Moving ahead: the role of Children 1st in improving child health in Georgia [Feb. 2001]

Through Children1st, Georgia's public health system coordinates
services across many programs to keep young children healthy--so
they are ready for prekindergarten at the age of four.
Moving Ahead
The Role of Children 1st in Improving Child Health in Georgia
Georgia Department of Human Resources Division of Public Health Family Health Branch

Table of Contents
Georgia's Response to Keeping Children Healthy . . . . . . . . . 1-2 The Rationale for the Children 1st System . . . . . . . . . . . . . . . . 3 The Children 1st Process . . . . . . . . . . . 4-5 Children 1st in Action . . . . . . . . . . . . 6-16
Children 1st in South Georgia . . . . . 7-9 Children 1st in Middle Georgia . . 10-13 Children 1st in North Georgia . . . 14-16 Children 1st Responds to Family Needs . . . . . . . . . . . . . . . . 17-19 Growth and Future Planning for Children 1st . . . . . . . . . . . . . . . . 20-21
The MISSION of Children 1st is to identify children who risk developmental, environmental, and medical conditions, so that needed interventions can be made to ensure optimal health and development.
The VISION of Children 1st is to become the primary point of entry for children and their families into Georgia's public health system and necessary community-based services.

Moving Ahead:
The Role of Children 1st in Improving Child Health in Georgia
February 2001 Publication #DPH01.04HW
Publisher: Georgia Department of Human Resources Division of Public Health Family Health Branch 2 Peachtree St., Suite 11-455 , Atlanta, GA 30303
Gary Redding Acting Commissioner Georgia Department of Human Resources
Kathleen E. Toomey, M.D., M.P.H. Director, Division of Public Health
Rosalyn K. Bacon, M.P.H. Director, Family Health Branch
Eve Bogan, M.A. Director of Programs & Services Family Health Branch
Susan Bertonaschi, M.S. Program Coordinator, Children 1st Family Health Branch 404-657-4143
Writer/Photographer: Beth Atkins Clinton, M.P.H. Consultant to the Family Health Branch
Graphic Design: Shadow Grafix, Inc.
Acknowledgments: Many people have worked together to develop Children 1st, and many continue to work to ensure its success for Georgia children and families. The large number of organizations and people who are appreciated include the Department of Community Health; current state public health leaders, listed at left; the many nurses, physicians, community/ agency representatives, and citizens who collaborate with Children 1st in every Georgia community; and the many generous families and helpful Family Health Branch staff members and district health personnel who took the time to contribute information or to be interviewed for this publication. This substantial final group includes especially the following individuals: Sandra S. Adams, Diane Bock, Pearlie Brown, Debra Chapman, Gloria Chen, Rebecca Hudgins, Beverly James, Katrina Kolade, Cara McDuffie, Tonya Newsom, Julie Samuelson, Suzanne Smith, Dr. Joseph R. Swartwout, Alice L. Trainer, B. Evans Ward, and Shelley Woodman.

Georgia's Response to Keeping Children Healthy

Children 1st reaches into every Georgia county to identify infants and children with preventable or treatable conditions that threaten their health and development, to refer families to child health services in public and private settings, and to keep Georgia children healthy.

O ver the past decade, Georgia has been among the top-ranking states devoted to nurturing and educating young children. Georgia provides universal prekindergarten

for 4-year-olds and has launched the Georgia Early Learning Initiative (GELI), which targets

infants and preschoolers. Children 1st is another outstanding example of Georgia's commit-

ment to nurturing young children and keeping them healthy and ready to learn.

Children 1st is a family-oriented statewide process of monitoring health care for newborns,

infants, toddlers, and children up to four years old who risk illness, developmental difficul-

ties, or other threats to their well-being and preparedness for school.

Enrollment in the

The Division of Public Health created Children 1st in 1992 as a key

Children 1st database component of its child health strategy. Just two years later, in 1994,

and referral system

Children 1st was recognized as an outstanding example of creativity in

is voluntary for

addressing public health needs. That year Children 1st received the

every family.

Vision Award for Excellence in Public Health Through Innovation at the

annual meeting of the Association of State and

Territorial Health Officials.

Public health planners in Georgia

Recent report from a Children 1st nurse:

have merged many streams of research experience to develop and guide this public/private

"One of the infants we were monitoring last year had gained only 12 ounces in her first two months of life. The family's pediatrician diagnosed her condition as "failure to thrive" and recommended that a Children 1st nurse visit the home daily to weigh the baby and observe the mother's feeding techniques."

approach to providing children at risk with appropriate health care, while paying attention to their home environments. "Starting early" is the strategy, which

"Our local county nurse complied with this request. She learned that the mother had had previous bouts of mental illness but had stopped attending her counseling sessions. The nurse referred the mother to a local mental health clinic and advocated for client transportation to help her keep her appointments. Children 1st followed

national child health and development studies have
proven repeatedly.

through on these referrals to be sure the services were put

into place."

The Children 1st early detection process helps to prevent or treat threatening conditions in newborns and children--so that they can stay healthy and develop the skills essential to family life, school, and participation in their communities.

"The baby began to gain weight and the mother began to attend her counseling sessions regularly and to keep her infant's check-up appointments. At nine months, the baby's weight was normal, at 13 pounds, 6 ounces."

"This type of family support, case management, and intervention at the right moment, made a big difference in this child's life--as well as her mother's."

Georgia's Response to Keeping Children Healthy

1

Examples of Georgia's federally or state-funded child health strategies

" The Perinatal Case Management program educates young mothers enrolled in Medicaid about the importance of early and regular prenatal care. Georgia's six regional perinatal centers take extraordinary care to follow up infants born prematurely or with conditions that call for special interventions. In FY 1999, the regional perinatal system served 5,151 infants and 11,526 pregnant women.
" Birthing hospitals test newborns for many conditions. In FY 1999, over 199,000 blood specimens were tested in the Georgia Public Health Laboratory, after which 50 infants were diagnosed with metabolic diseases, 140 were diagnosed with sickle cell anemia, and 5,500 were found to have sickle cell trait. In FY 1999, 38,000 newborns were screened for hearing disorders. In 2000, a major new statewide system of newborn hearing assessments was funded by the Georgia Legislature.
" Children's Medical Services (CMS) provides specialty health care services for children up to age 21 who have a wide range of chronic medical conditions. In FY 1999, over 15,000 Georgia children were helped.
" Babies Can't Wait (BCW) provides early intervention services to children up to age three with developmental disabilities. Approximately 7,000 Georgia children and families received services in FY 1999.
" District-level high-risk infant nurses visit the homes of infants under one year who are medically fragile.
" A Sudden Infant Death Syndrome (SIDS) information and counseling program educates the community, including new mothers, about how to prevent SIDS by putting infants to sleep on their backs.
" Eligible mothers receive infant formula and nutrition education through the WIC program (the U.S. Department of Agriculture's Special Supplemental Nutrition Program for Women, Infants, and Children). WIC also promotes breastfeeding as the best nutrition for infants.
" Health Check, formerly the Early Periodic Screening Diagnosis and Treatment (EPSDT) Program, provides preventive and primary health care services for children birth to age 21 who are enrolled in Medicaid or PeachCare for Kids. In 1997, approximately 180,463 children received health screenings through public or private health providers.
" Healthy Families helps teenage mothers in 17 Georgia counties learn to care for and nurture their babies while continuing their own education or job training.
" First Steps is a hospital-based program in several Georgia counties that places volunteers in birthing centers to help educate new mothers about infant care.

