Developmental Understanding & Legal Collaboration for Everyone

Developmental Understanding & Legal Collaboration for Everyone

DULCE Manual

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Contents

3 Overview

A. Introduction / Guiding Principles / History B. Logic Model: Providing Access to Concrete Supports C. DULCE Intervention D. DULCE Embedded in the Early Childhood System

9 Getting Started

A. DULCE Core Elements & Structural Expectations B. Family Specialist C. P atient-Centered Medical Home Team Relationship with the DULCE Family Specialist

? Primary Care Clinicians ? Linking to the Patient-Centered Medical Home (PCMH) & Community Resources ? Nursing ? Support Staff

13 Building the Expertise of DULCE Family Specialists

A. Brain Messages and Strategies for Supporting Early Brain Development B. Parenting/Child Development C. Concrete Supports D. Assessment Toolbox

? Newborn Behavioral Observations (NBO) ? Ages & Stages Questionnaires?, Third Edition (ASQ-3TM) ? Ages & Stages Questionnaires?: Social-Emotional (ASQ:SE) ? Patient Health Questionnaire (PHQ-9)

18 DULCE Intervention

A. Identifying Eligible Families B. Creating the Relationship with the Family (First Week Visit & One Month Visit) C. Partnering with the Family (Two Month Visit & Four Month Visit) D. Family's Next Steps (Six Month Visit) E. DULCE Intervention Flowchart

30 Family Assessment Inquiries

A. Probing Questions B. Screening Questions

? Housing & Utilities Screening ? Income & Nutrition Screening ? Interpersonal and Community Violence

33 Appendices

A. DULCE Activity Log B. DULCE Family Profile C. DULCE Checklists (Checklists for each Visit, Income and Housing & Utilities) D. Parent Handouts E. Sample Weekly Case Conference Agenda F. Suggested Areas to Cover During Mental Health Supervision Meetings

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DULCE Manual

1. Overview

A. INTRODUCTION / GUIDING PRINCIPLES / HISTORY

DULCE is an innovative pediatric-care-based intervention through which primary care clinical sites proactively address social determinants of health and promote the healthy development of infants from birth to six months of age and provide support to their parents. DULCE's intervention adds a Family Specialist (FS) to the pediatric care team, and the FS provides support for families with infants in the clinic setting, connecting them to resources based on parents' needs and priorities ? with the option of providing home visits, at the parents' choice. The DULCE intervention incorporates a protective factors approach and draws on and incorporates components of the Medical-Legal Partnership model to ensure that families have access to the resources they need.

The Center for the Study of Social Policy (CSSP) and city and county partners participating in Early Childhood-LINC (Learning and Innovation Network for Communities) will be testing DULCE in five clinical settings across the US, including three California counties (through county First 5 commissions in Alameda, Los Angeles and Orange Counties); Palm Beach County, FL (through the Children's Services Council); and Lamoille Valley, VT (through the Lamoille Family Center). Each community will implement DULCE in at least one clinic site serving at least 200 infants per year, and there will be a careful evaluation of the impact of DULCE on infants and families served as well as on selected indicators of health care delivery and health/social services utilization.

GUIDING PRINCIPLES

DULCE works to strengthen families by providing extra support during the critical first six months of life

DULCE is embedded in the patient-centered medical home DULCE works together with families to empower them to solve their own problems: don't do "for"

families, do "with" families

DULCE connection is universal, there is no stigma attached

DULCE brings the Strengthening FamiliesTM approach to routine healthcare for newborns. DULCE Family Specialists partner with parents of newborns ? with the dual goals of improving child development and reducing maltreatment. This is accomplished by providing families with support for any unmet legal needs and age-related information on child development in addition to ongoing friendly support from a Family Specialist. Since DULCE is part of a patient-centered medical home, benefits of the program not only accrue to the new baby and parents, but the whole family ? especially siblings.

Families meet with the DULCE Family Specialist at all routine visits. Home visits and telephone check-ins are scheduled depending on the families' preferences. At six months, the DULCE Family Specialist hands off care to the primary care team and any other ongoing early childhood services as necessary.

DULCE Manual

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DULCE Manual

Overview

HISTORY

The original Project DULCE adapted and combined elements of two existing programs: Healthy Steps and Medical-Legal Partnership | Boston (MLP | Boston). The evidence-based Healthy Steps program added a professional with knowledge of child development to the child's pediatric primary care team to support positive parenting through knowledge, modeling, ongoing support, referrals (when needed), optional home visits and a telephone phone line. MLP | Boston supported families by providing legal advice, consultations, and representation to address their civil legal needs. The DULCE Family Specialist, trained by MLP | Boston, identified legal and social needs that could have affected a child's health and development and took action either by helping the family to advocate for themselves or by referring the family to an appropriate public health, legal, or social service agency or resource (including MLP | Boston).

Findings from the first trial of DULCE at Boston Medical Center, published in the journal Pediatrics, demonstrated that the intervention: 1) increased the connection of parents to needed concrete supports and community resources, especially housing, solutions to financial crises (utility cut-offs, etc.), and assistance with immigration issues; 2) increased parents' utilization of well-child health care visits, so infants received more preventive care, including timely immunizations; 3) decreased use of emergency room care by DULCE participants (thus providing rewards for the health care provider and system); and 4) responded to the needs of parents, who actively sought out the program. A paper published recently in the journal Zero-To-Three offered case examples of DULCE's ability to address maternal depression and other pressing family needs. These results were achieved at modest cost, offering promise that DULCE is a replicable, universal and cost-effective approach that can be widely used in pediatric care settings to address toxic stress in low-income neighborhoods.

We would like to acknowledge that DULCE was developed at Boston Medical Center and originally funded as a research and demonstration project by the National Quality Improvement Center on Early Childhood (QIC-EC) which is funded by the U.S. Department of Health and Human Services, Administration for Children, Youth and Families, Office on Child Abuse and Neglect, under Cooperative Agreement 90CA1763. The purpose of QIC-EC is to generate and disseminate new knowledge and robust evidence about programs and strategies that contribute to child

maltreatment prevention and optimal development for infants, young children (0-5) and their families, including those impacted by HIV/AIDS, substance abuse, or abandonment. The strategies in this manual were adapted from the noted sources specifically for use in Project DULCE by staff paid through the QIC-EC and are available in the public domain thanks to the federal funding for the original project.

INTENDED AUDIENCE

This manual is designed to support implementation of DULCE at health centers that work in cooperation with early childhood systems of care. DULCE Family Specialists and members of the clinical care team will want to review the entire manual. Early childhood system leaders and quality improvement team members should find the first three sections particularly pertinent to their work. This manual, along with training, technical support, and quality improvement efforts, provide the basic information and resources needed to implement DULCE ? a cost-effective, universal program to link clinical care, families, and the surrounding communities.

B LOGIC MODEL: Providing Access to Concrete Supports

concrete supports

parental resilience

knowledge of parenting

DULCE Reduces Sources of Toxic Stress (Red Boxes)

upstream fractors

downstream results

food insecurity

housing insecurity

utilities insecurity

$

income insecurity

child problem behaviors

parent emotional & behavioral problems

non-nurturing & harsh parenting

family economic pressure

interparental conflict & low

warmth

child abuse & neglect

legal needs

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