HEAD START®

Well-Child Health Care: Making It Happen

Training Guides for the Head Start Learning Community

Table of Contents | Preface | Introduction | Module 1 | Module 2 | Module 3
| Continuing Professional Development | Resources

MODULE 2: partnerships in ongoing well-child health

Outcomes | Key Concepts | Background Information | Activity 1 | Activity 2 | Activity 3 | Activity 4 | Activity 5 | Activity 6 | Activity 7 | Activity 8 | Activity 9 | Next Steps
download these pdf attachments: Handout E | Handout F | Handout G | Handout H | Handout I | Handout J | Handout K | Handout L | Handout M | Sample Copy: Everyone's Role in Screening | Key to Activity 9: Keeping Up - Tracking Health Services

Outcomes

After completing this module, participants will be able to:

• prepare a strategy for assuring the delivery of well-child health care to Head Start children, based on community assessment;
  
  
• evaluate the quality of their program's screenings, exams, observations, and communication with parents regarding procedures and results;
  
  
• support parents in providing follow-up services to address identified health needs and track the provision of well-child health care services; and
  
  
• evaluate and improve their ability to individualize the Head Start program to match a child's identified needs.

Key Concepts

Well-child health care is the concern of all Head Start staff. The role that each staff member takes will vary, depending on the needs of their Head Start children and the services available in their community.

High quality screenings and exams are characterized by:

• Establishing partnerships with parents, Head Start staff, the "medical home," and the Health Services Advisory Committee
• Employing qualified individuals to perform the tests
• Utilizing standardized methods appropriate for the child's age and background
• Using creativity to solve challenges to accurate screenings and exams

Staff members individualize the Head Start program by responding to information they gather from each child's screening and from insights from the child's parents.

Head Start staff provides education for parents, as needed, so they can learn to obtain and administer medication and implement the follow-up plan after health needs are identified.

Background Information

A. The Elements of High Quality Screenings and Exams

Qualified and Trained Examiners

The initial screening and exam period around enrollment is the ideal time to link a child and family to their "medical home." The medical home provides the entire family with ongoing accessible health care. Once linked to a medical home, the parents can develop a long-term relationship with the health care provider. Medical and dental exams must be done by licensed health professionals—the medical exam by a physician, nurse practitioner, or physician's assistant, the dental exam by a dentist. Professional standards require specific procedures and equipment. In addition to the physical and dental exams, properly trained professionals at the medical home will test for anemia, tuberculosis, lead, metabolic disorders, or parasites.

To ensure the provision of well-child health care for each Head Start student, it is essential that Head Start staff assess the community of their families. For example:

- Is there a provider who can perform good developmental screens?

-Are pediatric dentists available?

- Do office hours accommodate working parents?

The Head Start program can then tailor its services to dovetail with existing services. Since well-child health care is a long-term goal, and children may spend only one or two years in Head Start, working towards continuity is important. Head Start's efforts are twofold: to assist families in accessing health services during their time with Head Start, and assuring that families are able to continue with their care in the future. Head Start works with health professional in the local community without duplicating their services.

In some instances, screenings for height/weight, vision, and hearing are performed by properly trained Head Start staff, parents, or volunteers—not the medical home. The Head Start staff does screen to identify concerns regarding a child's developmental, sensory, behavioral, motor, language, social, cognitive, perceptual and emotional skills. The screens are age and language appropriate for the child. Since information and techniques may change, training should be updated regularly.

Standardized and Appropriate Instruments

Instruments are the tools or methods that are used in screening such as the developmental checklist, nutrition questionnaire, and vision charts. High quality instruments are:

- Standardized: The screening instruments should be developed by experts and tested on large numbers of children. They must be "reliable" and "valid"—accurately assessing the child's capabilities when trained examiners perform them correctly. They must also be "normed" to determine the "normal range" of test results around the average that includes 95% of the healthy children tested.

- Appropriate: Screening instruments should be appropriate to the program's needs and resources. Programs should identify screening methods that are comfortable for the children. The time for screening should be short enough for a child to maintain concentration. Ideally, programs should use screening instruments normed on children of similar age, gender, culture, language, and economic background.

Effective Procedures

Evaluating the quality of screening and exam procedures can be subjective. Programs must aim to provide the best experience possible for all participants. The process should:

- Allow children to perform at their best. Children should be prepared in advance. During screenings and exams they should be made to feel comfortable, and the surroundings should help them concentrate.

