This publication provides an overview of the importance of early childhood brain development and explores four examples of early childhood brain-building models that can be effectively integrated into health centers and pediatric practices. This information is intended for providers and funders interested in supporting early childhood brain development.

The first few years of life provide a critical window of opportunity to promote brain development. Early life experiences have life-long effects on a child’s health, social and emotional well-being, behavior, school success, and earning potential.^{1 2 3} During the formative first few years of life, a baby’s brain forms millions of new neural connections, providing the foundation for future learning, behavior, and health.^{4 5} To make sure kids get off to a good start, some of the essential ingredients include providing caregivers with information on early childhood development, ensuring families have the basic necessities, and supporting the physical and emotional health of children and families.

Pediatric primary care and well-child visits provide a unique opportunity for promoting positive parenting practices and connecting families to additional resources.⁶ Contact with pediatric providers is frequent during the first few years of life. In 2017, 90 percent of children in the US under two years of age received a well-child checkup during the preceding year.⁷ That same year in Texas, over 96 percent of one-year-olds and over 89 percent of children age two to six enrolled in Medicaid had a visit with a primary care practitioner in the last year.⁸ Pediatric providers have trusted relationships with parents and can support the mental and physical health of parents by connecting them with needed treatment, services, and resources.⁹

Four Examples of Brain-Building Models that Health Centers Can Implement

Health care providers interested in promoting early brain development in their practice have many evidence-based models from which to choose, based on the needs of their community, the resources and goals of the health center, and implementation costs. Below, we highlight four models that health centers can implement to enhance parent-child interactions and early brain development. With support from the Episcopal Health Foundation, Texans Care for Children conducted interviews with national experts and on-the-ground staff implementing each of these models.

Please note this is not an exhaustive list and is not meant to be an endorsement of these models.

Click below for more information about each model.

Reach Out and Read (ROR): Reach Out and Read aims to support family interactions through shared reading. Pediatric providers who implement Reach Out and Read use new, developmentally appropriate books to model reading, talking, and playing for families with young children ages zero to five during well-child visits. While modeling, pediatric providers educate families about developmental milestones for language, cognitive, fine motor, and social-emotional development and provide an example of how a caregiver and child can successfully engage in a shared activity. Additionally, the model gives providers another tool to conduct developmental assessments during well-child visits. Families take the new book home, help parents serve as their child’s first teacher.

Background

Founded in 1989 at Boston Medical Center, Reach Out and Read (ROR) seeks to help families make reading a part of their routines and to supply the books families need to get started. ROR’s national network is composed of a National Center, approximately 30 regional or statewide affiliates, 34,000 pediatric providers, and more than 6,400 program sites. The national ROR network currently serves 4.7 million children and their families in the US, half of whom are from low-income families.¹⁰

ROR Texas, a statewide affiliate, works with over 950 medical providers in some 220 health centers sharing more than 240,000 books annually. In Texas, Medicaid or CHIP covers approximately 65 percent of children who receive books through ROR.

Numerous independent, peer-reviewed studies show the impact and effectiveness of ROR¹¹ including increased likelihood of parents to engage children in literacy activities¹², increased attendance at well-child visits¹³, and greater print and phonemic awareness before kindergarten entry.¹⁴

Implementation

To become an official ROR program, applicants must commit to collect routine data, submit an application, determine how books will be supplied (i.e., have funding for a year’s worth of books), and complete the online training course on program delivery. Sites must also designate staff to fill two roles: a Medical Consultant (pediatric or family primary care MD, DO, NP, or PA) to champion the program and a Program Coordinator to manage administrative responsibilities. In small practices, it is common for a Medical Consultant to fill both roles. To be in good standing with Texas and National ROR, sites must have 75 percent of medical providers complete the online training. This requirement may limit the ability for individual providers within a larger practice to become an affiliate.

Providers typically give books to families through the child’s fifth birthday, but some sites provide books indefinitely. The National Center estimates that the book purchasing and delivery cost, along with the cost associated with delivering the program, such as provider training time and Program Coordinator time, is approximately $100 per child for the full five-year program.¹⁵ The low cost and easily accessible, brief online training allow for wide scale implementation. If keeping a continuous supply of books is challenging for a health center, then identifying multiple book sources may ensure the health center always has enough of the right books. For providers who offer books in beyond the five-year well-check or give books to siblings, it is particularly important to have multiple, affordable sources of books.

The ROR model includes center-wide strategies, such as having books and literacy promotion throughout the health center, which can strengthen the message to families that reading together helps promote early literacy.