2

Georgia's Response to Keeping Children Healthy

The Rationale for the Children 1st System

T here is a simple rationale for the intense

and thorough Children 1st system of

Causes of Infant Deaths, Georgia, 1998

early identification and monitoring of child

health. If health providers do not diagnose

medical and developmental problems at the

time of birth or very early, infants may not

receive the health care or intervention that

they need--to prevent or ameliorate the con-

ditions that place them at risk.

Every adult has heard stories about

prekindergarten or early grade teachers who

discover that a new young student cannot

communicate, hear, or see well... to the

extent that their limited capacities interfere

with learning. Or gradually, over the child's

grade school years, teachers, parents, and

neighbors notice other health or behavioral

problems... sometimes too late for the best

treatment, and sometimes too late altogether every 100 babies are born low birthweight,

for the child to perform well in school.

which is under 5 1/2 pounds. Other child

Public health epidemiologists analyze

health data point to serious and potentially

Georgia child health problems annually.

preventable environmental dangers, such as

Between 1992 and 1997, even though the

lead poisoning, accidental injuries, a rise in

infant mortality rate declined by 11 percent, respiratory problems (which can lead to

a total of 1,021 infants died before their first asthma), and the persistent threat of child

birthday in 1997. (See graph.) Some of these neglect and abuse. (See causes of infant

deaths were preventable.

deaths above.)

Georgia continues to have high rates of

Over several decades, Georgia has

low birthweight and premature births--

developed many public and private pro-

conditions that can lead to developmental

grams to respond to problems early. All of

and health-related problems. Nearly 9 out of these programs are linked through the

Children 1st integrated

referral and database

Infant Mortality Rate per 1,000 Live Births

processes. (See sample

by Health District in Georgia, All Infants, 1997 listing of programs on

page 2.)

In addition, private

physicians, nurses,

and institutions in every

community both provide

care for and refer at-risk

children to Children 1st.

After child and family

needs have been assessed

by nurses, Children 1st

refers the families

promptly to programs,

agencies, and medical

providers for services and

follow-up over time.

The Rationale for the Children 1st System

3

The Children 1st Process

O verall steps in the Children 1st process involve identification, screening, family

assessment, referral, and monitoring.

Children 1st staff members in each

Georgia health district first identify the

names of newborns and children who may

need health or community-based services.

Risk Indicators on the Children

The staff members analyze birth records for risk factors and screen referral forms from hospitals, physicians, and health

1st Screening and Referral Form

and community agencies. Staff then obtain parental permission to enroll the child in the Children 1st

system, and arrange for nurses

# Mother's age, education, and to assess the family's needs.

marital status

They stress home visiting to

# Weight of the newborn (with

understand the child's family

less than 5 pounds 8 ounces

environment, to offer parents

being a negative indicator)

usable gifts and information

# Whether the mother smoked or

packets, and to inform the

drank alcohol during pregnancy

families of all incomes and

# Whether the mother received

cultural backgrounds about

1st trimester prenatal care

local community health

# Whether the newborn was in a

care and social services.

special care nursery after birth,

Children 1st refers each

experienced drug withdrawal syn- family, on a voluntary

drome, or has tested positive

basis, to a private physi-

for HIV

cian, public health

program, or community

Whether the child has had or has:

service for ongoing care.

# Respiratory distress, seizures,

They monitor the child's

or apnea

care until the age of four.

# Congenital infections such as

hepatitis B

Identification

# Acquired infections such as

For newborns, Children 1st

encephalitis or meningitis

staff members download

# A rare genetic condition such as

available Electronic Birth

Down's Syndrome, metabolic

Certificate (EBC) data regu-

disease, or sickle cell anemia

larly. Children 1st also

receives "hard copy" referral

Whether the child has other

forms for newborns and chil-

significant conditions such as:

dren from local health

# Hearing impairment

providers, agencies, and commu-

# Autism

nity institutions.

# Suspected visual

Since Children 1st has become

impairment

better known to local medical and

# Developmental delay

social service groups as the "point of

# Speech and language

entry" for children into the public health

delay

system, informed professionals have

learned to notify Children 1st about infants

and children whose risk criteria should be

examined. In some counties, Children 1st pro-

motes its phone number widely as the

primary access point for referrals into the child health system.

Screening

Children 1st

Children 1st staff members

plays a pivotal

screen the risk factors pre- role in Georgia's

sented for each infant or

statewide effort

child by using software that to keep children

organizes the Electronic

healthy and

Birth Certificate data accord- families

ing to risk criteria. They also functioning well.

analyze the referral forms

received from health partners. Part of this

process is to clarify whether the infant or

child has a regular medical provider.

The final step in the screening process is

to telephone parents personally to explain

Children 1st and ask permission to enroll

their child. These are the children whose

risk factors indicate a potential health or

environmental risk. (See the list of risk indi-

cators at left.)

In some health districts, participation is

almost 100 percent. In two health districts

recently, about 10-15 percent of parents con-

tacted did not elect to enroll their children,

generally because they felt the child was

receiving adequate medical care without out-

side monitoring. Children 1st nurses indicate

that the way they describe the system's bene-

fits is crucial to gaining the parents' interest.

Family Assessment

Assessing the family in its home environment

is an important part of Children 1st, whether

the home-based assessment is conducted

by a specific Children 1st nurse or another

public health nurse in

conjunction with another program's requirements. This is a step that goes beyond the "paper-screening" process and into the family home where decisions are made.
Children 1st home visiting

Home visiting by nurses is a characteristic of successful preventive health programs in many states.

brings a caring health profes-

sional into the child's home, with the parents'

permission, to learn more about the family's

needs, to bring useful gifts and practical

information, to inform the parents about

community resources, and to plan with the

parents for regular health care.

4 The Children 1st Process

Selected Family Assessment Form Indicators

The Children 1st Family Assessment Form captures and guides the computerization of home visit information. It outlines family strengths, weaknesses, and potential risky situations. Assessment categories cover the indicators listed at right, among others, in areas such as health and nutrition, education status, child rearing, and home environment.
The information collected also indicates whether the parent wishes to be referred for special community or health services and whether the family has a regular health provider. These indicators provide a basis for the nurse to offer resources that will help the family make decisions about the future.

Referral

Once the infant or child is enrolled and

assessed, Children 1st refers the individual

child for needed services. Children 1st also

records in its database the names of the

programs or services that parents have

been referred to so that monitoring can

take place. (See the list of some of these

services on page 2.)

Staff members base their referral recom-

mendations on the information gained

through the family assessment process. In

serious medical cases, the newborns may

already be in care if the birthing hospital has

noted the infant's need for immediate med-

ical care or developmental follow-up. To

keep abreast of at-risk infants being dis-

charged from

Dear Parents:

birthing hospitals,

Some time ago, you gave us verbal permission to enroll your child in Children 1st. Children 1st is a process to help children become

Children 1st staff members frequently attend hospital discharge

healthy and ready for school

meetings to dis-

success by age four. We do this

cuss continuity of

by staying in contact with your child's doctor and helping with

care issues.

referrals when needed.

