At the Intersection of Health, Health Care and Policy Cite this article as: Ryan Chao, Susan Bertonaschi and Julie Gazmararian Healthy Beginnings: A System Of Care For Children In Atlanta Health Affairs, 33, no.12 (2014):2260-2264 doi: 10.1377/hlthaff.2014.0706
The online version of this article, along with updated information and services, is available at: http://content.healthaffairs.org/content/33/12/2260.full.html
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Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 2014 by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
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GrantWatch By Ryan Chao, Susan Bertonaschi, and Julie Gazmararian
Healthy Beginnings: A System Of Care For Children In Atlanta For more than a decade the Annie E. Casey Foundation’s Atlanta Civic Site has invested in a comprehensive community change strategy in five neighborhoods near downtown Atlanta. The foundation pursues a three-prong strategy focused on improving educational outcomes for children, encouraging family economic success for adults, and positively transforming the community’s physical environment. The foundation recently integrated a focus on health into its community and family strengthening strategies. In this article we review the foundation’s Healthy Beginnings System of Care. Healthy Beginnings seeks to prevent or reduce health disparities through a community-based, coordinated care approach based in a high-quality early learning center. An initial evaluation found that in 2013 the program exceeded all of its performance requirements for the 279 enrolled children. Ninety-seven percent of the children had health insurance, 92 percent were up to date with immunizations, and 98 percent were current with developmental screenings. By building upon the partnerships formed through the foundation’s community change effort, Healthy Beginnings has dramatically increased neighborhood children’s access to health care and forms the basis for a cost-effective approach that can be replicated in other communities. ABSTRACT
A
tlanta, Georgia, is one of two cities designated by the Annie E. Casey Foundation as a Civic Site—a place where the foundation has a long-term commitment to improving the futures of at-risk children. Jim Casey, one of the founders of UPS, which is headquartered in Atlanta, created the
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foundation and named it after his mother. The foundation’s other Civic Site is Baltimore, Maryland, which is also the location of the foundation’s headquarters. In both cities, the Casey Foundation’s grant making provides the foundation’s best programs for supporting families while remaining responsive to local opportunities for well-defined,
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neighborhood-based, family-strengthening work aimed at improving the well-being of disadvantaged children. The Casey Foundation is devoted to advancing research and solutions to help children at risk of poor educational, economic, social, and health outcomes overcome barriers to success and to leading decision makers to invest in strategies based on solid evidence. Casey makes grants that help federal agencies, states, counties, cities, and neighborhoods create more innovative, cost-effective responses to the conditions that negatively affect children: poverty, unnecessary disconnection from family, and communities with limited access to opportunity. When the Casey Foundation launched its work in Atlanta in 2001, it analyzed data on the city’s neighborhoods. That research revealed that many of Atlanta’s most vulnerable children and families lived in five historic, mostly African American, neighborhoods located just south of downtown. These neighborhoods—Adair Park, Mechanicsville, Peoplestown, Pittsburgh, and Summerhill—make up the city-designated Neighborhood Planning Unit V (for a map showing these neighborhoods, see online Appendix Exhibit 1).1 This once-thriving and diverse community has experienced property disinvestment, a decrease in population, and economic decline during the past forty years. However, the area also has many important assets, including trusted community organizations and active residents who are dedicated to improving their neighborhoods. The foundation chose to make a longterm, open-ended commitment to improve conditions for low-income families in these neighborhoods. The Atlanta Civic Site’s work in the community involves a diverse group of partners focused on achieving measurable success in three areas: educational achievement, family economic success, and neighborhood transformation. Separate efforts in each of these areas can produce important results. However, the foundation believes that when the areas are
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bundled together so that families benefit from multiple programs simultaneously, the efforts can lead to life-changing results for children and families.
A Two-Generation Strategy The Casey Foundation believes that to achieve lasting positive outcomes for children, it is essential to work simultaneously with adults and children in the same family to help parents fulfill their role as their children’s first and continuing teachers. This two-generation strategy bundles together work with adults and children, creating a synergy of supports with greater impact than could be achieved by isolated programs that engage only one family member. The Atlanta Civic Site’s education strategies focus on ensuring that children are healthy, thrive socially and emotionally, and develop on track to achieve academic success by the third grade. Working with the Sheltering Arms Early Education and Family Centers (a leading provider of high-quality early education and day care programs throughout the Atlanta area), the Atlanta Public Schools, the United Way of Greater Atlanta, and other partners, the Casey Foundation created the Dunbar Learning Complex. The complex is composed of Educare Atlanta, a high-quality early learning center that enrolls approximately 200 children annually from the age of six weeks through prekindergarten, and Dunbar Elementary School, which serves approximately 385 children from the neighborhood from kindergarten through fifth grade. In addition, the complex is close to the Dunbar Neighborhood Center, which houses the Atlanta Civic Site’s offices and other key community partners, including the Center for Working Families. Research shows the importance of a child’s earliest years of life as the cornerstone of his or her health and development, which can provide a strong foundation for a child’s lifelong learning and success.2 Teachers at Educare Atlanta provide high-quality early education and care for young children in alignment with the elementary school’s curricula. This seamless continuum of programs is designed to coordinate and align standards, curricula, assessment, and instruction from prekinder-
garten to fifth grade, increasing teacher effectiveness and leading to improved academic achievement for all children in the Dunbar Learning Complex. Since it first opened in 2010, the Dunbar Learning Complex has achieved significant results for the neighborhood’s children. More than 85 percent of students now demonstrate age-appropriate literacy and numeracy skills—a vast improvement from the project’s baseline year, when fewer than half of local children met this developmental milestone. To support family economic success, the foundation strives to ensure that adults have jobs and are becoming able to support their families by accessing benefits such as job training and by building assets and wealth. The Atlanta Civic Site’s strategies bundle these services for low-income families, with the goal of having those parents employed and on a pathway to a family-supporting career while their children are on a pathway to educational success. This effort is led by the Center for Working Families, which provides a combination of workforce development, entrepreneurship, and asset-building programs to move families in the community toward economic success. Currently, 80 percent of students at Educare Atlanta have a parent enrolled at the center. Complementing the Atlanta Civic Site’s two-generation programs are multiple strategies focused on improving the physical environment of the community, such as efforts to convert vacant and abandoned homes into high-quality affordable housing and Mayor Kasim Reed’s Centers of Hope program, which has brought new recreation centers to the community. An intentional, inclusive approach to community engagement undergirds these and all other strategies for the Atlanta Civic Site, with the goal of involving community residents as partners and key decision makers.
