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Implementation Guidelines for the Healthy Babies,
Healthy Children Program - Phase II
Table of Contents
Early life experiences make a critical and long term difference in children’s health and well being. Decades of research are indicating that early interactions and experiences not only directly affect the way the brain is wired, but also have a decisive impact on emotional and intellectual development. Similarly, research has demonstrated that the acquisition of speech and language is the single best indicator of future cognitive development and academic success. These major advances in knowledge continue to inspire the implementation of Healthy Babies, Healthy Children and Preschool Speech and Language. Helping parents help their children in these vital first years is the driving passion behind everyone’s efforts.
As we enter the next phase, we need to celebrate the positives that are emerging as the program evolves across the province.
The purpose of the Phase 2 Implementation Guidelines is to help boards of health, MCSS area offices, and local health and social service providers plan and implement the enhanced Healthy Babies, Healthy Children program (HBHC) announced in the May 1998 Ontario Government Budget.
The HBHC program is being enhanced with increases of $10 million in 1998/99, $20 million in 1999/2000 and $10 million in 2000/01 for a total program commitment of $50 million by 2000/01.
Phase 2 will introduce new dimensions to the program that reflect the government's responsiveness to current research and field consultations. These include :
Healthy Babies, Healthy Children is a prevention/early intervention initiative intended to improve the wellbeing and long-term prospects of children. HBHC is a joint MOH and MCSS endeavour, which is designed to complement (and augment when appropriate) other existing community level initiatives. HBHC supports the integration of existing early intervention services in order to maximize the effectiveness of community resources.
The Office of Integrated Services for Children’s definition of service integration is the process by which a range of educational, health and social services are delivered in a coordinated way to improve outcomes for individuals and families.
Healthy Babies, Healthy Children is part of the Mandatory Health Programs and Services Guidelines for boards of health. Boards of health lead the community implementation process in partnership with MCSS area offices and other organizations that serve children.
In order to achieve its mandate, HBHC depends on the existence and continuation of other community level services. HBHC is not designed to fund organizations to carry out their existing service delivery mandate.
There are a number of principles for the HBHC program. It will :
Corporate leadership for HBHC is managed out of the Office of Integrated Services for Children, with the assistance of an interministry team. This team representing Health, Community and Social Services and Education, has aided in the development of ongoing policy and procedural requirements of the Healthy Babies, Healthy Children Program. In 1997 the Office provided the following :
The enhanced program will optimize the existing components of the program by :
This comprehensive approach to preventing poor outcomes for vulnerable children will increase the capacity for children to have their needs met along a continuum of developmental stages. Educating community partners regarding their responsibility to identify vulnerable children will help to ensure that children and families receive the support and intervention services they require.
The primary expectation of the HBHC program is to attain the following positive outcomes for children and families :
The momentum that HBHC has achieved in communities needs to continue in order for effective delivery of the program to be reached. Targets have been established for a number of the following elements in order to assist communities in their planning processes. Where products from OISC have not yet been distributed to the field, HBHC program sites should use interim measures. The Office of Integrated Services for Children is responsible for the following deliverables :
HBHC program sites are responsible for the effective implementation of each component :
In order to ensure that prevention and early intervention resources are maximized, it is important that HBHC link and coordinate with other community initiatives, where they exist, such as :
Making Services Work for People is a Ministry of Community and Social Services initiative which is engaging communities in local processes to reshape services for children and people with developmental disabilities. It is essential that policies and procedures developed by the HBHC program, be consistent with these local systems of service. HBHC and MSWFP services must ensure that case management/service coordination and referral practices are in sync at both the corporate and local level.
The HBHC program builds on existing services. The HBHC program must never duplicate or replace existing services.
A supplementary document outlining how MSWFP and HBHC fit will be released in the new year.
These guidelines are designed to assist the boards of health, MCSS area offices, local health and social service providers implement Phase 2. They will be supplemented by other documents that will provide more details and information on program requirements and best practices, including :
With the program enhancement, HBHC programs are to are to provide service pre-natally. Obstetricians, family physicians, and midwives are primarily responsible for providing prenatal medical care. The work of a group of clinicians and academics which has developed the ALPHA tool, has clearly shown that attention to psychosocial issues is critical during the antenatal period. The Healthy Babies, Healthy Children program is committed to developing and implementing a province wide complementary prenatal intervention element by 1999-2000. This element consists of :
The Screening Tool
The Larson tool was chosen because it was developed using an experimental research design, it was found to identify successfully families at risk, and literature reviews found ample evidence that associates the three items in the tool with risk. For information on how the tool was created and validated, refer to Healthy Babies, Healthy Children : Rationale for Screening and Assessment Tools, by Louise Hanvey. Consultation with professional organizations will guide revisions to this tool, specifically the question related to prenatal class attendance. Further details will be provided.
