Redesigning Health Care Practices to Address Childhood Poverty

Redesigning Health Care Practices to Address Childhood Poverty Arthur H. Fierman, MD; Andrew F. Beck, MD, MPH; Esther K. Chung, MD, MPH; Megan M. Tschudy, MD; Tumaini R. Coker, MD, MBA; Kamila B. Mistry, PhD, MPH; Benjamin Siegel, MD; Lisa J. Chamberlain, MD, MPH; Kathleen Conroy, MD, MS; Steven G. Federico, MD; Patricia J. Flanagan, MD; Arvin Garg, MD, MPH; Benjamin A. Gitterman, MD; Aimee M. Grace, MD, MPH; Rachel S. Gross, MD, MS; Michael K. Hole, MD, MBA; Perri Klass, MD; Colleen Kraft, MD; Alice Kuo, MD, PhD; Gena Lewis, MD; Katherine S. Lobach, MD; Dayna Long, MD; Christine T. Ma, MD; Mary Messito, MD; Dipesh Navsaria, MPH, MSLIS, MD; Kimberley R. Northrip, MD, MPH; Cynthia Osman, MD, MS; Matthew D. Sadof, MD; Adam B. Schickedanz, MD; Joanne Cox, MD From the Department of Pediatrics, NYU School of Medicine, New York, NY (Drs Fierman, Klass, Messito, and Osman); Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH (Drs Beck and Kraft); Department of Pediatrics, The Sidney Kimmel Medical College of Thomas Jefferson University and Nemours, Philadelphia, PA (Dr Chung); Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD (Drs Tschudy and Mistry); Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA (Drs Coker, Kuo, and Schickedanz); Office of Extramural Research, Education, and Priority Populations, Agency for Healthcare Research and Quality, US Department of Health and Human Services, Rockville, MD (Dr Mistry); Department of Pediatrics, Boston Medical Center, Boston University School of Medicine, Boston, MA (Drs Siegel and Garg); Department of Pediatrics, Stanford School of Medicine, Stanford, CA (Dr Chamberlain); Division of General Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA (Drs Conroy, Hole, and Cox); General Pediatrics, Department of Pediatrics, Denver Health, Denver, CO (Dr Federico); Department of Pediatrics, Warren Alpert Medical School of Brown University/Hasbro Children’s Hospital, Providence, RI (Dr Flanagan); Department of Pediatrics, George Washington University, Washington, DC (Drs Gitterman and Grace); Department of Pediatrics, Albert Einstein College of Medicine, The Children’s Hospital at Montefiore, Bronx, New York (Drs Gross and Lobach); Department of Medicine, David Geffen School of Medicine at UCLA (Dr Kuo); Department of Pediatrics (Drs Lewis, Long, and Ma), Center of Community Health and Engagement (Dr Long), UCSF Benioff Children’s Hospital Oakland, San Francisco, CA; Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI (Dr Navsaria); Department of Pediatrics, University of Kentucky College of Medicine, Lexington (Dr Northrip); and Department of Pediatrics, Tufts University School of Medicine, Boston, MA; Baystate Children’s Hospital, Springfield, MA (Dr Sadof) Dr Klass serves as national medical director for Reach Out and Read, for which she receives no compensation. The other authors declare that they have no conflict of interest. Address correspondence to Arthur H. Fierman, MD, Department of Pediatrics, NYU School of Medicine, Bellevue Hospital Center, 462 First Ave, Room A321, New York, NY 10016 (e-mail: [email protected]).

ABSTRACT Medical-Legal Partnership, Health Leads); and collaboration with home visiting programs. Changes to health care financing are needed to support the delivery of these enhanced services, and active advocacy by child health providers continues to be important in effecting change. We highlight the ongoing work of the Health Care Delivery Subcommittee of the Academic Pediatric Association Task Force on Child Poverty in defining the ways in which child health care practice can be adapted to improve the approach to addressing child poverty.

Child poverty in the United States is widespread and has serious negative effects on the health and well-being of children throughout their life course. Child health providers are considering ways to redesign their practices in order to mitigate the negative effects of poverty on children and support the efforts of families to lift themselves out of poverty. To do so, practices need to adopt effective methods to identify poverty-related social determinants of health and provide effective interventions to address them. Identification of needs can be accomplished with a variety of established screening tools. Interventions may include resource directories, best maintained in collaboration with local/regional public health, community, and/or professional organizations; programs embedded in the practice (eg, Reach Out and Read, Healthy Steps for Young Children,

KEYWORDS: child poverty; practice redesign; social determinants of health ACADEMIC PEDIATRICS 2016;16:S136–S146

A LARGE PROPORTION of children in the United States are living in poverty. US census figures in 2013 indicate that 19.9% (14.7 million) of children live in households with incomes below 100% of the federal poverty level, and 42.6% (31.4 million) live in households with incomes below 200% of the federal poverty level.1 By comparison, ACADEMIC PEDIATRICS Copyright ª 2016 by Academic Pediatric Association

15% of the total US population live below 100% and 34% live below 200% of the federal poverty level.2 Child poverty is found in all parts of the country, not only in urban and rural areas but also in suburban neighborhoods.3 It is well documented that poverty-related social factors place children at increased risk for experiencing negative effects

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on their health and well-being. Such factors include poverty (family income) itself, independent of other factors4; family disruption, parental depression, substance use, and other mental illness5,6; unsafe home and/or neighborhood environment, housing instability, and homelessness7–10; substandard educational food insecurity11–14; opportunity15; and low parent education and health literacy.16–18 In association with these poverty-shaped social determinants of health—“the circumstances in which people are born, grow up, live, work, and age”19—poor children experience higher rates of developmental delay, poor school achievement, and overall poor health.20,21 The negative impact extends into adulthood, with resultant adult poverty, lower educational achievement, unstable employment, involvement in the criminal justice system, and greater risk of adult diseases such as heart disease, diabetes, substance abuse, and depression.5,22,23 Increased awareness of the prevalence, distribution, and impact of child poverty on health and well-being has led major pediatric organizations in the US and clinicians who provide care to children to focus increasingly on child poverty as a problem, seeking solutions to mitigate and/or prevent the negative consequences of poverty on health. Poverty and Child Health is currently 1 of 3 Strategic Child Health Priorities of the American Academy of Pediatrics (AAP) Agenda for Children.24 Both the AAP and the Academic Pediatric Association have organized task forces to review the issues, make recommendations, and advocate for changes in health care delivery and financing in order to address child poverty effectively and improve child health and well-being. Here we highlight the ongoing work of the Health Care Delivery Subcommittee of the Academic Pediatric Association Task Force on Child Poverty in defining the ways in which child health care practice can be adapted to improve the approach to addressing child poverty.