Monitoring

We have been unable to deter-

Until the enrolled

mine if your child has been to the child is four years

doctor since our last contact with

old, or five years

you. Please call us at ________ to let us know which doctor is following your child's medical care. Thank you for your help and we look forward to hearing from you."

old as of 2001, the child's computer record is updated on a regular basis. Every six months, a letter goes out to

Sincerely,

the health or serv-

Children 1st Coordinator

ice provider or providers with a

Health/Nutrition # Immunization status of the child and mother # Health care access--whether every family member has a health care provider # Food quality or quantity in the home---whether the parents have a knowledge of basic nutrition, whether the family diet is adequate, and whether the mother is breastfeeding # The pregnancy or birth experience, such as the type of delivery, whether the infant was preterm, and whether the
infant or mother was in the hospital more than 48 hours (and why) # Child and maternal health status, such as the mother's energy, well-being, and reproductive health status; or the level of smoking in the household

Adult/Child Education

# Parents or guardian have high school or

form to indicate the child's current health status. Statewide, providers return about half of these forms to

GED degrees # School-aged children have passing marks in all classes # Older children have good school attendance (i.e., miss less than 10 days a year)

Children 1st. When health

Parenting/Child Discipline

care providers or service

# Who the child lives with in the

managers do not return

household

the follow-up form, however,

# Parenting satisfaction levels,

Children 1st staff members con-

indicated by whether interac-

tact the provider to see if the

tions with infant or children

child is still in their care

are positive

or has moved or been referred else-

# Whether the father

where. If Children 1st cannot

or male figure is involved

ascertain the child's current health

with the infant or

care status, staff members write the

children

parents. (See model letter at left.)

# Parental knowl-

If Children 1st staff members do not hear

edge of positive

from families by mail, they call the child's par-

child discipline

ents to confirm the child's situation and

methods

update the system. If the child is no longer in

# Parents'

regular care and the Children 1st nurse is con-

childhood

cerned about the child's well-being, she will

discipline

try to visit the home to ascertain why the

experience,

child is not being taken for regular health

whether

care visits. She will encourage the parents to

too strict

continue the child's medical visits and explain

or

the importance of "well child" visits as well as

severe

prompt medical care for sick children.

As of 2001, Children 1st will monitor

enrolled children routinely until they reach

the age of five. Some planners believe that

the Children 1st system should be

expanded to the age of 21--as in a pilot

project in Health District 2, headquartered

in Gainesville.

The Children 1st Process 5

Children 1st in Action
C hildren 1st nurses and coordinators coordinate their activities differently in each of Georgia's 19 health districts and 159 counties. Some have centralized the data processing and monitoring processes, while others rely more on county-based Children 1st nurses to handle data entry and health care monitoring as well as home visits. Some districts have integrated family assessment home visits into the work of ongoing public health programs, such as high-risk nursing for medically fragile infants under age one.
In all districts, however, the availability of Children 1st information on child health helps alert public health personnel
about access to--or lack of access to--health services. The theme is the same: reaching out to families to ensure appropriate interventions for newborns and young children who have or may develop conditions that affect their health
and development. The examples that follow illustrate how Children 1st works in several health districts--in South Georgia, Middle Georgia, and North Georgia. Subsequent discussions describe such important functions as family support, bilingual communications and cultural responsiveness, and nurse home visiting. Elements of future directions for Children 1st conclude the report.

A Children 1st process in every county
6 Children 1st in Action

In 1999, Children 1st:
" Screened 75,986 newborns for health and developmental risks
" Identified 21,429 newborns to be at risk for medical or developmental problems
" Made 21,869 referrals for infants and children up to age four to multiple public and private services
" Linked 10,424 infants and children to primary health care providers
" Conducted family assessments in the homes of 9,174 infants and children
" Monitored 23,462 infants and children concerning their ongoing access to health care (duplicated program count)

Bryan
Liberty Long
McIntosh

Glynn

Camden

Children 1st in South Georgia

I n Southeast Georgia, the Brunswick district health office of Children 1st

Coordinator Pearlie Brown and Program

Associate Shelley Woodman serves as the

hub of Children 1st activities in six counties.

"We download new birth data from the

EBC (Electronic Birth Certificate) twice a

week," Woodman reports. "Our software

prints out a screening and referral form on

any newborns with Children 1st risk criteria."

"We can see immediately what the risk

factors are for each infant. We also know

which of the newborns are noted as med-

ically fragile and whether the infants should

be referred to a special program. Medically

fragile infants, for example, will be visited in

the home for a year by our district's high-

risk nurse--with whom we will coordinate

any other needed services."

Ms. Woodman sends the names of the

EBC newborns to District 9-3's six county

nurses assigned to Children 1st.

Private

The county nurses then tele-

pediatricians

phone the parents directly to

collaborate with

explain Children 1st and request

public health

permission to enroll the child.

officials to deliver

"We mark the child PENDING

appropriate

until we hear from the county

health and social nurses," Coordinator Brown

services to

explains. "When the child is

newborns and

enrolled, PENDING is changed

children and

to ACTIVE. We close the file

their families.

only if the parent declines par-

ticipation, but let them know

that they can enroll at any time until the

child's 4th birthday. Only about 10-15 per-

cent decline our health care follow-up

services. Our nurses explain the purpose of

Children 1st, and most of the parents realize

it is to their advantage."

Brown continues: "We also receive hard-

copy referral forms from local health

providers, other health department pro-

grams, and collaborative agencies. After an

infant leaves the birthing hospital, a family

member or health provider might notice that

a problem has developed--such as "failure

to thrive" or a developmental delay. This is what happened with the Mincey family." (See page 8.)
Assessment, Referral, and Monitoring
After the county nurse receives the referrals from the Children 1st district office, assesses the family's situation, and gains parental approval, she refers the family to a medical provider or special program for any necessary services.
"It's worth it to assess the needs of families carefully in their homes," Brown stresses. "Many of the problems we find when we do home family assessments are situations such as inadequate or unsafe housing, the need for nutrition education, or the parents' lack of knowledge about services that can help them. If it weren't for our emphasis on home visiting, the county nurses might not identify facts important in the care of the child."
In Bryan County, County Nurse Manager Mabel Ansley is responsible for family assessments, for making and recording referrals, and for handling follow-up letters and phone calls to the service providers. "This is such a small community that we frequently know a new parent before she even becomes
Proud new parents Jignesh and Urvashi Mody visit the Bryan County Health Department in Pembroke with their one-month-old baby Richa, who is enrolled in the Children 1st system. The Modys recently moved to Pembroke.

Health District 9-3
Mabel Ansley, County Nurse Manager in Bryan County, weighs one-month-old Richa Mody.
"The Children 1st system is a way for us to keep services on track with infants and children who need more services than others--or a different type of health care."

Children 1st in South Georgia 7

pregnant." Ansley explains. "We link up with them during pregnancy and follow through to recommend WIC nutrition supplements and other services."
"We make sure the family has a regular health provider, whether public or private. Every six months we write the providers to confirm that the family is keeping up with medical check-ups and immunizations for the child. If we note from their response that the provider hasn't seen the child recently, we will call the home, talk to the parent, and explain the importance of regular visits."
"If the family doesn't have a telephone, I mail them a handwritten note to let them

know we are concerned. In some instances, new parents think health care is just for babies who are physically sick. We remind them of the value of weighing the child regularly and reviewing its developmental progress with a trained nurse or pediatrician."
The role of the computer in keeping up with information has impressed Ansley. "Before we computerized the system, we tried to keep track of babies and children in different notebooks--in addition to our medical files for clinic clients. Now, with computerized databases, it is really possible to know what is going on over time in all these families!"

A Babies Can't Wait therapist visited the home to assess Tyler's condition. She organized home visits for sensory stimulation, physical therapy, occupational therapy, and speech therapy.

"Tyler has been in the Babies Can't Wait program since July 14th," the mother noted on September 26th, "and since then he's been like a caterpillar turning into a butterfly!"

