Center for Healthier Children, Families & Communities Life Course Health Development: A Transformative Framework To Improve Childrens Health Neal Halfon,

Center for Healthier Children,Center for Healthier Children,Families & CommunitiesFamilies & Communities

Life Course Health Life Course Health Development: A Development: A

Transformative Framework Transformative Framework To Improve Children’s Health To Improve Children’s Health

Neal Halfon, MD, MPHNeal Halfon, MD, MPH

UCLA Schools of Public Health, Medicine, Public UCLA Schools of Public Health, Medicine, Public AffairsAffairs

UCLA Center for Healthier Children, Families and UCLA Center for Healthier Children, Families and CommunitiesCommunities

National Center for Infancy & Early Childhood National Center for Infancy & Early Childhood Health Policy Health Policy

MCHB-AIM Child & Adolescent Policy Support MCHB-AIM Child & Adolescent Policy Support CenterCenter

CityMatCH ’08, Albuquerque

September 21, 2008


Goals of this PresentationGoals of this Presentation

To review the evidence, importance and To review the evidence, importance and potential impact of the developmental potential impact of the developmental origins of health and diseaseorigins of health and disease

To consider the strategic role that the To consider the strategic role that the emerging Life Course Health emerging Life Course Health Development approach can play in Development approach can play in Advancing a progression Health Policy Advancing a progression Health Policy

Agenda Agenda Enabling significant Health Systems Reform Enabling significant Health Systems Reform

in the USin the US


Take home Points: Power of Take home Points: Power of LCHDLCHD

Life Course Health Development (LCHD) is different than a life course approach

LCHD –integrating framework Connecting the disparate parts of MCH Connecting MCH to rest of health and

human development Leverages MCH and Positions and

Prioritizes MCH policy Provides a new Operating Logic for

Transforming the Health System Powerful analytic model for solving

MCH problems


From Lifespan to LCHDFrom Lifespan to LCHD Lifespan models – connect the dots- Lifespan models – connect the dots-

linking early life to later lifelinking early life to later life Life stage models – periods of Life stage models – periods of

psychological development psychological development Life-course models – are concerned with Life-course models – are concerned with

patterns and pathways that connect the patterns and pathways that connect the dots between early and later lifedots between early and later life

Life Course Health Development models-Life Course Health Development models- Connect the dotsConnect the dots Describe the pathways or heath Describe the pathways or heath

trajectories trajectories Address the mechanisms that determine Address the mechanisms that determine

or influence health trajectoriesor influence health trajectories



LCHDLCHD

Where We Have BeenWhere We Have Been


0

20

40

60

80

100

Figure 22. Life expectancy at birth and at 65 years of age by sex: United States, 1901-2001

NOTE: See Data Table for data points graphed and additional notes.

SOURCE: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System.

Life Expectancy at birth

Life expectancy at 65 years

Year

Males

Females

Females

Males

Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2004

1901 1910 1920 1930 1940 1950 1960 1970 1980 1990 2001

Lif

e e

xp

ec

tan

cy

in

ye

ars


He

alt

h /

fu

nc

tio

na

l S

tatu

s

0 years 20 years 80 years

Life Span

Performance Span

Health Span


Social/Nutritional/Social/Nutritional/Epidemiological/ Epidemiological/

Developmental ShiftDevelopmental Shift Social Conditions dramatically changes Social Conditions dramatically changes

over this time periodover this time period Nature, Array, and Prevalence of Risk, Nature, Array, and Prevalence of Risk,

Protective and Health Promoting factors Protective and Health Promoting factors Nutritional Conditions change- high Nutritional Conditions change- high

sugar, high fat dietssugar, high fat diets Types, prevalence, distribution of acute Types, prevalence, distribution of acute

and chronic disease changes dramatically and chronic disease changes dramatically Developmental expectancies changeDevelopmental expectancies change Capacity of Medical Care to intervene, Capacity of Medical Care to intervene,

modify risk and treat disease modify risk and treat disease


The Evolving Health Care The Evolving Health Care SystemSystem

The First Era(Yesterday)

