By age three, a child’s brain has grown to 80 percent of its adult size and experiences during the first 1,000 days are critical to healthy brain development and social, emotional, cognitive, language, and physical development. Preventive measures taken in the first few years of life can have a significant and lasting impact on a child’s future health outcomes and overall success. New York is honing strategies to support healthy development during the first 1,000 days through primary care and trauma prevention strategies.
In October 2019, New York released recommendations from its Final Report of the First 1,000 Days Preventive Pediatric Care Clinical Advisory Group as part of the First 1,000 Days on Medicaid redesign initiative, which was launched in July 2017. It recognizes the critical role that Medicaid can play in the early life of children to help set them up for future success. The initiative also aims to work collaboratively with education programs and other sectors to deliver better results for children in New York.
Later in 2017, a group of stakeholders from different sectors and agencies, including education, child welfare, community-based organizations, public health, and mental health, convened to produce a plan for 10 proposed activities to be part of this initiative. Their first goal was to create a Preventive Pediatric Care Clinical Advisory Group that would develop a framework model for how to organize pediatric care in order to implement the Bright Futures guidelines. The framework model would identify barriers, possible incentives, and new system approaches to deliver the most effective care possible during well-child visits.
The advisory group included members from several child- and family-serving sectors that frequently partner with pediatric primary care, such as education, Early Intervention, and child welfare, and the group also sought feedback and participation from family representatives and community groups. The report, produced in October for the New York Medicaid program, details the group’s Model of Pediatric Population Health, which aims to build on the patient-centered medical home model with higher standards of care and care coordination. The focus of the model is on practice transformation to address the social determinants of health related to poverty, racism, and other environmental influences, and it integrates behavioral health care with traditional clinical care. The model lays out three tiers for integrating behavioral health:
- Tier 1: Services received by all children:
- Screening: Age-appropriate screenings for child development, maternal depression, and adverse childhood experiences (ACEs), social-emotional development, social determinants of health, and interpersonal violence
- Culturally sensitive anticipatory guidance focused on social-emotional/family health (e.g., Reach Out and Read, Vroom, lactation counseling, parent access for questions)
- Information about community resources (e.g., Head Start)
- Tier 2: Services received when a child or parent has an identified need: (Examples include developmental delay, housing or concrete services need, trauma, or maternal anxiety)
- Short-term counseling by early childhood mental health-trained professionals
- Care coordination by staff knowledgeable about early childhood services to facilitate connection with community resources
- Follow up and escalation to Tier 3 if needed
- Care delivered in a collaborative care model by the primary care provider, with support from mental health professionals either in the practice or remotely via tele-health
- Tier 3: Services received when a more complex need is identified for a child or parent
- Therapeutic intervention (e.g., dyadic therapy, parental mental health and substance use treatment) in the practice
- Referral to community-based mental health services when needed
- Case management (with early childhood skills) for all needs, including navigation across services
The report recognizes that there will be an increased need for behavioral health staff if the three-tier model is to be implemented successfully. The group envisions that half of the Tier 1 and Tier 2 services could be reimbursed under Medicaid based on diagnoses and fee-for-service payments, but that a capitated payment model might be more effective. For Tier 3 services, the report recommends a parallel to the value-based payment model used to fund collaborative care for adults through Medicaid. Capitated payments through value-based contracts between Medicaid managed care organizations and pediatric practices have been suggested by stakeholders as a potential path for a child-focused, population-based arrangement.
The goal of this model is to achieve health equity for all children and families by addressing systemic disparities, fostering trust between families and medical providers, promoting community linkages, and providing two-generational, trauma-informed, culturally competent, and integrated primary and behavioral health care.
The advisory group also produced a list of recommendations about committing to the Pediatric Population Health model through activities like investment in its core programs, including sustaining the HealthySteps model and sites funded by the NYS Office of Mental Health HealthySteps pilot, and the documentation of progress and outcomes for children as different aspects of the model are piloted. The other planned activities included in the First 1,000 Days on Medicaid initiative include a focus on early literacy, home visiting, development of data systems for cross-sector referrals, and a peer family navigators pilot program.
New York is not the only state focusing on the first few years of a child’s life as a critical period for improving health outcomes across the lifespan. Rhode Island’s First 1,000 Days of RIte Care, the state Medicaid program, aims to improve rates of developmental screening and coordination between pediatric care with family home visiting and Early Intervention. California’s Medicaid program, MediCal, is collaborating with the state’s Office of the Surgeon General to address ACEs with trauma screenings and provider training on trauma-informed care. As states continue to look for ways to improve health at all ages, early childhood is a period where increased coordination across sectors and agencies can lead to preventive strategies that have a lasting impact.
This blog is supported by the David and Lucille Packard Foundation. To learn more about state efforts to promote healthy child development, please visit NASHP’s Healthy Child Development State Resource Center.