Reflection: HRSA’s Early Childhood Comprehensive Systems Impact CoIIN

The National Institute for Children’s Health Quality (NICHQ) and the Health Resources and Services Administration’s Maternal and Child Health Bureau (HRSA/MCHB) hosted its Early Childhood Comprehensive System (ECCS) CoIIN Learning Session 6 in Atlanta, Georgia, on September 24 – 26, 2019. Having previously led a HRSA team in envisioning, crafting, and establishing this five-year ECCS CoIIN grant project in 2016, I was honored to attend the meeting, participate in many sessions, and provide closing reflections of “pearls, progress, and bright spots.”

HRSA’s Early Childhood Comprehensive System grant program began in 2003 and was originally awarded to all states to build partnerships between interrelated and interdependent agencies/organizations representing physical and mental health, social services, families and caregivers, and early childhood education to develop seamless systems of care for children from birth to kindergarten entry. In 2016, MCHB Administrator, Michael Lu, MD, at HRSA, understood the important foundation that ECCS provided in all states, but wanted to challenge us to answer the critical question about future investments in early system building: “System building, but to what end?”

Hence, the ECCS Impact grant program was created with the bold aim of improving the developmental skills of 3-year-old children by 25 percent from baseline over the next 5 years”. Twelve states and their 28 communities successfully competed for ECCS-I grants and are now in their third year of participating in the ECCS CoIIN, led by the National Institute for Children’s Health Quality (NICHQ). Dr. Michael Lu and I wanted to accelerate early childhood system building, bring CQI methodology to the field, and advance population-based measurement of child well-being. We knew at the time that we would be challenging the states and communities for bold leadership, innovation, and acceleration with such an aspirational goal.

The 160 participants at the ECCS CoIIN Learning Session included representatives from all 12 state Impact Grantees and their place-based communities including family partners, experts, faculty, and NICHQ Coordinating Center leadership and staff. Plenaries, workshops, and breakout sessions for all attendees were built around the key themes of family engagement, health and racial equity, collective impact, data and measures, policy, and sustainability. Parent voice and family leadership were strongly represented with a fireside chat on family engagement and another plenary by the Massachusetts team, “Incorporating a Racial Equity Lens in MA ECCS: Sharing our Process and Journey”. Laura Jana, MD, Janice Gruendel, PhD, Marion Earls, MD, and Dina Lieser, MD all contributed to the learning sessions. Cailin O’Connor, a Senior Associate from CSSP, discussed EC-LINC’s Early Childhood System Assessment and Toolkit. Alice Lam, JD, from Manatt, Phelps & Phillips, LLP, presented an overview of financing considerations for the ECCS CoIIN grantees, as articulated in Fostering Social and Emotional Health through Pediatric Primary Care: A Blueprint for Leveraging Medicaid and CHIP to Finance Change. I had closed the meeting with reflections on the past-to-present ECCS journey.

The ECCS CoIIN has been a journey of discovery and inspiration, far beyond a narrow developmental screening initiative. ECCS-I grantees were inspired by HRSA’s grand vision and rolled up their sleeves to find the paths toward the bold aim. As is so often true at the beginning of any continuous quality improvement effort, the start was “messy,’ which was surely true of the early years of the ECCS CoIIN. Now three years later, there is an emergence of greater clarity, innovation and acceleration. Some of state and local leadership have remained involved since the start of ECCS in 2005. Their collective and shared wisdom demonstrates clear adaptive leadership and strong commitments to iterative learning, co-creation, reflection, and adjustment. This amazing team shows their ability to embrace the fact that “change is the constant” of system building. It is inspirational to see collective impact in action, the use of data for improvement, the intentional linkage between child health systems, public health, and early childhood community building, and family leadership and engagement in all activities. Many of the exemplar grantees of advanced data collection are utilizing unique identifiers at birth, geo-mapping, equity and asset lens, rapid feedback of data to parents and partners, data for political change, data portals, and linkage between Help Me Grow, schools, childcare, and child health. For them, data is a major driver of change.