The Second Era(Today) The Third Era

(Tomorrow) Focused on acute Focused on acute

and infectious and infectious diseasedisease

Germ TheoryGerm Theory

Medical CareMedical Care

Insurance-based Insurance-based financingfinancing

Reducing DeathsReducing Deaths

Increasing focus on Increasing focus on chronic diseasechronic disease

Multiple Risk Multiple Risk FactorsFactors

Chronic Disease Chronic Disease Mgmt & PreventionMgmt & Prevention

Pre-paid benefitsPre-paid benefits

Prolonging Prolonging Disability free LifeDisability free Life

Increasing focus onIncreasing focus on achieving optimal achieving optimal health statushealth status

Complex Causal Complex Causal PathwaysPathways

Investing in Investing in population-based population-based preventionprevention

Producing Optimal Producing Optimal Health for AllHealth for All

Health System 1.0

Health System 2.0

Health System 3.0


2004 National Research Council 2004 National Research Council and Institute of Medicine Reportand Institute of Medicine Report


IOM/NRC Definition of IOM/NRC Definition of Children’s Health Children’s Health (2004)(2004)

““Children’s health is the extent to which Children’s health is the extent to which individual children or groups of children are individual children or groups of children are able or enabled to (a) develop and realize able or enabled to (a) develop and realize their potential, (b) satisfy their needs, and their potential, (b) satisfy their needs, and (c) develop the capacities that allow them to (c) develop the capacities that allow them to interact successfully with their biological, interact successfully with their biological, physical, and social environments.”physical, and social environments.”

From From Children’s Health, the Nation’s Wealth, Children’s Health, the Nation’s Wealth, National Academies Press, 2004.National Academies Press, 2004.


LCHDLCHD Defines Health as a developmental process Defines Health as a developmental process Builds upon Ecological and Transactional Builds upon Ecological and Transactional

models of Life Span Development models of Life Span Development Utilizes a rapidly Expanding Evidence Base Utilizes a rapidly Expanding Evidence Base

Life Course Chronic Disease EpidemiologyLife Course Chronic Disease Epidemiology Neurobiology Neurobiology Early Intervention ResearchEarly Intervention Research Economics of Human Capital FormationEconomics of Human Capital Formation Gene-Environment/ Social EpidemiologyGene-Environment/ Social Epidemiology


Health as a Developmental Health as a Developmental ProcessProcess

Health is a developmental processHealth is a developmental process Health developsHealth develops across the life course across the life course Health development can be represented by Health development can be represented by

health trajectorieshealth trajectories Critical/ Sensitive periodsCritical/ Sensitive periods Gene - Environment – InteractionGene - Environment – Interaction have have

different impacts during different periodsdifferent impacts during different periods Macro and Micro pathways delineate how Macro and Micro pathways delineate how

toxic environments and risky families get toxic environments and risky families get under the skinunder the skin

How Risk Reduction and Health Promotion Strategies How Risk Reduction and Health Promotion Strategies influence Health Developmentinfluence Health Development

FIGURE 4: This figure illustrates how risk reduction strategies can mitigate the influence of risk factors on the developmental trajectory, and how health promotion strategies can simultaneously support and optimize the developmental trajectory. In the absence of effective risk reduction and health promotion, the developmental trajectory will be sub-optimal (dotted curve). From: Halfon, N., M. Inkelas, and M. Hochstein. 2000. The Health Development Organization: An Organizational Approach to Achieving Child Health Development. The Milbank Quarterly 78(3):447-497.

Trajectory Without RR and HP Strategies

0 20

Hea

lth

Dev

elo

pm

ent

40 60 80Age (Years)

HP

RR Risk Reduction Strategies

Health Promotion Strategies

Optimal Trajectory

Protective Factors

HP HPHP

RR

RR

RR

Risk Factors


Fig.

From: Lamberts SWJ, van den Beld AW, van der lely A. The endocrinology of aging. Science. 1997;278:419-424.


From: Kuh D, Ben-Shlomo Y. A life course approach to chronic disease epidemiology. New York: Oxford University Press. 1997.


