2. Healthy Steps: Integrating Research Into Pediatric Practice Kathleen D. Ramos, PhD Rick Brandt-Kreutz, MSW, LCSW CHCC Pediatric Resident Workshop 1 August 2006

3. Agenda Background: What is Healthy Steps? Results of Fresno research on the Cadillac model of Healthy Steps How the Healthy Steps program at CHC is changing Plans for research on the new model Opportunities for residents to answer their research questions

4. Healthy Steps for Young Children 1994: Commonwealth Fund and Boston University 1995: 24 original sites Today: 34 sites

6. “I think Healthy Steps can help us do better what we already do.”

7. Healthy Steps Fresno and First 5 Grant: 2003 – 2006: $453,490 220 kids/families ≈43 residents

8. Healthy Steps Fresno COST? $933/year@162 families $402/year@463 families Fresno? $687/year@220 families

9. Components: Enhanced Well Child Care Home Visits by HSS Telephone Information Line Developmental Screening Special Printed Material Parent Groups Linkages to Community Resources Reach Out and Read Healthy Steps Families Clinical Team + Healthy Steps Specialist (HSS) * JAMA 12/17/03 Focuses on Behavior and Development Nurtures Families Provides Important Information Parents Want and Need Outcomes* Infants sleep on back Moms openly discuss feelings of sadness Moms use less physical punishment Moms match behaviors to children’s development Greater compliance with immunization schedule Parents and physicians more satisfied with care Quality Enhancement in Pediatrics and Family Medicine for Children 0 to 3 THE CADILLAC MODEL

10. Healthy Steps Healthy Steps Specialist followed a caseload of 220 patients with all the Healthy Steps services Protocol of intensive individual and family services Independent AND alongside the resident THE CADILLAC MODEL

11. Did it Help? Yes! (but only small numbers of families) How do we know?

12. Healthy Steps More likely to nurse beyond 12 months (33% HS versus 9% comparison) Less likely to introduce water (35% vs 75%), cereal (7% vs 34%), and other foods early Dads more involved in diapering (77% vs 60%) and bathing (67% v 42%) baby Moms and dads read to baby more frequently Moms more often offer explanations to children and less often use harsh parenting (threaten, yell, slap, spank) Less likely to visit the ED (0% vs 28% of toddlers)

13. The New Healthy Steps… The Prius Model

14. Healthy Steps Pediatrics and Family Medicine Expanded to Family & Community Medicine Healthy Steps Institute: October 24-26 Follow the resident and the resident’s patient Focus on education Community Expansion Support The Prius Model

15. http://www.fresno.ucsf.edu/pediatrics/program_info.htm Fresno, California supported by a grant from First 5 Fresno

16. Other Questions Did the Cadillac Model improve mother- child attachment? –Strange Situations being conducted this summer –Video clips: Quality of play Secure base behavior Self-soothing Avoidance & Resistance Secure behavior

17. Other Questions Do securely attached pairs show up for more well-child checks? Get sick less? Use clinic instead of ED? –Adults with secure attachment styles are more compliant patients, keep chronic diseases under better control, and trust their doctors more. Is infant sleep (particularly cosleeping and sleep training) related to security of attachment?

18. Other Questions Prevalence and correlates of bed-sharing among Mexican immigrant families –0-5 months: 68% –6-12 months: 63% –12-14 months: 62% Similar to other studies, bed-sharing is more common in father-absent homes; among young babies, associated with breastfeeding. Unlike other studies, bed-sharing is consistent across ages.

19. Other Questions What do you want to know about the clinic patients that we might be able to answer using this dataset? –Feeding –Reading promotion –Father involvement –Harsh parenting –Sleep habits –Attachment