February 2011

Beyond Medical Care:

An Integrated, Prevention-Oriented Child Health

System

Debbie I. Chang, MPH

Vice President, Policy & Prevention

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What is Nemours? Operating foundation dedicated to children's health & health

care

Integrated health system with a continuum of care including:– Clinical treatment– Health promotion and prevention services, including community-based– Research– Education– Policy and advocacy

Alfred I. duPont Hospital for Children and outpatient facilities in the Delaware Valley

Specialty care services in Northern/Central Florida; building new state-of-the-art Children’s Hospital near Orlando

Nemours Health and Prevention Services

In 2003, Nemours redefined its approach to address health as well as health care.

NHPS focuses on child health promotion & disease prevention to address root causes of health problems.– First initiative is preventing childhood obesity

NHPS complements and expands the reach of clinicians by providing a broader, community-based perspective.

NHPS target population includes all 228,000 children in Delaware as compared to the 50,000 children who use the Nemours pediatric care system.

The Current System

Many of our children’s programs were designed decades ago to treat infectious disease; they are not fully capable of addressing current threats such as:– Obesity– Chronic diseases– Mental illness

Our existing children’s system is:– Highly fragmented– Highly complex for families, providers and administrators– Financed by multiple public and private categorical funding

streams that perpetuate silos in the system

A Comprehensive Approach

Numerous reports suggest that health care alone is not sufficient to promote healthy child development.– Child health and well-being are influenced by multiple factors.

A comprehensive approach is needed that integrates and coordinates across health, education and human services

This comprehensive approach should consider:– The health and well-being of the whole child including the child’s

physical environment and social service needs; and– The child’s needs over the long-term

Critical Components of an Integrated Health System That Can Address Public Health Needs

1.Oriented toward health and address social determinants of health

2.Fosters health promotion and disease prevention at individual and population level

3.Incorporates public health, health care, and public and private sector

4.Inclusive of the unique expertise of partners including those not traditionally associated with health

5.Continuously measures and improving the health outcomes

6.Built on key health system capabilities, including a electronic medical records; appropriate mix of health professionals; and flexible, sustainable financing.

Source: The Commonwealth Fund, June/July 2009

Promoting Health and Prevention

Traditional Medical Model

Rigid adherence to biomedical view of health

Focused primarily on acute episodic illness

Focus on Individuals

Cure as uncompromised goal

Focus on disease

Expanded Approach

Incorporate a multifaceted view of healthChronic disease prevention and managementFocus on communities/ populations

Prevention as a primary goal

Focus on health

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Nemours Continuum of Care: Childhood Obesity Example

Community, environmental supports, policies, etc. for healthy lifestyles

Community services

Primary care prevention, early id and

management of at risk and less complex

cases

Inpatient services including surgery

Medical management of complicated

patients

Health Promotion and Prevention Services

Primary Care Practices

Specialty Outpatient and Inpatient Diagnostic and Treatment Services

Concept – Integrated Health System

Source: Hassink, Werk, June 2008

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What does a System Committed to Prevention Look Like?

A prevention-oriented child health system builds upon, and extends beyond, traditional prevention in primary care to look at the population level

Strategy makes use of socio-ecological model, looks beyond the individual to examine a range of other factors that affect health outcomes at multiple levels

Spreading policy and practice changes:– Population health-focused model: Defined program goals around reducing prevalence of

overweight and obesity– Strategies in multiple sectors: Exposure to consistent healthy choices/environments for

behavior change, all around 5-2-1-Almost None prescription– Strategic partnerships: Greatest potential impact, authority to make policy and practice

changes, ability to leverage resources– Knowledge mobilization: Providing evidence-based materials and tools– Social marketing: Creating and accelerating social policy and behavior changes

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The Model: Working with Over 200 Community Partners

Changing the health status and well-being of the most children possible through the deployment of evidence based policies and practices. Seeking the highest sustainable impact with the most efficient use of resources.