Birth

Early Infancy

Late Infancy

Early Toddler

Late Toddler

Early Preschool

Late Preschool

Age 6 mo 12 mo 18 mo 24 mo 3 yrs 5 yrs

Re

ad

y t

o le

arn

Strategies to Improve Health Development Trajectories

“At Risk” Trajectory

“Delayed/Disordered ” Trajectory

“Healthy” Trajectory

Back to Overall Model

Parent educationEmotional HealthLiteracy

Reading to child

Pre-school

Appropriate Discipline

Poverty

Lack of health services

Family Discord

Graphic Concept Adapted form Neal Halfon , UCLA

Health Services


Risk and protective factorsRisk and protective factors

Risk FactorsChild

FamilyCommunity

School

Protective FactorsChild

FamilyCommunity

School

OutcomeNegative vulnerability

Positiveresilience


LCHDLCHD

Connecting the Connecting the Dots Dots


Adverse childhood Adverse childhood events and adult events and adult

depressiondepression

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

0

1

2

3

4

5+

Odd

s R

atio

Adverse EventsChapman et al, 2004


Adverse childhood Adverse childhood events and adult events and adult

ischemic heart disease ischemic heart disease

0

0.5

1

1.5

2

2.5

3

3.5

0

1

2

3

4

5,6

7,8

Dong et al, 2004 Adverse Events

Odd

s R

atio


Adverse childhood Adverse childhood events and adult events and adult substance abusesubstance abuse

0

2

4

6

8

10

12

14

16

0 1 2 3 4+

0

5

10

15

20

25

30

35

40

0 1 2 3 4 5+

%

Self-Report: Alcoholism Self-Report: Illicit Drug Use

Dube et al, 2002 Dube et al, 2005

%


LCHDLCHD

Actionable Actionable Mechanisms for Mechanisms for

Intervention Intervention


Cumulative, Programming Cumulative, Programming and Pathway Mechanisms and Pathway Mechanisms

Influence LCHDInfluence LCHD Three basic mechanisms influence LCHD Three basic mechanisms influence LCHD

CumulativeCumulative - additive effect of multiple risks and - additive effect of multiple risks and protective factors, weatheringprotective factors, weathering

Programming Programming - time specific influence of - time specific influence of stimulus or insult during a critical or sensitive stimulus or insult during a critical or sensitive period on selection, adaptation, compensatory period on selection, adaptation, compensatory processesprocesses

Pathways-Pathways-chains of (eco-culturally constructed) chains of (eco-culturally constructed) linked exposures that create a constrained linked exposures that create a constrained conduit of gene-environment transactions conduit of gene-environment transactions


Cumulative SES (birth - 33 yrs) poor Cumulative SES (birth - 33 yrs) poor health, age 33health, age 33

0

5

10

15

20

25

MenWomen

% f

air/

po

or

hea

lth

% f

air/

po

or

hea

lth

Lifetime SES scoreLifetime SES scorebestbest worstworst

4 5 6 7 8 9 10 11 12 13 14 15 164 5 6 7 8 9 10 11 12 13 14 15 16

Source: Power et al, 1999Source: Power et al, 1999


LCHDLCHD

Programming Programming




Life Course Chronic Disease Life Course Chronic Disease Epidemiology: Barker Epidemiology: Barker

HypothesisHypothesis Affiliation: MRC Environmental Affiliation: MRC Environmental

epidemiology unit in South Hamptonepidemiology unit in South Hampton Design: Historical Cohort Design: Historical Cohort Key Finding: Fetal growth and Key Finding: Fetal growth and

development, and other factors, in development, and other factors, in first year(s) of life related to first year(s) of life related to cardiovascular and other chronic cardiovascular and other chronic disease in the fifth and sixth decadedisease in the fifth and sixth decade





Barker HypothesisBarker HypothesisBirth Weight and Coronary Heart Birth Weight and Coronary Heart

DiseaseDisease

0

0.25

0.5

0.75

1

1.25

1.5

<5.0 5.0-5.5 5.6-7.0 7.1-8.5 8.6-10.0 >10.0

Birthweight (lbs)

Age Adjusted Relative Risk

Rich-Edwards 1997


Birthweight and CVD Birthweight and CVD OutcomesOutcomes

Nurses’ Health StudyNurses’ Health Study

0

0.5

1

1.5

2

2.5

<5.0 5.0-5.5 5.6-7.0 7.1-8.5 8.6-10.0 >10.0

Birthweight (lb)

Rel

ativ

e ri

sk

CHDStroke HypertensionType 2 Diabetes

Curhan et al., Rich-Edwards et al.