Martius Mincey, Tyler's father, said he at first resisted accepting the fact that something was wrong. Now he is convinced that starting therapy right away was the best thing to do.

" In the Brunswick (Glynn County) family
of Martius and Anissa Mincey, a child care worker noticed that their 6-monthold son Tyler was not developing normally. The baby was not rolling over or holding a bottle.
"I suspected something earlier," the mother said, "and our second child care provider confirmed my suspicions. Tyler wouldn't grasp the bottle or eat food, and he wouldn't respond to our attempts to communicate with him. Then he began to stare at his hand for several minutes at a time."

"I cherish his life so much," he says. "I'm glad they have these programs to assist us. How else would a parent know what to do? The therapists set short-term goals at first, and now Tyler is already doing many of those things."
When Tyler reaches the age of three, Children 1st will continue to monitor his health care until he enters school. If he still needs therapy at three, he will be referred to other services to help prepare him for prekindergarten.
This is a success story because Tyler's problems were identified early and handled professionally. He is responding to therapy and may be perfectly fine by the age of three or earlier.

8 Children 1st in South Georgia

Integrating Child Health

Children 1st Coordinator Pearlie Brown

Services Through Collaboration and Healthy Families family assessment

Linda Huddleston, District Director of Public worker Joanne Howell locate a new

Health Nursing and Clinical Services in

teenage mother's home on a map of

Brunswick, emphasizes the cooperation

Brunswick. These health workers meet

among the many child health services

weekly with a First Steps hospital

available to parents.

volunteer to bring the best health care

"We have worked hard to integrate

possible to babies recently born at the

Children 1st into all child health and preg-

Southeast Georgia Regional Medical

nancy-related services," she explains. "The Center. First Steps volunteers offer parent

public health nurse working with a pregnant education to new mothers in the

mother is usually the first to visit the home hospital, and they follow up on their

after the birth, so this nurse can identify

needs for one month. Children 1st refers the new parent to any

children to be followed up by Children 1st." other needed services, including enrolling teenage mothers into

"Also, through the WIC nutrition

Healthy Families. Healthy Families in Glynn County offers an

program, we see new mothers every 2-3

array of services to pregnant teenagers and 1st- or 2nd-time

months. This is another way to help

teenage mothers.

Children 1st stay informed about the infant's

needs. All of our computerized district serv-

ice data are integrated, and once a child is

enrolled in Children 1st, all public health
sfiobhecCtaMrcCnaietotonbeechoametgnmysaviBneiTfdpuleolicfirdnrotrmilalreancuyhkaoretvrc.sadiernnencetntstllTnststomyaitsseCiotwhawyohi1heoennaetenisoesnanunctntt,abbnkotsCdctshoiere'uomnsaoaotbeaatrlrshconwml.SaebnosalerdsaSeooundebdecrthuudetowoqiwnhcosnettnirnunhiohufilaatsylcaamgmeotluttdpellroialplsiaiveciomerotsrsotteecnyopSCfp"hfpIpOCt.toitiono"PIduoshirouhepkeruerfiohhGwi.lrinnelendnoocaelacaidfBbiiocearikt,ptrvllgtettratliddlryolftwraeyaoaatmouhiaianrlibirchdrrinccnalsFmetenga-toaeesheiredeudirpmaghiossupeisdnnfiaBaelcspmtlseaawytewnciyhagrirevscntRmt11ahatiefoatei,oostaiunlcifhlsssechiynwntisslflttlnslyeltelgimkdeyrafwuaghstgnteeioroDh,,nohoecbsrdrhuwpeplpnjerernhsyuof.oaogatr,raiuusliroFillalnhivmtl-mnntrgegsaaoetfdribohtlBnnaeiereeeacecmdmsrhebcpsstistsial.opoeudrsebrececlaisincQalhECl.atvlSeuho"neee"oa"dpr""ryfitdrIsiedRlrntiAeqiiRsn"mRsneeeRg"rtutesc"venafiresq"benfal"tflieettuf7"oecrufeyio"ger2rsofirp"5dter4rrraar(s"0eesrr1eorlo2se0eRsce3rccil2rd1e2Ktd1rsnetd,dtrtd0ohe9tpe0dp0erao0ermi4et3a,nr8di1rv(patoa6lsep2aappW 5hdp2p5i1ssspioo7a5rrnn4p7cc1ucaoa2ieo051erreaftasgI8iieyaeohhttlcr0rnnnCtcnrrtathotfrciaeeesndhrhsee0onothettggtohtehennosnsiuornC)eil-fni6irlrlnrrsen,tiltattsdcarolrctrdheis)hHtssdGa2sesDectenrsegwernFfesrkidei0rrrreofleflEiertgortedevedeessfira0earmhnGeDinnetohrenfrrfnir1frettcefrrrerdegeefi-taeomdifeeetrccerRerhntdanrfino:errorbdidftorrsSiBrrsesueen'sedresteaeutttc9papdekdrhnfoartttdedaor-srsoiMiudfbre3ccaimseoI-ifrMtflbvneamfoiistofyalreoerfioysopslarofnnrCefdPdurisfa)orhesofcsortrddmrhuebieennC)SoealrecoohehirmilmostmptccnaraelgdtvmghotdeuahraFnrl(nreipuaeaorcJoataceoiirnStdh'edlslsdlutelealrdndlmoetilcnulinsspheluWtloiyGrdroyeececvdegocwht1mraerpraahinnatr1veisciPoctl-aortievte-,ubU.atiieoerlprco,neiatgDusl(spgeaernrtts,atcaishirnu,rhecstaaeacmcipcartheeo:snsooimtrpnanCeneiurostrrlgdidaspatgonveqh-lornrsviuecasreeseatueelmarnisrpsnrtttvsie-giooircnnaens d

Can't Wait and Children's

Medical Services."

Children 1st in South Georgia 9

Jasper Putnam Hancock

Monroe Jones Baldwin

Washington

Bibb

Wilkinson

Crawford

Twiggs

Peach

Houston

Health District 5-2

Children 1st in Middle Georgia

"O ur 13-county health district was one of the first to begin the screening and

referral process in 1992," reports B. Evans

Ward, the Children 1st Coordinator in Middle

Georgia's Health District 5-2. "We've taken a

keen interest in its development. We want to

be sure that at-risk newborns and children

enter into the public/private health system

promptly and stay there--so

that steps will be taken to pre-

vent medical complications and

missed opportunities."

The database monitoring and

reporting aspects of this dis-

trict's Children 1st system are

centralized. Ward and Cara

McDuffie, Program Assistant,

download the Electronic Birth

Certificate as soon as it

becomes available, and they col-

Cara McDuffie, Program

lect hard-copy referral forms

Assistant, and B. Evans Ward,

from their many public and pri-

Children 1st Coordinator

vate partners. "This year, the

hard-copy referral forms have

begun to reach us before the

EBC, so now we compare the two sources

to be sure we are learning all we can about

all newborns."

The district office sends the collected

names and referral forms out to county

nurses to contact the families directly. These

nurses telephone the families to inform them

about the system and make plans to visit the

home for a family assessment. The number

of names each county receives each month

varies from about three in Wilkinson County

to sixty in Bibb County.

After the family's agreement and the

home visit, the nurses make referrals to

needed services.

District 5-2 recently began to pay county

health departments on a per assessment

basis in order to improve the numbers and

quality of home visits made for Children 1st.

In some county health departments, the

pressure of clinic work keeps nurses from

getting out to conduct the home visits.