STRATEGIES FOR PRACTICE REDESIGN TO ADDRESS CHILD POVERTY The high prevalence and wide distribution of child poverty suggest that many, if not most, providers of pediatric health care in the United States are seeing some children in their practices who are poor or near poor. Hence, it is important for all child health providers to consider how their individual practices might transform in order to address the social determinants of health that affect poor children and their families. This transformation will require the development and implementation of a means to identify and address the social determinants of health affecting individual patients within the practice.25 The development or revision of the practice mission statement may be a useful first step in enhancing focus on the importance of social determinants of health within the practice’s patient population.26 IDENTIFYING SOCIAL DETERMINANTS OF HEALTH First and foremost, practice-level redesign to address poverty-related disruptions of health and well-being will

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require an effective strategy to identify the social determinants of health for individual children and families so that interventions can be tailored to those needs. This may be accomplished through the implementation within the practice of a periodically and universally administered general screening tool, with a mechanism for referral to community resources and/or more focused follow up of identified needs. A recent cluster-randomized trial of this approach compared with usual care demonstrated significantly higher rates of referrals as well as higher rates of actual enrollment of families into a variety of community resources.27 Universal screening may be performed using tools such as the WE CARE survey,27 the Survey of Wellbeing of Young Children (SWYC): Family Questions,28 the Medical-Legal Advocacy Screening Questionnaire (MASQ),29 the IHELLP (Income, Housing, Education, Legal status, Literacy, Personal safety) survey,30 the Health Leads survey (Figure), and the Bright Futures Pediatric Intake Form.31 Table 1 provides a summary comparison of the social determinants of health/poverty-related concerns addressed by each tool. Many of these tools can be completed by parents, scored by a nonphysician, and incorporated into the electronic health record. Upon identifying specific areas of concern through surveillance, more specific screening instruments may be considered. Increased selectivity and focus regarding the specific social determinants to be screened within individual practices may be facilitated by consultation with representatives of the communities that are served by the practice. Practices that do not have established community advisory groups may consider this mechanism in order to enhance the relevance of their screening process and content for their practice population. It should be noted that adding identification of social determinants of health to the ever-expanding “mandated” task list of the well-child visit introduces potential logistical challenges to child health care practices. Which screens to perform, who administers them, with what periodicity, and at what point during the well-child visit will depend on the level and scope of needs known to exist in the practice population, the affordability and accessibility of screening tools, the time for screen administration, staffing ratios, physical space, patient flow structure of the practice, and the availability of electronic health records. In addition to these logistical challenges, more evidence is needed to identify the optimal tools for social determinants of health screening as well as the optimal timing and frequency of screening. Nonetheless, the high prevalence and wide distribution of family poverty as well as the major impact of social determinants on health outcomes provide a compelling rationale for practices to consider initiating a process of routine screening at well-child care visits. RESPONDING TO IDENTIFIED SOCIAL NEEDS Having identified social needs through screening, practices will need to be prepared to respond to these needs. The manner and degree to which practices are able to respond will depend on an understanding of the level of

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Figure. Health Leads survey form. Form developed at Bellevue Hospital Center, New York, NY, and is available in English and Spanish from Health Leads ([email protected]).

need within the practice population and a consideration of available resources. Practices that care for lower proportions of poor children and/or have limited practice-based resources may rely primarily on interventions to link families to services available in the community. Practices with high proportions of families living in poverty and/or the capability to develop more practice-based resources while also making use of community linkages would also benefit from the ability to embed programs within the practice to address social determinants of health.

established telephone- or Internet-based resource tools. Practices may consider compiling and maintaining their own lists of community resources, but they also may be able to partner with other practices, local public health agencies, AAP chapters, and/or community agencies to maintain and update such directories. Telephone lines and Internet-based resources may be useful sources of information. COMPILING AND MAINTAINING A COMMUNITY RESOURCE DIRECTORY

LINKING FAMILIES TO COMMUNITY-BASED SERVICES Straightforward approaches not requiring excessive staff time or other in-practice resources include accessing a directory of community services and making use of

Compiling a list of community resources to have on hand for families is an excellent means of providing quick and targeted interventions during the child’s appointment.32 Perhaps the most widely available starting points

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Table 1. Commonly Used Tools to Identify Social Determinants of Health and Poverty-Related Concerns Surveillance Tool Domain

WE CARE27

Social determinant of health/poverty concern Parent education/literacy U Parent employment U Daycare U Child education/literacy Housing/homeless U Food insecurity U Fuel/utilities U Income assistance/public benefits Health insurance Clothing After school programs Legal assistance/immigration Home/neighborhood safety Domestic violence Parent depression Parent alcohol/drug use Supportive relationships Health screening, other questions Child general health Family health history Smoking in home Child behavior/development Tool characteristics Available languages English, Spanish Approximate reading level†