Odds Ratio.5 1 5

Combined

Dubois, 2006

Chen, 2006 M

Chen, 2006 F

Al Mamun, 2006

Reilly, 2005

Oken, 2005

Adams, 2005

Whitaker, 2004

Wideroe, 2003

Toschke, 2003

Bergmann, 2003

von Kries, 2002

Toschke, 2002

Power, 2002 M

Power, 2002 F

Smoking During Pregnancy & Offspring Obesity

Pooled AOR 1.46 (1.33, 1.59)

Oken et al., unpublished



Odds ratio of obesity: breast versus formula fed

Odds of obesity.5 1 1.5

Combined

Taitz (0)

Yeung et al (0.5)

Dewey et al (1)

Thorogood et al (1)

Armstrong & Reilly (3)

Grummer-Strawn and Mei (4)

Hediger et al (4)

Neyzi et al (5)

O'Callaghan et al (5)

Scaglioni et al (5)

Bergmann et al (6)

von Kries et al (6)

Wadsworth et al (6)

Richter (7)

Strbak et al (1-7)

Eid (8)

Li et al (8)

Maffeis et al (10)

Frye and Heinrich (10)

Liese et al (10)

Toschke et al (6-14)

Sung et al (11)

Gillman et al (12)

Elliot et al (15)

Kramer (15)

Kramer (15)

Tulldahl et al (16)

Poulton and Williams (26)

Parsons et al (33)

Breast feeding better Formula feeding better

0.87 (95% CI 0.85, 0.89)

Owen et al, Pediatrics , 2005 (From

Gilman)


LCHDLCHD

Programming leads to Programming leads to Latent EffectsLatent Effects

Long time horizons Long time horizons between exposure between exposure and outcomesand outcomes


Cumulative, Programming Cumulative, Programming and Pathway Mechanisms and Pathway Mechanisms

Influence LCHDInfluence LCHD Three basic mechanisms influence LCHD Three basic mechanisms influence LCHD

Cumulative - additive effect of multiple risks and Cumulative - additive effect of multiple risks and protective factors, weatheringprotective factors, weathering

Programming - time specific influence of stimulus Programming - time specific influence of stimulus or insult during a critical or sensitive period on or insult during a critical or sensitive period on selection, adaptation, compensatory processesselection, adaptation, compensatory processes

Pathways- Pathways- chains of (eco-culturally constructed) chains of (eco-culturally constructed) linked exposures that create a constrained linked exposures that create a constrained conduit of gene-environment transactions conduit of gene-environment transactions


Poverty & ECDPoverty & ECD

ParentDistress

ParentBehavior

ParentInvestme

nt

Child Cognitive

Development

Child Physical

Development

Child Social-

Emotional Developme

nt

Parent- and Family-Level Predictors

of Income And Hardship

Parent Work Status Job Prestige Education Level Parent Marital Status Race-Ethnicity

Neighborhood- and Community-Level Influences

Family Income Poverty

Financial

Hardship





LCHD: Childhood LCHD: Childhood Antecedents of later Antecedents of later

Childhood and Adult HealthChildhood and Adult Health

From Starfield 02/03

Source: van de Mheen et al, IJE 1998

Early social and material deprivation (financial,

educational, environmental)

