By Debbie I. Chang, MPH, Vice President, Policy and Prevention, Nemours & Mary Kate Mouser, Executive Director, Nemours Health and Prevention Services
Nemours, a children’s health system operating in the Delaware Valley (Delaware, New Jersey and Pennsylvania) and Florida, offers pediatric clinical care, research, education, advocacy and community-based prevention programs in the communities we serve.
In 2004, with childhood obesity rates continuing to climb and associated health outcomes increasing among the children and families we serve, we expanded our mission beyond providing clinical care to include health promotion and disease prevention.
We embraced a model of integrated care and prevention that would improve quality, address rising health care costs and improve the health of the population of children in Delaware.
Our goal was to prevent obesity, type 2 diabetes and other chronic conditions, not just for our patients, but for all children in Delaware. We began our efforts in the state of Delaware, with a focus on reaching children and families in the places where they live, learn and play. To execute on this strategy, we created a new operating division — Nemours Health and Prevention Services (NHPS).
As we looked at the mounting problems related to childhood obesity (in 2006, 17.6 percent of children ages 2-17 were overweight and 19 percent were obese)i and consulted with key stakeholders, it became clear that a multi-pronged approach with a focus on quality medical care combined with community-based prevention strategies offered the greatest likelihood of success. Under the umbrella of the “Campaign to
Make Delaware’s Kids the Healthiest in the Nation,” Nemours worked with partners from multiple sectors — schools, child care, primary care practices and community-based organizations— to positively influence children’s behavior and help instill healthy habits early in children’s lives.
Throughout the course of this work, Nemours assumed the role of an “integrator”, an entity working at a population level to promote prevention and improve health and wellbeing. We sought to spread and sustain what works, through a combination of approaches, including both policy and practice change. Nemours served as the engine that brought this successful community initiative together by forging strong relationships with multi-sector partners to reach a shared goal, assessing available community resources, identifying gaps, creating continuous feedback loops with the community and leveraging financial resources to support the work, all critical roles that an integrator serves.ii
For example, Nemours, working closely with the Delaware Department of Education, assisted school districts in examining existing wellness policies, strengthening and revising these policies when needed and possible and implementing them at the school level. This effort emphasized two key strategies:
- Focusing on district wellness policies to reach individual schools, taking advantage of the federal law requiring all districts participating in the National School Lunch Program to create local wellness policies; and
- Supporting the Department of Education in implementing fitness measurements and physical activity pilot programs in individual schools to demonstrate how physical activity can be folded into the school day and the benefits of doing so.
As part of our work with the education sector, we also forged strong partnerships in the early learning community—a group that is often overlooked, despite being a setting where a significant number of young children spend the majority of their day. Nemours identified this gap and then worked to address it through developing a comprehensive approach including promoting policy changes in state licensing regulations to improve the quality of nutritional and physical activity standards in licensed and family child care that would impact 54,000 children in Delaware.
A strong partnership with the state Child and Adult Care Food Program was instrumental in this work. We worked in partnership with early care and education training systems to support providers in implementing these standards, including offering technical assistance in structured learning sessions for child care providers that focused on healthy eating and physical activity.
From a public messaging perspective, a key area of focus for an integrator, we engaged community partners and supplemented our work through our ‘5-2-1-Almost None’ prescription for a healthy lifestyle. This effort encourages children and families to adopt a daily prescription to eat at least five servings of fruits and vegetables, engage in no more than two hours of recreational time in front of a screen, participate in at least one hour of physical activity and consume almost no sugar-sweetened beverages. Nemours engaged multiple partners in different settings such as public parks in pursuit of a shared goal of promoting healthy eating and physical activity. For example, Nemours worked with the Delaware Parks and Recreation Department to offer healthier food options in park vending machines, helped communities institute community walk days and spread the 5-2-1-Almost None message to schools, child care centers, youth-serving and community-based organizations, and various levels of government throughout the state.
Another important role of an integrator is to facilitate the leveraging of financial resources. In 2011 Nemours hosted the first Outdoor Summit for Sussex County, which brought together county and state officials, school district leaders and community leaders to strategize about how best to promote the need for their members and constituents to get 30 minutes of outdoor physical activity daily. Building from this work to convene and engage partners, that same year, the State of Delaware appropriated more than $7 million to improve Delaware’s walking and biking trails, with an additional $13.25 million appropriated in 2012.
