ITQIP linked CCHCs with 32 centers. Of these, 16 centers were in the immediate CCHC-linked group, and 16 were in the delayed CCHC-linked group. In all, 59 directors, 348 I/T teachers and 1,490 infants and toddlers were directly involved in ITQIP. Three centers from each group dropped out, leaving 13 centers in each group at the completion of the project (Table 2).
Over the 1-year period of CCHC linkage, 12 of the 32 programs had turnovers of two to four directors. This change in center leadership made the CCHCs' work to improve I/T care very difficult. For the immediate intervention group, three of the original 16 centers withdrew from the project. One center in the delayed intervention (contrast) group closed during the project period; two others withdrew from ITQIP. Some centers dropped out because they were so overwhelmed with maintaining ratios in classrooms and staffing issues that they believed they could not focus on their action plans.
This report compares pretest, Posttest 1 and Posttest 2 scores for the 13 immediate intervention sites and 13 delayed intervention (contrast) sites that remained enrolled in ITQIP for the full 3 years.
ITQIP did not require a specific time spent in the CCHC role for each linkage. The CCHCs in the immediate intervention group provided an average of 14 hours of consultation per site (range = 2.25–28.75 hours). The CCHCs in the delayed intervention (contrast) group provided an average of 12.5 hours of consultation per site (range = 2–32 hours). The CCHCs completed quarterly encounter forms to report the total hours of services to their linked center, including a checklist of onsite, phone, and e-mail services. The most common CCHC interactions with centers included providing health education for the director and staff, onsite consultation at the facility, technical assistance by phone or e-mail, providing print or audiovisual materials, helping the facility comply with state regulations, and developing health policies and procedures.
Topics chosen by the centers in the immediate intervention group and the delayed intervention (contrast) group and the number of centers that chose each topic are shown in Table 3.
Quantitative Comparison of Evaluation Tool Scores on the Pretest Versus the Two Posttests
The scores used in the quantitative comparisons are the sum of all scores on the Evaluation Tool, not only those for the topics that the center chose for special focus (Table 4).
Immediate intervention group. On the pretest, the range in scores was 175 to 267, with an average score of 212 out of a possible 318 points (66%). On Posttest 1, the range in scores was 213 to 297, with an average score of 254 out of a possible 318 points (79%). This change from the pretest to Posttest 1 was statistically significant (t = −4.62, p < .0001). Postest2 did not show any significant change from the average score on Posttest 1, showing that the initial results from the intervention were sustained in the next year (254 to 254).
Delayed intervention (contrast) group. On the pretest, the range in scores was 164 to 271, with an average score of 218 out of a possible 318 points (68%). On Posttest1, the range in scores was 149 to 257, with an average score of 221 out of a possible 318 points (69%). These changes from the pretest to Posttest 1 were not significant. Posttest2 showed significant change in the average score from Posttest 1 (221 points) to Posttest 2 (243 points; t = −1.80, p < .08) a year after this delayed intervention (contrast) group had received their CCHC linkage.
Immediate Intervention Versus Delayed Intervention (Contrast) Groups
The comparison of the average scores between the Immediate Intervention (212) and Delayed Intervention (Contrast, 218) groups on the pretest was not significant, showing that the groups were equivalent. The difference between the average scores of the immediate intervention (254) and delayed intervention (contrast, 221) groups on Posttest1 was statistically significant (t = −3.46, p < .002), showing the effectiveness of the CCHC intervention for the immediate intervention group. Posttest 2 showed no significant difference between the change in the average postintervention scores for the immediate intervention group 12 months after their CCHC-subsidized linkage and the delayed intervention (contrast) group (254 vs. 243) at the end of their 12 months of CCHC-subsidized linkage. See Figure 2 for the crossover comparison results.
Crossover comparison results. CCHC, child care health consultant; ECELS, Early Childhood Education Linkage System; ITQIP, Infant-Toddler Quality Improvement Project.
The crossover comparison results (Figure 2) show the relationship between the immediate intervention and the delayed intervention (contrast) groups in a crossover design. It clearly shows how effective the intervention (pretest to Posttest 1) was for the immediate intervention group and that the effects persisted after 1 year without a subsidized CCHC linkage (Posttest 1 to Posttest 2). It also shows that the intervention was effective when the delayed intervention (contrast) group was switched to receive the CCHC intervention with targeted training, technical assistance, and collaborative consultation a year after their pretest assessment (Posttest 1 to Posttest 2).