- Involve the parents. Throughout all exams, screenings, and observations, parents play an important collaborative role. It is important that they understand the procedures their children will undergo, give their consent, and understand the meaning of the results. Head Start staff should be able to explain all procedures and test results, even those they do not perform. Parents should be encouraged to ask questions about the procedures and results. Parents know their child best and can provide valuable information for screening. They should be encouraged to serve on advisory committees, to review procedures, assist in classroom- based screening, and accompany their children to the medical home for clinic-based screenings and exams.

Following Up On Screenings and Exams

- Assessment or diagnostic evaluation provides more in-depth testing or examination to determine whether, in fact, a child has a special health or developmental need. It is done by specialists in child health and development such as a physician, dentist, or psychologist. It also involves the parents, staff, and often other agencies such as schools, developmental centers, and the medical home. Assessment might include standardized developmental tests, specialized physical exams (e.g., neurological or occupational therapy evaluation), and laboratory tests (e.g., blood tests, urine tests, or X-rays).

The assessment might indicate that the child has:

- no specific problem and no follow-up is needed

- no specific diagnosis but some concerns; further observation and follow-up testing may be recommended

- a diagnosis of a health condition and recommendations for treatment and follow-up

- Diagnosis is the specific medical or developmental condition determined by a health professional. For example, a physician might diagnose anemia, and a psychologist might diagnose a learning disability.

A diagnosis helps to understand the child's condition and make specific recommendations for treatment and follow-up. It must not be used to label or stigmatize a child.

- Treatment, therapy, or intervention is the process of caring for any condition that the health professional diagnoses. The treatment aims to cure a health problem or reduce the impact of a disability. For example, a doctor might prescribe medication for anemia, and a psychologist might recommend special education services for a learning disability. Parents and staff in partnership are responsible to see that follow-up plans are developed and implemented.

- Follow-up involves re-evaluation of the child's progress by the parents, staff, and health care providers. How soon, how often, and with whom follow-up is needed depends upon the health condition and the treatment. For example, a child with a simple health problem (e.g., an uncomplicated ear infection) might need a single follow-up visit with one health care provider. A child with a more complex health problem (e.g., failure to thrive resulting from severe child neglect) might need frequent follow-up visits and evaluations over a longer period of time with many different health specialists.

Procedures need to be in place to track both well-child health care and treatment for medical needs. It is important to work with parents to ensure follow-up treatments for diagnosed medical needs found during the screening process. When there are difficulties in following up, it is crucial that program staff, parents, and health care providers re-evaluate the situation and work collaboratively to develop strategies to address the challenges. Health screening, exams, assessments, and diagnoses are only valuable when they are followed by appropriate treatment.

B. The Challenges to Quality Screenings and Exams

Head Start staff have many responsibilities in ensuring that screenings, exams, and immunizations are completed within the time frame specified by the Head Start Program Performance Standards. There are many details to coordinate, document, review, and follow up. All this can be very challenging because the process depends on the cooperation of all of the partners—staff, parents, health care providers, and children. Each partner has her own perspective, needs, and particular difficulties. Some of the challenges include:

• The Health Care System: In some areas, it can be difficult to find health care providers who are accessible, accept Medicaid/EPSDT, speak the families' languages, and are sensitive to families' diverse backgrounds. Some health care systems may restrict access to desired services or may not offer services of highest quality.
  
  
• The Head Start Program: Programs may have limitations in staffing and resources for screenings, exams and follow-up.
  
  
• Children: Some children may have difficulty cooperating with screenings and exams. It can be particularly difficult for younger children to complete complex procedures with unfamiliar examiners at the beginning of the school year.
  
  
• Families: Some families may not understand the importance of well-child health care, or they may have other issues that take priority over health care. They may have difficulty taking time off from work, getting transportation, or securing childcare for medical home appointments. Ensuring follow-up may be difficult for some families.

C. The Individualized Health Plan

When medical, developmental, or dental needs are identified, Head Start staff can best meet the needs of children by developing an Individualized Health Plan (IHP). The IHP is a written reference developed in partnership with parents, medical professionals, classroom staff and relevant members of the Head Start management team (dieticians, health coordinators). This plan guides the staff and parents in supporting the health of the student.

D. Everyone's Role in Well-Child Health Care

Well-child health care is an important part of everyone's job. No one person can—or should—be expected to be the only one "responsible" for the health of Head Start children. The responsibility must be shared among all staff.

Through everyday observations, any member of the staff can note a change in the child's health. It may be the dietician who notices the first signs of high blood sugar in a child or the bus driver who observes the first signs of a sickle cell crisis on the long ride to school. An administrator who is spending some time in a classroom can give some individual attention to a child who needs a bit of "TLC" (tender loving care) while recovering from a cold. A home visitor can work with a parent to plan meals high in iron for a child at risk for anemia, or suggest activities for a child whose behavior is challenging.

