The Early Learning Challenge in North Carolina

January 23, 2014

Marshall Tyson, MPH

NC Division of Public Health

Oscar Fleming, MSPH

National Implementation Research Network

Jeannine Sato

Center for Child and Family Health

NC Early Childhood Advisory Council

Race to the Top--Early Learning Challenge (ELC) Grant Program

Joint programUS Dept. of Health and Human ServicesUS Dept. of Education

37 applicants; 9 states selected, including NC

NC’s award: $69,991,121.00

4-year grants—Jan. 1, 2012–Dec. 31, 2015

NC Early Childhood Advisory Council

ELC Focus Bold action to improve

early learning and development

Supports states that demonstrate “commitment and capacity to build a statewide system that raises the quality of early learning and development programs so that all children receive

the support they need to enter kindergarten ready to succeed.”

NC Early Childhood Advisory Council

NC’s Implementation Strategy

Lead Agency: Early Childhood Advisory Council—responsible for overall coordination and specific projects

Participating State Agencies—responsible for specific projects:Division of Child Development and Early EducationDivision of Public Health Department of Public Instruction, Office of Early Learning

Contracts and MOUs with other state and local agencies and organizations, such as NC Partnership for Children and the National Implementation Research Network, FPG, UNC-CH

NC Early Childhood Advisory Council

NC’s Plan: Four Areas of Focus

Strengthen the state’s early childhood system and build its capacity to foster positive outcomes for young children

Enhance the quality of programs to serve young children and their families and improve access to high-quality programs

Strengthen the early childhood workforce to increase staff and system effectiveness and sustain change

Target high-intensity supports and community infrastructure-building efforts to turn around poor outcomes for young children in the state’s highest-need counties (Transformation Zone)

NC Early Childhood Advisory Council

NC’s Plan: Transformation Zone Strategy• Focus intensive effort in selected high-need

counties in northeastern North Carolina

• Increase capacity for effective collaboration and implementation to gain desired and sustainable results

• Provide comprehensive set of services and supports offered when and where needed—existing services and selected additional services (e.g., Family Strengthening services)

NC Early Childhood Advisory Council

NC’s Plan: Transformation Zone Strategy• Help achieve dramatically improved

outcomes for all young children

• Lessons learned through concentrated approach used to hone early childhood strategies improve outcomes for young children

across the state

NC Early Childhood Advisory Council

NC’s Transformation Zone

• 17 northeastern Tier 1 counties eligible

• After exploration and RFA process, 4 counties selected: Beaufort Bertie

Chowan Hyde

NC Early Childhood Advisory Council

GASTONCHEROKEE

SWAIN

MACON

GRAHAM

CLAY

JACK-SON

HAY-WOOD

HENDER-SONTRAN-

SYLVANIAPOLK

RUTHER-FORD

BUN-COMBE

YAN-CEYMADISON

MITCHELLAVERY

CLEVE-LAND

LINCOLN

CATAWBABURKE

MECKLEN-BURG

UNION

CABARRUS

ROWAN

IREDELL

STANLY

DAVID-SON

MONT-GOMERY

RANDOLPH

MOORE

ANSONRICH-MOND

HOKE

CHATHAM

LEEHARNETT

CUMBER-LAND

ROBESON

SCOT-LAND

BLADEN

SAMPSON

COLUMBUS

BRUNSWICK

NEWHANOVER

PENDER

ALA-MANCE

ORANGE

DURHAM

CASWELLPERSONGRAN-VILLE

VANCEWARREN

FRANKLIN

WAKE

NASH

JOHNSTONWAYNE

DUPLIN

GREENE

LENOIR

PITT

JONES

ONSLOW CARTERET

PAM-LICO

BEAU-FORT

CRAVEN

HYDE

DARETYRELLWASH-INGTON

BERTIE

MARTIN

PASQUO-TANK

HERT-FORD

CHO-WAN

CAM-DEN

PER-QUIMANS

CURRITUCKNORTH-AMPTON

GATES

HALIFAX

EDGE-COMBE

ROCKING-HAM

STOKESSURRY

FORSYTHGUILFORDYADKIN

DAVIE

ASHE

WATAUGA WILKES

ALLE-GHANY

CALDWELLALEX-ANDER

McDowell WILSON

Three streams of work in Northeast• Statewide projects• Transformation Zone projects and activities (4

counties)• Additional work in 15 surrounding counties

13 counties which were eligible through the grant Nash and Pitt--closely linked to those 13 counties;

home to many services

NC’s Transformation Zone

Division of Public Health

projects

Family strengthening Family Connects Triple P (Positive Parenting Program)