District 5-2 has overcome this situation by using the per case payment system instead of a lump sum to the health department.
"We receive the family assessment forms back in the district office for computerization and follow-up," explains Ward. "Every six months, we contact each health care provider to update the child's access to health care and to record the physician's services to the child."
Using Case Management Techniques
"We have good feedback from at least half of the providers, but we have to track down the rest to assure that the child is getting regular care. If we don't hear from the doctor, we write him or her again. Then we send out a letter to the parent and follow up with telephone calls or home visits."
"This extra tracking explains why we call our work case management," trained social worker Ward explains. "Families have so many diverse needs, and they sometimes need multiple services. This type of followup takes time and concentration, but isn't reflected in our statistics. The extra effort pays off in the child's health outcomes over time, however."
"This is also where technology can help assure quality of care," Ward continues. "Without computer technology, we couldn't handle the 3,000 Middle Georgia families we are monitoring right now."
Christy Sims, County Nurse Manager in Twiggs County, praises the fact that Children 1st acts as an advocate for families and provides an integrated approach to services for the child. "Because Twiggs has such a small population, about 12,000, my job combines the Children 1st process with several public health service programs, such as Children's Medical Services and Babies Can't Wait. I make home visits regularly to numerous homes for various reasons, and I sometimes find infants and children who are not getting the services they need."

10 Children 1st in Middle Georgia

"On a recent home visit I found an infant who at 11 months couldn't pull herself up. With the mother's permission, I enrolled the child in Children 1st and set her up with WIC nutritional supplements and regular doctor's appointments. Now the infant is progressing well."
"Children 1st was the most efficient way to get this mother and child into the services they needed. Now we will follow this family to assure health care for the child until the age of four," Sims concluded.
Collaboration Among Public Agencies and Private Organizations
Ward and McDuffie attend community meetings regularly to promote the Children 1st system and encourage local health and social services agencies to help locate and

refer families. Partners include health departments and other state/local departments, programs, and agencies; pediatricians; hospitals and health centers; and local groups such as United Way's Success By 6 and countywide Family Connection collaboratives in each county.
Ward collaborates with community boards and public health committees involved in maternal and child health, such as the regional perinatal system. McDuffie attends pediatric discharge rounds at the Medical Center of Central Georgia in Macon, a primary birthing hospital for mothers from Bibb County and other surrounding counties.
Staff members from several public health programs in the district meet frequently to review new births and compare notes on who is doing what and who is taking the lead. These programs include, for example, Babies

Bibb County public health nurses Peggy Schaveland (far right) and Sandy Milleman record information about 4-month-old Isaiah, who was born prematurely. When the mother, Gaby Johnson, was unable to bring the infant to the health department for a needed blood test because she lacked transportation, the nurses visited the home. After taking the blood sample, the nurses reviewed a schedule of up-coming immunizations and the availability of transportation services that could help the mother, who also has a 13-month-old son Cyle. Isaiah has been enrolled in Children 1st since he left the local hospital's NICU (neonatal intensive care unit).

""""""2a"1t"72sr2"4sai6sR3nep(pi4ppils(0"er2ncpa"iW af7tvta1a"ofal3"eiarperun6irrre"pcIenrrrSeReadmCDgaRnrKeeenaQcceRnnearAeeculntsrhietrpioeisoetfIstdsndlsyfseuredsstessitnetrftilssshgrneerrnidrerrtatrtoeenFrevemhrrrsoetengrerfstorseegfirreefeofesercdtseooefdbGtrietenrerdefioehre4dtfrrserr1fdEhorr9erse2cneeeferrrre6e1DeltdeSder6erfdll2oidd53eerroptfinryfdt2raece3c80orefrwfHafecofrfs1doomarh9,noofeRdtogrircCoiru1gnir2nericdmlfqhpenrlehrdeot0htdehmghasoiussgsmrifplr0m6g-ei:l)oodutRealtdet0)ra-dsaouaoorpbrrneuirn)r)siderltsn,fesrlpsnMkeeBtoointuksttannDdrorniaaoeyitIloel'giinttynsdonbrmsrnpoddihvetenffcigMofruasueiaeiefadpctiecerecbshnctanneanurehrrtttaieltlvCddtrrvisictited5vcaasbhFiicaaa2icc-nerlnouao2ho0tnetasfuilehssuneeohr0ols'lipteotonnran1drePrmtSwovWmmihspaleteMrfitipceiee-chtarolraseUhatlrvedcecinihcisosdnippttvirisa.lahaic,cgiddogsretleCmalaeernrlnayseeasrlrac,teivuemnapnitrGoaiipae,tqrcdsnine(aproaeusodceno(scaJrterecgirutttroiielsoayrrdn:1--

Children 1st in Middle Georgia 11

"Infant Leah Shelton of Perry, Georgia, who has Down's Syndrome, was enrolled in Children 1st shortly after birth and was referred immediately to Babies Can't Wait for developmental therapy. Her mother and father, both college graduates, are grateful for the services that this federally funded program offers to families of all income levels.
"I never thought I would need the kind of support system now available to us," says Leah's mother, Teresa. "Now I don't know what I would do without it. The therapist has taught us several techniques we can use to contribute
to Leah's physical development--such as facial exercises to stimulate her cheeks and build her upper lip. We've learned so much that will contribute to her progress, and if we need a speech therapist later, we'll have one."
"By the time Leah was born, we had already gone through a sort of grieving process--begun when the amniocentesis revealed hydrocephalus. So, after her birth we were ready to accept her and love her as she is. Her three-year-old sister adores her."
On a recent home visit with the mother, Houston County Children 1st nurse Louise Peyton learned that Leah is now turning over, both ways, and can pull out pegs on a peg board.
"Every child deserves a chance to grow up in a good environment--physically, psychologically, and mentally--and not all children have this chance," Peyton said. "Many times, parents just don't know what services are available to help them. Most parents welcome the information that Children 1st brings to them. They understand that we are here to help."

Can't Wait, Children's Medical Services, and WIC, all of which receive referrals from Children 1st. The goal is to coordinate services to prevent a family from being overwhelmed with home visits from a variety of providers.
Ward and McDuffie give out information at health fairs and conduct training sessions for nurses, doctors, and health personnel regularly, giving out appreciation awards to their

collaborators. In 1999, for example, the team trained in-hospital data entry clerks about their important role of recording newborn data accurately.
"These clerks contribute greatly to the Children 1st screening system, but they sometimes don't feel appreciated," says Ward. "We train them and give them feedback about the significance of their daily work. We give them

12 Children 1st in Middle Georgia

munity services. The coordinator forwards this information to planning groups, such as the Family Connection and Success By 6.

In Macon, Yolanda A. Law and Tammie W. Collins of United Way participate in a broad community effort in Middle Georgia to improve the lives of children under six. The goal reflects the name of the United Way initiative, Success By 6. They work with a large network of organizations and agencies to examine and evaluate strategies that work best.
Certificates of Appreciation because we respect their work for its relevance to each child's future."
All of the District 5-2 health and social service partners have "bought" into the system. They realize that only an actively managed, computerized system like Children 1st has the capacity to track health care continuity. Leila Anderson, Director of the Family Connection `Kids' Journey' in Houston County, says she can't imagine how communities functioned earlier, without Children 1st.
"Someone has to pay attention to children during these early developmental years before they reach school," says Anderson. "Also, the Children 1st county-bycounty data on `unmet needs' helps our community plan for the future."
Part of the Children 1st family assessment process is to record any family needs that cannot be addressed through current com-

Children 1st Helps to Integrate Child Health Services
The value of persistence is evident in the state's continual progress in making the health system work for children and families. Dr. Joseph R. Swartwout, District 5-2 Health Director, headquartered in Macon, says of the system:
"Children 1st is the focus for coordinating all child health services. The leaders of these services learn from Children 1st about any problems we are having with continuity of care, and they meet together periodically to better integrate their responses to family needs."
"Children 1st also plays an expertise role with outside organizations. In Baldwin County, for example, a recent referendum passed a 1 percent sales tax to create a 04year-old program in the school system. Our Children 1st experience and our eight years of data will help us participate with the county in the development of this new program. "
"We can't have education without health," Dr. Swartwout continued, "and Children 1st is a very important part of public health. Children 1st is the pole that holds the tent up, so to speak, because of its home-based assessments, computerized follow-up of care, and case management characteristics. Over time, we will show positive outcomes in terms of child health status."