We learned that ROR often paves the way for implementation of other brain-building models in the health center setting or centers implement ROR alongside other family supports. Many CenteringParenting sites in Texas, for example, integrate ROR into the group well-child visits. All active Video Interaction Project (VIP) sites also implement ROR, but there are no VIP sites in Texas as of late 2019.
Video Interaction Project (VIP): The Video Interaction Project (VIP) was developed as an enhancement to Reach out and Read (ROR) to promote parenting skills and family strengths in families with low incomes.¹⁶ VIP adds an additional staff member, known as an Interventionist, to the well-child visit. The Interventionist conducts video recordings of parent-child interactions and reviews the recording with parents to promote parent reflection and reinforce positive parenting behaviors.

Background

VIP was developed in NYU School of Medicine’s Department of Pediatrics and Division of Developmental-Behavioral Pediatrics. As of late 2019, no health centers in Texas have implemented VIP. It has been implemented in six New York sites and one site each in Pittsburgh, Pennsylvania and Flint, Michigan. Multi-site expansions are underway in New York City and Pittsburgh, but efforts to replicate the model are relatively new.

VIP has demonstrated significant improvements across developmental domains in empirical research.^{17 18} VIP is associated with enhanced social-emotional development¹⁹, lower levels of stress among parents, and decreased likelihood of developmental delays among high-risk families.²⁰

Implementation

The core component of VIP involves the Interventionist making video recordings of parents and their children engaging in play and/or reading aloud. The parent then reviews this video with the Interventionist, who reinforces responsive parenting behaviors and guides the parent towards better understanding with their child. Reflection is augmented with information on child development, toys, and books that are developmentally-appropriate as well as a copy of the video to review at home. VIP Interventionists have a Bachelor’s degree and speak the language of the primary population served.

Health centers implementing VIP can incorporate the Interventionist into the center flow for well-check visits. For example, the Interventionist may work with parents while they are waiting to see the medical provider or in between measurement, immunizations, and face-to-face time with center staff.

VIP implementation builds on the health center’s experiences integrating other models, such as ROR. All existing VIP sites implement ROR, and two sites implement HealthySteps as well.

The VIP Center of Excellence (COE) developed an implementation tool that includes preparing the medical provider who is championing VIP at the site to: serve as the day-to-day supervisor to the VIP Interventionist; integrate the Interventionist into the care team and work flow; identify spaces for confidential videoing and discussion; and provide storage space for equipment and materials. The COE provides training, clinical supervision, marketing materials, and patient tracking databases. The fact that the VIP Interventionist receives clinical supervision from the COE reduces the implementing organization’s responsibilities, allowing replication at a relatively low cost, approximately $175 to $200 per child per year.²¹

VIP accommodates a wide-range of adaptations for community cultural dynamics, including using live interventionist feedback without video and addressing prolonged caregiver separations due to reverse migration, or child welfare involvement. The SMART Beginnings project in New York City and Pittsburgh is a pilot that combines universally offered VIP to all families with newborns at two health centers (one in each city) with selected home visitation for populations with significant vulnerabilities.²²

For health centers in rural areas with a low volume of child well-checks, VIP Interventionists may take on other roles, including providing case management, assisting parents with completing screening tools, or completing other clinical tasks. The Interventionist may also serve two or more health center locations.
CenteringPregnancy and CenteringParenting: CenteringPregnancy is group prenatal care for women with similar due dates. It covers medical and non-medical aspects of pregnancy, including nutrition, common discomforts, stress management, labor and delivery, breastfeeding, and infant care. The model has been expanded to CenteringParenting, which brings parents, partners, support people, and their same-age infants together with their health care providers during child well-checks.

Background

Sharon Schindler Rising, a provider interested in more effective prenatal care, started the Centering model in the 1990’s. The model, now adapted beyond prenatal care, combines health assessment, interactive learning, and community building to help support positive health behaviors and drive better health outcomes through group medical visits. The Centering Healthcare Institute (CHI) works to extend access to their evidence-based framework for billable group medical visits across the US. CHI has scaled Centering to nearly 600 health care practices serving 70,000 families nationwide²³, including a number of Texas sites.