3rd grade

SWYC: Family Questions28

MASC29

U U U U

U U U

Health Leads*

U

U U U

U U

U U U U U U U

U U U

U U U U U

U U

IHELLP30

U U U U U U U U U U

Bright Futures31

U U U U U U U U U

English, Spanish, English, Spanish English English, Spanish English Burmese, Nepali, Portuguese 6th grade 7th grade 4th grade 4th grade 3rd grade

SWYC indicates Survey of Wellbeing of Young Children; MASQ, Medical-Legal Advocacy Screening Questionnaire; and IHELLP, Income, Housing, Education, Legal status, Literacy, Personal safety survey. *Based on the Health Leads Survey developed at Bellevue Hospital; see Figure. †Flesch-Kincaid Readability tool.

for building a community resource directory are public benefit programs and nonprofit organizations. Making connections with local government agencies, departments of health, and the offices of local elected officials can provide practices with the most direct means of obtaining up to date information about public benefit programs and how to access them. Public benefit programs that can help mitigate the circumstances of poverty and/ or help lift families out of poverty include the Supplemental Nutrition Assistance Program (SNAP), the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and Temporary Assistance for Needy Families (TANF). Despite the fact that these programs are well established and widely recognized, many eligible families have not accessed them because of lack of knowledge, administrative barriers, or misconceptions about eligibility. Many eligible families also may be unaware of or may require assistance in utilizing the Earned Income Tax Credit (EITC) and Child Tax Credit (CTC) programs.33 These programs have been shown to increase employment rates of single mothers,34 improve infant health outcomes,35 and increase child educational achievement.36,37 Even with limited resources, practices could assist families to access government benefit and tax credit programs by providing basic education and referral information to families. Safe, affordable, low-income

housing is in limited supply and often in suboptimal condition, and waiting lists for subsidized housing units are often long. Nonetheless, it would be useful for practice resource directories to maintain information so that families are aware of local voucher programs available through agencies such as the US Department of Housing and Urban Development (http://portal.hud.gov/hudportal/HUD) and the Department of Veterans Affairs Housing Choice Voucher Program (Section 8; http://www.va.gov/ homeless/hud-vash.asp). It also is useful for practice resource directories to include contact information for local private charities and community agencies as well as local chapters of national charity organizations to which families may be referred to obtain needed services. In addition to maintaining up-to-date referral information to connect families to governmental agencies and public and private charities, community resource directories typically will include updated information about local food banks; access to local produce and food markets; adult language, literacy, and GED programs; Head Start and Early Head Start programs; and home visiting programs (Table 2). The WE CARE Family Resource Book is one example of how this information may be organized. The book, kept in each examination room, contains 1-page tear-out information sheets listing community resources for each unmet need.

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Table 2. Resource Directories to Assist Children and Families Living in Poverty Program

Essential Elements      

Federal public benefit programs

Federal housing programs

 Programs and services commonly available through private charities, local community-based organizations, local governments, faith-based organizations

      

Supplemental Nutrition Assistance Program (SNAP) Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Temporary Assistance for Needy Families (TANF) Earned Income Tax Credit (EITC) Child Tax Credit (CTC) US Department of Housing and Urban Development (http://portal.hud.gov/hudportal/HUD) Department of Veterans Affairs Housing Choice Voucher Program (Section 8; http://www.va.gov/homeless/hud-vash.asp) Food banks, local produce/food markets Adult language/literacy/GED programs Libraries Head Start/Early Head Start programs Home visiting programs Safe outdoor and indoor spaces and programs for physical activity After-school programs

LOCAL/REGIONAL COLLABORATIVE EFFORTS TO SHARE RESOURCE INFORMATION

For many practices, comprehensive, up-to-date resource directories may be difficult to maintain. To overcome this potential barrier, practices may consider partnering with each other or with local public health agencies, AAP chapters, and community agencies to maintain and update such directories for the benefit of all providers in the community (Table 3). For example, Help Me Grow is a system designed to build collaboration across health care, education, and family support sectors in order to improve support for child development in at-risk families. Operating in 23 states, Help Me Grow includes outreach to providers and community organizations and a phone line/resource center for providers and parents in an effort to link families to needed developmental services (http://www. helpmegrownational.org/pages/what-is-hmg/what-is-helpme-grow.php). The Children’s Advocacy Project, CAP4Kids, facilitates the building of online, locally maintained and updated “parent handouts” (often in the form of online links to specific organizations and services) covering a wide range of social and emotional needs. Initially launched as a

residency program advocacy project in Philadelphia,38 this online, free Web site provides information for 13 locations. Participating practices in these localities use CAP4Kids in lieu of or to supplement their own resource directories and can also provide CAP4Kids with information regarding new resources and updates to existing resources. There are computerized tools that patients may use in the waiting room to link them to local community-based health, developmental, and social services resources. Help Steps, formerly the Online Advocate, is an example of an online resource tool for use in Boston, Massachusetts.39 TELEPHONE- AND INTERNET-BASED RESOURCE DIRECTORIES Families may also use resource directories that provide information by telephone or Web site (Table 3). United Way’s 211 phone line and Web site, a widely available 24-hour-a-day, 7-days-a-week service, covers over 90% of the US population. The 211 phone line or Web site links clients to resources for housing, jobs, food, health care, and addiction, mental health, and crisis intervention services. It also provides linkages to support services for special populations, including victims of disasters, victims of human

Table 3. Examples of Local/Regional Collaborations to Share Resource Information and Telephone- and Internet-Based Resource Directories Name Help Me Grow CAP4Kids (Children’s Advocacy Project)

URL

Description

http://www.helpmegrownational.org/pages/what-ishmg/what-is-help-me-grow.php http://cap4kids.org/whatiscap4kids.html

Available in 23 states, connection to developmental services Available in 13 cities, mostly Eastern United States, wide variety of services, user sourced and maintained Explores multiple needs, constructs customized lists of resources based on client responses; resource lists specific to Boston, Mass Available 24/7, throughout most of United States, wide variety of services Provides Web links and telephone numbers to assist in accessing national, state, and local resources for child care, early childhood education, special education services, family support, financial support, health and wellness, parenting programs