Focus On Health Despite the Casey Foundation’s multifaceted approach to community change, health had not been a primary focus of the Atlanta site’s work until 2009. However, the foundation has long recognized that children who live in poverty often experience significant and continuing issues with health, including
chronic asthma, poor hearing, vision and dental problems, attention deficit hyperactivity disorder, and heart conditions.3 In addition, disparities in physical and mental health between low- and higher-income children may persist into adulthood, limiting opportunities for learning and overall development and often contributing to gaps in educational achievement.4 In 2009 the foundation commissioned a scan of the health status of residents within the five neighborhoods it had been focusing on. The scan revealed serious health problems for the young children living there, including high rates of infant mortality, low birthweight, late or no prenatal care, diabetes, asthma, and malnutrition. The health scan pointed to challenges in accessing and participating in health services as a key factor behind many of the health problems experienced by young children in the five neighborhoods.4 When Educare Atlanta opened and its staff began to work with children and families, they saw these health problems firsthand and sought to address them. In recent years state agencies in Georgia have promoted the use of systems of care as a way to improve services for children; break down silos that isolate providers and public agencies; and encourage communication and collaboration among public and private agencies that serve children and families, especially in low-income communities. Systems of care are frameworks that incorporate a broad array of services and supports arranged into an organized network. These networks focus on the holistic needs of the child and family, coordinating prevention, intervention, and treatment services. They involve collaboration across agencies to support children and families through the provision of coordinated service delivery and child-focused interventions, and the matching of children to appropriate services. The Atlanta Civic Site, working with the neighborhood planning unit’s Partnership for Early Learning, recognized an opportunity in the state’s emphasis on systems of care. The partners submitted a successful application to the State of Georgia Governor’s Office for Children and Families to create a unique, community-based system of care that
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GrantWatch would integrate early childhood education and health services for children enrolled in Educare Atlanta. Named Healthy Beginnings, this system of care connects children and their families to health insurance and a medical home to support children’s continuing health and development. The system also ensures that children have immunizations, periodic developmental screenings, and follow-up care, with frequent check-ups and assessments where indicated. It also provides families with health education both individually and through monthly workshops for groups of parents. The Healthy Beginnings partners worked together to develop a system of care that supports high-quality preventive health care for all children enrolled at Educare Atlanta. The system is integrated with the work of teachers and other staff at Educare Atlanta, as well as local health care providers, and it ensures that there is an ongoing relationship between parent and physician. The community’s health scan had determined that there was no need to provide on-site health services at Educare Atlanta since the neighborhoods are only a few miles from downtown Atlanta, where several hospitals and two federally qualified health centers are located.4 Full implementation of Healthy Beginnings began in 2011. As of the end of 2013, 386 children had been enrolled, with their families receiving care coordination and health education. Children are discharged from the system of care when they leave Educare Atlanta, either because of matriculation to kindergarten or other family circumstances such as relocation. A $260,000 annual budget covers administrative costs, salaries and benefits for the staff (a project director; a health navigator, who is a registered nurse; and a part-time data administrator), and local evaluation activities.
