- Grantmaking organizations are uniquely suited to act as agents of change for system transformation.
- Local foundations are able to promote the integration of child and family services necessary to improve children's development.
- The grantmaking process identifies specific projects that will make a difference to service providers, families, and children.
- Foundations emphasize the importance of replication of supported work, locally, regionally, or nationally.
Foundations are charged with the task of making contributions to society in ways that government agencies are not equipped to do. As noted in a recent set of papers, "Large or small, focused on single issues or health broadly, committed to serving specific communities or the nation, grantmaking organizations can act as agents of change for system transformation."1 Providing funds for local-level innovation, core support, professional development, technical assistance, and evaluation are common functions of foundations-increasingly so, as government resources for these activities are harder to obtain. In doing so, foundations play an instrumental part in supporting innovative ideas and building infrastructure by promoting the development of new ideas, financing demonstration projects, evaluating effectiveness, and replicating models that work.2 Three foundations, The Commonwealth Fund, the Children's Fund of Connecticut, and the Hartford Foundation for Public Giving, played pivotal roles in developing Connecticut's Help Me Grow project-a program that began locally, evolved into a statewide strategy, and is now being considered for replication by other states throughout the country.
WHY FOUNDATIONS CHOOSE CHILD DEVELOPMENT AS A FUNDING AREA
Foundations, like other investors, try to reap the maximum gains from their contributions. In the arena of child health, foundations have concluded that investing in early childhood experiences yields the greatest rewards.3,4 There is substantial evidence that children's early life experiences, combined with their genetic and congenital endowments, provide the foundation for subsequent development, shape life trajectories, and influence future accomplishments.5 However, there are no guarantees that investing in early childhood programs will yield readily observable results and, when they do occur, results may not be apparent for many years. Some of the most effective early childhood interventions, like the High/Scope Perry Preschool study6 and the Elmira Nurse Home Visiting project,7 did not demonstrate some of their most important effects for ten or more years. Foundations are in a position to appreciate this uncertainty and can be patient while waiting to see a return on investment, knowing that making investments that affect young children remains the most certain and efficient way to have a major impact on society.
The concept of prevention is fundamental to early child development. However, with the exception of the Medicaid program, public funding consistently makes short shrift of prevention. As examples, there is almost no federal funding earmarked for research on preventive health care for young children; and an analysis of Connecticut's state budget, based on state and federal funds, found only 2 percent dedicated to prevention-related activities for children.8 Early childhood presents opportunities to promote optimal development, but also to prevent adverse long-term developmental outcomes, particularly social and emotional ones. Private funding has the luxury of taking the long view and thus is amenable to supporting efforts that focus on prevention.
Foundations differ in their approaches to adopting strategies that support services or promote system change. Programs that provide for service delivery generally have more immediate outcomes that often can be illustrated with a human face and story. System change is more difficult to accomplish. Promoting children's development, perhaps more than other social endeavors, requires the interaction and collaboration of numerous, interdependent service systems. Evidence of success usually appears as changes in processes, given that outcomes which are measured in terms of changed lives and improved child development may be obscure or not at all apparent. Although foundations with a national perspective are more likely to focus on system change through public policy, the integration of child and family services requires the kind of collaboration that local foundations have the unique ability and opportunity to promote. Partnering among national, state, and local funders is a good strategy to improve developmental services by coordinating policy change with local collaboration. Foundations can foster such partnerships and stimulate public attention and action by convening stakeholders and by providing early support for focused projects that contribute to the goal of improving children's development.
SELECTING PRIORITIES WITHIN CHILD DEVELOPMENT
Foundations can become involved in supporting work to improve children's development through many avenues, as the field involves psychology, education, medicine, as well as other disciplines that address basic scientific studies, clinical services, and public policy. Each foundation decides on its priorities and strategies based on its mission, its strengths, and its understanding of the field. The process of grantmaking rests on identifying specific projects that will make a difference to service providers, families, and children. While more narrowly focused projects are easier to explain, implement, and evaluate, some experts argue that this approach is unlikely to successfully enhance development unless complemented by other changes in the child's environment. Most organizations that serve children propose preventive interventions that are comprehensive, intensive, and flexible in nature; they deal with children in the context of their families and with families in the context of their communities.9
Foundations' interest in child development was heightened by discoveries regarding early brain development during the mid-1990s10 and reinforced by the publication of From Neurons to Neighborhoods: The Science of Early Childhood Development by the Institute of Medicine in 200011 and the Bush Administration's No Child Left Behind education reform legislation enacted in 2001.12 While many foundations had a long-standing interest in child development, these events created a more fertile ground by raising public awareness that children's development could be modified by experience. It was this new knowledge and understanding that led the Children's Fund and the Commonwealth Fund to focus resources on child development.