Questions for Discussion/Reflection

Think about a time when you, a family member, or friend received a screening test or exam. It might have been a physical exam, dental exam, hearing test, cholesterol test, mammogram, PAP smear, or other test.

• How would you rate the overall quality of the experience for you?
  
  
• What made it either a good or bad experience for you? For example:
  
  
  • Was the procedure explained to you in advance?
    
    
  • Were you made to feel respected and comfortable during the procedure?
    
    
  • Were the results thoroughly explained to you afterwards?
    
    
• Did you follow-through with what the physician suggested?

As you reflect on what made the experience pleasant or unpleasant for you, consider the features of screenings and exams that parents and children experience in your Head Start program.

Activity 1: Locating Services in Your Community

Purpose: Management staff will consider the well-child health care components required within the Head Start Program Performance Standards and determine how their own Head Start program can assure that all children receive the services.

For this activity you will need:

• Handout E: Planning for Services
  
  
• Section 1304.20: Child Health and Developmental Services of the Head Start Program Performance Standards for each participant
  
  
• Early and Periodic, Screening, Diagnostic, and Treatment (EPSDT) State Schedule

Step 1: Review with participants the section of 1304.20: Child Health and Developmental Services of the standards that describe essential well-child health care.

Distribute to each participant a copy of Handout E: Planning for Services, and your state's EPSDT schedule.

Step 2: Ask each participant to find a partner. Together, have them discuss the ways that children receive each aspect of well-child care in their community. Have participants consider the EPSDT requirements in their state.

Ask participants to think about the various types of well-child health care providers in their area. For example:

• Is there a sufficient number of dentists in the area? Do these dentist have expertise in treating young children?
  
  
• Are there adequate facilities at the community clinic for hearing evaluations?
  
  
• Are the majority of families covered by Medicaid? If so, are providers willing to accept this payment method for screenings? Do the providers spend enough time on screenings to achieve valid results?
  
  
• Are most families enrolled in a Health Maintenance Organization (HMO) to cover their health care? If so, what well-child health care is part of the benefits package?
  
  
• For migrant families, are clinics open during times when parents are not engaged in fieldwork?

Using Handout E and the state's EPSDT schedule, instruct the partners to rate each aspect of care according to its accessibility and quality: high quality, easily accessible, medium quality, some access, or low quality, not accessible.

Step 3: Ask participants to highlight those services on Handout E which they don't believe are available from the health care community in their locale.

Step 4: Give the group about 15 minutes to fill out their handouts.

Step 5: Ask each pair to choose one service that is easily accessible and of high quality, and share with the group. Ask them to describe how they assure that children receive this service.

Step 6: Ask each manager to use the materials from this workshop in planning the health care services in her own program. Lead a discussion with the participants that explores gaps in services in their community.

What does each manager do to ensure that services which are not currently available become available?

Are there things she can do in the short-term, such as:

• have staff members assist parents in transporting children to providers out of the area?
  
  
• hold some screenings on-site at Head Start?
  
  
• have meetings with local providers' organizations to advocate for more appointment times for Head Start children?
  
  
• hook up with a public health program like Women, Infant, and Children (WIC) to jointly publicize services?
  
  
• other…?

What can program managers do to assure services in the long-term? Can they…

• work with local state or tribal officials to recruit more providers to the area?
  
  
• contact a nearby university to help educate providers about quality services?
  
  
• other…?

Points to Consider:

• Head Start's commitment to wellness embraces a comprehensive vision of health for children and families. To achieve wellness a variety of health services are necessary. Head Start staff face challenges as they help families access quality, comprehensive health services.
  
  
• Head Start's role is different in different communities. Some Head Start programs may find a need to carry out some screenings on site. Others may find that the community providers' services fit nicely with the Performance Standards.
  
  
• How do we determine Head Start's role in the provision or tracking of services?
  
  
  • What aspects of the community situation contribute to quality?
    
    
  • What aspects of the situation may reduce the quality?
    
    
  • Some strategies to support the strengths are…
    
    
  • Some strategies to overcome the quality problems are…
    
    
• It is important to realize that short-term and long-term strategies can be carried out simultaneously. Both are essential in achieving the goal of high quality, comprehensive services.

Activity 2: Taking Inventory of Screenings and Exams

Purpose: This activity helps participants assess how well they, as individuals and as part of the total program, promote well-child health care. They will discuss the strengths and weaknesses of their program's screenings and exams, and identify areas for improvement. This activity is helpful for staff from all service areas.

For this activity you will need:

• Handout F: Taking Inventory, for each participant

Step 1: Distribute Handout F: Taking Inventory. This worksheet will help determine how well you are doing in well-child health care and screening. Take a few minutes to answer the questions.