NC Early Childhood Advisory Council

Family Connects(A.k.a. NorthEast

Connects

Family Connects

Oscar FlemingUse of implementation science

principles

Jeannine SatoReplicating the Durham Connects

model as Family Connects in the TZ

NC Early Childhood Advisory Council

State Health Directors Conference

January 23rd, 2014

Applied Implementation

Science

Oscar Fleming

National Implementation Research Network

FPG Child Development Institute

University of North Carolina at Chapel Hill

An Overview of the Active Implementation Frameworks

Agenda

• Introduction/Purpose

• Why Focus on Implementation? (5)

• What are the Active Implementation Frameworks (15)

• Fidelity and Outcomes

Why Focus on Implementation?

RESEARCH PRACTICE

Active Implementation is defined as a specified set of activities designed to put into practice an activity or program of known dimensions.

IMPLEMENTATION

“Children and families cannot benefit from interventions they do not experience.”

EffectiveInterventions

EffectiveImplementation

EnablingContexts

Socially SignificantOutcomes

Formula For Success

Applied Implementation Science

To effectively implement & realize the benefit of evidence-based and evidence-informed interventions, we need to know:• WHAT to do What is the usable intervention or package of

strategies? (e.g. evidence-based home visitation programs)

• HOW to do it Active and effective implementation and sustainability frameworks (e.g. strategies build competencies and create enabling contexts and conditions)

• WHO will do it Organized, purposeful, & active implementation support from linked implementation teams

Active Implementation

Active Implementation

Frameworks: The “What”

The effective interventions and approaches that will improve outcomes for children, youth and families.

Clear description of the programPhilosophy, values, principles (guidance)

Inclusion – exclusion criteria (beneficiaries)

Clear essential functions that define the program (core components)

Operational definitions of essential functions (practice profiles; do, say)

Practical performance assessmentHighly correlated with desired outcomes

Usable Intervention Criteria

Making It HappenActive Implementation Frameworks: The “How”

• Implementation Drivers result in competence and sustainability

• Improvement cycles support learning and change at multiple levels

• Stage-related work necessary for successful change

Implementation Drivers

Performance Assessment (Fidelity)

Coaching

Training

Selection

Integrated & Compensatory

Systems Intervention

Facilitative Administration

Decision Support Data System

AdaptiveTechnical

Com

pete

ncy

Driv

ers O

rganization Drivers

Leadership Drivers

Consistent Uses of Innovations

Reliable Benefits

Integrated & Compensatory

Rapid cycle (PDSA) problem solving

Shewhart (1931); Deming (1986)

Usability testing Rubin (1994); Nielsen (2000)

Practice-policy communication loop

Fixsen, Blase, Metz, & Van Dyke (2013)

Improvement Cycles

Implementation Stages

Exploration InstallationInitial

ImplementationFull

Implementation

2-4 Years

• Assess needs• Examine

intervention components

• Consider Implementation Drivers

• Assess fit

• Acquire Resources

• Prepare Organization

• Prepare Implementation Drivers

• Prepare staff

• StrengthenImplementation Drivers

• Manage change• Activate Data

Systems• Initiate

Improvement Cycles

• Monitor & manage Implementation Drivers

• Achieve and improve Fidelity and Outcomes

Implementation Teams with specific competencies “make it happen”

Minimum of three people with expertise in:

Innovations

Implementation

Improvement Cycles

Organization change

Active Implementation Frameworks: The

“Who”

• Why Teams?–Letting it happen

• Diffusion; networking; communication

–Helping it happen• Dissemination; manuals; websites

–Making it happen• Purposeful and proactive use of implementation practice and science

Based on Hall & Hord (1987); Greenhalgh, Robert, MacFarlane, Bate, & Kyriakidou (2004); Fixsen, Blase, Duda, Naoom, & Van Dyke (2010)

Implementation Stages

Organization/Agency Supports

Management (leadership, policy)

Administration (HR, structure)

Supervision (nature, content)

Practitioner/Staff Competence

State MCH/Title V Leadership

Imp

lem

enta

tio

n T

eam

Simultaneous, Multi-Level Interventions

Federal and National Supports

Implementation Teams

The Frameworks in Action

• Eastern NC: Working with teams in Chowan, Bertie, Beaufort, Hyde counties

• Purveyor Collaboration: Develop/enhance usable intervention criteria

• State Agencies: Collaborative support for implementation informed policy

A Final Word on Fidelity

• Achieving fidelity if a shared responsibility among Providers, their Home Agency, and Program Purveyors, among others.

