primary care to millions of low-income children and are we including them in our early childhood initiatives as a critical part of the service system and bringing along their skills just as we want to bring along the pediatricians’ skills, and are those who are the medical home for children included in your thinking about medical homes? Thirdly, community mental health centers, such as in Vermont as well as some other places, the community mental health centers are becoming a hub for the financing and supervision of early childhood mental health consultants to serve in childcare centers, Head Start centers, shelters and elsewhere.

Obviously, there are a number of programs, and we list more than 10 in the report that can help you, because they are flexible funding. Cross training for professionals, supports and services to parents that are otherwise uncovered, services to children at high-risk without a diagnosis and pilot projects and startup funds are all the things that the kind of seed money that you see in more flexible grant programs can be very important.

So how do we move ahead and finance policy and development of comprehensive early childhood systems to give kids a leg up? I want to stress that these are our 10 conclusions in the report of things that we think almost all states are ready to go with, or could be in short order ready to go with. One is, and I think many people have done this through their sex grants, is to convene a group to review the flow of funds. Take my diagram. Take some diagram you have in your state. Build your own. Start the conversation there and say how do we use these funds? How do they flow? What are the mechanisms through which they flow to reach down to the community level and what happens when they get to the community level? How are we blending and braiding them across? Who knows the difference between blending and braiding? What do you do when you braid? You weave things together. Do you know what a braid is? Do you know why they use braids to make rope? It’s stronger, okay. So, braiding is that, and then, how many of you have ever eaten a Flurry at Dairy Queen? Ah, they’re not confessing. They won’t raise their hands.

A Flurry is something different, so when you blend it and you put the cookies in the ice cream and you mash it up--first of all, you don’t improve your overall health, but second of all, you get what? You get a new flavor, so that blending is creating a new flavor, pulling the dollars together to create a new flavor. Some things, like Medicaid, are hard to make into a new flavor, but they’re not so hard to braid, and other things can be put together so you really get a new flavor of funding either at the state level or increasingly at the county or the local level, to put those dollars together. You won’t get there with all of your funding streams contributing unless you do some work to figure out where the money is. The other way to start this work in particular is to put together a children’s budget for your zero to five group. Just ask, how much money in each of these programs is being dedicated to children’s zero to five. Start with the base number and then begin to figure out what those dollars are used for.

Lee Schorr mentioned the support of inter-agency plans with written agreements and I think she and I really are in sync about this. You need to begin to change the culture so those agreements will work. You also need to write the agreements. It’s not enough to have a group that meets monthly. You have to have that group meeting monthly, making decisions that are then supported in formal policy, because otherwise what happens when the governor changes? What happens when you get a new Commissioner of Health or a new Commissioner of Human Services? If those agreements are not written, or people change jobs, you’re ending up in a position perhaps of starting all over again.

Adopting a statewide definition of risk factors for young children--there’s a very small federal program called Foundations for Learning and it offers a start as a way of making this list, but you know who these children are. You talk about them. They’re families and children who come into contact with multiple systems often and you know that they have risk factors and you know that they’re not being served by many of the programs. They’re falling through the cracks between health and child welfare--between Part C and community based screening. They’re just not quite getting to where they need to go and the more we can think about those risk factors in common, the more we can think about how the systems serve them and where the children fall in the cracks.

Maximizing existing funding is the second cluster in our top 10. Some of these things I’ve talked about before, about cross-training and flexible grants, as well as clarifying eligibility and payment mechanisms across programs. That whole business of payer of last resort is not only confusing to you, it’s really confusing at the provider level and heaven forbid that families would ever begin to understand it without a really good course in becoming their own case managers. How do we make that more seamless? How do we figure out, when children are eligible for Medicaid and Part C, how the dollars should flow and how many dollars are we failing to maximize in terms of federal match, because we don’t make those payment and eligibility mechanisms clear?