We will work with professional associations to determine how best to work the screening component into current practices. Subsequent to such discussions, it is our hope that physicians, midwives, nurses or other professionals will screen and refer pregnant women. Ideally all at-risk families will be identified and referred to appropriate services and supports early in pregnancy, however, families can be referred into the program at any time, or can themselves ask for service. Families can continue to participate in the HBHC program for as long as the program meets their needs. This may mean, for example, that the family enters the program prenatally, continues receiving services which may include lay home visiting through the birth of the baby and as the child develops, and then moves to other community based services with the assistance of service coordination. The HBHC program staff will assist with transition to services and supports as determined by family needs and program mandates.
Revisions to the HBHC Family Assessment Tool have been completed. A field committee which included representatives from Public Health, Infant Development and Children’s Aid Societies, reviewed feedback received from users and recommended changes to the rationale for selected items, anchor descriptions and interview questions in the Manual; the Family Assessment Worksheet; and format of the Tool.
Prevention and protection are part of the same continuum. It is important, however, to understand how the two assessment tools (HBHC and Child Protection) differ in intent. The Risk Assessment Tool (which is part of the Risk Assessment Model for Child Protection in Ontario) assists child protection workers in determining the future risk of abuse and/or neglect for a child. The HBHC Family Assessment Tool supports Public Health Nurses in identifying which children are at risk for poor development. The existence of similar items in both the HBHC and Child Welfare assessment tools are intended to facilitate linkages between HBHC family assessors and child protection workers, however, appropriate roles and responsibilities for each program’s service provider need to be clear.
Regional training will again be conducted to clarify the use of the assessment tool and other issues that emerged during the course of the tool’s revision, including the requirement to report child protection concerns to a CAS. This training will be a joint event involving Public Health and CAS staff and other staff as appropriate.
With the program enhancement, HBHC programs are able to provide services for children postnatally to age six. It is believed that heightened public awareness of healthy child development, in conjunction with a more consistent approach by professionals and community service providers (from health, social services, education and recreation sectors), will strengthen the community’s ability to respond to early warning signs with the provision of early intervention supports. The early identification of children at risk for poor developmental outcomes is part of the continuum of community prevention and protection services.
It is the intent of HBHC to develop a comprehensive model of early identification and early intervention that bridges the gap between infancy and school entry. Development of this element is currently underway.
Field consultations on proposed models will take place over the spring. An external expert committee will be convened to select an appropriate tool(s) to support the early identification process. Guidelines and tool(s) will be disseminated in 1999.
Home visiting as a strategy for improving parenting capacity and child development is an ongoing area of active research. Research is indicating that home visiting as a strategy is most effective if it is intensive, long-term, comprehensive, well integrated into other community services and flexible in responding to a family’s unique needs and strengths.
While the enhancement will give the program the flexibility to augment the lay home visiting component with public health nurse visits where appropriate, it is essential that the lay home visiting component be developed and preserved as a core service.
The enhancement will increase the number of postnatal home visits from an average of 13 visits per family, as originally proposed, to the level that research shows is needed to be of benefit to high risk families. The exact number and duration of the home visits will depend on the needs of the family and the level of risk. Guidelines to assist in determining how often and for how long visits should continue are being developed and will be distributed.
The benefits of a more intensive home visiting service include :
The use of lay home visitors is supported in the literature as well as in other program models, and is the primary model upon which the HBHC program is based. It is recognized, however, that in some situations, families may require home visits from a public health nurse. This enhancement will allow for a guideline of 25% home visiting by a public health nurse where appropriate, with lay home visiting comprising approximately 75% of the home visiting component.
There may also be situations in which, in responding to a family’s needs, assistance from other professionals will be required. Communities are encouraged to be creative in finding ways of providing families with the services they need within the existing network of service providers.
A large percentage of women in Ontario receive quality prenatal medical care. HBHC is an additional support to good family and child health. Prenatal intervention through the use of lay home visiting, augmented by professional home visiting, and the provision of milk coupons, where appropriate, will be introduced.