Policy and Practice Change Agenda

Community Infrastructure

Behavior Change

Healthy Children

to build and sustain

that supportsthat leads to

that evidence the usefulness of

Policy and Practice Change Agenda

Community Capacity

Behavior Change

Healthy Children

to build and sustain the

that supportthat leads to

that evidence the usefulness of

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Going to Where the Children Are With 5-2-1-Almost None

Together We Can Make Delaware’s Kids the Healthiest in the Nation– Kids Can’t Do It Alone– 5-2-1-Almost None

Integrated into all 4 sectors– Community– School– Child Care– Primary Care

– Helping accelerate policy and practice changes

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360o of Child Health Promotion

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Progress Results at the Population Level Results from the 2008 DSCH, compared to the 2006 DSCH, suggest that the

prevalence of overweight and obesity has leveled off for children ages 2 -17 years in Delaware

– Overweight remained unchanged at 17%

Evidence indicates the prevalence of obesity and overweight has leveled off in all Delaware counties and within subpopulations

Disparities still remain among racial groups

Nemours’ initiative is on track to achieve its 2015 goal for some populations

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School Sector Interventions

Strengthened and implemented wellness policies

– Impact: 90,180 children per year (2006-present) Learning Collaborative

– Impact: 90,180 children per year (2007-present)– Provide assistance with the implementation of

wellness policies (goals, action plans) and HB 471– Tools, training, technical assistance

Implemented HB 372: FITNESSGRAM®– Impact: 30,000 children (2006-present)– Assessment of fitness measured in grades 4, 7,9– BMI data optional by school

Implemented HB 471: 150 minutes of physical education/activity

– Impact: 26,112 children– Pilot from 2007-2009

Implementation of CATCH in elementary/middle/charter – Impact: 43,213 children (2005-present)

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Statewide regulatory change– Impact 54,000 children (2007-present)– Reduce sedentary behavior, promote health eating/physica activity– Child and Adult Care Food Program (CACFP)– Office of Child Care Licensing (OCCL)

Learning collaborative– Impact 2,750 children (2008-2009)– Translate policy into practice and support implementation

Training around Healthy Habits for Life (HHFL), CACFP– Impact 20,000 HHFL children/ 24,000 CACFP children (2007-present)

Child care technical assistance pilot program– Impact 775 children (2006-2008)

University of Delaware’s Institute for Excellence in Early Childhood– Impact to be determined; up to 54,000 children (2010-future)– Continue learning collaborative

Child Care Interventions

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Implementation of Expert Committee Recommendations on assessment, prevention, and treatment of childhood overweight

– Impact 207,000 children (2007-present)– Used by primary care providers, DE AAP, Medical Society of Delaware, Delaware

Academy of Family Physicians

Learning collaborative– Impact to be determined; up to 33,000 children (2010-future)– Provide tools, training, technical assistance for the implementation of Expert Committee

Recommendations

Nemours primary care strategy– Impact 50,000 children (2008-present)– Measuring BMI, identification of childhood

overweight, counseling on healthy lifestyles

Primary Care Interventions

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Commitments from medical community to promote the Expert Committee Recommendations

Prevention and health promotion built into Nemours Electronic Medical Record (EMR)– Nemours’ provider classification of BMI during well child visits doubled,

49% (2007) to 94% (2008) – Nemours’ providers offer lifestyle counseling to 95% of all patients

(almost double the national reported rate of 54.5%)

Delaware Primary Care Quality Improvement Initiative 19 multidisciplinary primary care teams achieved high results:– 98.2% of providers classified BMI or weight-for-length in 2009 (83% in 2007)– 88.6% of providers provided counseling on healthy lifestyles in 2009 (72.7% in 2007)– 88.1% of providers developed a care plan and family-management goals with

obese/overweight patients who were ready to change in 2009 (74.2% in 2007)

Primary Care Results

Key Principles

• Comprehensive, integrated systems for children are guided by the following principles:– Focus on child well-being outcomes and intervene early to prevent problems;– Coordination of programs and connection of services so that program silos are

eliminated and children are better served;– Reach children where they live, learn and play; and– Acknowledge that infrastructure and systems development are essential

elements of a comprehensive children’s system.

Debbie I. Chang, MPH

Vice President of Policy and PreventionNemours

252 Chapman Road, Christiana Building, Suite 200, Newark, DE 19702

(p) 302.444.9127 (e) dchang@nemours.org