Prior poor health, fetal nutrition,

case-mix

Immunologic& physiologic moderators

Prior adverse behavior

Prior poor physical activity

Current poor health/ premature mortality

Current poor physical activity

Current adverse behavior

Current social and material deprivation


LCHD: New LCHD: New Approaches to Approaches to Old ProblemsOld Problems


How are LCHD concepts How are LCHD concepts being usedbeing used

Health System Reform (US)Health System Reform (US) Aday’s Reinventing Public HealthAday’s Reinventing Public Health Breslow’s 3Breslow’s 3rdrd Era of Health and Health Care Era of Health and Health Care Snyderman’s Future Medical/Health System Snyderman’s Future Medical/Health System

analysisanalysis Health System Reform ( Intl)Health System Reform ( Intl)

UK – Acheson Report, Sure Start, Health UK – Acheson Report, Sure Start, Health Development AgencyDevelopment Agency

Canada –CIAR, Major Measurement Strategy Canada –CIAR, Major Measurement Strategy focused on curve shifting across the life coursefocused on curve shifting across the life course

WHO- ECD initiative, Commission on Social WHO- ECD initiative, Commission on Social Determinants of Health Determinants of Health


Disease ProgressionDisease ProgressionS

ympt

oms

Cos

t

Years

3 2

11 = current practice

2 = current capability

3 = future capability

Source: Snyderman R. AAP presidential address: the AAP and the transformation of medicine. Journal of Clinical Investigation. 2004;114(8):1169-1173 (suppl)


Paradigm ShiftTraditional medical

evaluation and recordProspective

evaluation and record

• Chief complaint

• History of illness

• Past medical history

• Family history

• Social history

• Physical exam

• Diagnostic tests

• Assessment and plan

• Health profile summary

• Current (immediate) Health Status

• Health risk analysis

– Genetic

– Environmental

– Lifestyle

• 1-year health plan

• 5-year health plan

Requires:• Life Span Health Risk assessments• Early detection• Means for prevention/early intervention• Individual health plan• Effective Life course health delivery

system• Effective reimbursement



Risk Assessment for Prospective Health


Sym

ptom

s

Cos

t

Years

Risk assessment decision support

Low risk High risk Early chronic

Late chronic

Health Promoting Plan Risk modification Disease management

Personalized health plan

Wellness education and Internet and health

provider guided planning for all

Wellness education and Internet and health

provider guided planning for all

Individual-focused; integrated provider systems. Focus on quality of life and palliation

at appropriate late stages



LCHD and Birth LCHD and Birth OutcomesOutcomes

Pregnancy

White

AfricanAmerican

Reproductive Potential

Age


LCHD and Birth LCHD and Birth OutcomesOutcomes

Pregnancy

White

AfricanAmerican

Reproductive Potential

Age


Life Course Health Life Course Health DevelopmentDevelopment

Poor NutritionStressAbuseTobacco, Alcohol, DrugsPovertyLack of Access to Health CareExposure to Toxins

Poor Birth Outcome

0 5 Puberty PregnancyAge

White

AfricanAmerican


LCHD: AA – White Birth LCHD: AA – White Birth outcomesoutcomes

Prenatal Care

Poor Birth Outcome

0 5 PregnancyPuberty

Internatal Care

Primary Care for Women

Early Intervention

Prenatal Care

Primary Care for Children

Age

White

AfricanAmerican


LCHD Framework:LCHD Framework:Service Delivery System Service Delivery System

ApplicationsApplications

Health ServicesHealth Services Moving from health maintenance to Moving from health maintenance to

health development organizationshealth development organizations Integration strategies for newly Integration strategies for newly

engineered health systemsengineered health systems Vertical – Primary, Secondary, Tertiary Vertical – Primary, Secondary, Tertiary Horizontal – Biological, Behavioral, Horizontal – Biological, Behavioral,

Social, Env.Social, Env. Longitudinal – Life-course/LifespanLongitudinal – Life-course/Lifespan


Source: Wise PH. “The transformation of child health in the United States.” Health Affairs. 23, No. 5 (2004): 9-25.