The OISC will continue to provide best practice information for your consideration. Research has demonstrated that lay home visitors are effective when they are well trained and given sufficient supervision. Recent experience out of Denver indicates that frequent (no less than weekly), effective, individual clinical supervision for each home visitor that is: focused on developing the visitor's strengths; helping her/him grow as a professional; helping her/him develop specific competencies for nurturing skills and resources in the families s/he serves; and dealing effectively with her/his own issues when they come up (e.g., emotional and social boundary issues, values conflicts with clients, etc.) should be provided.
There will be ongoing training needs for program staff to keep current with new research, best practices and teaching methods. A step by step training strategy will be developed and implemented over the next few years which will include such components as a train the trainer for Public Health staff, regional training and support for lay home visitors and public health nurse visitors, and on the job skill development. Training and support are vital dimensions to the program's development.
Boards of health with MCSS are expected to lead the development, promotion, marketing and implementation of community collaboration among the network of service providers.
Coordination of HBHC will include the identification, analysis, resolution, and ongoing monitoring of HBHC program issues and system issues. It is expected that the Boards of health will complete the work of protocol development with local CASs and other community agencies by December 1998.
Coordinators will be supported in this function with regular (e.g. quarterly) meetings for updates, sharing and problem solving in order to build a consistent and effective provincial program.
The well being of children is a shared community responsibility. Boards of health and Children’s Aid Societies have traditionally worked together, with the common goals of keeping children safer and providing opportunities for their optimal development. Through the sharing of some services and programs (e.g. Nobody’s Perfect) there is much common ground to build upon. The development of the HBHC-CAS Protocols formalized the collaborative partnership. The development of the recent risk assessment tools, the Family Assessment Tool used by Public Health Nurses, and the Risk Assessment Model for Child Protection in Ontario used by CAS, demonstrate further opportunities for closer collaboration between the two service systems.
Supplementary guidelines to enrich the existing working relationship between the two agencies have been developed to ensure that better communication and further linkages are capitalized. They were distributed in the fall of 1998.
One of the 5 program components identified in the original Implementation Guidelines was Case Management. Several communities implementing HBHC have indicated that they have chosen to refer to case management as service or case coordination. The new term 'Service Coordination' reflects the shift to the view of families as equal partners in the assessment, decision-making and intervention phases.
Guidelines expanding on the principles, roles and responsibilities within the service coordination model will be provided to stakeholders by 1999/2000.
Service coordination must bridge between the local health sites, MCSS services, and municipal services. Referral to programs administered under MSWFP must be consistent with the local MSWFP method to achieve the requirement of fewer points of access for MSWFP services.
The information technology system will provide an automated means to gather and maintain information about children and families that, with appropriate confidentiality safeguards, can be shared with initiatives that involve the same families. The information technology system will also support program monitoring, evaluation and research activities.
The development of the information technology system will be staged. The interim system will be available in the spring of 1999. In the first stage (2000- 2001), the boards of health and contracted service agencies will be networked to the Healthy Babies, Healthy Children application so that information can be shared for the purpose of service coordination. This will allow for provincial collection of program data. The second stage (2002) of the system's development will follow on completion of the first and will link additional community agencies to the application in order to ensure service coordination.
The development of the system will be managed provincially and will have extensive user input. Updates will be provided on an ongoing basis.
The provincial evaluation of Healthy Babies, Healthy Children Program will have two phases. Phase 1 was implemented in January 1998 and involves all health units. Its purpose is to monitor program implementation and it consists of the basic quarterly reporting on the activities and target group of the program.
The Phase 2 evaluation plan has yet to be finalized. An initial plan, however, has been developed in consultation with ministry staff, external public health researchers and academics. The purpose of Phase 2 will be to provide information that can be used in the on-going development and improvement of the program in order to increase the likelihood of meeting the objectives of the program which include :
In addition, Phase 2 will focus on a more in-depth assessment of the program activities and target group, a validation of the tools used in the program, and an in-depth study of the short and long-term outcomes of the program. An Evaluation Co-ordination Centre will be responsible for creating a network of people in all delivery sites, contracting with researchers for specific work and coordinating the various evaluation projects across the province.