At the start of the project, Michael Lu and I did not anticipate the extent to which this project would advance systems, family voice, and leadership in promoting “Parents in the Lead.” From the beginning of the project, family engagement and parent voice were established as one of the key drivers within the ECCS CoIIN driver diagram. Hence, ECCS CoIIN and early childhood system building has been established with an equity and cultural humility lens and ever-expanding activities for deeply listening and authentically partnering with families and communities. The teams have come to understand that engaged conversations with community partners often brings a “discomfort edge” along the equity journey of discovery. This ECCS CoIIN community has thus embraced the Five (5) Commitments for Change as noted in EC-LINC’s MANIFESTO for Race Equity & Parent Leadership in Early Childhood Systems. The EC CoIIN community aspires to honor and value all voices, the lived experiences of all partners and families, the history of injustices, racism, and inequities. As one of the ECCS CoIIN grantees noted in the quest to achieve improved developmental health outcomes: “We must honor the resiliency, hope, and possibilities that are arising in our shared faith toward building well-being for all and our collective liberation from the tragedies of the past.”

The ECCS CoIIN project appears to have been a front runner for new investments in early childhood system initiatives and as a result, has widened the path for further early childhood place-based investments: Maternal, Infant and Early Childhood Home Visiting Program, Preschool Development Birth through Five (PDG B-5), Pritzker Children’s Initiative, StriveTogether, Get Ready Guilford, The Early Childhood Learning and Innovation Network for Communities (EC-LINC), and a recent gathering of around 40 national early childhood leaders at Wingspread in January 2019. This visioning meeting was entitled, “Harnessing the Momentum of Community-led Early Childhood Initiatives to Accelerate Impact,” and hoped to advance a framework and early actions to increase the accessibility of the support, expertise, learning, and resources needed to implement well-functioning early childhood systems at scale. I believe that the collective work of the ECCS CoIIN community adds to and continues to inspire a growing movement of the place-based and early childhood system building.

Of course, the national and local context around the ECCS CoIIN is also moving forward. For example, the National Academies of Science, Engineering, and Medicine has released a number of recent consensus studies on advancing child well-being1, 2, 3, 4 with the most recent of which is Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda5, explicitly discussing for place-based, community and data-driven, cross-system efforts to advance well-being. Our ECCS CoIIN community, too, adds to and builds on this child well-being movement.

Early childhood system work has traditionally faced issues of sustainability, but given the growing emphasis on population health, Medicaid redesign, social determinants of health, value-based payment and outcome-focused efforts, future sustainability with policy initiatives is possible. In addition, expanded system-building efforts within the PDG B-3 grants and future population well-being measurement initiatives will surely bring many new sustainability opportunities. I encouraged the grantees to double down their efforts to take the work to the next level, which can include the identification of new policy levers, a narrow strategic agenda, and an intentional alignment with population-focused efforts.

Most of all, I was inspired by two major themes that crosscut the two-day gathering: (1) relationships, and (2) the power of narrative. One of the family partners noted, “Our communities can sometimes be without hope, but it’s our relationships that bring hope and possibilities for a brighter future.” As Janice Gruendel discussed in her plenary, our work is all about relational health at every level: early relational health between infants and all caregivers; relational health within families; and healthy relationships within our agencies and communities. The future of early childhood system building will be best driven by the story of real people, real communities, and real measured change. These teams of people are eager to tell their stories, share their learnings, and make visible their data. And most of all, what appears to drive the day-to-day efforts of this ECCS CoIIN community was best summarized by one of the fireside chat panelists in describing why she does this work. She said, “Success is the difference we make in the lives people every day—for what you give is what you get back a hundred fold.”

This vision and hope for the future of early childhood system building have far surpassed Michael Lu’s and my dream. We believed in the capacity of motivated and inspired people in activated communities to learn, grow, and inspire each other into actions that focus on the future well-being of their young children. Now, we get to witness that dream become a reality.


1 National Academies of Sciences, Engineering, and Medicine 2019. A Roadmap to Reducing Child Poverty. Washington, DC: The National Academies Press.

2 National Research Council 2019. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: The National Academies Press.

3 National Academies of Sciences, Engineering, and Medicine 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health. Washington, DC: The National Academies Press.

4 National Academies of Sciences, Engineering, and Medicine 2017. Communities in Action: Pathways to Health Equity. Washington, DC: The National Academies Press.

5 National Academies of Sciences, Engineering, and Medicine 2019. Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda. Washington, DC: The National Academies Press.