Changing Pattern of Childhood Changing Pattern of Childhood MorbidityMorbidity

Increase in chronic health problems Increase in chronic health problems (10-14%)(10-14%)

Greater recognition of mental health Greater recognition of mental health problems (15-20%)problems (15-20%)

Greater appreciation of role and Greater appreciation of role and impact of developmental health impact of developmental health problems – learning, language (10-problems – learning, language (10-17%)17%)



Children & Youth at Children & Youth at RiskRisk

4-6%Severe

Disabilities

12-16%Special Health

Care Needs

30-40%Behavioral,

Mental Health Learning Problems

50-60% Good Enough

What % are thriving ?

30% ?

40% ?

50% ?


How well is the 2.0 How well is the 2.0 Child Health Child Health

System System Performing?Performing?


The existing child health service The existing child health service systemsystem

Demand greater than services Demand greater than services availableavailable

Families have complex needs - often Families have complex needs - often beyond capability of any single beyond capability of any single serviceservice

Difficulty accessing servicesDifficulty accessing services Socio-economic gradient of accessSocio-economic gradient of access Focus on treatment rather than Focus on treatment rather than

prevention/early interventionprevention/early intervention Episodic contact Episodic contact Poor quality of Well Child CarePoor quality of Well Child Care


The existing child health service The existing child health service systemsystem

Fragmented service deliveryFragmented service delivery Different sectors (health, public health, Different sectors (health, public health,

population health, civic)population health, civic) Different funding streamsDifferent funding streams Different culturesDifferent cultures

Lack of co-ordinationLack of co-ordination Narrow programmatic criteria for eligibilityNarrow programmatic criteria for eligibility Variable understanding of child health issuesVariable understanding of child health issues Local community generally has limited Local community generally has limited

accountability or responsibilityaccountability or responsibility


How do we get the How do we get the health system that health system that

children need?children need?

Incremental vs. Incremental vs. TransformationalTransformational

Reforms Reforms


Transforming the Child Health Transforming the Child Health System: New Paradigm vs. Old System: New Paradigm vs. Old

SystemSystem Child health system was designed for Child health system was designed for

the first era of health care ( acute, the first era of health care ( acute, infectious disease model) infectious disease model)

It was upgraded a bit for the 2It was upgraded a bit for the 2ndnd era, era, with more regionalization, chronic with more regionalization, chronic disease caredisease care

Ill equipped for this new eraIll equipped for this new era Under-performingUnder-performing Facing many new challenges Facing many new challenges


Child Health 3.0 : the New & Child Health 3.0 : the New & Improved approachImproved approach

Integrated and comprehensive approach - Integrated and comprehensive approach - broadbanding of services to achieve curve broadbanding of services to achieve curve shifting outcomesshifting outcomes

Greater flexibility of services and improved Greater flexibility of services and improved coordination at local community levelcoordination at local community level

Increased community and consumer Increased community and consumer participationparticipation

Prevention, health promotion, early Prevention, health promotion, early intervention, intervention, developmental optimizationdevelopmental optimization focus focus

Focus on outcomes through Focus on outcomes through improved systems improved systems performanceperformance

Innovative funding and accountability Innovative funding and accountability arrangementsarrangements



Transformation Transformation FrameworkFramework

ComponentsComponentsCurrent Current SystemSystem

2.0 2.0

Transformed Transformed SystemSystem

3.03.0

Change Change Strategies Strategies

LogicLogic

Organization of Organization of Health Producing Health Producing SectorsSectors

Organization & Organization & Delivery of Individual Delivery of Individual CareCare

Medical Education & Medical Education & WorkforceWorkforce

MarketMarket

FundingFunding

PlanningPlanning

Regulation & Regulation & GovernanceGovernance

Performance Performance MonitoringMonitoring


Transformation Transformation FrameworkFramework

ComponentsComponentsCurrent Current SystemSystem

2.0 2.0

Transformed Transformed SystemSystem

3.0 3.0

Change Change Strategies Strategies

LogicLogic ID and Tx ID and Tx Disease Disease EpisodeEpisode

LCHD-LCHD-optimizing optimizing health health trajectoriestrajectories

Build LCHD Build LCHD prevention, prevention, promotion promotion into the DNA into the DNA of the Systemof the System

Organization of Organization of Health Producing Health Producing SectorsSectors

Silos, Medical Silos, Medical Care Care DominatesDominates

Integrated, Integrated,

Organization & Organization & Delivery of Individual Delivery of Individual CareCare

Vertically Vertically Integrated, Integrated, 11°°, 2, 2°°, 3, 3° care° care

Vertically, Vertically, Horizontally, and Horizontally, and Longitudinal Longitudinal Integ.Integ.

