I was honored to be invited to share my thoughts on the transformation of pediatric health care for the 2020 Paul H. Dworkin, MD Lecture. This lecture, given annually as a Pediatric Grand Rounds session at Connecticut Children’s, is named for Dr. Dworkin, a leading advocate in the growing call for child health providers to better address child well-being in collaboration with the community services that support children and families. This blog highlights the key points of my lecture about transforming child health services to ensure child well-being, promote equity, and ensure that child health services are front and center in health reform efforts.
Disparities in Early Childhood
Connecticut Children’s 2019 Community Health Needs Assessment (CHNA) highlights many disparities between Hartford residents and state residents in regards to income, poverty, high school graduation rates, chronic school absenteeism, health insurance, and disabilities.
The CHNA also articulates another deeply concerning issue – although all children have access to free public education, children in Hartford are entering our public education system already behind their suburban peers. Children in other urban areas face the same problem. Only 33% of Hartford children enter kindergarten on track and ready to learn, according to the Hartford Foundation for Public Giving’s report of the Early Development Instrument completed by kindergarten teachers in Hartford and West Hartford. Our schools cannot make up for all the disparities that are set in motion before children even enter their classrooms.
When we look at the reasons why children are not ready for school – documented in large, national, longitudinal studies – we see that health concerns and social-emotional issues exist for two-thirds of the children who lag behind in cognitive skills in kindergarten. Health and behavioral health are within the purview of pediatric primary care, a service that just about all children use frequently during the years before school entry. Therefore, the value of transforming pediatric primary care to increase its contribution to child well-being has far-reaching implications for the future of children and our population as a whole. Healthy children can attend, do well in, and benefit from school and ultimately participate in the workforce and our democratic society.
The question then becomes, what do we need to do to transform child health services to better address children’s well-being?
Essentials for Transformation
With funding from the Children’s Fund of Connecticut and the Connecticut Health Foundation, the Child Health and Development Institute convened a study group to explore transformation of pediatric primary care to increase its contribution to population health, promote health equity, and achieve better integration with community services. The study group’s work identified several essential components of transformed pediatric primary care, but I think three are most important.
First, we must connect child health services to the broader community, and all of its supports for children and families. Such connections allow child health services to better address the social determinants of health. By strengthening connections between child health and community services, we take advantage of all of the services that contribute to children’s well-being, including childcare, schools, home visiting, nutrition and housing services. Currently, the United States spends more on healthcare and less on social services than any other developed nation. Yet, we have the worst health outcomes. By embracing an “all sectors in” approach to healthcare transformation, we can start to reduce those overall costs and improve the overall health and well-being of our population, beginning with children.
Second, we need to identify and commit to outcome metrics that are shared across sectors. We will never achieve the outcomes that are predictive of lifelong success unless we gain cross-sector commitment to shared outcomes. States are increasingly holding health services accountable for such outcomes as school readiness, school attendance, third grade reading, and rates of high school graduation. If health care organizations continue to measure and monitor only their own performance in isolation from the larger set of services that contribute to children’s well-being, we will yield little to no forward progress. We must commit to and measure outcomes that are the result of service systems working together.
Third, we need to ensure that value-based payment reform recognizes and rewards the promotion and prevention opportunities in pediatric primary care. In addition, all payers must participate in new payment models as pediatric primary care sites cannot transform for one or a few payers only; they provide a universal service and need to deliver services equally for all children. Reform also needs to encompass payment for other services beyond office visits. Some of the services that can bring value include: telehealth, co-management, and home visiting.
Signs of Change
State Medicaid programs, health plans, and provider networks are already taking steps to pave the way for transforming pediatric care.
Oregon has advanced to a cross-sector measurement approach that embraces kindergarten readiness and third grade reading levels as essential outcomes for pediatric primary care services. Nationwide Children’s Hospital in Columbus, Ohio is committed to improving high school graduation rates among its community’s youth. Cincinnati Children’s is holding child health providers accountable for unaddressed vision and hearing problems.
In Connecticut, Medicaid is reimbursing providers for performance under the Person Centered Medical Home and Person Centered Medical Home Plus programs, encouraging improved performance in areas such as developmental and behavioral health screening and care coordination.
Also in Connecticut, the state Office of Healthcare Strategy is supporting Health Enhancement Communities, hubs that will facilitate and coordinate cross-sector collaboration among community resources that contribute to the health of children and families. Key outcomes for the Health Enhancement Communities are child well-being and healthy weight. This strategy will enhance protective factors for families, including: supporting social connections; building resilience so families can better handle life’s challenges; increasing knowledge of parenting and child development; providing concrete support in times of need; and addressing socio-emotional needs of children and their caretakers. Protective factors, as put forth by the Center for the Study of Social Policy, are measureable and impactful.
We have a tremendous opportunity to drive change that will truly make a difference in outcomes across the lifespan. I encourage families, providers, hospitals and payers to be bold in their thinking. Together, we can transform child health services and ultimately enhance both long-term outcomes and equity.
Lisa Honigfeld, PhD, is senior advisor to Connecticut Children’s Office for Community Child Health and vice president for health initiatives at the Child Health and Development Institute of Connecticut.
 Connecticut Children’s Medical Center. 2018 Community Health Needs Assessment. Available online: https://www.connecticutchildrens.org/wp-content/uploads/2017/02/CHNA-2016.pdf
 Hartford Foundation for Public Giving, results of the Early Development Instrument, 2013 to 2014 https://www.hfpg.org/files/9814/3645/2152/EDI-report2015-final.pdf
 Wertheimer R, Croan T, Moore KA, Hair EC. Attending kindergarten and already behind: a statistical portrait of vulnerable young children. Washington, DC: Child Trends; 2003.
 See the full report from the Study Group: https://www.chdi.org/index.php/publications/reports/other/transforming-pediatrics-support-population-health
 Bradley, Elizabeth H., and Lauren A. Taylor. The American Health Care Paradox: Why Spending More Is Getting Us Less.
 Center for the Study of Social Policy, Protective Factors Framework.
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Categories: Insights for Change