Help Steps (Online Advocate)

https://www.helpsteps.com/about.html

United Way 211 line

http://www.211.org/pages/about

Community services locator

http://ncemch.org/knowledge/community.php

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trafficking, veterans, and individuals reentering society from drug, alcohol, and mental health programs and from correctional facilities (http://www.211.org/pages/about). The Community Services Locator, developed and maintained by the National Center for Education in Maternal and Child Health, is a Web site that provides updated information for providers and families on how to locate national, state, and local resources to address child and family needs, including the following: child care, early childhood education, special education services, family support, financial support, and health and wellness and parenting programs (http://ncemch.org/knowledge/ community.php). Numerous other publicly available and proprietary social resource directories exist with varying degrees of ongoing maintenance and infrastructure to support their use. Generally caution should be taken to ensure that any directory used is up to date and has accurate information about services available. Given the many options available, it is well worth researching the best directories available on the basis of one’s particular practice geography and the most common patient needs.

EMBEDDING PROGRAMS WITHIN THE PRACTICE Many practices serving larger numbers of poor families have considered how to provide higher intensity, on-site interventions to address social determinants of health. Some practices, particularly those that are hospital based or within larger multispecialty groups, have access to the traditional model of on-site professional social work staff, case workers, and care coordinators to support some of the effort of identifying resources, connecting families, and tracking their progress toward obtaining needed services. Nonetheless, even in these instances, the demand for services often exceeds the capacity of available staff to respond, some needed interventions are not well addressed by this model, and health care financing as currently configured typically does not provide substantive support for staff to engage in the needed activities. In response, a number of programs embedded in the practice setting and often relying largely on philanthropic support have been developed to augment early child development and literacy, to provide access to legal advocacy, and to augment and extend the contributions of practice-based resource directories and traditional social work/care manager roles. Highlighted below are examples of well-established, practice-based programs as well as model programs in various stages of development or dissemination, which are designed to assist families living in poverty and to address social determinants of health. WELL-ESTABLISHED EMBEDDED PROGRAMS REACH OUT AND READ (ROR) ROR is an evidence-based, practice-embedded program to promote parent–child interaction, early language development, and literacy targeting families with children aged up to 5 years. The components of the ROR model, delivered at every well-child visit in this age group, include

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literacy-related activities in the waiting room, provider counseling of parents on the positive effects of book sharing and reading aloud on language development, and distribution of an age-appropriate book during the visit. ROR programs, serving over 4.5 million children annually at almost 5000 sites in all 50 states (http://www. reachoutandread.org/about-us/mission-and-model/literacypartners/), have been demonstrated to result in more frequent parent–child shared reading, more children’s books in the home, and higher expressive and receptive language scores in at-risk children.40 ROR is endorsed in the third edition of the Bright Futures Guidelines for Health Supervision41 and was cited in a 2014 AAP policy statement as an effective pediatric practice-based intervention to engage parents and prepare children to achieve their potential in school and beyond.42 HEALTHY STEPS FOR YOUNG CHILDREN Healthy Steps for Young Children is another evidencebased model to enhance child development, relying on child development specialists and using services embedded in pediatric practice combined with home visiting. Healthy Steps operates at 74 sites in 14 states, with the national program office located at Zero to Three (Margot KaplanSanoff, EdD, Healthy Steps, Zero to Three, personal communication, December 29, 2015). Services include participation of a Healthy Steps specialist in well-child visits; separately scheduled developmental and family health checkups; home visits focusing on newborn care, safety, developmental, and behavioral issues; parent support groups; informational handouts focusing on preventive issues; a child development telephone information line; and links to community-based resources (http:// healthysteps.org/about/healthy-steps-services/). The Healthy Steps program has been demonstrated to improve quality of care43,44 and to have modest positive impacts on parenting practices such as discipline, parent–child communication, and book reading.45,46 MEDICAL-LEGAL PARTNERSHIP (MLP) The MLP model, currently operative in almost 300 health care institutions in 36 states, facilitates clinician referral of families affected by social conditions that may have resulted from the inequitable application or underenforcement of laws, leading to denial of services and benefits. MLPs focus primarily on 5 main domains: income support and insurance, housing and utilities, employment and education, legal status, and personal and family stability (http://medical-legalpartnership.org/). Studies indicate that MLPs can reduce subjective stress and improve self-reported health and well-being, improve legal problem-solving skills and sense of empowerment, and improve health care utilization.47,48 Other studies have addressed program sustainability, demonstrating the ability to provide financial benefit to the clinical setting by resolving improperly denied insurance claims.49–51 In lieu of an established MLP, practices could consider approaching local law firms or private

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attorneys to see if they may be willing to undertake pro bono work. HEALTH LEADS Health Leads is a nonprofit organization currently operating sites in Boston, New York City, Washington, DC, Baltimore, and the California Bay area that connects practices with local groups of trained college student advocate-volunteers and a Health Leads site coordinator to support referral of patients to services for identified social needs. The advocates and site coordinator at each site develop and maintain a resource directory to assist in making referrals to community resources (eg, group support programs, tutoring, job training, physical activity programs, food banks) and public benefits (eg, SNAP, WIC, TANF, tax credit applications). Patients, parents, or providers complete a brief screening instrument to help identify needs (Fig). Providers then may “prescribe” resources, or patients may request services directly. Advocates connect families to the requested resources and follow up to try to ensure that family needs are met (https:// healthleadsusa.org/what-we-do/our-model/). Studies at the Baltimore site have demonstrated that the program reaches more families over time, that the majority of families have their identified needs met, and that health care providers receive feedback on the services provided to the families.52,53 MODEL EMBEDDED PROGRAMS UNDER DEVELOPMENT VIDEO INTERACTION PROJECT (VIP) The VIP is an evidence-based, primary care-based program designed to enhance the cognitive, language, and social-emotional development of low-income young children. During the well-child care visit, an interventionist (typically a child life/developmental specialist) conducts a session with the mother–child dyad focusing on parent– child interactions.54 After video recording the mother and child interacting together, the interventionist and mother review the video together, and the interventionist reinforces positive interactions and provides suggestions on missed opportunities for positive interaction with the child. The parent also receives learning materials and visit-specific pamphlets. The video is given to the parent, and new videos are added to the DVD at subsequent visits, thereby compiling an ongoing video record of the child’s development and the parent–child interactions that the family may review at home. In a randomized controlled trial of VIP among low-income Latina mothers, positive intervention effects were seen on cognitive development at 21 and 33 months.54,55 VIP also has been shown to reduce the duration of media exposure at 6 months56 and to reduce maternal depressive symptoms.57 Given the relatively high intensity of this intervention, the annual costs are remarkably modest.54 The feasibility of scaling up the VIP program for widespread implementation is currently under study.