Step 2: For each question on Handout F: Taking Inventory, ask a participant to briefly explain what it means and why it's important.

Step 3: Discuss the following questions, citing examples from specific screening and exam procedures (e.g., hearing test, screening for developmental concerns, etc.).

• Based upon the results of your worksheet, what screening activity do you do best? Which do you need the most help on?
  
  
• What does your program do best? What does your program need to work on?

Step 4: Discuss the following questions, again citing examples from specific screening and exam procedures:

• How do you think the children feel about the screenings and exams Head Start is required to complete? What could you do to make them ready?
  
  
• How do you think the parents feel about the screenings and exams? What could you do to make them feel more comfortable and involved?

Step 5: Ask participants to identify for themselves one aspect of screening that they would like to improve over the course of the school year. Write it down, sign it, and give it to your supervisor or partner. Ask the supervisor or partner to put a reminder on the calendar for the month of May to discuss how progress is going with screening.

Points to Consider:

• Head Start programs are required to document certain screening procedures in order to comply with the Performance Standards (e.g., completing screenings and exams within the time limit).
  
  
• Programs should also strive for the highest quality in well-child health care for Head Start children and families. Attention should be paid, for example, to truly preparing children, involving parents, supporting families' relationships with their "medical homes," and making best use of the Health Services Advisory Committee.

Well-Child Health Care: Making It Happen...

Baby Bottle Tooth Decay is decreasing in Alaskan Communities! The solution? Parent dental health advocates trained in oral-wellness curriculum are dispensing parental support, toothbrushes, and good information throughout the community.

Activity 3: Everyone's Role in Well-Child Health Care

Purpose: This activity give participants the opportunity to review a story of one Head Start program's experience with screening and identify the roles and responsibilities of all the partners: Head Start staff, parents, children, and health care providers. Participants will identify the challenges to good screenings and develop strategies, including advocacy and collaboration building, to overcome the difficulties.

For this activity you will need:

• Handout G: Health Screening at Twin Oaks Head Start, for each participant
  
  
• Flip chart paper and markers, or blackboard and chalk

Step 1: Explain that this exercise will illustrate the importance of everyone's role in screenings, identify challenges to good screenings, and develop strategies to overcome them.

Step 2: Distribute Handout G: Health Screening at Twin Oaks Head Start. Read the story aloud or ask a participant to volunteer to read it aloud.

Step 3: Explain that we will diagram the Screening Story. Staff, parents and health care providers all support health screening like spokes support a wheel.

Following the sample copy of Everyone's Role in Screening as your guide, draw a circle with the word "health screening" in the middle on flip chart paper or on a blackboard. Draw and link at least five smaller "role" circles to the "health screening" circle.

In each role circle, have participants list a partner in screening:

• Staff (e.g., Teacher, Health Coordinator, Family Service Worker)
  
  
• Parents
  
  
• Children
  
  
• Health Care Providers
  
  
• Community Volunteers
  
  
• Health Services Advisory Committee

Step 4: Have participants list activities for each role that support screening. Write down the activities as smaller spokes off the "role" circles (e.g., Dentist: conduct dental exams).

Step 5: Point to a specific role (e.g., Parents) and ask participants:

• Why is this role important?
  
  
• What would happen if this partner were not involved in screening?

Point to an activity (e.g., Family Service Worker: arrange for an interpreter for non-English speaking parents) and ask participants:

• Why is this activity important?
  
  
• What would happen if this activity were not completed?

Step 6: On the flip chart paper or blackboard, write a heading "Challenges" on the left. Have participants brainstorm a list of the major difficulties in this program's screening story. Write them down in this column.

Step 7: To the right of the column for Challenges, write a heading "Strategies." Have participants brainstorm some strategies by which the key partners can work together to overcome the challenges to screening. Write them down in this column.

Step 8: Ask participants to think beyond this example of dental screening and exams:

• Give examples of other screenings that involve many partners and activities.
  
  
• Give examples of other challenges to screening that you've experienced, and strategies that were developed among the partners to overcome the difficulties.

Points to Consider:

• Important screening activities include:
  
  
  • Working as a team among staff to complete health screening and exams
    
    
  • Ensuring that the Health Services Advisory Committee plans and reviews the screening program
    
    
  • Training people conducting screenings and exams
    
    
  • Preparing children for screenings
    
    
  • Informing and involving parents in all aspects of screenings
    
    
  • Explaining screenings and exam results to parents
    
    
  • Supporting parents with follow-up with health care providers
    
    
  • Ensuring confidentiality of screening results
    
    
  • Involving community partners in screenings
    
    
  • Completing required screenings within the required time limit
    
    
• The challenges to screening tend to involve and affect more than one of the partners in screening. Therefore, the partners must work together to develop effective strategies to overcome the challenges.