• If the goal is worth achieving its worth spending time to build the required infrastructure

• Programs like Connects that have evidence, well defined core components and operationalized essential functions make your work easier, if not easy, and significantly increase your chances for Socially Significant Outcomes.

Thank You!

Oscar Fleming, MSPH

– 919-962-7193– oscar.fleming@unc.e

du

Frank Porter Graham Child Development Institute

University of North Carolina

Chapel Hill, NC

http://nirn.fpg.unc.edu/ www.scalingup.org

www.implementationconference.org

For More Information

HTTP://NIRN.FPG.UNC.EDU

Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M. & Wallace, F. (2005). Implementation Research: A Synthesis of the Literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network (FMHI Publication #231).

Implementation Research: A Synthesis of the Literature

Implementation Science

©Copyright Dean Fixsen and Karen Blase

This content is licensed under Creative Commons license CC BY-NC-ND, Attribution-NonCommercial-NoDerivs. You are free to share, copy, distribute and transmit the work under the following conditions: Attribution — You must attribute the work in the manner specified by the author or licensor (but not in any way that suggests that they endorse you or your use of the work); Noncommercial — You may not use this work for commercial purposes; No Derivative Works — You may not alter or transform this work.  Any of the above conditions can be waived if you get permission from the copyright holder.

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Evidence-based Universal Home Visits for Parents of Newborns

NC DPH January 23, 2014

Improving Child Well-Being by bridging new parent needs with community resources.

The “CONNECTS” Home Visiting Model

Growing Healthy Babies

Why Universal?

• Public health approach improves community health • No stigma• All parents have needs (94% in research)• Short term triage (gateway) to more intensive services.

Newborn nurse home visits should be normalized, much the way prenatal care has become the standard of care.” – Dr. Robert Murphy, CCFH

The Connects model

Feedback loop between hospitals, doctors, service agencies to strengthen community system of care.

What we do

All areas correlate to empirically based risks for child abuse.

Nurses:• assess• quantify

needs• resolve or• refer • follow up

Who’s Involved?NC Early Childhood Advisory Council

Local leaders

How is it Funded?• State and federal grants• Private foundations• Medicaid reimbursement (in some cases)• Local government funds

Who are Stakeholders?• Health departments• Hospitals• Primary care providers• Social service agencies

FACT:99% of mothers surveyed say their DC visit was helpful to them and their baby.

Impact Evaluation Results

Age 12-month administrative hospital record reviews:

• 85% fewer hospital overnights

• 50% less total infant emergency medical care

Randomized Controlled Trial at age 6-month (in-home interview results):

• More community connections

• More mother-reported positive parenting behaviors

• Higher quality mother-infant relationship

• Higher quality home environment

• Higher quality child care usage

• Less clinical anxiety for mother

• 37% less infant emergency medical care through 24-month

• Significant decrease from 0-12 months; decrease sustained through 24-months

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 240

0.5

1

1.5

2

2.5

3

Mean Cumulative Number of Emergency Care Episodes Birth - 24-Months

Total ED Visits: Control FamiliesTotal ED Visits: DC Families

Child Age in Months

Cum

ulati

ve E

mer

genc

y Ca

re E

pisd

oes

Rural Replication

• Race to the Top Early Learning Challenge• Multiple interventions in Transformation Zone• ~ 800 births• High poverty • High unemployment • 5 birth main hospitals, some out of county • Diversity among counties (not within)

The Connects Offering

• Universal home visits = no stigma

• A triage system for entire community

• A way to strengthen system of care

• Technical support and certification for high fidelity, to replicate outcomes

Model Requirements• Universal reach, RN staff• Partnered hiring, training & fidelity checks with

Connects for certification• Adherence to the model (documentation and

performance measures)• Exclusivity in program staffing, salary and work

assignments• A regional/team approach to cover population

What next?• Connects is ideal for:

– Expand public health gateway– Strengthen systems of care– Track and ID service gaps and usage– Reduce child abuse– Save infant ER costs

• Tool kit for adoption/sustainability plan• Lessons learned during replication• Goal to serve families & replicate outcome results

Jeannine SatoProgram Directorj.sato@duke.edu

919-668-3295www.durhamconnects.org

Questions?