Implementing Healthy Steps (National Evaluation 1996 Protocol) Meets HHS Criteria

This report focuses on Healthy Steps as implemented in the 1996 evaluation. HHS has determined that home visiting is not the primary service delivery strategy and the model does not meet current requirements for MIECHV program implementation.

Model implementation profile last updated: 2015

Model overview

Theoretical approach

Healthy Steps was a universal parenting intervention implemented between 1996 and 2001. The HomVEE review is based on Healthy Steps as implemented in the 1996 national evaluation, and referred to as Healthy Steps (national evaluation 1996 protocol), or HS (national evaluation). Sites enrolled in the national evaluation followed a protocol that incorporated home visits. However, home visiting is not the primary method of service delivery in the current model guidelines, and implementation of the HS (national evaluation) is no longer supported.

HS (national evaluation) was designed to enhance pediatric primary care for children from birth to age 3 and their families by incorporating preventive developmental and behavioral services into routine practice. The model strived to enhance the knowledge and confidence of caregivers as a means of promoting children’s well-being. It focused on aspects of the caregiving environment amenable to change. Infancy is a suitable period for intervention because it is a time of rapid child development and high stress for parents, and parents are likely to be open to new ideas. The model was designed to be universal, with services offered to all families in participating practices, in recognition that all parents have concerns and questions about their children’s health, behavior, and development. Operating through pediatric practices allowed the program to periodically reach children and parents during the developmentally critical first few years of children’s lives.

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Implementation support availability

The Commonwealth Fund, a foundation that aims to improve the health care system for vulnerable populations, developed the program’s vision and provided financial support and direction. A team from Boston University School of Medicine, Department of Pediatrics, designed the program, trained site staff, and provided technical assistance to the sites in the national evaluation. The Healthy Steps National Program Office (NPO) created additional program materials and supported implementation during visits to monitor fidelity. ICF Consulting directed and coordinated implementation. As of 2015, Zero to Three, a national organization that focuses on the health and development of infants and toddlers, operates Healthy Steps.

HS specialists participated in biweekly technical assistance teleconference sessions with key training staff from the Boston University training team. Teleconferences provided a forum for answering questions, reinforcing training, and troubleshooting implementation issues. Teleconferences continued throughout the demonstration program period, but, over time, decreased in frequency and focused more on clinical concerns and less on implementation issues.
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Intended population

HS (national evaluation) was designed for parents with children from birth through age 2. For the evaluation, enrollment was limited to families with newborns less than 4 weeks old. Any such family served by a practice that participated in the national evaluation could enroll in the program, except for families that (1) planned to move or change pediatric practices within six months, (2) did not speak fluent English or Spanish, (3) planned to put their child up for adoption or in foster care, or (4) had a child who was too ill for an office visit within the first four weeks of life.

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Targeted outcomes

The national evaluation model was designed to promote (1) the clinical capacity and effectiveness of pediatric primary care to better meet the needs of families with young children; (2) the knowledge, skills, and confidence of mothers and fathers in their child-rearing abilities; and (3) the health and development of young children.
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Model services

The HS (national evaluation) had seven major elements. Parents were offered:

  • Home visits from HS specialists, timed to reach parents at children’s key developmental junctures during the first three years. For example, a home visit conducted in a newborn’s first few weeks of life encouraged continued breastfeeding and supported parents as they established their caregiving patterns. A home visit when a baby was about 9 months old and becoming mobile focused on safety hazards and childproofing.
  • Enhanced well-child care appointments before, after, or during well-child appointments, during which HS specialists answered questions about child development and encouraged early reading to children.
  • Child development telephone information line, staffed by HS specialists, for parents to ask questions about day-to-day worries and developmental concerns.
  • Child development and family health check-ups, to detect developmental or behavioral problems and identify family health risks.
  • Written materials that emphasized prevention and health promotion on medical, developmental, and practical topics. For example, parents received a Child Health and Development Record that chronicled immunizations, physical growth, developmental milestones, and parental concerns through age 18.
  • Parent group meetings, facilitated by the HS specialists, for social support and opportunities for interactive learning.
  • Linkages to community resources, consisting primarily of a list of community resources compiled by HS specialists.

Sites in the HS (national evaluation) followed protocols and other guidance in the training and operations materials. These materials guided specialists and other clinicians on relaying child development, safety, and other recommendations to parents.

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Model intensity and length

HS specialists were expected to offer a minimum of six home visits to each family by the child’s third birthday. Home visits occurred at key developmental junctures, including the first few weeks after birth, and as children became mobile at about 9 months of age.

Well-child visits followed standard pediatric guidelines, which called for nine visits during the first three years.

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Adaptations and enhancements

The HS (national evaluation) did not allow for site adaptation. HS has continued to be implemented in sites not in the national evaluation, however. In one adaptation, sites that provide prenatal assistance only offer families a supplement called PrePare. PrePare adds an average of three prenatal home visits. Home visitors cover general topics on the transition to parenthood and overcoming family-specific risk factors.

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Organizational requirements

HS (national evaluation) was implemented by pediatric and family medicine practices, including group practices and clinics within a hospital or health maintenance organization.

HS sites in the national evaluation followed written protocols and guidelines that described key model elements and the role of the HS specialist.

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Staffing requirements

HS used a team approach to primary health care for young children. The team included (1) the HS specialist, who conducted home visits, staffed the telephone line, attended well-child care appointments, and facilitated parent group meetings and (2) the pediatric or family medicine clinicians, who served HS families during well-child care appointments.

HS specialists were professionals with training in early childhood development, nursing, or social work.

HS specialists were supervised by physicians or administrators in the pediatric or family practice where they worked.

The model required home visitors to participate in pre-service training. Key personnel from each site participated in an initial HS training institute in Boston, Massachusetts. Key personnel who attended the training were expected to orient all staff in their practice to the program.

The model also required home visitors and other site staff to participate in ongoing professional development. Key personnel participated in two additional annual training institutes after the initial training institute.

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