Advancing DULCE’s Strength-Based Approach

DULCE, Developmental Understanding and Legal Collaboration for Everyone, is a universal, evidence-based approach that seeks to transform the ways families with newborns experience the delivery of services and supports. CSSP has been engaged in the evolution of DULCE since its inception at Boston Medical Center’s Pediatric Clinic in 2012, where we led a Randomized Controlled Trial on DULCE through a federally funded Quality Improvement Center on Early Childhood. Since 2015, with generous support of The JPB Foundation, CSSP has led the work of adoption and adaptation of DULCE across the country, where DULCE is now in 9 states, operating in 14 communities and 17 clinics.

DULCE is a partnership between the health, early childhood, and legal sectors, and is delivered in pediatric medical homes located in under-resourced communities. Local clinic sites are typically identified by the early childhood system building organization, and they serve predominately Medicaid-insured patients. DULCE is offered to all newborns in the clinic, with no eligibility criteria other than being a parent of a newborn. This targeted universalism approach to family well-being was designed to reduce the systemic exclusion and stigma families may feel when accessing support, all the while providing tailored resources based on family-identified priorities.

DULCE is a strength-based approach, implicitly designed around The Strengthening Families Protective Factors. By embedding a Family Specialist (often a community health worker) into the medical home to partner with families—and through the support of a cross-sector Interdisciplinary Team representing health, early childhood, and public interest law—families with infants receive the supports and services most important to them. 

The DULCE Family Specialist is trained in the Brazelton Touchpoints Approach, a developmental-relational approach uses strengths-based attitudes and relationship-based strategies to engage with families to understand their child’s development. The Touchpoints Approach is a method of reflective practice which can also assist the DULCE Family Specialist in their critical responsibilities of engaging in critical and sensitive conversations with families to identify their goals in a strengths-based and collaborative manner.

To date, DULCE has led with an aim of implementing the American Academy of Pediatrics’ Bright Futures Guidelines to address social determinants of health. Family Specialists are trained to screen for health-related social needs inclusive of food security, employment security, financial supports, utilities, transportation, housing stability, housing health & safety, maternal depression, and intimate partner violence. Our current success rates build on the evidence from the original RCT:

  • Family participation and completion rates are high—98% and 87% respectively
  • Practices screen almost 100% of families for HRSN, with more than 70% receiving referrals based on those needs
  • Practices saw a 50% increase in the proportion of families completing all well-child visits on time

Building on these successes, our funder, The JPB Foundation challenged us to lead even more intentionally with family strengths and goals, rather than focusing exclusively on need. What would it look like if we built on the success of DULCE to date by enhancing and implementing family care plans, based on the concept of goal concordant care, to support families to meet their goals for themselves and their newborn child? Could DULCE be a mechanism to prompt practice changes so that care is organized and incentivized to meet family preferences and priorities? Can systems to designed and improved to support goal attainment?  

CSSP accepted the challenge and began to uncover the possibilities of family-centered goal setting and care planning within DULCE. Through research and discussions with existing DULCE sites and DULCE’s National team of expert consultants, CSSP began a process of highlighting the ways we can further honor what matters most to families—leading with the family’s individual’s values, hopes, priorities, and concerns. In partnership with three DULCE communities in Milton, VT, West Palm Beach, FL and Louisville, KY, we are co-designing and testing the practice of family-centered goal setting and attainment. As we elicit family goals, support the meeting of the goals, and monitor progress, we will also be looking at what these goals mean at a practice and system level. Local DULCE leaders representing health, early childhood systems and public interest law, alongside parent leaders, will seek to understand the root causes of system successes, gaps and barriers in families realizing their goals, and take action to address those most critical. Capitalizing on the early childhood system building organizations’ role as a convenor, funder and integrator in the community, these local teams will investigate the value of DULCE to detect trends, identify common barriers and gaps,  and ultimately seek to reshape health and early childhood policies and practices.  

CSSP works to advance child and family health through innovations that link early childhood and health systems, building healthy early relationships, ensuring access to concrete supports, and sharing power with families. We believe this approach to family flourishing in DULCE—providing the opportunity to more intentionally address the values, hopes, priorities and goals of parents of young children AND being responsive to families’ concerns and needs—can transform the systems of support that help families thrive. We look forward to sharing our early learnings over the coming months.