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PARENT MENTORS A recent report details a promising, cost-effective program using parent mentors to assist uninsured, Medicaid/CHIP-eligible families to enroll and maintain health insurance coverage. Preliminary findings demonstrate that families assigned to a trained parent mentor were more successful in obtaining, maintaining and renewing insurance coverage, obtaining primary care providers, meeting previously unmet health care needs, and reducing out-of-pocket health care costs.58 PARENT PROGRAM The Parent-focused Encounters, Infants to Toddlers Intervention (PARENT), is a team-based approach to well-child care that utilizes a health educator as a “parent coach” to expand the capacity of providers to meet the needs of families living in poverty.59 The PARENT coach serves as the main provider of routine anticipatory guidance, psychosocial screening/referral, and developmental and behavioral surveillance and screening during well-child visits. In a randomized controlled trial of PARENT among 251 low-income parents of young children, PARENT demonstrated robust improvements in the receipt of preventive care services (eg, psychosocial screening, health education and guidance, developmental screening, and surveillance) and experiences of care, and substantially reduced emergency department visits. PARENT can improve the receipt of comprehensive well-child care for low-income families, and potentially lead to cost savings by reducing emergency department utilization.60 EXTENDING THE REACH OF THE PEDIATRIC PRACTICE: PARTNERSHIP WITH HOME VISITING PROGRAMS Child health care practices may engage in partnerships with any number of social support agencies and programs to augment what can be provided to poor children and families within the practice setting. True coordination of services to promote child health and well-being across health care, social service, community, and/or governmental sectors is not yet well developed. However, as models of health care delivery continue to evolve toward management of populations to improve health and reduce cost, the incentives for child health care practices to forge true collaborations are likely to increase. Home visiting is one example of a service with which child health care practices may collaborate more closely as health care systems continue to evolve, and the AAP has called for pediatricians to partner with home visiting programs.61 Home visiting programs to support maternal–child health, which have a history of integration within the public health and medical systems in Europe, became a focus of interest in the United States in the 1970s as a mechanism to promote early child development, improve parenting, prevent child abuse, and reduce other health disparities.61 While a broad and deep research base exists, many challenges remain in understanding the effects of early child home visiting programs. Studies vary greatly in terms of

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Table 4. Evidence-Based Models of Home Visiting With Positive Effects on Child Health and Well-Being* Reported Favorable Outcomes for: Home Visiting Program

Health Care Coverage/Use

Health Behaviors/Other Health Outcomes

Birth Outcomes

NR

NR

NA or NR

Early Head Start—Home Visiting

NR

NR

NA or NR

Early Intervention Program for Adolescent Mothers Early Start (New Zealand) Family Check-Up Healthy Families America (HFA)

Y Hospital days/admissions, [ immunization [ Well-child, dental visits NR [ No. of well-child visits, [ health insurance coverage

NR

No effect

No effect NR NR

NA or NR NA or NR Y Low birth weight

Healthy Steps

[ 1 mo well-child visits, [ DTP vaccines NR

No effect

NA or NR

NR

NA or NR

Y Emergency department visits

[ Percentage mothers attempted breast-feeding NR NR

Y Low birth weight NA or NR NA or NR

Home Instruction for Parents of Preschool Youngsters (HIPPY) Nurse Family Partnership (NFP) Parents as Teachers Play and Learning Strategies (PAL) for Infants

No effect NR

NA indicates not applicable; NR, not reported. *Adapted from the Home Visiting Evidence of Effectiveness (HomVEE) review.58

Language development; externalizing behaviors Mental development; approaches to learning; attachment, security, social problems NR Behavioral problems Behavioral problems Mental and cognitive development; internalizing and externalizing behaviors No effect Vocabulary; classroom adaptation, academic self-image Language; infant vulnerability Mastery motivation; self-help (age 3 y) Negative affect

Decreased Child Maltreatment [ Family involvement with child protective services Y Physical punishment (36 mo)

NR Y Hospital visits for trauma NR Parenting behaviors

No effect NR Y Health care encounters for injuries, substantiated abuse/neglect NR NR

