Using Bright Futures in Public Health Efforts to Promote ... · Futures is a comprehensive set of health super-vision guidelines for children from birth through age 21 titled Bright

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Using Bright Futures in Public Health Efforts

to Promote Child Health:Findings from

Six Case StudiesFFeebbrruuaarryy 22000066

Suggested Citation: Zimmerman B., Gallagher J., Gwinner V., Ferreira M., Ledsky R., & Sternesky L.(February 2006). Using Bright Futures in Public Health Efforts to Promote Child Health: Findings

from Six Case Studies. Washington: Health Systems Research, Inc.

This document was produced by Health Systems Research, Inc. under a contract(Task Order 250-01-0011-02(02)) from the Maternal and Child Health Bureau, Health

Resources and Services Administration, U.S. Department of Health and Human Services.

Health Systems Research, Inc.

Using Bright Futures in Public Health Efforts to Promote Child Health: Findings from Six Case Studies

Table of Contents

SYNTHESIS OF FINDINGS

Background ..................................................................................................................1

Methodology ................................................................................................................2

Synthesis of Case Study Findings..............................................................................3

Factors Facilitating Bright Futures Adoption at the State Level ....................................................................................................3

Why Bright Futures Is Used ....................................................................................4

Who Is Using Bright Futures ..................................................................................6

How Bright Futures Is Being Used ........................................................................7

Policy Development and Program Planning ....................................................7

Education and Training of Health and Related Professionals....................................................................................................10

Clinical Practice ..............................................................................................13

Education and Outreach to Families and Communities ............................................................................................14

Challenges and Strategies....................................................................................16

Sustaining Bright Futures ....................................................................................24

Looking to the Future ................................................................................................26

Conclusion ..................................................................................................................27

CASE STUDIES

Georgia ....................................................................................................................GA-1

Louisiana ..................................................................................................................LA-1

Maine ......................................................................................................................ME-1

South Carolina ........................................................................................................SC-1

Virginia ......................................................................................................................VA-1

Washington..............................................................................................................WA-1

Health Systems Research, Inc. Page i


Bright Futures Case Studies:

Synthesis of Findings from Six States

Beth Zimmerman, M.H.S.Valerie Gwinner, M.P.P., M.A.

This report presents a synthesis of the findingsfrom a series of case studies exploring how theBright Futures for Infants, Children, andAdolescents initiative has been used in sixStates to promote children’s health. The casestudies were conducted by Health SystemsResearch, Inc. (HSR) for the Health Resourcesand Services Administration (HRSA)’sMaternal and Child Health Bureau (MCHB)as part of the first national evaluation of BrightFutures. The purpose of the case studies is toprovide an indepth look at the multiple waysin which Bright Futures has been used at theState level to create a broader, more compre-hensive vision of child health and to expandthe range and types of individuals engaged inpromoting bright futures for all children.

Background

The Bright Futures for Infants, Children, andAdolescents initiative was launched in 1990,with support from MCHB and from theMedicaid Bureau of the Health Care FinancingAdministration (now the Centers for Medicareand Medicaid Services). It was designed toimprove the quality of health services for chil-dren through health promotion and diseaseprevention, using a developmentally basedapproach to address children’s physical and psy-chosocial needs within their family andcommunity context. The centerpiece of BrightFutures is a comprehensive set of health super-vision guidelines for children from birththrough age 21 titled Bright FuturesGuidelines for Health Supervision of Infants,Children, and Adolescents, published initiallyin 1994 and as a second edition in 2000.1

The national evaluation of Bright Futures hasincluded both a process evaluation and an out-come evaluation plan. The State case studiesand this synthesis report represent some of theproducts of that plan.

The case studies describe the Bright Futuresstories in six States, including Georgia,Louisiana,Maine, SouthCarolina,Virginia, andWashington.This report presents thecross-site find-ings from thosecase studies.After an initialdiscussion ofthe methodology used to conduct this project,the report presents a synthesis of case studyfindings that addresses the following topics:

� Factors that facilitate the adoption ofBright Futures at the State level

� Why Bright Futures is used

� Who uses Bright Futures

� How Bright Futures is being used

� Challenges in using Bright Futures andstrategies for addressing them

� Sustainability of Bright Futures.

The report concludes by presenting areas fornational-level focus, as suggested by keyinformants, for supporting the ongoing use ofBright Futures as part of child health improve-ment efforts.

Health Systems Research, Inc. Synthesis of Findings Page 1


1 A third edition, being developed under the leadership of the AmericanAcademy of Pediatrics (AAP), will be released in 2007.

Bright Futures is a national health

promotion and diseaseprevention initiative thatuses a developmentally-

based approach toaddress children’s physi-

cal and psychosocialneeds within their family and community context.

HSR’s Bright Futures evaluation products areall available on HSR’s Bright Futures Web pageat www.hsrnet.com/brightfutures. Those prod-ucts include this synthesis report, the sixindividual State case studies, the process evalu-ation report, and a how-to guide on promotingthe use of Bright Futures in States and commu-nities. Also available at this site are links to an array of Bright Futures training and educational resources.

Methodology

The case studies were conducted using qualita-tive research methods to gather data about theuse of Bright Futures in selected States. NineStates were identified as potential case studysites, based largely on the findings of theprocess evaluation indicating their active use ofBright Futures as part of State public healthinitiatives to improve child health. After initialconversations with these, the six States indicat-ed above were selected to participate in thestudy.2

Working in collaboration with MCHB, HSRdeveloped several overarching research ques-tions to guide the study. These are presented inTable 1.

Based on these research questions, HSR devel-oped a discussion guide to frame thekey-informant interviews, the vehicle throughwhich data for the case studies was gathered.The discussion guide addressed the followingbroad areas:

� Background on the key informant’s organization/agency

� Organization/key informant’s introductionto Bright Futures

� Bright Futures infrastructure

� Use of Bright Futures

� Bright Futures partnerships

� Outcomes of Bright Futures use

� Lessons learned

� Plans for the future.

Key-informant interviews were conducted byHSR researchers in person or by telephone



Table 1.Research Questions

� Why was Bright Futures selected for use byStates? What components/attributes of BrightFutures were thought to be of value to their efforts?

� What components/attributes of Bright Futuresare actually being employed to achieve State publichealth goals and objectives?

� What has been States’ experience using BrightFutures? What has been the perceived value ofadopting Bright Futures? Were there any unanticipated benefits or problems?

� What are the core elements of successfulState/local Bright Futures implementation efforts?

� How have States and communities provided leadership in implementing Bright Futures?

� How is Bright Futures being integrated into ongoing child health promotion systems at the State and community levels?

2 The three States identified as potential sites that were not included in thestudy included Illinois, Kansas, and Massachusetts. In these cases, Stateofficials generally did not believe there was enough information available todevelop a case study.

during mid-2005. HSR researchers conductedsite visits to two of the States – Washingtonand Virginia – and interviewed key informantsby telephone in the remaining four States.Whether carried out in person or by phone,HSR worked closely with a main contact ineach State to identify a range of key informantsusing Bright Futures at both at the State andcommunity levels. Depending on the State,key-informants in the case study sites may haveincluded officials from State and local depart-ments of health and other public agencies, theprivate provider community, and staff membersof home visiting programs, Head Start, andother community-based programs. (A list ofkey-informants for each State is provided at theend of each case study report.)

Synthesis of Case StudyFindings

The individual case study reports explore thevarying contexts in which Bright Futures wasadopted, how use of Bright Futures evolved, andthe diverse forms it has taken. They also look atthe challenges encountered and lessons learnedin each of the six individual case study States.This report considers the overarching findingsand lessons that can be drawn from a cross-sitereview – punctuated with specific examplesdrawn from the study States. The aim of thisreport is to provide a synthesis of informationthat may serve to enlighten other States andlocalities interested in adopting or expandingtheir use of Bright Futures to help promote thehealth of children.

Factors Facilitating Bright FuturesAdoption at the State Level

Bright Futures was designed as a national ini-tiative meant to be used in multiple anddiverse settings throughout the United States.Significant efforts were made early in the devel-opment of the Bright Futures materials todisseminate them widely and spread knowledgeabout and understanding of the program. As aresult, there are many examples all across thecountry of ways in which Bright Futures hasbeen or currently is being used in training,family and community outreach, and publicand private health practice – examples that arehighlighted in the Bright Futures process evalu-ation report. However, among all of theseexamples, six States stood out for having mostactively integrated Bright Futures and adoptedit as a formal or systematic component of theirchild health promotion efforts.

It is clear from these six case studies that theadoption of Bright Futures on a larger scale atthe State level is not a matter of simple policyor program changes. Instead, it is highlydependent on a convergence of several key fac-tors, which may vary slightly from one State toanother but generally include:

� The presence of Bright Futures champions

� A State policy environment that valuesprevention, systems integration, or both

� The identification of a specific need –such as for strengthened child health standards – that can be addressed with Bright Futures

� The existence of periods of change – suchas shifts in staff, administration, or reporting



requirements – that may provide opportuni-ties for introducing new approaches

� The ability to pursue multiple and variedstrategies for spreading awareness and use ofBright Futures.

These and additional related factors also helpdetermine a State’s ability to sustain a BrightFutures initiative over time, as discussed laterin this report.

Why Bright Futures Is Used

Numerous reasons were cited by key informantsin describing why they had chosen to use BrightFutures within their State health department,particular program, or private practice. Takentogether these underscore particular attributes ofBright Futures that make it especially useful andapplicable to efforts aimed at improving thequality of children’s health care through training,education, policy development, and clinicalpractice. These attributes include:

� The focus on prevention. This aspect ofBright Futures is frequently identified bypublic health professionals and private prac-titioners as a key reason that the initiativewas initially seen as a good fit with theirpolicy priorities or practice styles. For exam-ple, the prevention focus of Bright Futuresfit very well with the South CarolinaDivision of Oral Health’s guiding principleswhich specifically identify prevention as apriority. This attribute was also central tothe Louisiana Office of Public Health’sadoption of Bright Futures as a resource indeveloping preventative approaches forimproving infant health and reducing men-

tal health problems. In Virginia, the preven-tion base was important not only forinitiating interest in Bright Futures but alsofor maintaining buy-in through changes instaff and State administrations.

� The family-centered and community-oriented

approach of Bright Futures. Similar to the pre-vention focus of Bright Futures noted above,these factors are priorities across multipleState health administrations. For example, inVirginia, thefamily focusof BrightFutureshelped toovercome thereservationstoward theprogram of anew StateHealthCommissioner. In Georgia and Louisiana,educating and empowering parents was cen-tral to efforts to improve child healthoutcomes at the State level. In Washington,several local initiatives and Head Start pro-grams were attracted to the parent educationcomponents of Bright Futures, which theyviewed as both parent-friendly and compre-hensive. They took this interest further bydeveloping accordion-style family healthorganizers to help parents be more informedand engaged in their children’s health care.

� The comprehensiveness of Bright Futures

and its organization around developmental

periods. These factors help make BrightFutures a useful vehicle for reaching a largenumber of children of different ages and



“Bright Futures camealong at the right time,

providing a neededemphasis on social history and family context, especiallyparental concerns.”

– STATE PUBLIC HEALTH

EMPLOYEE, LOUISIANA

with diverse health and developmentalneeds. For example in Georgia, the StateMedicaid staff identified Bright Futures as

being a “perfectfit” for theState’s MedicaidEarly andPeriodicScreening,Diagnosis, andTreatment(EPSDT)Program due tothe develop-mental focus,the match withEPSDT perio-

dicity schedules, and its step-by-stepdescription of anticipatory guidance. InMaine, the comprehensive scope of BrightFutures, including its focus on primary careand inclusion of oral and mental health, wasdetermined to provide an appropriate anduseful standard of care for the State. The abil-ity to find comprehensive and consistenttypes of information for children of all ageranges – for example, by providers who seemany children of multiple ages in the courseof one day or by outreach workers whoseclients may include both teenage mothers andtheir infants – was also cited frequently as astrong attribute of Bright Futures.

� Bright Futures provides a framework and

common language that can appeal to broad

audiences and across diverse disciplines.

Key informants describe the usefulness ofBright Futures in creating a commonground on which to unite individuals fromdifferent departments or disciplines around a

shared focus on improving child health. Thishas facilitated cross-agency and interdepart-mental collaborations at the State level. Inaddition, the clear and concise language ofthe Bright Futures materials has promotedinterdisciplinary training and understanding.For example, Bright Futures oral health andmental health materials have been used inmultiple States to train nonspecialists andfacilitate interdisciplinary program coordination.

� The Bright Futures materials are attractive,

easy to use, and flexible. These features arerepeatedly cited as reasons for using theBright Futures materials within healthdepartments, in private practice, and withfamilies and the community. For example,key inform-ants inMainedescribed thematerials ascontainingsubstantiveinformationorganized inan easy-to-access manner. In addition, the fact thatthey are updated and revised by MCHB andAAP is an important advantage.

� The Bright Futures materials are useful

resources for training programs. They provideuseful tools to support trainings in multiplepublic and private practice settings for bothpreservice and in-service training. Some ofthe features of the materials that respondentsfound particularly useful included the factthat the content is well-organized and acces-



“The Bright Futures materials contain

substantive informationorganized in an easy-to-access manner.”

– KEY INFORMANT, DEPARTMENT

OF HEALTH AND HUMAN

SERVICES, MAINE

“The Bright Futures in Practice: Oral Healthguide is a very usefulresource. It discusses oral health issues in a

way that is easily understood by nondental

professionals and emphasizes oral health

as part of overall health.”–STATE DENTAL CONSULTANT,

GEORGIA

sible, the language is clear, and the informa-tion and anticipatory guidance help prepareproviders for real world situations with chil-dren and families.

� The broad support for Bright Futures by major

health professional associations and organiza-

tions involved with children’s health and

development. This helps build a support net-work for Bright Futures and reducespotential resistance to the Bright Futuresguidelines or philosophy.

In addition to these particular aspects of BrightFutures that appealed to key informants, twobroad reasons were identified which explain theimpetus for the adoption of Bright Futures.One is associated with the notion of “fit”; thatis, for many individuals and States using BrightFutures, the compelling reason for doing so isbecause its philosophy and attributes reflecttheir key values. This connection was observednot only in State health departments and pro-grams but also within private pediatric settings,where the focus on prevention, anticipatoryguidance, families, and developmentalapproaches reflect the values of the individualpractitioners.

The second overarching reason for adoptingBright Futures to emerge from these case stud-ies is that it provides a solution to one or moreneeds or problems. Among those issues thatBright Futures was identified as helping toaddress were enhancing the content and consis-tency of child health supervision; helping tobring people together around a common goalof improving health for children and with acommon language; building consistency andcomprehensiveness across programs, disciplines,

and practicesettings; andfacilitating theintegration offamilies andcommunitypartners in child health promotion.

Who Is Using Bright Futures?

Much consideration was given during thedevelopment of Bright Futures regarding theintended audience for this initiative. From thestart, the audience that was envisioned forBright Futures included providers, families, andcommunity representatives or entities – buildingon the concept that each of these groups repre-sents important partners in the promotion ofhealthy children. From these case studies, it isclear that all of those audiences are representedamong Bright Futures users and that the rangeof individuals and entities that are using BrightFutures is quite diverse and varied.

Within the State health and social servicesdepartments represented in these case studies,there was a broad range of individuals andoffices engaged in the use and promotion ofBright Futures. These included representativesfrom areas such as family health services,Medicaid, oral health, home visiting and casemanagement programs, adoption and fostercare, mental health and substance abuse, nutri-tion, health education, public health nursing,quality management, school health, and childcare provision and licensing. In several cases,the State Governor also was involved in initia-tives and activities integrating Bright Futures.



Bright Futures is often adopted

as a solution to a need or problem.

In addition, Bright Futures was being used bymultiple individuals and groups at the local

and regionallevels.Examples thatemerged fromthese case stud-ies includedrepresentativesfrom privatepractice, schoolhealth, nursing,medicalschools, StateAAP Chapters,child careproviders, fami-lies, Head Startorganizations,

family support programs, diverse healthy childprograms, and community entities, such as theChildren’s Museum of Richmond, VA. Thetypes of health care providers involved in usingBright Futures are quite diverse as well.Examples include pediatricians, nurse practi-tioners, medical students and residents, schoolnurses, dentists and other oral health profes-sionals, nutritionists, mental health providers,and lay outreach workers. Private partners alsohave supported the dissemination of BrightFutures materials and activities. For example,Henrico County in Virginia partnered with alocal hospital to develop a Bright Futures-inspired folder for families to keep track oftheir children’s immunizations and healthrecords.

How Bright Futures Is Being Used

Describing how Bright Futures is used is com-plex because of the multiple and diverse waysin which it is implemented. This is entirelyconsistent with the nature of Bright Futures,which was developed for multiple uses andwidely disseminated to encourage a broad anddiverse application. In practice, Bright Futuresis indeed a patchwork of activities – often hap-pening independently of each other or crossingpaths in both planned and unplanned ways.

To capture the breadth and depth of the waysin which Bright Futures is being used in the sixcase study States, this section is organizedaccording to several major categories of activi-ty: policy development and program planning,professional education and training, clinicalpractice, outreach and education tofamilies/communities, and systems integration.It is important to note that, given the publichealth focus of these case studies, most of thisinformation is based on examples from publichealth policy, planning, and practice; addition-al examples from private practice settings areincluded where available.

Policy Development and ProgramPlanning

Bright Futures has been used to guide thedevelopment of policies and plans aimed atimproving the quality of children’s health careand children’s health outcomes. Some haveused Bright Futures as a tool for improvingState performance on key child health indica-tors. Others have looked to Bright Futures as astandard for child health care. IntegratingBright Futures into policies and plans has alsobeen an important strategy for institutionaliz-



The range of individualsand entities using

Bright Futures is wide and varied. A few

examples from thesecase studies illustrate

their diversity:

� Port Gamble S’KlallamTribe Head Start

� Richmond Children’sMuseum

� Child care licensing agents� Pediatric residents� School nurses� State AAP chapters.

ing the philosophy and approaches to careespoused by Bright Futures.

Responding to poor health outcomes. In severalcases the adoption of Bright Futures at theState level was a direct response to poor Statehealth outcomes or low performance standards. The following examples illustratethree States that used Bright Futures in these circumstances:

� In Louisiana, there was an identified needfor a comprehensive approach by the publichealth system to respond to high rates ofinfant mortality, low birthweight, and childmaltreatment. The Bright Futures preven-tion-focused approach and materials wereused to train public health nurses, nutrition-ists, and other professionals to improveinterviewing and counseling skills, use antic-ipatory guidance, and increase healthpromotion with families. In addition,Louisiana State policymakers used BrightFutures as a guide for revising the nutritionservices offered by local agencies through theSupplemental Food Program for Women,Infants, and Children (WIC).

� In Georgia, the State integrated BrightFutures into its EPSDT program, calledHealth Check, as part of its efforts toimprove performance on certain child healthbenchmarks (e.g., child abuse and neglect,parent education, mental health). The familyeducation and resource materials fromBright Futures have been identified asimportant resources in helping the programto meet its quality review standards andMedicaid requirements to include anticipa-tory guidance in EPSDT.

� In South Carolina, Bright Futures wasused within the context of a statewide initia-tive led by the Governor to improve schoolperformance that recognized the role ofhealth in academic achievement. A survey ofschool nurses identified oral health as a toppriority issue, and the State Oral HealthDirector spearheaded the development ofBright Futures-based formal oral healthguidelines for schools in South Carolina.

Developing new State standards for child health.

Some States have used Bright Futures morespecifically as the framework for developing anew State standard of health care for childrenand adolescents. For example:

� In Maine, the Bright Futures Guidelinesfor Health Supervision of Infants, Children,and Adolescents have been applied as thestandard of care for physicians enrolled asproviders in the State’s public insurance pro-grams. Bright Future also was used in Maineto revise the State nursing standards, includ-ing those related to school nurses. As a wayto help promote and integrate the use ofBright Futures as the standard of qualityacross the State, the Maine Medicaid/StateChildren’s Health Insurance Program(SCHIP) program developed new clinicalforms based on Bright Futures to be used forall recommended well-child visits. Providerswho complete the forms are reimbursed atan enhanced rate.

� In Washington Bright Futures was used asthe framework to improve Medicaid andEPSDT services for children from birth toage five using interdisciplinary partnershipsamong family practice, pediatric, and other



children’s services providers with a focus onearly child health and development. With agrant from the Commonwealth Fund, theState launched a pilot of this project work-ing with families in Head Start, Tribal healthcenters, and other public health venues inWhatcom County.

� In Georgia, Bright Futures has been usedas a resource to develop new dental screeningrequirements for school-aged children and asa source for updating manuals for well-childscreenings on topics such as adolescent healthand children with special health care needs.The State’s former State Dental Director hasmoved to a new role as the Region IV HeadStart Oral Health Consultant, where he ishelping to update the Head Start program’sperformance standards regarding oral healthto promote more consistent guidance forHead Start and Early Head Start in areas suchas tooth brushing, use of toothpaste, andapplication of fluoride varnish.

� In Virginia, the Bright Futures guidelineswere adopted more broadly as the officialState standard for child health. This includ-ed an official kickoff event, development ofa Bright Futures Virginia Web site, designa-tion of two Bright Futures Coordinatorswithin the State Department of Health, andconvening of a Bright Futures AdvisoryCommittee composed of public and privatepartners focused on spreading BrightFutures into private practice and communitylevel activities. The adoption of BrightFutures as a State standard for child healthalso has helped policymakers and advocatesfor child health in their efforts to integratethe quality of care promulgated by Bright

Futures into public policies, such as require-ments for school physicals.

Institutionalizing Bright Futures through State

policies, performance measures, and plans.

Several States have tried to further institution-alize the use of Bright Futures across theirpublic health programs by inserting BrightFutures into official plans and documents. InWashington, Bright Futures has been incorpo-rated as part of the Title V needs assessmentperformance measures. In Virginia, BrightFutures is specifically referenced in State regu-lations regarding EPSDT program services andchildren’s eligibility for special health needsservices. It is integrated in the PerformanceImprovement Plan for mental health services,was identified as a strategy in 18 of the State’s54 Healthy People Virginia 2010 objectives,and has been required to be included in work-plans and strategic plans across the State’sDepartment of Health.

The institutionalization of Bright Futures inpublic policy and program planning is impor-tant, not only for sustaining the qualitystandards and philosophy that Bright Futuresrepresents but also for the ripple effect it cre-ates in improving public health practice. Thehope of the types of policy changes describedhere is that they will help change the conceptu-al framework for child health from thetraditional, medically based model to one thatis more holistic, developmentally based, andgrounded in the family and community con-texts in which children live and grow.



Education and Training of Health andRelated Professionals

One of the most widespread uses of BrightFutures across all of the case study States is inthe education and training of health profes-sionals, both in the preservice trainingenvironment and in opportunities for continu-ing education. This is in part because the

Bright Futuresguidelines andmaterials areseen as very useful in pro-moting childand adolescenthealth and well-ness due to their

comprehensiveness, anticipatory guidance, andeasy-to-use formats. It is also because trainingis so critical to spreading the understandingand use of Bright Futures across diverse prac-tice settings and environments. Thus, traininghas been a priority area for numerous Statestrying to promote the broader use of BrightFutures among providers, families, and com-munities to improve knowledge, skills,consistency, participation, and ultimately thequality of children’s health.

For example, in Georgia, in response to surveysof local public health staff members regardingtheir training and technical assistance needs,the State hired additional staff members tosupport the use of Bright Futures. They desig-nated a Bright Futures “point person” whoholds district-level Bright Futures trainings thatoffer continuing education credits for publichealth staff members. The trainings focus onthe use of Bright Futures in the context of theState EPSDT program and as a way to foster

improvements in the State’s child health indica-tors. Similarly, the two designated BrightFutures Coordinators in the VirginiaDepartment of Health have developed andconducted numerous Bright Futures trainingsacross the State’s public health districts. Thesewere directed at many types of audiences, rang-ing from public health nurses and homevisitors to child care consultants, nutritionists,and new employees within the HealthDepartment’s Office of Family Services. TheCoordinators developed specialized trainingtools and programs, including a tabletop dis-play to be used in community settings and atmeetings to help educate parents about BrightFutures. In both Georgia and Virginia, as inthe other case study States, trainings have takenthe forms both of general introductions toBright Futures and of more targeted trainingsoriented toward particular health professionalsor areas of focus, such as nutrition, oral health,or mental health.

Here are some select examples that illustratethe range and types of targeted trainings thathave been undertaken:

� Public health nurses. This group was amajor focus of Bright Futures training acrossall of the States interviewed for these casestudies. For example, in Louisiana, all of theState’s public health nurses (approximately500) were trained in using the BrightFutures guidelines, including techniques forimplementing the anticipatory guidance andstrengthening interviewing and counselingskills related to child health. In Maine, oneof the State’s earliest Bright Futures activitiesconsisted of training the regional publichealth nursing staff to use the Bright Futures



Training is critical to spreading the

understanding and use of Bright Futures

across diverse practice settings

and environments.

health supervision guidelines. In Virginia,numerous training efforts targeted publichealth nurses and nurse practitioners,including the development of distance learn-ing materials developed with a grant fromHRSA that could be used for continuingeducation credits.

� School nurses. This group of professionalsalso has been a target of Bright Futurestraining activities across various States. Forexample, in Washington State, the BrightFutures mental health materials have beenused to train members of the School NurseCorps, which serves rural school districtsthroughout the State. Washington alsodeveloped a train-the-trainer model thatthese school nurses could take back and usein their districts. In South Carolina, 400 ofthe State’s 500 school nurses took part inregional trainings on oral health using theBright Futures materials.

� Private providers. In Maine, as part of theeffort to adopt Bright Futures as the stan-dard of care for the State’s public insuranceprograms (in which 89 percent of the State’sprimary care providers participate),statewide trainings were conducted for childhealth providers to describe the BrightFutures philosophy and health supervisionstandards. Trainings were also conductedwith the State immunization program staff,who in turn incorporated Bright Futuresinto their one-on-one meetings with privateproviders.

� Child care providers. This audience is seen asan excellent one for Bright Futures, sincechild care providers are well-placed to look atchildren from a developmental standpoint

and interact so directly with both childrenand parents. There are multiple examples ofways Bright Futures has been used with thisgroup. For example, the Port GambleS’Klallam Tribe in Washington State usesBright Futures as part of its Head Start pro-gram toencourage par-ents to beactive partnersin their chil-dren’s healthand to increaseeducationabout nutri-tion andphysical activi-ty. In Virginia,Bright Futuresis used as aresource andeducational tool by child care licensing agentswho work with child care providers to ensurethey meet licensing standards.

� Community health workers and home visiting

program staff members. This audience wasthe focus of multiple trainings in each of thecase study States. For example, in SouthCarolina, trainings were conducted with layhealth workers in faith-based organizationsto support their role in addressing the oralhealth needs of their communities.Participants received copies of the BrightFutures Oral Health Pocket Guide. InVirginia, the Department of Health’s twoBright Futures coordinators worked withJames Madison University to develop a BrightFutures manual for community health work-ers that was distributed to the Resource



The Bright Futures materials help

to convey what it meansto practice health

promotion and preventive care.

They offer real-life scenarios that illustratethe types of situations

providers will encounterwith children and

families in the practice setting.

Mothers Program which provides home visitsto high-risk mothers and their infants.

� Nutritionists. State nutritionists inLouisiana, South Carolina, and Virginiawere trained to use the Bright Futures inPractice: Nutrition manual. In Louisiana,this manual was also used as a resource fordeveloping parent education materials.Unfortunately, in Virginia, there was a totalturnover of the State nutrition staff follow-ing this training, so many effects were dissipated.

� Cross-disciplinary and cross-agency trainings.

Several States used Bright Futures oralhealth materials to conduct trainings withoral health providers and with nondentalproviders, such as nurse practitioners, pedi-atric residents, childcare providers, andschool nurses. Similarly, the Bright Futuresmental health materials have been usedwidely to train not only mental health andsubstance abuse providers (including thosewho do not work with children typically) butalso many other types of providers, such asfamily life educators, school nurses, andhome visiting program staff members. InGeorgia, the State offered seven regionalcross-agency trainings directed at staff mem-bers from areas such as early childhood, childcare, substance abuse, and child welfarefocused on the social and emotional develop-ment of children from birth to age 5. Thesetrainings included the presentation and distri-bution of numerous Bright Futures resources,including the health supervision guidelinesand Bright Futures in Practice: MentalHealth. Similar activities focused on theneeds of older children are being planned.