Children 1st in Middle Georgia 13

Dade Caloosa Walker
Chattooga Gordon

Floyd

Bartow

Polk
Paulding Haralson

Health District 1-1

Children 1st in North Georgia

T he ten rural counties of Health District 1-1 are nestled among hills and valleys in the top northwest corner of Georgia, bordering on Tennessee. Rome, in Floyd County, is the largest city in the area, although the fastest growing counties are those further east, close by Interstate 75.
Diane Bock, Children 1st Coordinator for this district, has overseen the reorganization of Children 1st over the past two years. Children 1st currently monitors 2,161 infants and children in the ten counties.
"Our Children 1st system is now a truly integrated child health approach to helping families," Bock explains. "We learned in 1998 that we would need to bring resident Children's Medical Services clients into our district for ongoing care--instead of sending them to Atlanta for care. This meant that we had to reorganize."
To handle referrals for these additional clients, and to better integrate the district's Children 1st screening and assessment system, Bock began hiring child health

coordinator nurses for each county health department. Each of these nurses works closely with Babies Can't Wait service coordinators, as well as other county maternal and child health programs such as WIC and the immunization registry.
"If we help infants and children early, and keep them healthy as they grow up, they will be ready for school," Bock says. "If a child can't learn, and gets labeled as a slow learner, the child's performance will get worse and worse. If we don't help little kids now, and look at the whole family situation, problems will escalate. The children suffer, and ultimately the community suffers. Early intervention saves children and saves money."
Cathy Green, County Nurse Manager for the Bartow County Health Department in Cartersville, cites Children 1st as an excellent umbrella for screening and service referrals. "Although Children 1st is not well known to the public, we have seen its successes in our public health program here in Bartow," she

Father and mother Steve and Laura Day admire their new baby girl, Stephanie, in the Cartersville Medical Center, Bartow County, some nine hours after her birth.
Through Children 1st, it is Georgia's intent for health practitioners to know the health status of every infant at birth, to follow up on any infants who need special care after birth, to ensure that all infants and children have a regular health care provider, and to help any families who need referrals and followup to ensure the health of their children.
14 Children 1st in North Georgia

Diane Bock, right, Children 1st Coordinator in North Georgia's Health District 1-1, reviews the birth records of a newborn with Nicole Nowell, Bartow County Health Department Child Health Coordinator.
says. "When our Children 1st nurse Nicole Nowell goes into family homes, she learns about issues that greatly affect the child's growth and development. She finds unsafe housing and lead hazards that can be corrected; she finds a newborn's siblings whose health care has lapsed; and she finds toddlers with impaired hearing or vision who need services right away."
"Because of our rapidly growing population," she continues, "we will soon need more than one nurse here in Bartow to handle Children 1st functions. As it is, we cross-train our other public health nurses to do Children 1st family assessments also."
"This is a great system. If we can keep each child healthy, we will not only contribute positively to the lives of these

children, we will also save hundreds of tax dollars," Green believes.
Margaret Bean, District Director of Public Health Nursing and Clinical Services, remembers when Children 1st began in her district in the early 1990s--with one computer and no funding. "We didn't realize the potential of this process at first, but now we wonder how we ever did without it."
"This is public health at its best--strategically linking people and systems and programs and communities. Rather than concentrating on direct clinical services, public health can offer case management for an entire population through Children 1st-- by steering families to needed services and mobilizing communities to develop resources for unmet needs."
"A crucial aspect of this type of case management is to reach the at-risk children early and educate parents about child health and development," Bean observes. "Children with minor medical problems can develop major problems if they are not referred to treatment and monitored regularly; respiratory distress can turn into asthma, and ear infections can lead to hearing loss. No one family can have all the knowledge it needs. Children 1st brings information about both medical and community resources into the home."

Nurse Carla DeBerry, the Child Health Coordinator in Chattooga County, sees Children 1st as the umbrella for all child health services in public health and for all referrals to private health providers and community services.
"We all work together in this community to see that families get what they need to keep their children healthy... from infant car seats to appointments with specialists," DeBerry says. "I am busy every moment ...talking to new mothers, visiting homes, following up on Children 1st and Children's Medical Services clients...and linking this information to other public health programs such as Babies Can't Wait. I enjoy my job!"

Nurse practitioner Robin Shepherd and her husband own the Trion Medical Center Walk-In Clinic, a Christian ministry in rural Chattooga County. This is the only walk-in medical clinic in the county, and the only clinic open on Saturdays. She is one of the private practitioners who receives Chattooga County Children 1st referrals.
The center recently initiated a Spanishlanguage clinic for the many Latino families in the area, many of whom have no health insurance. Shepherd has also organized an indigent medication program that helps low-income families.

Children 1st in North Georgia 15

Angel Padgett of Summerville, in Chattooga County, is now a healthy 19-month-old toddler. However, she was born prematurely at 24 weeks' gestation, weighing 1 pound 4 ounces. After leaving the hospital neonatal unit, she received medical oversight from high-risk infant nurses and received developmental therapy from Babies Can't Wait. Angel's mother, Linda Wade, responded to the help Children 1st offered and attended parenting seminars, studied child development literature, and began working as an assistant in the Early Head Start Center where Angel is now enrolled.

"My baby has struggled to reach

this point," says Wade, "and I'm

going to do everything possible for

her to have a healthy, productive

future. I am so glad that Children 1st

is there to help me."

Quarterly Reporting

Pam Payne, Children 1st Nurse and Child Health Coordinator in the Walker County Health Department, loads a baby scale and a Children 1st tote bag of gifts into her station wagon for a visit to a new baby's home. Voluntary home visiting is key to the Children 1st approach to building relationships with parents and showing that county nurses care about each child's health. Most new parents welcome the visit and the resource information they receive.
"Home visiting is an important part of Children 1st," she says. "You don't know what new families have to cope with until you go to their homes. Three out of four of our families don't have telephones. We make an effort to reach them to tell them about the health care referral and follow-up system."

