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1 DULCE Manual Developmental Understanding & Legal Collaboration for Everyone
1DULCE Manual
Developmental Understanding & Legal Collaboration for Everyone
2 DULCE Manual
ContentsOverview
A. Introduction / Guiding Principles / HistoryB. Logic Model: Providing Access to Concrete SupportsC. DULCE Intervention D. DULCE Embedded in the Early Childhood System
Getting StartedA. DULCE Core Elements & Structural ExpectationsB. Family SpecialistC. Patient-Centered Medical Home Team Relationship with the DULCE Family Specialist
• Primary Care Clinicians• Linking to the Patient-Centered Medical Home (PCMH) & Community Resources • Nursing• Support Staff
Building the Expertise of DULCE Family Specialists A. Brain Messages and Strategies for Supporting Early Brain Development B. Parenting/Child Development C. Concrete Supports D. Assessment Toolbox
• Newborn Behavioral Observations (NBO) • Ages & Stages Questionnaires®, Third Edition (ASQ-3™) • Ages & Stages Questionnaires®: Social-Emotional (ASQ:SE) • Patient Health Questionnaire (PHQ-9)
DULCE Intervention A. Identifying Eligible FamiliesB. Creating the Relationship with the Family (First Week Visit & One Month Visit)C. Partnering with the Family (Two Month Visit & Four Month Visit)D. Family’s Next Steps (Six Month Visit)E. DULCE Intervention Flowchart
Family Assessment Inquiries A. Probing Questions B. Screening Questions
• Housing & Utilities Screening • Income & Nutrition Screening • Interpersonal and Community Violence
Appendices A. DULCE Activity LogB. DULCE Family ProfileC. DULCE Checklists (Checklists for each Visit, Income and Housing & Utilities)D. Parent HandoutsE. Sample Weekly Case Conference AgendaF. Suggested Areas to Cover During Mental Health Supervision Meetings
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1. Overview
A. INTRODUCTION / GUIDING PRINCIPLES / HISTORY
DULCE is an innovative pediatric-care-based intervention through which primary care clinical sites proactively address social determinants of health and promote the healthy development of infants from birth to six months of age and provide support to their parents. DULCE’s intervention adds a Family Specialist (FS) to the pediatric care team, and the FS provides support for families with infants in the clinic setting, connecting them to resources based on parents’ needs and priorities – with the option of providing home visits, at the parents’ choice. The DULCE intervention incorporates a protective factors approach and draws on and incorporates components of the Medical-Legal Partnership model to ensure that families have access to the resources they need.
The Center for the Study of Social Policy (CSSP) and city and county partners participating in Early Childhood-LINC (Learning and Innovation Network for Communities) will be testing DULCE in five clinical settings across the US, including three California counties (through county First 5 commissions in Alameda, Los Angeles and Orange Counties); Palm Beach County, FL (through the Children’s Services Council); and Lamoille Valley, VT (through the Lamoille Family Center). Each community will implement DULCE in at least one clinic site serving at least 200 infants per year, and there will be a careful evaluation of the impact of DULCE on infants and families served as well as on selected indicators of health care delivery and health/social services utilization.
GUIDING PRINCIPLES
DULCE works to strengthen families by providing extra support during the critical first six months of life
DULCE is embedded in the patient-centered medical home
DULCE works together with families to empower them to solve their own problems: don’t do “for” families, do “with” families
DULCE connection is universal, there is no stigma attached
DULCE brings the Strengthening Families™ approach to routine healthcare for newborns. DULCE Family Specialists partner with parents of newborns – with the dual goals of improving child development and reducing maltreatment. This is accomplished by providing families with support for any unmet legal needs and age-related information on child development in addition to ongoing friendly support from a Family Specialist. Since DULCE is part of a patient-centered medical home, benefits of the program not only accrue to the new baby and parents, but the whole family – especially siblings.
Families meet with the DULCE Family Specialist at all routine visits. Home visits and telephone check-ins are scheduled depending on the families’ preferences. At six months, the DULCE Family Specialist hands off care to the primary care team and any other ongoing early childhood services as necessary.
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HISTORY
The original Project DULCE adapted and combined elements of two existing programs: Healthy Steps and Medical-Legal Partnership | Boston (MLP | Boston). The evidence-based Healthy Steps program added a professional with knowledge of child development to the child's pediatric primary care team to support positive parenting through knowledge, modeling, ongoing support, referrals (when needed), optional home visits and a telephone phone line. MLP | Boston supported families by providing legal advice, consultations, and representation to address their civil legal needs. The DULCE Family Specialist, trained by MLP | Boston, identified legal and social needs that could have affected a child's health and development and took action either by helping the family to advocate for themselves or by referring the family to an appropriate public health, legal, or social service agency or resource (including MLP | Boston).
Findings from the first trial of DULCE at Boston Medical Center, published in the journal Pediatrics, demonstrated that the intervention: 1) increased the connection of parents to needed concrete supports and community resources, especially housing, solutions to financial crises (utility cut-offs, etc.), and assistance with immigration issues; 2) increased parents’ utilization of well-child health care visits, so infants received more preventive care, including timely immunizations; 3) decreased use of emergency room care by DULCE participants (thus providing rewards for the health care provider and system); and 4) responded to the needs of parents, who actively sought out the program. A paper published recently in the journal Zero-To-Three offered case examples of DULCE’s ability to address maternal depression and other pressing family needs. These results were achieved at modest cost, offering promise that DULCE is a replicable, universal and cost-effective approach that can be widely used in pediatric care settings to address toxic stress in low-income neighborhoods.
We would like to acknowledge that DULCE was developed at Boston Medical Center and originally funded as a research and demonstration project by the National Quality Improvement Center on Early Childhood (QIC-EC) which is funded by the U.S. Department of Health and Human Services, Administration for Children, Youth and Families, Office on Child Abuse and Neglect, under Cooperative Agreement 90CA1763. The purpose of QIC-EC is to generate and disseminate new knowledge and robust evidence about programs and strategies that contribute to child
Overview
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maltreatment prevention and optimal development for infants, young children (0-5) and their families, including those impacted by HIV/AIDS, substance abuse, or abandonment. The strategies in this manual were adapted from the noted sources specifically for use in Project DULCE by staff paid through the QIC-EC and are available in the public domain thanks to the federal funding for the original project.
INTENDED AUDIENCE
This manual is designed to support implementation of DULCE at health centers that work in cooperation with early childhood systems of care. DULCE Family Specialists and members of the clinical care team will want to review the entire manual. Early childhood system leaders and quality improvement team members should find the first three sections particularly pertinent to their work. This manual, along with training, technical support, and quality improvement efforts, provide the basic information and resources needed to implement DULCE – a cost-effective, universal program to link clinical care, families, and the surrounding communities.
LOGIC MODEL: Providing Access to Concrete SupportsB
concrete supports
parental resilience
knowledge of parenting
upstream fractors downstream results
food insecurity
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parent emotional & behavioral
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interparental conflict & low
warmth
child abuse & neglect
child problem behaviors
DULCE Reduces Sources of Toxic Stress (Red Boxes)
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DULCE focuses on supporting six family protective factors:
1. PARENTAL RESILIENCE: A parent’s ability to bounce back from difficulties
1. SOCIAL CONNECTIONS: A network of informal or formal supports (e.g., friends, family, faith group)
2. CONCRETE SUPPORTS: Knowing where to turn for help and how to navigate these systems (e.g., identifying and accessing programs to help with food, housing, utilities, child care, etc.)
3. KNOWLEDGE OF PARENTING AND CHILD DEVELOPMENT: Parents know what to expect as their children grow and what behaviors are appropriate at for a given age
4. SOCIAL AND EMOTIONAL COMPETENCE OF CHILDREN: Children learn to talk about and handle feelings
The intervention model, based on the relationship between the DULCE Family Specialist and the family, builds upon the known trajectory of child and family development. The DULCE Family Specialists provide: 1) information on healthy child development, 2) parenting support, and 3) advocacy by connecting families to existing community resources available to them.
Once a baby is born, there is tremendous change in the family structure, and often the need for family support peaks at this time. By one month of age, most families have begun to settle into new routines that set the tone for coping strategies for months, and even years, to follow. It is also at this time that infant crying – and lethal maltreatment – peaks. The Family Specialist provides the knowledge about infant development (particularly related to developmental milestones, temperamental styles and goodness of fit, attachment and self-regulation) during the well child and home visits.
This model also recognizes that helping families to access resources that meet concrete needs – food, income, housing and utilities – may reduce maltreatment. Simultaneously, meeting basic needs may enhance a family’s capacity to meet future needs that may arise, which
is a protective factor that strengthens the family. Local medical-legal partnerships provide on-site training and ongoing consultation and support services to DULCE Family Specialists about these concrete needs. These local medical-legal partners are also is available to work directly with families when needed.
The first four visits focus on concrete needs, child care, and the baby’s developing temperament and personality. The six-month visit is used as a wrap-up to the intervention and transferring any ongoing support to the family-centered medical home. The goal is to inform and empower families to become independent with the skills needed to advocate for themselves. The following table summarizes the relationship between the DULCE intervention/healthcare visits and the family protective factors.
C. DULCE INTERVENTION
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DULCE Embedded in the Early Childhood System D
NEWBORN: The focus of DULCE is to maximize child development and
minimize maltreatment for all newborns.
PARENTS: DULCE provides parental support and information
on child development which gives parents an opportunity to
develop confidence in their capacity to parent and be attuned
to their child’s needs. Parent engagement plays a critical
role in the design and accountably of DULCE.
DULCE: The DULCE Family Specialist adds to the
support network of the newborn’s extended family
and friends. If this network does not exist, the Family
Specialist can assist in establishing one.
COMMUNITY: With knowledge about many of the local
resources for families, the Family Specialist helps to connect
new families to these established programs.
PUBLIC SUPPORTS: If needed, DULCE connects families to public
supports providing the basic needs upon which families can grow strong.
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DULCE Embedded in the Early Childhood System
Getting Started2.A. Implementation Factors
Implementation of DULCE is accomplished by hiring a Family Specialist, providing support through the DULCE clinical team, and using a continuous quality improvement model to adapt and improve the DULCE approach to the local environment.
1. The DULCE Family Specialist has a background in child development or a related field and works with newborn patients and their families. Intervention is delivered through co-managed routine healthcare maintenance visits, as well as support through home visits, telephone, email and community visits. (Estimated up to 200 families per year.)
2. The DULCE Clinical Team consists of the medical champion (MD or PNP), a mental health professional, and a medical-legal partnership liaison (lawyer and/or paralegal as appropriate). The practice administrator will be available as needed. The team will serve to support the Family Specialist in at least two ways:
• Weekly case conferences to discuss every case seen by the Family Specialist during the past week and to plan for the next week's visits (estimate of 1 to 2 hours). See Appendix E for a Sample Weekly Case Conference Agenda.
• Support as needed for more urgent patient needs.• The mental health provider also provides mental health supervision for the Family Specialist. See Appendix F
for Suggested Areas to Cover During Mental Health Supervision Meetings
3. A key component of DULCE’s further testing and refinement is a new Quality Improvement (QI) function to be implemented in association with DULCE in each jurisdiction. The QI component is being introduced so that local leaders can:
• Ensure that the core elements of the DULCE model are implemented effectively• Track the progress of the DULCE implementation and address any challenges that arise in a prompt manner,
with full participation by the Clinical Team• Adapt aspects of implementation as needed to respond well to emerging local conditions and challenges, and• Learn about and document, in real time, how DULCE is being implemented, so that the approach can be
spread locally and, hopefully, eventually taken to greater scale nationally.
The QI function will be co-designed in each site by local leaders, working with the CSSP national team and the QI partner. It is envisioned that the QI team in each site will consist of:The Family Specialist delivering the intervention
• A clinical practice champion (a pediatric health care provider in the clinic setting)• A mental health provider, either from the clinic setting or a community provider engaged as a partner in the
intervention. • A representative of the local medical-legal partner
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• Representatives of the Parent Leadership Group who are themselves parents who bring or have brought their children for care at the clinic site
• A DULCE champion (possibly a QI coach) from the EC-LINC lead organization or agency
In summary, DULCE adds a Family Specialist to the healthcare team. Family Specialists work as part of a multidisciplinary team that includes many disciplines (pediatric clinicians, child development, medical-legal partnership, nursing, child life, and social work) to create a holistic approach to the child and the family.
The core elements of DULCE are components that every site will be asked to implement. They are the essential building blocks of DULCE. The intervention would not be complete without any one of the elements listed below.
DULCE implementation requires: 1) adherence to the core elements, and 2) a commitment to using formal quality improvement approach to adapt and improve the program to better serve the patients and community at each site. Parents, the DULCE clinical team, and Early Childhood systems leaders all participate in local monitoring and improvement efforts. This approach retains the key learnings from evidence-based practice while providing the needed flexibility to continually adapt DULCE for the needs of every patient in each implementation site. The core elements are:
1. Universal Access: DULCE is offered to all infants and their families for the first six months of a child’s life, through their routine primary care visits.
