2019 Framework for Child Health Services: Executive Summary

A FRAMEWORK FOR CHILD HEALTH SERVICES:

Promoting optimal health, development, and well-being for all children

March 26, 2019 

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Executive Summary

In 2009, the Child Health and Development Institute published The Framework for Child Health Services,* which outlined how pediatric health services can be delivered in collaboration with other services children use, such as family support services and early care and education services. The 2009 Framework concluded with several recommendations for strengthening the essential components of pediatric care to improve early identification of children at risk for poor life outcomes and their connection to helpful community services. The role of the medical home,† developmental surveillance and screening, care coordination, and alignment of local and state level initiatives were all highlighted through specific recommendations, which would strengthen child health services and support families in improving health and developmental outcomes among their children.

The 2019 Framework for Child Health Services: Promoting optimal health, development, and well-being for all children, reviews progress in implementing the recommendations put forth in 2009 and identifies key areas for inclusion in designing a new framework to guide innovation and improvements in child health services. Policy reform, system building, and practice change in Connecticut have combined to advance many of the recommendations from the 2009 Framework.

Notably, the State has experienced wide adoption of the medical home model of primary care, with more than half of the State’s children who are insured by Medicaid receiving care from a primary care site that is recognized by the National Committee for Quality Assurance as a medical home. The adoption of the medical home model in Connecticut has brought developmental screening, care coordination, and accompanying practice education to many pediatric primary care sites within the State.

In some ways, however, policy and practice change have not coalesced to bring the recommendations from the 2009 Framework to scale across the State. Systems of care coordination for children in Connecticut remain disparate and difficult for families to navigate. While we have expanded care coordination capacity in Connecticut, there is a need to ensure that multiple care coordination efforts are integrated to best support families with seamless connections within and across service sectors. The lack of robust state-level coordination has hindered uptake of promising innovations that could bring efficiency to service provision and support families in their optimal use of services. Mid-level developmental assessment, an innovation that quickly identifies children’s developmental needs and ensures that they are connected to community resources, is another example of a recommendation from the 2009 Framework that has not achieved scale and spread and has left too many families working to fill in gaps in services when their children do not qualify for publicly funded interventions.

The 2019 Framework considers the significant progress made since the 2009 Framework, existing strengths, as well as opportunities to improve children’s health and well-being that have not been fully realized in Connecticut. The new Framework draws on current knowledge about supporting population health to craft a new understanding of, and set of recommendations for, improving child health services within the context of community service systems. Key concepts necessary for consideration in this new framework include:

1. Cross-sector collaboration in care delivery. A child health service system that is proactive in helping families address “social determinants of health” through connection to a broad array of services and service sectors. These include services such as housing, nutrition, and faith-based initiatives.
2. Innovation in payment and care delivery. Inclusion of key elements of the 2010 Affordable Care Act (ACA),‡ specifically those that ensure access to health insurance and promotion of innovation within health care delivery. Provisions in the ACA allow opportunities to transform health services and Medicaid through demonstration projects that explore new arrangements in health care payment methodologies, financial support for services not traditionally included in health care payments, and patient-centered and -driven service models.
3. Integration with current health reform initiatives. Child health services are central to both the Primary Care Modernization (PCM) and Health Enhancement Community (HEC) initiatives, both funded through the State Innovation Model (SIM). PCM is committed to including pediatric primary care in efforts going forward to add upfront, bundled payment for primary care sites to build infrastructure and support expanded services. The HEC initiative has identified “child well-being” as one of two key outcomes for HECs funded through State dollars. The second key outcome is “healthy weight,” another area in which early behaviors are key to lifelong health.
4. Identify, monitor, and report cross-sector outcomes. Health reform efforts in a growing number of states recognize a broader set of outcomes from health care services. We increasingly understand that health care, within a comprehensive system of services, can contribute to such outcomes as school readiness, school attendance, social competence, family resiliency, and general well-being. Although these outcomes may not lend themselves to immediate measurement, proxy measures, such as the protective factors,§ can inform evaluation and improvements in the “value” of health care services.
5. Child health is family health. If health services are to have a larger contribution to long-term outcomes for children, they must work to strengthen families’ capacities to nurture children. Disparate funding streams and regulations that determine eligibility for services are barriers to pediatric health care providers addressing children’s needs within the context of their families.