Numerous research studies have found that CenteringPregnancy improves outcomes²⁴ including lower risk of preterm birth, lower risk for low birthweight babies, fewer days in the neonatal intensive care unit, higher rates of breastfeeding initiation²⁵, and cost savings.²⁶ While the evidence base²⁷ for CenteringParenting is growing, there is a randomized control trial currently underway to determine the effectiveness of the CenteringParenting intervention on school readiness in early childhood, as measured by language development at 24 months, in addition to health care utilization, child routine care, parenting stress, and caregiver behaviors and attitudes²⁸. The Center for the Study of Social Policy featured CenteringParenting as an evidence-based model with the unique ability to help create opportunities for families to connect with other families, build deep social connections with one another and the care team, and learn about child development, parenting, and self-care from shared experiences.²⁹

Implementation

CenteringPregnancy group prenatal care follows the recommended schedule of ten prenatal visits, but each visit is 90 minutes to two hours long. Mothers engage in their care by taking their own weight and blood pressure and recording their own health data. Once health assessments are complete, the provider and support staff lead discussions and interactive activities designed to address timely health topics while leaving room to discuss what is important to the group. Mothers also have private time with their provider.

CenteringParenting follows a similar approach as CenteringPregnancy. CenteringParenting is CHI’s pediatric group care model that offers family-centered care to parents, caregivers, and children, who meet with their health care team for nine well-child visits over the first two years. Under CenteringParenting, a visit begins with individual well-child health assessments, immunizations, and developmental screenings that follow the American Academy of Pediatrics (AAP) Bright Futures™ nationally recognized guidelines.³⁰ Parents are engaged in their baby’s care, tracking growth, immunizations, and oral health. They engage in discussion and interactive activities on topics including attachment, safe sleep, breastfeeding, nutrition, early literacy, development, and safety. In CenteringParenting group sessions, parents and caregivers also monitor their own health goals and address key topics, including stress management, nutrition and weight, and family planning.

Both models can be adapted to address other needs. We encountered sites in Texas that integrated dental check-ups, food bank services, SIDS classes, car seat safety, maternal behavioral health, and WIC, for example.

Providers describe a number of benefits of the model, including its ability to help people take charge of their own health care, the model’s focus on community building, and the peer learning that takes place in group health care. Providers can see multiple patients at once, which limits the number of times that providers answer the same or similar questions while also increasing providers’ facetime with patients. In South Carolina the government has launched several initiatives to promote the adoption of CenteringPregnancy, providing additional evidence of the program’s impact. A study of the South Carolina program found cost savings from better outcomes (fewer babies born at a low birthweight and fewer neonatal intensive care unit visits) due to participation in CenteringPregnancy among low-risk pregnant women with Medicaid.³¹

There are a few key steps for sites that want to implement Centering. They must convene a steering committee and assign a Centering Coordinator to manage and support the work. Both models of group care require changes to the work flow and scheduling. An appropriate space is required to conduct the group, which is often a barrier for health centers with limited space.

In interviews with Centering sites in Texas, they identified additional steps and challenges to consider. They noted that having multiple providers implement the model allows for rotating schedules. Additionally, interviewees pointed out that it was important for all staff to know how to explain Centering. Challenges included accurately estimating the amount of staff time needed for scheduling and administrative tasks. Health centers can sometimes benefit from extra Medical Assistants to help with administration and serve as a co-facilitator of the group. Health centers noted that adequate funding is needed to cover start-up and accreditation costs, training expenses for new staff, and ongoing training of existing staff. Some staff stated that providing child care for siblings during groups is a major challenge.

Group composition and dynamics are critical to initial implementation and retention of group members. CenteringPregnancy research has shown the model to be successful with various populations from different racial and ethnic backgrounds.^{32 33 34} In Texas, three of the five sites we interviewed stated that Hispanic moms have higher retention rates.

Sites often start with CenteringPregnancy and add CenteringParenting as mothers give birth and continue group care for well-child visits. For this transition to go smoothly and to accomplish the best continuity of care, prenatal, postpartum, and pediatric practices must be integrated. Integration may be easier for community health centers that provide a range of services across a patient’s life and have services that are co-located.

An increasing number of states, including New Jersey, New York, South Carolina, and Montana, are leading collaborations between state agencies, payers, and providers to integrate CenteringPregnancy and value based-payment within maternity care. Strategies include enhanced reimbursement and expansion of their Medicaid programs.³⁵

In Texas, Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs) may be better positioned to cover the costs to deliver and support the Centering model than small independent practices because they are paid an all-inclusive encounter rate. However, this rate may not cover all of the costs of staff time to recruit and schedule families, conduct administrative tasks, and coordinate the combination of group and individual medical care. CHI provides Implementation Awards to FQHCs and Community Health Centers interested in starting Centering in their communities. The Awards include customized implementation support and group facilitation training.³⁶

Texas Medicaid policy offers an option for curriculum-based group prenatal visits, with a procedure code modifier for billing, and explicitly describes CenteringPregnancy as a qualifying curriculum. However, there is not an equivalent option for group well-child checks in Texas Health Steps.
HealthySteps (HS): HealthySteps (HS), a program of ZERO TO THREE, is an evidence-based, interdisciplinary pediatric primary care program that promotes the health, well-being, and school readiness of babies and toddlers, with an emphasis on families living in low-income communities. HS includes leadership from a Physician Champion and a child development professional, known as a HealthySteps Specialist, who is integrated into the primary care team and provides tailored support for common and complex concerns that physicians may not have time to address in well-checks.