2. Family Specialist: A family specialist, who is part of the primary health care team, works with families to promote healthy child development using a protective factors approach.
3. Medical-Legal Partnership: The family specialist is trained and supported by the local medical-legal partners; other medical-legal partner resources may also be available to the family.
4. Parents as Partners: Parents are partners; DULCE recognizes that parents are the most important people in an infant’s life. Parents direct the services they want and need, and have meaningful roles in program, design, implementation and accountability.
5. Community Connections: Families have access to and can connect with, the supports, services and opportunities they need, aided by collaborative relationships between DULCE and other community services and supports.
6. Continuous Quality Improvement: Data are collected and used for continuous learning and practice and program improvement.
In addition to the core elements, there are three structural elements that we are asking local partners to address. These help define the
context in which DULCE will be implemented and represent local commitment to develop the intervention in a way that will have impact on large numbers of infants and their families, and contribute to the development of an effective early childhood system. The structural elements are:
1. Lead Local Partner: works with other local leaders to plan DULCE implementation, track the progress of the intervention and connect DULCE to other related interventions that promote an infant’s healthy development.
2. Spread Strategy: plans to expand the use of DULCE more broadly in the local jurisdiction.
3. Sustainable Financing Strategy: fiscal sustainability is considered from early-on in the implementation.
DULCE adds a Family Specialist to the healthcare team. Family Specialists work as part of a multidisciplinary team that includes many disciplines (pediatric clinicians, child development, medical-legal partnership, nursing, child life, and social work) to create a holistic approach to the child and the family.
• Skills & Core Competencies of the Family Specialist:• Ability to observe adults, babies and the dyad of parent and child• Ability to collaborate with collateral services and supports • Ability to provide advocacy and community resources to families
or knowledge of where to refer families for advocacy • Knowledge about providing services in the home and natural
environment• Knowledge about infant development particularly related to
developmental milestones, temperamental styles and goodness of fit, attachment and self-regulation
• Knowledge of adult development particularly around parenthood• Knowledge about cultural influences on individuals and families
DULCE Family Specialists are the new element of the Patient-Centered Medical Home team that includes a primary care clinician, PCMH/community resources, a nurse and support staff. The following describes the DULCE Family Specialist’s individual relationship with each member of the team.
B. DULCE Core Elements & Structural Expectations
C. Family Specialist
D. The Patient-Centered Medical Home Team Relationship with the DULCE Family Specialist
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PRIMARY CARE CLINICIANS
As members of a team with one goal – the best interests of the family – the primary care clinician and Family Specialist come from different perspectives and focuses. As such, they are able to come up with more than one strategy to reach that goal. With their on-going conversations about individual families, the clinician and Family Specialist can provide a better continuity of care.
INSIDE THE EXAM ROOM
1. The Family Specialist has already spoken with the family prior to being seen in the exam room and the family may have mentioned something important that needs to be discussed. However, if that issue is not raised, the Family Specialist is also in the room and is able to say, “Didn’t you also want to talk about…?”
2. Some families can be “chaotic” and with the Family Specialist in the room, there is another “set of hands” to:
• Help with siblings
• Hold the baby to give a parent a break
• Get something out of the diaper bag
OUTSIDE THE EXAM ROOM
1. As another member of the team, the Family Specialist can reach out to families between appointments and communicate with the clinician in person or by the medical record.
2. The Family Specialist is able to follow up with a family and update the clinician on questions and concerns such as:
• Clinician cannot reach the family because voicemail is full – why?
• Did the family make it to the shelter?
3. The Family Specialist can make a home visit.
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"The following cases illustrate that the introduction of a Family Specialist into the patient-provider relationship lays the groundwork for more meaningful conversations.
When I see a DULCE Family Specialist in the exam room I am very grateful. The Family Specialists are enormously
helpful as they are able to help my families in ways that I am not – the non-medical issues that have a great impact on a
family’s health.– ERICA KAYE, MD"
Family Specialist
Family Clinician
Case One: Mom’s Mental Health While children are the pediatric clinician’s primary patients, these clinicians are also concerned about the wellbeing of all family members.
The clinician knows the mother of a newborn since her older children are also patients of this primary care provider. Mom has had longstanding mental health issues and this clinician has been concerned that Mom has not done anything to help herself for almost two years – either therapy or medication. Unlike past conversations on this issue with Mom, a Family Specialist is now part of the discussion. The conversation can be more in-depth and carries more weight for Mom. This time, Mom understands the clinician’s level of concern about her mental health needs.
Following this initial discussion, the DULCE Family Specialist had two more conversations before Mom decided to see someone about her mental health issues: one conversation was at a well child visit and the other was over the phone. After these conversations, Mom went by herself to the mental health therapist. After her visit with the therapist, the Family Specialist had a long talk with Mom during a home visit where they were able to further discuss the state of Mom's mental health. Since Mom’s mental health issues were being addressed with medication, the Family Specialist was able to reinforce the importance of following the therapist’s prescription.
“While caring for this baby, I also wanted the mom to be well. I would not have had that conversation on my own. This family made progress that without DULCE may never have happened.” – Pediatric Primary Care Clinician
Case Two: 19-Year-Old Mom with No SupportAs a first-time mom, this young woman had many questions regarding infant development. While the primary care clinician was comfortable answering these questions, the DULCE Family Specialist was able to give more in-depth answers; thereby making the guidance
"When I see a DULCE Family Specialist in the exam room I am very grateful. The Family Specialists are enormously
helpful as they are able to help my families in ways that I am not – the non-medical issues that have a great impact on a
family’s health.– ERICA KAYE, MD"provided to this new mom much more detailed.
After the first few contacts – both in person and by phone – there was a good level of trust established between this mom and the Family Specialist. Then, at a late Thursday afternoon well child visit, after a few supportive inquiries by the Family Specialist, Mom revealed that she had only one can of formula remaining for the entire weekend. It was obvious that something needed to be done right away.
In this case, the Family Specialist was able to meet with Mom the next day and obtain coupons for additional formula for the weekend. The earlier child development conversations laid the groundwork for the very practical conversation about getting food for the weekend – a crisis
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averted. For this mom, one person – the Family Specialist – was able to provide support for both child development and concrete needs.
Case Three: A Really Fussy Baby and Two Very Frazzled Parents As first time parents, these parents were very concerned about how fussy their baby was and talked about how “inconsolable” their child was. However, from a medical point-of-view, the clinician knew that this baby was doing just fine – there were no medical issues that needed to be addressed. Nevertheless, the clinician also realized that a real crisis could arise if these parents became so fearful about their crying baby that they decide to take this “seriously ill” child to the emergency department (ED). Once this baby got to the ED, a septic workup would inevitably be done.
Fortunately, the DULCE Family Specialist was able to help both in and out of the exam room. While in the exam room with the family, the Family Specialist was able to model calming behaviors in addition to enabling the parents to focus on their discussion with the clinician. Then, between well child checkups, the Family Specialist was able to answer their many questions over the phone in addition to teaching them skills on how to calm their child at a home visit. These parents were not left alone to learn by trial and error.
The Family Specialist not only helped to build the parents’ confidence, the Family Specialist was to support the parents as they grew their capacity as parents. The Family Specialist was able to provide a “parenting toolkit” while reinforcing what a good job they were doing.
Reporting back to the clinician, these parents stressed how they benefited from the continuity of care with the Family Specialist at well child visits in addition to the home visits. These parents also liked that the Family Specialist was involved for only six months – giving them a goal to work towards. They felt the first six months were the most critical and were feeling quite confident as parents at their last visit with the DULCE Family Specialist.
Depending on the needs and circumstances of a family, it is essential that DULCE Family Specialists communicate openly and regularly with relevant staff in the patient-centered medical home, and with the surrounding community Early Childhood System leads. Each clinic and community will have their own staffing arrangements, but the patient-
centered medical home focus on care coordination and co-located mental health resources often result in social work or care management staff within the clinic. Frequent communication between the DULCE family specialist and these staff members will result in coordinated care for those families who may benefit from ongoing support.
There are occasions when a family is involved with other programs or professionals prior to working with a DULCE Family Specialist. In these cases, the Family Specialist can complement and support the services already being offered. Other times, families with needs beyond the scope of the services offered by the DULCE Family Specialist will need referral. The following are some of the situations where a Family Specialist should seek support from a licensed professional (MD, RN, or LICSW):
• Social and/or concrete needs are beyond the Family Specialist’s range (e.g., assistance for families who are dealing with homelessness and need to find housing)
• Mental health referrals for parents• Mandated Reporting of suspected child abuse or neglect, and
communication with the state child protective services regarding investigations or open cases
• Referrals for domestic violence • Other ongoing needs or unresolved issues that they may occur
when the DULCE baby is six months old and transitions out of the program
NURSINGSimilar to any other member of the Medical Home Team, the DULCE Family Specialist assists the nursing staff in maintaining an efficient patient flow in the clinic. In particularly busy settings, good communication with the nursing staff is important, especially when there are changes in patients’ rooms.
As vaccines and immunizations are a big part of a child’s first six months, the Family Specialists can help answer any questions that parents may have with the immunization process. In this way, parents are better prepared when the nurse arrives with their child’s immunizations.
SUPPORT STAFF
FRONT DESK / CHECK-INMaintaining accurate information is vital to good patient care, as is an efficiently run clinic. DULCE Family Specialists can assist in this in the following situations:
• Provide any address or family information changes that are pertinent to a child’s medical record
• Help with appointment reminders and late-arrival policy reminders
• chedule pending and follow-up appointments • Serve as a liaison between staff and families for a smoother visit
LINKING TO THE PATIENT-CENTERED MEDICAL HOME (PCMH) & COMMUNITY RESOURCES
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Building the Expertise of DULCE Family Specialists
3.
A. Brain Messages and Strategies for Supporting Early Brain Development
We now know much more than we ever did about the process of early brain development. Infants begin learning from the moment of birth, when they first experience the environment outside the womb. DULCE helps parents make the important connection between the world that a newborn experiences, and how brains begin to grow. Brains start to develop on day one and the first six months of life are an extraordinary time for a child’s brain development.DULCE Family Specialists have found the following practices particularly effective when working with families:
• Use of the Touchpoints approach, particularly the Newborn Behavioral Observation tool• Use of an evocative object• Discussing with parents how babies learn and grow by using “brain messages”
This area of knowledge is more fully described in Brain Messages and Strategies for Supporting Early Brain Development, which was originally developed by the original Boston DULCE Family Specialist team and extensively updated with new material from the Harvard Center on the Developing Child. Additionally, DULCE Family Specialist receive Touchpoints Training and participate in ongoing educational and training opportunities.
DULCE Family Specialists will receive Brazelton Touchpoints Individual Level Training so they can incorporate elements of the Brazelton Touchpoints approach into their practice. The Touchpoints approach helps professionals engage around key points in the development of young children. Touchpoints training serves to support professionals to foster parenting skills and the parents’ enjoyment of their child, while strengthening the bond between the provider and the family.
When trained in this approach, the Family Specialists will:• Understand the theories and concepts of the Touchpoints approach, with emphasis on the developmental and relational elements of parent-child-
provider relationships, and their practical applications
B. Parenting/Child Development
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• Enhance their delivery of care to families by using relationship-building strategies and communication tools based on the Touchpoints approach
• Observe and participate in encounters that demonstrate the Touchpoints approach of collaborative anticipatory guidance
Local medical-legal partnerships provide the basis for the concrete supports training, coaching, and back-up that the DULCE Family Specialists receive. The relationship is designed to strengthen the risk detection and problem-solving capacity of the Family Specialists, with families, as opposed to a more traditional referral of legal emergencies exclusively.
Local medical-legal partnerships equip the healthcare, public health, and human services teams with legal problem-solving strategies that promote health equity for vulnerable people. By integrating legal problem-solving as a core component of patient care, medical-legal partnerships address the complex needs of low-income patients to ensure that they are able to meet their basic needs for food, housing and utilities, education and employment, health care, and personal and family stability and safety.
In the DULCE context, local medical-legal partnerships train the Family Specialists in three core domains related to concrete supports:
1. Securing Nutrition and Income Supports, Stabilizing Housing, and Protecting Utilities for Families
2. Hunger Prevention3. Income Supports
These training sessions emphasize:• How professionals from differing backgrounds can partner with
each other to advocate effectively for patients and families.• Best practices for spotting “red flags” regarding barriers to health-
promoting services and supports.• Building role-appropriate skills and strategies the Family
Specialists can deploy with families to successfully access vital resources.
Medical-legal team members continue to support the Family Specialists by:
1. Attending weekly team case reviews and contributing legal problem-solving insight as needed and appropriate.
2. Responding rapidly to consults from the Family Specialists with respect to specific families with evolving needs.
3. Determining whether a particular family’s situation is so complex or acute that it requires a comprehensive legal intake interview, and as a corollary, facilitate a referral to a pro bono lawyer volunteer for full legal representation (in a small number of instances, also conducting the intake and facilitating an appropriate referral).