Current thinking about “population health” underlies the above concepts. Population health has taken on several meanings, but virtually all interpretations consider health equity, a broad set of health outcomes, social determinants of health, interventions and policies across sectors, and long-term societal and financial implications of health services.** In Connecticut, the medical home model of primary care delivery, care coordination across sectors, priorities to address early childhood as an essential component of lifelong outcomes, and collaborative relationships across public and private organizations remain relevant to a new framework for child health services and population health goals within the State.

The 2019 Framework concludes with the following recommendations, derived from the five key concepts discussed above in combination with ongoing opportunities supporting an increased focus on the role of health services in children’s health and development into adulthood.

1. Multipayer demonstration project. Support the State’s health insurers’ participation in a demonstration project that transforms child health services and, specifically, pediatric primary care by supporting efficacious innovations and interventions that, in collaboration with community services, strengthen families to promote children’s optimal health, development, and well-being. A multi-payer demonstration project can yield important findings that inform universal support for, and adoption of, key services, such as crosssector care coordination, promotion of the protective factors to boost resiliency, use of nutritionists to establish optimal feeding practices, universal home visiting, and group well-child care.
2. Cross-agency collaboration. State agencies with early childhood responsibilities and authority (eg, Department of Social Services, Department of Public Health, Office of Early Childhood, Department of Children and Families) should convene with commercial insurers, philanthropic organizations, and family members to design and develop a child health system that braids and blends available public and private dollars in support of children’s health and well-being. Further, funding that ensures linkage of children and families to services through the United Way 211 Child Development Infoline and regional care coordination collaboratives should sustain linkages between primary care services and community-based resources for children of all ages.
3. New models for financial analysis. The Office of Policy and Management should develop the capacity to perform return on investment and other financial analytics that consider services across agencies and service sectors and monitor the short-, medium-, and long-term cost savings, cost benefit, and return on investment from an expanded health promotion system for all children.
4. Seamless system of care coordination. Care coordination services for children and their families should be centralized and brought to scale statewide through the strengthening of regional care coordination collaboratives. These collaboratives, currently supported by DPH’s Children and Youth with Special Health Care Needs program, would benefit from expanded support and collaboration with other service sectors that provide care coordination. A comprehensive care coordination system should cross-train care coordinators to work within a variety of disciplines and share training and resource materials to improve linkage to services and create seamless systems of care for children.
5. “What gets measured gets done.” A strength-based approach to child and family services, such as the Strengthening Families Protective Factors Framework, should be embraced by all State agencies and their programs and services. Adopting such an approach will promote the optimal health and development of all children and provide measurable short-term outcomes that speak to longer-term ones. Health outcomes should also be considered across the life span and sectors as the impact of health on school attendance, school success, social relationships, and life outcomes needs to be measured. 

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REFERENCES

* Dworkin P, Honigfeld L, Meyers J. A framework for child health services: Supporting the healthy development and school readiness of Connecticut’s children. Child Health and Development Institute. March 2009.

† American Academy of Pediatrics, Policy Statement. The medical home. Pediatrics. 2004;113(5):1545-1547

‡ https://www.healthcare.gov/glossary/affordable-care-act/ 

§ Harper Browne, C. The Strengthening Families Approach and Protective Factors Framework: Branching Out and Reaching Deeper. Washington, DC: Center for the Study of Social Policy; September 2014.

** Kindig D, Asada Y, Booske B. A population health framework for setting national and state health goals. JAMA. 2008;299:2081-2083.