For the Immediate Intervention Group After 1 Year of Linkage With a CCHC
Among the items in each topic area (Table 1), the following items showed statistically significant improvement (pretest to Posttest 1).
Medication administration. The director had documentation that the staff who are authorized to give medications have received medication administration training within the year from a health professional (p < .001).
Safe sleep. The number of written safe sleep policies containing the required elements increased (p < .05). Teachers (p < .01) and parents (p < .05) reviewed the safe sleep policies and were educated about safe sleep practices (p < .05).
Child abuse. Child abuse policies contained the required elements (p < .05). Both infant and toddler teachers were educated about child abuse and how, as mandated reporters, they are required to personally report incidents they suspect might involve child maltreatment (p < .001). The number of centers having required clearance documents on file for teachers increased (p < .05).
Active opportunities for physical activity. Infants (birth through 12 months of age) were taken outside two to three times per day, as tolerated (p < .05). Toddlers (12 months through 3 years) went outside except in weather that poses a significant health risk (p < .05).
Diaper changing. Before the beginning of the diaper change, changing table paper was placed over the diapering surface, followed by the gathering of supplies needed for the diaper change from the containers in which they are stored and use of gloves (p < .05).
Hand hygiene. Observed times when toddlers (p < .01) and the toddler teachers/caregivers (p < .05) should have washed their hands showed statistically significant improvement after CCHC linkage.
For the Delayed Intervention (Contrast) Group After 1 Year of Linkage With a CCHC
Among the items in each topic area (Table 1), the following items showed statistically significant improvement (Posttest 1 to Posttest 2).
Safe sleep. Safe sleep policies that contained all the elements that should be in a safe sleep policy per CFOC3 standard 184.108.40.206. (p < .05; AAP et al., 2011). The facility had documentation that parents reviewed the center's safe sleep policy and were educated about safe sleep practices (p < .05). There was no soft or loose bedding or other objects in a crib when an infant was in the crib (p < .05). Caregivers and teachers checked on sleeping infants often enough (about every 5 minutes) to be sure that the infant was still breathing (p < .05).
Medication administration. The name of a child to receive medication was verified before the medication was administered to that child (p < .05).
Diaper changing. Bottom clothing was removed, including shoes and socks, if feet were unlikely to be kept from contacting soiled skin or surfaces. If clothing was soiled, it was removed and placed in a plastic bag (p < .05).
Special needs. The number of care plans submitted that included the required elements in a care plan for children with special needs per the CFOC3 standard 220.127.116.11 increased (p < .05; AAP et al., 2011).
Additional Findings of Interest
Immunization documentation. Only one center chose to work on documentation of up-to-date immunization status as an action plan focus. Overall, the immunization data for the two groups showed low compliance with CFOC3 standard 18.104.22.168 (AAP et al., 2011) and PA's immunization regulations (PA Department of Human Services, 2008). On the pretest, in the immediate intervention centers, 22% of the immunization records for infants and 43% of the immunization records for toddlers were up to date. Little change occurred for this group on Posttest 1 (36% for infants, 43% for toddlers.) On the pretest for the delayed intervention (contrast) centers, 25% of the immunization records for infants and 40% of the immunizations records for toddlers were up to date. On Posttest 1 the delayed intervention (contrast) centers improved from 25% to 38% for infants but dropped from 40% to 27% of the records for toddlers showing up-to-date vaccines.
Care plans for children with special needs. The data for the two groups showed low compliance with CFOC3 standard 22.214.171.124 (AAP et al., 2011) that lists the components for care plans. Combining the immediate intervention and delayed intervention (contrast) center findings for this topic, the pretest showed that 66 I/Ts were identified with special health care needs in the 32 centers initially enrolled in ITQIP. Only 15 (23%) of I/Ts with identified special health care needs had any care plan signed by a health care professional. Only 1 of 66 I/Ts with special health care needs had a care plan signed by a health care professional that had all necessary components for optimal daily and/or emergency care. Posttest 2 showed that 39 I/Ts were identified with a special health care need in the remaining 26 centers. For children identified by the centers as having a special health care need, 62% did not have a care plan. Fifteen (38%) of those with identified special health care needs had a care plan signed by a health professional. Four of the 15 care plans had all the required elements. Examples of children who had special needs and had no care plan signed by a health care provider included children with gastroesophageal reflux taking Ranitidine, febrile seizures, asthma, multiple epinephrine autoinjectors onsite, autism, nonfebrile seizures, and torticollis and plagiocephaly, which required that the child wear a helmet each day.
J Pediatr Health Care. 2017;31(6):684-694. © 2017 Mosby, Inc.