Bright Futures also has been used within aca-demic medical institutions for the preservicetraining of medical students/residents, nursingstudents, and other health care professionals.For example:

� In Washington, Bright Futures materialshave been integrated into the curricula ofthe schools of Nursing, Public Health, andMedicine and in MCHB-funded trainingprograms. The University of Washington’sFamily and Child Nursing Program devel-oped mini-videos for nurse practitionersdemonstrating the application of BrightFutures in a well-child visit within the con-text of its emphasis on partnerships,communication, health promotion, timemanagement, education, and advocacy.Bright Futures materials also are used innurse practitioner courses and in continuingeducation courses for graduate nurses.

� Pediatric residents at both VirginiaCommonwealth University (VCU) MedicalSchool and Tulane University School ofMedicine have been trained in the clinicalapplications of Bright Futures. BrightFutures in Practice: Oral Health is also fea-tured at an annual lecture to students of theMedical College of Georgia School ofDentistry.

� VCU faculty members have collaboratedwith partners from the State’s Departmentof Health, AAP Chapter, and Medicaidoffice to develop a series of Web-based train-ing modules based on Bright Futures andpresented as individual case studies. Theseare targeted to pediatric, nursing, and nutri-tion students, and to a secondary audienceof family practice physicians, nurse practi-



tioners, physician assistants, Medicaidproviders, community health providers, clin-ic nurses, and unlicensed assistive personnel.

Faculty members explain that the BrightFutures materials, especially the pocket guides,are very useful tools for working with medicalresidents and health profession students. Thesehelp explain how to conduct a preventive carevisit and illustrate the types of interactions thatfuture providers can expect to encounter in theclinical practice setting.

Clinical Practice

In keeping with its goal of improving the qual-ity of child health care, Bright Futures has beenused in the clinical practice setting to improvequality assurance and consistency acrossproviders. For example, in Georgia, the BrightFutures anticipatory guidance was integratedinto the EPSDT well-child exams as a strategyto help improve State child health indicators.In Virginia, the State AAP President participat-ed in the development of a new ADHDassessment tool, inspired by Bright Futures,that could be used by providers, teachers, andothers working with children. This was inresponse to concerns raised in the State legisla-ture that the rates of ADHD diagnoses andmedication were too high (e.g., 26 percent ofboys in Norfolk had been diagnosed withADHD).

In Maine, Bright Futures has been used not onlyto ensure quality and consistency across EPSDTvisits but also to “close the loop” between well-child health exams and needed followup forchildren in the public health system. The MaineMedicaid program has devised clinical formsbased on Bright Futures for all recommended

well-child visits within the program. Thoseforms are submitted to the State’s MedicaidBureau, whichreviews themand sends thoseneeding fol-lowup to theState’s publichealth nurseswho work withfamilies andlocal agencies toensure thatappropriate fol-lowup isobtained. Thenurses commu-nicate with thereferringprovidersregarding the outcome of the followup activities.

In Georgia, the State has an 80 percent targetmeasure for the provision of parenting educa-tion as part of well-child exams. Resultsindicate that public health district scores haveincreased since the introduction of BrightFutures and now average a score of 95 percent.

At the individual private practice level, twopractices in Virginia described using BrightFutures-based clinical forms and the BrightFutures guidelines, tip sheets, and family mate-rials to help meet auditing and reportingrequirements for well-child visits and certainchronic-care or specialty visits. They noted thatthese materials also helped improve consistencyand record keeping across a busy practice withmultiple providers.



In Maine, providers using the Bright Futures

clinical forms are reimbursed at a higher

rate. This incentive, coupled with State

agency support, hashelped providers andplanners to put into practice a broader

definition of well-childcare that includes

mental health, social and cognitive

development, oral health, and family

relationships.

Education and Outreach to Families and Communities

One of the central features of Bright Futures isits recognition of the critical role played byfamilies and communities, who are the centralplayers in children’s day-to-day environments,in promoting children’s health. States inter-viewed for these case studies have incorporatedthis philosophy into their Bright Futures activi-ties. Efforts to engage families andcommunity-based organizations are describedbelow.

Direct outreach to families. States conduct out-reach to families about their children’s healththrough both provider-client encounters andbroader communications strategies.

� Provider-client encounters. Other than well-child visits, which take place in clinicalsettings, Bright Futures was most commonlyidentified by the case study States as beingused in direct client encounters that takeplace as part of home visiting and case man-agement programs for at-risk children,pregnant women, and families, such asLouisiana’s Nurse Family Partnership pro-gram for low-income, first-time mothers andtheir babies. Home visiting programs useBright Futures to improve the quality andconsistency of their educational and outreachefforts. Indeed, home visiting program staffmembers and other key informants referredto the Bright Futures guidelines as a homevisiting “handbook,” the “bible for healtheducation,” and the “gold standard” for homevisiting. They noted the value of the caseexamples and family materials for providinghome visitors with clear language for speakingto high-risk families, especially regarding dif-

ficult topics such as mental health, violence,and sexuality. Bright Futures’ comprehensive-ness andorganizationaround devel-opmentalperiods werecited as facili-tating theprovision ofage-appropri-ate information and guidance to families; thisis especially useful for less-experienced work-ers or those who see children of multiple ages,including adolescent mothers with youngchildren. The anticipatory guidance and pre-ventive focus of Bright Futures also were seento be important in helping families in crisis,who are overwhelmed with issues of daily liv-ing, to think about longer-term issues relatedto their child’s healthy development (e.g.,why it is important to read to children or stayup to date on immunizations).

� Broader communications strategies.

Another approach used by the case studyStates for reaching families with BrightFutures-based health promotion messages isto use broader-based outreach strategies,such as mass-marketing campaigns. SouthCarolina is conducting a “Happy 1stBirthday” social marketing campaign basedon Bright Futures oral health recommenda-tions which encourages parents to begin oralhealth care during infancy. In Virginia, theOffice of the Governor initiated the devel-opment of a New Parents’ Kit including ababy’s first year calendar and other materialsbased on Bright Futures for distribution byhospitals, and the Bright Futures



“Bright Futures is the bible for health

education. It is clear, concise, and easily understandable.”

—HEALTH DEPARTMENT STAFF,SOUTH CAROLINA

Coordinators are working to develop a videoby teens for teens to encourage regular useof health care services. Maine sends eachfamily with a child enrolled in itsMaineCare public insurance program, forwhich Bright Futures is the standard of care,reminders about scheduled well-child visitsand a guide describing why preventive careis important, explaining what to expect dur-ing medical and dental checkups andoffering a section for parents to keep trackof questions they wish to ask their provider.

School-related efforts. As described earlier,numerous States have engaged school nurses intheir Bright Futures training activities. Beyondthat, States also recognize the potential offeredby schools for directly reaching children andtheir families by incorporating Bright Futuresmessages into academic lessons. One strategyhas been to link Bright Futures to academicstandards. For example, the Virginia BrightFutures Coordinators successfully advocated forthe inclusion of information from BrightFutures materials on nutrition and physicalactivity into the physical education curriculumfor the Virginia Standards of Learning, whichguide the content of public school curriculaacross the State, and are working on doing thesame for oral health messages. On a more indi-vidual level, Bright Futures has been used as aresource in the development of IndividualEducation Plans (IEPs) for special-needs chil-dren, as reported by some private healthpractitioners working with schools to developIEPs for their patients.

Efforts focused in child care settings. Given thesignificant amount of time that children spend

in child care,and the influ-ence of childcare providershave with chil-dren and theirparents, this isanother settingin which some of the case study States havetargeted Bright Futures efforts. For example,South Carolina has developed activities for usein the child care setting to educate and engageyoung children in oral health; the State’s BrightFutures-based Child Care Center Oral HealthTraining Curriculum includes activities forchildren as well as parent education sheets toreinforce center-based lessons in the home. TheVirginia Bright Futures Coordinators are alsoworking with child care providers and theState’s Head Start training network to integrateBright Futures health promotion elements intothe child care setting.

Partnerships with community organizations. Thecase study interviews identified some interest-ing examples of partnerships with communityorganizations to disseminate Bright Futures mes-sages and engage Bright Futures champions innonhealth care settings. In South Carolina, theDepartment of Health is working with faith-based partners to implement a lay oral healtheducation program incorporating Bright Futuresmessages in high-risk communities. Anotherexample of a community-based Bright Futurespartner was the Children’s Museum ofRichmond, VA. A museum representative servedon the Bright Futures Virginia Advisory Board,the museum made Bright Futures materialsavailable in its family resource room, and it



Schools, child careproviders, and

community organizationsare important partners

for disseminating Bright Futures messagesto children and families.

sponsored family resource fairs and communityeducation events on child development.Although the museum’s focus on Bright Futureswas not sustained over time, it provided a prom-ising example of how museums can be effectivepartners in promoting health education in anenvironment that may feel less threatening thana health care setting to some consumers.

Challenges and Strategies

As described above, the case study States havesucceeded in using Bright Futures in myriadways to promote children’s health. The key-informant interviews in all States, however, alsoidentified important ongoing challenges thathinder efforts both to maintain and enhanceexisting Bright Futures activities, as well as toexpand their scope and engage a broader arrayof Bright Futures partners. This section discussesthe major challenges experienced across theseStates, as well as strategies for addressing these.An overview of these challenges and strategies ispresented in Table 2.

CHALLENGE

Engaging private providers. The need to expandBright Futures buy-in and use among private-sector providers was an issue identified by all ofthe case study States. Even in States in whichthe State AAP Chapter is an active BrightFutures partner, such as Virginia, engagingproviders at an individual level remains a long-term and ongoing process. The challenge isparticularly difficult to overcome in Stateswhere, although public health leaders may havea strong commitment to Bright Futures pro-motion, private-sector leadership has notidentified adoption of Bright Futures as a pri-

ority. The case study findings indicate thatmany private providers in each State viewBright Futures (if they know about it) as some-thing that duplicates existing guidelines, islikely to take too long to include in the tighttime frames allocated for well-child visits, andwill not be adequately reimbursed.

Strategies

While highlighting the difficulty and ongoingnature of addressing this challenge, the casestudies also revealed numerous strategies forfacilitating private providers’ buy-in of BrightFutures:

� Incorporate Bright Futures into State

Medicaid/SCHIP program protocols, policies,

and reimbursement schedules. Support ofBright Futures health supervision guidelinesby the State Medicaid program was reportedto be a critical factor in facilitating providerreceptivity to Bright Futures. Maine adoptedBright Futures as the standard of care for itsMaineCare public insurance program andreports that most of the participatingproviders are complying with Bright Futuresstandards, as evidenced by their submissionof clinical forms for each recommendedwell-child visit designed by the State basedon Bright Futures. The State reimbursesproviders at an enhanced reimbursementrate for completing these forms and providesongoing training and support to physiciansin their compliance with the Bright Futureshealth supervision standards.

� Integrate Bright Futures into preservice and

continuing education training programs for

health professionals. Reinforcing a majorfinding of the national process evaluation,



Table 2.Challenges to State Bright Futures Efforts and Strategies for Addressing Them

CHALLENGE STRATEGIES

� Incorporate Bright Futures into State Medicaid/SCHIP programprotocols, policies, and reimbursement schedules

� Integrate Bright Futures into preservice and continuing educationtraining programs for health professionals

� Engage the State AAP Chapter as a Bright Futures partner� Identify Bright Futures champions among private providers

� Introduce change incrementally� Present Bright Futures as a tool for bringing added value to

existing practices or programs� Take advantage of periods of change� Offer continuing education credits for Bright Futures trainings

� Offer multistaged training opportunities� Allocate resources for individualized followup training� Tailor training opportunities and materials

� Institute Bright Futures through policies and procedures that willremain in effect beyond staff changes

� Incorporate Bright Futures into staff orientation materials and programs

� Require that Bright Futures be incorporated into work plans� Identify opportunities resulting from the staff changes

� Solicit support for materials dissemination from internal and external partners

� Build the cost of materials into new proposals for funding� Access materials online

� Incorporate Bright Futures into accepted frameworks� Frame Bright Futures as a tool for addressing a concern or

problem� Identify opportunities in which Bright Futures can serve as a

resource� Reach out to new partners

� Review the national Bright Futures process evaluation, State-specific case studies, Bright Futures how-to guide, and list of other online resources (www.hsrnet.com/brightfutures)

� Visit the AAP Bright Futures Web site (www.aap.org/brightfutures)� Reach out to others active in using Bright Futures� Share the Bright Futures story



Engaging private providers

Translating policy into practice

Providing ongoing trainingtargeted to audience needs

Dealing with staff turnover

Obtaining funding for Bright Futures materials

Engaging partners who maynot see themselves asfocused on child health

Getting information aboutexisting Bright Futuresresources and the experi-ences of others in usingBright Futures

the case studies emphasize the importance ofincorporating Bright Futures into healthprofessional training programs as a meansfor promoting its use among providers oncethey enter practice. A major benefit ofWashington’s contractual relationship withthe University of Washington (UW) tospearhead Bright Futures activities is theclose proximity and ongoing relationshipsbetween the contracted Bright Futures staffand other university staff members, whohave fostered the use of Bright Futuresmaterials as part of curricula in UW’s healthprofessionals schools including the Schoolsof Nursing, Public Health, and Medicine. Asdescribed earlier, key informants from aVirginia medical school emphasized thevalue of Bright Futures materials for prepar-ing residents trained in hospital settings forprimary and preventive care practice, andpublic and private Bright Futures Virginiapartners recently launched a Web-basedBright Futures training module for healthcare professionals for which continuing edu-cation credits are available.

� Engage the State AAP Chapter as a Bright

Futures partner. In some States, the StateAAP chapter has been a longstanding BrightFutures partner, and State efforts have bene-fited, for example, from resources to

distribute healthsupervisionguidelines tochapter mem-bers, thecommunicationsnetwork with

Chapter members, and political clout in leg-islative and policy advocacy efforts. In other

cases, the State AAP Chapter is just becom-ing involved in helping to engage the privateprovider community in Bright Futures.Some State AAP chapters report thatstronger leadership from the national AAPorganization is needed before Bright Futuresis likely to be become a higher priority; it isanticipated that the national AAP’s release ofthe third edition of the Bright Futureshealth supervision guidelines, which willintegrate existing AAP health supervisionguidelines, will offer a critical opportunityfor national AAP leadership to bolster Stateand provider-level involvement in BrightFutures efforts.

� Identify Bright Futures champions among

private providers. Providers who have usedBright Futures and found it to be a usefultool are likely to be among the most influen-tial people in raising awareness about andinterest in Bright Futures among providerswho have yet to integrate it into practice.The case studies and the process evaluationfound that just one Bright Futures champi-on within a practice setting can haveconsiderable success in integrating its useacross the practices’ providers. Featuringthese Bright Futures champions at profes-sional meetings can help to spread interestmuch more broadly.

CHALLENGE

Translating policy into practice. Closely relatedto efforts to engage private providers is thechallenge of translating policies establishingBright Futures as a standard of care into prac-tice, both in private and public health settings.Although adoption of Bright Futures at a Statelevel is a powerful tool for change, translating



State AAP Chapters are critical partners in promoting BrightFutures use among private providers.

State-level policies into practice at the regionaland local levels requires ongoing effort andresources. Key informants described the chal-lenges that are typically experienced whenclinical staff members are asked to modify well-established routines in order to incorporate anew way of doing business. In some cases, dis-trict or local level leadership resisted changesinstituted at the State level.

Strategies

The case studies indicate that the followingstrategies can help to facilitate the adoption ofBright Futures in both public- and private-sec-tor settings:

� Introduce change incrementally. Whileintroducing a completely new way of doingbusiness may be met with understandable

skepticism,modifications ofprotocols withwhich providersare alreadyfamiliar are like-ly to beaccepted morereadily. Forexample, inGeorgia, publichealth nurseswere initially

uncertain how State-level efforts to improvethe quality of Health Check (Medicaid/EPSDT) screening exams would affectthem, they but were happy to see that,rather than requiring them to use complete-ly new clinical forms, Bright Futures wasincorporated into existing forms. In a busyprivate practice, time is needed for building

consensus and matching different practicestyles with new approaches.

� Present Bright Futures as a tool for bringing

added value to existing practices or programs.

In the face of financial pressures and timeconstraints, it is unrealistic to expect staffmembers to adopt new practices unless thesecan bring clear added value to their work.For example, in several instances the accept-ance of new patient encounter forms, basedon the Bright Futures guidelines, was due torecognition that the forms were easier to usethan prior ones, saved time, and ultimatelyimproved service delivery by adding greaterefficiency and accuracy in patient records. Inaddition, public health administrators notethat presenting Bright Futures as a resourcerather than as a mandate draws a muchmore favorable response.

� Take advantage of periods of change. Periodsof change offer natural opportunities forintegrating Bright Futures. For example,staff changes in a clinical or public healthsetting can offer the chance to introduce orrenew interest in Bright Futures. SeveralStates include Bright Futures materialsamong those provided to new staff membersto introduce them to the Bright Futures phi-losophy and to use as a resource in their jobresponsibilities.

� Offer continuing education credits for Bright

Futures trainings. In order to meet profes-sional continuing education requirements,health professionals are often looking foropportunities to participate in trainings.Numerous States use these credits as anincentive for health professionals to learn



“To adopt Bright Futuresacross a busy

practice, you have to acknowledge that

practitioners all have their own practice

styles. To implementchange, you must findconsensus and matchthose practice styles.”

—PEDIATRICIAN,PRIVATE PRACTICE

about Bright Futures and ways that it can beused in various settings.

CHALLENGE

Providing ongoing training targeted to audience

needs. One of the most commonly cited chal-lenges had to do with developing andproviding Bright Futures training to publichealth professionals, health care providers, andothers who work with children. Several respon-dents commented on the absence of a nationaltraining module to accompany the BrightFutures program and materials and simpleguidance to help explain the varied aspects ofBright Futures. In addition, while the regionalworkshops held in many of the case studyStates were a useful strategy for rolling outState Bright Futures initiatives and providing abroad overview of Bright Futures, participantsin these sessions frequently noted the need formore concrete, hands-on assistance in deter-mining how the health supervision guidelinescould be applied within their own settings.

Strategies

Although the need for training in the casestudy States is an ongoing one, the followingexamples demonstrate ways in which they havetried to address this need.

� Offer multistaged training opportunities.

Several States built in multiple opportunitiesto train the same target audience to allowfor skill building and sharing of experiences.In Washington, school nurses were broughttogether first for a general train-the-trainerprogram designed to facilitate their ability toaddress mental health issues. Participantswere required to develop a Bright Futuresworkplan describing how they intended to

train other school nurses. The training par-ticipants were brought together againapproximately 9 months after the initialtraining to discuss implementation experi-ences in the field.

� Allocate resources for individualized followup

training. After conducting regional BrightFutures trainings to launch its BrightFutures-based EPSDT quality improvementinitiative, Georgia hired a staff person whoseresponsibilities included providing addition-al trainings to assist local public healthproviders in implementing Bright Futures intheir own clinics. A critical component ofthis strategy is ensuring that local levelproviders are aware of this resource and howto access it.

� Tailor training opportunities and materials.

While some case study States have offeredtraining for a cross-section of providers, oth-ers have found it important also to offertrainings more tailored to the needs of spe-cific target audiences, such as child careproviders and school nurses. In a few cases,the States also have developed tailored cur-ricula to usein thesetrainings aswell as inhealth pro-fessionalstraining pro-grams, which have contributed to the BrightFutures resource base. However, due to theresource intensive nature of this strategy andthe desire to avoid reinventing the wheel,key informants emphasized the importanceof learning about and using existing



Bright Futures trainingsshould be tailored to meet the needs

of different target audiences.

resources. They noted that this continues tobe a challenge and emphasized the impor-tance of bolstering capacity at the nationallevel for increasing awareness of and facili-tating access to existing Bright Futuresresources.

CHALLENGE

Dealing with staff turnover. Another frustrationnoted by key informants was the frequency ofstaff changes that occur in public health andother settings. These staff changes carry costs interms of both institutional memory andresources invested in Bright Futures training.On the other hand, as indicated by the strategiesidentified below, staff changes also can presentopportunities for furthering Bright Futures.

Strategies

The following strategies can help to maintainand even strengthen Bright Futures efforts inthe event of staff changes continually experi-enced in both public health and private sectorsettings.

� Institute Bright Futures through policies and

procedures that will remain in effect beyond

staff changes. Incorporating the BrightFutures philoso-phy, strategies,and use ofmaterials intopolicies andprocedures canformalize theintegration ofBright Futuresand sustain it

over time despite changes in personnel.Bright Futures can be incorporated into

memoranda of understanding, contracts,strategic plans, regulations, requests for pro-posals, and position descriptions. Forexample, as the standard of care forMaineCare, Bright Futures is reflected inpatient encounter forms used by providersand incorporated into the Public HealthNursing Policy and Procedure Manual.

� Incorporate Bright Futures into staff orienta-

tion materials and programs. Inclusion ofBright Futures into staff orientation proce-dures and materials ensures that new staffmembers recognize the value placed onBright Futures within the organization.Several case study States reported the valueof Bright Futures materials in orienting newpersonnel to their positions and the organi-zational philosophy and providing anongoing resource for health promotionactivities.

� Require that Bright Futures be incorporated

into work plans. In some case study States,participants in certain trainings were requiredto develop work plans to implement BrightFutures. As part of the Bright FuturesVirginia launch, the State held a multidaytraining session for teams of public healthstaff members from local districts, and eachteam was required to develop a 6-month planfor implementing Bright Futures in their dis-trict. A followup at the end of this period oftime indicated that 80 percent of those planshad been implemented.

� Identify opportunities resulting from staff

changes. While the departure of staff mem-bers who have been trained in BrightFutures can hinder efforts to institutionalizeBright Futures use, staff changes also intro-



“You have to institutionalize

Bright Futures. As people move around,

if you don’t write it down, it gets lost.”

—STATE HEALTH DEPARTMENT

EMPLOYEE, VIRGINIA

duce periods of change that can facilitateintroduction of Bright Futures, especiallywhen the departed staff person was resistantto its adoption. Further, the relocation ofstaff members who are convinced of BrightFutures’ value can facilitate the adoption ofBright Futures in new settings. Finally, newstaff members can help bring renewed ener-gy to Bright Futures-related endeavors andfoster another generation of Bright Futureschampions.

CHALLENGE

Obtaining funding for Bright Futures materials. Inthe earlier years of the Bright Futures initiative,Pfizer was a major corporate sponsor andplayed a critical role in disseminating hardcopies of the Bright Futures materials, especial-ly to pediatricians and families. For the BrightFutures trainings hosted by the case studyStates, State health department funds typicallyhave been used to purchase a limited supply ofmaterials for training participants. However,both State and local-level key informants notedthat the costs of these materials are prohibitive-ly high, limiting their ability to share thematerials with public health staff members andothers expected to adhere to Bright Futuresstandards, as well as to promote its use both byexisting and potential Bright Futures partners.

Strategies

While the difficulty of purchasing adequatesupplies of Bright Futures materials remains aparticularly challenging one for State and localBright Futures partners, the following strategiesmay help to address the demand for materials.

� Solicit support for materials dissemination

from internal and external partners. If con-vinced of the value of Bright Futures, policyand program decisionmakers within StateTitle V, Medicaid, WIC, early intervention,child care, and other venues may be able toallocate funding for purchasing materials.Private partners also may be willing to sup-port outreach efforts by funding thedistributionof BrightFuturesmaterials totheir mem-bers oraffiliates. Forexample, theVirginiaState AAPChapter distributed copies of Bright FuturesGuidelines for Health Supervision to itsmembers when the State adopted BrightFutures as its standard of care.

� Build the cost of materials into new propos-

als for funding. Bright Futures can be a usefultool in an array of child health promotionactivities that may be supported by public orprivate grant funding opportunities. Costsassociated with materials dissemination mayalso be included as part of funding proposals.

� Access materials online. Although keyinformants emphasized that online access toBright Futures materials does not replace theneed for dissemination of hardcopies, allnationally produced Bright Futures materialsare available online on AAP’s Bright FuturesWeb site free of charge.



Policy and program decisionmakers

convinced of the value of Bright Futures may

be able to allocate funding for purchasing

Bright Futures materials.

CHALLENGE

Engaging partners who may not see themselves

as focused on child health. Some agencies ororganizations, especially those that are notexplicitly focused on health care or healthissues, may not recognize the role that BrightFutures can play in helping them to achievetheir goals. While the potential audience forBright Futures is extremely broad, engagingthem takes ongoing commitment, time, andresources.

Strategies

The following approaches can help to ensureongoing progress in the goal of widening thebase of Bright Futures partners.

� Incorporate Bright Futures into accepted

frameworks. In cases in which an organiza-tion could have a major impact on childhealth but Bright Futures is not a ready fitto their way of doing business, it may benecessary to incorporate Bright Futurescomponents into existing guidance or frame-works. As noted earlier, case study Stateshave found that incorporating BrightFutures messages into academic standards oflearning can be critical to engaging schoolsas Bright Futures partners.

� Frame Bright Futures as a tool for addressing

a concern or problem. While potential BrightFutures partners may view Bright Futures asnice, they are unlikely to embrace the phi-losophy and materials actively unless it isseen as a positive response to a perceivedproblem that is important to them, such ashelping children learn in school or reducingchildhood obesity. Numerous case studyStates used Bright Futures as a tool forimproving performance on child health indi-

cators or enhancing quality of care andfound these goals to be helpful in unifyingdiverse groups of stakeholders in efforts topromote child health and safety.

� Identify opportunities in which Bright Futures

can serve as a resource. While many peoplemight know about Bright Futures, it takesrepeated reminders of its existence and iden-tification of how it can be used in order tofacilitate its widespread adoption. Keyinformants stressed the importance of BrightFutures advocates continually seeking oppor-tunities – often readily available in theirongoing job responsibilities such as servingon committees addressing health and socialservice issues – in which Bright Futures canserve as a useful resource.

� Reach out to new partners. There remainssignificant opportunity for broadening thenumber and range of Bright Futures part-ners. Taking the time to identify potentiallyinterested audiences (e.g., youth clubs, sum-mer camps, business groups) andintroducing them to Bright Futures can paymultiple divi-dends. It canimprove theconsistencyof health pro-motionmessagesacross a community or State, and it canengage a broader array of providers, families,agencies, and organizations in efforts toimprove children’s health.



Bright Futures resourcesare available online at:

www.aap.org/brightfutures

www.hsrnet.com/brightfutures

CHALLENGE

Getting information about existing Bright Futures

resources and the experiences of others in using

Bright Futures. While there is a diverse andbroad array of individuals, agencies, and organi-zations using Bright Futures in many differentways, the people and activities largely remaindisconnected. Key informants indicated a strongdesire to obtain more easily information aboutother Bright Futures activities in their own andother States and share experiences and resources.

Strategies

Numerous strategies were identified or request-ed by key informants to help further theexchange of information and resources aboutBright Futures and its uses in diverse settings.

� Review the national Bright Futures process

evaluation, State-specific case studies, Bright

Futures how-to guide, and list of other online

resources. These materials offer a wealth ofinsight regarding the history and evolutionof the Bright Futures initiative, the types ofindividuals and organizations that have usedBright Futures, and why and how they havedone so. They are available atwww.hsrnet.com/brightfutures.

� Visit the AAP Bright Futures Web site. Inaddition to providing access to online BrightFutures materials, AAP’s Bright Futures Website (www.aap.org/brightfutures) providesinformation on new developments in BrightFutures and highlights resources of interestto the Bright Futures community. The sitealso includes examples of “Bright Futures inPractice” showing how Bright Futures isbeing used in different States across thecountry and among different categories of

organizations (e.g., county health depart-ments, nonprofit organizations).