MarketMarket Embedded, Embedded, Competition on Competition on ValueValue

FundingFunding Pay for illness Pay for illness carecare

Invest in health Invest in health capitalcapital

Performance Performance MonitoringMonitoring

Individual Individual quality,quality,

Systems Systems Performance Performance Measures- ind, Measures- ind, pop, communitypop, community


Targeted Targeted

InterventionsInterventions

NU

MB

ER

OF

CH

ILD

RE

N

FUNCTION

Median

High income

Low income

VULNERABLE

Universal Curve Shift

DISABLED

Clinical/Individual Clinical/Individual InterventionsInterventions


NU

MB

ER

OF

CH

ILD

RE

N

FUNCTIONVULNERABLE

Median

High income

Low incomeUniversal Curve Shift


CHILD

FAMILY

NEIGHBORHOODSERVICES

COMMUNITY

POLICY Includes:

Physicians, dentistsSchools

Child Care

Child HealthFamily Support

Education

Clinical/Individual

TargetedUniversal

Civic Society


Pediatric Office 2.0Pediatric Office 2.0

Developmental Services

Home-visitingnetwork

Early Intervention

Child CareResource &ReferralAgency

Early HeadStart& HeadStart

Early ChildMental Health Services

Preventive Care

Acute Care

Chronic Care


Parenting Support

Lactation Support


18 month visit 18 month visit

Pediatric Care 2.0Pediatric Care 2.0 C.D – DisabilityC.D – Disability Screen 4-6 % w/ Screen 4-6 % w/

disability disability Screening tools & Screening tools &

PathwayPathway Pediatric Office Pediatric Office

connected to connected to Regional CenterRegional Center

Pediatric Care 3.0Pediatric Care 3.0 Optimize Optimize

Developmental Developmental HealthHealth

I.D 30-40% I.D 30-40% developmental risk developmental risk

Screening tools & Screening tools & PathwayPathway

Pediatric Office Pediatric Office connected:connected:

Child care Child care Many other programsMany other programs Coordination Coordination Regional center ++Regional center ++


Preventive Care

Acute Care

Chronic Care


DS Community Services Pathway

ScreeningPediatric Services

Sector

SurveillanceCommunity Services and Resource Sector

AssessmentPeds/HPlan/

PHSector

Evaluation (IDEA Sector

Child Care/FamilyResource Center

Mid-LevelAssessment

Center

Surveillance

Program

Program

IDEARegionalCenter for

DevelopmentalDisabilities

OtherSpecialized

Services

COORDINATIONCOORDINATIONCENTERCENTER


0 1 3 5 7 Years

Trajectory Optimizing Service Linkage Pathway

NHV FRC

PED

ROR FRC

PED

SR FRC

PED

Tutor FRC

PED

Pediatric Continuity

Network Connections

Dev

elop

men

t

Optimal Health Development

Lower Health Development

Trajectory


Optimizing Trajectories: Multisector Multilevel StrategiesOptimizing Trajectories: Multisector Multilevel StrategiesH

ealt

h D

evel

op

men

t

0 20 40 60 80Age (Years)

Social WelfareSocial Welfare

FamilyFamilysupportsupport

EducationEducation

HealthHealth

FamilyNeighborhood ServicesCommunity

Policy

Child


Early Childhood System Building BlocksEarly Childhood System Building Blocks

Family SupportServices

ChildHealth

Services

Desired Outcomes at School EntryFamily Capacity and

FunctionEmotional / Social /

Cognitive Development Physical Health & Development

Trajectory of Child Development and Family Function

Birth

Early Infancy

Late Infancy

Early Toddler

Late Toddler

Early Preschool

Late Preschool


Rea

dy

to le

arn “At Risk” Trajectory



A.