iRn""e"c""fSlDeueRtrRuRdiAprceitIeraneiedrtfiosfeineflgdsteeensemergnrrretttrrsreoohtibersetaidshefieddesoedeco5rt2f5d12horn336fi22e41elr08l7et7pstorioc,3on1tnawcch28fqiHCgcoahni0ilunaihmeihdng0glagtdii0rtlh-6mlsadrer:rd)t)-ie,nnrseRtruonekDerdinstnnioBokitsinrot'aftsieyprnIftbnpiafMhcuesirftnteeebrahievrts1rlnesad2via-cCitl10iaritcceFfa0hnhaoieon1nemdorlslam'lmfitSNoteclhseWtwdhoechcrerivisaar-cltUmdisihlaticatepry,leeeGmrepsidnae,aeri,oacar(aqrascn(gecJtuldieicutpaaioolrr:yrantedce1r--rs """""""""1"5p"7t"285r1to72p5a8rc(71rp7ap8pl6a1oiptf8i21np8aaotiao0runpae0p0iaertprrr7nrpriiar8etaensronaKapegaeenrmn(rntgccnraieWsensrdtetsyhe)sntorsnaternsseI,sintetrtClrrshtsnrsdeEvetfssreseeietfnrrfirosserfecerreefretgerrsereerafrnferrferleerFsferrineedresreerofrredrdcherrerfdoeefdreeerofdedfrafderdoforedfrosrorSrefdlfrrfoeortaofdesmaorcgrutredormlsfeabecmoroepmetnhalstrpcohptpaitsdoasflpaielrodMr)nunonolelrooglyvddccnehtdym,ieaudteeclmhaarcaieedaeceotnnsedlunbiatuvgndshuctuiesedutaccisnrsnaacetvhoeouigootguirerpictvu,onraenePriinon,tlcessepitresooehvcaerltnrseoilrlcsnaiaaGngenhgsnltrrEgCsivasoseDaua-imnascnprensde-sd

16 Children 1st in North Georgia

Children 1st Responds to Family Needs

Emphasis on Family Support
Children 1st stresses that a positive and caring family environment is the precursor to a infant's healthy growth and development-- and a primary component of child health. This conviction is the rationale for the inhome family assessment process and for the broad-based environmental risk criteria included in the screening and referral form. Another foundation of Children 1st is the belief that families gain confidence through parent education and joint decision-making.
In Cobb and Douglas, the two Greater Metropolitan Atlanta counties that constitute Georgia's Health District 3-1, Children 1st and other public health approaches are combined into a unit called Family Support. This unit is managed by Sandra S. Adams, Children 1st Coordinator for the district.
"In our two counties Children 1st is the single point of entry for children up to age four into the public health system," Ms. Adams reports. "This has resulted in much better coordination of all public child health programs and an integrated system of referrals to private practitioners and community-based services."
"We moved to `family support' as the title for our unit because we realized the extent to which a family's environment affects the health outcomes of its children. Eight twoperson teams perform the family assessments

in the home and follow through on referrals in a family support/case management style. Each team finds at-risk children and gets them into services that will help them."
"On every team we have an R.N. and a family support worker, backed up by our central office staff members who maintain the Children 1st database and stay in touch with the health providers the families have chosen. These teams meet regularly with representatives of all child health programs, such as Babies Can't Wait and Children's Medical Services, to review families' needs and respond to them in a coordinated, family-friendly way."
Bilingual Communications and Cultural Responsiveness
In many areas of Georgia, from the Vidalia onion fields of the south to the carpet and chicken industries of the north, the influx of Spanish-speaking families has been substantial throughout the 1990s. Today, Georgia's Spanish-speaking population numbers about one million. Many are agricultural and construction workers, although others own small and large businesses and have substantial incomes. Most of the hourly-wage workers and their families have immigrated from Mexico, sometimes through California, and some are from other countries.

Children 1st Family Support Worker Carol Spears and Sue Lepper, Supervisor, prepare for a home visit in Douglas County.
As Lepper says, "We practically never have a family decline enrollment in Children 1st because of all we have to offer: familyoriented assessments and follow-up efforts to keep their children healthy. Further, we are seen as friendly, caring, and nonjudgmental!"

Dr. Brenda Marino, neonatologist, who oversees neonatal services at WellStar Kennestone Hospital in Cobb County, refers about 750 babies to Children 1st annually. She is convinced that the family support approach to health will benefit these children.
"NICU babies are getting smaller and smaller," she warns, "with resultant developmental delays that might not be noticeable until after the baby leaves the neonatal unit. Young couples and teenage mothers might not realize that these fragile infants are not developing as they should. Without Children 1st, these babies might not get the individual follow-up that they and their families need."
"Babies born at 23-24 weeks' gestation are now surviving because of our incredible technological capacities. But when they survive, they face many serious developmental hurdles. The parents of these infants need intense levels of support to ensure that the child will develop to its full potential. They don't know what the community has to offer them, and Children 1st staff can help them learn."

Children 1st Responds to Family Needs

17

Jesus Gregorio Paredes, 7 months, visits the Gordon County Health Department with his grandfather, Jose, a native of Mexico who moved to Georgia with his family after living in California. A bilingual health worker helps nurses interpret specific health instructions for Spanish-speaking clients.

Report from a Children 1st coordinator:

Many health districts now have

"In one Children 1st home visit, a public health nurse visited

Spanish-speaking health workers

a first-time Guatemalan mother who did not speak or

and bilingual interpreters who have understand English. A bilingual staff member accompanied

improved communications and

the nurse, however, and they learned that the mother did

health education for these new-

not know how to take care of the baby. They also learned

comers. In the counties around

that a family relative was coming to the home every day to

Gainesville, the headquarters for

care for the infant while the mother rested."

Health District 2's Children 1st, the increasing need for bilingual health providers has been substantial because of exponential growth in the Latino population. Tonya Newsom is the Children 1st Coordinator in this

"During the home visit, the nurse demonstrated to the mother how to mix formula, feed the infant, and hold and burp the baby. She also encouraged the mother to
always hold the baby while feeding her, to strengthen the infant-mother bond."

13-county district.

"She linked the mother to Spanish-language

In 2000, during a Children 1st home visit

health teaching classes at the county health

for a child, two bilingual family assessment

department where the baby would be

workers discovered a 3-month-old baby girl

weighed each week to ensure the

who had been having tonic klonic seizures.

infant's adequate weight gain

This was an infant who had been born

and growth."

healthy and was not enrolled in the Children Increasing

1st system, even though she had been in the numbers of local Latino

birthing hospital's Neonatal Intensive Care families have led to cultural responsiveness in

Unit (NICU) for a period of time.

several other Georgia health districts. Children

The Latino mother said she had taken the 1st nurse Lisa Palmer in Glynn County took a

baby to a physician for treatment, but had

12-week Spanish course that has helped her

been turned away because she did not have communicate with Mexican families who have

an interpreter with her. The Children 1st work- come to the Brunswick area to work in

ers immediately arranged an appointment

seafood-processing plants. She frequently

with Dr. Greg Smith, a local pediatrician. After meets the Latino mothers first when they are

examining the infant, Dr. Smith admitted her pregnant, through the perinatal case manage-

to the hospital and took charge of her care. ment program she also works with."

With this help from Children 1st, the baby

"It makes a big difference when we go into

began to receive appropriate care. The family the homes of the families and become accepted

is now being monitored.

and trusted," she says. "You'd be surprised at

"This event is an excellent example of the the mothers who will wait for our visit before

ongoing need for us to target a coordinated they will call the doctor about a problem.

system of care for the Latino population," Knowing that a friendly `baby nurse' under-

Newsom says. "With proper funding and

stands them and agrees with their concerns

resources, Children 1st can provide this

gives them the confidence to go into a health

important service."

provider's office to follow up on a problem."

18

Children 1st Responds to Family Needs

Program assistant and interpreter Guadalupe H. Valdez, who works in Marietta for Health District 3-1 (Cobb and Douglas counties), recently accompanied a Children 1st nurse, Jean Bradley, in a visit to the Trevino home to check on the youngest baby, Karina. Seora Valdez explained to the parents, Bernardo and Matea Trevino, and brother and sister Bernardo, Jr., and San Juanita, how to watch the baby's behavior for specific stages of development. She emphasized that holding, talking to, and singing to the baby encourages brain cell growth and stimulates cognitive development.