� Reach out to others active in using Bright

Futures. The AAP Bright Futures Web sitehas contact information for individuals andorganizations featured in its “Bright Futuresin Practice” examples. The State-specific casestudies also include names of key informantsinterviewed for the study. These representBright Futures champions and other indi-viduals eager to share stories and strategies.

� Share the Bright Futures story. Key inform-ants noted that there are numerous largemeetings devoted to issues such as Medicaid,maternal and child health, public healthtraining, and such that provide excellentopportunities for sharing presentations,posters, and information. In addition, theycited other information exchange opportuni-ties that should be further utilized, such asassociation and public health network list-servs and newsletters. Two States, Virginiaand Washington, have developed their ownBright Futures Web site or electronicnewsletter. Several individuals expressed thehope that there would be more MCHB-sponsored national meetings specificallydesigned to talk about Bright Futures.

Sustaining Bright Futures

One of the research questions explored in thecase studies had to do with identifying the coreelements of a successful Bright Futures imple-mentation effort. This question helped to elicitinformation not only on how State-level BrightFutures efforts and activities are adopted morebroadly at the State level but also how they



evolve and are sustained over time. In some ofthe case study States, Bright Futures activitieshave gathered momentum over a period of

years andbecome increas-ingly influentialin guiding Statehealth promo-tion activitiesfor children andfamilies. Inother cases, theuse of BrightFutures was ini-

tially strong but then diminished. In most ofthe study States, the use of Bright Futures con-tinues to evolve, with ongoing efforts to engagenew partners and to identify new ways thatBright Futures could be used in health promo-tion efforts. It is important to note, however,that all of the study States experienced timesduring which Bright Futures was more or lessactively used. Furthermore, reflective of the var-ied audiences and uses for Bright Futures, theretypically have been multiple paths being fol-lowed in the same State, often at the same time,to further the Bright Futures philosophy andmessages.

The Bright Futures case studies, as well as thenational process evaluation conducted previous-ly, indicate that successfully integrating BrightFutures into child health promotion efforts andsupporting its ongoing use and evolution overtime depends on several factors:

� Bright Futures champions. Individuals whobelieve in the value of Bright Futures andcan identify it as a resource in efforts toaddress various needs and problems are criti-

cal not only to initiating Bright Futures usebut also its growth and long-term sustain-ability. While expanding the number andtypes of champions is key to broadeningopportunities for using Bright Futures, thecase studies demonstrate that even one indi-vidual in a key leadership position – withthe capacity to influence staff orientation,training, and policy development – can bevery influential in infusing Bright Futuresprinciples and messages into State healthpromotion efforts.

� Ongoing commitment and resources. Theexperience of the case study States indicatesthat spreading use of Bright Futures is anongoing and long-term process, with timeand resources needed to engage partners,develop champions, provide training, andfoster opportunities for using Bright Futuresin various venues and across changing times,administrations, priorities, and staffs. InStates that have identified one or more staffpersons to serve as Bright Futures coordina-tors or point persons (e.g., Virginia,Washington, Georgia), key informantsemphasized the value of this approach forgrowing and sustaining Bright Futuresefforts. Title V funds have provided a majorsource of support for these staff resources,both within health departments and, in thecase of Washington, through contractedstaff. Grants from public and private sourcesand, in the case of Washington, aCongressional earmark also have supportedBright Futures activities. A lack of funds forcritical activities – such as Maine’s need totranslate Bright Futures clinical forms intoan electronic format that can be used withthe State’s new electronic medical records



To be sustainable, Bright Futures effortsneed champions and

continued commitment of resources. They

also must bring addedvalue and be integrated

into program policy and planning.

system – can greatly hamper Bright Futuressustainability efforts.

� Added value. For Bright Futures to beaccepted and integrated into practice over asustained period of time, it must add valueto the people and organizations using it. The States that have used Bright Futuresover time have reported its value in suchareas as improving quality standards, provid-ing a framework for policies and programs,and delivering consistent health promotionmessages.

� Integration of Bright Futures into policies

and programs. Integrating Bright Futuresinto policies, strategic plans, and program-matic goals and structures that will remain inplace through changes in administrations andstaff can help to lay a strong framework forits continued use and support.

When considering Bright Futures’ sustainabili-ty over time, it is important to recognize that

Bright Futuresmay be sus-tained explicitlyor implicitly.While many keyinformantsstressed thevalue of the

“Bright Futures” label and status as a nationalinitiative with broad public and private supportin obtaining buy-in for its use, others notedthat the Bright Futures philosophy andapproach is often used but not identified byname. For example, in South Carolina, BrightFutures has been used extensively by Statehealth department officials to shape policies

and programs to promote children’s oral health,but the “Bright Futures” name is not widelyrecognized by local-level partners.

Looking to the Future

The case studies indicate that Bright Futureshas served as a valuable resource in efforts topromote quality of care, broaden the array ofpartners involved in improving children’shealth, and improve consistency in health pro-motion messages. Based on these experiences,the case study States identified, and are pursu-ing, additional opportunities for using BrightFutures to further health promotion goals. Forinstance, Several States noted their ongoingwork to introduce Bright Futures to new part-ners and to develop targeted training materialsfor certain audiences.

As described above, States face numerous chal-lenges in furthering their Bright Futuresefforts. While the case studies illuminatedstrategies that States could use for addressingthese, key informants noted that in some areas,national leadership from the MCHB/HRSA,AAP, or others could be particularly helpful.These areas include:

� Facilitating linkages across States using

Bright Futures to share experiences, resources,

and lessons. Key informants expressed adeep interest in being better connected toothers using Bright Futures, especially toreduce duplication of effort in sharing train-ing and other resources. In addition todisseminating the Bright Futures case studyreports, one avenue for addressing this needis providing an opportunity for BrightFutures leaders to meet in person, which



“A lot of what we do is what Bright Futuresoffers; we just never put that name on it.”

— KEY INFORMANT IN LOUISIANA

would allow for more indepth exchanges,foster a more connected Bright Futures com-munity that could bolster Bright Futuresefforts into the future, and also informnational efforts led by MCHB and AAP toprovide support for the initiative’s ongoingdevelopment and evolution. Developing aneasily accessible centralized clearinghouse ofexisting Bright Futures resources includingthose produced at the State level also wouldhelp to address this identified need.

� Providing nationally produced training and

publicity resources to facilitate outreach to

new partners. As noted previously, keyinformants noted an ongoing need for moretargeted training resources to introduce vari-ous audiences to Bright Futures andfacilitate its use in practice; having suchresources available at the national level (andwhich would build on those developed byStates) would reduce greatly the burden onStates and others to develop new materialson their own. Similarly, States noted thatnationally developed Bright Futures publici-ty materials that simply describe what BrightFutures is, clearly identify Bright Futures asa national initiative, and include a sectionfor State-specific information would help tosimplify outreach strategies and create morelinkages and cohesion among Bright Futuresactivities nationally.

� Integrating Bright Futures in Federal funding

opportunities. Explicit reference to BrightFutures in MCHB and broader HRSA-sup-ported funding opportunities, as well as thoseoffered by other Federal agencies, would raisethe visibility of Bright Futures, provide incen-tive for its use, and offer financial support for

Bright Futures activities. Given the reporteddifficulty of financing purchases of BrightFutures materials, Federal support for materi-als dissemination in these fundingopportunities or other means (e.g., engaginga new corporate partner to support materialsdissemination as Pfizer did previously) alsowould be very helpful to State and localBright Futures efforts.

� Engaging private providers. Bright Futuresclearly has been more widely used in thepublic sector than in the private sector.Numerous key informants stressed the needfor stronger national leadership in moreactively engaging State AAP chapters in pro-moting Bright Futures among theirmembers. Given that many pediatricproviders have viewed Bright Futures andAAP’s existing health supervision guidelinesas being duplicative, the convergence ofthese two sets of guidelines in the forthcom-ing third edition of the Bright Futuresguidelines will present a critical opportunityfor more broadly engaging private providersas Bright Futures partners.

Conclusion

In summary, the Bright Futures case studiesillustrate the varied roles that Bright Futureshas played in public health efforts to improvechild and family health. The study findingsalso confirm the great potential that remainsfor broader application of the Bright Futuresphilosophy and approach in ongoing efforts tonurture the optimal growth and developmentof children.



Georgia’s Bright Futures Story

Laura Sternesky, M.P.A.Beth Zimmerman, M.H.S.

FFeebbrruuaarryy 22000066

Health Systems Research, Inc. Georgia’s Bright Futures Story Page GA-1


Introduction

In Georgia, Bright Futures has been used bypublic health officials as part of an overalleffort to improve child health indicators in theState. In particular, these efforts have focusedon incorporating Bright Futures’ use intoMedicaid-covered well-child exams delivered bylocal health departments, especially by enhanc-ing the anticipatory guidance provided toparents. Bright Futures also has been utilized aspart of the State’s broader efforts to improvechild health, especially in the areas of mentalhealth and oral health. This case study, basedon key informant interviews conducted in mid2005, describes how Georgia has utilizedBright Futures in these various ways.

Context for Bright Futures

Leadership for Georgia’s Bright Futures initia-tives lies with the Division of Public Health(DPH) Services, Family Health Branch (FHB),Office of Infant and Child Health (ICH), locat-ed within the Georgia Department of HumanResources. The mission of FHB is to promotethe physical, mental, spiritual, and social well-being of children and families throughpartnerships with communities. To achieve thisgoal, FHB spearheads a number of programs,including those focused on the delivery of well-child care, early intervention, newbornscreening, school health, and the developmentof collaborative child care systems.

Of the programs administered by FHB, themajor focal point for Georgia’s Bright Futures-related efforts has been the State’s Well ChildProgram, which supports the delivery of pri-mary and preventive care services for children

up to age 21 through the State’s MedicaidEarly and Periodic Screening, Diagnosis, andTreatment (EPSDT) program, known asHealth Check. As a result of the State’s effortsto link all Medicaid recipients with a medicalhome, most children on Medicaid now receivetheir care in private physicians’ offices.However, in some areas of the State, localhealth departments continue to play an impor-tant role in providing Health Check screeningexams in their areas. Looking to the future, theState envisions an increased role for localhealth departments in providing such care tofoster children.

Through an agreement with the GeorgiaDepartment of Community Health, FHB/ICHis responsible for conducting quality monitor-ing reviews and providing technical supportand training to Health Check providers. It is inthis role that ICH has promoted the use ofBright Futures in Health Check examinations.Although ICH’s quality monitoring and sup-port functions encompass both public andprivate Health Check providers, the DPH todate has focused primarily in encouraging theuse of Bright Futures in the public sector.

Initiating Bright Futures

The impetus for Bright Futures use in Georgiagrew out of a review by the DPH FamilyHealth Branch leadership of Georgia’s rankingin the annual KIDS COUNT report publishedby the Annie E. Casey Foundation which pro-vides national and State-by-State benchmarksof child health status. Georgia public healthofficials were concerned that Georgia’s childwellness indicators, including those on whichGeorgia ranked above the national average,

were not as high as they should be. To addressthis situation, the Family Health Branchlaunched a statewide effort aimed at improvingGeorgia’s child health status indicators.

In developing their strategies, State publichealth officials focused on Medicaid as animportant vehicle for reaching a large numberof children, especially those at high risk forpoor health outcomes. In particular, they con-sidered how the quality of the Health Checkexaminations could be enhanced. It was decid-ed that strengthening the focus on anticipatoryguidance would help to improve child healthindicators broadly.

In looking for tools to support this goal, Statestaff identified Bright Futures and found it tobe a “perfect fit” for EPSDT. Key informantsnoted several reasons for this conclusion,including Bright Futures’ organization bydevelopmental period, its match with theEPSDT periodicity schedule (which outlines atwhat age well child screening exams should bereceived), its content, and its step-by-step guid-ance regarding the provision of anticipatoryguidance. The Bright Futures health supervi-sion guidelines were also appealing becausethey complemented the developmental screen-ing approach – “Ages & Stages” – used duringa Health Check visit; that is, Bright Futuresmaterials could be used to address issues identi-fied during the developmental assessment.

Based on its positive review of Bright Futures,the State took several steps to integrate BrightFutures into the Health Check program during2002 and 2003. In accordance with Medicaid’srequirement that anticipatory guidance bedelivered as part of EPSDT exams, ICH iden-

tified parent education as an indicator for theHealth Check quality reviews – establishing an80 percent target for this measure. HealthCheck monitoring and exam forms wererevised based on Bright Futures to emphasizethe delivery of comprehensive anticipatoryguidance. ICH also encouraged the use ofBright FuturesFamily TipSheets as infor-mationalhandouts forfamilies. Whileuse of the formsand Bright Futures materials is not mandated,local health departments tend to use or adaptHealth Check forms and follow guidance pro-vided by the DPH, especially given its role inconducting Health Check quality reviews.

The State held four regional Bright Futureskickoff meetings to “roll out” Bright Futuresand introduce the new Health Check forms tolocal public health providers. Representativesfrom each of Georgia’s 19 public health dis-tricts – representing the State’s 159 countyhealth departments – attended the regionaltrainings. Each district received an array ofBright Futures materials, including the BrightFutures health supervision manual and comple-mentary pocket guide, the Bright Futures inPractice guides on oral health and mentalhealth, and family materials including theBright Futures Tip sheets and FamilyEncounter Forms, and districts were told howto obtain or purchase additional copies.



Georgia uses Bright Futures as a tool for strengthening the

quality of EPSDT well-child exams.

Evolution of Bright FuturesOver Time

Consistent with the original vision that BrightFutures could support Georgia’s efforts toimprove its performance on various childhealth benchmarks, the State has built andexpanded upon its initial Health Check activi-ties in various ways. Driven by surveys of localpublic health staff members regarding theirtraining and technical assistance needs, theState has hired additional staff members withresponsibility for supporting Bright Futures useat the local level and also has conducted aseries of regional Bright Futures trainingsfocused on mental health. Oral health is anoth-er area in which Bright Futures has influencedState policy and programs, as well as broaderregional and national efforts addressing theneeds of children in Head Start. These aredescribed below, followed by examples of howBright Futures has been incorporated intopractice at the local level.

Building State Capacity to ProvideBright Futures Support at the Local Level

After the regional Bright Futures trainings thatfocused on Health Check were conducted,additional steps were taken to facilitate BrightFutures use at the local level. An evaluation oftraining participants found that Bright Futureswas positively received but more training wasneeded to help translate it into practice. Inresponse to this need, in April 2003, ICHhired Ancel Lawrence as a public health nurseconsultant to ICH’s Well Child Program. Ms.Lawrence conducts Health Check quality

reviews of local providers as one of three ICHstaff members who, through an agreement withthe Medicaid division within the Departmentof Community Health, monitor and providetechnical assistance for Health Checkproviders. Ms. Lawrence is the primary BrightFutures “point person.”

One of Ms. Lawrence’s responsibilities in thisrole is to hold district-level Bright Futurestrainings for local public health staff members– for which continuing education credits areavailable – to support the provision of high-quality Health Check exams. To complementthe Bright Futures components of the HealthCheck monitoring and exam forms, the train-ings include general information about BrightFutures and the health supervision materials aswell as interactive discussions, focused on caseexamples, intended to illustrate how the mate-rials can beapplied in localpublic healthpractice. Thesediscussions takeplace within thebroader contextof how theState and localproviders, working collaboratively, can fosterGeorgia’s progress on child health indicators.

A particular area of focus in the trainings, con-sistent with the Health Check quality reviewmeasures, is the importance of doing stronganticipatory guidance, especially for specificpopulations such as children who are suspectedof being maltreated, abused, or neglected.



The State health department

has designateda Bright Futures “point

person” who offers training to local public

health programs.

The State has placed a high priority on reduc-ing child abuse and neglect, especially amongfoster children, and key informants note thatBright Futures can be used to prevent or

address thisproblem byeducating par-ents, helpingto createstronger fami-

lies, and identifying abuse and neglect so thatintervention becomes a primary action.

As indicated earlier, the State has an 80 percenttarget measure for the provision of parent edu-cation as part of well-child exams.Ms. Lawrence indicates that health districts’overall scores for this indicator currently aver-age 95 percent or above and have increasedsince Bright Futures was introduced, and dis-tricts that use Bright Futures usually scorehigher on Health Check reviews. While countyhealth departments tend to use the standardHealth Check screening form developed byICH, different types of assessment forms areseen in private practice. According to keyinformants interviewed for this case study fromboth the public and private sectors, BrightFutures is not commonly used in private physi-cians’ offices.

In carrying out her role as the Bright Futureslead trainer and presenter, Ms. Lawrencereports using the full complement of BrightFutures materials. She uses both the BrightFutures Web sites of both the AmericanAcademy of Pediatrics (AAP), supportedthrough AAP’s Bright Futures cooperativeagreement with the Maternal and Child HealthBureau, as well as the one supported by

Georgetown University, which correlates nicelywith EPSDT. She also reported that the BrightFutures newsletter produced by AAP is helpful.However, knowledge of AAP’s role in BrightFutures and the availability of online resourceswas quite variable among local level keyinformants.

Addressing Children’s MentalHealth Issues

Mental health is another important area inwhich Bright Futures has been used in Georgiaand one that is strongly linked to the State’sefforts to reduce child abuse and neglect.Surveys of local public health staff membersindicated that they needed more skills inaddressing the range of behavioral and mentalhealth issues being faced by families withwhom they work. In particular, staff in homevisiting programs expressed a need for addi-tional family resources.

In response, Susan Bertonaschi, theCoordinator of Children 1st, the single pointof entry for public health children’s services,collaborated with the Department of Familyand Childen Services and other agencies thatoften serve the same clients to develop a cross-agency training program on these issues. In2004, the State sponsored a series of sevenregional trainings around the State on thesocial and emotional development of the youngchild (birth to age 5), with a major focus onBright Futures. During the training, partici-pants received a bag of Bright Futuresresources, including the health supervision andmental health books as well as guidance onhow to use the Bright Futures in Practice:



Bright Futures is part of the State’s

approach for reducingchild abuse and neglect.



Mental Health guide from one of the individu-als who led its development at the nationallevel. Attendees included a total of approxi-mately 430 district and county staff membersfrom early childhood, child care, substanceabuse, child welfare, and other State agenciesand larger community agencies that work withchildren in this age group. By including abroad range of professionals working with fam-ilies with young children, the regional trainingswere intended to allow consistent messages tobe conveyed by the broad range of providersdealing with mental health issues faced by thispopulation.

Based on evaluations of the trainings that indi-cated that they were well-received, the State in

2005 began toproceed withplans for con-ducting asimilar seriesof trainingsfocused on theneeds of chil-dren in

middle childhood. It is hoped that a subsequentseries focused on adolescents will be conductedas well. To complement this work, the FHBalso developed a resource directory of licensedmental health service providers who work withchildren and families. The directory includesapproximately 1,200 licensed clinicians.

Improving Children’s Oral Health

Another area in which Bright Futures has beenutilized in Georgia’s public health efforts is oralhealth. Joseph Alderman, the former State

Dental Director, who continues to provideconsultation to the Georgia Department ofHuman Resources’ oral health program,described the Bright Futures in Practice: OralHealth guide as being a very useful resource forstatewide oral health promotion efforts. In par-ticular, he notes that the guide discusses oralhealth issues in a way that is easily understoodby nondental professionals, emphasizes oralhealth as part of overall health, and has beenupdated recently (in pocket guide form). Dr.Alderman identified several ways in which theBright Futures oral health guide has been uti-lized in Georgia as well as in broader-reachingoral health promotion efforts:

� Dissemination of guidance/information to

public health professionals and other oral

health stakeholders. As the State’s DentalDirector, Dr. Alderman sent copies of BrightFutures in Practice: Oral Health to the oralhealth contacts in the health districts whenthe book was released. He has conductedand continues to conduct lectures to publichealth professionals in districts (nurse practi-tioners, public health nurses, and othersfrom dental and nondental staffs) about oralhealth. Bright Futures messages incorporatedin these lectures include how Bright Futuresaddresses oral health supervision, how BrightFutures assesses risk, and how to get BrightFutures materials. In addition, Dr. Aldermanconducted a 2-day course in late 2004 at theMedical College of Georgia School ofDentistry on providing dental care to chil-dren with special health needs in which hepresented information on Bright Futures.He also does an annual lecture at this schoolon oral health and Bright Futures.

Georgia uses Bright Futures

to promote the delivery of consistent messages

across a broad range of child health professionals.



� Development of State program rules and

guidance. In 2005, Georgia is providingmore detailed information concerning therequirement that all children entering publicschool get nutrition, eye, ear, and dentalscreening exams. Dr. Alderman is consultingwith the State’s oral health program to devel-op the dental screening requirements, andBright Futures is being utilized in thateffort. Bright Futures also was used as asource for updating manuals (on such topicsas children with special health care needs,

adolescenthealth, andwomen’shealth) uti-lized by localhealth depart-ments forwell-child

screenings with anticipatory guidance relatedto oral health. This work was done withinICH as part of Ms. Lawrence’s work toupdate Health Check procedures and manu-als. The goal was to integrate oral health andnutrition for all age groups in all manuals.

� Development of national policy/program

guidance. Dr. Alderman has translated hisGeorgia-based Bright Futures experience tohis current role as the Region IV Head StartOral Health Consultant. Oral health recent-ly has become one of Head Start’s priorityareas, and efforts are focused on updatingthe program’s performance standards in thisarea and increasing the focus on preventionof dental problems among children in HeadStart and Early Head Start. Bright Futures isbeing used as part of this national effort as aresource for development of consistent guid-

ance for Head Start/Early Head Start pro-grams in such areas as tooth brushing,appropriate use of toothpaste, and applica-tion of fluoride varnish. In addition, BrightFutures was noted as a tool for promotingconsistent adoption of Medicaid and otherpolicies supporting the initiation of dentalvisits by 1 year of age – an important oppor-tunity for providing anticipatory guidance tofamilies around oral health – and also forfacilitating the delivery of anticipatory guid-ance on oral health by nondentists who aremore likely than dentists to see children dur-ing infancy and the toddler years.

Use of Bright Futuresat the Local Level

Discussions with local-level key informantscentered on how Bright Futures has beenapplied in Health Check and other programsadministered by local health departments. Asnoted earlier, the level of involvement in well-child Health Check screenings by public healthnurses is dependent upon the county in whichthey work. For this case study, key-informantinterviews were conducted with public healthnurses from numerous local health depart-ments with some role in conducting well-childscreenings as a complement to those conductedin the private sector, as well as in nurse homevisiting programs for at-risk families.

In response to the initial trainings on BrightFutures and Health Check, local-level keyinformants noted a great deal of excitementfrom the State regarding Bright Futures butwere initially unsure what it meant for them.Originally, some nurses thought that theywould have to start using all new Health

Bright Futures is informing policy

development at the State and national levels to improve

children’s oral health.

Check forms based on Bright Futures, but theywere happy to see that Bright Futures wasincorporated into existing forms. Most nursesnoted that while incorporation of BrightFutures into Health Check has not changedthe way they conduct health screenings neces-sarily, Bright Futures supports the delivery ofmore comprehensive anticipatory guidance –focusing on both physical and mental healthneeds – than might otherwise be done andhelps nurses to cover the most important issuesat each visit, helping to make better use of thetime available. They note that the BrightFutures emphasis on parent education helps toincrease parental understanding in a nonthreat-ening way and provides basic information onhow to direct children’s behavior. Simplifyingand streamlining paperwork and supportingproviders in connecting families to communi-ty-based resources were other benefits noted ofBright Futures, in addition to its use helpingsome health departments to score higher ontheir Health Check quality reviews conductedby ICH.

Beyond the Health Check forms, public healthnurses report using an array of Bright Futuresmaterials including the books, pocket guides,Family Tip Sheets, and Family EncounterForms. Many nurses reported using the materi-als to guide discussions with parents aboutwhat should be happening with a child at eachstage of development. Health department nurs-es noted that families are very appreciative ofthe time spent on parent education and ofBright Futures materials, especially the FamilyTip Sheets or Family Encounter Forms (differ-ent clinics reported using one or the othermore frequently) that are reviewed with parents

during the visitand given tothem to takehome. They fre-quentlyindicated thathaving “some-thing we canput our hands on” and give to parents to takehome was important, especially in assuring par-ents that their baby is reaching appropriate milestones.

Some barriers regarding use of the materialswere noted, in particular the expense of thematerials and the difficulty of copying them.Nurses also noted that clients require many dif-ferent types of teaching methods due todifferent education levels and circumstances,and it would be helpful to have more materialsand methods to meet families’ needs. Nursesindicated a need for lower-literacy materialsand simple, concise information. Picture illus-trations were noted as something that would behelpful to convey messages to low-literacyclients. There was varying levels of knowledgeamong key informants regarding the full rangeof Bright Futures materials (including Spanish-language materials for families) and theavailability of online materials.

In addition to use during Health Check exams,Bright Futures is used in some local-level homevisiting programs aimed at reducing childabuse and neglect. For example, Bright Futureshas been integrated into the Visiting EducationNurse in Transition (VENT) program inGordon County, part of the Rome district.VENT is a pilot program – the county’s pri-mary prevention grant program – to reduce



Local public health programs report that

Bright Futures has helped to strengthen

parent education services.

child abuse and neglect, through which at-riskmothers with at least one child under the ageof 1 receive home visiting services, averaging atleast one visit per month during the first yearof life. Bright Futures has been integrated intothis home visiting program as the basis ofVENT forms for use during the 1-, 2-, 4-, 6-,and 12-month visits; the focus of these forms isdevelopmental milestones, safety issues, andparenting information. Nurses in this programnote that Bright Futures helps to focus andfacilitate conversations between home visitorsand clients about nutrition, home environ-ment, sleeping, and other issues. They also usethe nutrition and oral health books and giveout information on issues such as baby bottletooth decay. The Bright Futures mental healthbook was also noted as being very helpful. Thehome visitors copy materials for families fromthe book and use the Edinburgh scale includedin the mental health toolkit for determiningpostpartum depression. They noted that whilethe issue of where to refer women who screenpositive remains, given the paucity of mentalhealth providers in the area, the tool has beenhelpful in documenting the problem and advo-cating for more resources to address it. InFloyd County, Bright Futures also is being usedin a secondary child abuse prevention programproviding medical/nursing consultation tosocial workers conducting child abuse investigations.

Challenges

Interviews conducted for this case study alsoidentified two areas in which Georgia is facingongoing challenges in expanding the State’scontinued efforts to promote Bright Futuresuse. These include barriers to its adoption by

private providers and the need for more com-munication and hands-on support at the locallevel. Each is discussed in turn below.

Engaging Private Providers

In considering barriers to the State’s efforts topromote Bright Futures, the one that clearlyemerged as the major challenge was expandingits use in the private sector. While BrightFutures has been integrated into the way inwhich public health nurses conduct HealthCheck screenings, the extent to which it is usedamong private providers appears to be verylimited. This is of particular concern amongpublic health officials because the bulk ofpatients receive care in the private sector.

Leaders of the Georgia AAP Chapter notedthat although they recognize that the nationalAAP is involved in promoting Bright Futures,there is someresistance to itby its members.Several reasonsfor this wereidentified. Inaddition to Bright Futures’ length and cumber-some nature, critical factors working against itsuse include the existence of multiple nationalguidelines for child health delivery, even withinAAP, and the variation in standards amongpayers. Also, given the flat reimbursement feefor well-child visits, anything that is perceivedas increasing the time spent in a visit can bedifficult to implement.

State health officials and leaders of the GeorgiaAAP Chapter both reported that the two enti-ties have a strong relationship and collaborate



More work is needed to engage privateproviders in using

Bright Futures.



on many issues, such as standardizing develop-mental screening practices for the State andplanning for physician training to supportimplementation of the new standards (effectivefor the Medicaid program as of October 1,2006).1 To date, however, encouraging BrightFutures use among private pediatricians has notbeen prioritized as an area for collaboration.Representatives of the Georgia AAP Chapterreport that although Bright Futures is listed asa tool for anticipatory guidance on its Web siteand they have shared information on BrightFutures as part of the Women, Infants, andChildren program nutrition outreach efforts,they have not received any requests from mem-bers for information on Bright Futures and donot believe that many members are using thisanticipatory guidance tool in their practices.