Organization And Implementation We describe the main components of the Healthy Beginnings System of Care below. In addition, Appendix Exhibit 21 presents a more detailed overview of the Healthy Beginnings main components of care management, education and parent engagement, and collaborative partnership. The Healthy Begin2262
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A system of care such as Healthy Beginnings represents a relatively modest investment: $932 per child. nings System of Care logic model is presented in Appendix Exhibit 3;1 it provides an evaluation framework that outlines the inputs and results of Healthy Beginnings. Healthy Beginnings employs one registered nurse (from Children’s Healthcare of Atlanta, a nonprofit organization), known as the health navigator. The navigator supports parents and helps them learn how to work with health care professionals on behalf of their children. The health navigator meets with the parent or parents of each child enrolled in Educare Atlanta to obtain the child’s health history and understand his or her current status regarding health insurance and participation in a medical home. The health navigator also coordinates regular visits to pediatricians and other health care providers when indicated, even helping parents make telephone calls to schedule appointments, sending follow-up text messages as appointment reminders, providing lists of questions to take to doctor’s appointments, and encouraging parents to take care of their own health. If a child or another family member needs additional supports, such as asthma management or resolution of legal issues, the health navigator helps connect the family with resources to address those needs. By teaching families how to understand the system and get the help they need, the navigator strengthens parents’ confidence and their ability to advocate for their children. Because the health navigator’s office is located in the Educare Atlanta center, interactions between parents and the navigator occur naturally. Pregnant women are linked to the Healthy Start Program of the Center for Black Women’s Wellness so they can receive home visits to promote prenatal care early and throughout their pregnancy. The health navigator also connects parents to the Center for Working Fami-
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lies, if necessary, to ensure that they receive public benefits for which they are eligible and participate in training programs that are available to them. Families who live in unsafe and unhealthy housing conditions are referred to the Green and Healthy Homes Initiative at the Center for Working Families. This initiative provides low-cost assistance for home renovation and weatherization to alleviate health hazards in homes in the community and improve their fuel efficiency. Educare Atlanta staff support all children and families enrolled in the school through the administration of developmental screening tools. They use the Ages and Stages Questionnaires, a tool that helps parents and educators track a child’s social and emotional development, for all children in the classroom. When screening results reveal a developmental concern, a multidisciplinary team meets to share the concern and related information with the family and develop a plan of action. The team includes parents, staff members from Educare Atlanta, the health navigator, and representatives of other partner agencies as appropriate. The Atlanta Civic Site’s director of health promotion provides overall management of Healthy Beginnings by working directly with the health navigator, data administrator, Educare Atlanta staff, members of an advisory board (discussed below), and other community partners in the system to ensure a coordinated approach. The Healthy Beginnings database has been specifically developed to support this coordinated approach among partners. It provides a unified health history for each child, contains detailed information about health needs of the child and family members, and ensures that children’s needs are not neglected because of miscommunication between families and providers. The database also helps parents and Educare Atlanta staff track children’s health and developmental status, including immunizations and referrals to early intervention services. The fourteen-member advisory board includes members from the early education, pediatric, behavioral health, public education (including the Atlanta Public Schools), and public health communities; state and federal agencies (includ-
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ing the Georgia Department of Public Health); and the Casey Foundation. Advisory board members bring different professional backgrounds and perspectives to this work. However, they share a commitment to reducing health disparities by working with children from birth and strengthening the capacity of families to care for their children and advocate on their behalf. The advisory board provides formal governance and visible, high-level leadership and advocacy for Healthy Beginnings. A health task force and subcommittees whose members are from the organizations represented on the advisory board implement the direction set by the board.
First Evaluation Results In 2011, at the conclusion of the first program year of Healthy Beginnings, the Atlanta Civic Site contracted with Emory University’s Rollins School of Public Health to evaluate the program in its early stages. The overall goal of this evaluation was to understand and improve processes and determine the short-term effects of Healthy Beginnings on enrolled children and their families. The results of this evaluation suggest that the Healthy Beginnings System of Care has been effectively implemented and has exceeded expectations in terms of achieving the goals of the State of Georgia Governor’s Office for Children
and Families.5 The Emory evaluation included results from the office’s System of Care Satisfaction Survey. The survey, which was completed by 148 parents of children enrolled in Healthy Beginnings in 2013, indicated overwhelmingly positive satisfaction with the system of care (Exhibit 1). For each question on the survey, at least 74 percent of respondents strongly agreed that they were satisfied. Very few respondents (fewer than 6 percent) reported that they were neutral, and none strongly disagreed that they were satisfied.5 In terms of short-term outcomes for participating children, Healthy Beginnings exceeded all of its performance requirements from the Governor’s Office for Children and Families in 2013. For example, more than 90 percent of the children had health insurance and were up-to-date in their immunizations (Exhibit 2). Nearly all children visited a medical home at least annually, and 98 percent were current with developmental screenings, according to the Ages and Stages Questionnaires (data not shown).5 In its early implementation stages, the Healthy Beginnings coordinated care approach has ensured that participating children and their families have health insurance and receive regular immunizations, ongoing health care from a primary care physician and dental health provider, and regular developmental screenings and follow-up care. In addi-
tion to the continuous improvement of the process and systems, the next step for the program will be scaling up its effects.