DULCE sites are likely to observe a capacity-building trajectory in the Family Specialists around concrete supports that reflects greater reliance on the medical-legal partner during the beginning of the partnership; this is predictable since Family Specialists typically bring more direct experience and training in child development than they do in concrete supports advocacy. Over time, the training and consultative relationship between the Family Specialists and the medical-legal partner will cause more sophisticated (and potentially fewer) consults to the medical-legal partner because the Family Specialists have developed greater knowledge and understanding of role-appropriate advocacy strategies. The stronger the relationship between the Family Specialists and the medical-legal partner, the greater the likelihood that barriers to securing concrete supports will be detected – and hurdled – before a family is experiencing a health or legal emergency.
Please note that these tools are suggestions for local implementation, drawn from the original implementation. Other tools that serve a similar purpose, with similar validation and ease of use, may be used in place of these suggestions. Sites should take into consideration the trademark and copyright restrictions and availability in the public domain or costs associated with the use of trademarked tools.
NBO: Newborn Behavioral Observations The NBO is a structured set of observations designed to help the clinician and parent together, to observe the infant's behavioral capacities and identify the kind of support the infant needs for his successful growth and development. The NBO system consists of a set of 18 neurobehavioral observations, which describe the newborn's capacities and behavioral adaptation from birth to the third month of life. While it describes the infant's capacities, the NBO also provides parents with individualized information about their infant's behavior so that they can appreciate their baby's unique competencies and vulnerabilities and thereby understand and respond to their baby in a way that meets her/his developmental needs. DULCE teams will be offered training on the NBO during the first year of implementation.
ASQ-3™: Ages & Stages Questionnaires®, Third Edition The parent-completed Ages & Stages Questionnaires®, Third Edition (ASQ-3™) is a family-friendly way to screen children for developmental delays between one month and 5½ years, without any gaps between the questionnaire age intervals. Recommended by top organizations such as the American Academy of Neurology, First Signs, and The Child Neurology Society*, ASQ-3 is highly valid and reliable. ASQ-3’s questions on behavior and communication also help elicit parent concerns that may point to autism.
C. Concrete Supports
D. Assessment Toolbox
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ASQ-SE: Ages & Stages Questionnaires®: Social-EmotionalEarly identification of social-emotional problems is crucial, as more and more children are experiencing poverty and other risk factors for depression, anxiety, and antisocial behavior. The Ages & Stages Questionnaires®: Social-Emotional, Second Edition (ASQ:SE-2™), a highly reliable, parent-completed tool with a deep, exclusive focus on children’s social and emotional development, can pinpoint behaviors of concern and identify any need for further assessment or ongoing monitoring.
PHQ-9: Patient Health Questionnaire (See http://www.cqaimh.org/pdf/tool_phq9.pdf)
The PHQ-9 is the nine item depression scale for assisting primary care clinicians in diagnosing depression as well as selecting and monitoring treatment. The primary care clinician and/or office staff should discuss with the patient the reasons for completing the questionnaire and how to fill it out. After the patient has completed the PHQ-9 questionnaire, it is scored by the primary care clinician or office staff. There are two components of the PHQ-9:
• Assessing symptoms and functional impairment to make a tentative depression diagnosis, and
• Deriving a severity score to help select and monitor treatment • The PHQ-9 is based directly on the diagnostic criteria for major
depressive disorder in the Diagnostic and Statistical Manual Fourth Edition (DSM-IV).
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4. DULCE INTERVENTION
A. IDENTIFYING ELIGIBLE FAMILIES
Recruitment is universal – DULCE is offered to all families with newborns receiving care. With universal recruitment of families, there is no stigma attached to participating in this program.
Families meet with DULCE Family Specialists at all routine visits and for home visits and telephone check-ins depending on the needs of the family – working with families to empower them to solve their own problems.
At six months, the DULCE Family Specialist transitions care to the primary care team – pediatrician, nurse, and any other ongoing services at the clinic – or in the family’s neighborhood, as necessary.
Parents as Advisors, Experts and Accountability Advocates
Parental leadership and engagement is a strong component of all aspects of DULCE design and implementation. The aim is to ensure that the innovations targeted to help families are meeting the mark by co-investing with families, the end users, to co-design innovations, track implementation and provide advice about potential improvements. DULCE sites create an array of opportunities for parents and other constituents to test, assess and ultimately improve services, interventions and strategies that are intended to benefit them; seeking outreach on parents reflections on the effectiveness, usefulness and respectfulness of the climate in which services and strategies are offered. DULCE includes parents in the co-design of each community’s intervention, rely on the feedback from parents to sharpen individualized care and interactions with Family Specialists and engage parents in the quality improvement and accountability chain of DULCE.
B. CREATING THE RELATIONSHIP WITH THE FAMILY (FIRST WEEK & ONE MONTH VISITS)
DESIRED RESULT: Family meets Family Specialist and begins to form a therapeutic allianceThe DULCE Family Specialist helps parents make the adjustments that come with each newborn baby – and assists them in engaging with their child’s patient-centered medical home (PCMH).
DULCE is a relationship-based practice. Beginning in the first visits, the Family Specialist makes sure a family feels comfortable talking about their new baby, other family members, and any pressing needs or concerns that they may be experiencing. The open-ended probing questions in the first two visits encourage parents to develop this relationship with the Family Specialist. Parents have the opportunity to observe and talk about their baby – and their experiences as parents – in a safe and nurturing environment. Family Specialists support two important family matters that come into focus soon after birth: 1) knowledge of the baby’s development and related parenting strategies, and 2) concrete supports for the family. Through conversations with the family, the Family Specialist discovers where the family feels safe to begin – Will this family discuss their concrete or social needs first or are they going to lead with questions about the child’s development? Once families develop trust in their Family Specialist, they often speak freely about a wider range of topics. While some parents may wait till the four- or even six-month visit to ask for help, others feel comfortable asking right away.
No matter where the family begins, at each visit the Family Specialist introduces specific strategies for supporting early learning. These strategies or “brain messages” make parents more aware of how their interactions with their baby support their newborn’s brain development.
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“I wish every family were in DULCE.”
– Marissa Hauptman, MD
Relationship-based practice starts with building a trusting relationship with the family. From the very first meeting, Family Specialists observe a family’s cultural background, style of communication, and child-rearing practices. For example, in some families the grandparents may be very involved with child rearing and share the daily care of the child, and, out of respect, the Family Specialist might address the grandparents before addressing the mother. How the Family Specialist asks questions and to whom these questions are addressed may be as important as the words that are said. If there are extended family members in the room, paying attention to who is asking most of the questions gives an indication of the family’s hierarchical structure. However, Family Specialists need to balance respecting the role of the extended family while also empowering the parents. Making sure that everyone feels respected and included in the child’s development sends the message that the baby’s wellbeing matters to everyone: those who come to the clinic visit as well as those who may only be present at the home visit.
While some babies may come with several family members to a well child visit, many other babies arrive with just their mother or father. For this reason, probing questions like “When you need help with the baby, who helps you?” and “Do you feel safe leaving the baby with that person?” are very important. It is essential to find out who else helps to care for this child, how they may affect the child’s care, and if they have questions regarding the care of the baby. There might be somebody at home who has a significant influence on the child’s mom or dad. Knowing who is physically there in the room – and their role – is important, “What is your relationship to this baby?” or “Who have you brought with you today?” Knowledge of the family’s home life informs the work of the Family Specialist.
Talking with the family about their child’s development before the pediatric clinician (a pediatrician, nurse practitioner, physician’s assistant, or a family medicine doctor) enters the exam room is a great way to begin establishing a relationship with the family. Then, during the visit, if the clinician talks about a subject previously discussed with the family, the role of the Family Specialist is validated. For example, many parents raise the concern about spoiling their child, a topic that is frequently discussed with parents of newborns. The Family Specialist can start this conversation with: “Has anyone talked with you about spoiling this baby? You know, babies can’t be spoiled at this age.” At this point, new parents may state that some family members and/or friends have told them, “Oh, you are spoiling that child!” Later, when the clinician confirms what the Family Specialist said about spoiling, the parent may feel a level of comfort and think, “OK, so maybe my baby can’t be spoiled at this age.” The clinician and Family Specialist, by explaining normal child development, can teach parents that young babies are not capable of manipulating others. This knowledge gives parents the confidence they need when family and friends may be communicating negative messages about the baby: “That child is so bossy.” or “Your baby is just being manipulative.” As mentioned earlier, in addition to offering support regarding child development and related parenting strategies, Family Specialists also focus on families’ concrete needs. While some families are very open to discussing these needs at the outset, other families might take more time to open up. In one example, a Family Specialist had a very good relationship with a mom who eagerly focused on her new baby and was always asking for more information about child development and parenting strategies. The new mom wanted to know what would be her baby’s next stage, and what she should be doing to help her child. Even though the visits centered on child development, the Family Specialist also offered information about housing and utilities to which mom would reply, “I’ll think about it.” Then, at the six-month visit, mom stated, “I really do need some help.” What mom and baby needed was shut-off protection for the gas and electricity and mom wanted to know how to apply for help with paying these utilities. This mom struggled because she “… didn’t like to ask for things.” However, because a trusting relationship was established, the mom was able to finally open up and ask for help with some very basic – and critical – needs for her new family.
The DULCE Family Specialist and clinician work as a team. During the first meeting, the Family Specialist may discuss child development in general or perhaps a particular issue with which a parent is struggling. When the clinician later validates what the Family Specialist said or when the Family Specialist repeats what the clinician said earlier, the parent thinks, “OK, perhaps I can trust them. They have some good ideas for me.” This teamwork serves two important functions in linking families with the patient-centered medical home:
• It allows parents to look to the clinic staff as valuable sources of information about child development and resources.• It encourages parents to view the PCMH as a place where families can safely discuss the social, emotional, and concrete support issues they face.
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FIRST WEEK VISIT
At the Two Month visit, Mom and the Family Specialist had some time in the exam room to talk before the clinician came in. Mom mentioned that her son was crying a lot: “It’s sort of getting better. The thing that really does the trick when he’s crying is feeding him.” Mom thought that she did not have enough milk when breastfeeding; so after breastfeeding, she also gave her son a formula bottle. From the baby’s appearance, the Family Specialist could see that he was really big for his age. The Family Specialist mentioned that the clinician would be going over the baby’s growth chart and that she could “…see he’s growing! The clinician will definitely talk about that.” The Family Specialist then observes that “… babies don’t cry just because they’re hungry.” Mom’s concern was about crying and the Family Specialist’s concern was about over-feeding. This was the opening to have a conversation about self-soothing and other ways this mom could respond to her son’s crying before giving him a bottle.
One of the first things the clinician states after viewing the growth chart, “Your baby has gained a lot of weight since the last visit.” Mom says, “Yeah, we were just talking about that.”
Mom was assured by the clinician that her son was getting enough food and growing well – confirming what the Family Specialist had said – but now mom has other techniques to use when her son starts to cry.
“I’m not telling you how to be a parent, I’m just providing some skills for you.” Due to the process of family recruitment, items 1 through 6 are typically
addressed by the First Month Visit if the family is being seen for the first time at that well child visit by the Family Specialist.
1. Introduce the DULCE model to the family and start developing the relationship with them during the well child visit by asking the probing questions below.
2. Probing questions (the ones in bold are the important ones) a. Tell me about the baby’s name. How did you choose the name?b. When you need help with the baby, who helps you? Do you feel
safe leaving the baby with that person?c. How did the delivery go? How about the pregnancy?d. What has it been like caring for the baby this first week?e. What do your other children think about the new baby?
3. During the visit, use the First Week Checklist to observe the interaction between the caregiver and the baby and, if necessary, introduce issues that were shared during the conversation in the waiting or exam room. Ask interpersonal and community violence questions.
4. Perform screening of income situation via Income and Nutrition Screening Checklist that your team has updated and amended to reflect common income barriers and available remedies in your particular region/community. (This can be postponed to the next visit as needed.)
5. Introduce the evocative object to be used in all the well child visits to demonstrate baby’s behaviors to support parent/child attachment (it can be a ball, rubber ducky, spoon, or something similar). Use this object to demonstrate baby’s visual tracking and following.
6. Infuse brain messages into visit as appropriate: soft spot, reflexes, protect the neck, provide comfort & love by holding & rocking, tracking
7. After the well child visit, offer to continue the conversation with the Family Specialist in the consulting room/office or offer a home visit or Family Specialist office visit (no co-pay).
8. Provide parent with Family Specialist contact information and discuss steps for the next meetings.
9. Give the First Weeks handout: provides information on development, nutrition, and income supports; your team should update and amend this document to reflect common housing problems, available remedies in your state, and resources accessible in your community.