Leaders of the Georgia AAP Chapter noted thatseveral factors would affect their interest in pro-moting Bright Futures’ use among the State’spediatricians, most notably a directive from thenational AAP office or interest from their mem-bers. In order to facilitate its use in the field,especially when AAP releases the third editionof Bright Futures (which will integrate currentAAP health supervision guidelines), the GeorgiaAAP Chapter noted that educational materialsand assistance will be needed to help providersintegrate Bright Futures easily into their prac-tices. In addition, approval from Medicaid wasnoted as being essential in order for it to beadopted as a standard, as providers are unlikely

to adopt an approach without support fromsuch a major payer.

Fostering Communication and Support at the Local Level

Interviews with key informants uncoveredvarying degrees of communication among thevarious child health providers. A theme thatemerged from key-informant interviews wasthe need to share information among publichealth providers, as well as between public andprivate providers, about Bright Futures andhow it is being used.

Despite the State’s conduct of numerousregional trainings on Bright Futures and theavailability of aState BrightFutures pointperson, localkey informantsoften reported adesire for moreclarity and support from the State in how touse the Bright Futures materials in their ownsettings. While the trainings at both the broad-er regional and smaller district levels (includingmultiple local health departments) were notedas useful overviews of the Bright Futuresapproach, it was felt that smaller 1-day trainingsessions for providers “at the same level” onhow to use Bright Futures in clinics are neededto realize fully the benefit of Bright Futures.The importance of providing advance notice oftrainings was emphasized to ensure that entireteams of staff members, who will use BrightFutures together and support each other, canattend. Videos were another type of support

Tailored, hands-on training is needed

to maximize Bright Futures use at the local level.

1 Standardized developmental screening tools are required at ages9 months, 18 months, 24 months, and 36 months. Suggested screeningtools include ASQ, PEDS, or other standardized screening tools withspecificity of at least 80 percent. A Bright Futures health supervisionquestionnaire or other similar template is recommended at all otherHealth Check visits.



identified for providing more indepth guidanceon how to use Bright Futures.

Lessons Learned

Overall, the Georgia Bright Futures experiencehighlights several lessons learned regarding theuse of Bright Futures, as discussed here:

� Bright Futures can be utilized as a flexible

tool in broad-reaching child health promotion

efforts. Bright Futures has been used inGeorgia to support a range of activities tostrengthen clinical practice, train health pro-fessionals, educate parents, and developpolicies related to child health. This varieduse helps to promote the delivery of consis-tent messages across public health providersserving families at high risk for poor healthoutcomes.

� Integrating Bright Futures into current

practices can facilitate its acceptance. It wasnoted that incorporating Bright Futuresprinciples into the way work was alreadybeing done in the State helped to garnerbuy-in of the end users. In particular, inte-grating Bright Futures into Health Checkexam forms helped to ease the inclusion ofBright Futures into well-child exams con-ducted by public health nurses.

� Bright Futures can help to streamline and

enhance the delivery of comprehensive

anticipatory guidance during well-child exams.

The experience of public health nursesworking in clinical settings and conductinghome visits indicates that Bright Futures canbe used as a tool for delivering more consis-tent and comprehensive anticipatory

guidance to families. Although public healthproviders may have more time to spend withfamilies than private practitioners, insightsfrom public health nurses indicating thatBright Futures can help to focus discussionswith families and, if incorporated into examforms, also streamline related paperworkmay help to engage private practitioners touse Bright Futures.

� Champions are needed at all levels. In orderfor Bright Futures to be integrated in localpractice, there must be someone at the locallevel to “run with it,” and there is also aneed for someone to embrace it at top leveland make sure that staff members have theresources and support they need to facilitateimplementation. It is also useful to haveindividuals “in the trenches” who have usedit and can help to share lessons in how it canbe implemented successfully. This lessonmay be particularly relevant to hopes forbetter involving private providers in BrightFutures efforts – stronger advocacy by lead-ers in the private sector for Bright Futuresuse at the national, State, and local levelswill be needed to build a base of support inthe private practitioner community.

� Tailored support and training is needed to

facilitate implementation. In addition tobroad overviews of the Bright Futures phi-losophy and materials, front-line providersexpressed a need for clear guidance in howmaterials can be used in practice and sup-port and training tailored to the setting inwhich they work. Better linkages to othersusing Bright Futures in the State and acrossthe Nation can help to respond to this need.



Sustainability and FutureDirections

By incorporating Bright Futures into a range ofongoing initiatives aimed at improving chil-dren’s health, Georgia has taken importantsteps to foster its use into the future, particu-larly in the public-health sector. However,ongoing support tailored to the needs of keystakeholders is needed to further promote itsuse and realize its benefits in multiple venues.

Building on its experiences to date, ICH lead-ers are working to introduce Bright Futures toother agencies and organizations also interestedin promoting children’s health, such as theGeorgia Department of Education, the Parent-Teacher Association, the Governor’s Councilon Developmental Disabilities, and others par-ticipating in the Georgia Early ChildhoodComprehensive Systems building initiative.Partnerships such as these will be important tocontinue to support Bright Futures’ use in thepublic-health sector as well as to expand its useby private providers with a major role in pro-moting the health and development ofGeorgia’s children.

Key Informants

AAnncceell LLaawwrreenncceeWell Child ProgramOffice of Infant and Child HealthDivision of Public Health ServicesGeorgia Department of Human Resources

SSuussaann BBeerrttoonnaasscchhiiChildren 1stOffice of Infant and Child HealthDivision of Public Health ServicesGeorgia Department of Human Resources

JJoosseepphh AAllddeerrmmaannFormer Dental Director, Georgia Departmentof Human ResourcesRegion IV Head Start Oral Health Consultant

SShheellbbaa KKeeyyPutnam County Health Department

DDeenniissee DDaasshheerrCoweta County Health Department

WWiillmmaa HHaammSpalding County Health Department

LLyynnnn CCrreessss,, JJuuddyy HHoowweerrttoonn,,

aanndd MMeellaanniiee VVaauugghhnnGordon County Health Department

RRiicckk WWaarrddGeorgia Chapter of the American Academy of Pediatrics

Louisiana’sBright Futures Story

Marisa Ferreira, M.P.H., R.D.Judith Gallagher, R.N., Ed.M., M.P.A.

Health Systems Research, Inc. Louisiana’s Bright Futures Story Page LA-1


Introduction

This Bright Futures case study, based on keyinformant interviews conducted in spring2005, describes how and why Bright Futureswas initially adopted by Louisiana and how itsutilization has evolved. The State’s utilizationof Bright Futures has fluctuated over time asthe focus of the State’s public health system haschanged. Bright Futures initially was used as atool for strengthening the provision of directservices in public health clinics. Over time, asthe State’s role in direct care diminished, BrightFutures has been used in other child healthpromotion efforts, including those related toinfant mental health and nutrition. Currently,Bright Futures use is primarily focused in theState’s Nurse Family Partnership (NFP) pro-gram, a home visiting program for first-time,low-income pregnant women and their infants.


The Louisiana Department of Health andHospitals, Office of Public Health (OPH),Center for Preventive Health identifies as itsvision the promotion of “a healthy populationabsent of disease and risk factors for disease.”The primary responsibility of the Center isprotection of public health through the man-agement of programs and activities that engagein anticipatory guidance to prevent the occur-rence of disease or to minimize its effects afterit has occurred.1 Housed within the Center forPrevention are maternal and child health(MCH); immunization; nurse home visiting;Women, Infants, and Children (WIC); andschool-based health services, among other pro-

grams and activities. The State is subdividedinto 64 parishes or counties, which are organ-ized into nine regions.

In the late 1990s, the OPH MCH programundertook a variety of efforts to addressLouisiana’s high rates of infant mortality, lowbirthweight, and child maltreatment. Infanthealth and mental health were identified as twoprimary focus areas in which local healthdepartments could work with families toimpact the health of their infants and children.State officials began their search for a compre-hensive approach to health promotion tosupport local health departments in addressingthese areas.


Around the same time that State officials weresearching for a way to assist the local healthdepartments in addressing infant and mentalhealth, a team from the National Center forEducation in Maternal and Child Health(NCEMCH), which spearheaded growth of theBright Futures initiative with the FederalMaternal and Child Health Bureau, contactedLouisiana officials and offered to conducttraining to introduce them to the BrightFutures approach and materials. Agreeing thatBright Futures was a good fit for the Louisianapublic health agency, given its focus on preven-tion, State officials welcomed the opportunityto obtain training and to offer the guidelines tothe public health nurses and medical staffmembers.

Through MCH Block Grant funding, all pub-lic health registered nurses and medical doctorswere given copies of Bright Futures: Guidelines1 Department of Health and Hospitals Web site:

http://www.oph.dhh.louisiana.gov/centersfad6.html?DID=3



for Health Supervision of Infants, Childrenand Adolescents. Additionally, these staff mem-bers, approximately 500 in all, receivedtraining to familiarize themselves with BrightFutures and to receive information on how touse the materials in practice. Training focusedon interview and counseling skills related tochild health and development and anticipatoryguidance appropriate to each health visit. Thisinitial training was co-led by the State publichealth staff and the staff from NCEMCH.Subsequently, Bright Futures training was conducted across the State by the Louisianapublic health staff. Bright Futures soon becamethe model for care in the State’s public healthclinics.

In addition to public health nurses and physi-cians, training was offered to other public

health profes-sionals,includingnutritionists,to support theimplementa-tion of BrightFutures.

Approximately 20 State nutritionists attendedthe State training and received the BrightFutures in Practice: Nutrition manual in addi-tion to the Health Supervision Guidelines.State nutritionists viewed Bright Futures as acomprehensive resource for delivering nutritionservices to the families of infants and children,and therefore useful as a resource for trainingand developing nutrition education materials.Consequently, State WIC officials decided touse the Bright Futures guidelines as a referenceto guide the revision of WIC services offeredby local agencies.

Once training was underway, OPH launchedanother major initiative using Bright Futures.This initiative was designed to revise, pilot-test,and implement a new version of the ChildHealth Record & Checklist. These forms werean integral part of the documentation processused in the Office of Public Health clinics inthe State; the revised versions included age-spe-cific screening and assessment forms for everyhealth visit from birth to 6 years. In describingthe final version of the child health record, onekey informant explained, “Bright Futures camealong at the right time, providing a neededemphasis on social history and family context,especially parental concerns.” In addition to thechild health record, OPH developed FamilyTip Cards based on Bright Futures that werealso disseminated statewide.

Bright Futures was incorporated into Kidmed,the screening portion of Louisiana’s Early andPeriodic Screening, Diagnosis and TreatmentProgram. Although Kidmed used the periodici-ty schedule recommended by the AmericanAcademy of Pediatrics (AAP), the health educa-tion component of Kidmed, tailored to thechild’s age and health status at the time of thescreening service, corresponded to BrightFuture’s description of developmentally appro-priate milestones.

Evolution of Bright Futuresover Time

Soon after the initial training was completed,the Louisiana Department of Health andHospitals endured significant changes, includ-ing budget cutbacks and staff layoffs. Thesechanges brought an end to the provision ofdirect child health services by the public health

Louisiana conductedtrainings around the

State to introduce Bright Futures as

a model of care for itspublic health clinics.



care system, consequently leaving the privatesector as the sole provider of direct services.

This reorganization prompted a shift in therole of the public health nurses at the locallevel away from the direct delivery of care andtoward an emphasis on prevention throughcounseling and education. Although public

health nursesno longerused BrightFutures todeliver directservices, theycontinued touse BrightFutures tostructure andenhance the

provision of counseling and anticipatory guid-ance services. These efforts are described below.

� Infant mental health. Just prior to theimplementation of Bright Futures, PaulaZeanah, Ph.D., of the Maternal and ChildHealth division developed an intensive train-ing program in infant mental health as partof an overall effort to reduce the State’s ris-ing incidence of infant abuse and neglect.The training consisted of a five-session, 30-hour training program for public healthnurses and other nonmental health profes-sionals. The training was designed toimprove knowledge and skills of staff mem-bers in the early recognition of factors andconditions that place the infant and caregiv-er at risk for immediate, as well as long-termproblems in social, emotional, and cognitivegrowth and development. MCH has subse-quently trained all nursing and social work

staff members in infant mental health in allregions of the State. Bright Futures, with itsemphasis on parent-infant relationships andsocial-emotional development, was a naturalpartner in the overall goal of increasing pub-lic health staff knowledge, understanding,and skills in infant mental health.

� WIC Supplemental Nutrition Program.

Building on the participation of WIC staffin statewide Bright Futures training asdescribed earlier, State WIC officials devel-oped training materials based on the BrightFutures in Practice: Nutrition book moretailored to the needs of WIC staff. The pur-pose of the training materials was to providea general orientation to the Bright Futuresnutrition concepts and stimulate ideas as tohow to use the materials in WIC settings.

� NFP Program of Louisiana. An importantprogram directed by OPH in Louisiana,although available in many States aroundthe country, is the NFP program. NFP is ahome visiting program with services provid-ed by specially trained public health nurses.The program focuses on prenatal and earlychildhood interventions to improve thehealth and social functioning of low-income,first-time mothers and their babies. Homevisits begin before the 28th week of preg-nancy and continue through the child’ssecond birthday.2 The program operates inall nine regions of the State, mostly in rural,underserved areas. The project is supportedby the OPH through MCH/Title V andMedicaid funding; collaboration with theOffice of Mental Health helps provide an

2 http://www.oph.dhh.state.la.us/maternalchild/nursehome/index.html

As the public health system moved away

from a focus on directdelivery of care,

Bright Futures was integrated into

prevention-focused counseling and

education activities.



additional mental health component.3 NFPadopted Bright Futures to guide the conductof the child health home visits conducted bythe NFP nurses. Use of the Bright Futuresguidelines assists in the provision of compre-hensive anticipatory guidance that include afocus on both health and psychosocial issues.

The supervisors of the NFP team supportthe utilization of these guidelines, since theyserve to ensure that at each home visit, allimportant anticipatory guidance areas are

consistentlyand thorough-ly covered. Inaddition, as ithas becomemore difficultfor NFP torecruit nurseswith publichealth or

MCH backgrounds, the guidelines are par-ticularly useful to nurses less experienced inthe provision of age-appropriate informationand guidance. The NFP program in RegionIX has developed a policy that states,“Bright Futures is to be introduced, dis-cussed and used in new staff training andalso in creating new materials.” Additionallyin Region VI, the NFP supervisor developedher own staff policy and procedure manualusing Bright Futures materials and madethese available online.

Another area in which Bright Futures hasbegun to emerge as a useful tool is in medicalschool curricula. At Tulane University School

of Medicine, pediatric residents are trained inthe clinical applications of Bright Futures.There are also a small number of professors atLouisiana State University that have includedBright Futures in their curricula, although useof Bright Futures in Louisiana medical schoolsdoes not appear to be widespread.

Challenges and LessonsLearned

As illustrated in this case study, key informantsinterviewed for this study describe the State’sBright Futures efforts as having been focusedprimarily in the public health arena. Highlightsand lessons from this experience include thefollowing:

� Bright Futures can be used as part of com-prehensive programs to address an array ofpublic health issues, such as high rates ofinfant mortality, low birthweight, child mal-treatment, and infant mental health.

� Champions and partners are needed tosustain and advance the use of the BrightFutures staff (for example, OPH staff mem-bers familiar with Bright Futures supportedefforts to incorporate Bright Futures intoNFP programming).

� Ongoing Bright Futures training is essential.

With regard to furthering the use of BrightFutures, one of the important challenges iden-tified is expanding the use of Bright Futures inthe private sector. Practitioners in private prac-tice were identified as being less likely thanother types of child health professionals to befamiliar with and to have “buy-in” to Bright

3 2003 Louisiana Health Report Card, Preventive Health Outreach, Serviceand Education Programs.

Bright Futures guides the delivery of comprehensive

anticipatory guidance in a statewide home visiting program for

at-risk pregnant womenand new mothers.



Futures.Furthermore,given the lim-ited numberof pediatri-cians andobstetriciansthat acceptindividualsenrolled inthe State’s

medical assistance program as patients, as wellas the competing demands on the public healthagency’s resources, it is difficult for the State topromote actively the use of Bright Futures out-side of the public health community.

This challenge is beginning to be addressed,however. Recently, the Louisiana Chapter ofthe AAP has begun to promote Bright Futuresamong its members. The State AAP chapterrecently sponsored a 2-day conference in con-junction with the Louisiana State UniversityHealth Sciences Center in which PaulaDuncan, Professor of Pediatrics at University ofVermont and member of the national AAP’sBright Futures Steering Committee, conducteda presentation on Bright Futures and NewPractice-Based Approaches to PromotingEmotional Well Being and Partnerships withParents. This conference was targeted to pedia-tricians, pediatric specialists, and familypractice physicians, as well as registered nurses.This effort by the State AAP chapter to pro-mote Bright Futures may also help to address arelated area of need identified by key inform-ants – expanding the use of Bright Futures intraining programs for health professionals.

Future Directions andSustainability of Bright Futures

For many years, Bright Futures has played animportant role in Louisiana’s public healthefforts to improve children’s health, althoughthe State’s focus on actively promoting BrightFutures has varied over time. Initially, OPHconducted a widespread effort to train publichealth employees across the State on the BrightFutures approach and to provide them with theBright Futures materials. With OPH’s shift infocus away from the provision of direct clinicalservices, the momentum of Bright Futures sig-nificantly slowed.

As of 2005, the major use of Bright Futuresappears to be among public health nurses whoprovide home visiting services as part of theNFP program. Nurses working within NFP areaware of Bright Futures and are encouraged touse the materials. However, the utilization ofBright Futures is not regularly monitored andthe degree of understanding of the materialsvaries among the nurses in different regions.Some regions of the State appear to be moreeffective in promoting and utilizing BrightFutures than others, primarily because theseregions have better access to training and sup-port through “champions” who truly believe inthe Bright Futures philosophy. An example ofthis disparity is the variance in knowledgeamong NFP nurses about what Bright Futuresresources are available. Some staff membersinterviewed for this project reported that theywere aware of the first edition of the guidelinesfor health supervision but not of any otherBright Futures materials, while other staffmembers interviewed stated that they routinelyused the pocket guides, tip sheets, or mental

Bright Futures is utilizedas part of medical training curricula

in some Louisiana medical schools, andefforts are expanding

to engage privateproviders in using

Bright Futures in practice.



health or nutrition guidelines. Therefore, whileindividual Bright Futures champions are sustaining efforts in some regions, the State isno longer taking as active a role in disseminat-ing the use of Bright Futures as broadly as itonce did.

Sustainability prospects, however, must be con-sidered in light of reports by some keyinformants that they are often using the BrightFutures philosophy and approach in their workwith children and families, but not alwaysidentifying their work as Bright Futures. Infact, one key informant summarized by stating,“A lot of what we do is what Bright Futuresoffers; we just never put that name on it.”

Such reports reflect some progress in integrat-ing Bright Futures into ongoing child healthpromotion efforts. In addition, the AAP’srecent promotion of Bright Futures and its lim-ited use in medical school curricula arepromising developments. However, moreBright Futures champions who enthusiasticallyand persistently advocate for Bright Futures areneeded for Bright Futures to flourish morebroadly in the State.

Key Informants

PPaauullaa ZZeeaannaahhDirector of the Nurse Family Partnership ProgramLouisiana Department of Health and Hospitals Office of Public Health, Maternal and Child Health Division

CCyynntthhiiaa SSuuiirreeAssistant Supervisor of Nurse FamilyPartnershipLouisiana Department of Health and Hospitals Office of Public Health

CCiinnddyy HHiillggeerrPublic Health Nurse V and Supervisor of Nurse Family PartnershipLouisiana Department of Health and Hospitals Office of Public Health

MMeeggaann LLoouuqquueeRegional Nurse Practitioner and Long Term Public Health NurseLouisiana Department of Health and Hospitals Office of Public Health

Maine’sBright Futures Story

Judith Gallagher, R.N., Ed.M., M.P.A.Marisa Ferreira, M.P.H., R.D.

Health Systems Research, Inc. Maine’s Bright Futures Story Page ME-1


Introduction

The Maine Department of Health and HumanServices identifies as its mission “to providehealth and human services to the people ofMaine so that all persons may achieve andmaintain their optimal level of health and theirfull potential for economic independence andpersonal development.” Since 1998, BrightFutures has played an important role in work-ing toward achievement of that mission bystrengthening the comprehensiveness and qual-ity of the health supervision provided toMaine’s children and adolescents. The follow-ing describes the organizational context for thisrole, how the use of Bright Futures was initiat-ed and evolved, current status, and futurechallenges. This case study is based on key-informant interviews conducted by researchersat Health Systems Research, Inc. during mid-2005.


The Department of Health and HumanServices (DHHS) was established by PublicLaw in July 2004 by combining and reorganiz-ing the former Departments of HumanServices and Behavioral and DevelopmentalServices.1 Key goals of this reorganization wereto support primary prevention efforts and tofacilitate the provision of integrated services toMaine residents.

The DHHS Office of MaineCare Services, for-merly the Bureau of Medical Services (BMS), isresponsible for the organization, implementa-tion, and monitoring of the State’s MaineCareprogram. MaineCare is a health insurance pro-

gram funded jointly by the Federal Centers forMedicare and Medicaid Services and the States.Through Title XIX (Medicaid) and XXI (StateChildren’s Health Insurance Program, SCHIP)of the Social Security Act, MaineCare provideshealth insurance benefits for eligible childrenand adults enrolled in Medicaid and SCHIP.2

Due to the expansion of health insuranceaccess for Maine residents, the DHHS PublicHealth Nursing Program no longer providesdirect clinical services to children and adoles-cents and focuses instead on health education,health promotion, health assessment, and advo-cacy. Activities within these functions includestandard setting and enforcement, policy devel-opment, training, and collaboration with otherpublic and private sector agencies. TheDepartment contracts with a variety of agencies(e.g., Visiting Nurse Associations, community-based programs) that provide direct publichealth services.


Leadership staff members in BMS and thebroader DHHSbecame awareof BrightFutures at aboutthe same timebut in dissimilarways. In 1998,soon afternational SCHIP legislation was passed, theFederal Maternal and Child Health Bureau dis-tributed Bright Futures: Guidelines for Health

1 Department of Health and Human Services; State of Maine. Available at:www.maine.gov/dhhs. Accessed January 10, 2006.

2 Annual Report to the State Legislature MaineCare, SFY 2004.

The comprehensivenessof Bright Futures

guidelines led to theiradoption as a standard

of care for Maine.



Supervision of Infants, Children andAdolescents to each State Health Department,including Maine’s. The DHHS Nursing leader-ship was impressed with the document andconducted in-service education with regionalnursing staff members to encourage its use;subsequently, Bright Futures became the“handbook” for home visiting services through-out the State. At about the same time, theBMS Quality Assurance Manager was con-cerned about the lack of a standard of healthsupervision care for health care providers tofollow and the increase in mental health andother related needs. Her research identified theBright Futures health supervision guide. Shethen brought together a group that includedthe Director of Immunizations, the MedicalDirector, private-sector providers, and otherBMS staff members to discuss the desiredattributes of a standard of health supervisioncare for children and adolescents and their fitwith Bright Futures. The group determinedthat the comprehensiveness of Bright Futureswith its focus on primary care and inclusion oforal and mental health provided an appropriateand useful standard of care for Maine.

Parallel to this process, other changes wereoccurring in the State’s child health programsand systems. The State’s Early and PeriodicScreening, Diagnosis, and Treatment (EPSDT)program was centralizing services and begin-ning to provide home visiting care for allenrollees. At this same time, the BMS also wasassisting DHHS with building an immuniza-tion registry. This timely coming together of anarray of needs and activities coupled with thepresence of champions including the MedicaidMedical Director and the DHHS Maternaland Child Health (MCH) Medical Director,

who envisioned the long-term usefulness ofBright Futures, resulted in the establishment ofa role for Bright Futures in the provision ofcare to children and adolescents enrolled inpublicly funded health insurance programs inMaine. The following section describes howthe role of Bright Futures evolved.

Evolution of Bright Futures

Once the decision had been reached to useBright Futures: Guidelines for HealthSupervision as the standard of care forMaineCare, the staff had to determine how toimplement the utilization of these standards.Implementation involved an array of issuesincluding engagement, training, and retentionof providers across the State and the develop-ment of policies and procedures to promoteutilization of and compliance with the standards:

� Policy development. Recognizing that it isnot easy for providers to alter the manner oftheir practice and in appreciation of thefinancialpressuresexperiencedby providers,the leaders ofBMS andDHHS knewit would beimportant toinvolveproviders inthe development of clinical forms thatembodied the Bright Futures standards andalso to offer financial incentives to encour-age adoption of the Bright Futures

Maine developed clinical forms based on Bright Futures for

all recommended well-child visits. Providers who

complete the forms are reimbursed at an

enhanced rate.



standards. To these ends, a group of pedi-atric and family physicians were broughttogether to develop age-appropriate clinicalforms that would be used to document thecare provided and make referrals. The groupsubsequently developed a series of 19 formsthat begin with the Bright Futures healthexam for newborns and end with a formdesigned to guide the Bright Futures examfor 18- to 20-year-olds. The forms are avail-able at the MaineCare Web site,www.state.me.us/bms/providerfiles/bright_

future.htm. In addition, enhanced reimburse-ment was made available to providers whocompleted the Bright Futures forms. Thereimbursement is about $20 more than previous reimbursement with the specificamount dependent on the age of the childand the extent of the Bright Futures exami-nation required. The MaineCareReimbursement Code for Bright FuturesPreventive Medicine is available atwww.state.me.us/bms/provider/childrens/

rate_comparison_chart and is compared with reimbursement rates for non-BrightFutures care.

Policies were also established to promote theparticipation of families in the MaineCareprogram. Using the Bright FuturesPeriodicity Schedule, MaineCare MemberServices sends to each family with a childenrolled in MaineCare a checkup reminderletter. The letter encourages the family tomake an appointment with their child’sprovider, and offers assistance to the familyin arranging an appointment and obtainingtransportation as needed. Including in thesemailings is a brochure and healthy visitguide describing why preventive care is

important and what is likely to transpire atmedical and dental visits. The guide alsoincludes a section for parents to write downquestions they wish to ask their child’sprovider. Finally, a postage-paid foldoutpostcard is included to enable families toinquire about additional assistance fromMaineCare.

As Bright Futures continued to becomeestablished, it was also used to influence pol-icy in a range of areas. For example, BrightFutures is used to guide overall nursing stan-dards including those for school nursing.The staff at DHHS led a legislative taskforce in 1998 on early care and educationthat focused on the development of a hand-book for parents. The task force used BrightFutures to guide the development of thishandbook.

� Engagement of providers. The StateMedicaid Medical Director led efforts toengage providers in the utilization of BrightFutures as the standard of care forMaineCare. MaineCare policies were estab-lished that required physicians to enroll asEPSDT providers and through this processindicate their intention to follow the BrightFutures standards. A letter accompanied byBright Futurematerials wassent toprovidersdescribingBrightFutures andrelated policyand reimbursement changes. The providerrelations staff from BMS, under the leader-

Trainings were conducted to introduce

Bright Futures to physicians participating

in the State’s MaineCare program.



ship of the State Medicaid Director and theDHHS MCH Medical Director, conductedstatewide provider trainings to describe theBright Futures philosophy, discuss the healthsupervision standards, and answer questions.Trainings were also conducted with the Stateimmunization program staff, which in turnincluded Bright Futures training in theirone-on-one meetings with private providers.Others involved in training included theState public health nurses located in each ofthe Regional Offices, who also play a majorrole in helping local providers become famil-iar with Bright Futures. Finally, BMSmaintains a MaineCare provider file, andthrough this mechanism, the staff can iden-tify newly enrolled MaineCare providers. A packet of Bright Futures information ismailed to these providers who may alsorequest onsite in-service sessions to assistthem with implementation of BrightFutures.

� Closing the loop. Discussions about theBright Futures philosophy and the develop-ment and introduction of the Bright Futuresforms led to an exploration of how to useBright Futures to “close the loop” betweenthe conduct of the health assessment examand needed followup. The MaineCare physi-cian advisory group along with staffmembers from BMS and DHHS were con-cerned that needed followup was not alwaysprovided. Therefore, a process was put inplace to ensure that this problem wasaddressed.

