Ira Hillman -

Mar 22, 2023

New Pathways for Equity and Impact in Early Childhood

In case you missed it, in early November, the Stanford Center on Early Childhood convened 200+ funders, policymakers, researchers, and community members to help launch the new Center, under the leadership of Dr. Phil Fisher. The theme of the day was “New Pathways for Equity and Impact in Early Childhood,” and I was grateful to be part of a discussion titled Pediatrics: A Critical Partner to Promote Early Childhood Development and Learning.

In my conversation with the pediatricians and community leaders on the panel, I highlighted the collaborative efforts we support that leverage pediatric primary care to promote early relational health, and the ways in which coalitions like Pediatrics Supporting Parents and Nurture Connection are centering the voices of parents and families in the work and in the governance structure. I also shared some of the positive feedback we are hearing about the emotional connection training for pediatricians that is being piloted by Reach Out and Read in partnership with Columbia University Pediatrics.

I hope the panel sparks your interest in the science of emotional connection between parents/caregivers and their children and inspires you to join our early relational health movement at Nurture Connection.

Read the Transcript

Eric Abrams 00:02

I am very, very happy and honored to introduce our next panel chair. Dr. Lisa Chamberlain. Dr. Chamberlain is Professor of Pediatrics at the Stanford School of Medicine, and another member of the Leadership Council for the Stanford Center on Early Childhood. This really reflects the importance that we place on the education and health care partnership as early childhood as an early childhood approach. Her recent work has focused on the pediatrician as a key access point for early childhood intervention, including early literacy and numeracy. Dr. Chamberlain is also founder and co-director of the Stanford Pediatric Advocacy Trust, a nationally replicated program that trains pediatricians to address child poverty through community and policy engagement. Dr. Chamberlain is going to lead a discussion on the critical importance of the pediatrician as a partner in early childhood learning and development. The bios for the other speakers are in your programs, and please welcome Dr. Lisa Chamberlain.

Dr. Lisa Chamberlain 01:18

Thank you so much, and welcome back from lunch. Kendall had said, you know, her panel was what the class is like before they go to lunch, and the kids are wiggly. And it made me think what’s the class like after lunch? I believe everyone takes a nap, so you can get out your mat. And I’ll know that if you’re all snoozing, it’s not going well, but we’ll do our best. So yes, welcome back, we hope that you are enjoying our sunshine.

The fellowship here, the energy is palpable, and we just couldn’t be happier to have you all here. So, as I was introduced, I’m a general pediatrician. I have worked in the community with some of my lovely colleagues from Ravenswood Family Health Center. I was general pediatrician there for 14 years and more recently have been at the Gardner Packard Clinic, which is right near Redwood City. So, I’ve been so blessed to take care of so many patients like one of the families you heard from this morning, and have really been rooted in that community practice for many years. It informs everything that I do.

I also have a public health background. Go Cal! Am I allowed to say that? I have an MPH from Cal. I know! We don’t have a public health school; what was I supposed to do? And that was so eye opening to me — to really understand what I was seeing clinically, to understand the power of poverty. And when I did my training, we didn’t have the language around the social determinants of health, and understanding all of that, but I could feel it. And so that training really helped me understand how you think about community, think about authentic partnerships, and do that work. And so, I’m coming from a place of having taken care of patients in our community and thought a lot about how the social determinants of health and poverty really do influence the life course.

So, you can only imagine how excited I am about an early childhood center that brings these worlds together. It’s very exciting. Kind of weird, frankly, for pediatricians to be at a GSE event. We talk a lot about transdisciplinary work, but it’s remarkably difficult to really do that transdisciplinary work. But we believe that to solve complex problems, like the ones we’re talking about, we need to take a different approach. We can’t keep approaching things the way we’ve been thinking about them before. And one of the really important parts of that is to start to work together across disciplines. It’s hard. We have different language. We have different perspectives. But that is where the spark of innovation comes. It is from different fields sharing ideas and learning from each other. So, we’re very excited about that.

One of the things I wanted to kind of frame up a little bit, because so many people here are from education, is the framing around Medicaid and the important role that pediatrics does bring to this partnership. So, when I’m on call, and Ryan and I are on call a lot together in the nursery, we see all these beautiful babies that are being born. And about 50% of the kids in California who are born, the payer is Medicaid, so they are on public insurance. The other half more or less are in private insurance. Those publicly insured babies, almost 100%, except for few unfortunate moments in the ER or the parking lot, they’re born in our hospital. And so, we have this touch point of 100% of the kids that we have this important moment with, and then they go out into our communities. And as you know, they go in a lot of different directions, and they all end up again together in kindergarten. And so, kind of between these two points, the health care system has many touch points.

