November 25, 1998

To:Board of Health

From:Medical Officer of Health

Subject:Healthy Babies, Healthy Children Program

Purpose:

This report outlines the requirements necessary to ensure that the Healthy Babies, Healthy Children Program meets current standards.

Funding Sources, Financial Implications and Impact Statement:

Not applicable.

Recommendations:

It is recommended that:

(1)this report be received for information; and

(2)this report be forwarded to the Children and Youth Action Committee and the Community and Neighbourhood Services Committee for information.

Background:

The report "Implementation of Healthy Babies, Healthy Children Program" was submitted in tandem to the January 12, 1998, meeting of the Interim Board of Health and the January 15, 1998, meeting the Community and Neighbourhood Services Committee (the Committee) in order to expedite a Council decision on these matters. The Board of Health's recommendations were reported to the Committee and then forwarded to Council for approval. The report of the Interim Board of Health headed "Implementation of Healthy Babies, Healthy Children Program" was adopted, without amendment, by the Council of the City of Toronto at its meeting held on February 4, 5 and 6, 1998.

The Committee, at its meeting on January 15, 1998, directed that the Acting Medical Officer of Health report to the Children's Action Committee, the Interim Board of Health and the Community and Neighbourhood Services Committee on the requirements necessary to ensure that the Healthy Babies, Healthy Children Program meet current standards. This report addresses that request.

Comments/Discussion:

Healthy Babies, Healthy Children is a joint Ministry of Health and Ministry of Community and Social Services prevention and early intervention initiative. Provincial Implementation Guidelines for Healthy Babies, Healthy Children (August 1997) outline the program objectives and components.

The objectives of the program include: to increase access to and use of needs-based services and supports for children who are at risk for poor physical, cognitive, communicative and psychosocial development, and their families; to increase effective parenting in high risk families; and to increase the proportion of high risk children achieving appropriate development milestones.

The program consists of five components: a network of service providers to ensure that families with children (prenatal to age 6) who are at risk have access to a range of prevention and early intervention services; linking families with children (prenatal to age 6) to appropriate supports and services in the community; universal screening prenatally and at birth to identify those at risk who will be further assessed to identify the high risk families with children; home visiting to ensure that high risk families with children (prenatal to age 2) who would benefit from lay home visiting have access to this service; and ensuring that a case manager is identified for all high risk families.

Healthy Babies, Healthy Children does not address or fund home visiting by public health nurses for all new mothers at risk, e.g., who have breastfeeding concerns and need support in the early discharge period; the program addresses longer term healthy child development outcomes.

Healthy Babies, Healthy Children Program Update

Networks of Service Providers

The Toronto Healthy Babies, Healthy Children Planning and Implementation Committee meets monthly to promote and support setting up the program in Toronto. The Committee includes members from local Healthy Babies, Healthy Children networks as well as representatives from Children's Aid Societies, Toronto Children's Services, the preschool speech and language initiative, and the Aboriginal and Francophone communities.

Network guidelines were developed with input from the Planning and Implementation Committee and local networks. The network guidelines provide direction related to planning and service provision, and are intended to provide some consistency in the role of networks

Inventory of Service Providers

To facilitate the development of the inventory of services, questionnaires were sent out in late 1997 to community agencies that offer programs and services to families with children prenatal to age 6 requesting that they describe their services and how these would be accessed. The results of the questionnaires form the basis for the inventory.

By providing a description of the kinds of services available in an area, the inventory will help highlight gaps in service, barriers to accessing services and areas in need of greater coordination. This will provide useful information in planning services. Although the initial goal is to produce a hard copy of the inventory, considerable work has been done to lay the foundation for the development of an on-line version that can be accessed electronically. The first edition of the inventory will be distributed to community agencies by the end of 1998 with an electronic version to follow pending information on community agencies' information technology capacities.

Universal Screening/Intake

As 98 percent of women deliver their babies in a hospital, hospitals were selected as the starting point for universal screening. As of the end of October 1998, all Toronto hospitals with obstetrical units are using the universal screen with mothers at the time of birth. Since hospital staff play an active role in referring and ensuring follow-up of families in need of service, Healthy Babies, Healthy Children adds a more consistent and comprehensive universal screening tool to be used across Ontario. Hospitals assisted public health with the design of support and training materials for hospitals following a train-the-trainer model. Client information materials have been developed to promote and inform the public and families about the program.

A Hospital Implementation Evaluation Committee was formed to evaluate the process of implementing the universal screening component. The committee was comprised of staff representing hospitals and public health. Information collected through this evaluation process provided helpful suggestions to support program implementation. Plans are in place to phase in prenatal screening and alternate entry points into the program.

Direct Service

The direct service component of the program funded by Healthy Babies, Healthy Children focuses on assessment and resource linkage by public health nurses and lay home visitors. Public health nurses do a detailed assessment of families referred to the program. Staff allocations to the program are determined by assessing the extent of the at-risk group using existing data including number of births and other demographic information.

