Discussion and Conclusions
Quality early education and child care have been shown to be associated with lifelong benefits (Garcia et al., 2016). Young children are especially vulnerable to infectious diseases and injuries because of their age-appropriate behavior and abilities, their immature immune systems, and their lack of understanding of risk. Maintaining safe and healthful environments and practices involves removal of hazards and provision of policies and procedures, as well as compliance with quality standards by everyone in the group.
Numerous studies have shown the effectiveness of child care health consultation. This study focused on I/T care. The immediate intervention group showed significant improvement in policy development for safe sleep and child abuse and in education about safe sleep practices, preventing child abuse, and medication administration training. Some improvement in diaper changing and hand hygiene procedures occurred. The delayed intervention (contract) group showed significant improvement in safe sleep procedures, policies and education, medication administration procedure, diaper changing procedures, and care plans for children with special needs with appropriate information and signed by a health care provider.
"The immediate intervention group showed significant improvement in policy development for safe sleep and child abuse and in education about safe sleep practices, preventing child abuse, and medication administration training."
The data collected by ITQIP show that many children with special needs lacked appropriate care plans. After finding little improvement in the immediate intervention group for centers having care plans with needed elements, ITQIP chose this topic as the focus of an MCHB-required continuous quality improvement initiative. ITQIP provided an audioconference for the CCHCs and gave them resources for teaching what should be in a care plan. CCHCs reported that they were most successful at helping the centers have complete, useful care plans for children with disease-specific conditions.
The areas chosen to target varied from center to center. Immunization was chosen by only one center. At the time of the study, neither regulation inspectors nor quality rating assessors were checking whether the center had documentation that the enrolled children were up to date with their vaccines. With little incentive or sanctions, documentation of up-to-date immunization status was poor.
Improvements occurred in some practices specified in selected CFOC3 standards. Many of the directors said they appreciated the help they received from the CCHCs that ITQIP linked with their centers. The director of one center, part of a corporation with centers in 12 states, advocated for improving sleep policies for all the centers in her company. This advocacy could lead to widespread improvement.
"Many of the directors said they appreciated the help they received from the CCHCs that ITQIP linked with their centers."
The centers that participated in this project were STAR 2 and STAR 3 programs that responded to an invitation to participate in ITQIP to improve. They were willing to contribute a modest copayment to work with a CCHC and wanted to raise their STAR rating and consequent higher payments for subsidized enrollees. This selection bias is likely to have influenced the observed improvements.
A limitation of the study is the small sample size due to limited funding for the project. Also, although the study assessed practices for 13 CFOC3 standards (AAP et al., 2011), the centers addressed only three topic areas. Little improvement was seen in topics that were not chosen or chosen less frequently. Change in leadership at the centers with varying levels of interest in working on the action plans made improvement difficult.
Another limitation of the study is the variability in child care operation from one facility to another and from year to year. Evaluators were unlikely to have been evaluating the same children from pretest through Posttest 2. Different teachers/caregivers and children may occupy designated rooms in a facility. ITQIP did not require that the CCHCs spend a specific amount of time with their centers. The time and type of service provided by CCHCs varied widely. Although CCHCs reported the total time and types of services they provided, they were not asked to report the time spent in each type of service (onsite visits, phone calls, or e-mails).
CCHCs support health and safety practices and environments that prevent harm and promote health and development of children, as well as overall wellbeing for families and early education staff. Currently, only 17 U.S. states have a statutory requirement for early childhood education programs to have child care health consultation (Honigfeld, Pascoe, Macary, & Crowley, 2017). Of these, two states require CCHC involvement only if the facility cares for sick children (Honigfeld et al., 2017).
None of the centers in this project continued their relationship with their CCHC after the year of subsidized linkage. Some directors stated that although they found the CCHC very helpful and informative, the cost of the CCHC was prohibitive. Some said they would continue the CCHC on a fee basis if they could budget for it in the future. Other studies have shown that linkage of centers with CCHC improves health and safety compliance. ITQIP showed this is true for I/T programs, too.
This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant No. H25MC26235
Community-Based Integrated Service Systems. The information, content, and/or conclusions in this paper are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. Government.
J Pediatr Health Care. 2017;31(6):684-694. © 2017 Mosby, Inc.