Insights for Change

So Much for Effectively Managing My Travel Schedule!

By: Paul H. Dworkin, MD

I typically find the time between early fall and the winter holidays to be an incredibly busy travel period. I suspect that this is due to a combination of returning to full activity after the summer vacation lull and organizers attempting to schedule meetings prior to the onslaught of weather challenges and holiday-related family activities. I pride myself on being cognizant of the perils of travel overload and the weariness that comes with spending too much time in airports, so I try to be highly selective in my commitments. Yet a recent array of attractive and meaningful opportunities encouraged me to let down my guard and participate in five important and valuable national meetings within a span of four weeks.

While each convening offered a distinct framing and agenda, all of them related to the theme of how to best provide integrated care for children within the context of health care reform and the evolution to value-based care payment models. The convenings varied in the extent to which they focused primarily on health care reform and child health services transformation, or on broader considerations relevant to early childhood comprehensive system building. Despite differences in framing and emphasis, the meetings introduced and reinforced a collection of critical concepts with important implications for our collective efforts to strengthen families and promote children’s optimal health, development, and well-being.

I am pleased to attempt to highlight select implications from this series of convenings that are of special relevance to our efforts at Connecticut Children’s Office for Community Child Health. Admittedly, the selections reflect my personal bias and interests, and are not intended to be comprehensive in nature.

Destination 1: Los Angeles

In early November, I attended the first annual meeting in sunny Los Angeles of the Lifecourse Intervention Research Network (LCI-RN), which was organized by the UCLA Center for Healthier Children, Families, and Communities and supported by the Maternal and Child Health Bureau. The primary objective of the meeting was to provide a brief overview of the LCI-RN and to share and build connections as a network, while also beginning the development of the network’s research nodes. Helpful themes for the many discussions included a three-horizon framework for change (incremental, disruption, transformational); science as an inherently incremental model; the distinction between the biomedical model of health systems and the biopsychosocial, life course health development model of healthcare systems; and screening as a starting point for discussion with families, as opposed to an algorithm for referral. As with many of the convenings, participants engaged in extensive exploration of meaningful life course outcomes. While we did not reach consensus, many participants agreed that potential measures worthy of consideration include school readiness, high school graduation, incarceration, stable full-time employment, and homelessness.

Destination 2: New York City

After crisscrossing the country, I attended a convening on toxic stress and Medicaid organized by The JPB Foundation in New York City. The meeting attendees included grantees in the Foundation’s toxic stress portfolio, including our Help Me Grow National Center, as well as those focused on Medicaid. Despite this diversity among attendees, participants validated and reinforced a number of key themes and issues integral to our work. Select examples included:

  • the importance of a focus on the early identification of ”rising risk” children and families;
  • the notion of nurturing to promote early childhood development;
  • the imperative of two- and multi-generational approaches to strengthening families, including the importance of parent activation and co-production of programs and services;
  • care coordination as a crucial component of system building;
  • and the profound importance of addressing social and environmental issues, as exemplified by the need for healthy, stable, and secure housing.

As in other convenings, speakers cited the potential for expanding the role of Medicaid reimbursement to include social and educational needs, such as affordable housing and interventions to advance student success in school. Policy discussions included:

  • the worrisome, recent decrease in children’s Medicaid enrollment;
  • the opportunity for states to assume primary responsibility for leveraging Medicaid to strengthen families;
  • the benefits of blending administrative and financial resources to achieve economies of scale;
  • the untapped potential of demanding accountability for federal Early Periodic Screening, Diagnosis, and Treatment (EPSDT) guidelines;
  • and the potential for demonstrating cost savings, cost benefit, and return on investment over both the short and long term to justify investments in early childhood.

The meeting organizers challenged attendees to consider such daunting issues as how to define and achieve scaling of efficacious innovations, how to best ensure sharing of information across sectors such as health and education, and how to elevate such critical but ethereal attributes as hope into meaningful and measurable outcomes. Participants were also challenged to consider how they may best collaborate to achieve common goals.

Destination 3: Washington, DC

Next, in mid-November, I was on to the first of three convenings held in the nation’s capital. The UCLA Center on Healthier Children, Families, and Communities partnered with the Washington, DC-based Duke-Margolis Center for Health Policy to organize, “Designing the Future of Value-Based Payment for Kids.” The meeting featured a “deep dive” into alternative payment models. It highlighted the differing beliefs and experiences of those engaged with such models, the extent to which such models focus on medical care rather than social determinants, the diverse thinking regarding specific model details, the many challenges to implementation, and the inability to identify any “ideal” single model to inform current efforts. Discussion achieved consensus on the importance of a focus on health promotion, demonstrating value for families, engaging diverse sectors, advancing the notion of accountable health communities, engaging all payers in model design, identifying meaningful short- and long-term outcomes, the need for risk stratification, opportunities for blending and braiding funding, and advancing the need for longer time frames to capture return-on-investment. A far-ranging discussion on outcomes offered a wide array of potentially meaningful and provocative options, such as pregnancy intentionality, infant mortality, mood disorders, childcare expulsion, out-of-home placements, school readiness, literacy, school absenteeism, high school graduation, equity, and juvenile justice. Formidable challenges include ensuring access to information and the utility of a highly functional information technology platform, securing the critical role of a backbone/integrator organization, and best engaging community members and the need for community-level measures.