The following section describes the infrastructure that is emerging through the on-going implementation of HBHC. The individual structures play a crucial role in the management and delivery of the overall program. More work is needed to refine the defined roles and responsibilities of the various groups. Also, the proposed functions outlined under each structure will need further discussion so that we can solidify and strengthen our working relationships. Our partners will be consulted to clarify system accountability issues.
3.1 Implementation Working Groups (referred to in Phase 1 Guidelines as Networks of Service Providers)
Membership : management representatives of agencies working with families with children (prenatal to six) closest to front line.
Although the primary responsibility for program planning and implementing Healthy Babies, Healthy Children rests with the boards of health in partnership with MCSS area offices a broad range of organizations involved in children’s service must be part of the ongoing implementation process. In the original Implementation Guidelines for HBHC, the Network was responsible for the implementation plan. Over the course of the program's development, this working group’s role has been expanded to include the functions below. The name of this working group does not have to change as its functions are the critical aspect.
The following are functions of the HBHC Coordinator. They do not necessarily have to be vested in one person, but may be shared among different individuals and/or agencies depending on local needs and strengths.
Through a service contract with the provincial government, Boards of Health are responsible for ensuring the delivery of HBHC on a local level.
The following functions were identified in Phase 1 and revisions will follow after further consultations. As system planner and manager, the area offices, with support from Ministry of Health and district health councils, will ensure :
This Office has program and policy development responsibility for the provincial program through an interministry team with representation from Public Health Branch (MOH), Children’s Service Branch (MCSS), Management Support Branch (MCSS), Operations and Field Services (MET) and other branches as issues arise. The Ministry of Health has overall accountability, through the Office of Integrated Services for Children.
We believe it will be beneficial for communities to have some sort of mechanism for overseeing the development of the local prevention/early intervention system. This could be facilitated via an "Integrated Children's Services Committee" comprised of senior level funders and planners responsible for children. As some communities are developing or already have existing senior level funders/planners committee for children and youth, the functions are more important than the structure or title of the group. Some functions might include :
Consultation with HBHC and provincial committees such as AMO, OMSSA, OPHA and ALPHA will help guide the evolution of such a committee. At this stage in our thinking, the local HBHC Coordinator could provide staff support to this committee and bring forward issues from the Implementation Working Group for resolution.
As Healthy Babies, Healthy Children is meant for all families in Ontario, the boards of health, in partnership with First Nations communities and Aboriginal organizations, must begin the process of developing an appropriate model that will meet the unique needs of First Nations communities (on reserve). Creative approaches will be required to respond not only to the documented levels of need, but also to the circumstances of remoteness and isolation in certain First Nations communities. The enhancement to HBHC will create an Aboriginal strategy that will evolve in stages :
a) each board of health will engage in joint planning to develop service plans for the delivery of HBHC to First Nations communities;
It is expected that the plans for HBHC in First Nations communities will be jointly developed by Public Health and representatives from First Nations. The intent of the plans is to develop linkages within the existing federal (and any new proposed initiatives) and provincial services, in order to find creative solutions to the delivery of HBHC services. In recognition of the shared responsibility with the federal government for services on reserve, the province will continue discussion, specifically calling upon Canada to play a cooperative and supportive role.
HBHC needs to be flexible, therefore, we hope that the spirit and principles of the program will remain consistent, while recognizing that the packaging may look different in each community.
Boards of health will work with First Nations over the next 6 months to produce a product that includes the following components :
The parameters for the service plan development are :
Boards of health will be informed of their program allocation in advance of the service plan development to facilitate the planning. Plans are to be sent to the Office of Integrated Services for Children. These will be reviewed by an interministerial team including representation from the Aboriginal Health Office, and Aboriginal Issues in the Community Services Unit.
Provincial representatives will meet with Boards of Health and First Nations to provide further details.
The intent of the guidelines is to describe the evolving fabric and content of the Healthy Babies, Healthy Children Program. We recognize that the challenge will be finding the right balance between the government’s requirement that children and families throughout the province have access to a consistent level of evidence based practice and core services, and allowing communities the flexibility to customize the use of their resources to achieve improved outcomes, based on the community’s strengths and needs. This is part of the partnership and accountability mechanism that drives the implementation of this unique program.
For more information about the Healthy Babies, Healthy Children Program, please contact :
Early Years and Healthy Child Development Branch
Call the ministry INFOline at 1-800-268-1154|
(Toll-free in Ontario only)
In Toronto, call 416-314-5518
Hours of operation : 8:30am - 5:00pm
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