New Evidence of DULCE’s Family-Centered Impact

Peer-reviewed journal articles can provide clear evidence of the effectiveness of new approaches to caring for children and families. This week, the DULCE team published an article in Pediatrics, the official journal of the American Academy of Pediatrics. This article–the first of several in the pipeline–presents CSSP’s evidence of the effectiveness of the DULCE cross-sector approach to implementing the Strengthening FamiliesTM framework in primary care for children.

DULCE offers integrated cross-sector care for infants and their families who live in under-resourced communities. Parents meet the DULCE Family Specialist the first time they bring their new infant in for primary care. The Family Specialist, a specialized community health worker, is the focal point of a team the includes a medical provider, a legal partner, a mental health provider and a member of the local early childhood system. The team holds case conferences weekly, and quality improvement meetings monthly.

This new paper presents the results of DULCE adoption in five sites over an 18-month period, beginning in 2017. Quality improvement methods, based on plan-do-study-act cycles, allowed for local innovation within core components of the DULCE approach. The results were impressive:

  • DULCE implementation increased the proportion of infants who received all recommended routine pediatric visits from 46% to 65%;
  • Virtually all families were screened for seven health-related social needs, including food insecurity, financial/employment, housing instability, housing conditions, utilities needs, caregiver depression and intimate partner violence; and
  • Importantly, all DULCE families who disclosed barriers to concrete supports, maternal depression, or intimate partner violence were asked about their desire and preferences for support, and virtually all actually received resources (ranging from resource information to actual goods to facilitated referrals to community-based organizations) through their relationship with the DULCE Family Specialist.

This learning has broader implications, reinforcing the power of principles driving CSSP’s approach to supporting infants and their families: 

  1. Family engagement drives success;
  2. Quality improvement methods support the scale-up of approaches with proven efficiency from randomized trials to broader populations across diverse contexts; and
  3. Cross-sector collaboration is critical to effectively meeting system and family needs.
  • Family engagement drives success. DULCE delivers care where parents already bring their children, and actively engages them in determining the dose and content of the intervention. As a result, 76% of families completed the 6-month program, representing about 90% of those who continued to receive infant primary care at their enrollment site. Rather than singling out families deemed “high-risk” and recruiting them into programs that require commitment of time and effort, DULCE honored the effort that families already put in to bringing their infants in for health care and used a systematic approach to identifying family needs and preferences.

This approach reflects CSSPs practical approach to addressing the effects of racism and reducing bias. For example, many risk assessment protocols tend to be more likely to categorize black or brown parents as “high-risk,” creating a presumption of need (deficit) and increased scrutiny on some families. DULCE’s commitment to universal screening within a relational practice promotes individualized, rather than group, assessment of needs and preferences. DULCE will deepen parent engagement through further evolution that formalizes parent and family goal setting to supplement evidence-based screening methods.

  • Quality improvement can allow successful adaptation to variations in local circumstances and changes over time. CSSP’s Friends of Evidence effort has highlighted some of the difficulties of over-reliance on randomized controlled trials. This new paper replicated (and even exceeded) the results of the earlier randomized controlled trial that formed the basis of DULCE. Innovations included shifting from Family Specialists with training in child development to community health workers, dropping DULCE home visits in favor of greater availability to families at the time of their visits, anchoring DULCE in local and regional early childhood systems, and numerous other changes. This paper demonstrates an intentional approach to evidence-based interventions using statistical process control methods to foster innovation and improvement, while maintaining fidelity to key processes and outcome–rather than more rigid fidelity measures geared to ensuring adherence to fixed models.
  • DULCE embodies cross-sector collaboration to meet the needs of families. This paper, published in a journal read by pediatricians, addresses one of the most vexing problems in primary care: how can the system support families to bring their children in for care? Traditional primary care offers valuable preventive services (including immunizations) as well as screening for common childhood conditions and monitoring of growth and development. However, many families with limited resources don’t receive this recommended care in a timely manner. The health system expends resources to reach out to families and bring them in for care, with mixed success. The DULCE approach identified systemic barriers to care including problems with insurance coverage and transportation and provided relational care through dedicated Family Specialists that helped parents understand and experience the benefits of accessing resources available to them through the patient-centered medical home. This paper’s focus on the achievement of system-defined markers of success–attendance at routine visits and completion of recommended screening and assessment–represents the value of authentic partnership with the systems involved in care for children and families, and the development of innovative resources and approaches that help. CSSP expects that new DULCE sites will be able to use these data to leverage health system resources to support families, and to link DULCE to progress on quality metrics.