BMS receives an average of 5,500 BrightFutures forms per month and reviews eachwithin 24–48 hours of receipt. Forms of

patient visits that require followup (whichtotal in excess of 400 per month) are for-warded to the DHHS public health nurseswho work with families and local agencies toensure that the followup care needed is pro-vided. Followup may include providingassistance with the identification of a med-ical or dental provider, arranging fortransportation, referring “no-shows” to theImmunizationProgram, orconducting ahome visit.Home visitsprovided bythe publichealth nursesare also conducted in accordance withBright Futures; Bright Futures guidelines areincorporated into the Public Health NursingPolicy and Procedure Manual and havebecome the “gold standard” for the provi-sion of services offered via home visits. Eachpublic health nurse has been provided with acopy of the guidelines and uses it to guideinfant, child and family assessments andfamily education and counseling.

To complete the circle, the public healthnurses communicate with the referringproviders regarding the outcome of the fol-lowup activities. A memorandum ofunderstanding was developed and becameeffective January 1, 2005 between BMS andthe Public Health Nursing Program for theconduct of these followup activities. PublicHealth Nursing is reimbursed for theFederal share of nursing time spent review-ing Bright Futures forms and providing followup.

Patients that require followup after

a well-child exam receive home visits

conducted in accordancewith Bright Futures bypublic health nurses.



� Incorporation of Bright Futures into physician

practice. Bright Futures continues to be theaccepted standard of care for the provisionof preventive care to children and adoles-cents enrolled in MaineCare. This policy isclearly indicated on the MaineCare Web siteand in MaineCare Policies and Procedures,and there is evidence that it has been imple-mented widely. Since in Maine, providersare required to complete an enrollmentprocess to participate in EPSDT (and thencan serve children covered under both theMedicaid and SCHIP portions ofMaineCare), the BMS can track providerparticipation. As of June 2005, the BMSstaff estimated that 89 percent of primary

care physi-cians inMaine areenrolled inMaineCareand that most

of these providers are complying with theutilization of the Bright Futures standardsand documenting this with submission ofthe Bright Futures forms. BMS and DHHSstaff members interviewed for this projectattributed the significant and sustainedinvolvement of physicians to the availabilityof the enhanced reimbursement rates andthe ongoing training and support providedby BMS and Public Health Nursing. Staffmembers felt that the Bright Futures incen-tives and State agency support helped to getpeople thinking differently and more inclu-sively about well-child care and facilitatedthe utilization of a broad definition of well-child care embodied in Bright Futures thatincludes mental health, social and cognitive

development, oral health, and family relationships.

Key informants interviewed for this study citedan array of attributes identified by them and bycolleagues that promoted the adoption andongoing utilization of Bright Futures as guide-lines for preventive health care for children andadolescents enrolled in MaineCare. Theseattributes are categorized by function includingthe provision of information, the facilitation ofcommunication and the promotion of quality.

� Information. The comprehensiveness of theguidelines, especially the inclusion of mentalhealth and oral health and the stand-alonemental health, nutrition, and oral healthbooks were cited as critical attributes of thematerials. The materials were also describedas containing substantive information organ-ized in an easy-to-access manner.

� Communication. The Bright Futures formspermitted the sharing of informationbetween primary care providers and publichealth nurses and others to promote coordi-nated care. They also facilitate the sharing ofinformation between parents and providers.

� Quality assurance. The use of BrightFutures promotes statewide consistency inthe level of preventive care provided to chil-dren and adolescents enrolled in MaineCareand permits the DHHS to review the BrightFutures forms for compliance with standardsof care.

The Bright Futures clinical forms are

widely used by MaineCare physicians.



Lessons Learned and FutureChallenges

Maine has taken significant steps to implementBright Futures successfully as the standard ofcare for the MaineCare Program. In additionthe Bright Futures Health SupervisionGuidelines are used to guide the provision ofservices offered by the State’s public healthnursing via their home visiting program. BrightFutures also has played a significant role informing policy and program directions in otherareas, including early care and education.

As a result of these efforts, the State has learneda great deal about the factors that facilitate andsupport achievement of desired outcomes andabout the challenges ahead. The following is adescription of lessons learned that appear tohave been influential in promoting and sustain-ing the utilization of Bright Futures in Maine:

� Bright Futures responded to specific con-

cerns of policy and program decisionmakers.

Staff members at BMS were concernedabout the lack of a standard of care for chil-dren and adolescents enrolled in MaineCare,

while staff atDHHS wereinterested instrengtheningthe contentand consisten-

cy of services offered via the home visitationprogram. Utilization of Bright Futures wasviewed as a direct response to these concreteneeds and not as some new program uncon-nected to current policy and program issues.

� Staff members were aware of the existence

of Bright Futures. For Bright Futures to be

used, policy and program staff membersmust be aware of its existence. In 1998, theBright Futures Health Supervision docu-ment was distributed free of charge to StateDHHS programs, and as a result, theDirector of Public Health Nursing learnedof its usefulness. Because Bright Futures wasInternet searchable, the staff at BMS discov-ered it while researching standards ofpreventive health care for children and adolescents.

� Champions of Bright Futures helped to pro-

mote utilization of the standards and related

materials. The Medical Directors of bothMaineCare and DHHS/MCH, along withother leaders at BMS and with PublicHealth Nursing, actively promoted the useof Bright Futures. They shared informationand enthusiasm about Bright Futures withothers (e.g., Women, Infants, and Children[WIC] and immunization programs; EarlyCare and Education Task Force), which builtsupport for the utilization of Bright Futures:Guidelines for Health Supervision ofInfants, Children and Adolescents.

� Bright Futures is used as a mechanism to

strengthen systems of care. Therefore, BrightFutures is not an “add-on” to other activitiesbut rather is integral to the MaineCare sys-tem of care. The Bright Futures clinicalforms are included in the clinical recordsmaintained by providers with copies sent toBMS to document and monitor the provi-sion of care. In addition, the information onthese forms is used to trigger followup activ-ities conducted by the public health nursingstaff. This institutionalization of BrightFutures helps to ensure the sustainability of

Bright Futures was utilized as a direct

response to the needs of current programs.



current efforts and promote its use in future efforts.

� Leaders understood the importance of

realistically addressing issues related to

implementation of Bright Futures. MaineCareand public health nursing leaders recognizedthe importance of identifying barriers toimplementation of the Bright Futures stan-dards and the need to address these inrealistic ways. To promote the involvementof the provider community, the State includ-ed practitioners in the development of theBright Futures forms and created anenhanced reimbursement system to facilitateutilization of the standards. Statewide andindividual training was conducted to assistproviders with the integration of the BrightFutures standards into their MaineCarepractices.

� The philosophy of DHHS supports services

integration and collaboration. Collaborationbetween BMS and DHHS Public HealthNursing played a key role in promoting theutilization of Bright Futures. This collabora-tion has continued over the years and isformalized through a memorandum ofunderstanding. Other important partnersinclude the WIC and ImmunizationPrograms. The recently reorganized DHHScites as primary values the integration ofservices via collaboration. This philosophycreates a working environment that supportsa systems approach to service delivery thatincludes the integration of Bright Futures.

Maine also faces several challenges to the sus-tainability and ongoing growth of BrightFutures. These challenges include:

� Continued access to Bright Futures

materials. Issues include the cost of materialsand the need for additional/revised materi-als. The DHHS is experiencing difficultymaking the Bright Futures products avail-able that arecited in theDHHSPublic HealthNursingManual asfunds formaternal child health has been reduced inthe State. While the MaineCare programsupports Bright Futures, it too does not havethe financial resources to purchase materials.However, the State WIC program has beenable to be of some assistance by purchasingthe Bright Futures Nutrition materials.

The staff indicated an interest in the devel-opment of additional Bright Futuresmaterials targeted at families particularlyaround parenting styles. Additional empha-sis should also be placed on assuring thecultural sensitivity of materials and appro-priate reading levels. It also would be helpfulto send Bright Futures pocket guides to eachMaineCare provider to promote clinical carethat meets the Bright Futures standards.

� Implementation of an electronic medical

record system. The State is moving to theimplementation of an electronic medicalrecords system, and BMS is working with acontractor to develop an interface that willpermit the uploading of Bright Futures datainto the electronic system. However, com-pletion of this is at least 2 years in thefuture, and BMS currently does not have

Additional funding is needed to make

Bright Futures materialswidely available

to providers.


adequate numbers of staff members to hand-enter data from the Bright Futures forms ofpatients who required followup into theelectronic record system. The goal of BMS isto have electronic Bright Futures forms thatcan be uploaded into the new medicalrecord system and thus permit the aggrega-tion of data. However, BMS is in need ofadditional financial resources to proceedwith this activity.

� Use of Bright Futures in private-sector health

care. While the State has been very effectivein implementing Bright Futures-guided pre-ventive care for children and adolescentsenrolled in MaineCare, less is known aboutthe utilization of the Bright Futures stan-dards with children and adolescents who areprivately insured. While it can be assumedthat most providers are caring for both pub-licly and privately insured children andadolescents and it intuitively seems reason-able that providers would not offer twolevels of care, little is known about compli-ance with Bright Futures standards fornon-MaineCare patients. An ongoing chal-lenge is to ensure that all children andadolescents in Maine are offered and obtainhigh quality comprehensive and appropriatepreventive care.

Overall the State has identified many opportu-nities in which Bright Futures can be ofsignificant help in the promotion of the healthof children and adolescents. Bright Futures isplaying a crucial role in providing solutions toan array of quality assurance and delivery system issues.


Key Informants

BBrreennddaa MMccCCoorrmmiicckkManager of Quality Management Unit at Bureau of Medical ServicesDepartment of Health and Human Services,Office of MaineCare Services

KKaarreenn CCaasseeyyEPSDT CoordinatorDepartment of Health and Human Services,Office of MaineCare Services

EElllleenn BBrriiddggeeMaine Department of Health and HumanServicesMaine Center for Disease Control and PreventionPublic Health Nursing

South Carolina’sBright Futures Story

Beth Zimmerman, M.H.S.

Introduction

In South Carolina, Bright Futures has been anintegral tool in the State’s efforts to improvechildren’s oral health. These efforts focused ini-tially on school-age children and, with supportfrom the Robert Wood Johnson Foundation,have expanded to address the oral health needsof younger children, including infants, tod-dlers, and preschoolers, as well as children withspecial health care needs. The State’sDepartment of Health and the Environment(DHEC) has spearheaded the use of BrightFutures in Practice: Oral Health in policydevelopment, family and community educationand outreach, and provider training initiativesdesigned to address the oral health goals out-

lined inHealthy People2010. This casestudy, based onkey informantinterviews conducted inspring 2005,

tells the story of how Bright Futures inPractice: Oral Health has been used in SouthCarolina to reduce the significant burden oforal disease among its young citizens.


As the State agency charged with promotingand protecting the health of the public, DHEChas been a central player in the State’s effort toimprove the oral health of children. Oralhealth activities within DHEC are spearheadedby the Division of Oral Health, housed withinthe Bureau of Maternal and Child Health. This

division has championed the use of BrightFutures in South Carolina’s oral health promo-tion efforts. The Bright Futures philosophy isalso clearly reflected in the Division’s guidingprinciples, which are as follows:

� Prevention and education are priorities.

� Treatment is available, accessible, afford-able, timely, and culturally competent.

� Responsibility is shared among patients,parents, providers, employers, and insurers.

� Collaboration by government, higher edu-cation, and the private sector ensuresresources, quality, and patient protection.

Although the Division of Oral Health is cur-rently a vibrant and active unit within thebroader DHEC agency, this was not always thecase. In fact, between 1991 and 2001, SouthCarolina did not have a State Oral HealthDirector. Without this key leadership positionfilled, the State’s dental public infrastructuresuffered.

However, the publication in 2000 of the U.S.Surgeon General’s landmark report, OralHealth in America, renewed the State’s atten-tion to oral health problems. The SurgeonGeneral’s report documented the widespreadproblems of unmet oral health needs amongAmericans, especially those in low-income pop-ulations, and also highlighted the highprevalence of decay among children and thenegative impact of untreated dental disease onchildren’s development and ability to learn. Inresponse to these problems, South Carolinaundertook a variety of actions to address theoral health problems of its population. For

Health Systems Research, Inc. South Carolina’s Bright Futures Story Page SC-1


South Carolina has utilized Bright Futures

to develop oral health promotion policies, curricula, and campaigns.

example, the State established a Children’s OralHealth Coalition1 and developed a State oralhealth plan which provided a comprehensiveblueprint for oral health promotion and diseaseprevention.

Another critical action taken by the State wasto fill the long-vacant State Oral HealthDirector position through an agreementbetween DHEC and the Federal HealthResources and Services Administration, whichdesignated a Federal assignee for this role. In2001, Dr. Ray Lala became South Carolina’sOral Health Director. As described below, healso became the State’s primary Bright Futureschampion as he worked to rebuild the State’spublic health infrastructure.


The use of Bright Futures in Practice: OralHealth was initiated by the State’s new OralHealth Director, who had prior experienceusing Bright Futures as a resource for oralhealth training. This section describes howBright Futures was used initially to address theoral health needs of South Carolina’s school-agechildren.

School Nurse Training

Upon joining DHEC as the State’s first OralHealth Director in a decade, Dr. Lala becamequickly engaged in the range of State initiativesunderway to improve oral health. Particularpriority, however, was placed on efforts toenhance the oral health status of school-age

children. The Governor at this time had an ini-tiative to improve school performance, onewhich recognized the role of health in academ-ic achievement. Building on this initiative, theChildren’s Oral Health Coalition conducted asurvey of school nurses which identified oralhealth as their top priority concern. In turn,the Coalition asked Dr. Lala for help in train-ing school nurses in how to address students’oral health needs.

In determining how best to respond, Dr. Laladrew on his past experience as a clinical andadministrativedentist in theIndian HealthService, duringwhich time heprovided train-ing to HeadStart programsin oral health. For that endeavor, he found theBright Futures in Practice: Oral Health guide-lines to be a useful resource for communicatingabout oral health to individuals without formaldental training and facilitating interdisciplinarycoordination. He noted Bright Futures’ clearand concise information as helping to conveyinformation in an easily understandable way.

Based on that experience, DHEC’s Oral HealthDirector, in collaboration with the State’sDepartment of Education (DOE), utilizedBright Futures to train and serve as an educa-tional resource in oral health for SouthCarolina’s school nurses:

� Training. Dr. Lala conducted four regionaltrainings for the State’s school nurses. In



Bright Futures was a useful resource for training school

nurses in how to address student’s oral health needs.

1 The Coalition was established as part of the South Carolina Department ofEducation’s Healthy Schools project, funded by the Centers for DiseaseControl and Prevention.

developing the training content, he drewheavily on Bright Futures in Practice: OralHealth, especially in relation to the deliveryof age-appropriate anticipatory guidance tothe child and family regarding oral health.Four regional trainings were conducted for400 of the State’s 500 school nurses. Tomake the training available for the remain-ing school nurses as well as newly hirednurses, a telecast was conducted and video-taped copies were shared with local healthdepartments. The content also has beenincorporated into ongoing trainings con-ducted by the health department for newschool nurses and other public health nurses.

� Educational resources. DHEC and theChildren’s Oral Health Coalition decidedthat Bright Futures materials also would be

useful forschool nursesto have onhand in devel-oping theirschools’ inter-ventions. Alimited num-

ber of Bright Futures in Practice: OralHealth books were provided as resources tothe schools. In addition, Bright Futures OralHealth Cue Cards were purchased for schoolnurses to be used as tools to support theprovision of oral health supervision includ-ing risk assessment, anticipatory guidance,and delivery of recommended services.

Dental Health Program Guidelinesfor Schools

Building on the trainings for school nurses, thenext step in bolstering schools’ ability toimprove children’s oral health and, in turn,enhance their ability to learn was the develop-ment of formal guidelines for school dentalhealth programs. No national guidelines forschool dental programs were available onwhich to base State guidelines, so DHEC’sOral Health Director set out to write his own.Once again, the Bright Futures oral healthguidelines were a major resource to which heturned.

The resulting Guidelines for South CarolinaSchool-Based Dental Prevention Programsexplicitly indicates that school dental programsshould include services recommended in BrightFutures in Practice: Oral Health, includingdental assessment, treatment and/or referral,followup, and case management. Other exam-ples of how Bright Futures is reflected in theguidelines include its emphases on:

� Prevention of dental caries over treatment

� Community involvement in planning and development of school-based dentalprograms

� Educational efforts for individual andcommunity awareness of oral health and thebenefits of dental preventive measures suchas dental sealants

� Collaboration among oral health providersand other health services staff members andregular school personnel to assess and meetthe health, developmental, and educationalneeds of the students



“At DHEC, Bright Futures is the bible for health education. It is clear, concise, and easily understandable.”

-HEALTH DEPARTMENT STAFF

� Advocacy for the establishment and reten-tion of oral health education in the school’soverall curriculum

� Coordination of services delivered at theschool with those delivered in the community

� Integration of school dental programs withthe overall community public health andoral health systems.

Dr. Lala noted the importance of BrightFutures in successfully obtaining support forthe guidelines from key stakeholders includingDHEC leadership and legislators, who were

very receptiveto guidelinesbased on anationallydevelopedmodel of carewith supportfrom the

Federal Government and a broad range of den-tal professional and other organizations. Aparticularly important outcome of this supportwas DHEC’s allocation of resources to hire aSchool Oral Health Program Coordinator towork with DOE’s Healthy Schools Oral HealthProject to implement the new school dentalprogram. This position, which was filled by adental hygienist, added a critical new compo-nent to the State’s re-emerging dental publichealth infrastructure. Moreover, whenChristine Veschusio joined DHEC in this rolein October 2002, the State obtained anotherimportant Bright Futures champion.

Once the guidelines were developed, the nextstep was to implement them. A central compo-

nent of the dental preventive program guide-lines was the specification that oral healtheducation services be provided in the schools.To implement this specification, curricula wereneeded for use in the classrooms. Given theneed to build lessons within the existing aca-demic framework, the DOE took the lead indeveloping the oral health curricula, with inputfrom DHEC and members of the Children’sOral Health Coalition Curriculum Committee.Oral health curricula were developed forkindergarten, second grade, and seventh gradeto reinforce DOE’s health and safety learningstandards at these grade levels. The guides con-tain lessons, primarily designed for classroomuse, that encourage students to take care oftheir teeth as well as teach them oral heathconcepts. Kindergarten lessons, for example,include hands-on activities on the proper wayto brush and floss teeth, the dental office,healthy recipes, and safety rules to prevent oralhealth injuries. In seventh grade, lessonsaddress additional age-appropriate oral healthtopics such as resisting tobacco use and orthodontics.

Bright Futures’ role in this phase of curriculumdevelopment was not explicit; the DOE staffdrew on other resources in developing theircontent in accordance with academic stan-dards. However, curricula for younger ageswere later developed under DHEC’s leadershipthat more extensively drew upon BrightFutures as a resource.

Evolution of Bright Futuresover Time

Bright Futures was an important tool in theState’s work during 2000–2002 to address the



The use of Bright Futures helped

to garner support for new oral health

promotion guidelines for schools.

oral health needs of children, as describedabove, and has continued to be an extremelyvaluable tool for its ongoing and expandedefforts in this area. In late 2002, SouthCarolina was awarded a 3-year $960,000 grantfrom the Robert Wood Johnson (RWJ)Foundation through its State Action for OralHealth Access Program. This grant supportedSouth Carolina’s establishment and operationof its More Smiling Faces in Beautiful Places(MSF) initiative, which is aimed at increasingaccess to oral health for children from birth toage 6 and for children and adolescents withspecial needs, with particular focus on minori-ties and economically disadvantagedpopulations who are uninsured or underin-sured. This focus responds to the findings of astatewide dental needs assessment conductedduring the 2001–2002 school year showingthat one-third of kindergarteners had untreatedtooth decay, with Black children experiencingsignificantly more untreated decay than Whitechildren.

In addition to the needs assessment findings,program planners cite Bright Futures inPractice: Oral Health, as well as Healthy

People 2010goals and therecommenda-tions of dentalprofessionalorganizations,as providingsupport for

the project. DHEC officials also point toBright Futures as an underlying framework forMSF’s major components, which include:

� Creation of an integrated oral health net-work of dentists, physicians, nursepractitioners, dental hygienists, public andprivate health providers, community healthcenters, and churches to increase access tooral health care

� Provision of pediatric oral health trainingprograms for medical and dental professionals

� Establishment of a system to link medicalhomes with oral health care providers, pro-vide patients with resources, screen foreligibility for Medicaid or other insuranceprograms, and arrange patient transportation

� Provision of educational guidance and sup-port to parents and families that enablethem to become effective managers of theirchildren’s oral health needs.

In interviewing key informants, several specificexamples of how Bright Futures has been uti-lized as part of the MSF oral health initiativewere noted:

� Staff orientation. All staff working onDHEC’s oral health initiatives are intro-duced to Bright Futures in Practice: OralHealth to communicate the guiding philoso-phy of the DHEC Oral Health Program.The Oral Health Director, who utilizedBright Futures in his program developmentwork, provided it to the School Oral HealthProgram Coordinator when she joinedDHEC, and she, in turn, has provided it tostaff and consultants working with her. Shealso provided copies of the book to the MSFcoordinators in each of the six target coun-ties. Use of Bright Futures by staff at the



Bright Futures is one of the underpinnings

of the State’s extensiveefforts, funded by the

RWJ Foundation, to improve oral health.

State and local levels helps to foster thedevelopment of consistent messages acrossprogram components.

� Partnership development. Strengtheningpartnerships among dentists, other healthprofessionals, and community organizationsis at the core of the MSF initiative. BrightFutures’ merging of dental and medicalinformation was noted as helping to facili-tate interdisciplinary communication andpartnerships, and its emphasis on the com-munity role in health helps to buildconnections between health professionalsand community agencies and organizationsserving children. At the local level, publichealth staff members trained in BrightFutures have assisted schools with imple-

mentationof the oralhealth cur-riculadevelopedand sharedby DOE,providing afoundation

for broader involvement of public healthstaff members in health education andhealth promotion activities for school-agechildren. However, the cost of BrightFutures materials limited the number ofcopies that could be shared with schools andother partners. State officials noted thatfunding for additional copies would help tomake the resources more readily recognizedand available by partners.

� Curriculum development and training. UnderMSF, DHEC has spearheaded the develop-

ment of several curricula for both medicaland nonmedical professionals for whichBright Futures in Practice: Oral Healthserved as a major resource. These includePediatric Oral Health for the MedicalProfessional; Infant Oral Health 101, apractical guide for planning to integrateinfant oral health into a general dental prac-tice; and a Child Care Center Oral HealthTraining Curriculum, which includes activi-ties to be used in child care centers toeducate and engage young children in oralhealth, as well as parent education sheets.The South Carolina Dental HygienistsAssociation has supported the use of the lat-ter curriculum by hosting a train-the-trainersession at its 2005 annual meeting. Trainingsalso have been conducted for lay healthworkers in faith-based organizations to sup-port their role in addressing the oral healthneeds of their communities. Participants incurriculum trainings receive copies of theBright Futures Oral Health Pocket Guide.

� Advocacy. Bright Futures was also noted asbeing a useful tool for advocacy with theMedicaid agency regarding children’s dentalbenefits. Its recommendation, reflective ofthose of professional dental and pediatricassociations, that children see a dentist uponeruption of the first tooth or by age 1,whichever comes first, has been used to sup-port requests that the State Medicaid agencyupdate the Early and Periodic Screening,Diagnosis, and Treatment dental periodicityschedule to cover dental screenings forinfants. This schedule currently indicatesthat dental screening services begin at age 3.



Bright Futures can help to deliver consistent

messages over time to different audiences

and through multiple messengers.

� Community outreach. Another componentof MSF is the conduct of a “Happy 1stBirthday” social marketing campaign which,based on the aforementioned recommenda-tions, encourages parents to begin oralhealth care for infants, including brushingtheir children’s teeth early and taking themto the dentist, by their first birthday.


South Carolina’s experience in using BrightFutures to improve children’s oral health pro-vides important lessons into how this resourcecan be used to address public health goals.These include the following:

� Bright Futures champions are critical. SouthCarolina’s experience with Bright Futuresdemonstrates how one person in a leadershipposition – especially with the capacity toinfluence staff orientation, training, and pol-icy development – can foster widespreadinstitutionalization of Bright Futures princi-ples and messages into a State’s public healthinfrastructure.

� Use of Bright Futures materials for staff ori-

entation can help to create champions. Thiscase study supports the value of using BrightFutures guides to communicate a philosoph-ical approach to public health and relatedactivities. Individuals who are introduced toBright Futures as a guide by their supervi-sors and mentors are likely to draw on it forvarious purposes, thus influencing the shapeand focus of programs, partnerships, andtraining pursued by these individuals.

� Bright Futures can be a valuable resource for

policy and program development. By drawingon Bright Futures as a resource during criti-cal periods of change in the State’s oralhealth system, South Carolina was able tofoster the development of oral health pro-grams and policies that are stronglygrounded in Bright Futures principles. Theseinclude the importance of prevention, healtheducation, a focus on the family, and com-munity partnerships.

While Bright Futures has been used extensivelyby DHEC to foster a health promotion/diseaseprevention model for oral health efforts in theState, the importance of expanding the explicituse of Bright Futures by key partners wasnoted. In particular, further work is needed tobuild Bright Futures into curricula for healthprofessionals. Dentists were noted as being lesslikely than other kinds of child health profes-sionals to know about Bright Futures. (Therecently completed pediatric oral health curric-ula aimed at medical and dental professionalsare aimed at supporting these critical partnersin applying Bright Futures to their particularenvironments.) Encouraging schools to be part-ners in community health efforts and to useBright Futuresalso can bechallenging, asthe academicframework forschool-basedlessons may make Bright Futures a less-than-obvious choice as a resource, given its health orientation.

The cost of Bright Futures materials limitedthe number of copies that could be shared with



More opportunities exist to expand the network of

Bright Futures partners.

schools and other partners. Funding for addi-tional copies would help to make the resourcesmore readily recognized and engage new partners.

Future Directions andSustainability of Bright Futures

Bright Futures has been instrumental in SouthCarolina’s efforts to strengthen its dental publichealth infrastructure and efforts to improvechildren’s oral health, beginning with school-based activities and expanding to include thebroader initiatives funded through MSF. BrightFutures messages have formed the foundationfor and are reflected in the policies and pro-grams that have been developed in SouthCarolina over recent years related to children’soral health.

By utilizing Bright Futures as the underlyingframework for oral health promotion policies,curricula, and campaigns, and thereforeembedding Bright Futures principles and mes-sages into South Carolina’s infrastructure andtools for oral health promotion, sustainabilityprospects are strong. This form of sustainabili-ty, however, acknowledges that Bright Futures’role may not be recognized by the many part-ners involved in the varied oral healthpromotion activities that have been groundedin Bright Futures. Indeed, while local-level keyinformants interviewed for this case study werefamiliar with Bright Futures, they noted itsmost explicit use at the State level by DHECin crafting oral health initiatives.

Given the end of RWJ funding for the MSFproject in early 2006, there have been numer-ous efforts to integrate the project’s Bright

Futures-based activities into the ongoing workof DHEC and various partner organizations.For example:

� Oral health education based on BrightFutures has been integrated into ongoingtrainings conducted by DHEC for publichealth nurses and school nurses.

� DHEC is partnering with the SouthCarolina Dental Hygiene Association to pro-vide training to child care centers statewideusing the Child Care Center Oral HealthTraining Curriculum based largely onBright Futures. An online training curricu-lum is envisioned in the future.

� DHEC is working with faith-based part-ners to implement a lay oral healtheducation program, again incorporatingBright Futures messages, in high-risk communities.

� DHEC collaborates with the WIC pro-gram to promote oral health to WIC clients.In additionto providinganticipatoryguidance toclients, train-ing will alsosoon beginfor WIC eli-gibility staff to complete an oral screeningon infants and young children to assess theiroral health status.

� Bright Futures-based oral health educa-tional components are being integrated intomedical and dental school curricula andcontinuing education programs for practic-ing providers.