As a children’s health system with a wealth of clinical resources at our disposal, Nemours leveraged data contained in our electronic health record system to establish a childhood obesity quality improvement initiative that not only alerts a doctor when a patient’s Body Mass Index (BMI) is above the healthy weight range but also outlines appropriate follow-up and counseling for families. From 2007-2008, a significant first step was that the number of our providers noting BMI during a well care visit for children almost doubled.
As a complex problem linked to deeply-rooted societal patterns, childhood obesity is difficult to fight. Reversing the trends will take many years. However, Delaware is progressingiii: between 2006 and 2008-09, the overweight/ obesity rate for children ages 12-17 decreased from 41.4% in 2006 to 35.2% in 2008-09 and the overweight/obesity rate in Sussex County decreased from 40.2% in 2006 to 38.5% in 2008-09.iv And data from a new, statewide survey to be released in 2013 shows promising indicators, including positive trends in parental awareness of messaging, child behavior and other key areas of intervention.
Delaware’s demographics are comparable to those of many other states; progress in fighting childhood obesity here will provide the nation with important information in this long term battle. Our obesity prevention work continues today, with an emphasis on applying the model we used with great success in Delaware to other states where preventable chronic diseases are taking a toll on the nation’s children.
This focus on spread and sustainability underpins our work as integrator. In 2012 Nemours and our partners, including the National Initiative for Children’s Healthcare Quality, Child Care Aware of America, American Academy of Pediatrics and others, will implement evidence-based, practice-tested learning collaboratives in collaboration with local early care and education providers in Arizona, Florida, Indiana, Kansas, Missouri and New Jersey. Our goal is to help these providers adopt nutrition, breastfeeding support, physical activity and screen time policies and practices to improve the health of children under their care.
Nemours’ commitment to building sustainable partnerships with a proven impact on population health left us well positioned to build on our childhood obesity prevention work by expanding to other health issues, most notably asthma. This expanded work is enabling us to further enhance and build on our role as an integrator, impacting the children and families we serve.
In Delaware, 11 percent of children have asthma, the sixth highest rate in the country. In addition, children under four are twice as likely to be hospitalized with asthma as any other age group and are four times as likely to have asthma-related hospitalizations as adults. To address this issue, Nemours created the ‘Optimizing Health Outcomes for Children with Asthma in Delaware’ project, with the goal of reducing asthma-related emergency department visits by 50 percent and asthma-related hospitalizations by 50 percent for all children in Delaware by 2015.
To achieve this, we are combining a pediatric primary care medical home model with a population health approach strategy to create healthier environments for children throughout the state. In addition to investing private funds, Nemours has leveraged federal funds from the Centers for Medicare and Medicaid Innovation to support our work as integrator. We are piloting our approach at three primary care sites, with an enhanced family-centered medical home model that brings subspecialty asthma care into the primary care setting. Through this approach, our patients will receive well-coordinated care from an interdisciplinary team of physicians, nurses, care coordinators, licensed mental health professional and community health workers (CHW). The CHWs will serve as patient navigators, who help individuals coordinate, access and manage multiple services and supports by connecting our patients with appropriate community-based services and providing case management of their non-medical needs. The CHWs will coordinate their work with community health liaisons, who partner with neighborhood leaders to develop infrastructure in schools, child care, housing and other systems to reduce asthma triggers and promote a healthier environment. This will enable a continuous feedback loop, whereby the insights gleaned from the navigator will inform the work of the integrator, with a goal of catalyzing population level change in the community.
At Nemours, our mission to improve the lives of children doesn’t stop at the doors to our hospitals and clinics. Our commitment to helping children grow up healthy and reach their full potential drives us to consider all the ways we can help develop the next generation of kids in all the communities we serve. We see ourselves as shared guardians of children’s health and leverage our more than seven decades of experience to mobilize and integrate communities in pursuit of an integrated approach to improved quality of care for kids, lower costs for the health care system, and ultimately better population health.
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i Nemours Health and Prevention Services. Delaware Survey of Children’s Health. Newark, Delaware 2009.
ii Nemours. “Integrator Role and Functions in Population Health Improvement Initiatives.” May 2, 2012. http://www.improvingpopulationhealth.org/Integrator%20role%20and%20functions_FINAL.pdf
iii Chang, Debbie I., Gertel-Rosenberg, Allison, Drayton, Vonna L., Schmidt, Shana and Angalet, Gwendoline B. “A Statewide Strategy to Battle Child Obesity in Delaware.” Health Affairs. March/April 2010 — Volume 29, Number 3.
iv Nemours Health and Prevention Services. Delaware Survey of Children’s Health. Newark, Delaware 2009.