HELP ME GROW: A CASE STUDY
The Help Me Grow program began in 1998 when agencies and organizations in Hartford, Connecticut banded together to support the developmental surveillance activities of the city's pediatric clinicians. Three foundations of different size, scope, and mission played an important role in supporting Help Me Grow. The Hartford Foundation for Public Giving, one of the country's largest community foundations, serves the city of Hartford and surrounding communities. It provided the initial grants for the local demonstration project, known as ChildServ, which served as a precursor to Help Me Grow. The Children's Fund of Connecticut is focused on ensuring that children in Connecticut have comprehensive, effective, community-based health and mental health care. It helped develop a training infrastructure to adapt and use the Educating Practices in the Community (EPIC) approach to help educate pediatric and primary care providers about early detection and surveillance and the resources available through Help Me Grow. Finally, the Commonwealth Fund, a private, national foundation that makes grants to improve health care practice and policy, supported the development, implementation, and evaluation of the EPIC module.
The Children's Fund of Connecticut
The Children's Fund of Connecticut was created in 1992 as a supporting organization of the Connecticut Children's Medical Center. Its initial endowment was derived from the closure of a hospital for children with chronic and disabling conditions. When the hospital closed, the majority of its assets were used to support the development of an acute care children's hospital in Hartford. A portion of the funds, however, were set aside to establish the Children's Fund to be used for community-based primary and preventive care for children throughout Connecticut.
The Children's Fund board of directors was faced with the challenge of determining how to have the greatest impact. They chose to focus on long-term systems change rather than funding research or individual programs. More than a decade after its inception, the Children's Fund remains committed to prevention and systemic change. The organization focuses on comprehensive, effective, community-based health and mental health care systems for children and their families that will result in better outcomes for children, particularly those who are underserved.
To help carry out its agenda, the Children's Fund created the Child Health and Development Institute (CHDI) in 1997. Together, the Children's Fund and CHDI have become champions of selected, evidence-based innovations in pediatric and primary care practice, supporting demonstration, evaluation, dissemination, and sustainability through policy, as well as regulatory and financial reforms. The current strategies include: medical homes for all children; strengthening the capacity to address behavioral health concerns in primary care settings; and health and mental health consultation in early care and education settings. Help Me Grow touches on each of these practice improvement strategies.
The Children's Fund's approaches to influencing change in practice include: 1) increasing the competency of caregivers and health professionals; 2) increasing access to information on child health and development; 3) promoting more comprehensive service and support systems based on knowledge of child development and best practices; 4) building an informed network of researchers, policymakers, and practitioners to promote systems change; and 5) becoming a resource to policy leaders committed to improving the health and development of children.
To provide information and enhance the competency of health care professionals, the Children's Fund supported the adaptation of EPIC, a model of physician education developed by the Pennsylvania Chapter of the American Academy of Pediatrics (AAP). EPIC (Educating Providers in their Communities) employs an academic detailing approach that uses trained peer professionals to make onsite presentations about specific issues in child health and development to physicians and their staff members. EPIC evolved from observations of pharmaceutical detailing and was originally called "counter detailing."12 The emphasis is on office-based change using clinical information and practical office tools. The Children's Fund gave a grant to the Connecticut chapter of the American Academy of Pediatrics (AAP) to build the infrastructure needed to operate EPIC. Through EPIC, information about Help Me Grow has been disseminated to more than 150 primary care practices throughout Connecticut.
The Commonwealth Fund
The Commonwealth Fund was established in 1918, with the simple charge from its benefactor "to do something for the welfare of mankind." In 1922, The Commonwealth Fund began a Child Health Demonstrations program, with a goal of safeguarding the health of expectant mothers, laying a good health foundation for children in "the early sensitive and formative period of their growth and health supervision and the formation of the essential health habits in school children."13 Although that program is no longer in existence, it signaled an enduring interest by The Commonwealth Fund in promoting the optimal development of young children.
In July 2003, The Commonwealth Fund awarded a grant to educate Connecticut physicians on developmental surveillance and referral practices. The grant supported Help Me Grow by allowing the development and distribution of a formal curriculum and a tool box of clinical materials. That grant also supported qualitative and quantitative evaluation of the training process and its impact on clinical practice. The Commonwealth Fund-a national foundation-became involved in this local project because Help Me Grow had a primary focus on improving early child development services as a core component of preventive pediatric care, a central theme of The Commonwealth Fund's grantmaking goals. In addition, the project was seen as an innovative approach to changing how the health care system operates, facilitating collaboration across systems. The existing support from other foundations and from the state gave some assurance that Help Me Grow would be sustained over time. Help Me Grow also appeared to be a potentially replicable model that could be adopted by other municipalities and states. The award by The Commonwealth Fund emphasized the importance of a good quality evaluation and products that could be readily disseminated. It also provided national visibility to the model.
Funders have multiple goals and approaches. They aim to support efforts to influence attitudes and motivate key stakeholders by providing data and information or establishing service standards; increase competence through education and resources, including best practices; and support change through policy initiatives, partnerships, or programs that offer recognition or reimbursement. Finally, almost all foundations hope that the work they support will be replicated in other settings locally, regionally, or nationally. To this end, foundations ordinarily expect grantees to include a dissemination plan as part of their projects.
Both The Commonwealth Fund and the Children's Fund brought this perspective to their collaboration with Help Me Grow. Key components of Help Me Grow include training, evaluation, and building the capacity of pediatric practices to effectively conduct early detection and surveillance and make appropriate referrals. What began as a local demonstration project in one community is now a statewide system benefiting thousands of children and families, supported and sustained through state funding. This is one investment that has clearly yielded a great return.
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