Activity 4: Exploring the Challenges

Purpose: This activity helps staff identify the challenges and develop strategies for ensuring well-child health care for Head Start children.

For this activity you will need:

• Handout H: Exploring the Challenges, for each participant

Step 1: This exercise allows participants to discuss the challenges to well-child health care from different perspectives.

Step 2: Take a few minutes to review Handout H: Exploring the Challenges.

Step 3: The group will discuss each situation with each participant taking a different perspective. Beginning with situation #1, have each participant identify the role that he or she will play: one person will be the staff person, another the parent, and the third a health care provider.

Take a moment to get into the perspective of your role. Reread the situation and focus on your feelings and the difficulties from your perspective.

Step 4: Take five or 10 minutes to play out the situation. Begin by trying to understand everyone's perspective. Try to move the discussion toward strategies that will help overcome the difficulties.

Step 5: Change roles and proceed to the next situation. Discuss all of the situations in the same manner. Continue to change roles to ensure that everyone has the chance to play every role.

Step 6: Discuss how this activity felt from the perspective of the staff, parent, and health care provider.

• What are some differences in perspective that can get in the way of the partnership in well-child health care and screening?
  
  
• What is the "common ground" to emphasize in order to promote the partnership in well-child health care and screening?
  
  
• How might you incorporate "taking a different perspective" into your daily work experience?

Points to Consider:

• In order to empower parents in well-child health care we must be sensitive to families' beliefs and challenges. We should provide basic information and work together to try to overcome the difficulties.
  
  
• The challenges to well-child health care tend to involve more than one of the partners. Therefore, Head Start staff, parents, and health care providers must all work together to develop effective strategies to overcome the challenges.
  
  
• We can facilitate communication and cooperation by standing firmly on our "common ground"—everyone's concern for the best interests of the child.

Activity 5: Well-Child Health Care Dilemmas

Purpose: This activity allows participants to evaluate different scenarios for aspects that support or reduce quality well-child health care. Participants will brainstorm strategies for improving their ability to make well- child health care "happen."

For this activity you will need:

• Handout I: Dilemmas in Assuring Well-Child Health Care for each participant.
  
  
• Flip chart paper and markers

Trainer Preparation Note:

Before the training, write down the discussion questions from Step 3 on flip chart paper.

Step 1: Explain to participants that this activity will give them the chance to assess the strengths and problems in various scenarios dealing with the provision of well-child health care.

Step 2: Divide participants into small groups of three to five people. Ask them to imagine they are consultants to help Head Start programs improve the quality of delivering well-child health care.

Step 3: Distribute Handout I: Dilemmas in Assuring Well-Child Health Care to each participant. Explain that each program's dilemma has both quality problems and strengths.

Instruct each group to review each scenario and discuss the following questions (posted on flip chart paper):

• What aspects of the situation contribute to quality?
  
  
• What aspects of the situation may reduce the quality?
  
  
• Some strategies to support the strengths are...
  
  
• Some strategies to overcome the quality problems are...

Step 4: Reconvene the group and discuss each dilemma with each small group reporting back about the strengths, problems, and strategies they identified. List the strategies on flip chart paper.

Step 5: Ask participants to think about these dilemmas and their experiences with assuring all the elements of well-child health care in their own programs. Ask participants to discuss some of the advantages and disadvantages of:

• Having Head Start staff instead of parents take children to their dental appointments?
  
  
• Holding a child health screening clinic instead of sending children to their "medical home" for screenings and examinations?
  
  
• Using screeners who are teachers, parents, and volunteers rather than health professionals?

Step 6: Ask participants to briefly describe any other creative and successful strategies that programs have used to ensure well-child health care, including the completion of screenings and exams, tracking services, and education. Have you heard about any interesting methods that you might like to try in your program?

Points to Consider:

• The goal of well-child health care is best served when there is a partnership between parents, staff, and health care providers.
  
  
• Screenings and exams alone do not ensure well-child health care—a tracking system must be in place to ensure follow-up to meet identified needs and the delivery of routine immunizations and examinations.
  
  
• There are many challenges to quality screenings and exams, such as time limits and the lack of resources. Programs should aim to preserve quality, since a poor quality screening or exam is of no benefit and may be harmful. If compromises must be made, they should be made with the advice of health consultants and the Health Services Advisory committee.

Activity 6: Sam's Story Part Two—Supporting Parents

Purpose: This activity helps participants develop skills in supporting parents in accessing well-child health care and services to follow-up on needs identified in screenings and examinations.