Bright Futures can serve as a resource

for crafting messagesrelated not only to

children but to broaderpopulations as well.

The DHEC oral health staff indicated thatother divisions within the agency have utilizedBright Futures or are interested in doing so.That DHEC leadership was also noted as beingsupportive of Bright Futures indicates anopportunity to expand use of Bright Futuresmaterials more broadly within the healthdepartment.

In looking to future oral health promotionefforts, DHEC officials indicated that theywould like to expand the focus from youngand school-age children to adolescents andeventually to elders. Although these popula-tions of interest extend beyond Bright Futures’focus on children, DHEC officials indicatedtheir belief that, although the Bright Futuresmessages would need to be tailored, they arerelevant across the age spectrum. Use of BrightFutures in health promotion activities for thesebroader populations would represent anotherimportant evolution in the use of BrightFutures to a broad array of public health efforts.



Key Informants

CChhrriissttiinnee VVeesscchhuussiiooDental Health Program CoordinatorSouth Carolina Department of Health and Environmental Control

RRaayy LLaallaaOral Health Director (2001–2004)South Carolina Department of Health and Environmental Control

MMaarryy KKeennyyoonn JJoonneessCurriculum Development ConsultantSouth Carolina Department of EducationSouth Carolina Department of Health and Environmental Control

BBrraadd SSmmiitthhDirector of Health EducationLow Country Public Health District

TTrriisshhaa CCoolllliinnssDirector of Health EducationPee Dee Public Health District

RRoocckkyy NNaappiieerrPediatric DentistAiken, SC

Virginia’sBright Futures Story

Valerie Gwinner, M.P.P., M.A.Beth Zimmerman, M.H.S.

Introduction

This Bright Futures case study, based on keyinformant interviews conducted in spring 2005,describes the experiences of the Commonwealthof Virginia, in which the Bright Futures philoso-phy, guidelines, and specific components havebeen well-integrated into public health policyand practice at the State level. In an initiativespearheaded by the Virginia Department ofHealth (VDH) and State Nurses’ Council, theBright Futures Guidelines for HealthSupervision of Infants, Children, andAdolescents were adopted as the official Statestandard for children and adolescent health carein the spring of 2000. Currently, Bright Futuresis specifically identified as a strategy in 18 of theState’s 54 Healthy People Virginia 2010 objec-tives. It is referenced as a resource or guidelinein State health regulations regarding mentalhealth and Medicaid’s Early Periodic Screening,Diagnosis, and Treatment (EPSDT) Program.Each division and member of the VDH hasbeen required to address Bright Futures in bothoffice-level strategic plans and individual-levelworkplans.

The following describes Virginia’s adoption ofBright Futures as the State child health stan-dard and ways in which it has beenchampioned through policy, training, educa-tion and outreach, collaborations, and servicedelivery to promote better quality health careand supervision for children. This case studyillustrates the varied contexts in which BrightFutures has been used within the public andprivate sectors and many of the challenges thatcome with trying to transfer health guidelinesand a new way of promoting children’s health

into practice. Lessons learned from BrightFutures Virginia are highlighted, as are consid-erations for the future.

Context for Bright FuturesVirginia

In the late 1990s, VDH began to undertake anupdate of the State’s standards for child health,as they did not reflect current practice andwere based on a medical model of care. Thegroup charged with the task of devising recom-mendations for updates and revisions was theState Nursing Council – a group housed with-in VDH that was composed of public healthnurses from each of the State’s 35 HealthDistricts. The Nursing Council embracedBright Futures as a model for the new Statestandards, because it provided a way to movefrom a very clinically based set of standards toone that was more comprehensive. BrightFutures also represented a better fit with thehealth department’s emphasis on working withcommunity partners, the Public HealthServices’ identified 10 essential services,1 andthe four areas of focus of the Title V Maternaland Child Health (MCH) programs.2 Withthese combined benefits, the Council felt thatby using Bright Futures, it would be able toaccomplish far more than by simply rewritingthe standards. The Council recommended tothe Health Commissioner that Virginia adopt

Health Systems Research, Inc. Virgina’s Bright Futures Story Page VA-1


1 U.S. Department of Health and Human Services, Public Health Service,Public Health Functions Steering Committee. The public health workforce: anagenda for the 21st century. Full report of the Public Health FunctionsProject. Washington: U.S. Department of Health and Human Services; 1994.

2 Core public health services for the maternal and child population focus onfour major areas: infrastructure building services, population-based services,enabling services, and direct health care services. Source: Maternal andChild Health Bureau Strategic Plan: FY 2003–2007.Available at: http://mchb.hrsa.gov/about/stratplan03-07.htm.Accessed January 31, 2006.

the Bright Futures guidelines as the new Statechild health standard. Several specific attributesof Bright Futures were cited as reasons for thisrecommendation, including the following:

� The comprehensiveness of the BrightFutures guidelines and the fact that theyexisted in a ready-to-use format. This was animportant consideration for a group that didnot have the resources to reinvent the wheel.

� The prevention-focused, family-centered,community-oriented, and developmentallybased approach of Bright Futures. Thesethemes resonated strongly with the HealthCommissioner, whose background in inter-national health and development made herparticularly sensitive to the roles of preven-tion and community in promoting childhealth. They also were cited as critical toachieving buy-in from both health andsocial service department administrators.

� The widespread support for the BrightFutures guidelines from major health profes-sional organizations, such as the AmericanAcademy of Pediatrics (AAP), which hadtaken part in its development. This was seenas an advantage in helping to stem resistanceto the new guidelines from health careproviders.

� The attractiveness of the Bright Futuresmaterials.

� The fact that the Federal Maternal andChild Health Bureau (MCHB) was takingon the responsibility for updating and revis-ing the guidelines over time, representing aconsiderable savings of cost and effort forthe State.

As a result of these factors, the Bright Futuresguidelines met with approval and support fromthe Health Commissioner and DivisionDirectors within the State Health Department.In early 2000, the Commissioner convened aBright Futures Advisory Committee to helppromote statewide adoption of Bright Futuresand to develop a training plan to address waysthat the guidelines and materials could be usedto improve the quality of child health supervi-sion across the Commonwealth. Thiscommittee was composed of representativesfrom the State and local health departments,public and private health practices, healthorganizations such as the AAP VirginiaChapter (AAP-VA), Healthy Families Virginia,the March of Dimes, and community partnerssuch as the Richmond Children’s Museum.Most of these individuals either were already orsoon would become strong champions ofBright Futures and continue to promote its usetoday.


In the spring of 2000, the State HealthCommissioner announced the adoption ofBright Futures as the official standard of carefor children and adolescents in Virginia. A for-mal kickoff was held on June 7, 2001, tolaunch the Bright Futures Virginia campaign.

Campaign efforts focused primarily on trainingthe public health staff at the State and districtlevels to understand the purpose and philoso-phy of Bright Futures and to translate itsconcepts and materials into practice in family,community, and service delivery settings.Trainees also received additional resources and



materials to conduct further information shar-ing within their health districts to help spreadthe knowledge and use of the Bright Futuresguidelines and resources.

In addition to this training, VDH undertook amajor effort to disseminate the Bright Futuresmaterials using monies from Title V funding.Copies of the full health supervision guidelineswere distributed to more than 120 school nurs-es and 1,300 pediatricians across Virginia.Accompanying these was a letter from theHealth Commissioner explaining that BrightFutures represented the new State standard forchild health care. Bright Futures materials alsowere sent to each of the 135 local healthdepartments. A Bright Futures Pocket Guidewas distributed to every VDH employee work-ing with children and families, and 10,000Bright Futures Health Records were distributedto the local health departments for use inimmunization clinics; Women, Infants, andChildren (WIC) clinics; home visiting pro-grams; schools; and community health fairs.

A Bright Futures Virginia Web site(www.vahealth.org/brightfutures) was created aspart of the official program launch to highlightthe Bright Futures mission, goals, and activi-

ties. It also served as an information-sharingtool for members of the Bright FuturesAdvisory Group. The site offers links to BrightFutures materials and describes Bright Futuresactivities that have taken place in diverse publicand private settings across the State.

Another product of the official Bright FuturesVirginia launch was the designation of twoBright Futures Coordinators within VDH.These two individuals had served as the co-chairs for the State kickoff and representedstrong champions of Bright Futures. The roleof Bright Futures Coordinator was added totheir existing responsibilities within the HealthDepartment, and there was no additionalbudget attached to their Bright Futures respon-sibilities. In spite of these limitations, however,the Coordinators have succeeding in craftingan annual Bright Futures plan for theDepartment each year. They have integratedBright Futures promotion and activities intotheir other work for the Department, and theyhave managed to obtain funding from theOffice of Family Health Services (TitleV/MCH funding) and from other State andprivate agencies to support training, materialsdissemination, and collaborations promotingthe use of Bright Futures. The fact that the twoCoordinators came from different divisions andrepresented different professional groups (nurs-ing and social work), each with extendedprofessional networks, proved to be an impor-tant asset in promoting Bright Futures.

Equally important, the Bright FuturesCoordinators have been strong advocates forkeeping the philosophy and presence of BrightFutures alive within the State government overtime and across multiple staff changes and



Bright Futures Virginia

GGOOAALLSS

1. Increase family knowledge and skills

regarding health promotion.

2. Train health professionals to incorporate

Bright Futures guidelines, principles, and tools.

3. Develop and maintain community partnerships

promoting the health of children and families.

administrations (e.g., integrating BrightFutures Guidelines into the strategies for reach-ing 18 of the 54 Healthy People 2010State-specific goals). One of the twoCoordinators has remained in that positionsince its inception, integrating Bright Futuresinto all of her activities. For example, she pre-sented the prevention focus of Bright Futuresto colleagues from the Department of SocialServices’ (DSS) child abuse prevention divisionfor inclusion in its 5-year plan.

According to individuals interviewed for thiscase study,3 having designated Bright Futurespoint persons within VDH has been very valu-able, despite the lack of funding for theposition. It has offered them the ability to leadfrom within, which has been important for

promotingBright Futuresimplementa-tion acrossVDH and itsdistricts. Therole has given theCoordinatorsthe opportu-nity to findout whatother agencies

or programs need to improve services andhealth promotion, and the Bright Futuresmaterials have provided a resource to offerthem. The role of Coordinator also has beenuseful for negotiating bureaucratic hurdles(e.g., facilitating approval for printing materi-als). Other key informants note that the

diplomatic and collaborative style of theCoordinators has been an important factor inthe positive contributions associated withBright Futures and the Coordinator positions.

Evolution of Bright FuturesVirginia

Beyond the official State adoption of theBright Futures guidelines, the evolution ofBright Futures Virginia included efforts to dis-seminate the Bright Futures approach andmaterials across the State and provide trainingto help translate the Bright Futures conceptand resources into practical applications. Thissection highlights those efforts and ways inwhich Bright Futures Virginia has evolved toinclude its continued integration into Statepolicies and activities; has reached beyond theHealth Department to other State-level organi-zations; and has been used in efforts toimprove the quality of child health education,outreach, and practice at the local level.

Training

VDH initially focused resources and attentionto training initiatives aimed at spreading theunderstanding and use of the Bright Futuresapproach and materials, both within VDH andat the community level through the Statehealth districts. The two Bright FuturesCoordinators developed multiple training pro-grams and materials (e.g., PowerPointpresentations, materials describing the coreconcepts and competencies of Bright Futures),and they offered numerous training sessionsacross the State. An early example was a multi-day training provided to four-person teams –



3 Note: A list of key informants is provided at the end of this case study.

The State Bright FuturesCoordinators initially

were the onesrepeatedly raising

the question, “How does this fit with

the Bright Futures guidelines?” They knew it was a sign of progress

when others started asking the question

themselves.

comprised of a mix of public health clinicnurses, school nurses, home visitors, dentalstaff members, nutritionists, child safety spe-cialists, and other public health professionals –from 33 of the State’s 35 health districts. Eachteam was required to develop a 6-month planfor implementing Bright Futures in their dis-trict. A followup by VDH at the end of those6 months indicated that 80 percent of thoseplans had been implemented.

The Bright Futures Coordinators developednumerous targeted training sessions to showhow Bright Futures could be integrated intodiverse types of public health practice and out-reach. Examples of training activities rangedfrom summer sessions for regional school nursecoordinators to trainings for public healthnurses, nurse practitioners, nurse child careconsultants, nutritionists, and new employeeswithin VDH’s Office of Family Services.

Multiple training efforts were directed at usingBright Futures as a resource for home visitingprogram coordinators and outreach workersfrom programs such as Healthy Start, theResource Mothers Program, and the ChildHealth Improvement Project. TheCoordinators also developed tabletop displayson Bright Futures that could be used by com-munity groups or in professional meetings toeducate parents and professionals about theBright Futures approach, core concepts, andmaterials.

Bright Futures oral health materials were usedin trainings with dentists and dental assistantsas well as with nondental providers such asnurse practitioners, pediatric residents, pre-school providers, and staff members fromprograms such as WIC and Head Start.Trainings based on the Bright Futures mentalhealth materials were also provided to familylife educators, school nurses, and home visitingprogram workers to help them discuss andscreen for depression and other mental disorders.

In collaboration with the Department ofMedical Assistance Services, the Bright FuturesCoordinators integrated sections on howBright Futures could be used to increase quali-ty and efficiency in the practice setting as partof the training providers received across theState on the Medicaid EPSDT program. Theyalso collaborated with the Department ofEducation, Governor’s Office, and AAP-VA tooffer Bright Futures training and materials toschool nurses during annual school nurses con-ferences and training sessions. They met withrepresentatives from the departments of familypractice, pediatrics, and nursing at the



One of the lessons from all the training that was developed

and implemented by the official Bright Futures Coordinators in Virginia

was the importance of finding a quick and easy way to describe the

program and its philosophy:

OOVVEERRAARRCCHHIINNGG CCOONNCCEEPPTTSS

� Prevention works� Families matter

CCOORREE CCOOMMPPEETTEENNCCIIEESS

� Partnerships� Communication� Health promotion and injury prevention� Education and anticipatory guidance� Time management� Advocacy

University of Virginia and Medical College ofVirginia to develop and distribute the BrightFutures Pediatric Case Studies within these twoacademic medical centers. The twoCoordinators also worked with James MadisonUniversity, using Healthy Start Project funds,to develop a Bright Futures Core ConceptTraining Manual for community health work-ers that was distributed to Resource MotherProgram Coordinators for use with their localstaff. In addition, Bright Futures VirginiaCoordinators have collaborated with thenational Bright Futures Workgroup to seekgrant funding from HRSA to develop distance-learning materials based on Bright Futures foruse by health providers as part of their continu-ing education training.

Public Health Programs andPlanning

Another major area in which there has beenmuch State-level focus has been in the incorpo-ration of the Bright Futures guidelines andresources into Virginia’s public health andhuman service programs and planning.Examples of these from discussions with keyinformants are presented below:

Social Services

� Bright Futures is specifically referenced inState regulations concerning the need toinform physicians and mental healthproviders about the comprehensive servicesavailable through the EPSDT component ofMedicaid.4 The requirements refer directly

to the BrightFuturesguidelinesand under-score the waythey supportEPSDT.Regulationsalso referencethe usefulnessof BrightFutures as amodel for targeting diverse types of healthprofessionals.

� Bright Futures has been integrated into thescreening documentation used to determinechildren’s eligibility for special health needsservices.

� The Bright Futures guidelines and Bright Futures in Practice: Mental Healthhave been piloted with plans for fully incorporating them into the training forstaff members and parents in the foster parent and adoptions programs.

� Bright Futures is referenced as a standardin official memos and manuals of the DSS.

� The Department’s experience and familiar-ity with Bright Futures is seen as an asset tobe highlighted to funders; it is thus integrat-ed into every grant application they submit.

� The Bright Futures guidelines and mentalhealth guide are specifically referenced in theDepartment’s Performance ImprovementPlan for Mental Health Services for FosterCare and Adoption Services.



4 For example, HJ166 references the Bright Futures Guidelines as the frame-work for EPSDT State legislation.

In Virginia, Bright Futureshas been used by anarray of State publichealth and human

services agencies andprograms including

Medicaid, foster care and adoption, mentalhealth and substanceabuse, family services,

school health, oral health, and child care.

Mental Health and Substance Abuse

� The Bright Futures materials are cited as abasis on which to develop mental healthscreening tools; as a resource for the trainingof resource and foster parents; and as a toolfor promoting collaboration between theDepartment of Mental Health, MentalRetardation, and Substance Abuse Services(DMHMRSAS) and the DSS.

� Bright Futures is listed as a resource foreducators and health professionals workingwith children on mental health issues,including nonclinical behavioral health pro-fessionals and community service providers.In his 2005 report to the Governor and theLegislature on the redesign of State mentalhealth services to meet the President’s NewFreedom Act requirements, theCommissioner of DMHMRSAS presentedplans for using the Bright Futures approachto reach families and to promote health, notjust rehabilitation.

� The Bright Futures mental health materi-als are being used as a model to help mentalhealth and substance abuse professionals –who are experienced in working with adults– learn to work with children, adolescents,and families on issues such as child develop-ment, substance abuse, mental disorders,and early intervention.

� Bright Futures has been used as a resourceto help pregnant and parenting women withsubstance use disorders to learn to use med-ical care appropriately for themselves and fortheir children, including such issues as whatto expect during a well-child visit, whattypes of questions to ask, and how to givetheir children medications appropriately.

Oral Health

� The Bright Futures oral health materials,particularly the anticipatory guidance com-ponents, have been integrated into thedesign, training, and application of theState’s Bright Smiles Program, which targetspreschool children ages 0 to 5 years.

� The Division of Dental Health in theOffice of Family Health at VDH and itsstrong Medicaid, local community dentalclinic, and professional dental associationcontacts have used the Bright Futures guide-lines as a tool for successfully promotingincreased State reimbursement rates for oralhealth services for children.

� The Department currently is distributingthe Bright Futures oral health materials topublic schools and trying to integrate oralhealth into the State curriculum andStandards of Learning5 requirements forschool-age children.

Family Services

The Bright Futures guidelines and materials areused as manuals and reminder sheets to helpnurses, nutritionists, and outreach workers talkwith families about their child’s health anddevelopment. These also are seen as offeringlanguage and tips for how to approach sensitivetopics such as safety, mental health, or sexuality.

School Health

� The Bright Futures Coordinators success-fully advocated for the inclusion of



5 The Virginia Standards of Learning for Public Schools reflect the State’sexpectations for student learning and achievement in grades K–12 for subjects including, English, mathematics, science, history/social science,technology, fine arts, foreign language, health and physical education, anddrivers’ education.

information from the Bright Futures materi-als on nutrition and physical activity intothe physical education curriculum for theVirginia State Standards of Learning.

� Virginia’s adoption of Bright Futures as theState standard was used by representativesfrom MCHB, AAP-VA, and theDepartment of Education to argue success-fully for the inclusion of (and Medicaidreimbursement for) urinalysis as a standardrequirement for school health forms whenthese were revised in 2001.

Collaborations Across Departments and Divisions

One of the notable aspects of Bright FuturesVirginia has been the extent to which it haspromoted cross-departmental collaborations atthe State level. With a strong State policyemphasis on building systems of care, numer-ous State-level divisions and departments areworking together more extensively than before,according to key informants. In some cases,

particularlyinvolvingEPSDT andsocial services,cross-depart-mentalcollaboration

is not only necessary due to cuts in fundingbut also is mandated by law. In the face ofthese needs, Bright Futures has been seen as auseful vehicle for helping to conduct intra- andinterdepartmental collaborations. As one keyinformant describes it, the initiative’s focus onprevention, families, and community involve-ment has helped to create the necessarycommon ground. The following examples illus-

trate some of the ways described by keyinformants that Bright Futures has helpedengender State-level collaborations and activi-ties across the departments of health and socialservices:

� Many at-risk clients are served by multiplepublic agencies. Bright Futures has beencredited with offering a way to provide use-ful resources and consistency across thesemultiple agencies and diverse programs. Ithelps to provide a common link betweenareas such as health, recreation, education,substance abuse services, mental health, andsocial services that make up a “system ofcare” for these clients.

� Bright Futures has been used to help pro-mote collaboration around EPSDT acrosseducation, social services, mental health, andother health services for children who are inthe public health system. This cross-depart-mental collaboration is described as creating asynergy, which has been used to help smoothand streamline the integration of mentalhealth and Medicaid/EPSDT services.

� Bright Futures has been used as a standardof care in State legislative activity directing astudy on lead poisoning (GA 2002 SJ65ER),in a Medicaid agency study of EPSDT (GA2002 HJ166), and in the recommendationsfor improving ADHD services (GA 2003HD12). The legislative activity was theresult of AAP members’ advocacy.

� Bright Futures Guidelines have been usedto define the school entry physical exam andto determine if it met criteria to beMedicaid reimbursable.



Bright Futures has helped to provide

consistency across multiple agencies

serving at-risk families.

� The Bright Futures mental health materi-als and the initiative’s comprehensiveapproach are being used to help assembleand integrate formally disparate areas ofactivity within DMHMRSAS. These includechildren’s health, substance abuse, and men-tal health, which involve diverseprofessionals whose areas of activity have notoverlapped traditionally. Bright Futures hasserved as a unifying tool to show how men-tal health, physical health, and childdevelopment fit together as integral parts ofchild health and well-being.

Education and Outreach

Home visiting. One of the effects of the State ofVirginia’s early emphasis on adopting the

Bright Futuresguidelines,disseminatingthe materials,and offeringtraining onhow to usethem has beenthe integra-tion of BrightFutures intopublic educa-tion andoutreachefforts with

families, communities, and individuals whointeract with children. One of the most fre-quent examples has been the use of BrightFutures materials across diverse types of homevisiting and case management programs.

Several individuals interviewed for this studydescribed using Bright Futures as a central toolfor home visiting and case management withat-risk children, pregnant women, and families.The Bright Futures guidelines were cited inparticular as being very useful resources,described in some cases as a “guidebook” or“bible” for home visiting. Informants alsoemphasized the usefulness of tip sheets andfamily materials that could be distributed tofamilies during home visits. Some of the posi-tive attributes of the Bright Futures materialsthat have made them valuable to home visitorsand case managers include:

� Their attractiveness and completeness

� Their availability online or free of charge(through dissemination efforts funded bythe State or MCHB and its partners)

� Their usefulness for helping staff membersto think about issues they otherwise mightmiss and triggering questions when outreachworkers are tired

� The assistance in considering the teenmother’s progress in her own development aswell as that of her infant

� The fact that the Bright Futures materialsoffer home visitors and case workers lan-guage that they can use to discuss particulartopics with families, especially sensitive top-ics such as violence, sexuality, and mentalhealth

� The way the vignettes and descriptions inBright Futures help prepare staff membersfor real-life situations



Home visitors note Bright Futures’

usefulness in talking to clients about their

children’s developmentalmilestones, difficult

topics such as mentalhealth issues and

violence, and longer-term issues related to

their child’s health that families may lose

sight of in the midstof daily crises.

� The fact that the anticipatory guidancehelps reassure families regarding typicalbehaviors and developmental milestonesassociated with the age of their child

� The way the anticipatory guidance helpsfamilies in crisis, who are overwhelmed withissues of daily living, to think about longer-term issues related to their child (e.g., why itis important to read to a baby or stay up todate on immunizations).

Positive youth development programs. The BrightFutures materials on promoting healthy bonedevelopment of teen girls through nutritionand physical activity have been used in a groupeducation and mentoring program for youthages 9–15 years considered at high risk forpregnancy due to having a sibling who is a teenparent. The program also promotes schoolachievement, avoidance of drugs and cigarettes,delay of early sexual initiation, future careerplans, and voluntary community service.

Child care. The Bright Futures Coordinators areworking with the child care providers andHead Start training networks to integrateBright Futures health promotion elements intothe child care setting. This is seen as a promis-ing area for further outreach because of the factthat child care workers are well-poised to inter-act with children and families, see thechildren’s health needs, and discuss with par-ents about their child’s health anddevelopment.

Child health records. The Henrico County pub-lic health district, which serves manyimmigrant families, formed a partnership witha local hospital to create and distribute a plastic

pocket folder that could be used by families tokeep their Bright Futures child health recordthat includes information on immunizationsand other health records.

Museum education. A more unique example of alocal educational initiative involves theChildren’s Museum of Richmond, which inte-grated Bright Futures into some of its childand family enrichment initiatives. The muse-um’s approach targets the whole child withmethods to stimulate discovery, development,and understanding within the context of chil-dren’s families and environments. In the early2000s, the museum signed on as a communitypartner of Bright Futures Virginia and sent arepresentative to serve on the Bright FuturesVirginia Advisory Board. It collaborated withVDH to sponsor family resource fairs andtrainings on child development featuringBright Futures. The museum hosted an eventwith the health department featuring childdevelopment specialist T. Berry Brazelton, andit made Bright Futures materials available in itsFamily Resource Room. Although the muse-um’s focus on Bright Futures was not sustainedover time, it provided a promising example ofhow museums can be effective partners in pro-moting health education in an environmentthat may feel less threatening than a health caresetting to some consumers.

New Parents’ Kit. The Office of the Governorinitiated the development of a New Parents’Kit, distributed to all parents of newborns inhospitals across the State. This kit containseasy-to-understand materials and resources fornew families, including a baby’s first-year calen-dar based on Bright Futures; information on



child safety; abedtime book;a BrightFutures childhealth record;and links to

resources on issues such as child care, healthinsurance, and parenting support. More than110,000 copies of the kit have been producedin English and Spanish and distributed to par-ents all across the State. The State estimatesthat 70 percent of new parents received kits in2005, and Governor Mark Warner proposedallocating an additional $300,000 in Statefunding to continue the program in 2006.Governor Tim Kaine, who just took office inJanuary 2006, is continuing support of the Kit,which fits well with his emphasis on earlychildhood education.

Video for Teens. To address the fact that themajority of teens do not access regular healthcare supervision visits, the Bright FuturesVirginia Coordinator is in the process of devel-oping a video by teens for teens. It promotesan understanding of prevention and seekingregular health care, working in partnershipwith a health care provider, being an advocatefor oneself, and the concept of time manage-ment during office visits.

Private Practice

AAP-VA. The State’s efforts to promote the useof Bright Futures have been greatly boosted bythe active endorsement and promotion ofBright Futures on the part of AAP-VA. TheChapter includes information and updates onBright Futures in its newsletters to members

and invites the State Bright FuturesCoordinators to give presentations at the orga-nization’s semiannual meetings andpresentations to other groups. AAP-VA collab-orates with Bright Futures champions acrossthe State in statewide and national policy plan-ning meetingsand efforts. TheAcademy hasbeen an instru-mental ally inthe promotionof the BrightFutures standards in Medicaid reimbursementsand school health requirements and also hashelped to ensure smooth partnerships withAAP members in academic health institutions,such as in the development of the Web-basedtraining modules.

Individual practices. Individual pediatricianshave introduced Bright Futures materials andintegrated its concepts in quality improvementefforts and in developing medical homes.

Partnerships with schools. Another area inwhich private health practitioners have usedBright Futures as a resource has been in theirwork with school systems to develop IndividualEducational Plans for special-needs children orin the development of school health activities.

Training for Health Care and OtherProfessionals

Training medical residents. Several key inform-ants interviewed for this study underscored theimportance of integrating Bright Futures intothe training of future providers as an effective



The Governor’s Officespearheaded

development of a New Parents’ Kit that features information from Bright Futures.

The Virginia AAP Chapterhas been an active

and influential Bright Futures partner.

way of encouraging its use in clinical practice.Representatives of the Virginia CommonwealthUniversity Medical School engaged in trainingresidents and health professional students with-in the academic medical center contextexplained that they saw Bright Futures as anexcellent way to teach preventive care and tomodel the types of interactions future providerscan expect to encounter in the practice setting.They noted that many residents, for example,are trained within a hospital setting where thefocus is mainly on acute and emergency care.As a result, they receive little exposure to thetype of primary and preventive care they arelikely to encounter in a private pediatric orfamily practice.

