Project HOME 3-year $1.2M grant funded by the Office of Head Start, Administration for Children and Families Project Team Lise Youngblade, PhD, & Karen Caplovitz Barrett, PhD, co-Principal Investigators Collaborators: Francisco Palermo, PhD, Department of HDFS Jonna Pearson, PhD, Department of Journalism and Technical Communication Ann Bruce, PhD, CSU Extension Kimberly Miller, PhD, Tri-Ethnic Center and Department of Psychology Jennifer Anderson, PhD, & Laura Bellows, PhD, Department of Food Science & Human Nutrition Graduate Students (Laura Hahn, Jamie Wensink, Liz Zimmerman, Melanie Kelsea, April Thomas, Lydia Linke, Marie LeHaye, Hayley Jackson) Partners Head Start State Collaboration Office CO Department of Public Health & Environment, CO Medical Home Initiative CO Department of Health Policy & Financing Head Start programs in 3 Colorado areas

Goal To refine, implement, evaluate, and sustain a family-empowering, culturally sensitive, replicable train-the-trainers curriculum for improving Head Start families’ healthcare literacy skills

Background Children eligible for Head Start are at risk for non-optimal use of the healthcare system. Risk factors include: Low SES (income, education, resources, challenging life situations) Cultural factors System barriers These risk factors, in concert with non-optimal use of healthcare, set children on potential pathway to increasingly poor health outcomes and concomitant expensive service utilization. Has an accelerated effect because effects of poor health early in life are difficult to reverse, become more complex with added comorbidities, and become extremely expensive to the system. None of the risks are completely presumptive, so great opportunity for early intervention.

Background An important impediment to low-SES families’ optimal use of the healthcare system is their need for further knowledge and skills related to: Recognizing health warning signs and knowing how to respond Understanding common childhood illnesses Distinguishing symptoms that require a visit to a healthcare provider from those that one can care for at home An intervention study showed that such healthcare training with Head Start families can reduce emergency department and clinic visits (Herman & Mayer, 2004; Herman, 2007). Parent report of Medicaid utilization suggested reduced Medicaid costs Project HOME will adopt a more stringent approach of accessing actual Medicaid program usage data.

Background Health policy has grappled with these issues and coalesced around a model of pediatric access known as “Medical Home” Medical Home is not a place, but rather a set of guiding standards for ensuring that healthcare is accessible, community based, family-centered, continuous, comprehensive, coordinated, compassionate, and delivered in a culturally competent environment Medical Home promotes an empowering partnership between family and provider, and creates a coordinating center for both medical and non-medical needs When implemented, research demonstrates improvement in access to care, pediatric health outcomes, improved system efficiencies, and control of healthcare spending

Expected Outcomes Goal: Improve Healthcare Literacy Skills for Head Start Families. Improved parent knowledge about health, use of healthcare and available resources Increased understanding about Medical Home Improved parent behavior with increased use of preventive care, identification of medical home and decreased inappropriate ER and clinic use. Increased preventive health behavior (eating and physical activity)

Intervention Components Three areas What to do when their child is sick Understand the healthcare system, what a Medical Home is & why it is important Promote health through nutrition and physical activity We train Head Start family workers and other interested staff to provide this curriculum Head Start staff provide parent training

Training Materials Used What to do when your child gets sick English & Spanish Medical Home Brochure Medical Home Resource List Food and Activity Cards

Measures Pre/post knowledge tests at each parent meeting Medical Home (4 multiple-choice questions) What to do when your child is sick (11 multiple-choice questions) Each question has 1 right answer Parent surveys (baseline, 1 month, 3 months, 6 months) Demographics Healthcare utilization (self report of source & amount of use) Medical home assessment of usual source of care (qualities, barriers) Healthy Eating and Physical Activity

First Year Consents and at least some Surveys from 132 families (72 Spanish, 60 English); 83% Hispanic/Latino; 6% Native; 2% each Black, Asian; 52% of children were girls 79 have pre/post training data 39 have pre/post/follow-up for medical utilization reports, medical home, and nutrition/activity outcomes

First Year Initial Results: Knowledge Compared test average from pre-to-post: Parents improved from 63% correct to 68% correct on Medical Home test (trend level significance, p < .08). Parents improved from 76% correct to 87% correct on What to Do When Your Child is Sick test (statistically significant at p < .001) Compared by primary language, English-speaking and Spanish-speaking parents showed the same pattern of results, although overall English-speaking parents had greater percentages of correct answers.

First Year Initial Results: Healthcare Utilization Pretest--Posttest—Followup Contrasts F(1,37): Times Visit doctor when sick : significant linear decline from 2.05 to 1.54 times in past 3 months, F(1,37)= 10.52 p = .003 Times see specialist: no change (1.26 to 1.21). Times go to ER when sick: significant decline pre to post, from 1.23 to 1.08, F(1,37) = 4.83 p=.034 Times go to ER when hurt: no change from 1.03 to 1.00 Days child absent from preschool: significant linear decline from 2.28 to 1.13, F(1,37) = 52.68 p <.001 Days parent misses work due to child illness: significant linear decline from 1.36 to 1.08, F(1,37)= 9.735 p =.003. No interaction with language, but Spanish speakers report slightly lower overall absence from preschool

Change from Pretest to Follow-up

Change from Pretest to Follow-up

Change from Pretest to Follow-up

First Year Initial Results: Identification of medical home Pretest—Posttest—Follow-up Contrasts: Pre-post increase in families’ identification of medical homes for their children (F[2,34]=8.579, p<.0001). Qualified by ethnicity (Latino or non-Latino; F(2,34)=3.816, p<.05)

Change from Pretest to Follow-up Percentage of Families Identifying Medical Home

Change from Pretest to Follow-up Percentage of Families Identifying Medical Home: by Latino Ethnicity

First Year Initial Results: Nutrition and Activity Pretest—Posttest—Follow-up Contrasts: Child Behavior: Child ate fruit/vegetables in last week: no change Child spent 15 minutes in physical activity with parent: no change Child watched TV: significant linear decrease Parent beliefs: Importance of child eating fruit/vegetables: significant increase Importance of child being physically active: significant increase

Change from Pretest to Follow-up Child watched TV

Change from Pretest to Follow-up Important for child to eat fruits/vegetables

Change from Pretest to Follow-up Important for child to be physically active

Limitations and Future Directions Restricted sample size, missing data Use of parent report Lack of control group Future directions Evaluate impact on behavior through analysis of Medicaid claims Additional sites with diverse families Modifications in training Inclusion of control group