For this activity you will need:

• One copy of Handout J: Sam's Story—Part Two

Step 1: Distribute and review with participants Handout J: Sam's Story—Part Two

Step 2: Discuss the following questions:

• What follow-up would be helpful with the family?
  
  
  • When would you want to follow up?
    
    
  • Who should be involved?
    
    
  • Who would you ask?
    
    
  • What would you say?
    
    
• In your Head Start community, how would you support parents in accessing well-child health care (including dental care)?
  
  
  • Who would you talk to?
    
    
  • Who would help?
    
    
  • Are there logistical barriers? (Transportation? Office hours that are difficult for working parents?)
    
    
  • Are there cultural barriers? (A different belief system regarding cures? Language barriers?)
    
    
• How would you document the interventions in the child's health record?
  
  
• How are recent changes in legislature preventing or promoting access for your families?

Step 3: Discuss any experience that you have had with supporting parents in accessing well-child health care and follow-up services.

• What was successful?
  
  
• What was not successful?

Step 4: Discuss the following:

• What if there were several children in the classroom who were diagnosed with the same problem?
  
  
  • What additional classroom or family interventions might be helpful?
    
    
  • What might be done as a group to access health care and deliver follow-up services?

Points to Consider:

• It is important that the parents and key staff understand the results of screenings and exams, the diagnoses, and the recommended treatment and follow-up.
  
  
• Careful documentation is crucial to facilitate comprehensive review and appropriate assessment, treatment, and follow-up to meet each child's health needs.
  
  
• For common health problems, programs should determine which classroom, multifamily, and community interventions might help. This might involve more extensive public education and advocacy.

Activity 7: Observing is Screening

Purpose: This activity helps participants appreciate the role of daily observations in screening.

For this activity you will need:

• One copy of Handout K: Observation Worksheet, for each participant

Step 1: Take 30 minutes to observe two children playing. It can be in a center or home-based setting. Select a boy and a girl who are approximately the same age.

Step 2: Using Handout K: Observation Worksheet, jot down your observations of each child's physical appearance, emotions, behavior, and skills. Write any additional observations in the "Other" section.

Be sure to document your observations in specific, descriptive terms. For example, under "Emotional State" you might write "playing and laughing with other children" rather than "okay."

Step 3: Take 30 to 40 minutes to discuss your observations with your coach or partner(s). Begin your discussion by giving a brief description of each child.

Step 4: Based on your experience with children:

• Make a check on your worksheet next to each of your observations that you think falls "within the normal or typical range" for children that age.
  
  
• Circle any item that you have concerns or questions about possibly being "outside of the normal or typical range" for children that age.

Step 5: Use your worksheets to discuss the following questions. First, focus on the checked "normal" or "typical" features:

• Did you have mostly "typical" checks for these two children? If so, what does this mean?
  
  
• Look at one feature that is checked for both children. Were the children the same, or did they both appear "normal" but in different ways?
  
  
• Consider the other children in the program. How much variation do you see in this feature among the children?
  
  
• What does this tell you about the range of normal appearance, behavior, and skills among children at a given age?

Step 6: Next, focus on the circled "questions" or "concerns" features:

• What made you feel concerned about this observation?
  
  
• What does it mean that you have circled some features? How is the meaning of your observations similar to the meaning of screening?
  
  
• Who would you want to discuss these observations with? What would you want to tell them about your observations and what would you ask them about your observations?
  
  
• What further evaluation or follow-up might be helpful to address your questions or concerns?

Step 7: Take one of your circled items. State what further evaluation (i.e., screening test, exam, assessment, or evaluation) might be needed.

Imagine that the results of this further assessment were normal.

• What does this imply about the role of your observations in screening?
  
  
• How would you plan to be alert to further developments with this child?
  
  
• Would you want to repeat the screening or exam to be sure there are no problems?

Step 8: Take another one of your circled items. State what further evaluation (i.e., screening test, exam, assessment, or evaluation) might be needed.

Imagine that this further assessment indicated that the child had a special health condition or disability.

• What does this imply about the role of your observations in screening?
  
  
• What might you want to find out about the cause, treatment, and outcome for the health condition?
  
  
• Are there any possible implications for screening for other family members (e.g., younger siblings) or classmates?

Points to Consider:

• Both parents and teachers have the opportunity to observe children in various activities. Careful observations of each child over time are important elements of screening.
  
  
• Most of children's appearance, behavior, and skills fall within the broad range of "normal or typical" for children that age.
  
  
• Observations of concern include signs of physical or emotional pain, difficulty participating in activities, and difficulties in social interactions.
  