The Bright Futures materials, including theguidelines, vignettes, and anticipatory guid-ance, were seen as a useful tool for helping toprepare residents for that setting. In particular,the key informants cited the usefulness of theBright Futures pocket guides as teaching toolsfor helping residents learn how to conveyinformation to parents. They explained thatone important challenge that residents face isfiguring out how much information to giveparents without overwhelming them and with-in a short office visit. The pocket guides offerexamples of how to focus on a few essentialpieces of information that can be conveyed toindividual families and tailored to their needs.The Virginia Commonwealth School ofNursing has used the Bright Futures materialsin its education of nurses for more than 5 years– noting that it is especially useful for commu-nity-based nurses.

However, in spite of the value of BrightFutures in the preprofessional training context,

key informants noted that its use does notseem to be widespread across the State’s multi-ple health care professional schools.

Web-based training modules. Another major ini-tiative of Bright Futures Virginia that targetsthe training of health care professionals hasbeen the development of a set of six Web-basedtraining modules that incorporate the BrightFutures guidelines and anticipatory guidancewith EPSDT services for children and teens.These have been the product of a major collab-oration that hasbrought togeth-er a number ofthe State’s keyBright Futureschampions,includingVDH’s twoBright FuturesCoordinatorsand representatives from AAP-VA, the StateMedicaid Office, and the Virginia Common-wealth University Medical School. The teamalso has used a medical writer and graphicdesigner to help develop these modules.

The primary audience for these training mod-ules consists of pediatricians, family practicephysicians, nurse practitioners, physician assis-tants, Medicaid providers, community healthcenters, clinic nurses, nutritionists, school nurs-es, social workers, dentists, and unlicensedassistive personnel. The project’s secondaryaudience includes pediatric, nursing, and nutri-tion students. The modules address thefollowing topics:



The State launched a Bright Futures

Web-based training module for health care

professionals developedin collaboration

with public and private partners.

� Overview of Bright Futures

� Developmental assessments

� Medical assessments, immunizations, andscreenings

� Anticipatory guidance

� Integrating Bright Futures into the prac-tice setting

� Reimbursements for well-child visits

� Materials for families.

Each 30- to 45-minute module provides train-ing on well-child exams and access to screeningtools and informational materials that can behanded out to parents. It also provides links toother sources of information and materials. It isexpected that, along with serving as a usefulprofessional education tool, the modules willfurther energize the Bright Futures Virginiacampaign. The modules are available online atwww.vcu-cme.org/bf.

Examples of Other Applications of Bright Futures in Virginia

In addition to the way Bright Futures has beenintegrated into public health policy and prac-tice, education, and training described above,key informants cited a number of other ways inwhich Bright Futures is being used in healthcare, educational, family, and community set-tings across the State.

Child care licensing. The Healthy Child CareAmerica Project in Virginia uses the BrightFutures guidelines as part of the State registra-tion process for child care providers and the

training of the child care nurse consultants sta-tioned at local health departments. It is part ofthe core curriculum of the training throughwhich child care providers must go to becomeregistered. It also is a tool that licensing agentsuse during child care inspections to helpincrease the comfort level of child careproviders in addressing and discussing childhealth issues. In addition, licensing staff mem-bers use the Bright Futures materials as aresource to help guide child care providers onhow to implement quality improvements whentheir level of care does not meet the requiredstandard.

Head Start. Head Start developed a HealthyStart toolkit that was distributed to child carecenters (including family home care and faith-based centers) and includes Bright Futuresmaterials. Ten thousand of these kits have beenproduced. There is an 8-hour, four-part train-ing that is required to obtain the toolkit, whichincorporates much of the philosophy, text, andmaterials from Bright Futures. The toolkitfocuses on preventive health, the environment,nutrition, immunizations, lead poisoning,SIDS, shaken baby syndrome, asthma, andmore. There are also plans to incorporateBright Futures mental health materials into thistool kit. Key informants note that there is agreat demand for these types of materials inSpanish.

Improving the quality of assessments for ADHD.

The President of AAP-VA participated in thedevelopment of a new assessment tool to screenchildren for ADHD. This was in response toconcerns raised in the State legislature that therates of children diagnosed and medicated for



ADHD were too high (e.g., 26 percent of boysin Norfolk, VA, had been diagnosed as havingADHD). They developed and pilot-tested aBright Futures-inspired assessment tool toinform providers, teachers, and others whointeract with children how to identify childrenwho may need to be screened for ADHD.

Challenges

The individuals interviewed for this case studycited numerous examples of challenges theyencountered in implementing Bright Futures.Equally important, they shared numerousstrategies that could be used to address thesechallenges, which also are incorporated in thissection.

Training. One of the most commonly citedchallenges had to do with developing and pro-viding Bright Futures training to public healthprofessionals, health care providers, and otherswho work with children. Several respondentscommented on the absence of a national train-ing module to accompany the Bright Futuresprogram and materials. Also lacking, they said,was simple guidance to help explain the variedaspects of Bright Futures: the underlying phi-losophy, the guidelines, and the sets ofmaterials for different audiences of providers,trainers, teachers, parents, and so forth. Twoindividuals mentioned having seen a videotapeproduced by Henry Bernstein of the BrightFutures Health Promotion Workgroup,6 featur-ing some of the original authors and mindsbehind Bright Futures. Although they foundthis videotape to be very useful, they noted it

was difficult to come by and not well-known.

Several individuals interviewed for this studywere unaware of any centralized communica-tions or information sharing structure in placeto share resources and training tools regardingBright Futures. As a result, they complained ofhaving to reinvent the wheel in terms of train-ing. They noted that there had been somediscussion between State-level Bright Futuresproponents in Virginia and in WashingtonState to work together on training, but theseinitiatives had faltered due to staff and fundinglimitations. The call for greater investment andcoordination surrounding training for BrightFutures was a common theme across the State,particularly among program managers eager touse Bright Futures more fully with their staffand activities.

Translating policy changes into changes in prac-

tice. Although the official adoption of BrightFutures as the State child health supervisionguidelines has gone a long way toward integrat-ing Bright Futures into the policies andactivities of VDH, getting individuals to trans-late this into practice remains an importantchallenge. Individuals working at both theState and District levels commented that, evenwith the State’s official adoption of BrightFutures, this news has not trickled down sys-tematically to the regional and local levels.Moreover, without the ability to sustain thetype of effort, resources, and attention thataccompanied the official launch of BrightFutures Virginia, institutional memory is lostover time and awareness dissipates. As oneState employee put it, “As people move around,if you don’t write it down, it gets lost.”



6 http://www.pediatricsinpractice.org/faq.html

In some cases, State staff members deliberatelychose not to adopt Bright Futures into practicein spite of the mandate. For example, in oneState Health District early efforts to use BrightFutures were purposely hindered by key staffmembers opposed to the idea of change. As aresult, it was not until there was a change ofleadership in that district that Bright Futureswas introduced and implemented. In addition,there has been an unevenness of use of BrightFutures by different divisions even within theOffice of Family Health Services, as some man-agers have not felt that the Bright Futuresmaterials were directly related to their particu-lar service area.

The Bright Futures Coordinators explain thatthey feel it is incumbent upon them to stay

alert to oppor-tunities inwhich BrightFutures mayassist the workof particularprograms andto foster cham-pions withindifferent officesand programs.Thus, for exam-ple, they seizeopportunities tointegrate Bright

Futures when educational materials are beingdeveloped or revised or when there is a chanceto have materials translated into diverse languages.

Staff turnover. One of the great challenges inVirginia has been ensuring the life and sustain-ability of Bright Futures over time and in theface of staff changes within VDH. Many earlytraining and dissemination efforts aroundBright Futures have been lost due to changes inpersonnel. For example, the entire VDH com-munity nutrition team in Richmond hasexperienced a 100 percent turnover since theeffort was made to train them to use the BrightFutures nutrition materials. The new staff per-son who was assigned to become a BrightFutures liaison for nutrition was just about tolaunch new initiatives when she was deployedto Iraq. Similarly, much of the effort that wentinto developing a mental health training cur-riculum based on Bright Futures was lost whenone individual who had been instrumental inits design and presentation left for a new joband others moved in different directions. Thus,staff changes can carry costs in terms of bothinstitutional memory and resources.

However, staff changes have not resulted alwaysin a net loss for State Bright Futures initiatives.In some cases, proponents of Bright Futureshave taken their knowledge of the program’sbenefits and successes with them to newdepartments and agencies, promoting greatercross-fertilization. For example, when oneBright Futures champion moved from theDepartment of Mental Health, where she wasinvolved in developing a training curriculumaround the Bright Futures mental health mate-rials for school nurses, substance abuseproviders, and community mental healthproviders, she took that experience with her toa new position in the DSS. There she high-lighted ways Bright Futures could be



“It is not enough to saythat Bright Futures is the standard of care.

The State needs to make certain that

the news gets out, theexpectation is made

known, and that peopleacross the State

understand that they are expected to adopt

Bright Futures.”–DISTRICT ADMINISTRATOR

incorporated in her work with foster childrenand adoptive families. She introduced BrightFutures to her colleagues and became a BrightFutures point person within the division.

In a similar example, a staff person who hadpreviously used Bright Futures in her workwith substance-using women and their depend-ent children introduced Bright Futures into hernew position within the Department of MentalHealth. There she has been instrumental inhelping to integrate the Bright Futures mentalhealth materials with efforts aimed at trainingsubstance abuse and mental health providers towork more effectively with families, children,and adolescents.

Within the Department of Health, the firstBright Futures Co-coordinator moved into thePediatric Screening and Genetic Services, unitwhere she continues to use Bright Futures. Forexample, she has raised questions about how touse Bright Futures materials with expectantparents and in interviews related to familymedical history. Those questions have led tothe development of the Bright Futures VirginiaChild Health Record.

Staff changes within the Medicaid departmentare reported to have brought new energy andsupport for Bright Futures. In that case, BrightFutures has been well-integrated into policiesand regulations regarding areas such as EPSDTand children with special health care needs, andthe influx of new leadership within the depart-ment is reinvigorating the weaving of BrightFutures into policy and program planning.

Promoting change within the practice setting.

Although AAP-VA promotes Bright Futuresuse in pediatric practice and e-mails articles

and materials on the initiative to its 800 chap-ter members across the State, intervieweessuggest that it is not easy to get individuals inprivate practice to buy into a new project orchange their habits. Similarly, individuals fromthe State and County Health Departments alsodescribed difficulties convincing public healthstaff members to adopt new forms or materialsbased on Bright Futures. In both the publicand private practice settings, key informantscautioned that it was important to introducechange incrementally with time for buy-infrom staff. They suggested that any newmethod of doing business must bring addedvalue in an easy-to-use fashion without disrupt-ing the practice flow.

For example, in one setting the use of newclinical forms, based on Bright Futures, provid-ed a way to document visits to meetrequirements for insurance audits – recordingwhat takes place in a well-child visit, includingdevelopmental milestones and anticipatoryguidance. The forms were ultimately also rec-ognized asbeing useful forimproving serv-ice delivery byadding greaterefficiency andaccuracy inpatient records.In a county-level publichealth setting,the introduc-tion of newintake forms was made easier when staff dis-covered these were simpler to use, inexpensive,easy to adopt without having to duplicate old



“To adopt Bright Futuresacross a busy

practice, you have toacknowledge that

practitioners all have their own practice

styles. To implementchange, you must findconsensus and matchthose practice styles.”

– PEDIATRICIAN, PRIVATE PRACTICE



records, and useful for improving consistencyacross patient visits and different practitioners.

Costs. A commonly cited limitation, particular-ly among local public health programs, was thecost of obtaining Bright Futures materials. Theability to obtain free or low-cost materials –especially ones that can be distributed to fami-lies – was on the “wish list” of several of therespondents.

Lessons Learned

Numerous important lessons can be gleanedfrom the Bright Futures Virginia case studyregarding the use and integration of BrightFutures within public and private settings atboth the State and local levels. These lessonsinclude the following:

Champions are critical. Bright Futures Virginiahas benefited greatly from the presence of pro-gram champions within the State HealthDepartment, State Health Districts, AAP-VA,academic training institutions, private practice,and community entities. In addition, the desig-nation of the State Bright Futures Coordinatorshas supported the ongoing work of two State-level point persons in actively marketing BrightFutures, developing targeted training fordiverse public health staff members, and help-ing to coordinate intragovernmental orpublic/private partnerships to expand the useand value of Bright Futures in practice.

Take advantage of periods of change. Periods ofchange offer natural opportunities for intro-ducing and integrating Bright Futures, such asresponding to the need for new State child

health guidelines or for new forms to meetEPSDT or insurance auditing needs. Staffchanges at the State or local level or within apractice setting also can offer the chance tointroduce or renew interest in Bright Futures.

Bring added value to existing programs or prac-

tices. In the face of financial pressures and timeconstraints, it is unrealistic to expect staffmembers to adopt new practices unless thesecan bring a clear added value to their work. Forexample, in several instances the acceptance ofnew patient encounter forms, based on theBright Futures guidelines and anticipatoryguidance, was due to a recognition that theforms were easier to use than prior ones, savedtime, and ultimately improved service deliveryby adding greater efficiency and accuracy inpatient records.

Use Bright Futures as a policy tool. Because theBright Futures guidelines reflect the acceptedstandard of care of major health professionalorganizations such as AAP, they can be used asa framework for promoting policy changes –for example, ensuring that EPSDT screeningsand reimbursements reflect the guidelines orthat school health forms include the develop-mentally appropriate recommended screenings.With the State’s formal adoption of BrightFutures as the official child health standard,VDH, AAP-VA, and others have been able tosuccessfully argue for its inclusion in State reg-ulations, performance improvement plans, andprogram planning.

When working at the local level or within an indi-

vidual practice setting, introduce Bright Futures

as a resource rather than as a mandate. In con-trast to the effectiveness of a State mandatewithin State health policies and agencies, at thelocal level, the presentation of Bright Futures asa resource draws a more favorable responsefrom people on the ground, especially thoseworking in financially strapped programs. It isparticularly effective if they can identify waysin which Bright Futures can fill gaps.

Integrate Bright Futures into health professional

training. Key informants from both the publichealth and private practice settings pointed outthat getting Bright Futures into the preservicetraining of health professionals is an effectiveway to spread its use and influence. They alsonoted that it is far easier to train medical andother health professional students to use BrightFutures than to get practitioners to changetheir ways of working.

Take advantage of creative opportunities for

spreading the understanding and use of Bright

Futures. For example, numerous sites inVirginia are introducing Bright Futures in thechild care setting either through training or asa tool for quality control and licensing, becausechild care providers are well-placed to interactwith children and families around issues ofhealthy development. Several respondents citeduseful existing networks and e-mail lists thatcould serve as good communication vehiclesaround Bright Futures initiatives. For example,AAP-VA has a strong network of providermembers accessible through e-mail lists andnewsletters, the Healthy Families Program haseasy access to local sites and a ready-made net-

work in which to promote Bright Futures, andoral health specialists have a national commu-nications link through the National Maternaland Child Oral Health Resource Center.

Sustainability of Bright Futures Virginia

The national process evaluation of BrightFutures7 revealed that there are several keycomponents necessary for developing and sus-taining Bright Futures in States andcommunities. All of these components are pres-ent in the case of Bright Futures Virginia, andthey have helped to ensure a continual presenceof Bright Futures within efforts to improve thequality of health and social services for childrenand families at the State and community level.Specifically, these components include the following:

� Time. Bright Futures was officially adoptedby the State in 2000 and has had time toexpand incrementally across State agenciesand programs, as well as within community,academic, and practice settings. The chal-lenge remains to sustain interest in the coreconcepts of Bright Futures across changingtimes, administrations, and staff.

� Training. This was a key area of focus byState administrators and planners followingthe official adoption of Bright FuturesVirginia. Proponents of Bright Futures with-in the Departments of Health, MentalHealth, and Social Services continue toapply for funds and develop new methodsfor training providers and individuals who



7 This report is available electronically at http://www.hsrnet.com/brightfutures

work with children to incorporate the BrightFutures materials into their work.

� A sustained commitment. Early on, BrightFutures Virginia benefited from the sus-tained commitment of major leaders,including the Nursing Council, State HealthCommissioners, and agency heads. The pro-gram’s comprehensiveness and its focus onfamilies, communities, and prevention havebeen central to maintaining sustained supportfrom top-level administrators, including thecurrent Governor, AAP-VA, agency heads,and numerous champions across the State.

� Champions. Bright Futures Virginia hasnumerous champions at the State, regional,and local levels. These champions representa multitude of areas of focus ranging frompublic health to academic medicine, privatepractice, social services, professional associa-tions, schools, and local organizations.Within the State government, the personwho has served in the role of Bright FuturesCoordinator since its inception has played acentral role in developing Bright Futuresacross the State. She has used training, out-reach, consistency, and creative strategies toeducate people about Bright Futures andintegrate the program across multiple activi-ties and players. Her connections with andsupport from other champions in the Statehas led to continued cross-fertilization andcollaborations to develop tools and trainings,submit grant applications, and create newproducts such as the Web-based trainingmodules for health professionals.

� Bringing added value. In Virginia, BrightFutures has provided a framework for

improving quality standards, consistency,and efficiencies in policy and in practice.

The official adoption of Bright Futures as theState guideline and the widespread incorpora-tion of components of Bright Futures withinState goals, plans, and policies have gone a longway to help sustain and expand the program inVirginia. Nonetheless, Bright Futures Virginiawill continue to face challenges related to nego-tiating funding constraints, expanding trainingopportunities, confronting resistance tochange, facing staff and priority shifts, andneeding to maintain fresh interest in the pro-gram – even among its champions. Aninteresting example of this last point emergedfrom the case study discussion with a group ofBright Futures champions from a countyhealth department. This group noted that tak-ing part in the case study interview was itselfan opportunity for them to feel re-energizedabout the program. The discussion promptedthem to consider the value of reconvening agroup to talk about common challenges, strate-gies, resources, and ways they are each usingBright Futures.

Future Directions for Bright Futures Virginia

The individuals interviewed for this study indi-cated several areas of focus for future directionswith Bright Futures. Among the more immedi-ate of these were efforts to obtain Federal grantfunding to further expand and develop trainingaround the Bright Futures mental health mate-rials; the updating and dissemination of theWeb-based modules for the training of healthprofessionals; and further integration of Bright



Futures in the activities of the Departments ofMental Health, Social Services, and Medicaid.

Participants in this case study also noted areasof growth in which they would like to seeBright Futures evolve. One of these was tomake further use of electronic technologies.For example, VDH just has issued a request forproposals to develop electronic health records –providing an opportunity to consider how toinclude Bright Futures in the process. Otherpotential examples include helping individualsshare information and resources about BrightFutures across the country, expanding the use

of BrightFutures as ateaching toolwith families(e.g., touch-screeninformationbased on BrightFutures in wait-

ing rooms), and expanding its use with medicalstudents (e.g., electronic versions of the pocketguides that can be loaded onto a PDA).

Another future direction that was noted wasthe need for greater communications mecha-nisms about Bright Futures, including nationalmeetings, Web-based exchanges, and otheropportunities to share ideas and resources.Respondents cited listservs and networks inwhich they worked and said they would like tosee more opportunities to share information,for example, on which schools of nursing orsocial work are integrating Bright Futures intotheir training and curricula.

On the wish list of the Bright FuturesCoordinators was the desire to develop the

family and community components of BrightFutures more fully. One idea that was sharedwas the possibility of establishing connectionswith family and community organizations,such as the Parent-Teacher Association oryouth organizations. Another idea was to useBright Futures as a resource regarding schoolnutrition. The Federal Child Nutrition Actreauthorization requires all local school districtsby fall 2006 to initiate a school wellness planpromoting healthy nutrition and physical activ-ity and evaluating the results. Bright Futurescould be integrated into this effort and pro-moted by school nurses and pediatricians.

Further opportunities have been cited for usingthe Bright Futures concepts as the new admin-istration under Governor Kaine promotes earlychildhood education, as the State Board ofHealth promotes a plan to decrease the humanand financial costs of chronic disease throughprevention, and as the new VDH position ofWomen’s Health Coordinator develops programs.

Conclusion

The extent and long-term range of BrightFutures within VDH and across the State ismore extensive than in most other States acrossthe Nation. This has been due largely to theadoption of Bright Futures as the official Statestandard of child health care and to the exis-tence of important champions within VDH. Itis also a reflection of the unusual degree ofcross-agency and cross-departmental collabora-tion that has taken place at the State levelaround Bright Futures frameworks and activi-ties. In addition, there have been importantchampions, allies, and partners outside of the



“It takes personal commitment and

connections to keepchampioning a program

like Bright Futures.”—BRIGHT FUTURES CHAMPION

IN VIRGINIA

State government, including key members ofAAP-VA, whose contributions have furtherstrengthened the reach and impact of BrightFutures in Virginia.

It is important to note, however, that theefforts of Bright Futures champions in Virginiahave not been as smooth and comprehensive asthey might have wished, especially at the dis-trict and local levels. Instead, they have had toseize individual opportunities and target specif-ic areas of focus as a function of funding,staffing, and other considerations. However,the efforts and activities of Bright FuturesVirginia come together in a great patchwork,which is indeed extensive and accuratelyreflects the multiple and diverse aspects ofBright Futures itself.





Bright Futures Co-coordinators

CCaatthheerriinnee BBooddkkiinnProgram Manager, Resource Mothers ProgramDivision of Women’s and Infants’ Health, VDH

SShheerrrryy SShhrraaddeerrSchool Health Nurse Specialist, Division ofChild and Adolescent Health, VDH

Additional State- and Local-Level Key Informants

LLiissaa AArrmmssttrroonnggNutrition Manager, Division of WIC &Community Nutrition Services, VDH

DDoorraa BBuuttlleerrTechnical Assistance and Quality AssuranceSpecialist, Healthy Families Virginia

BBrriiaann CCaammppbbeellllEPSDT Coordinator, Department of MedicalAssistance Services

PPaammeellaa FF.. CCooooppeerrDivision of Family Services, Virginia DSS

KKaarreenn CC.. DDaayyDirector, Division of Dental Health, VDH

LLeesslliiee EEllllwwooooddPresident, AAP-VA, Chief of Pediatrics, KaiserPermanente Northern Virginia Area

AAllllaann FFrriieeddmmaannProfessor and Chairman, Division of GeneralPediatrics, Virginia Commonwealth UniversityMedical Center

BBeetthhaannyy GGeellddmmaakkeerrRepresentative, Healthy Child Care America,Program Director, Early Childhood Health, VDH

SSttaacceeyy HHiinnddeerrlliitteerrDirector of Pediatrics, Central Virginia Health District

PPaamm KKiinnggSenior Public Health Nurse, Immunizations ,and Home Visits, Arlington County HealthDepartment

CCoolllleeeenn KKrraafftt(will be AAP-VA President in July 2006)Private-practice physician

MMaarrtthhaa KKuurrggaannssOffice of Child and Family Services, VirginiaDMHMRSAS

LLiinnddaa MMeellooyyFaculty Advisor, Division of General Pediatrics, Virginia Commonwealth University Medical Center

CCiinnddyy MMiilllleerrNurse Supervisor and MCH Coordinator, Russell County Health Department

TThheerreessee PPaannaaggiissWIC Supervisor, Arlington County HealthDepartment

VViirrggiinniiaa SSaallbbPublic Health Nursing Supervisor, CaseManagement and Outreach, Arlington CountyHealth Department

JJuuddyy SSmmiitthhCoordinator, Jefferson Area ComprehensiveHealth Investment Project

TThhoommaass SSuulllliivvaannImmediate past President, AAP-VAPrivate-practice physician

SSuussaannnnee ddee llaa TToorrrreeResource Mothers of Arlington (located in the Arlington County Health Department)

PPaatt WWoollllaarrddClinical Supervisor, Child Health, ArlingtonCounty Health Department

Key Informants

Washington’sBright Futures Story

Marisa Ferreira, M.P.H., R.D.Rebecca Ledsky, M.B.A.

Introduction

Washington State uses Bright Futures in abroad variety of ways to support health promo-tion and health education activities designed toimprove children’s health and well-being. Infact, Washington State’s Bright Futures initia-tive is quite unique, in that the State hasdemonstrated ongoing commitment to fundingBright Futures activities, has retained a majoruniversity to provide leadership for BrightFutures activities, and most recently hasreceived a Congressional earmark that has posi-tioned Bright Futures further at the forefrontof health promotion in the State. This casestudy provides a detailed description of howthe Washington State Department of Health’s(DOH) Office of Maternal and Child Health(OMCH) initiated the use of Bright Futuresand how its utilization has evolved over time.The primary source of information used towrite this case study was a series of key-inform-ant interviews conducted during spring 2005.The case study also draws on findings from aprocess evaluation conducted in 2002.


The OMCH, part of the DOH’s Communityand Family Health Division, maintains a mis-sion “to promote a community that supportsthe health of women (especially pregnantwomen), infants, children, adolescents, andchildren with special health care needs(CSHCN).”1 One of several programs housedwithin the OMCH is the Child andAdolescent Health (CAH) section. It is thissection that has spearheaded Bright Futuresefforts within the State.

Although OMCH is the primary entity withinthe State health department to facilitate BrightFutures use and promotion, it contracts with theUniversity of Washington (UW) to take a leadrole in spearheading Bright Futures activities onits behalf. At the time this case study was con-ducted in 2005, the contract between the DOHand the UW was in its sixth year.


A combination of events occurring over a sev-eral-year period between the late 1990s andearly 2000s contributed to the introduction ofBright Futures implementation across theState. During this time, the focus of the States’health districts shifted away from the provisionof direct care to a more population-basedfocus, which resulted in a redefinition of therole of public health. Within this context, theOMCH was awarded a State SystemsDevelopment Initiative (SSDI) project grantfrom the Federal Government, whose goal wasto “facilitate the development of State-levelinfrastructure which would, in turn, supportthe development of systems of care at the com-munity level.” 2 The development of BrightFutures activities at the State level was alsoinformed by the experiences of one of its coun-ties, which had used Bright Futures as afoundation for community health improvement efforts.

SSDI Program Initiation Activities

The SSDI program, funded by the FederalMaternal and Child Health Bureau (MCHB),was designed to complement the Title V/MCH

Health Systems Research, Inc. Washington’s Bright Futures Story Page WA-1


1 http://www.doh.wa.gov/cfh/mch/default.htm2 http://hmecbp.org/resources/workshop2/SSDI%20Grant%20Guidance%20Summary.pdf

Block Grant Program and to strengthen thecapacity of the State MCH and CSHCN agen-cies. After being awarded an SSDI grant, theDOH assembled a group of stakeholders fromthe MCH community to determine the rolethe OMCH would assume with regard toensuring the quality of health care in the con-text of health care reform and the shift in therole of the local health districts.

Bright Futures: Guidelines for HealthSupervision of Infants, Children, andAdolescents was introduced by an MCH publichealth nurse consultant who had learned aboutthe guidelines when the materials were firstpublished in 1994. At that time, while she rec-ognized the usefulness of the guidelines inpromoting health and wellness, the OMCHdid not have the capacity or resources to pro-mote the Bright Futures initiative. However,with the advent of the SSDI grant award, anew opportunity for implementing BrightFutures was presented and the MCH stake-holders began to explore how the utilization ofBright Futures could contribute to health pro-motion efforts in the State. Although themajority of stakeholders agreed to support theuse of Bright Futures in promoting the healthof children and adolescents, concerns wereexpressed by a small group of pediatricians whofelt that Bright Futures was the “Cadillac” ver-sion of health supervision and thereforeimpossible to implement. The group of assem-bled stakeholders also discussed the importanceof involving partners with sufficient capacity tosupport implementation of Bright Futuresactivities.

Whatcom County Bright FuturesProject

In addition to the SSDI award, the use ofBright Futures in Washington was facilitatedby a grant awarded by the CommonwealthFund to the Washington Medical AssistanceAdministration of the Department of Socialand Health Services (DSHS). The purpose ofthe grant was to improve Medicaid/Early andPeriodic Screening, Diagnosis, and Treatment(EPSDT) services for children from birththrough age 5 by developing an interdiscipli-nary model of early child health anddevelopment services through partnershipswith family practice and pediatric physicians,agency providers, and other children’s servicesproviders.