Implications For Scaling Up Healthy Beginnings Because of Health Beginnings’ early success, the program will expand in 2015 to two other early learning centers that feed into the Atlanta Public Schools. Although the system of care is in its early stages and just entering a scaling strategy in Atlanta, the Casey Foundation has witnessed the immense benefit of integrating a focus on health into its community development strategies. For the following reasons, we believe that this approach both is adaptable to other neighborhoods and can be nested within other existing community change initiatives.6 First, a system of care such as Healthy Beginnings strengthens the role of parents in their children’s healthy development. When families have a medical home and are able to understand their child’s medical needs, they are better able to act on their child’s behalf and navigate the system to get the supports they need. Second, a system of care increases families’ access to the existing services, instead of creating services that may already be available in the community. Every community has a unique mix of health and support services. The empha-
Exhibit 1 Results From Healthy Beginnings Respondents To The State Of Georgia Governor’s Office For Children And Families System Of Care Satisfaction Survey, 2013 Survey item My beliefs and values were respected
No. of responses 145
Mean response 4.8
Strongly agree 78%
Agree 20%
Neutral 1%
Staff/service provider has been available to me when I needed
148
4.8
78
20
1
Any concerns I had were addressed in a timely manner and handled well I felt I was involved in making decisions for myself and my family
148 148
4.8 4.8
75 76
22 19
1 2
All materials/handouts I received as part of the program were useful and easily understood
148
4.8
78
22
0
The services I received were helpful
146
4.8
78
18
2
Staff helped me find services I needed, if applicable I would recommend services to others
148 148
4.7 4.8
74 82
18 15
5 2
Overall, I am satisfied with the services that I received
148
4.9
85
14
1
SOURCE Emory University Rollins School of Public Health analysis of data from the State of Georgia Governor’s Office for Children and Families Grants Management System GMS database. NOTES There were 148 respondents. Responses were on a five-point scale, ranging from 0 (strongly disagree) to 5 (strongly agree). “Not applicable” was also a possible response.
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GrantWatch Exhibit 2 Performance Of Healthy Beginnings On The State Of Georgia Governor’s Office For Children And Families Outcomes Measures, 2013 Percentage of target children:
Performance requirements
Results
Immunized against childhood diseases With health insurance
At least 90% At least 90%
92% 97
Using ER for primary care during funding year
No more than 10%
With at least 1 health care visit in past 12 months With at least 1 dental visit in past 12 months
At least 90% At least 57%
6 98 80
SOURCE Emory University Rollins School of Public Health analysis of data from the Healthy Beginnings database. NOTES The records of 279 children were evaluated. ER is emergency room.
sis on increasing access to, and reducing duplication of, services contributes to the cost-effectiveness of the approach. Third, a system of care improves teachers’ ability to understand each child’s development so that they can better adapt their teaching to the needs of individual children. Fourth, a system of care leads to interactions among professionals—across disciplines and organizations—who work with young children. Healthy Beginnings’ advisory board and subcommittee members represent multiple organizations that serve young children and families, from early childhood education and behavioral health to developmental science and medicine. Fifth, a system of care shifts resources toward preventing serious problems,
thus reducing the need for expensive remediation and intervention. Families are supported in making and keeping regular appointments for well-child visits and immunizations and are connected to resources, such as asthma management programs, that help keep chronic health conditions from getting out of control and reduce time away from learning at school. Finally, a system of care such as Healthy Beginnings represents a relatively modest investment. The overall budget to serve 279 children at Educare Atlanta during 2013 was $260,000 for direct services, or $932 per child. This cost included administration, coordinated care management, training and technical assistance, and evaluation. A broad range of supporters have funded
the program, including the Governor’s Office for Children and Families, the Casey Foundation, the United Way of Greater Atlanta, and many in-kind donors. When compared with the cost of responding to a crisis (through, for example, emergency department visits or hospitalizations) or the cost of missed opportunities (such as a child’s struggling in school because of developmental delays), a system of care is a sensible investment.
Conclusion The Annie E. Casey Foundation has been investing in multiple human capital and housing and public open spaces redevelopment strategies in the neighborhoods of Neighborhood Planning Unit V in Atlanta for more than a decade. Although the Healthy Beginnings System of Care is still in its early stages, the foundation has found the concurrent focus on community change and health to be highly compatible with its family strengthening strategies—and a critical contributor to the well-being of the community’s children and families. ▪ Ryan Chao ([email protected]) is vice president of the Annie E. Casey Foundation, in Baltimore, Maryland. Susan Bertonaschi is director of health promotion at the Annie E. Casey Foundation Atlanta Civic Site, in Atlanta, Georgia. Julie Gazmararian is an associate professor in and director of graduate studies at the Emory University Rollins School of Public Health, in Atlanta.
The data presented in the article were published in an evaluation of the Healthy Beginnings System of Care (see Note 5 in text).
NOTES 1 To access the Appendix, click on the Appendix link in the box to the right of the article online. 2 Annie E. Casey Foundation. Climbing the ladder of reading proficiency: the first two years of Atlanta’s Dunbar Learning Complex [Internet]. Atlanta (GA): AECF; 2012 [cited 2014 Nov 4].
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Available from: http://www.aecf .org/m/resourcedoc/AECFClimbingTheLadderOfReading Proficiency-2012-Full.pdf 3 Case A, Lubotsky D, Paxson C. Economic status and health in childhood: the origins of the gradient. Am Econ Rev. 2002:92(5): 1308–34.
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4 Mosaic Group. NPU-V health scan. Unpublished report prepared for the Annie E. Casey Foundation and Atlanta Civic Site. Baltimore (MD): Mosaic Group; 2009. 5 Gazmararian J, Tan C, Whelchel M. Healthy Beginnings System of Care: 2013 evaluation report. Unpublished report. Atlanta (GA):
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Emory University Rollins School of Public Health; 2014. 6 Jehl J. Healthy Beginnings: a system of care for young children in Atlanta’s NPU-V report. Unpublished report prepared for the Annie E. Casey Foundation and Atlanta Civic Site. Annapolis (MD): The Foundation; 2012.