And adopting the policies and billing mechanisms that support developmental services, there is some extremely impressive work going on in this, much of it funded by the Commonwealth Fund. The list of 20 or more projects is too long for me to enumerate here, but what states are doing in their ABCD II projects and what they did in their ABCD I projects is a place to start. If you’re not getting the materials from the Commonwealth Fund, at least in the executive summary format, I encourage you to do so. It’s very important work and instructive for all of us whether it’s people functioning at the individual pediatrician level, or people running state agencies.

The third set, in our 10 Ways to Move Forward, are about focus. I think that for a lot of us, these tasks are overwhelming in already busy jobs, and you want to do well and you want to do good and sometimes just figuring out the place to start is a challenge. So, start with one high-risk population. Start with that CAPTA group. Start with children in childcare who have behavioral problems. Just figure out where you want to start and make a go of it. The second is to think about financing two-generation strategies and parent child interventions. This really fits into the category of what Lee Schorr was talking to us about in terms of what works. If we’re not investing in a relationship-based approach to improving the development of our youngest children, we are not relying on what works. The science is pretty good. It’s about 35 years old and it’s really time we paid more attention to it. We all got the brain research part, but we somehow, once again, failed to put the parents into that context with the brain research. We said yes, we need to stimulate all those neurons and we need to stimulate them so that we get the child from birth out into the neighborhood and ready to learn and ready for school, but it still is by and large the parent, and those early relationships that’s going to determine how those neurons grow to a thriving child in a neighborhood. And if we’re only paying attention to child focused strategies, we will not get the results that we want.

The 10th one is what to do about all these children at risk who aren’t yet eligible for entitlements? They’re not quite ready to be diagnosed with a mental health condition so they’re not going to qualify for Medicaid Mental Health. They’re not quite developmentally and delayed enough to meet your state’s criteria for Part C. They don’t really fall into the narrow set of things that you’ve had to elect in order to make your children with special health care needs dollars pay off. What happens to those children in your state? Are you paying attention to them? What happens if they’re screened and they’re just not quite making the cut? Are we figuring out a way to bring them in for interperiodic screens under EPSDT into something called the CEDARS Program in Rhode Island which is an alternate service track, into at least a data base so we can see if we check back in a year, how that family’s doing and whether they ought to be evaluated again. Why are we losing those children through the cracks? You’re very good at this sort of work in Title V agencies and I think it’s very important work to be done.

I just want to flip back now for a couple of minutes to say this is the kind of thinking we want to help you do. We want to learn from you in our Project Thrive work. We’re going to be issuing something called “Short Takes” which is short Issue Briefs which are these longer papers and a virtual policy sharing network to provide some peer-to-peer learning for state MCH policy leaders as well as technical assistance and learning via web based calls. We have budgeted one meeting a year for a policy roundtable, again where we bring advocates and researchers and policy thinkers and leaders from states together, to move a strategy forward, some new tools for policy development and some opportunity for tailored technical assistance in response to your state requests.

Because of the audience here today, I wanted to say in particular, I see special opportunities for those MCH and children with special health care needs directors and Title V programs. We really are hoping that you will participate in the virtual policy-sharing network with your peers from other agencies. To move this work at the policy level is going to take your interest and focus. We encourage you to read Short Takes, and if you don’t have time, let that project director read those longer Issue Briefs and bring those ideas back to you, but we really hope to engage you in this process and to ask you from time to time to participate in these policy roundtables, to help us learn about more feasible fiscal strategies and how the ideas we offer are working in practice so we can then share that back with others, as well as to be linked to national policy resources. From my point of view, we know more now than we ever have before about the importance of early experience, about what interventions work--albeit we don’t know all we’d like to know--about the strengths of families and how to maximize them and work in a family centered, family support manner and the power of collaboration. I think that the talk you heard this morning stressed how important it is that we work together in partnerships.

We want to help you build Comprehensive Early Childhood Systems. We want to hear from you about how we can help and I’ll just say that on the back of the brochures that are out there for you, there are phone numbers and contact information for myself, Leslie Davidson is a pediatrician at Columbia who is a senior advisor to this product, and for Jane Knitzer who will be very integrally involved in this with us. Thank you.