DSHS offered communities an opportunity toapply for funds through this grant to supportBright Futures efforts at the local level.Whatcom County applied for and receivedfunding through this grant to implement theWhatcom County Bright Futures Project,through whichseveral pilot sitessuch as Tribalhealth centersand Head Start,with staff mem-bers who workdirectly with families, were funded to incorpo-rate Bright Futures. Funding was providedfrom 2000 to 2003. During this time, a coun-ty-level Bright Futures Coordinator was hiredto facilitate the project, a developmentalscreening workgroup was convened to developrecommendations for screening practices andthe use of Bright Futures materials, and Bright



The Whatcom CountyBright Futures Project provided a foundation

for broader State Bright Futures efforts.

Futures pocket guides and encounter formswere purchased for use within the pilot pro-grams. The Whatcom pilot also conductedtraining for staff members from the pilot siteson how to use the Bright Futures materials.

Based on these efforts, Whatcom Countyserved as a model for the rest of the State onhow to bring together community partners andaddress public health concerns using the BrightFutures approach. Unfortunately, however,with the end of the grant in March 2003, theproject officially concluded, and due to lack offunding, many of the Bright Futures activitiesalso ceased.

In summary, as a result of the activities ensuingfrom the SSDI and Commonwealth grants,partnerships at both the State and local levelswere formed and the Bright Futures seed wasplanted. Bright Futures was integrated intomany programs and has continued to grow.Descriptions of these partnerships and the vari-ous ways in which Bright Futures is beingimplemented follow.

Evolution of Bright Futures

The DOH-UW Partnership

Based on the experiences described above, theState of Washington decided to make a com-mitment to develop Bright Futures effortsfurther. Recognizing that the resources neces-sary to move forward with this work wouldextend beyond its current capacity, the DOH-OMCH looked to the University ofWashington for assistance.

Building on an existing contract with the UW’sCenter on Human Development and Disabilityto manage the Medical Home LeadershipNetwork for CSHCN project, the OMCHenhanced the contract to include the manage-ment ofStatewide BrightFutures activi-ties. Thisarrangementbegan in FederalFiscal Year2000–2001 andis currently inits sixth year.Over this time,a total of $282,000 has been awarded byOMCH to UW for Bright Futures activities,all of which has come from the State’sTitle V/MCH funds or other MCHB-adminis-tered grant programs. As described later, thesefunds were supplemented in the fifth projectyear with a $465,000 Congressional earmarkfor Bright Futures activities. A detailed break-down of funding sources, amounts, andtimeframes allocated to UW for State BrightFutures activities is presented in the appendix.

In the early contract years, one part-time staffmember was engaged to provide technical assis-tance to those in the State interested inpursuing the utilization of Bright Futures toimprove health promotion. In 2004, staffingwas increased to two part-time UW staff members.

In the beginning, there was a lack of clarityabout the targeted audiences for Bright Futurespromotion and the specific direction the tech-nical assistance should take. Therefore, UW



The State health department contractswith the University of

Washington to carry outBright Futures activities

including outreach, training, and technical

assistance to local programs.

staff members coordinated a range of BrightFutures promotional activities to introduce anddisseminate Bright Futures materials broadly.Activities included the provision of education,training and technical assistance, and the con-duct of presentations regarding Bright Futuresat Statewide conferences. Other importantactivities have included:

� Promoting Bright Futures in the field. In aneffort to develop models of how local pro-grams could use Bright Futures materialseffectively for health promotion, the UWfunded seven Bright Futures DemonstrationProjects. Community programs were invitedto develop a demonstration project to imple-ment and measure Bright Futures activitiesfor a period spanning 9–10 months. Theefforts were supported with a small stipendof either $1,000 or $500. The seven agen-cies that applied were all funded: threeprograms were funded at the $1,000 level,and four were funded at the $500 level. Allseven projects additionally received ongoingtechnical assistance and support from staff atthe UW.

� Developing electronic communications

mechanisms. Additionally, UW staff mem-bers worked to develop electroniccommunication capabilities in an effort to

keep BrightFutures playersconnectedthroughout theState. An elec-tronicnewsletter andlistserv have

been developed and maintained. A StateBright Futures Web site is currently underdevelopment, an idea that stemmed fromthe implementation of the Bright Futureslistserv. The Web site will be designed tohighlight Bright Futures projects across theState and to promote partnerships throughthe sharing of ideas and information. It willbe a component of the DOH Web site andtherefore accessible to a wide audience.

Through these efforts, word began to permeatein various arenas, and Bright Futures utiliza-tion gained momentum. In interviewing keyinformants, examples of how Bright Futureshas been utilized as a result of this initial effortwere described. These are presented below,organized into categories describing the use ofBright Futures in academic training programs,other training activities, and by State agenciesand other partner organizations.

Integration of Bright Futures intoAcademic Training Programs

A benefit of having the UW as a major BrightFutures partner was the close proximity andongoing relationships between the contractedBright Futures staff members and other univer-sity staff members. These relationships fosteredthe use of Bright Futures materials as part ofcurricula in university-based higher educationand advanced training programs within andbeyond the UW. These included the UW’sSchools of Nursing, Public Health, andMedicine; MCHB-funded training programs;and the Washington State University College ofNursing. Examples of how Bright Futures has



An electronic newsletterand listerv help to

disseminate informationabout Bright Futures

activities and resources. A State Bright FuturesWeb site is currentlyunder construction.

been utilized in academic training programs areprovided:

� The Family and Child Nursing Program

of the UW School of Nursing. Bright Futures:Guidelines for Health Supervision andBright Futures in Practice: Mental HealthPractice Guide and Toolkit was seen bySchool of Nursing faculty as a valuableteaching tool to use with both students andpatients. Subsequently, a mini grant waswritten and the program received fundsfrom Bright Futures Washington to developshort videos demonstrating the BrightFutures Core Concepts of Partnership,Communication, Health Promotion/IllnessPrevention, Time Management, Education,and Advocacy.3 The videotapes review therole of pediatric nurse practitioners in well-child visits of young children. Thevideotapes are useful for demonstration ofthe application of Bright Futures conceptsand have helped to raise awareness of BrightFutures in the UW School of Nursing.Bright Futures tools developed at theNational and State levels (e.g., Family TipSheets, Adolescent Health Fact Sheets) arealso introduced in nurse practitioner coursesthat are taught at the UW. One key inform-ant described the usefulness of BrightFutures materials to nurse practitioners bystating her belief: “Primary care physiciansdon’t have the time to fully address healthsupervision with parents, and nurse practi-tioners do.”

� MCHB-funded training programs. BrightFutures also has been incorporated into

academic training through the UW MCHB-funded training programs. For example,trainees in the MCHB-supported Maternaland Child Health Leadership Education inNeurodevelopmental and RelatedDisabilities (LEND) MCH TrainingProgram must complete a community-basedproject in order to graduate from the pro-gram, and Bright Futures is included as anoption for the community project.

� Library resources. Bright Futures:Guidelines for Health Supervision andBright Futures in Practice: Mental HealthPractice Guide and Toolkit have beenplaced on reserve by the School of Nursingfaculty at the UW Medical Library.Instructors reported that Bright Futures isan organized tool for health promotion thatis developmentally focused and preventionoriented and therefore a valuable resourcefor nursing students, public health students,and others.

� Intercollegiate College of Nursing/

Washington State University College of

Nursing. Faculty members at this nursingschool have incorporated Bright Futures intovarious nurs-ing programcurricula andintegratedthe materialsinto continu-ing educationcourses forgraduate nurses. Bright Futures is taught asone of several sets of health supervisionguidelines for infants, children, and adoles-



3 The core concepts were developed by the Bright Futures Health Promotion Workgroupbased at Children’s Hospital Boston.

Bright Futures has been incorporated into

curricula in nursing, medical, and other health professional training programs.

cents. To heighten familiarity with theBright Futures material, research assign-ments are given that incorporate use of thematerial. Based on their positive experienceswith Bright Futures, some faculty membersare working to bring Bright Futures to otherenvironments that incorporate health pro-motion and education; currently, some ofthese faculty members are exploring the useof Bright Futures in summer camps. Afterintroducing this idea to a national organiza-tion of summer camps, a next step – writingan article about Bright Futures and its campapplications – has been initiated.

Bright Futures TrainingActivities

As a result of the efforts of the DOH-OMCH,the UW, and other stakeholders in spreadingthe word about Bright Futures, various groupsbecame interested in learning more about thisapproach to child health supervision and beganto request training on how to implement theapproach and use the materials. As a result ofthis interest, Bright Futures training moduleswere developed and tailored to specific groups.Training activities for two of these groups aredescribed here.

� School Nurse Corps. The School NurseCorps is a statewide program focused on theprovision of nursing services to small ruralschools and is responsible for staffing each ofthe nine Educational Service Districts (ESD)in the State of Washington. Each month,representatives from each ESD gather inOlympia to share information and obtaintraining related to their nursing functions.

During one such meeting, the Nurse Corpsstaff expressed an interest in the BrightFutures inPractice:MentalHealth bookand request-ed trainingon how touse the mate-rials effectively. The OMCH agreed thatschool nurses were an important group toget involved in Bright Futures and thereforegranted additional monies to the UW toprovide the training. As a result, SchoolNurses on Bright Futures in Practice:Mental Health, a train-the-trainer model,was developed and training was provided toschool nurses in August 2004. Participantswere required to develop and write a BrightFutures workplan describing how theyintended to train other school nurses intheir own and surrounding districts. A sec-ond followup training, Bright FuturesSchool Nurse Mental Health PromotionInstructor Training, was offered in spring2005, which operated primarily as a debrief-ing where participants reported on theirtraining experiences and other BrightFutures implementation efforts. Informalfeedback showed that the material was well-received by the nurses and that they areroutinely using the materials in their work.

� Child Care Health Consultants. HealthyChild Care Washington, a statewide net-work of Child Care Health Consultants(CCHCs) located in every local health juris-diction, is another group that indicatedinterest in Bright Futures as a comprehen-



School nurses and Child Care HealthConsultants have beenimportant audiences

for Bright Futures training.

sive health promotion resource. CCHCs arepublic health nurses whose role is to providehealth education and training to child careproviders. CCHCs indicate that the BrightFutures materials are an organized and acces-sible training tool to use with child careproviders who do not have any health back-ground. The UW staff helped developBright Futures training modules to beincluded in an existing resource, the ChildCare Health Consultant Resource Kit.

Other Examples of Bright FuturesUse by State Agencies and OtherPartner Organizations

While the OMCH has served as the principalleader in the promotion of Bright Futures inthe State of Washington, many other Statehealth promotion programs have been instru-mental in this effort. The activities describedabove have been complemented by thoseoccurring within various State agencies andother partner organizations, as illustratedbelow.

OMCH. In addition to its previously describedleadership roles, the OMCH has incorporatedBright Futures into existing health promotionsystems and/or new activities.

� CHILD profile. Housed within the OMCH,Children’s Health Immunizations Linkagesand Development (CHILD) Profile is theState’s health promotion and immunizationregistry system. Bright Futures was seen as anatural fit with the goals of this system.CHILD Profile sends a mailing of informa-tional materials to the family of everynewborn in the State and regular mailings

continue until the child turns 6 years old.The information provided corresponds withthe topics that are assessed at periodic well-child visits with a health care provider.Bright Futures materials serve as a resourcefor the development of newsletter messagesabout immunizations, well-child checkups,growth, development, and safety.

� Adolescent fact sheets. Bright Futures wasused as a resource by staff members from theCAH section to develop Adolescent HealthFact Sheets. The fact sheets were developedfor adults who work with adolescents orwho are parents of teenagers. A series of 16fact sheets were developed touching on sub-jects such as depression and suicide, eatingdisorders, and special needs and disabilities.The fact sheets can be downloaded from theDOH Web site at www.doh.wa.gov/cfh/

adolescenthealth.htm.

� Mental health partnerships. The DOHrecently received a grant for a project titledBright Futuresfor Childrenand Youth inFoster Care.The staff fromthe CAH divi-sion, inconjunctionwith the stafffrom the childwelfareagency, developed and submitted a proposalto HRSA to assist the State in addressingchild and adolescent mental health issues.The proposal focused on the development ofa training curriculum, based on Bright



Bright Futures has been used for multiple

purposes by various State agencies

and programs, includingmaternal and child

health, Medicaid, childwelfare, and public

instruction agencies.

Futures in Practice: Mental Health, for fos-ter parents and foster care advocates toincrease their ability to sustain and improvethe mental health of children and teens intheir care. Bright Futures will be used as aresource for the training program, as it pro-motes the integration of social, emotional,and mental health into overall health, there-by promoting a holistic approach to theneeds of children and teens.

Medical Assistance Administration of the DSHS.

Bright Futures was used as a resource by theMedicaid Program in the redesign of the pro-gram’s State Well Child Exam Forms. Theforms were revised to include anticipatoryguidance messages specific to the age of thechild at the time of the health visit. DSHS alsosupported the previously described trainingprograms for school nurses on mental healthpromotion and use of Bright Futures mentalhealth materials.

Office of Superintendent and Public Instruction

(OSPI). OSPI worked closely with the DOHand the UW to prepare the training programsfor school nurses on mental health promotionand use of Bright Futures mental health materials.

Family Voices. Washington State’s Family Voicesorganization is serving as one of five pilot sitesfor the Tufts University and the nationalFamily Voices office Centers for DiseaseControl and Prevention-funded project, FamilyMatters: Using Bright Futures to PromoteHealth and Wellness for Children withDisabilities. Funds are provided under this ini-tiative to evaluate the effectiveness of Bright

Futures in getting health and wellness messagesto families of CSHCN. The national office ofFamily Voices developed the Bright FuturesFamily Pocket Guide and encourages families,including those with special needs children, touse it to help them understand and coordinatetheir child’s health care.

Head Start and the Early Childhood Education and

Assistance Program (ECEAP). Three local effortsin Washington State have conducted extensiveoutreach to the staffs of Head Start, EarlyHead Start, and ECEAP programs. TheWhatcom County Bright Futures project, thePuget Sound Educational Service District’sEarly Head Start Program, and SpokaneCounty Head Start all provide pocket guides tostaff members who work directly with familiesto help them feel more comfortable in dis-cussing the range of health issues of concern tofamilies. In addition, Encounter Forms forFamilies are distributed along with accordionfolder-style health organizers to help familiesbecome more informed and engaged partnersin their children’s health care. Spokane CountyHead Start is highlighted below:

Spokane County Head Start

Staff members at Spokane County HeadStart were looking for a resource to use withtheir parents that was different. They werelooking for something that was comprehen-sive, yet parent friendly. At a regional HeadStart meeting, they were introduced to BrightFutures material by the Washington BrightFutures team and thought that the materiallooked interesting. After doing furtherresearch into what Bright Futures could offer,Spokane County Head Start decided to pres-ent their own training on Bright Futures forother area Head Start and ECEAP social



workers. Spokane County Head Start usesBright Futures in a variety of ways. All of theBright Futures books are used within the pro-gram in addition to the Encounter Forms.Staff members have developed their own ver-sion of the health organizer and have evengone a step further and developed a financialorganizer for parents. Bulletin boards, mag-nets with Bright Futures tips, and newslettershave all been additionally developed andshared across sites. Spokane County HeadStart is housed with many other communityorganizations, a point that was cited as sup-porting utilization of Bright Futures becauseit enabled them to collaborate and shareideas. In fact, currently, Spokane CountyHead Start staff members are often calledupon by the State to assist with trainings onuse of Bright Futures.

Early Childhood Programs. In 2003, the OMCHreceived a unique source of funding forexpanded Bright Futures activities. TheOMCH and the Georgetown UniversityNational Center for Education in MaternalChild Health developed a proposal for theSenate Health and Education Committee tofund a project whose purpose was to “deter-mine if applying and using Bright Futuresprinciples and materials helps to enhance out-comes of existing health promotion systems forchildren and their families enrolled inWashington State early childhood care andeducation programs.” 4 Senator Patty Murrayfrom Washington State, who chaired thisSenate committee, was familiar with the suc-cess of previous OMCH Bright Futuresprojects and sponsored the proposal for aCongressional earmark. The $465,240 appro-priation passed through Congress in 2003 andwas to provide initially 17 months of funding

to the DOH to implement Bright Futures inEarly Childhood but recently has beenapproved for an extension through June 2006.

Bright Futures in Early Childhood has usedBright Futures as the core foundation to buildon established health systems in pilot site pro-grams representing Head Start, Early HeadStart, ECEAP, and child care programs. Aunique aspect of this project is the inclusion ofan evaluation piece. Outcomes being assessedinclude improvement in meeting required earlychildhood healthstandards by thepilot sites;direct-servicestaff members inthe pilot pro-grams indicatingimprovedknowledge, skill,and confidencein health promo-tion practiceswith childrenand their fami-lies; and familieswithin the pilotprogram indicat-ing enhancedknowledge and confidence in health promotionpractices for their children. The evaluationcomponent will assist the OMCH to assessproject activities and outcomes and also to tai-lor the project for replication in other areas ofthe State.

Eleven pilot sites have been chosen for thisproject and are comprised of 65 centers servinga total of 2,422 children across the State. Staff



4 Bright Futures in Early Childhood Care and Education Fact Sheet, 2004

In 2003, Washingtonreceived an earmark

from Congress to support the use of Bright Futures in early childhood

programs. The State is evaluating the

experiences of HeadStart, Early Head Start,

and other early childhood centers

in incorporating BrightFutures health

promotion activities into this setting.



members from the pilot programs have partici-pated in health promotion trainings, developedBright Futures work plans for their individualprograms, initiated the use of Bright Futures intheir programs, and started data collection. Eachsite has developed its own unique strategies toincorporate Bright Futures into their program;one of these sites is highlighted below:

Port Gamble S’Klallam Tribe Head Start

Port Gamble S’Klallam Tribe Head Start staffwas attracted to Bright Futures because theyfelt that it empowered parents and encour-aged them to be active partners in theirchildren’s health care. One of the tribe’s chiefgoals is encouraging members to obtain theirhealth care on the reservation. Head Startstaff recognized that Bright Futures couldassist them in achieving this goal. After theinitial training provided by the UW, Head Startmanagement staff came back to PortGamble and began to develop their own workplan for utilizing Bright Futures. Their goalwas to increase the awareness of Head Startfamilies about nutrition and physical activitytopics. Some of the activities that they com-pleted include: developing a bulletin boardpromoting physical activity and using thephysical activity pyramid with pictures of staffand children from the program, placing BrightFutures nutrition and physical activity tips onthe back of the weekly menu that is senthome with the children, and sponsoring aparent mini-retreat using Bright Futuresmaterial as a resource for curriculum devel-opment. Parents of the children were alsoprovided with and oriented to “My Family’sHealth Organizer,” a folder that containsdividers to file information about appoint-ments, test results, bills, medical care, dentalcare and immunizations.

Increasing DOH-OMCH Bright Futures Capacity

In 2004, as attention to Bright Futures contin-ued to grow across Washington State, the CAHsection of the OMCH felt it was necessary todevelop a position to focus on Bright Futuresefforts. The Bright Futures staff person’s role isthe overall coordination of Bright Futuresefforts across the State to maximize collabora-tion and minimize duplication of effort.

One of the section’s first activities after devel-oping this position was to organize a jointmeeting between Washington and VirginiaBright Futures stakeholders. Representativesfrom Virginia and Washington as well as thenational American Academy of Pediatrics werealso present. There were multiple objectives forthis meeting, the primary being to inform andadd breadth to Bright Futures activities in thetwo States. It also served to establish the rela-tionship between two States with multipleBright Futures activities and give them a groupstructure within which to work.


Washington State faces several challenges tosustainability and ongoing growth of BrightFutures. Local-level key informants stressed theneed for the State to play a bigger role in facili-tating information sharing and promotingpartnership building at the local level. Forexample, although Washington has a StatewideBright Futures campaign with active local play-ers, these local players were often not informedabout each other’s activities and did not feelvery connected to the statewide effort.



Additional challenges cited by key informantsinclude the following:

� Continued access to Bright Futures

materials. A common issue identified duringkey-informant interviews was the cost ofmaterials. OMCH funding has supportedpurchasing Bright Futures materials to somedegree for trainees and program staff mem-bers participating in OMCH-sponsoredtrainings and projects. However, these mate-rials are expensive, and most often, traineesand others needed to purchase some or all ofthe Bright Futures materials they wished touse for Bright Futures implementation with-in their programs.

� Need to offer evidence of successful

utilization. In order to promote BrightFutures as a standard of care, it is importantto communicate, widely, successful efforts inusing Bright Futures as a standard and thepositive outcomes that result.

� Broad-based participation of health care

providers is important. While communityhealth providers readily engage in BrightFutures, most primary health care providersdo not. The lack of inclusion of BrightFutures in the professional training of theseproviders often limits their ability to use theguidelines. This is compounded by the lackof resources to distribute Bright Futuresmaterials widely to primary care providers.

� Sharing of Bright Futures resources across

the State. Organizations would benefit frombeing made aware of the Bright Futuresefforts of others. Frequently during the sitevisits, it was evident that programs of similarnature are unnecessarily reinventing the

same wheel; that is, using valuable resourcesto develop an application of Bright Futuresthat has already been developed by anotherprogram.

� Networking is crucial to expanding the Bright

Futures initiative. In order to facilitate BrightFutures imple-mentation, itis necessary toensure thatprograms havea way to com-municate withone another.Often duringsite interviews,it was clear that programs are unaware ofavailable Bright Futures resources.

Washington State’s experience with BrightFutures thus far also offers valuable lessonsabout program development and sustainability.Key informants identified the following as crit-ical to Washington’s experience in supportingand expanding Bright Futures:

� Grow incrementally. Bright Futures was seenas a strategy for responding to issues result-ing from changes in the health care deliverystructure and for facilitating health promo-tion activities in an organized,age-appropriate, and developmentally appro-priate manner.

� Develop partnerships. While the leadershipof one agency is important, equally impor-tant is engaging other stakeholders topartner in efforts to promote and integrateBright Futures in child health-focused activities.

Ongoing challengesinclude paying

for Bright Futures materials, engaging more primary health

care providers,and facilitating

communication amongBright Futures partners.

� Funding is critical. Dedicated resources,including funding and staff time, are essen-tial to provide the coordination, training,promotion, and materials needed to facili-tate the utilization of Bright Futures. Inorder to replicate and expand Bright Futuresimplementation further across the State,additional funding support must be secured.

� Stakeholders must take ownership.

Stakeholders who learn about Bright Futuresand understand its efficacy in promotingchild health must assume responsibility forpromoting Bright Futures and teaching oth-ers about its usefulness in order to encourageits broader use.

� Providers and consumers need in-person

introduction to Bright Futures. The “personaltouch” by the UW, the OMCH staff, andother stakeholders is the best way to intro-duce Bright Futures to those who areunaware of the materials or unclear abouthow to use them for health promotion.

� Training is essential. Training provides anopportunity to learn about not only thematerials but also how to apply them to theparticular needs of specific audiences.

� Provide ongoing support, mentoring, and

coaching. While individuals and groups maybe initially enthusiastic about BrightFutures, without ongoing support andencouragement, it is difficult to maintainthat enthusiasm.

Future Directions and Sustainabilityof Bright Futures in Washington

While Bright Futures activity in WashingtonState began slowly, it has, with time and thedetermination of advocates and champions,gathered momentum and become increasinglyinfluential inguiding theStates’ healthpromotingactivities forchildren andadolescents(including thosewith specialhealth careneeds) and theirfamilies. Evidence of this is the incorporationof Bright Futures as a Title V needs assessmentperformance measure to promote best practicesin child and adolescent health in the State andthe inclusion of Bright Futures in Statewideconferences focused on child health – forexample, the Washington Association for theEducation of Young Children and the Partnersin Mental Health Development of Childrenconferences.

The groundwork which has been laid for theintegration of Bright Futures clearly provides asolid platform for future efforts. Past successplus the presence of a dedicated staff positionenables the State to explore new opportunitiesto use Bright Futures to promote health andwellness. Opportunities under discussioninclude developing linkages with health careplans, expanding mechanisms for the distribu-tion of Bright Futures materials, and developingstrategies to track health promotion outcomes.



With time and the determination

of Bright Futures champions, Bright

Futures has becomeincreasingly influential in guiding the State’s

health promotion activities for children

and families.



Other future directions suggested by keyinformants include the following:

� Identify opportunities to incorporateBright Futures into funding proposals.

� Promote the use of Bright Futures by con-sumers through linkages with private-sector,family-oriented groups.

� Increase collaboration with local healthdepartments and MCH regional teams.

� Identify a champion within the UWSchool of Dentistry who is willing to learnabout Bright Futures and, as a result, incor-porate it into curricula.

� Work with the OMCH Oral HealthDirector in expanding access to oral healthservices as outlined by Bright Futures.

Overall, key informants stressed the value ofBright Futures as a unique resource that focusedon age- and developmentally appropriate guid-ance useful to a range of stakeholders, includingpolicymakers, providers, and families. Theyemphasized the attractiveness of the materialsand the organization of content as factors influ-encing their usefulness. The DOH-OMCH andits partners have identified a wide range ofopportunities in which Bright Futures can playa major role in fostering child and adolescenthealth promotion. Pursuing these will help tofurther strengthen health promotion efforts inthe State.

JJuuddyy SScchhooddeerrWashington State Department of Health

TTeerreessaa CCooooppeerrWashington State Department of Health

SSuuee WWeennddeellUniversity of Washington

JJeeaann MMyyeerrssUniversity of Washington

JJaanneett CCaaddyyFamily and Child Nursing Program, University of Washington School of Nursing

TToorryy CCllaarrkkee HHeennddeerrssoonnDepartment of Health/Maternal Child Health:Child and Adolescent Health – Mental HealthPartnerships

GGaayyllee TThhrroonnssoonnHealth Services Program SupervisorOffice of Superintendent of Public Instruction

LLoorrrriiee GGrreevvssttaaddDepartment of Health/Maternal Child Health:Child and Adolescent Health – Early ChildhoodPartnerships

JJaann GGrroossssPublic Health Consultant, Early ChildhoodSpecialist

BBaarrbb LLaannttzzDepartment of Social and Health Services

CCaassssiiee JJoohhnnssttoonnFamily Voices

LLyynnnn NNeellssoonnSchool Nurse Corps

KKrriiss LLiisshhnneerr MMiilllleerrAssociate ProfessorIntercollegiate College of Nursing/WashingtonState University College of Nursing

DDiiaannee UUpphhooffffEarly Head Start Program Manager, Puget Sound Educational Service District Early Head Start

JJaanneell DDuuddlleeyySocial Services SpecialistSpokane County Head Start

KKaarrrroonn MMccGGrraaddyy

JJiillll MMoorraannPort Gamble S’Klallam Tribe Head Start



Key Informants



Appendix

Funding for Washington State Bright Futures*

1 10/1/00-9/30/01 $12,000 $$1122,,000000

2 10/1/01-9/30/02 $32,000 $10,000 $$4422,,000000

3 10/1/02-9/30/03 $52,000 $10,000 $$6622,,000000

4 10/1/03-9/30/04 $72,000 $$7722,,000000

5 10/1/04-9/30/05 $52,000 $465,240 $$551177,,224400

6 10/1/05-9/30/06 32,000 $10,000 $$4422,,000000

TToottaallss $$225522,,000000 $$2200,,000000 $$1100,,000000 $$446655,,224400 $$774477,,224400

*All funding reflected in this table has been directed, through a variety of contracts, to the University of Washington to support Bright Futures activities.

** This funding source is administered by the Federal Maternal and Child Health Bureau.

STATE AGENCYPARTNERSHIPS

FOR PROMOTINGCHILD AND

ADOLESCENTMENTAL HEALTH

GRANT**

BRIGHT FUTURESEARLY

CHILDHOOD(CONGRESSIONAL

EARMARK)

TOTALSTITLE V MCHBLOCK GRANT

**

COMMUNITYINTEGRATED

SERVICES SYSTEMCHILD CARE

GRANTS**

DATESPROJECT YEAR

Documents

Using Bright Futures in Public Health Efforts to Promote ... · Futures is a comprehensive set of health super-vision guidelines for children from birth through age 21 titled Bright