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First Week Follow UpBetween the First Week and First Month Visits, the Family Specialist will:1. Contact the community resources discussed and those which the
family and the health care team have agreed will best address the needs identified by the parent(s).
2. Contact your local medical-legal partner if needed. 3. Call the family one day before the next appointment and ask about
the baby and caregiver and remind them of the appointment. Ask the family if they can arrive 15 minutes before the appointment to talk with the Family Specialist.
4. Offer optional home visit.5. During a phone call to the parent prior to the next visit, solicit
parent feedback on the desired results of visit: Family meets Family Specialist and begins to form a therapeutic alliance.
Possible questions based upon what happened during the visit:• Did you use any of the materials that I gave you? If so, how? • How effective were the referrals I made for you? If they were not,
why?• How useful was the advice? If it wasn’t, why?• Would you share any of this information with friends, family, or
other new parents?
ONE MONTH VISIT1. Family Specialist asks the family about the past few weeks in
regards to caring for the baby, explain the well child visit and set an agenda of possible issues or questions to discuss with the clinician.
2. Probing questions (the ones in bold are the important ones) a. What has it been like caring for the baby in the past week?
What happens when your baby cries? What do you do? How do you feel?
b. What do you notice that your child can do?c. What do you enjoy most about the baby? What worries you the
most?d. Are there any major changes in the family since the baby was
born?e. What are your plans for the next couple of months?
3. During the well child visit, use the evocative object to assess the baby’s ability to follow visual items; use the One Month Checklist to ask about developmental accomplishments and concerns. Also ask about sleeping and eating patterns, household accommodation to the new baby and family adjustment. During this visit the clinician or Family Specialist will ask about maternal depression and smoking. In either case, applicable referrals need to be made. Additionally, if another member of the family smokes, a referral to a smoking cessation program can be made for that person.
4. Perform Income & Nutrition Screening Checklist if it was not addressed at the prior visit.
5. Infuse brain messages into the visit as appropriate: opening fisted hands, turning towards familiar voices, talking
6. Assess the need for extra help (social work, mental health, or
informal supports either through the practice or community).\7. Follow up on issues discussed at previous visit, specifically
income resources.8. Parent Feedback on previous handout: Did you use the handout?
What was helpful about the handout?9. Give One-Month Old handout: provides information on
attachment, maternal depression, changes when a baby arrives and protective factors that might help in the adaptation process.
NOTE: Assess smoking in the first meeting if there are concerns or clues that the baby is living in a house where someone smokes or is being exposed to secondhand smoke.
One Month Follow UpBetween the One Month and Two Month Visits Family Specialist will:1. Contact the community resources discussed and those which the
family and the health care team have agreed will best address the needs identified by the parent(s).
2. Follow up on income resources.3. Contact your local medical legal partner if needed.4. Follow up call during the month between the well child visits to
check in and remind the family about the next appointment. Ask them if it is possible to come 15 minutes early to talk with Family Specialist.
5. During a phone call to the parent prior to the next visit, solicit parent feedback on the desired result of visit: Family meets Family Specialist and begins to form a therapeutic alliance.
Possible questions based upon what happened during the visit:• Did you use any of the materials that I gave you? If so, how? • How effective were the referrals I made for you? If they were not,
why?• How useful was the advice? If it wasn’t, why?• Would you share any of this information with friends, family, or
other new parents?
C. PARTNERING WITH THE FAMILY (TWO MONTH & FOUR MONTH VISITS) DESIRED RESULTS: 1) Parents learn something new AND VALUABLE about their baby and baby care, and 2) Concrete needs identified and steps taken to address them
When the First Week and One Month Visits are completed, the Family Specialist has often established a relationship where the family:
• Has come to trust the Family Specialist • Feels more comfortable asking questions about child development
and/or any pressing concrete needs/concerns • Better understands the role of the DULCE Family Specialist
During the first month of a baby’s life things are new and exciting and seem to be happening very quickly, but by two months the family is
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getting more comfortable with having a new baby in the home. The baby is now moving from being a newborn – who mainly sleeps and eats – to a more alert child starting to interact with others. At this age, babies are starting to smile and begin engaging with people more. With this in mind, the Two Month Visit starts with probing questions focusing on expectations:
• “Is this experience of having a baby what you expected?”• “What has been easier than you expected?”• “What has been harder than you expected?”
The visit then goes on to explore either concrete or emotional needs that the family may have with the probing question, “What do you do when you are feeling stressed, tired, need a break?” Hopefully, with the rapport that has now been established, the family feels comfortable enough to start talking about needs that at first they may have been reluctant to discuss with the Family Specialist. This is a good time to talk about applying for SNAP benefits (food stamps), making sure that mom is up to date with her WIC information for the baby, or applying for utility shut-off protection if needed. If the family does not raise these issues, it is important for the Family Specialist to provide basic information about these benefits to parents. Even if the family does not act on this information, by providing it at this visit, families can at least begin to think about these matters. By asking these questions, the Family Specialist is identified as someone who cares about the family and can be trusted to talk to about concerns or needs the family may have. Consequently, if the family does decide to apply for any of these benefits, there is time to follow up with them to make sure the benefits are in place before the family graduates from DULCE. However, if these concrete supports are in place, this is the time to focus on child development since these newborns are becoming more interactive and parents are taking more notice of what their baby is doing. Furthermore, babies are a little bigger and more mature now and parents are not as nervous about engaging in new and different activities. Besides holding their heads up better, babies are starting to express some real enjoyment while engaging in new activities with people and objects.
At this time, babies are still sleeping a lot – and hopefully there is a lot of cuddling going on – but this is often the time when babies are starting to cry more – the peak of the crying curve is three months. It is essential for the Family Specialist to talk about the stress caused by this increased crying. The changes occurring now are significant. During the first month, when parents are really tired, things may have been a bit “hazy,” but now, at two months, parents may be talking more about the stress associated with their crying baby and are settling into what their life with this new baby is going to be like. Parents are now ready, maybe even eager, to talk about child development.
Two other important probing questions at the Two Month Visit are, “Have you been out of the house without the baby? What did you do?” These outwardly simple questions generate a wealth of information. The answers might give some insight regarding a parent’s mental health or the level of support that exists within the family. These questions reveal how active new parents are outside of the home, how comfortable they feel about going out, and if there are others available to look after the
baby. Additionally, this gives the Family Specialist an opportunity to discuss how the baby is starting to form attachments. Many new parents feel that they have to spend as much time as they can with their child. This is a good time to remind parents that they need: 1) time to rest, 2) to have some alone time so as to not become too overwhelmed, and 3) to spend time with partners, friends and family without their child.
During the first two visits, when the Family Specialist is establishing the relationship with a family, parents may have been embarrassed to talk about being stressed and tired. But now, having established a sense of trust, answers like, “Yes, this is a lot harder than I thought it would be” or “Yes, I’m very stressed right now” are more forthcoming.
Given the length of time between the Two and Four Month Visits – and the baby’s increased physical development – this is a great time to schedule a home visit. A home visit at three-months allows the Family Specialist to check in and begin anticipatory guidance on developmental changes, movement, tummy time, and language development. Since there is now an established relationship, families are often more accepting of a home visit when suggested at the Two Month Visit. Additionally, the Family Specialist can talk about child development or follow up on a specific concrete need at this home visit.
The Four Month Visit is very exciting because babies are now starting to move about and parents are really excited to share all of the new things that their child is beginning to try. This is a wonderful opportunity for the Family Specialist to begin discussing child development, especially about how parents can interact with their child: things they can do, games they can play, and how to talk with their baby. A lot of parents are embarrassed and will admit that they “feel silly having a conversation” with their baby. If there was enough time at the Two Month visit, “parallel talk” may have been introduced at that time. (Note: Parallel talk is simultaneously doing something with the child and narrating for the child what is happening: “We’re putting on socks.” “We’re taking a bath.”). At four months, babies are beginning to respond to parallel talk. Despite the fact that many people automatically talk this way with babies, formally discussing this with parents is important. A new parent might happily say, “I’m already doing that!” This not only gives new parents a feeling of confidence, but it is a great opportunity for the Family Specialist to assure them that they are doing a really good job – too many parents do not get to hear that often enough.
Asking about a parent’s support network is a major focus of the Four Month Visit: “Who else takes care of the baby? “How is that going?” But even the probing question, “Is there any change in the baby’s eating?” or having a conversation with a parent about the baby’s changing sleeping patterns is an opportunity to discuss the parent’s support network. Finding out if anyone else helps with feeding their baby or if someone else stays with the baby while they are resting during the day allows the Family Specialist to find out if the primary caregivers are taking some time for themselves.
Another reason the social network questions are important is that between the Two Month and Four Month visits, many people have either already gone back to work or are starting to think about childcare
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in anticipation of going back to work. For some families, the discussion about going back to work occurs at the Two Month Visit. So, if someone is going to back to work when the baby is four-months-old, this change may have already happened or families are really thinking how to make it happen. Making sure that parents have the needed support and are talking about who they want taking care of their child when they are not at home is really important. Undoubtedly, the majority of parents have very mixed emotions about the transition back to work and the changes this brings about for their baby.
Babies at this age can be demonstrating very different abilities and temperaments: some babies are rolling over whereas some babies are content not to move around very much. Using the evocative object demonstrates for the parents what the child can do and what skills will be developing in the next few weeks or months. While the Family Specialist does not want to alarm parents, they do want to make parents aware that some milestones might develop over the next month. If there are any developmental concerns at the Four Month Visit, the Family Specialist may also want to administer the Ages & Stages Questionnaire (Section 3-D, Assessment Toolbox). This questionnaire is usually administered at the Six Month Visit, but there may be some “firsts” occurring and parents may also have some concerns. These are tools to begin discussing what the baby is doing. Informally, some of the questions could even be integrated into a conversation with parents; the Family Specialist can then follow up at the Six Month Visit regarding anything that was a concern.
The probing question, “What do you do with your baby during the day (e.g., infant stimulation, language, patterns of family life)?” is intended to find out what activities parents are doing with the baby and how that interaction feels for them and for the baby. This is at the heart of DULCE. Parents can be appropriately feeding their child, changing diapers as needed and having babies sleep in a safe environment, but the other activities – the playfulness initiated by parents – are what enhances the development of the child and supports the parent/child attachment.
The Four Month Visit is the time that the Family Specialist needs to start preparing the family for the final visit with the Family Specialist at a well child visit, especially since a bond has now been established. The time between the Four Month and the Six Month Visits is when the Family Specialist needs to:
• Follow up on the referrals that were made• Think about the work that still needs to be done• Find additional resources• Communicate more by phone• Offer another home visit• Plan time at the Six Month Visit for closure with the family
The two months leading up to the last visit will go by very fast. It is important to keep reminding families that the Six Month Visit will be the last one with the Family Specialist – this way the family is not surprised.
As a relationship-based practice where Family Specialist partners with
the family and often follows the family’s lead, visits do not follow a prescribed formula. However, at each visit the Family Specialist does discuss strategies for supporting early learning. These strategies or “brain messages” make parents more aware of how their interactions with their baby support their newborn’s brain development.
Family Specialists can connect families who request information and/or assistance with concrete needs to public agencies and community organizations.When the Family Specialist was talking with Mom on the follow up call between visits, Mom had some questions about income supports, in particular about applying for food stamps.
At the next well child visit, the Family Specialist brought an ap-plication for SNAP (formerly food stamps) and reviewed it with Mom so she would be able to complete it at home. The Family Specialist assured Mom that she should “feel free to give me a call if you have any questions.”
Two days later Mom called with a question regarding her father’s income and whether or not it needed to be noted on the SNAP application. The Family Specialist consulted with Medical Legal Partnership and the decision was that Mom’s father had to write a letter stating that he did not provide or share food with Mom and the new baby.
Mom then took the application to the SNAP office where the application and associated documentation was reviewed. Mom called the Family Specialist to report that in ten minutes the application was completed and submitted and that it would take about 30 days for the application to be processed.
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TWO MONTH VISIT
1. Ask the family about how it has been caring for the baby in the past few weeks, explain the well child visit and set agenda for the visit with possible issues to discuss with the clinician.
2. Probing questions (the ones in bold are the important ones) a. Is this experience of having a baby what you expected? What has been easier than you expected? What has been harder than you expected? b. How much is the baby crying? What do you do to calm the baby? c. Have there been any unexpected stresses, crises and/or illness in your family since the last visit? d. What do you do when you are feeling stressed, tired, need a break? e. Is it easy or difficult to know what your baby wants? f. Have you been out of the house without the baby? What did you do?
3. During the well child visit ask about developmental accomplishments and concerns. Use the Two Month Checklist to ask about sleeping and eating patterns, family adjustment, and the family’s housing situation. Use the evocative object to demonstrate the baby’s ability to visually track 180 degrees and to reach for objects.
4. Perform screening of housing situation via Housing & Utilities Screening Checklist that your team has updated and amended to reflect common housing problems and available remedies in your particular region/community, including pest, mold, heat and crowding. (This can be postponed to the next visit as needed.)