  
• Observations should be discussed with other individuals who have observed the child over time and know the child best, such as parents and teachers. If teachers and parents agree that there are concerns, they need to be carefully documented and assessed along with other history and screening information. It means that the child might have a special need, and further observation, discussion, and/or evaluation may be necessary.

Activity 8: Program Planning

Purpose: This activity illustrates how information from screenings, exams, and assessments can affect plans for classroom interventions and parent education.

For this activity you will need:

• Handout L: Program Planning Stories (Separate the stories and attach to each story the corresponding fact sheet from Appendix B)
  
  
• Appendix B: Well-Child Health Care Fact Sheets that correspond to the Program Planning Stories:
  
  
  • Story #1: Anemia Screening
    
    
  • Story #2: Immunizations
    
    
  • Story #3: Developmental Screening
    
    
  • Story #4: Nutrition Assessment

Step 1: Explain that participants will be part of an interdisciplinary team conference to review screening and assessment results and develop program plans.

Step 2: Divide participants into four groups: #1, #2, #3, and #4. Instruct each group to begin by…

• having each participant identify his role and function within the interdisciplinary team conference.
  
  
  • Each group should have a representative of health, disabilities, social service, education, and family involvement functions.
    
    
  • Participants may or may not choose to play their actual roles.
    
    
• assigning a "recorder" who will report back to the large group.

Step 3: Distribute to Group #1 the Program Planning Story #1 with its attached fact sheet (Anemia) that corresponds to that story. Distribute the handouts in the same manner to Groups #2, #3, and #4.

Step 4: Allow the groups 15 minutes to review their stories and the fact sheets and then develop a program plan to meet the needs of the situation. Address the following questions:

• What else might you need to know?
  
  
• What are some sources of information among the families, community, and health professionals?
  
  
• What is the role of the parents? What parent education would you provide?
  
  
• What is the role of Head Start staff? What classroom interventions might you make?
  
  
• How would you document and follow up your program plan?

Step 5: Bring the groups back together. Have each recorder read the story aloud and summarize that group's plan.

Encourage other participants to add their comments.

Step 6: Ask participants to describe some health problems that many children in your program have experienced.

• Have you done interdisciplinary team conferences to discuss the problems?
  
  
• What kinds of classroom-wide, multifamily, and/or community interventions have you tried to address these common health problems?
  
  
• Who has been helpful within the program and outside the program?
  
  
• Has this activity given you any ideas about new strategies that you might like to try to address common health problems?

Points to Consider:

• When several children and families in the program have the same health problem, programs should consider what classroom, multifamily, and community interventions could help. These might include education and advocacy.
  
  
• To address health problems, programs should obtain all of the necessary information about the causes and possible interventions for the problem.
  
  
• Sources of information on health issues include program staff, parents, local health care providers, departments of public health, health consultants, and regional/national health agencies.
  
  
• It is important that the parents and key staff understand:
  
  
  • the results of the screenings and exams, the diagnoses, and the recommended treatment and follow-up;
    
    
  • the measures to take at home and school to treat and prevent the problem; and
    
    
  • the importance of comprehensive well-child health care, beyond addressing the identified health problem.
    
    
• Discussions with families should be sensitive to their knowledge, beliefs, practices, living situation, and resources.
  
  
• Careful documentation is crucial to facilitate comprehensive review and appropriate assessment, treatment, and follow-up to meet each child's health needs.

Activity 9: Keeping Up—Tracking Health Services

Purpose: This coaching activity helps participants assess their program's health tracking system and develop skills in tracking and determining what and when health follow-up is needed.

For this activity you will need:

• Handout C: Child Health Records (from Module 1) or your own agency records
  
  
• Handout M: Trackville Head Start Tracking Instrument
  
  
• Appendix A: Recommendations for Well-Child Health Care or your own state EPSDT guidelines
  
  
• Key to Activity 9: Keeping Up—Tracking Health Services
  (For Trainer Only)

Trainer Preparation Note:

If you want to update the child health records and tracking instrument so that they reflect current information and have current dates, you will find blank copies of these handouts that you can fill out in Appendix C: Blank Records & Forms.

Step 1: Explain that this activity will help assess your program's health tracking system and develop skills in reviewing tracking records.

Step 2: Ask the participant(s):

• What is the current system that you use to track children's health services in your program? How has it been working for you? What are your system's strengths? What are its' weaknesses?
  
  
• Are you considering upgrading to a new computerized system or an improved version of an existing system? What have been your sources of information? What have you learned? What else do you need to find out? (Make plans to get the additional information needed.)

Step 3: Distribute Handout C: Child Health Records (from Module 1). Explain that this child, Janine, is attending Trackville Head Start. Distribute Handout M: Trackville Head Start Tracking Instrument. Explain that this tracking instrument includes the health records of Janine's class in the program.