The online version of this article, along with updated information and services, is available at: http://content.healthaffairs.org/content/33/12/2260.full.html
For Reprints, Links & Permissions: http://healthaffairs.org/1340_reprints.php E-mail Alerts : http://content.healthaffairs.org/subscriptions/etoc.dtl To Subscribe: http://content.healthaffairs.org/subscriptions/online.shtml
Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 2014 by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
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GrantWatch By Ryan Chao, Susan Bertonaschi, and Julie Gazmararian
Healthy Beginnings: A System Of Care For Children In Atlanta For more than a decade the Annie E. Casey Foundation’s Atlanta Civic Site has invested in a comprehensive community change strategy in five neighborhoods near downtown Atlanta. The foundation pursues a three-prong strategy focused on improving educational outcomes for children, encouraging family economic success for adults, and positively transforming the community’s physical environment. The foundation recently integrated a focus on health into its community and family strengthening strategies. In this article we review the foundation’s Healthy Beginnings System of Care. Healthy Beginnings seeks to prevent or reduce health disparities through a community-based, coordinated care approach based in a high-quality early learning center. An initial evaluation found that in 2013 the program exceeded all of its performance requirements for the 279 enrolled children. Ninety-seven percent of the children had health insurance, 92 percent were up to date with immunizations, and 98 percent were current with developmental screenings. By building upon the partnerships formed through the foundation’s community change effort, Healthy Beginnings has dramatically increased neighborhood children’s access to health care and forms the basis for a cost-effective approach that can be replicated in other communities. ABSTRACT
A
tlanta, Georgia, is one of two cities designated by the Annie E. Casey Foundation as a Civic Site—a place where the foundation has a long-term commitment to improving the futures of at-risk children. Jim Casey, one of the founders of UPS, which is headquartered in Atlanta, created the
doi:
foundation and named it after his mother. The foundation’s other Civic Site is Baltimore, Maryland, which is also the location of the foundation’s headquarters. In both cities, the Casey Foundation’s grant making provides the foundation’s best programs for supporting families while remaining responsive to local opportunities for well-defined,
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neighborhood-based, family-strengthening work aimed at improving the well-being of disadvantaged children. The Casey Foundation is devoted to advancing research and solutions to help children at risk of poor educational, economic, social, and health outcomes overcome barriers to success and to leading decision makers to invest in strategies based on solid evidence. Casey makes grants that help federal agencies, states, counties, cities, and neighborhoods create more innovative, cost-effective responses to the conditions that negatively affect children: poverty, unnecessary disconnection from family, and communities with limited access to opportunity. When the Casey Foundation launched its work in Atlanta in 2001, it analyzed data on the city’s neighborhoods. That research revealed that many of Atlanta’s most vulnerable children and families lived in five historic, mostly African American, neighborhoods located just south of downtown. These neighborhoods—Adair Park, Mechanicsville, Peoplestown, Pittsburgh, and Summerhill—make up the city-designated Neighborhood Planning Unit V (for a map showing these neighborhoods, see online Appendix Exhibit 1).1 This once-thriving and diverse community has experienced property disinvestment, a decrease in population, and economic decline during the past forty years. However, the area also has many important assets, including trusted community organizations and active residents who are dedicated to improving their neighborhoods. The foundation chose to make a longterm, open-ended commitment to improve conditions for low-income families in these neighborhoods. The Atlanta Civic Site’s work in the community involves a diverse group of partners focused on achieving measurable success in three areas: educational achievement, family economic success, and neighborhood transformation. Separate efforts in each of these areas can produce important results. However, the foundation believes that when the areas are
Downloaded from content.healthaffairs.org by Health Affairs on August 31, 2015 at UNIVERSITY OF MANITOBA
bundled together so that families benefit from multiple programs simultaneously, the efforts can lead to life-changing results for children and families.
A Two-Generation Strategy The Casey Foundation believes that to achieve lasting positive outcomes for children, it is essential to work simultaneously with adults and children in the same family to help parents fulfill their role as their children’s first and continuing teachers. This two-generation strategy bundles together work with adults and children, creating a synergy of supports with greater impact than could be achieved by isolated programs that engage only one family member. The Atlanta Civic Site’s education strategies focus on ensuring that children are healthy, thrive socially and emotionally, and develop on track to achieve academic success by the third grade. Working with the Sheltering Arms Early Education and Family Centers (a leading provider of high-quality early education and day care programs throughout the Atlanta area), the Atlanta Public Schools, the United Way of Greater Atlanta, and other partners, the Casey Foundation created the Dunbar Learning Complex. The complex is composed of Educare Atlanta, a high-quality early learning center that enrolls approximately 200 children annually from the age of six weeks through prekindergarten, and Dunbar Elementary School, which serves approximately 385 children from the neighborhood from kindergarten through fifth grade. In addition, the complex is close to the Dunbar Neighborhood Center, which houses the Atlanta Civic Site’s offices and other key community partners, including the Center for Working Families. Research shows the importance of a child’s earliest years of life as the cornerstone of his or her health and development, which can provide a strong foundation for a child’s lifelong learning and success.2 Teachers at Educare Atlanta provide high-quality early education and care for young children in alignment with the elementary school’s curricula. This seamless continuum of programs is designed to coordinate and align standards, curricula, assessment, and instruction from prekinder-
garten to fifth grade, increasing teacher effectiveness and leading to improved academic achievement for all children in the Dunbar Learning Complex. Since it first opened in 2010, the Dunbar Learning Complex has achieved significant results for the neighborhood’s children. More than 85 percent of students now demonstrate age-appropriate literacy and numeracy skills—a vast improvement from the project’s baseline year, when fewer than half of local children met this developmental milestone. To support family economic success, the foundation strives to ensure that adults have jobs and are becoming able to support their families by accessing benefits such as job training and by building assets and wealth. The Atlanta Civic Site’s strategies bundle these services for low-income families, with the goal of having those parents employed and on a pathway to a family-supporting career while their children are on a pathway to educational success. This effort is led by the Center for Working Families, which provides a combination of workforce development, entrepreneurship, and asset-building programs to move families in the community toward economic success. Currently, 80 percent of students at Educare Atlanta have a parent enrolled at the center. Complementing the Atlanta Civic Site’s two-generation programs are multiple strategies focused on improving the physical environment of the community, such as efforts to convert vacant and abandoned homes into high-quality affordable housing and Mayor Kasim Reed’s Centers of Hope program, which has brought new recreation centers to the community. An intentional, inclusive approach to community engagement undergirds these and all other strategies for the Atlanta Civic Site, with the goal of involving community residents as partners and key decision makers.