Destination 4: Washington, DC Again

The Center for the Study of Social Policy next hosted a two-day convening of their Pediatrics Supporting Parents (PSP) Medicaid and CHIP State Implementation Workgroup just before Thanksgiving. Seven participating states included many affiliates of the Help Me Grow National Center. I had the opportunity to share our thoughts on how we can, and must, leverage Medicaid to transform child health services. In doing so, I acknowledged both the “golden opportunity” afforded by the explosion in our knowledge of brain development, early child development, and the “biology of adversity” (i.e., toxic stress, adverse childhood experiences, social determinants of health, inequity), as well as the “burning platform” of the growth in retail clinics that challenge the viability of child health services as we know them. Specific discussion focused on how to best leverage benefits afforded by the EPSDT program and a sharing of states’ innovative approaches to improving children’s health and well-being. A poignant conversation offered insights on strategies to address inequity, including authentic partnering, inclusion, shared benefits, commitment to the future, responsiveness to the cause of inequities, and humility.

Destination 5: Washington, DC Yet Again

The series of meetings concluded in early December with a convening organized by the Nemours Children’s Health System in collaboration with the Duke-Margolis Center for Health Policy entitled, “Paying for Value and Integrated Care for Children and Families.” Nemours leadership spoke emphatically and inspirationally on the immense power of investing in children’s health and the extent to which this is a smart investment based on a relatively modest cost and the capacity to redefine health outcomes. They highlighted the Integrated Care for Kids (InCK) model to illustrate the Center for Medicare and Medicaid Innovation’s (CMMI) focus on children and families, including integrating physical and behavioral health, linking home-based and center-based care, and committing to meaningful outcome measures. I was pleased to have the opportunity to share Connecticut’s State Innovation Model and highlight the role of Health Enhancement Communities in strengthening the capacity of the medical home as a health neighborhood. Discussion on pediatric alternative payment and delivery models reinforced many themes expressed at the earlier convenings, including:

  • the need for payment models to support, rather than drive, the care delivery model;
  • the need to focus on long-term benefits and implications;
  • the opportunity created by the impending mandate for Medicaid quality metrics;
  • and the advantage of integrated payer and provider systems.

Discussion also highlighted the imperative of cross-sector data sharing, workforce redesign, and patient and community engagement and equity. Oregon and New York leaders shared descriptions of exemplary, state-level models. The meeting concluded with experts speaking on such critical issues as the blending and braiding of funding mechanisms and governance structures to create alignment across payers and community partners.

My Key Takeaways

During all convenings, I consistently attempted to validate critical themes that we embrace and promote within our work. Fortunately, such validation was plentiful. Examples of such themes include, but are not limited to, the imperative of cross-sector collaboration and data sharing, the utility of technology applications, the need to focus on model and system sustainability, the utility of measuring efficacy through both proximate and distal outcome measures, the wisdom of advancing an approach of “targeted universalism,” the importance of framing issues to secure support while balancing measures of model fidelity and core components with the notion that, “all politics is local,”  the elevation of developmental promotion rather than prevention as our ultimate goal, the importance of a focus on strength-based approaches, and the need to advance collective efficacy at the community level.

Admittedly, discussions raised more critical questions than definitive answers. Furthermore, the challenges of child health services transformation and system reform are daunting. Nonetheless, the unprecedented attention to critical issues led by such an impressive array of experts and prestigious organizations is reason for optimism. These convenings reinforce the extent to which we share a collective mission and vision. We must all pledge to nurture our partnerships and our collective engagement to achieve our common goals for child health services transformation.  Together, we can and will succeed.

Read more of our Insights for Change blogs here.

Paul H. Dworkin, MD is executive vice president for community child health at Connecticut Children’s, director of Connecticut Children’s Office for Community Child Health and founding director of Help Me Grow National Center. Dr. Dworkin is also a professor of pediatrics at UConn School of Medicine.  Learn more »

To sign up to receive E-Updates from Connecticut Children’s Office for Community Child Health, click here.

Leave a Reply