Ask participants to enter Janine's health record into the Trackville Head Start Tracking Instrument in space #15.

Step 4: Distribute Appendix A: Recommendations for Well-Child Health Care or your own state EPSDT guidelines.

Ask participants to use the preventive care guidelines and review the Trackville Head Start Tracking Instrument to identify children or records that need follow-up for any reason. For example:

• Is any data entered incorrectly?
  
  
• Are any records or health services not up-to-date with the EPSDT guidelines?
  
  
• Are there children with abnormal results who need repeat screening, follow-up evaluation or treatment?
  
  
• Are more than the usual number of children failing a screening? Is there a problem with its administration?

Instruct participants to circle elements that need follow-up and note what follow-up is needed for each. Allow 10-20 minutes.

Step 5: Review with participants the Trackville Head Start Tracking Instrument. Beginning with Janine, identify any elements in the health records that need follow-up. Then proceed with each of the children, identifying the follow-up needed. (See Key to Activity 9: Keeping Up—Tracking Health Services.)

Step 6: Explain that, once a need for follow-up and a timeframe has been determined, programs need a "tickler file" or reminder system. Ask:

• What system do you have to remind you of follow-up needed to complete missing health services, further evaluation or treatment, and follow-up for children to stay up-to-date on age-appropriate preventive health care and immunizations?
  
  
• How has your system been working for you? What are your system's strengths? What are its weaknesses?
  
  
• Do you need to improve your reminder system? What have been your sources of information? What have you learned? What else do you need to find out? (Make plans to get the additional information needed.)

Step 7: Have participants look at the entire class of children on the Tracking Instrument. Ask:

• Are there any common problems that are apparent? (For example, are many children missing growth measurements or vision screening? Are many children not up-to-date on their immunizations? Do many children have anemia?) What plans might you make to address these concerns?
  
  
• How are you using this information to plan services with your Health Services Advisory Committee, Policy Council, and health care providers in your community?

Points to Consider:

• Tracking involves systematic documentation and review of children's health records. Effective tracking tools help identify the health services that children have received and children who require follow-up.
  
  
• The program's tracking system must facilitate the sharing of necessary information among staff including the program director, component coordinators and other designated staff.
  
  
• Specific staff must be designated, trained and monitored in entering and reviewing tracking data.
  
  
• The program's tracking system must be reviewed regularly to ensure that the information is current and relevant to the program.

Download Key to Activity 9: Keeping Up—Tracking Health Services (For Trainer Only) [pdf 17 KB]

Next Steps: Ideas to Extend Practice

Review Your Program's Screenings and Exams

As part of your annual program self-assessment, conduct a "Quality Review" of your program's screening instruments and procedures. Interview children and parents to find out if the screenings and exams were adequately explained to them, if they were made to feel comfortable and involved, and how the process could be improved. Collaborate with other Head Start programs to learn creative approaches to solving screening challenges.

Discuss screenings at a meeting with staff members, parents, Health Services Advisory Committee, Parent Council, and health care providers. You may wish to discuss the following issues:

• Do the screenings and exams effectively identify children's health needs and involve the parents in their child's health care?
  
  
• Do they involve cooperation of staff, parents, and health care providers?
  
  
• How can the screening process be improved?

Keep Health Care Follow-up on the Agenda

Periodically, reserve time to share information about the families' challenges in following through on their children's health care. Gather ideas about how best to support the parents. Develop methods to track the delivery of services to Head Start students.

This system could include a master calendar shared by parents and staff stating when the child is due for services, or an organized system of transportation to and from appointments. Health professionals could be brought on-site to facilitate delivery of services. Screening alone will not ensure well-child health care; following through with preventive services and services to meet special needs is essential.

Assemble a Multicultural Health Panel

When Head Start screenings and exams identify health problems and recommend treatment, the family might not complete the follow-up if their health beliefs are very different from the recommendations.

Invite health experts, families, and community members from different cultural backgrounds to discuss health beliefs and practices of different cultures represented in your Head Start program. Topics of discussion may include the following:

• How to maintain good health
  
  
• What causes illness
  
  
• Who are the health care providers
  
  
• What are appropriate treatments
  
  
• The importance of establishing a "medical home," screenings, exams, and follow-up treatment for identified needs
  
  
• The importance of well-child health care

Well-Child Health Care: Making It Happen...

The Health Coordinator from Heartland Head Start in Bloomington, Illinois volunteered to scrub surgical instruments at the month adult free dental surgery clinic. As a result of the volunteer work, the oral surgeons now provide dental surgeries free for Head Start children without insurance or accept what Medicaid pays.