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Child FIRST

Child Development

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populations chosen for study; the specifics of the intervention being delivered—its intended focus, intensity, duration, fidelity in delivery, and method for maintaining its integrity over time; the personnel delivering the intervention (trained worker, paraprofessional, or professional); outcomes measured and how they are measured; and attribution of causality in interpreting results.61–63 In response to the call of experts for the establishment of a home visiting research network to address these issues,64 the Home Visiting Applied Research Collaborative (HARC) was established in December 2013. This research network includes 290 home visiting programs, 60 home visiting networks in 48 states and territories, and 158 researchers from more than 13 disciplines (http://www.hvrn.org/currentpbrn-members.html). Multiple studies have been completed or are in progress within the HARC research network (http://www.hvrn.org/harc-projects.html). Under the authority of the Patient Protection and Affordable Care Act, the Federal Home Visiting Program was established, with current authorization of $1.9 billion for evidence-based home visiting. To inform the Federal Home Visiting Program effort, the US Department of Health and Human Services commissioned a systematic review of the effectiveness of home visiting models, the Home Visiting Evidence of Effectiveness (HomVEE) review, which highlights that there are a number of evidence-based models of home visiting with notable (although often modest) positive effects on various aspects of child health and well-being, most notably in the realms of child development, health care utilization, and child maltreatment.65 Table 4 highlights selected HomVEE outcomes and evidence-based programs. The integration of home visiting and primary care/medical home models has been supported by the AAP.61 Furthermore, the integration of home visiting and familycentered medical home models is in keeping with the recent call by the Institute of Medicine to integrate primary care and public health efforts in order to improve population health and bend the cost curve.66,67

FINANCING TO SUPPORT PRACTICE REDESIGN AND PROVIDER EFFORT In order to establish effective screening processes to address child poverty, embed poverty-related programs into a practice, and provide care coordination and effective communication with community partners, these activities must be reimbursed appropriately through health care financing structures. Although the National Committee for Quality Assurance patient-centered medical home standards embrace the concept of care coordination, support in the form of payment to providers for efforts to bridge medical care with the social service, education, legal, municipal, and/or public health service sectors is not routinely available within most of these models, thereby disincentivizing providers to address these issues. Large-scale surveys of primary care physicians characterize a great need to address social determinants of health through clinical practice, but very few providers feel equipped in their own

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practice to do so.68 Incorporation of appropriate payment mechanisms within medical home models is needed to support this type of care coordination.59 With the advent of the Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS) has supported Accountable Care Organization (ACO) models under Medicare, in which groups of medical providers and other service delivery organizations are incentivized to reduce hospitalizations by improving coordination of care.69 These models have focused predominantly on health care cost savings and care coordination for patients with chronic illnesses within the adult Medicare population. However, these same types of models could be applied to crosssector care coordination for children living in poverty, and the pediatric medical community can play an important role in advocacy efforts to broaden the application of these models to serve children and families living in poverty. Practices providing care to large numbers of poor children would also benefit from increased Medicaid reimbursement rates to support the screening and intervention strategies described herein. With the proper reimbursement support for their efforts, pediatric medical providers could continue and expand their critically important role in assisting families to rise out of poverty and to mitigate the negative effects of poverty on the health and well-being of children.

SUMMARY AND CONCLUSION Child poverty is highly prevalent and widespread in the United States and has a substantial negative impact on child health and well-being. The negative impact extends into adulthood, with resultant consequences to individual adult health, health care costs, and society at large. Pediatric health care providers and their national organizations are increasingly focused on working to prevent and mitigate the effects of poverty. Although the details of when and how often to screen are not well established, a number of practical screening tools are available to identify important social determinants of health commonly associated with poverty. Having identified specific needs, child health care practices will require well-worked-out mechanisms to assist families. Evidence-based approaches include providing linkages to community-based services; embedding developmental, legal, and community resource services within the practice; and partnering with home visiting programs. Currently provision of these services by child health practices depends primarily on volunteer and philanthropic programs, as health care financing largely is lacking to address child poverty and social determinants of health. Child health care providers can play an important role in advocating for payment mechanisms to support evidence-based programs that can effectively address child poverty and the social determinants of health.

ACKNOWLEDGMENTS We thank the following for their participation and contributions to the Health Care Delivery Subcommittee of the Academic Pediatric Association Task Force on Child Poverty: Kelly Hall; David M. Keller, MD;

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PRACTICE REDESIGN TO ADDRESS CHILD POVERTY

Marjorie S. Rosenthal, MD, MPH; Anita Shah, DO; Roy Wade, MD; and H. Shonna Yin, MD, MS. Received for publication October 6, 2015; accepted January 5, 2016. 21.

REFERENCES 1. DeNavas-Walt C, Proctor BD. Income and Poverty in the United States: 2013. Washington, DC: US Government Printing Office. US Census Bureau Current Population Reports P60-249. Available at: https://www.census.gov/content/dam/Census/library/publications/ 2014/demo/p60-249.pdf; 2014. Accessed September 14, 2015. 2. Henry J. Kaiser Family Foundation. Distribution of total population by federal poverty level. Available at: http://kff.org/other/stateindicator/distribution-by-fpl/. Accessed December 20, 2015. 3. Kneebone E, Berube A. Confronting Suburban Poverty in America. Washington, DC: Brookings Institution Press; 2014. 4. Brooks-Gunn J, Duncan GJ. The effects of poverty on children. Future Child. 1997;7:55–71. 5. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14:245–258. 6. Dube SR, Anda RF, Felitti VJ, et al. Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study. JAMA. 2001;286:3089–3096. 7. Meyers A, Cutts D, Frank DA, et al. Subsidized housing and children’s nutritional status: data from a multisite surveillance study. Arch Pediatr Adolesc Med. 2005;159:551–556. 8. Grant R, Shapiro A, Joseph S, et al. The health of homeless children revisited. Adv Pediatr. 2007;54:173–187. 9. Silverstein M, Conroy K, Sandel M. Screening for social determinants of health in pediatric primary care. Pediatr Ann. 2008;37: 740–746. 10. Sugiyama T, Leslie E, Giles-Corti B, Owen N. Associations of neighbourhood greenness with physical and mental health: do walking, social coherence and local social interaction explain the relationships? J Epidemiol Community Health. 2008;62:e9. 11. Kirkpatrick SI, McIntyre L, Potestio ML. Child hunger and long-term adverse consequences for health. Arch Pediatr Adolesc Med. 2010; 164:754–762. 12. Alaimo K, Olson CM, Frongillo EA Jr, et al. Food insufficiency, family income, and health in US preschool and school-aged children. Am J Public Health. 2001;91:781–786. 13. Cook JT, Frank DA, Berkowitz C, et al. Food insecurity is associated with adverse health outcomes among human infants and toddlers. J Nutr. 2004;134:1432–1438. 14. Whitaker RC, Phillips SM, Orzol SM. Food insecurity and the risks of depression and anxiety in mothers and behavior problems in their preschool-aged children. Pediatrics. 2006;118:e859–e868. 15. Oshansky SJ, Antonucci T, Berkman L, et al. Differences in life expectancy due to race and educational differences are widening, and many may not catch up. Health Aff. 2012;31:1803–1813. 16. Braveman P, Egerter S. Overcoming Obstacles to Health: Report From the Robert Wood Johnson Foundation to the Commission to Build a Healthier America. Princeton, NJ: Robert Wood Johnson Foundation; 2008. 17. Schiller JS, Lucas JW, Peregoy JA. Summary health statistics for US adults: National Health Interview Survey, 2011. National Center for Health Statistics. Vital Health Stat. 2012;10:1–218. 18. DeWalt DA, Dilling MH, Rosenthal MS, et al. Low parental literacy is associated with worse asthma care measures in children. Ambul Pediatr. 2007;7:25–31. 19. Commission on Social Determinants of Health. Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health. Final Report of the Commission on Social Determinants of Health. Geneva: World Health Organization; 2008. 20. Halle T, Forry N, Hair E, et al. Disparities in Early Learning and Development: Lessons From the Early Childhood Longitudinal Study—Birth Cohort (ECLS-B). Executive summary. Washington, DC: Child