Early Care and EducationPrograms

B.

C.


Early Childhood System 2.0: Building BlocksEarly Childhood System 2.0: Building Blocks

Univ

ersa

l

Disc

retio

nary

Cate

goric

al /

Inte

nsiv

e Care Coordination

Medical Home

ChildHealth

Services

Developmental ServicesMedical Services

Home Visiting

Prt C (B-to-3)\CYSHCNSpec Ed




Birth

Early Infancy

Late Infancy

Early Toddler

Late Toddler

Early Preschool

Late Preschool


Rea

dy

to le

arn

“At Risk” Trajectory



A.

B.

C.

Un

iversa

l Pre

sch

oo

l

Head

Sta

rt &

Fam

ily L

itera

cy

Early H

S

Early Care & Education

Family Support Services

Family Resource Centers


Child Health Services Building BlocksChild Health Services Building Blocks


ChildHealth

Services





.


Child Health Services Building BlocksChild Health Services Building Blocks


ChildHealth

Services





.


Early Childhood System 3.0Early Childhood System 3.0Desired Outcomes at School Entry

Family Capacity and Function

Emotional / Social / Cognitive Development Physical Health &

Development

.

Surveillance

Assessment

Family Resource Center

ECE Center

Health Center

Co-located or virtually connected service centers – creating new pathways

Screening


Systematic Data CollectionSystematic Data CollectionFor trackingFor tracking Health Development Health Development

TrajectoriesTrajectories

School Readiness

5 ysBirth 1yr 4 ys3 ys2 ys

Pediatric Early Child Assessment

Birth Certificate

Preschool Assessment

• Physical Wellbeing & motor dev’t• Social & emotional dev’t• Approaches to learning• Language dev’t• Cognition & general knowledge


What does LCHD New Synthesis What does LCHD New Synthesis Provide to the Discourse on Health Provide to the Discourse on Health

System ReformSystem Reform?? Big Idea – Forward lookingBig Idea – Forward looking Integrative FrameworkIntegrative Framework

Connect up an increasingly balkanized fieldConnect up an increasingly balkanized field Reframe for health system reform goalsReframe for health system reform goals Positions child/MCH in Vanguard of Positions child/MCH in Vanguard of

New Era in Health and Health Care New Era in Health and Health Care ReformReform

New Rational for current and future New Rational for current and future activitiesactivities


Take home Points: Power of Take home Points: Power of LCHDLCHD

Life Course Health Development (LCHD) is different than a life course approach

LCHD –integrating framework Connecting the disparate parts of MCH Connecting MCH to rest of health and

human development Leverages MCH and Positions and

Prioritizes MCH policy Provides a new Operating Logic for

Transforming the Health System Powerful analytic model for solving

MCH problems


LCHD Framework: Think LCHD Framework: Think Different!Different!

Developmentally - in order to optimize Developmentally - in order to optimize outcomesoutcomes

Population and upstream determinants of Population and upstream determinants of the outcomes that we want to achievethe outcomes that we want to achieve

How to shift population risk curves and not How to shift population risk curves and not just work at the individual leveljust work at the individual level

How to use alignment, connection, How to use alignment, connection, networking strategies to join up people, networking strategies to join up people, sectors, systems into a more functional sectors, systems into a more functional approach - open source for a flatter health approach - open source for a flatter health policy worldpolicy world

How to change the culture of the system we How to change the culture of the system we work inwork in

To frame health in terms of its life long To frame health in terms of its life long impactsimpacts


UCLA Center for Healthier UCLA Center for Healthier Children, Families and Children, Families and

CommunitiesCommunities& &

National Center for Infancy and National Center for Infancy and Early Childhood Health PolicyEarly Childhood Health Policy

AIM-MCHB Child and Adolescent AIM-MCHB Child and Adolescent Policy Support CenterPolicy Support Center

Http.//Http.//healthychild.ucla.eduhealthychild.ucla.edu

Documents

Center for Healthier Children, Families & Communities Life Course Health Development: A Transformative Framework To Improve Childrens Health Neal Halfon,