5. Infuse brain messages into visit as appropriate: head circumference, attraction to novelty, bored/distraction
6. If a home visit has not been done: offer a home visit.7. Parent Feedback on previous handout: Did you use the handout?
What was helpful about the handout?8. Give Two-Months Old handout: provides information on sleeping
and eating patterns, introduces tips to promote language, social interaction and healthy development. Review the information on “Babies learn a lot at this age.” The handout also provides information on safe/healthy homes and utilities protection when needed; your team should update and amend this document to reflect common housing problems, available remedies in your state, and resources accessible in your community.
Two Month Follow Up
Between the Two Month Visit and the Fourth Month Visit Family Specialist will:
1. Contact additional resources on which the family and health care team have agreed.
2. Follow up on housing and income resources.3. Contact your local medical-legal partner if needed.4. Make a follow up call during the two months in between well child
visits: check in and remind the family about the next appointment.5. During a phone call to the parent prior to the next visit, solicit
parent feedback on the desired result of visit: Parents learn
something new AND VALUABLE about their baby and baby care, and concrete needs identified and steps taken to address them.
Possible questions based upon what happened during the visit:• Did you use any of the materials that I gave you? If so, how? • How effective were the referrals I made for you? If they were not,
why?• How useful was the advice? If it wasn’t, why?• Would you share any of this information with friends, family, or
other new parents?
FOUR MONTH VISIT
1. Ask the family about how it has been caring for the baby in the past few weeks, explain the well child visit and develop agenda of possible issues to discuss with the clinician.
2. Probing questions (the ones in bold are the important ones) a. Has there been any change in the baby’s eating? b. Who else takes care of the baby? How is that going? c. Who helps you when you need to take some time off? d. What do you do with your baby during the day (e.g., infant stimulation, language, patterns of family life)? e. What do you do to calm your baby? What do you do if that does not work?
3. During the well child visit:• Use the Four Month Checklist to ask about developmental
accomplishments and concerns. • Use the evocative object to demonstrate reaching and grasping for
objects.• Find out if the family and/or clinician have any developmental
concerns that need an Early Intervention referral. Note: The Ages and Stages can be used as a screening measure if there are concerns about development.
4. Perform Housing & Utilities Screening Checklist if it was not addressed at the prior visit.
5. Infuse brain messages into visit as appropriate: routines/repetition/practice, social smile, what babies like to do
6. Follow up with the family about access to resources to which they were referred.
7. Parent Feedback on previous handout: Did you use the handout? What was helpful about the handout?
8. Give Four-Months Old handout: provides information on language development and ways to help baby’s healthy development, introduce the development of emotions. Additionally, this handout provides information and links the family to community resources and provides information on healthy housing and utilities protection.
Four Month Follow Up
Between the Four Month and the Six Month Visit Family Specialist will:1. Contacts additional resources on which the family and the health
care team have agreed.2. Follow up on referrals to income and housing resources.3. Contact your local medical-legal partner if needed.4. Make a follow up call during the two months in between well child
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visits: check in and remind the family about the next appointment.5. During a phone call to the parent prior to the next visit, solicit
parent feedback on the desired result of visit: Parents learn something new AND VALUABLE about their baby and baby care, and concrete needs identified and steps taken to address them.
Possible questions based upon what happened during the visit:• Did you use any of the materials that I gave you? If so, how? • How effective were the referrals I made for you? If they were not,
why?• How useful was the advice? If it wasn’t, why?• Would you share any of this information with friends, family, or
other new parents?
D. FAMILY’S NEXT STEPS (SIX MONTH VISIT)DESIRED RESULTS: 1) Family concrete needs met, 2) Family views health center as a place to get support for themselves and their families – beyond “getting shots” and 3) Where appropriate, family has made a connection with other elements of the early childhood system of care.
By the Six Month Visit, the Family Specialist has established a good working relationship with the family. It is vital to check in with parents at this visit on the status of any referrals, specifically about whether the family is comfortable with the referrals that have been made. These include:
• Developmental referrals such as early intervention programs or community support agencies
• Concrete support referrals for legal assistance or applying for transitional assistance with housing and/or food programs
There can be any number of reasons why families have not followed up with a referral and are still “thinking about it.” And this may be especially true for immigrant families, as they can be very nervous about referrals involving a government agency. Their fear may be associated with: 1) personal experiences from their country of origin, 2) anxiety that this may affect their current status in the United States, especially if they are undocumented, or 3) belief that it could hurt the chances of sponsoring another family member to come to the United States. Whatever the reason, if the Family Specialist finds out that there are some referrals still “pending,” it is a good idea to discuss next steps with both the family and the clinician, in addition to making sure the family has the right contact information. This ensures that everyone is aware of the situation and enables the clinician to follow up with the family at the next appointment.
In regards to child development, the Six Month Visit focuses on what has been happening during the last two months and prepares parents for the upcoming three months – many important development phases happened between the child’s six-month and nine-month well child visits. Most notably, some babies start to crawl. For this reason, safety around the home is a topic that needs to be discussed at this time. If there has been a home visit between the Four Month and Six Month
Visits, safety around the home can be discussed at that time. If safety is discussed at a home visit, the Family Specialist can get on the floor – along with parents – to demonstrate what it looks like from a baby’s point of view. This is a great way to teach new parents about how to make their home safe for their child.
Between six and nine months babies also start to experience both separation anxiety and stranger anxiety, something the Family Specialist can begin to look for at the Six Month Visit. As in previous visits, the Family Specialist can discuss different strategies with the family. These strategies or “brain messages” make parents more aware of how their interactions with their baby support their newborn’s brain development. New parents may be surprised and concerned that their baby, who would go with just about anybody before, now does not want to go to Grandma and starts to cry in Grandma’s arms. Babies now just want to be with either Mom or Dad. Also, if parents have returned to work, the Family Specialist may hear, “She was OK with me going back to work a few months ago. And now … she just cries and cries and cries.” Consequently, discussing separation and stranger anxiety with parents (e.g., letting them know that it is normal and why it is normal for their baby to be reacting this way) gives many parents an opportunity to breathe a little bit easier. Understanding that children are developmentally right where they should be, lets parents know that they are not doing anything wrong.
Another way to discuss separation and stranger anxiety is by introducing the concept of object permanence – the ability to know that objects and people continue to exist even though they can no longer be seen or heard. Something as commonplace as walking into a room and seeing a baby’s furrowed brow and the look that says: “Who are you?” is a good way for the Family Specialist to begin this discussion: “If you recall, at an earlier visit, I was able to hold your baby with no problem. Now, I am getting a, ‘I don’t know who you are!’ look.”
Another developmental milestone appearing around this age is learning about “cause and effect” – which can be especially frustrating for parents since it may be interpreted by them as “being defiant.” Family Specialists can prepare parents by explaining that their baby might start dropping things – the cause – and its associated effect – “Ooh I’m dropping this and you’re picking it up!” At first, parents may think it is cute when their baby laughs and is having a good time, “Wow, aren’t we having fun dropping and picking this up.” There are also some parents who may get really frustrated because they think the child is being disobedient or provoking when this behavior is done over, and over again. Explaining that this how children learn and that this is actually enhancing their child’s brain development gives parents a better understanding of their child’s behavior. Family Specialists can take this time to talk about both redirecting a child’s behavior and techniques on how parents can stay calm.
Since this is the last visit the Family Specialist has with the family, a nice way to conclude this visit is to review where the relationship started and where it is now. The Family Specialist can talk with the family about the baby’s milestones over the past six months, “When we first met … and now ….” Additionally, the Family Specialist can discuss how the family
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has changed and how well they have adjusted to this newest member.
After reviewing the family’s progress, the Family Specialist can close this visit by talking about next steps for this family. Understandably, since Family Specialists take their lead from the family this is very individualized, but making sure the family understands that there is no change as to how they interact with their medical home is important to point out to all families. To ensure that nothing has been forgotten, the following key areas can be quickly reviewed by the Family Specialist to make sure that everything for this family has been covered:
Community Link(s) Early Intervention Social Work Legal Mental Health
SIX MONTH VISIT
1. Ask the family about past weeks situation, explain the well child visit and develop agenda of possible issues to discuss with the clinician.
2. Probing questions: • How are you doing? • Are there any changes or new stresses for you, the baby, and the
family or in the neighborhood?• How would you describe your baby? • How does your baby act around other people?
3. During the well child visit, use the Six Month Checklist to ask about developmental accomplishments and concerns. Use the
evocative object to demonstrate grasping and transferring hand-to-hand. Talk about child care needs and possible referrals.
4. Complete the six-month Ages and Stages Questionnaire. 5. Infuse brain messages into visit as appropriate: early literacy,
object/person permanence, separation and stranger anxiety 6. Assess the need for extra help (e.g., social work, mental health,
legal, or informal supports either through the practice or community). Also re-assess need for Early Intervention referral.
7. Check the status of the referrals to the resources needed by the family.
8. Ask about safety at home (child-proofing home).9. Give the Six-Months Old handout: provides tips about play,
language and motor skills. It introduces possible things to expect in the child development from this point to 9- month well child visit. Additionally, this handout provides information about safety at home.
10. Review both the baby’s and family’s progress.11. Explain what will happen next. 12. Solicit feedback from parent. The desired result of the last
visit is in reality the desired result for the six-month DULCE intervention: Family concrete needs met, family views health center as a place to get support for themselves and their families – beyond “getting shots” – and, where appropriate, family has made a connection with other elements of the early childhood system of care.
• How helpful were the materials?• How effective were the referrals?• How useful was the advice? • Overall, in the past six months what was most helpful?• What would have been more helpful?• What advice would you give us to help other parents in DULCE?
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Between the First Week and the One Month visit FS will:
1. Contact the community resources which the family and the health care team have discussed and agreed on to address parent-identified needs.2. Contact MLP if needed.3. Call the family one day before the next appointment and ask about baby and caregiver and remind them of the appointment. Ask the family if they
can arrive 15 minutes before the appointment to talk to FS.4. Offer optional home visit.
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Due to the process of family recruitment, items 1 through 6 are typically addressed by the First Month Visit if the family is being seen for the first time at that well child visit by the Family Specialist.
1. Introduce the DULCE model to the family and start developing the relationship with them during the well child visit by asking the probing questions below.2. Probing questions (the ones in bold are the important ones)
a. Tell me about the baby’s name. How did you choose the name?b. When you need help with the baby, who helps you? Do you feel safe leaving the baby with that person?c. How did the delivery go? How about the pregnancy?d. What has it been like caring for the baby this first week?e. What do your other children think about the new baby?
3. During the visit, use the First Week Checklist to observe the interaction between the caregiver and the baby and, if necessary, introduce issues that were shared during the conversation in the waiting or exam room. Ask interpersonal and community violence questions.
4. Perform screening of income situation via Income and Nutrition Screening Checklist (Link to Section 5-B, Screening Questions) that your team has updated and amended to reflect common income barriers and available remedies in your particular region/community. (This can be postponed to the next visit as needed.)
5. Introduce the evocative object to be used in all the well child visits to demonstrate baby’s behaviors to support parent/child attachment (it can be a ball, rubber ducky, spoon, or something similar). Use this object to demonstrate baby’s visual tracking and following.
6. Infuse brain messages into visit as appropriate: soft spot, reflexes, protect the neck, provide comfort & love by holding & rocking, tracking 7. After the well child visit, offer to continue the conversation with the Family Specialist in the consulting room/office or offer a home visit or Family Specialist
office visit (no co-pay). 8. Provide parent with Family Specialist contact information and discuss steps for the next meetings. 9. Give the First Weeks handout: provides information on development, nutrition, and income supports; your team should update and amend this document
to reflect common housing problems, available remedies in your state, and resources accessible in your community.
First Week Visit
1. Family Specialist asks the family about the past few weeks in regards to caring for the baby, explain the well child visit and set an agenda of possible issues or questions to discuss with the clinician.
2. Probing questions (the ones in bold are the important ones) a. What has it been like caring for the baby in the past week? What happens when your baby cries? What do you do? How do you feel?b. What do you notice that your child can do?c. What do you enjoy most about the baby? What worries you the most?d. Are there any major changes in the family since the baby was born?e. What are your plans for the next couple of months?
3. During the well child visit, use the evocative object to assess the baby’s ability to follow visual items; use the One Month Checklist to ask about developmental accomplishments and concerns. Also ask about sleeping and eating patterns, household accommodation to the new baby and family adjustment. During this visit the clinician or Family Specialist will ask about maternal depression and smoking. In either case, applicable referrals need to be made. Additionally, if another member of the family smokes, a referral to a smoking cessation program can be made for that person.