22.

23.

24.

25.

26. 27.

28. 29.

30. 31.

32.

33.

34.

35. 36.

37.

38.

39.

40.

41.

S145

Trends. Available at:, http://www.childtrends.org/wp-content/ uploads/2013/05/2009-52DisparitiesELExecSumm.pdf; 2009. Accessed February 15, 2016. Flaherty EG, Thompson R, Litrownik AJ, et al. Adverse childhood exposures and reported child health at age 12. Acad Pediatr. 2009;9: 150–156. Dong M, Giles WH, Felitti VJ, et al. Insights into causal pathways for ischemic heart disease: Adverse Childhood Experiences Study. Circulation. 2004;110:1761–1766. Shonkoff JP, Garner AS. Technical report: the lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129: e232–e246. American Academy of Pediatrics. AAP agenda for children—strategic plan. Available at: https://www.aap.org/en-us/about-the-aap/ aap-facts/AAP-Agenda-for-Children-Strategic-Plan/pages/AAP-Age nda-for-Children-Strategic-Plan.aspx. Accessed August 30, 2015. Schickedanz A, Dreyer BP, Halfon N. Childhood poverty: understanding and preventing the adverse impacts of a most-prevalent risk to pediatric health and well-being. Pediatr Clin North Am. 2015;62:1111–1135. Forehand A. Mission and organizational performance in the healthcare industry. J Healthc Manage. 2000;45:267–277. Garg A, Toy S, Tripodis Y, et al. Addressing social determinants of health at well child care visits: a cluster RCT. Pediatrics. 2015;135: e296–e304. Survey of Wellbeing of Young Children (SWYC). Family Questions. Available at: http://www.theswyc.org/. Accessed February 15, 2016. Keller D, Jones N, Savageau JA, et al. Development of a brief questionnaire to identify families in need of legal advocacy to improve child health. Ambul Pediatr. 2008;8:266–269. Kenyon C, Sandel M, Silverstein M, et al. Revisiting the Social History for Child Health. Pediatrics. 2007;120:e734–e738. Bright Futures. Pediatric intake form. Available at: http://www. brightfutures.org/mentalhealth/pdf/professionals/ped_intake_form.pdf. Accessed February 15, 2016. Fleegler EW, Lieu TA, Wise PH, et al. Families’ health-related social problems and missed referral opportunities. Pediatrics. 2007;119: e1332–e1341. Welfare Peer Technical Assistance Network. The Earned Income Tax Credit (EITC): supporting the working poor in creating long-term self-sufficiency. Washington, DC: US Department of Health and Human Services. Available at: https://peerta.acf.hhs.gov/sites/default/ files/public/uploaded_files/EITC%20Newsletter.pdf; 2006. Accessed September 14, 2015. Dahl M, DeLeire T, Schwabish J. Stepping stone or dead end? The effect of the EITC on earnings growth. Madison, Wis: Institute for Research on Poverty, University of Wisconsin, Madison. Discussion Paper 1365–09. Available at: http://www.irp.wisc.edu/publications/ dps/pdfs/dp136509.pdf; 2009. Accessed September 14, 2015. Hoynes H, Miller D, Simon D. Income, the Earned Income Tax Credit, and infant health. Am Econ J Econ Policy. 2015;7:172–211. Milligan K, Stabile M. Do child tax benefits affect the well-being of children? Evidence from Canadian child benefit expansions. Am Econ J Econ Policy. 2011;3:175–205. Dahl GB, Lochner L. The impact of family income on child achievement: evidence from the Earned Income Tax Credit. Am Econ Rev. 2012;102:1927–1956. Taylor DR, Maniar P. The Children’s Advocacy Project of Philadelphia’s Cap4Kids Survey: an innovative tool for pediatrician–community-based organization collaboration. Clin Pediatr. 2007;46: 512–517. Wylie SA, Hassan A, Krull EG, et al. Assessing and referring adolescents’ health-related social problems: qualitative evaluation of a novel Web-based approach. J Telemed Telecare. 2012;18:392–398. Mendelsohn AL, Mogilner LN, Dreyer BP, et al. The impact of a clinic-based literacy intervention on language development in inner-city preschool children. Pediatrics. 2001;107:130–134. Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents. 3rd ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2008.