Background

ZERO TO THREE piloted HS in two sites, in Washington, D.C., and Virginia, in 1995. The Commonwealth Fund then funded replication efforts at Boston University School of Medicine and a national randomized controlled trial conducted by Johns Hopkins University. Over the next 20 years, the HS network grew gradually to 74 sites with minimal financial support from Boston University School of Medicine. ZERO TO THREE reassumed responsibility for the program in 2015 and began leading National Office operations. Since then it has worked to strengthen and formalize the network.

In late 2019, there were 162 HS sites nationwide, including one in Texas in Tarrant County.³⁷ Initially implemented by health care centers, many recent replications have been led by other types of community organizations working closely with pediatric primary care providers.

Under the model, HS Specialists join the pediatric primary care team to ensure universal screening and provide interventions, referrals, and follow-up to the whole family. HS Specialists address common and complex concerns, including feeding, behavior, sleep, attachment, depression, adapting to life with a baby or young child, and other social service needs. The HS population-based, risk-stratified model includes three tiers of intervention intensity. Tier 2 and Tier 3 include clinical mental health support.

HS effectiveness was studied through a 15-site national evaluation and was found to prevent negative child and parent outcomes and enhance positive outcomes,³⁸ including greater security of attachment, fewer child behavior problems,³⁹ and improvement in some parenting practices beyond the duration of the intervention.⁴⁰ Results from one site-level evaluation included discussion of important developmental topics more often during well-child visits and timelier well-child visits and immunizations.^{41 42}

Implementation

The ZERO to THREE HS National Office outlines pre-implementation requirements with training and core components requirements that must be met within three years of implementation, including team-based well-child visits, child and family screening, child development and behavior consultation, care coordination, and positive parenting guidance and information. The HS model allows flexibility in the delivery of the core components.⁴³

Health care system leadership engagement and buy-in are reported as key to implementing HS. This model works best when medical providers are open to adapting traditional practice to more of a team-based approach.

Working shoulder to shoulder with the medical provider, the HS Specialist draws on the trusted relationship the provider has with the family. HS Specialists work with families on previously unidentified and unaddressed issues families are facing. One HS Director described the HS Specialist as asking the questions no one else is asking. The HS Specialist pays close attention to parent responses during screenings and celebrates a child’s cognitive, behavioral, and social-emotional development to connect with and engage parents. It is important that the language and racial and ethnic diversity of the HS Specialists reflects who they serve.

The data collected by HS Specialists can provide a valuable feedback loop so that communities, providers, and families can better identify and understand the challenges to healthy child development and therefore develop a clear plan to address the challenges.

Currently, Texas Medicaid and CHIP policy limits the screenings that are eligible for reimbursement. Without expansion of those policies, Texas Medicaid or CHIP will not reimburse for many of the screenings conducted by the HS Specialist. Some clinical interventions for families with high needs, provided to families in Tier 2 and Tier 3, are provided by HS Specialists who are Licensed Mental Health Clinicians and may be eligible for billing insurance. Implementing organizations will need safeguards to ensure the services offered by the HS Specialist are not restricted to services eligible for Medicaid/CHIP reimbursement. Funding from Healthy Outcomes through Prevention and Early Support (HOPES), which is administered by the Prevention and Early Intervention (PEI) division of Texas Department of Family and Protective Services, can be used to implement a variety of home visiting models with adaptations based on individual community needs, including implementation of HS in Tarrant County, TX.

References

  
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Zuckerman, B. “Two-Generation Pediatric Care: A Modest Proposal.” PEDIATRICS Volume 137, number 1, January 2016. http://pediatrics.aappublications.org/content/pediatrics/137/1/e20153447.full.pdf

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Reach Out and Read - National Center.  https://reachoutandread.org/why-we-matter/the-evidence/

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Mendelsohn, A.L. PowerPoint presentation “Innovative Models for Preventing School Readiness in Pediatric Primary Care.” June 7, 2018. https://www.videointeractionproject.org/about-vip.html

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Resource for Providers and Payers from HealthySteps: https://www.healthysteps.org/article/national-and-site-level-evaluations-9

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