Columbia University Mailman School of Public Health

New York

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Strategies

IECMH in Pediatric Care: Risk Factor, Child Social-Emotional Development, and Maternal Depression Screening and Response

HealthySteps (HS) is an evidence-based national model that integrates supports for young children’s optimal development, including IECMH, into primary care. New York State currently has 46 HealthySteps sites, including 20 operated in the New York City area by the Bronx-based Montefiore Medical Center, 17 sites across the state supported by the state’s Office of Mental Health, and at three Federally Qualified Health Centers (FQHC) in New York City funded by the Robin Hood Foundation. The HealthySteps National Office is housed at Zero to Three.

HS programs integrate a child development expert, the HealthySteps Specialist (HS Specialist), into the pediatric primary care practice or any clinic where well-child visits are provided. HS provides three tiers of services. Tier 1 is available to all families in the practice and consists of child development and social-emotional/behavior screening, maternal depression and family needs screening, and a family telephone support line to address questions on a variety of topics including child development, parenting, and behavior. The HS Specialist manages the screening and referral process for the practice and the support line.

The second tier of services, for families with mild concerns, includes HS Specialist consultations with families about child development and behavioral concerns, care coordination, positive parenting guidance, and early learning resources. The third tier of services, for families in need of more intensive services, consists of preventive services, including those in Tiers 1 and 2, as well as regular contact with the family during each well-child visit and at other times, as needed. The HS Specialist also makes referrals to community resources as needed, including to infant and early childhood mental health services, such as evaluation and dyadic treatment, and for maternal depression evaluation and treatment.

HS provides a recommended child screening schedule based on the AAP’s Bright Futures guidance, which includes child social-emotional screening. Family needs screening, or family risk factor screening (see research summary on risk factor screening and response), is also included in the required screenings. To maintain their HS status, sites must meet fidelity requirements for family needs screening, with at least 75 percent of children age 0-3 having at least one family member screened each year for needs related to food insecurity, housing instability or homelessness, utilities, transportation, interpersonal safety, substance misuse, and tobacco use. HS programs can use a HS-developed family needs screener, which is comprised of items taken from validated screening instruments. Sites may also screen for the seven family needs above using their own tools, such as the SEEK Parent Questionnaire. In the HS planning and implementation process, sites develop comprehensive lists of community resources, which are used when families require referrals for needs identified in the screens.

Sites must meet fidelity metrics related to child social-emotional screening (see research summary on child social-emotional screening and response) and may use either the Ages & Stages Questionnaire: Social-Emotional, Second Edition (ASQ:SE2) or the Baby Pediatric Symptom Checklist (Baby PSC), which is part of the SWYC, the Survey of Well-Being of Young Children. Sites must also meet fidelity metrics related to maternal depression screening (see research summary on maternal depression screening and response) and may use either the Edinburgh Postnatal Depression Scale (EPDS) or Patient Health Questionnaire (PHQ)-2/9.

After expressing interest and securing funding, potential HS sites work with the HS National Office at a two- to three-day HealthySteps Institute to train the site and plan implementation. The HS Specialist, physicians, practice managers, and other site staff attend the institute. After the HealthySteps Institute, the site begins implementing the model with the support of six additional technical assistance sessions provided by the National Office.

New York’s current 46 sites grew from an initial site developed at Montefiore Medical Center in the Bronx in 2006. Its success there led to the expansion to 19 additional sites within the Montefiore Health System in the New York City area. Inspired by the achievements at Montefiore, in 2016 the state’s Office of Mental Health provided three-year grant funding to start 17 sites across the state. Expansion to other sites in New York State has likewise occurred organically, often through word of mouth or growth within a health system that already had a HealthySteps site. The National Office focuses on supporting this network of sites to ensure sustainability.

Financing

Start-up costs, including the training institute and TA, are typically $25,000. Once the model is being implemented at a site, a full-time HS Specialist can usually support the provision of Tier 1 services to 2,000 children annually, and offer Tier 2 and 3 services to 300 of those children in each tier. The cost of providing services to the 300 children in Tier 3 can average up to $450 annually per child, which covers the HS Specialist salary, administrative costs, and any site-specific enhancements or adaptations such as optional home visits and parenting groups. HS sites vary in their sources of funding for covering the cost of providing these services, and the National Office supports sites in identifying and pursuing sustainable sources of funding.

In New York, 17 sites have been funded with state general funds from the state Office of Mental Health for a three-year grant period starting in 2016. As this period has drawn to a close, the National Office has convened a learning collaborative with sites on how to bill Medicaid for services. The National Office is also working with each site individually to identify additional sources of funding, including grants and reallocation of systems funds, in which the health system reroutes surplus revenue from other departments to fund HS services. To support the reallocation of system funds, the National Office helps sites make the case to health system leadership for funding HS because of its contribution to cost savings, service quality, and meeting targets such as child screening rates. One site is now 90 percent funded through Medicaid. Other sites combine Medicaid funding and reallocation of system funds.

Montefiore sites have been funded predominantly through reallocation of system funds, as well as grant funding and through Medicaid reimbursement. New York will also look to funding strategies used in other states. For example, in Texas, sites are supported by state funds for child abuse and neglect prevention efforts. In Colorado, there have been dedicated state funds in the State budget for two years in a row.

In New York, there are multiple payment methods for billing Medicaid, including variations related to the credentials of the service provider. These variations, along with HS Specialists having a range of credentials, affect how they can be reimbursed by Medicaid, which creates a challenging and inconsistent payment landscape for sites. HS Specialists are frequently social workers with mental health training, psychologists, early childhood educators, and/or nurses with experience in early childhood development (the minimum requirement is a bachelor’s degree, although a master’s degree is preferred).

Monitoring and Evaluation

National- and site-level evaluation research on HS has been conducted for more than 20 years. Beyond the national randomized controlled trial, researchers at HS sites in New York found that children who had screened at risk for social-emotional difficulties and received HS services showed significant improvements in subsequent social-emotional screenings compared to children in need of services whose caregivers declined services. Researchers also found that HS reduced the gap in risk of social-emotional difficulties between children whose mothers had experienced childhood trauma and those whose mothers had not.

In 2015, oversight of HealthySteps sites was transferred to a newly-created National Office, based at Zero to Three. The National Office formally revised the model and identified its core components. They also created fidelity metrics that sites must meet to call themselves HealthySteps sites.

Sites must submit annual reports that include fidelity information. From 2019, new sites have three years to meet the fidelity metrics, and existing sites have five years. The National Office is currently waiting to receive the second year of the new annual reports, which will help the National Office develop technical assistance to support sites so that they deliver HS with fidelity.

One challenge is that HS has not developed its own data system, which means all the sites’ monitoring data are drawn from their own electronic medical records. Consequently, sites have found it easier to track screenings than to track referrals and follow-ups for positive screens, since extracting this information typically involves examining text fields. Sites are interested in exploring ways to develop more effective tracking, which would also support efforts to bill for services. The National Office is developing a client-level data system designed specifically for HS Specialists, which will help address these challenges.

Special thanks to Suzanne Brundage, Director, Children’s Health Initiative, United Hospital Fund, for providing information for this profile, and to the following individuals at HealthySteps for providing information for and reviewing this profile: Rahil D. Briggs, National Director; Johanna Lister, Director of Policy; Jennifer Tracey, Senior Director of Growth and Sustainability; and Danielle Robbio, Communications Manager.