4. Perform Income & Nutrition Screening Checklist if it was not addressed at the prior visit. (Link to Section 5-B, Screening Questions)5. Infuse brain messages into the visit as appropriate: opening fisted hands, turning towards familiar voices, talking 6. Assess the need for extra help (social work, mental health, or informal supports either through the practice or community).\7. Follow up on issues discussed at previous visit, specifically income resources.8. Parent Feedback on previous handout: Did you use the handout? What was helpful about the handout?9. Give One-Month Old handout: provides information on attachment, maternal depression, changes when a baby arrives and protective factors that might
help in the adaptation process.
NOTE: Assess smoking in the first meeting if there are concerns or clues that the baby is living in a house where someone smokes or is being exposed to secondhand smoke.
One Month Visit
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Between the One Month visit and the Two Month visit FS will:1. Contact additional community resources which the family and the health care team have agreed onto address parent-identified needs.2. Follow up on income resources.3. Contact MLP if needed.4. Make a follow-up call during the month in between the WCV: check in, remind family about next appointment and ask them to come early if they
can to talk to FS.
1. Ask the family about how it has been caring for the baby in the past few weeks, explain the well child visit and set agenda for the visit with possible issues to discuss with the clinician.
2. Probing questions (the ones in bold are the important ones) a. Is this experience of having a baby what you expected? What has been easier than you expected? What has been harder than you expected? b. How much is the baby crying? What do you do to calm the baby? c. Have there been any unexpected stresses, crises and/or illness in your family since the last visit? d. What do you do when you are feeling stressed, tired, need a break? e. Is it easy or difficult to know what your baby wants? f. Have you been out of the house without the baby? What did you do?
3. During the well child visit ask about developmental accomplishments and concerns. Use the Two Month Checklist to ask about sleeping and eating patterns, family adjustment, and the family’s housing situation. Use the evocative object to demonstrate the baby’s ability to visually track 180 degrees and to reach for objects.
4. Perform screening of housing situation via Housing & Utilities Screening Checklist that your team has updated and amended to reflect common housing problems and available remedies in your particular region/community, including pest, mold, heat and crowding. (This can be postponed to the next visit as needed.)
5. Infuse brain messages into visit as appropriate: head circumference, attraction to novelty, bored/distraction6. If a home visit has not been done: offer a home visit.7. Parent Feedback on previous handout: Did you use the handout? What was helpful about the handout?8. Give Two-Months Old handout: provides information on sleeping and eating patterns, introduces tips to promote language, social interaction and
healthy development. Review the information on “Babies learn a lot at this age.” The handout also provides information on safe/healthy homes and utilities protection when needed; your team should update and amend this document to reflect common housing problems, available remedies in your state, and resources accessible in your community.
Two Month Visit
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Between the Two Month visit and the Four Month visit FS will:1. Contact additional resources on which the family and the health care team have agreed.2. Follow up on housing and income resources.3. Contact MLP if needed.4. Make a follow-up call during the two months in between WCV: check in and remind the family about the next
Income Screening(Note: This screening can be done by the FS at the first visit, but needs to be done by the second visit.)“In these challenging economic times, many families are struggling to put food on the table or to pay the rent or utilities.”
1. Do you have enough food to adequately feed yourself and your family this week?
2. What do you do when you find yourself running out of food for the child(ren)?
3. Do you have any type of income?4. If already receiving any type of public benefits – TAFDC, SNAP SSI, housing
assistance: did you notify your case worker that you have a new baby?5. If no income: do you have any concerns about applying for public assistance?6. Are you up to date in the payment of your rent and utility bills? 7. If parent has older child or children: do you have affordable childcare? 8. Do you and your child(ren) and other family members have health
insurance? What type?9. Do you have enough food to adequately feed yourself and your family this
week?
Notes: TAFDC: Transitional Aid for Families with Dependent ChildrenSNAP: Food Stamps/Cash AssistanceSSI: Supplemental Security Income
Housing and Utilities Screening
“I know that affordable, healthy and safe housing is hard to come by.”1. Do you have your own apartment or do you share with other people?2. Have you informed the landlord about the baby? (only when living in
subsidized housing)3. Are you concerned about the safety or stability of your housing?4. Does your housing have any unhealthy conditions? (lead paint, mold, pests,
etc.)5. Is it hard to keep rodents, insects or mold away?6. Do you owe any money on your rent or utility bills?7. Do you have utility shut-off protection?8. Do you have a low income utilities discount?
Follow up on income support issues:• Do you have any income?• If you previously received public benefits, were those benefits increased
when the baby was born?• If you did not previously receive public benefits, have you applied?
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1. Ask the family about how it has been caring for the baby in the past few weeks, explain the well child visit and develop agenda of possible issues to discuss with the clinician.
2. Probing questions (the ones in bold are the important ones) a. Has there been any change in the baby’s eating? b. Who else takes care of the baby? How is that going? c. Who helps you when you need to take some time off? d. What do you do with your baby during the day (e.g., infant stimulation, language, patterns of family life)? e. What do you do to calm your baby? What do you do if that does not work?
3. During the well child visit:• Use the Four Month Checklist to ask about developmental accomplishments and concerns. • Use the evocative object to demonstrate reaching and grasping for objects.• Find out if the family and/or clinician have any developmental concerns that need an Early Intervention referral. Note: The Ages and Stages can be used as a
screening measure if there are concerns about development. 4. Perform Housing & Utilities Screening Checklist if it was not addressed at the prior visit. 5. Infuse brain messages into visit as appropriate: routines/repetition/practice, social smile, what babies like to do6. Follow up with the family about access to resources to which they were referred.7. Parent Feedback on previous handout: Did you use the handout? What was helpful about the handout?8. Give Four-Months Old handout: provides information on language development and ways to help baby’s healthy development, introduce the development
of emotions. Additionally, this handout provides information and links the family to community resources and provides information on healthy housing and utilities protection.
Four Month Visit
Between the Four Month and the Six Month visit FS will:1. Contact additional resources on which the family and the health care team have agreed.2. Follow up on referrals to income and housing resources.3. Contact MLP if needed.4. Make a follow-up call during the two months in between WCV: check in and remind the family about the next appointment.
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1. Ask the family about past weeks situation, explain the well child visit and develop agenda of possible issues to discuss with the clinician. 2. Probing questions:
• How are you doing? • Are there any changes or new stresses for you, the baby, and the family or in the neighborhood?• How would you describe your baby? • How does your baby act around other people?
3. During the well child visit, use the Six Month Checklist to ask about developmental accomplishments and concerns. Use the evocative object to demonstrate grasping and transferring hand-to-hand. Talk about child care needs and possible referrals.
4. Complete the six-month Ages and Stages Questionnaire. 5. Infuse brain messages into visit as appropriate: early literacy, object/person permanence, separation and stranger anxiety 6. Assess the need for extra help (e.g., social work, mental health, legal, or informal supports either through the practice or community). Also re-assess need
for Early Intervention referral.7. Check the status of the referrals to the resources needed by the family.8. Ask about safety at home (child-proofing home).9. Give the Six-Months Old handout: provides tips about play, language and motor skills. It introduces possible things to expect in the child development from
this point to 9- month well child visit. Additionally, this handout provides information about safety at home.10. Review both the baby’s and family’s progress.11. Explain what will happen next. 12. Solicit feedback from parent. The desired result of the last visit is in reality the desired result for the six-month DULCE intervention: Family concrete
needs met, family views health center as a place to get support for themselves and their families – beyond “getting shots” – and, where appropriate, family has made a connection with other elements of the early childhood system of care.
Six Month Visit
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A. PROBING QUESTIONS
Probing questions – the ones in Bold are priorities – create an opportunity for the family to tell the Family Specialist how things are going. They are open-ended questions designed to create teachable moments for the Family Specialist.
First Week Visit1. Tell me about the baby’s name. How did you choose the name?
2. When you need help with the baby, who helps you? Do you feel safe leaving the baby with that person?
3. How did the delivery go? How about the pregnancy?
4. What has it been like caring for the baby this first week?
5. What do your other children think about the new baby?
One Month Visit1. What has it been like caring for the baby in the past week? What
happens when your baby cries? What do you do? How do you feel?
2. What do you notice that your child can do?
3. What do you enjoy most about the baby? What worries you the most?
4. Are there any major changes in the family since the baby was born?
5. What are your plans for the next couple of months?
Two Month Visit1. Is this experience of having a baby what you expected? What has
been easier than you expected? What has been harder than you expected?
2. How much is the baby crying? What do you do to calm the baby?
3. Have there been any unexpected stresses, crises and/or illness in your family since the last visit?
4. What do you do when you are feeling stressed, tired, need a break?
5. Is it easy or difficult to know what your baby wants?
6. Have you been out of the house without the baby? What did you do?
Four Month Visit1. Has there been any change in the baby’s eating?
2. Who else takes care of the baby? How is that going?
3. Who helps you when you need to take some time off?
4. What do you do with your baby during the day (e.g., infant stimulation, language, patterns of family life)?
5. What do you do to calm your baby? What do you do if that does not work?
Six Month Visit1. How are you doing?
2. Are there any changes or new stresses for you, the baby, and the family or in the neighborhood?
3. How would you describe your baby?
4. How does your baby act around other people?
B. SCREENING QUESTIONS
Screening questions enable the Family Specialist to assess the family’s strengths and areas of concern. Answers to these questions will assist the Family Specialist in making referrals to your medical-legal partner or community resources. Communities replicating DULCE are strongly
Family Assessment Inquiries 5.
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encouraged to review, customize, and amend these screening questions to better reflect local conditions. For example, areas of documented need among different vulnerable family populations in your region/community, state and local laws that may be more or less protective of families than those in the Commonwealth of Massachusetts and the City of Boston (where DULCE was piloted), and community-based resources that vary in their accessibility.
Housing & Utilities Screening1. Do you have your own apartment or do you share with other
people?
2. Have you informed the landlord about the baby? (only when living in subsidized housing)
3. Are you concerned about the safety or stability of your housing?
4. Does your housing have any unhealthy conditions? (e.g., lead paint, mold, pests etc.)
5. Is it hard to keep rodents, insects or mold away?
6. Do you owe any money on your rent or utility bills?
7. Do you have utility shut-off protection?
8. Do you have a low income utilities discount?
Follow up on income supports issues:
1. Do you have any income?
2. If you previously received public benefits, were those benefits increased when the baby was born?
3. If you did not previously receive public benefits, did you apply for any?
Income & Nutrition Screening(Note: This screening needs to be done at the first meeting, if it is the First Week or One Month visit)
1. Do you have enough food to adequately feed your self and family this week?
2. What do you do when you find yourself running out of food for the child(ren)?
3. Do you have any type of income?
4. If already getting any type of public benefits such as TAFDC (Transitional Aid for Families with Dependent Children), SNAP (Supplemental Nutrition Assistance Program; may also be known as Food Stamps/Cash Assistance), SSI (Supplemental Security Income), and/or housing assistance: Did you notify your case worker that you have a new baby?
5. If no income: do you have any concerns about applying?
6. Are you up to date in the payment of your rent and utility bills?
7. If parent has older child or children: Do you have affordable childcare?
8. Do you and your child(ren) and other family members have health insurance? What type?
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9. Do you have enough food to adequately feed yourself and your family this week?
Interpersonal/Community ViolencePossible way to introduce and normalize issues of interpersonal and community violence:
“Because unfortunately violence is so common in our society, I have started asking all of my patients about it. I would like to ask you a few questions…”
1. Do you feel safe in your home and community?
2. How is conflict between adults usually settled in your home? (e.g., some people take a time out, some yell, some threaten or hit)
3. Are you currently receiving child support?
4. Have you ever considered or taken out a restraining order against someone in the past year?
5. Since the last time I saw your child, has anything really scary or upsetting happened to your child or anyone in your family? If there is a history of family violence, it is vital to assess the safety of the family now.
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APPENDICES
Child’s Name and DOB Family’s Name DULCE Case Number
DULCE ACTIVITY LOG
Date: Time starts: Time ends: Place or Telephone#: Agency involved: Who initiated the meeting or call: Name of participants:
Content of the conversation:
Plans and agreements:
Follow up date: Needs MLP triage: YES NO Needs to be referred: YES NO and where:
Date: Time starts: Time ends: Place or Telephone#: Agency involved: Who initiated the meeting or call: Name of participants:
Content of the conversation:
Plans and agreements:
Follow up date: Needs MLP triage: YES NO Needs to be referred: YES NO and where:
Date: Time starts: Time ends: Place or Telephone#: Agency involved: Who initiated the meeting or call: Name of participants:
Content of the conversation:
Plans and agreements:
Follow up date: Needs MLP triage: YES NO Needs to be referred: YES NO and where:
DULCE Family Specialist Signature
Date of Intake Child’s Name Family’s Name Pediatrician’s Name
DULCE Case # Child’s DOB Contact Phone # DULCE Family Specialist
DULCE FAMILY PROFILE
Child’s Information
*Child’s Full Name*Date of birth *Age at intake*Medical Record # *Medical Insurance*Race *Ethnicity*Languages Primary: Secondary:*Mailing Address*City/State/Zip Code*Contact Phone # 1. 2. *Emergency Phone # 1. 2.E-mails
Family Information
*Mother’s Full Name*Date of birth Educational levelCountry of birth Years in the U.S.