Focus On Health Despite the Casey Foundation’s multifaceted approach to community change, health had not been a primary focus of the Atlanta site’s work until 2009. However, the foundation has long recognized that children who live in poverty often experience significant and continuing issues with health, including
chronic asthma, poor hearing, vision and dental problems, attention deficit hyperactivity disorder, and heart conditions.3 In addition, disparities in physical and mental health between low- and higher-income children may persist into adulthood, limiting opportunities for learning and overall development and often contributing to gaps in educational achievement.4 In 2009 the foundation commissioned a scan of the health status of residents within the five neighborhoods it had been focusing on. The scan revealed serious health problems for the young children living there, including high rates of infant mortality, low birthweight, late or no prenatal care, diabetes, asthma, and malnutrition. The health scan pointed to challenges in accessing and participating in health services as a key factor behind many of the health problems experienced by young children in the five neighborhoods.4 When Educare Atlanta opened and its staff began to work with children and families, they saw these health problems firsthand and sought to address them. In recent years state agencies in Georgia have promoted the use of systems of care as a way to improve services for children; break down silos that isolate providers and public agencies; and encourage communication and collaboration among public and private agencies that serve children and families, especially in low-income communities. Systems of care are frameworks that incorporate a broad array of services and supports arranged into an organized network. These networks focus on the holistic needs of the child and family, coordinating prevention, intervention, and treatment services. They involve collaboration across agencies to support children and families through the provision of coordinated service delivery and child-focused interventions, and the matching of children to appropriate services. The Atlanta Civic Site, working with the neighborhood planning unit’s Partnership for Early Learning, recognized an opportunity in the state’s emphasis on systems of care. The partners submitted a successful application to the State of Georgia Governor’s Office for Children and Families to create a unique, community-based system of care that
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GrantWatch would integrate early childhood education and health services for children enrolled in Educare Atlanta. Named Healthy Beginnings, this system of care connects children and their families to health insurance and a medical home to support children’s continuing health and development. The system also ensures that children have immunizations, periodic developmental screenings, and follow-up care, with frequent check-ups and assessments where indicated. It also provides families with health education both individually and through monthly workshops for groups of parents. The Healthy Beginnings partners worked together to develop a system of care that supports high-quality preventive health care for all children enrolled at Educare Atlanta. The system is integrated with the work of teachers and other staff at Educare Atlanta, as well as local health care providers, and it ensures that there is an ongoing relationship between parent and physician. The community’s health scan had determined that there was no need to provide on-site health services at Educare Atlanta since the neighborhoods are only a few miles from downtown Atlanta, where several hospitals and two federally qualified health centers are located.4 Full implementation of Healthy Beginnings began in 2011. As of the end of 2013, 386 children had been enrolled, with their families receiving care coordination and health education. Children are discharged from the system of care when they leave Educare Atlanta, either because of matriculation to kindergarten or other family circumstances such as relocation. A $260,000 annual budget covers administrative costs, salaries and benefits for the staff (a project director; a health navigator, who is a registered nurse; and a part-time data administrator), and local evaluation activities.
