SECTION I. THE HELP ME GROW EXPERIENCE
- Children and their families benefit from a coordinated, region-wide system of early detection and care coordination.
- Extensive outreach is required to link at-risk children and their families to programs and services.
- While expansion of developmental programs may fail to receive support, enhancement of such programs may be politically acceptable.
- A single point of access facilitates referrals to developmental programs and services.
Despite being the capital city of a wealthy state, Hartford is one of the nation's poorest cities. More than 40% of the city's children live in families with income below the federal poverty level, while 25 to 30% of kindergarten students reportedly lack the emotional, behavioral, and/or developmental resources necessary for success in school.1 The city's child health providers have had a longstanding interest in enhancing services to children and their families, and especially in strengthening primary care services. In the mid-1990s, new opportunities encouraged the efforts of pediatric providers. With a national focus on children's school readiness, new models of pediatric care emerged, such as the Healthy Steps for Young Children program of The Commonwealth Fund.2 In Hartford, with support and encouragement from the Hartford Foundation for Public Giving (HFPG) Brighter Futures initiative, child health providers considered how to better meet the needs of its children and their families to promote optimal developmental outcomes.
ChildServ was developed on the assumptions that children with developmental and behavioral problems were eluding early detection, that many initiatives existed to provide services to young children and their families, that a gap existed between child health services and early childhood education/child development programs, and that Hartford's children and their families would benefit from a coordinated, region-wide system of early detection and care coordination. In addition to the region's child health providers and HFPG, planning partners included the City Health Department and its Child Development Program (CDP), parent groups, child health advocates, and the state's Part C early intervention program (Birth to Three).
COMPONENTS OF CHILDSERV
Begun in 1998, components of ChildServ included: training child health providers in effective developmental surveillance; creating a resource inventory of community-based programs supporting children's development and families; developing a referral and monitoring system to link young children and their families with early childhood services and support; and performing data collection and analyses of children's developmental needs and regional resources. The resource inventory included primary and specialty medical care providers, early childhood education and child care programs, developmental disabilities assessment and intervention programs, mental health services, family and social support programs, and child advocacy and legal services.
The centerpiece of ChildServ was the triage and referral system, accessed by child health providers via a toll-free telephone number. The referral process addressed both the needs of the child and family circumstances. For a child with clear concerns in a family with no evident barriers to referral, the child health provider would contact ChildServ and describe concerns (e.g., language delays, behavioral difficulties, parenting issues) and the care coordinator would identify appropriate services from the inventory (e.g., developmental and language evaluations; play- and parent support groups) and contact the family to facilitate referrals. The care coordinator would again contact the family after 2 weeks to ensure enrollment and provide feedback to the primary care provider (Figure 1). The care coordinator addressed such barriers as the lack of phone access to the family by a referral to the city's Child Development Program (CDP), which would provide outreach and deliver the information to the family's home (Figure 2). When the developmental needs of the child or family were unclear, the CDP provided home-based developmental assessment (Figure 3). For those infants appearing to meet the eligibility criteria for the state's early intervention program, a call to ChildServ would result in a direct referral to Birth to Three (Figure 4).
EXPERIENCE WITH CHILDSERV
One hundred and fifty-five children were referred to ChildServ during its first year of operation, with 300 referrals over 2 years and 500 over 3 years. More than 80% of referred children were of preschool age or younger. More than two-thirds of referrals were for single needs, such as parenting assistance and support, developmental assessment, or speech and language assessment or services. Two-thirds of referrals were at no expense to either the family or their health plan. Ensuring a family's access to programs and services required extensive outreach, with an average of 7 contacts required per referral.3
At follow-up, 40-60% of referred children were receiving services. About one-fifth of families chose to not pursue recommended programs and services, while up to 30% of families were lost to follow-up. Nearly 90% of Hartford's child health providers were familiar with ChildServ, with 90% receiving training, up to three-quarters making at least one referral, and all providers being at least somewhat satisfied with the program's activities.
Lessons learned from our experience with ChildServ informed advocacy for statewide expansion of the program. While expansion of early intervention services to include at-risk children was considered unacceptable to legislative and administrative leaders, the enhancement of access to programs and services for all children, including those at risk, through at single point of entry was politically expedient and supported. That ChildServ addressed concerns with children's behavior was consistent with the state's focus on expanding community-based mental health programs and services through such initiatives as Connecticut Community KidCare. The effectiveness of ChildServ in linking children and their families to programs and services through outreach and care coordination addressed concerns with the limitations of such outreach as practiced by the state's Medicaid managed care organizations.
The Connecticut Legislature funded the Children's Trust Fund to development a statewide expansion of ChidServ in 2002. The goal of the program, renamed Help Me Grow, is to help child health professionals, parents, and child care providers to identify and support children with developmental and behavioral concerns. The target population is at-risk children who are not eligible for early intervention (Birth to Three), Preschool Special Education, or the State's Children with Special Health Care Needs programs and services. Partners include the State Department of Mental Retardation, the Department of Education, and the Department of Public Health, as well as United Way Infoline, Connecticut's provider of telephone information and referral on community services, human services, and crisis intervention. Support has been provided by the Commonwealth Fund, the Child Health and Development Institute of Connecticut, and the Connecticut Chapter of the American Academy of Pediatrics.
Child Development Infoline now provides a single point of access for developmental and behavioral programs and services. Care coordinators link children and their families to programs and services included within the Help Me Grow resource inventory, while also initiating referrals to Birth to Three, Preschool Special Education, or the Children with Special Health Care Needs program, as indicated. Child development community liaisons maintain regional service inventories and support referrals through outreach activities. Other components of Help Me Grow include the education and training of child health providers, child care providers, and parents, as well as an evaluation of the program's effectiveness (Figure 5). Our Connecticut experience will hopefully guide the development of early detection and care coordination systems in other states.
1. Ford JD, Sanders MR. Too Young to Count? Promoting the Health and Development of Connecticut's Young Children and their Families
. Farmington, CT: The Child Health and Development Institute of Connecticut; 2001.
2. Zuckerman B, Kaplan-Sanoff M, Parker S, et al. The healthy steps for young children program. Zero to Three
© 2006 Lippincott Williams & Wilkins, Inc.
3. McKay K, Shannon A, Vater S, et al. ChildServ
: lessons learned form the design and implementation of a community-based developmental surveillance program. Infants and Young Children
. 2006;19:In press.