*Father’s Full Name*Date of birth Educational levelCountry of birth Years in the U.S.
*Sibling 1 Date of birth *Sibling 2 Date of birth *Sibling 3 Date of birth
*Extended family involved 1. 2.
*Family wants a home visit Yes No *Possible date
Who lives at home? And what other adults are supporting the family (genogram/ecogram optional)
* This information is meant to be gathered during the first intake. Only ask the information that is not available in the MedicalRecord. Confirm/update address and phone number.The rest of this form is intended to be completed during the rest of the well child visits. Avoid asking sensitive questions duringthe first intake unless clinically necessary (mother obviously distressed).
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Date of Intake Child’s Name Family’s Name Pediatrician’s Name
DULCE Case # Child’s DOB Contact Phone # DULCE Family Specialist
Additional Information and Future Plans
Income situation (family reports) No needs reported at intake Report needs at intake Receives/In process income support
Needs
Housing and utilities situation Own/renting private Renting subsidized Sharing with family Sharing with friends
Shelter Homeless Have utilities low income discount
Have shut-off protection
Family’s perception of Housing and utilities situation
Satisfied Unsatisfied (check problems below)
Looking to move Already in a waitlist Possible Eviction Difficulty paying rent Problem with landlord Prob. pests Prob. mold Prob. paying bills Safety problems Over crowded Prob. flood Not adequate for
health condition
Enrollment in public programs at intake (concrete supports) Yes No
Cash Assistance SSI WIC Section 8 Welfare Food Stamps Fuel Assistance Public Housing Childcare voucher Others Specify
Family Health problems
Family Mental Health information Family Educational challenges
Disabilities in the family
Family’s current work situation
Both parents work
Only father Only mother Neither
Mother’s future plans Stay at home Work Full Time Work Part Time Study
Father’s future plans Stay at home Work Full Time Work Part Time Study
Baby’s age at the time of employment/study
Possible caregiver/Child Care
Infant involved in other programs at the time of the intake Yes No
Specify
Infant developmental, social or emotional needs at the time of intake Yes No
Possible referrals
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FIRST WEEK VISIT CHECKLIST
1. Introduce DULCE model and trigger questions
a. Tell me about the baby’s name. How did you choose the name?b. When you need help with the baby, who helps you? Do you feel safe leavingthe baby with that person?c. How did the delivery go? How about the pregnancy?d. What has it been like caring for the baby this first week?e. What do your other children think about the new baby?
2. Development and relationship checklist (only check the ones that youobserved or are reported)
Responds to parent’s face and voice Focuses on and follows faces Cries when hungry or uncomfortable Brings hands to mouth Grasps your fingers Attempts to hold a up head when pulled to sit Moves all extremities Parent responds to infant cues Parent beginning to recognize hunger cries Parent can identify several ways to comfort infant Parent recognizes when infant is alert and ready for interaction
3. Other resources
Community violence conversation Evocative object. Use it to demonstrate baby’s visual tracking and following Offer a Home Visit Income screening Give Handout Provide your contact information to family Additional resources given
ONE MONTH VISIT CHECKLIST
1. Trigger questions
a. What are your plans for the next couple of months?b. What happens when your baby cries? What do you do? How do you feel?c. What do you notice that your child can do?d. What do you enjoy most about the baby? What worries you the most?e. Are there any major changes in the family since the baby was born?
2. Development and relationship checklist (only check the ones that youobserved or are reported)
Sleeps for 3-4 hours at a time Stays awake for one hour or more Tries to self-comfort by sucking on fingers Focuses on and follows faces Turns head in the direction of parent’s voice Focuses on and follows brightly colored toy Responds to sound by blinking, crying, quieting, startling, and changing respiration Parent and infant seem comfortable with feeding Parent uses face and voice to help infant focus or be comforted Parent recognizes and responds to infant’s cues Parent beginning to predict infant’s responses to environment Parent beginning to offer support during transitions Parent and infant beginning to establish routines
3. Other resources
Assess smoking if concerns or clues there is smoking in the home Sleeping and eating patterns Evocative object. Use it to demonstrate baby’s ability to track 180 degrees Offer a Home Visit Income screening/follow-up on discussion of income resources Give Handout Provide your contact information to family Additional resources given
TWO MONTH VISIT CHECKLIST
1. Trigger questions
a. Is this experience of having a baby what you expected? What has beeneasier than you expected? What has been harder than you expected?b. How much is the baby crying? What do you do to calm the baby?c. Had there been any unexpected stresses, crisis and/or illness in your familysince the last visit?d. What do you do when you are feeling stressed (tired, need a break)?e. Is it easy of difficult to know what your baby wants?f. Have you been out of the house without the baby? What did you do?
2. Development and relationship checklist (only check the ones that youobserved or are reported)
Makes eye contact Smiles when adult smiles Coos and vocalizes when talked to Shows interest and pleasure in interaction with caregivers Has some head control when held upright Coordinates head and eye movements Turns toward interesting toys: visual and auditory When placed on tummy, infant lifts head, neck, and chest with forearm support Parent uses face and voice to encourage social response from infant Parent responds to infant’s cues and shows awareness of infant’s distress Parent supports infant’s focus on interesting toys Parent and infant have established routines Parent can predict infant’s response to transitions/changes
3. Other resources
Screening for housing situation Sleeping and eating patterns Evocative object. Use it to demonstrate baby’s ability to follow visual items Offer a Home Visit Income screening/follow-up on discussion of income resources Give Handout Give tips on language development, social interactions and how infants learn Additional resources given
FOUR MONTH VISIT CHECKLIST
1. Trigger questions
a. Has there been any change in the baby’s eating?b. Who else takes care of the baby? How is that going?c. Who helps you when you need to take some time off?d. What do you do with your baby during the day (infant stimulation, language,patterns of family life)?e. What do you do to calm your baby? What do you do if that does not work?(Introduce the concept of temperament and complete the Healthy Steps Temperament Scale)
2. Development and relationship checklist (only check the ones that youobserved or are reported)
Smiles, laughs, and squeals Babbles, coos, blows bubbles, makes raspberries Uses vowel and consonant sounds for example: “dada” “baba” Demonstrates range of affect, spontaneous smile Uses palm and fingers to grasp toys; bats at mobile Reaches for and explores toys with fingers and mouth Rolls from tummy to back Sits with support Bears some weight on feet when held upright May appear easily distracted and less interested in feeding due to excitement in discovery of outside world Parent uses face and voice to encourage social response from infant Parent responds to infant’s vocalizations; infant recognizes parent’ voice Parent recognizes and responds to infant’s facial expressions Parent initiates play with infant Parent encourages play with toys Parent has incorporated play as a daily routine Parent has techniques to support infant during difficult transitions
3. Other resources
Screening for housing situation or follow-up if addressed in previous visit Use of Ages and Stages to assess if concerns about development Referral to Early Intervention Evocative object: Use it to demonstrate baby’s ability to reach and grasp Provide information on language development and development of emotions Offer a Home Visit
Give Handout Additional resources given
SIX MONTH VISIT CHECKLIST
1. Trigger questions
a. How are you doing?b. Are there any new stresses or changes for you, the baby, and the family or in
the neighborhood?c. How would you describe your baby?d. How does your baby act around other people?
2. Development and relationship checklist (only check the ones that youobserved or are reported)
Sits with support; without support for a short time Creeps or scoots on her bottom Rolls over Reaches to grasp and explores toys Transfers objects from hand to hand Uses hand to rake small objects Shakes, bangs, and drops objects Imitates razzing noise and uses consonant-vowel combinations Points finger or shakes head to indicate need Understands simple phrases (“bye-bye”) Self-comforts Shows caution with strangers Parent responds to infant’s expressed needs; infant is responsive Parent initiates familiar games Parent encourages infant’s vocal imitation; infant babbles reciprocally Parent puts infant on the floor to play and plays with infant on the floor Parent expands play with infant Parent recognizes when infant is over-stimulated
3. Other resources
Complete 6 month Ages and Stages Assess need for referral to LAUNCH, other intensive program or Early Intervention Check status of referrals made to resources needed by the family As about safety at home. Discuss child proofing Evocative object: Use it to demonstrate baby’s ability grasp, roll or creep to reach a desired object Provide tips on play, language and motor skills
Provide anticipatory guidance on what to expect in development until 9m visit Give Handout Additional resources given
INCOME SCREENING CHECKLIST
(Note: This screening has to be done at the first meeting; either if it is the First Week or One Month visit.)
“In these challenging economic times, many families are struggling to put food on the table or to pay the rent or utilities.”
1. Do you have enough food to adequately feed yourself and your family thisweek?
2. What do you do when you find yourself running out of food for thechild(ren)?
3. Do you have any type of income?
4. If already getting any types of public benefits – TAFDC, SNAP SSI, housingassistance: did you notify your case worker that you have a new baby?
5. If no income: do you have any concerns about applying?
6. Are you up to date in the payment of your rent and utility bills?
7. If parent has older child or children: do you have affordable childcare?
8. Do you and your child(ren) and other family members have healthinsurance? What type?
9. Do you have enough food to adequately feed yourself and your family thisweek?
Notes: TAFDC: Transitional Aid for Families with Dependent Children SNAP: Food Stamps/Cash Assistance SSI: Supplemental Security Income
HOUSING & UTILITIES SCREENING CHECKLIST
“I know that affordable, healthy and safe housing is hard to come by.”
1. Do you have your own apartment or do you share with other people?
2. Have you informed the landlord about the baby? (only when living insubsidized housing)
3. Are you concerned about the safety or stability of your housing?
4. Does your housing have any unhealthy conditions? (lead paint, mold, pestsetc.)
5. Is it hard to keep rodents, insects or mold away?
6. Do you owe any money on your rent or utility bills?
7. Do you have utility shut-off protection?
8. Do you have a low income utilities discount?
Follow up on income supports issues:
1. Do you have any income?
2. If you previously received public benefits, were those benefits increasedwhen the baby born?
3. If you did not previously receive public benefits, did you apply for any?
44 DULCE Manual
First Weeks New babies sleep for 16 - 17 hours a day. Try taking a nap or
resting when your baby is sleeping.
Babies tell you they are hungry by: smacking their lips, turning
their heads to find the nipple, becoming fussy and crying.
New babies can see about 8 -12 inches, the distance between the
baby and mom’s face while feeding. This is a good time to talk to,
touch and make eye contact with your baby. Your baby may stop
sucking briefly to look at you and listen to your voice.
You may feel tired and stressed. Maybe someone can help you
with: burping, changing diapers, cooking, or even just letting you
talk about how you are feeling.
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Your baby is able to pay
attention to people and sounds –
this grows every day!
MOST BABIES ARE BORN
ABLE TO HEAR, SEE,
SMELL, AND FEEL THE
PEOPLE AND THINGS
THAT ARE CLOSE BY.
It’s all about sleeping and eating
45DULCE Manual
F i r s t W e e k s
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Crying: This is how babies talk Babies cry when they are tired, hungry, hot or cold, need a diaper
change, are over stimulated. Sometimes, just because! It may not be easy to figure out, but over time you will learn more about
what works for your baby. You need time to get to know each other! It’s like meeting someone new.
What to do: Calmly hold your baby close to your shoulder or chest, or you can
swaddle (wrap) your baby in a blanket. It’s like the womb – warm and close.
Quietly sing, hum or talk to your baby, or softly play calm music. Gently rock your baby or go for a quiet walk.
After you have tried everything that usually works, it’s OK to place your baby, face up, in the crib and give yourself time to calm down.
Reach out to family and friends.�Try to find other new moms who live nearby – you will all have
something to talk about!
FOR MORE INFORMATIONCALL YOUR PEDIATRICIAN(888)555-1212
DULCE FAMILY SPECIALIST(555)543-5432
How does your baby let you know it’s time to eat?
What works to comfort your baby?
Public benefits for families with a new baby Babies cry when they are tired, hungry, hot or cold, need a diaper
change, are over stimulated. Sometimes, just because! It may not be easy to figure out, but over time you will learn more about
what works for your baby. You need time to get to know each other! It’s like meeting someone new.
What to do: Calmly hold your baby close to your shoulder or chest, or you can
swaddle (wrap) your baby in a blanket. It’s like the womb – warm and close.
Quietly sing, hum or talk to your baby, or softly play calm music. Gently rock your baby or go for a quiet walk.
After you have tried everything that usually works, it’s OK to place your baby, face up, in the crib and give yourself time to calm down.
Reach out to family and friends.�Try to find other new moms who live nearby – you will all have
something to talk about!
555-543-5432
By the next well child visit, many babies are able to:
Bring their hands to their mouth
Hold their heads up longer
Move their arms and legs more
Sleep longer... stay awake longer –
enjoy this time!