Organization And Implementation We describe the main components of the Healthy Beginnings System of Care below. In addition, Appendix Exhibit 21 presents a more detailed overview of the Healthy Beginnings main components of care management, education and parent engagement, and collaborative partnership. The Healthy Begin2262
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A system of care such as Healthy Beginnings represents a relatively modest investment: $932 per child. nings System of Care logic model is presented in Appendix Exhibit 3;1 it provides an evaluation framework that outlines the inputs and results of Healthy Beginnings. Healthy Beginnings employs one registered nurse (from Children’s Healthcare of Atlanta, a nonprofit organization), known as the health navigator. The navigator supports parents and helps them learn how to work with health care professionals on behalf of their children. The health navigator meets with the parent or parents of each child enrolled in Educare Atlanta to obtain the child’s health history and understand his or her current status regarding health insurance and participation in a medical home. The health navigator also coordinates regular visits to pediatricians and other health care providers when indicated, even helping parents make telephone calls to schedule appointments, sending follow-up text messages as appointment reminders, providing lists of questions to take to doctor’s appointments, and encouraging parents to take care of their own health. If a child or another family member needs additional supports, such as asthma management or resolution of legal issues, the health navigator helps connect the family with resources to address those needs. By teaching families how to understand the system and get the help they need, the navigator strengthens parents’ confidence and their ability to advocate for their children. Because the health navigator’s office is located in the Educare Atlanta center, interactions between parents and the navigator occur naturally. Pregnant women are linked to the Healthy Start Program of the Center for Black Women’s Wellness so they can receive home visits to promote prenatal care early and throughout their pregnancy. The health navigator also connects parents to the Center for Working Fami-
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lies, if necessary, to ensure that they receive public benefits for which they are eligible and participate in training programs that are available to them. Families who live in unsafe and unhealthy housing conditions are referred to the Green and Healthy Homes Initiative at the Center for Working Families. This initiative provides low-cost assistance for home renovation and weatherization to alleviate health hazards in homes in the community and improve their fuel efficiency. Educare Atlanta staff support all children and families enrolled in the school through the administration of developmental screening tools. They use the Ages and Stages Questionnaires, a tool that helps parents and educators track a child’s social and emotional development, for all children in the classroom. When screening results reveal a developmental concern, a multidisciplinary team meets to share the concern and related information with the family and develop a plan of action. The team includes parents, staff members from Educare Atlanta, the health navigator, and representatives of other partner agencies as appropriate. The Atlanta Civic Site’s director of health promotion provides overall management of Healthy Beginnings by working directly with the health navigator, data administrator, Educare Atlanta staff, members of an advisory board (discussed below), and other community partners in the system to ensure a coordinated approach. The Healthy Beginnings database has been specifically developed to support this coordinated approach among partners. It provides a unified health history for each child, contains detailed information about health needs of the child and family members, and ensures that children’s needs are not neglected because of miscommunication between families and providers. The database also helps parents and Educare Atlanta staff track children’s health and developmental status, including immunizations and referrals to early intervention services. The fourteen-member advisory board includes members from the early education, pediatric, behavioral health, public education (including the Atlanta Public Schools), and public health communities; state and federal agencies (includ-
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ing the Georgia Department of Public Health); and the Casey Foundation. Advisory board members bring different professional backgrounds and perspectives to this work. However, they share a commitment to reducing health disparities by working with children from birth and strengthening the capacity of families to care for their children and advocate on their behalf. The advisory board provides formal governance and visible, high-level leadership and advocacy for Healthy Beginnings. A health task force and subcommittees whose members are from the organizations represented on the advisory board implement the direction set by the board.
First Evaluation Results In 2011, at the conclusion of the first program year of Healthy Beginnings, the Atlanta Civic Site contracted with Emory University’s Rollins School of Public Health to evaluate the program in its early stages. The overall goal of this evaluation was to understand and improve processes and determine the short-term effects of Healthy Beginnings on enrolled children and their families. The results of this evaluation suggest that the Healthy Beginnings System of Care has been effectively implemented and has exceeded expectations in terms of achieving the goals of the State of Georgia Governor’s Office for Children
and Families.5 The Emory evaluation included results from the office’s System of Care Satisfaction Survey. The survey, which was completed by 148 parents of children enrolled in Healthy Beginnings in 2013, indicated overwhelmingly positive satisfaction with the system of care (Exhibit 1). For each question on the survey, at least 74 percent of respondents strongly agreed that they were satisfied. Very few respondents (fewer than 6 percent) reported that they were neutral, and none strongly disagreed that they were satisfied.5 In terms of short-term outcomes for participating children, Healthy Beginnings exceeded all of its performance requirements from the Governor’s Office for Children and Families in 2013. For example, more than 90 percent of the children had health insurance and were up-to-date in their immunizations (Exhibit 2). Nearly all children visited a medical home at least annually, and 98 percent were current with developmental screenings, according to the Ages and Stages Questionnaires (data not shown).5 In its early implementation stages, the Healthy Beginnings coordinated care approach has ensured that participating children and their families have health insurance and receive regular immunizations, ongoing health care from a primary care physician and dental health provider, and regular developmental screenings and follow-up care. In addi-
tion to the continuous improvement of the process and systems, the next step for the program will be scaling up its effects.