Responding to

medical appointments. In many cases, the

Family Environments:

home visit ensures culturally appropriate

Talking to Parents at Home

assistance--such as arranging for inter-

Visiting families in their homes--known as preters if the parents do not speak English.

home visiting--is a proven way for health

The Children 1st family assessment

and social services agencies to inform fami- process operates on the assumption that

lies about community-based programs and to informed families can determine what is in

develop service plans that will meet their

their best interests, and that decisions about

children's needs. Home visiting has been a children are best made in partnership

part of health and social services systems in between parents and service providers.

the United States for more than 100 years. Another assumption is that all families have

Current programs in many states rely on strengths that can be identified and built

home visits as a way to reach families with upon, and that families benefit from inter-

information, counseling, and referral services. actions with caring, trained individuals who

In Arizona, lay health workers who reside in can present options and discuss possible

the communities they serve have improved solutions amid comfortable surroundings.

prenatal care and pregnancy outcomes for

In many health districts, in-home visits

mothers. In one New York program, parapro- elicit the crucial information necessary to

fessional workers in high-risk areas have

identify needs and refer families to appro-

enabled thousands of families to gain access priate services. In some cases, different

to prenatal care, insured health care, and

programs combine their interests and proto-

other social services. In an Oregon program, cols so that the nurse can gather information

public health coordinators use home visiting for more than one program's purpose.

as their primary route to helping families with In FY 2000, Children 1st conducted family

health and developmental problems.

assessments in 7,068 homes of at-risk infants

In Georgia, Children 1st emphasizes home and children statewide. This was the number

visits by trained nurses, relying on national of in-home assessments out of the 17,260

evaluations that show strong results using infants and children who had received at-risk

this strategy to improve the health of women ratings on the Children 1st screening and

and children. Throughout the state, Children referral forms. The balance of family assess-

1st coordinators note the beneficial impact of ments took place in other ways, through

home assessments on families' attitudes

telephone calls, records reviews, or through

toward and access to local health services, the specific public health programs where

plus their subsequent follow-through with they were receiving care.

"There is no substitute for going

Topics cited most frequently by mothers
as most helpful during nurse home visits in 1999: Gwinnett, Rockdale, and Newton counties

into the homes," emphasizes Peggy Schaveland, a nurse for Children 1st in Bibb County. "We learn about so much that affects the child's health

and development. We can help pre-

vent problems that might not be

evident when the mother and chil-

dren are all dressed up to visit the

doctors' office or health department."

A 1999 evaluation of home assess-

ments in Health District 3-4 showed

that home visits were popular with

42 new mothers from Gwinnett,

Rockdale, and Newton counties

who were interviewed by nurses.

Two-thirds of these mothers were

first-time parents of infants less than

one year old. (See figure at left.)

Evaluators concluded that nurse

home visits should remain at the

core of the Children 1st process.

Nurses take Children 1st "goodie bags" to new parents when they visit their homes to welcome the new baby. The bags contain parenting magazines and diapers, growth charts, nutrition information, educational materials about child development and nurturing, community resource materials, and assorted items such as a sippy cup, toothbrush, bib, and a colorful book to read to infants.
In many districts, Children 1st also reaches out to help families on holidays. In Glynn County, staff members take turkey dinners to Children 1st families at Thanksgiving, and they give out presents at Christmas. The presents are collected at a First Steps luncheon prior to the Christmas season.

Children 1st Responds to Family Needs

19

Growth and Future Planning for Children 1st

At Gordon Hospital in Calhoun, newborn hearing assessments are already routine, under the direction of Dr. Joseph L. Joyave, pediatrician.

Universal Newborn Hearing Screenings
Children 1st has an integral role in implementing Georgia's new universal newborn hearing screening program, established by the Georgia Legislature. The program identifies newborns with hearing loss so that they can receive immediate attention. (Delays in treatment can cause increased hearing loss over time, which affects the development of language and school readiness.)
Children 1st coordinators are setting up processes with birthing hospitals so that the results of hospital screenings can be entered into Children 1st newborn files, and so that repeat tests or referrals for services can be processed by Children 1st staff.
"It isn't surprising that Children 1st has been selected to manage the new statewide newborn hearing screening process," comments Rosalyn K. Bacon, Director of the Family Health Branch. "We have the system to incorporate the tracking of this important service for every new baby in Georgia. We will ensure that the screenings have taken place in hospitals, that appropriate referrals are made, and that follow-up protocols are appropriate."

Staff Committees
Several state/local committees continue to improve the Children 1st system. A forms committee, made up of several district coordinators, is making revisions to the screening and referral form, as well as other forms, to respond to the needs of nurses and local health personnel who use the data.
Another statewide committee is studying the effects of changes in statewide information technology on Children 1st work. The Electronic Birth Certificate (EBC) system, for example, can be delayed, to the extent that Children 1st coordinators must use many other methods to identify at-risk newborns. In many districts, staff members use the EBC to double check names, comparing the EBC list with the hard-copy referrals received from birthing hospitals and health partners.
Still another committee is studying the need for improved community-based communications--to better describe the role of Children 1st to health partners and the community as a whole.

A feasibility study in Coastal Health District 9-3 is taking a step into the future by examining one cohort of births thoroughly to determine precisely how many babies were born to residents in the district in 1999. This study is designed to create an accurate cohort of births for the district, with the idea that other districts could use the methodology as well. The difficulties of achieving this include current variations between vital records data, EBC data, clinical records data, and other data on newborns that Children 1st collects on a monthly/annual basis.
Researchers are reviewing files and duplicates or missed births in (1) EBC records for 1999--a year when the system was not operational for a part of the year; (2) electronic clinical records; (3) the electronic immunization registry; and (4) the Children 1st database for the Coastal Health District. Their hope is to ascertain a valid 1999 denominator that would be the accurate number of resident newborns.
Here Children 1st Program Associate Shelley Woodman, left, learns about the progress of the study from Marsha Pierce (middle), and Lori McDaniel.

20

Growth and Future Planning for Children 1st

The Family Health Branch's Single Point of Entry model aims to improve the integration of child health services across the state. This model involves developing a consensus on terminology across public health departments and disciplines, and devising common assessment and intake procedures for a "single point of entry" for children to enter the public health system. The integration of services and policy strategies across population groups will better serve children and families.

Recommendations
A recent report on Children 1st confirmed the essential role of the process in ensuring the health of Georgia infants and young children. The report's recommendations concentrated on several areas:
" The need to obtain secure funding for each health district to respond to the needs of families with children who risk health and developmental problems.
" The need to ensure in-home family assessments for all families considered to be at risk.
" The need to increase public awareness activities about the importance of identifying children early, and following up on the child's health care throughout the preschool years.
" The need to improve the integration of local services to families by furthering state and community partner collaboration.
" The need to improve statewide data management systems to support the required timeliness of Children 1st processes.
The report concluded as follows: "The mission of Children 1st remains: to identify families early so that preventive efforts are taken to ensure that all of Georgia's children have the chance to have a healthy childhood and be ready for school success. The Children 1st system is poised to be the cornerstone of an integrated system in Georgia to address this mission."
For further information, contact the local Children 1st Coordinator at each Georgia District Health Department.

Growth and Future Planning for Children 1st

21

A Children 1st process in every county

Moving Ahead
The Role of Children 1st in Improving Child Health in Georgia
Georgia Department of Human Resources Division of Public Health Family Health Branch February 2001