46 DULCE Manual
One Month Old It’s normal to feel worried and stressed. It’s even normal to feel
that you may not be a good parent.
Trust yourself. You know more than you think.
After giving birth, it is normal to be tired, upset with others,
restless, worried or sad. It’s due to the changes your body went
through while pregnant and giving birth.
Talk with a friend or family member. Take a walk, watch your
favorite TV show, or listen to music. Do what you enjoy and what
makes you feel happy. Get help from others.
1575 EYE STREET, NW, STE 500 | WASHINGTON, DC 20005 | WWW.CSSP.ORG
By now, most babies:
Comfort themselves by
sucking on their fingers
Respond to sounds by
blinking their eyes, crying,
becoming quiet, or changing
how they breathe
WATCH HOW YOUR BABY:
SEES AND FOLLOWS
BRIGHTLY COLORED TOYS
FOLLOWS FACES AND
SOUNDS – MOSTLY YOUR
VOICE!
Changes in your life
47DULCE Manual
O n e M o n t h O l d
tel 5432 Any Street West, Townsville, ST 54321 555-543-5432 fax www.yourwebsitehere.com
Babies need parents who also take care of themselves
If being sad and tired continues for more than a few weeks, if there are
big changes in your eating or sleeping habits, or if you lose interest
in things that you enjoyed in the past, talk with a trusted health care
clinician or your family specialist.
FOR MORE INFORMATIONCALL YOUR PEDIATRICIAN(888)555-1212
DULCE FAMILY SPECIALIST(555)543-5432
How does your baby let you know it’s time to eat?
How does your baby let you know what is needed?
Get to know your baby Little by little you will get to know what your baby is telling you.
Some babies rub their eyes, pull their ears, or look away when
tired. Others may cry and fuss when a diaper needs changing.
Calmly talk or sing and look your baby in the eye. Pick up and hold
your baby often.
When your baby is safe and cared for, your baby feels secure and
loved.
555-543-5432
Babies’ brains grow better when they feel secure, loved and basic needs are met.
My baby does not stop crying?
Even long-time parents have a hard time.
After 6 to 12 weeks, babies should start to cry less.
If rocking, singing, the pacifier and blanket do not
work:
Gently hold your baby.
Try peaceful sounds like talking or singing. Other
babies may want less light and more quiet.
Take a break. Ask family and friends to help.
Stay calm, even if it is difficult. This helps your
baby to stay calm. If you are getting angry and
stressed, it’s OK to put your baby in a crib, or
other safe place, and take a 5-minute break.
Public benefits for families with a new baby A safe home, access to healthy food and community support are
great ways to give your baby a good start in life.
Your eligibility for many types of public benefits may change with
the birth of a child.
Even working families can get help from the Supplemental Nutrition
Assistance Program (SNAP), known as Food Stamps in the past.
Parents caring for a child with disabilities may be able to get
disability benefits.
Undocumented parents may apply for benefits for their citizen
children.
Some legal immigrants can receive public benefits.
If people are denied public benefits, they can ask for a hearing and
bring an advocate.
By the next well child visit, many babies are able to: Make eye contact and have some head control Smile when smiled at Coo and make sounds when talked to Look and wiggle at others Lift head, neck and chest when placed on their tummy
48 DULCE Manual
Two Months Old A baby’s first smile may even help parents forget how tired
they are.
Babies love to hear voices and see faces and colors.
Your baby sees and will do what you do – so keep smiling!
Things to do with your baby Talk about things with color, sound and motion.
Explain what you are doing as you change, bathe, dress and feed
your baby.
Make silly faces – your baby will soon copy you.
1575 EYE STREET, NW, STE 500 | WASHINGTON, DC 20005 | WWW.CSSP.ORG
By now, most babies:
Recognize familiar faces,
sounds and words
Follow you with their eyes
Hold their head up
Coo or make sounds when
you talk to them
Celebrate your baby’s first smile
49DULCE Manual
T w o M o n t h s O l d
tel 5432 Any Street West, Townsville, ST 54321 555-543-5432 fax www.yourwebsitehere.com
Babies learn a lot at this age
Babies notice everything. Talk and play with your baby when you read. You are teaching your
baby how to talk and how to relate to the world around them. Watch how your baby acts when you make a face or change your
voice.
Repeat things over and over again – that’s how babies learn.
FOR MORE INFORMATIONCALL YOUR PEDIATRICIAN(888)555-1212
DULCE FAMILY SPECIALIST(555)543-5432
What are some new things your baby has learned?
What do I do when my baby does not stop crying?
Sleeping and eating Now, babies sleep more at night. Enjoy the extra sleep!
Before you go to bed, try to wake your baby up to eat. You both
might get more sleep.
With more time between eating, how does your baby tell you it is
time to eat?
555-543-5432
Safe & healthy homes give babies a good start in life
Help is available for families who have problems
with lead paint, mold, roaches, and rats.
To increase your chances of getting housing
assistance, apply to local and state-wide housing
programs both in and around your community.
By law a tenant cannot be evicted by a landlord
without a court decision.
There may be some help available with home heating
costs for low-income families.
Low-income households that include an infant, elder,
or a person with a serious or chronic illness have the
right to heat and electricity all year long. To qualify,
a financial hardship form and letter from your doctor
must be submitted.
All low-income households have the right to heat
during the winter. A financial hardship form must be
submitted.
If you have any questions, ask your DULCE family
specialist for help.
By the next well child visit, many babies are able to: Laugh and play games like peek-a-boo Reach out to explore your face and their toys Maybe, roll over!
Returning to work or school
If being sad and tired continues for more than a few weeks, if there are big changes in your eating or sleeping habits, or if you lose interest in things that you enjoyed in the past, talk with a trusted health care clinician or your family specialist.
NAME
PHONE
NAME
PHONE
Who helps you with your baby?
50 DULCE Manual
Four Months Old
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By now, most babies:
Smile, babble, coo and laugh
Know familiar people –
especially you!
Play some games
Reach for things and roll
over from tummy to back
Babies are learning so much Have fun with your baby every day. When you play together, your
baby is learning many new things.
When upset, does your baby calm down without your help?
Sometimes, just hearing your voice or seeing your smile can calm
your baby.
When babies begin to roll over, be careful not to leave them alone
on a bed or couch.
REMEMBER – Take care of yourselfBeing a parent takes a lot of energy. Let people know when you need help.
Reach out to people in your community.
Join a parent group.
Ask your local community center, place of worship, health center,
or childcare center if they offer a group.
Ask your DULCE family specialist for help finding a group.
51DULCE Manual
F o u r M o n t h s O l d
tel 5432 Any Street West, Townsville, ST 54321 555-543-5432 fax www.yourwebsitehere.com
What is your baby feeling?
Babies are starting to express feelings like happy, sad and mad. When you see these feelings, you can teach them about feelings by asking: “Did that make you happy?” “Are you sad?” “Are you glad we are at the park?” “What are you mad about?” “Why are you so upset?”
Of course babies are not talking yet. But hearing these words will help them express feelings when they do start to talk.
FOR MORE INFORMATIONCALL YOUR PEDIATRICIAN(888)555-1212
DULCE FAMILY SPECIALIST(555)543-5432
New things to do...
Have fun while your baby is learning Read books, sing songs, play peek-a-boo. Babies learn by doing
the same thing over and over again. When babies laugh, they are
saying, “I remember this!”
Put your baby in front of a mirror and smile! How many funny faces
can you both make?
Place a toy in front of your baby. Does your baby reach out and
grab it? If not, place the toy in your baby’s hand – your baby will
quickly learn how to hold it.
555-543-5432
Safe & healthy homes give babies a good start in life
Help is available for families who have problems
with lead paint, mold, roaches, and rats.
To increase your chances of getting housing
assistance, apply to local and state-wide housing
programs both in and around your community.
By law a tenant cannot be evicted by a landlord
without a court decision.
There may be some help available with home heating
costs for low-income families.
Low-income households that include an infant, elder,
or a person with a serious or chronic illness have the
right to heat and electricity all year long. To qualify,
a financial hardship form and letter from your doctor
must be submitted.
All low-income households have the right to heat
during the winter. A financial hardship form must be
submitted.
If you have any questions, ask your DULCE family
specialist for help.
By the next well child visit, many babies are able to: Babble and may even say: da-da, ma-ma, ba-ba Grab things on their own Roll over and may even sit with support
Places to go
Go to the park, a playgroup, library story time, or a “mommy & me” group. Ask your pediatrician, DULCE family specialist and others about different family activities in and around your community.
...with your baby ...to take care of yourself
Helpful hint about food: talk with your doctor about introducing solid foods.
Trust yourself – you are the expert on your child!
52 DULCE Manual
Six Months Old
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By now, most babies:
Sit with support – may even
sit with no support for a short
time
Respond to sounds by
blinking their eyes, crying,
becoming quiet, or changing
how they breathe
Roll over
Reach and grab toys
Pass things from one hand to
the other
Copy sounds and put
different sounds together like
pa, ma, and da
Point with their fingers
Playing is how babies learn Babies learn by touching, tasting, and throwing everything they
can!
Roll a ball back and forth between you and your baby – you are
teaching your baby about taking turns!
When you are having fun, so is your baby. But your baby is also
learning many new things!
How does your baby play and learn?
53DULCE Manual
S i x M o n t h s O l d
tel 5432 Any Street West, Townsville, ST 54321 555-543-5432 fax www.yourwebsitehere.com
Learning to talk
Babies now babble more: ba-ba, ma-ma and da-da. This is how they learn to talk. Listen for new sounds and repeat them back. Take turns “talking” –
a lot of fun for your baby. Teach new words. When sharing a book, point to pictures and say
out loud what you are pointing to. Have fun watching your baby try to say these new sounds and words!
Tell your baby what you are doing as you change a diaper, give a bath, and feed your baby.
Your baby may not talk back – that’s OK. Just hearing you talk is how you teach your baby.
FOR MORE INFORMATIONCALL YOUR PEDIATRICIAN(888)555-1212
DULCE FAMILY SPECIALIST(555)543-5432
What new things does your baby do?
Babies love to explore Soon your baby will sit without help and start to crawl.
Babies move very quickly and get to things like hot coffee! Now is
the time to “child-proof” your home to keep your baby safe.
Use stair gates and window guards.
Get down on the floor with your baby. What does the world look
like from there? Are there dangerous objects that need to be moved?
Babies grab everything: cords, plastic bags, balloons – you name it!
Remove things that can hurt your baby – the things that fit into your
baby’s mouth.
555-543-5432
By the next well child visit, many babies are able to: Crawl and may even pull themselves up Play games like peek-a-boo Put more sounds together Tell the difference between people they know and people theydon’t know Wave bye-bye
Use your village
Include family and friends in activities with you and your child.
If your child is in childcare, try to meet other parents there.
If your child is not in childcare, try to meet other children and parents at:A parkPlay groups at a community center or YMCAStorytime at the library
Who are some other parents you can get support from?
Food Source Hotline
Code Violations
Domestic Violence HotlineEnergy Assistance
Child Care Referral
Adult Literacy Hotline
Food Stamps Eligibility
Resources for you and your baby
54 DULCE Manual
APPENDIX EDULCE Weekly Case ConferenceSample Agenda
PurposeProvide support for the Family Specialist by:
1. Discussing all of the cases seen during the past week and to plan for the next week’s visits
2. Support, as needed, for more urgent patient needs
TimeEstimate of 1 to 2 hours
ParticipantsDULCE Clinical Team (medical champion, mental health professional, family specialist and medical-legal partnership liaison); practice administrator as needed
Case Presentations• Background information: family history, facts about pregnancy/
delivery, narrative of baby’s arrival to family, discussed in a way to ensure the protection of family confidentiality
• Current family situation: personal, family/community resources, child development, assessed child and family’s needs, presenting problem(s), and history of the presenting problem(s)
• Services provided to child and family• Other services needed (if too many, how to prioritize these
services)• Questions to discuss with the team
55DULCE Manual
APPENDIX FSuggested Areas for the Mental Health Provider to Address During Routine Supervision Meetings with Family Specialist
• Number of families seen since last meeting• Number of families in crisis and reason for crisis• Invite in-depth sharing of details about a particular situation,
infant, parent, their interactions, strengths, concerns• Create awareness of the multiple perspectives of the infant, family
and fellow practitioners • Explore the emotional experiences being described when
discussing the case or response to the work
The Center for the Study of Social Policy (CSSP) works to secure equal opportunities and better futures for all children and families, especially those most often left behind. Underlying all of the work is a vision of child, family and community well-being which serves as a unifying framework for the many policy, systems reform, and community change activities in which CSSP engages.
Center for the Study of Social Policy
1575 Eye Street, Suite 500 Washington, DC 20005 202.371.1565 telephone
50 Broadway, Suite 1504 New York, NY 10004 212.979.2369 telephone
1000 N. Alameda Street, Suite 102 Los Angeles, CA 90012 213.617.0585 telephone
Published March 2016
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