In an attempt to avoid duplicating lay home visiting services and to enhance those services already existing, Toronto Public Health contracted with five agencies (six programs) for lay home visiting. For those areas not serviced by contracted agencies Toronto Public Health hired lay home visitors using the Parents Helping Parents job category that exists in the former City of Toronto. Each Parent Helping Parents home visitor is mentored by a Healthy Babies, Healthy Children public health nurse.

Intensive training (initial and ongoing) of the lay home visitors both by Toronto Public Health and the contracted agencies has taken place regarding the lay home visitors' understanding of their role and the boundaries of their role. The Provincial Healthy Babies, Healthy Children Guidelines for a Curriculum for Training Lay Home Visitors provided a baseline for training. Staff from Toronto Public Health and the contracted agencies have begun to work together to develop one comprehensive framework for lay home visiting in Toronto.

The Province initially funded lay home visiting for an average of 13 home visits over the child's first two years of life. In 1998, new municipal funds allowed for expansion of the former City of Toronto Parents Helping Parents Program (a birth to 3 years intensive lay home visiting program) so that the same percentage of high risk families receive intensive lay home visiting across the new City. The Province recently announced enhanced funding for Healthy Babies, Healthy Children in order to increase the intensity of lay home visiting. This will result in an additional $1-5 million to the City of Toronto, with the potential for additional funds in future years.

Case Management/Resource Facilitation

The case management component for the Healthy Babies, Healthy Children Program is in its initial stage of development. The Province is in the process of developing case management/service coordination guidelines. Process indicators will need to be identified and tracked to monitor development and implementation. The resulting data, together with qualitative input from those involved, will provide the information needed to ensure that the process of case management can be continually improved.

Data Collection/Program Evaluation

Using the North York Nursing Information System (NYNIS), the postpartum screening data and other pertinent information are entered centrally at one office and can be printed electronically at any one of the 14 offices where nurses provide services to the clients residing in the areas. This supports timely service from the Healthy Babies, Healthy Children public health nurse and client information can be updated any time at any one of the 14 offices in the City.

The Government of Ontario has recently approved a plan to move forward with the development of an information technology system to support the Healthy Babies, Healthy Children Program.

The December 1997 Mandatory Health Programs and Services Guidelines, prepared by the Ministry of Health Public Health Branch, outline the minimum requirements and indicators to plan and implement the Healthy Babies, Healthy Children Program. (See Appendix A)

A Provincial Evaluation Coordinating Centre will be coordinating the evaluation of this program. Each component of the program will be evaluated in order to test program assumptions and the effectiveness of such a strategy. Specifically the following will be examined: the target group (children at risk of poor developmental outcomes and high risk families), the lay home visitor, the community networking process, validation of the tools used in the program, as well as short and long-term outcomes for families and children in the program.

Conclusions:

As a summary, standards and best practices will be ensured by adherence to the provincial and locally adapted implementation guidelines, monitoring of program and service indicators, use of validated screening and assessment tools, formative and outcome evaluation of all program components, and a sufficient level of staffing, mentoring, supervision and training to support implementation of the program.

The Healthy Babies, Healthy Children Program is designed to ensure that all families with children (prenatal to age six) who are at risk for physical, cognitive, communicative and/or psychosocial problems have access to effective, consistent early intervention services. Looking ahead, we will need to ensure that services are harmonized across the new City to support the Healthy Babies, Healthy Children Program.

Contact Name:

Joanne Cooper, Coordinating Manager, Healthy Babies Healthy Children Program

Tel:(416) 392-7451

Fax:(416) 392-1483

Dr. Sheela V. Basrur

Medical Officer of Health

Appendix A

Mandatory Health Programs and Services Guidelines

The board of health shall plan and implement the Healthy Babies, Healthy Children Program in accordance with the Ministry of Health/Ministry of Community and Social Services Implementation Guidelines for The Healthy Babies, Healthy Children Program (August, 1997). This shall include as a minimum:

(a)coordinate services for at-risk and high-risk children ages 0-2 years. This shall include as a minimum:

(i)collaborate with the Ministry of Community and Social Services and community providers in the development of an inventory of prevention, early intervention and treatment services for children,

(ii)develop protocols with providers and agencies for screening and referral of children and families to appropriate services,

(iii)Monitor and support appropriate use of protocols,

(iv)link families and children to appropriate community supports, and

(v)ensure identification of a case manager for high-risk children receiving services.

(b)ensure the delivery of a lay home visiting program for high-risk families prenatally and with newborns. This program shall include as a minimum:

(i)conduct a brief assessment of referred at-risk families,

(ii)conduct in-depth home assessment of referred high-risk families,

(iii)develop and implement a home visiting program tailored to the needs of individual families,

(iv)link at-risk and high-risk families to alternate and/or additional community supports; where these are inadequate or unavailable, and the family could benefit from home visiting by a nurse or other health professional, these services must be provided,

(v)ongoing training to lay home visitors on child development,

(vi)monitor the program delivered by lay home visitors, and

(vii)coordinate the home visiting program with other community family supports and services.

(c)lay home visitors will provide information and skills development regarding the following:

(i)developmental milestones and how to promote healthy child development

(ii)factors contributing to achievement of milestones, and

(iii)community supports.