Implications For Scaling Up Healthy Beginnings Because of Health Beginnings’ early success, the program will expand in 2015 to two other early learning centers that feed into the Atlanta Public Schools. Although the system of care is in its early stages and just entering a scaling strategy in Atlanta, the Casey Foundation has witnessed the immense benefit of integrating a focus on health into its community development strategies. For the following reasons, we believe that this approach both is adaptable to other neighborhoods and can be nested within other existing community change initiatives.6 First, a system of care such as Healthy Beginnings strengthens the role of parents in their children’s healthy development. When families have a medical home and are able to understand their child’s medical needs, they are better able to act on their child’s behalf and navigate the system to get the supports they need. Second, a system of care increases families’ access to the existing services, instead of creating services that may already be available in the community. Every community has a unique mix of health and support services. The empha-
Exhibit 1 Results From Healthy Beginnings Respondents To The State Of Georgia Governor’s Office For Children And Families System Of Care Satisfaction Survey, 2013 Survey item My beliefs and values were respected
No. of responses 145
Mean response 4.8
Strongly agree 78%
Agree 20%
Neutral 1%
Staff/service provider has been available to me when I needed
148
4.8
78
20
1
Any concerns I had were addressed in a timely manner and handled well I felt I was involved in making decisions for myself and my family
148 148
4.8 4.8
75 76
22 19
1 2
All materials/handouts I received as part of the program were useful and easily understood
148
4.8
78
22
0
The services I received were helpful
146
4.8
78
18
2
Staff helped me find services I needed, if applicable I would recommend services to others
148 148
4.7 4.8
74 82
18 15
5 2
Overall, I am satisfied with the services that I received
148
4.9
85
14
1
SOURCE Emory University Rollins School of Public Health analysis of data from the State of Georgia Governor’s Office for Children and Families Grants Management System GMS database. NOTES There were 148 respondents. Responses were on a five-point scale, ranging from 0 (strongly disagree) to 5 (strongly agree). “Not applicable” was also a possible response.
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GrantWatch Exhibit 2 Performance Of Healthy Beginnings On The State Of Georgia Governor’s Office For Children And Families Outcomes Measures, 2013 Percentage of target children:
Performance requirements
Results
Immunized against childhood diseases With health insurance
At least 90% At least 90%
92% 97
Using ER for primary care during funding year
No more than 10%
With at least 1 health care visit in past 12 months With at least 1 dental visit in past 12 months
At least 90% At least 57%
6 98 80
SOURCE Emory University Rollins School of Public Health analysis of data from the Healthy Beginnings database. NOTES The records of 279 children were evaluated. ER is emergency room.
sis on increasing access to, and reducing duplication of, services contributes to the cost-effectiveness of the approach. Third, a system of care improves teachers’ ability to understand each child’s development so that they can better adapt their teaching to the needs of individual children. Fourth, a system of care leads to interactions among professionals—across disciplines and organizations—who work with young children. Healthy Beginnings’ advisory board and subcommittee members represent multiple organizations that serve young children and families, from early childhood education and behavioral health to developmental science and medicine. Fifth, a system of care shifts resources toward preventing serious problems,
thus reducing the need for expensive remediation and intervention. Families are supported in making and keeping regular appointments for well-child visits and immunizations and are connected to resources, such as asthma management programs, that help keep chronic health conditions from getting out of control and reduce time away from learning at school. Finally, a system of care such as Healthy Beginnings represents a relatively modest investment. The overall budget to serve 279 children at Educare Atlanta during 2013 was $260,000 for direct services, or $932 per child. This cost included administration, coordinated care management, training and technical assistance, and evaluation. A broad range of supporters have funded
the program, including the Governor’s Office for Children and Families, the Casey Foundation, the United Way of Greater Atlanta, and many in-kind donors. When compared with the cost of responding to a crisis (through, for example, emergency department visits or hospitalizations) or the cost of missed opportunities (such as a child’s struggling in school because of developmental delays), a system of care is a sensible investment.
Conclusion The Annie E. Casey Foundation has been investing in multiple human capital and housing and public open spaces redevelopment strategies in the neighborhoods of Neighborhood Planning Unit V in Atlanta for more than a decade. Although the Healthy Beginnings System of Care is still in its early stages, the foundation has found the concurrent focus on community change and health to be highly compatible with its family strengthening strategies—and a critical contributor to the well-being of the community’s children and families. ▪ Ryan Chao ([email protected]) is vice president of the Annie E. Casey Foundation, in Baltimore, Maryland. Susan Bertonaschi is director of health promotion at the Annie E. Casey Foundation Atlanta Civic Site, in Atlanta, Georgia. Julie Gazmararian is an associate professor in and director of graduate studies at the Emory University Rollins School of Public Health, in Atlanta.
The data presented in the article were published in an evaluation of the Healthy Beginnings System of Care (see Note 5 in text).
NOTES 1 To access the Appendix, click on the Appendix link in the box to the right of the article online. 2 Annie E. Casey Foundation. Climbing the ladder of reading proficiency: the first two years of Atlanta’s Dunbar Learning Complex [Internet]. Atlanta (GA): AECF; 2012 [cited 2014 Nov 4].
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Available from: http://www.aecf .org/m/resourcedoc/AECFClimbingTheLadderOfReading Proficiency-2012-Full.pdf 3 Case A, Lubotsky D, Paxson C. Economic status and health in childhood: the origins of the gradient. Am Econ Rev. 2002:92(5): 1308–34.
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4 Mosaic Group. NPU-V health scan. Unpublished report prepared for the Annie E. Casey Foundation and Atlanta Civic Site. Baltimore (MD): Mosaic Group; 2009. 5 Gazmararian J, Tan C, Whelchel M. Healthy Beginnings System of Care: 2013 evaluation report. Unpublished report. Atlanta (GA):
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Emory University Rollins School of Public Health; 2014. 6 Jehl J. Healthy Beginnings: a system of care for young children in Atlanta’s NPU-V report. Unpublished report prepared for the Annie E. Casey Foundation and Atlanta Civic Site. Annapolis (MD): The Foundation; 2012.