S146

FIERMAN ET AL

42. AAP Council on Early Childhood. High PC, Klass P. Literacy promotion: an essential component of primary care pediatric practice. Pediatrics. 2014;134:404–409. 43. Johnston BD, Huebner CE, Anderson ML, et al. Healthy Steps in an integrated delivery system: child and parent outcomes at 30 months. Arch Pediatr Adolesc Med. 2006;160:793–800. 44. Minkovitz CS, Hughart N, Strobino D, et al. A practice-based intervention to enhance quality of care in the first 3 years of life: the Healthy Steps for Young Children program. JAMA. 2003;290: 3081–3091. 45. Minkovitz CS, Strobino D, Mistry KB, et al. Healthy Steps for Young Children: sustained results at 5.5 years. Pediatrics. 2007;120: e658–e668. 46. Johnston BD, Huebner CE, Tyll LT, et al. Expanding developmental and behavioral services for newborns in primary care: effects on parental well-being, practice and satisfaction. Am J Prev Med. 2004;26:356–366. 47. Klein MD, Beck AF, Henize AW, et al. Doctors and lawyers collaborating to HeLP children—outcomes from a successful partnership between professions. J Health Care Poor Underserved. 2013;24: 1063–1073. 48. Weintraub D, Rodgers MA, Botcheva L, et al. Pilot study of medical– legal partnership to address social and legal needs of patients. J Health Care Poor Underserved. 2010;21:157–168. 49. Sandel M, Hansen M, Kahn R, et al. Medical–legal partnerships: transforming primary care by addressing the legal needs of vulnerable populations. Health Aff. 2010;29:1697–1705. 50. Romney MC. Medical–legal partnerships as a value-add to patientcentered medical homes. Health Policy Newsl. 2011;24:1–2. 51. Knight R. Health care recovery dollars: a sustainable strategy for medical-legal partnerships? White paper, Capacity and Sustainability Working Group. Boston, Mass: MLPC, Capacity and Sustainability Working Group. Available at: http://www.washingtonmlp.org/s/ Medical-Legal-Partnership-Health-Care-Recovery-Dollars.pdf; 2008. Accessed October 6, 2015. 52. Garg A, Marino M, Vikani AR, et al. Addressing families’ unmet social needs within pediatric primary care: the health leads model. Clin Pediatr. 2012;51:1191–1193. 53. Vasan A, Solomon BS. Use of colocated multidisciplinary services to address family psychosocial needs at an urban pediatric primary care clinic. Clin Pediatr. 2015;54:25–32. 54. Mendelsohn AL, Dreyer BP, Flynn V, et al. Use of videotaped interactions during pediatric well-child care to promote child development: a randomized, controlled trial. J Dev Behav Pediatr. 2005;26: 34–41. 55. Mendelsohn AL, Valdez PT, Flynn V, et al. Use of videotaped interactions during pediatric well-child care: impact at 33 months on parenting and on child development. J Dev Behav Pediatr. 2007;28: 206–212.

ACADEMIC PEDIATRICS 56. Mendelsohn AL, Dreyer BP, Brockmeyer CA, et al. Randomized controlled trial of primary care pediatric parenting programs: effect on reduced media exposure in infants, mediated through enhanced parent–child interaction. Arch Pediatr Adolesc Med. 2011;165:42–48. 57. Weisleder A, Mendelsohn AL. Reducing maternal depressive symptoms through promotion of parenting in pediatric primary care. Clin Pediatr. 2014;53:460–469. 58. Flores G, Walker C, Lin H, et al. A randomized controlled trial of the effects of parent mentors on insuring uninsured minority children [abstract 3650.3]. Paper presented at: Pediatric Academic Societies; 2015. 59. Coker TR, Moreno C, Shekelle PG, et al. Well-child care clinical practice redesign for serving low-income children. Pediatrics. 2014; 134:e229–e239. 60. Coker TR, Chacon S, Elliott MN, et al. Well-child care clinical practice redesign: a randomized controlled trial (RCT) of a parent coachled model for low-income children [abstract 1360.1]. Paper presented at: Pediatric Academic Societies; 2015. 61. Council on Community Pediatrics. The role of preschool homevisiting programs in improving children’s developmental and health outcomes. Pediatrics. 2009;123:598. 62. Sweet MA, Applebaum MI. Is home visiting an effective strategy? A meta-analytic review of home visiting programs for families with young children. Child Dev. 2004;75:1435–1456. 63. Olds DL, Sadler L, Kitzman H. Programs for parents of infants and toddlers: recent evidence from randomized trials. J Child Psychol Psychiatry. 2007;48:355–391. 64. Duggan A, Minkovitz CS, Chaffin M, et al. Creating a national home visiting research network. Pediatrics. 2013;132:S82–S89. 65. Avellar SA, Supplee LH. Effectiveness of home visiting in improving child health and reducing child maltreatment. Pediatrics. 2013;132: S90–S99. 66. Institute of Medicine. Primary Care and Public Health: Exploring Integration to Improve Population Health. Washington, DC: Institute of Medicine; 2012. 67. Tschudy MM, Toomey SL, Cheng TL. Merging systems: integrating home visitation and the family-centered medical home. Pediatrics. 2013;132:S74–S81. 68. Robert Wood Johnson Foundation. Health Care’s Blind Side: The Overlooked Connection Between Social Needs and Good Health. Summary of Findings From a Survey of America’s Physicians. Princeton, NJ: Robert Wood Johnson Foundation. Available at: http://www. rwjf.org/en/research-publications/find-rwjf-research/2011/12/healthcare-s-blind-side.html; 2011. Accessed September 14, 2015. 69. Centers for Medicare and Medicaid Services. The Affordable Care Act: helping providers help patients—a menu of options for improving care. Available at: https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/ACO/Downloads/ACO-MenuOf-Options.pdf. Accessed September 14, 2015.