We see them for their checkups, if you can think back to your pediatrician, and you had those checkups there. It’s a horror show for children, I understand that they go to get their shots and whatnot. But as they get older, we start to talk about other things. We talked about literacy. We talked about books. We talked about relationships and families and identify opportunities to help with food support, housing support, transportation, these sorts of things. So, we have a lot of touch points. And one of the things I realized was that while we do participate in almost all pediatric programs — now in a program called Reach Out and Read, which is a great program that distributes books — we didn’t have a lot of other things we were doing. And I just really felt like, after seeing so many of my fabulous four- and five-year-olds going off to kindergarten, knowing that there was a lot more developmental potential that I hadn’t been supporting. And that took me to the School of Education in 2016 to do a sabbatical. And I really appreciated the generosity of the leadership in the School of Education that let me hang out with them for some time to learn what more could we do. What else could we harness the pediatric office for?

Those touch points over all that time… and not only do we have 100% access to these kids, 100% of the kids that are that are hardest to find… we have their trust. A lot of studies have shown that outside of immediate family, the next most trusted individual for advice for their children are the staff and the pediatric office: the pediatricians and the fabulous nursing support there. And so, we have trust, and we have access. And yet we’re not tapping that yet. And that’s what this center hopes to change.

We hope that with collaboration between education, the science, the modalities, the new tools that we need, in combination with this incredible access and trust, that we can really help, and support, and become a new and, hopefully, welcome part of the early childhood education community. So that is what we have teed up for you today thinking about how pediatrics can be a more central partner in promoting early childhood education. We have this world-class panel to help us think about these questions at a really critical juncture in time. As we come out of this pandemic, I think a lot of us are thinking: let’s hit the reset button, let’s think differently. And this center just couldn’t have better timing for that.

So, a little framing, we’re just going to hopefully talk for about 20-25 minutes. And we really want to open this up for conversation. So, this panel, I hope will be a little deviate a little bit from previous ones. We really want to spark conversation, because I do think these are some new ideas. So, as you’re sitting and listening, please think of questions and get ready to pop up and answer them.

All right, so I will introduce our speakers as we go, and all the complete bios are in the packet. I don’t want to waste too much time on that. So, let’s get started. We thought, and this was Ira’s idea, that a great way to get started was to talk a little bit about our why. Our why and our what for the panelists here. How did they end up here? What was the motivating factor and a little bit of their story, so you can get to know us a little bit? So, let’s start with that, Ira.

Ira Hillman 08:11

Hi, everybody. I’m actually going to add to the why and the what. I’m going to talk about who. And I think about who is on my mind as I think about why I do this work. And it’s the same two people who are on my mind every day, and they’re my two kids. My husband and I have two kids; our son, we’re planning his bar mitzvah for January. So somehow when I started this work, we they were in early childhood, so it made sense. And our daughter just turned 11, and she was born at 28 weeks, five days.

We built our family through adoption. And I think about the fact that she was in that NICU with very limited care, in terms of caregiving from a nurturing parent or caregiver for almost two months before we brought her home. But the magic of the work that we support at Einhorn Collaborative, which is really focused on early relational health and emotional connection for parents and children from birth, is that even after a two-month period, I’ve seen the magic of what the nurturing relationships that we’ve been able to develop with our children have not just on them, but they have on me.

And so, when I come home from work at the end of the day, and I’ve got lots on my mind, my daughter doesn’t just say how was your day, she comes and gives me a hug. And she knows that that hug regulates me and calms me, and so that’s the power of this work.

Another piece of the puzzle for our family is that we are raising two Black kids here in America. We think about the fact every day that our kids are facing barriers and challenges that I’ve only read about. And so, how can we find ways for those of us who have different lived experiences to come together across those differences and create the kind of culture that we want for our society? And this is a place again, where I think early relational health takes hold. Because if you grow up in a family where you have… you experience these mutual and reciprocal relationships, then you show up in the world with this orientation towards mutuality and reciprocity, which allows you to understand our common humanity and see problems as something that we solve together. And so, this is critical work. In terms of pediatrics, you know, if we want to do this work with parents and families, and you want to do it early and often, the place to do that is in pediatric care. That’s why we focus on several collaboratives, which I’ll talk more about later, that are centered in pediatric care to bring early relational health and emotional connection to all families.

Dr. Lisa Chamberlain 11:06

Thank you, Ira. Let’s go to Kitty Lopez next. Kitty is the executive director of First 5 San Mateo County, which for over 20 years has been committed to creating opportunity for all kids in San Mateo County and has led wide-ranging collaboratives that have invested over $150 million. So, let’s start with. Thank you, Kitty, for all you have invested in our local community. And yeah, your who, your why, your how.

Kitty Lopez 11:31

Before I do the what and the who, I have to shout out to my First 5 family network. I know there are many in the house. Yay. Thank you for being here. I have four of my First 5 commissioners here. Thank you for being here. Awesome. So, I’ve had the pleasure to work in San Mateo County for over 20 years.

The first 12 years I worked as Executive Director, some of you know this, at Samaritan House, a large safety net organization in San Mateo. And I was always very proud of that work, proud of our nonprofit community. But I would often say, please put us out of business. I want kids and families to have what they need from the get-go. And so, when it was coming time for me to leave, before they kind of shoved me out or said, when is Kitty leaving? And I looked at something else. I am not an early childhood person. But I soon became that early childhood advocate. I looked at First 5, because if I wanted to really change the system and have a greater impact, we know from all of the research, and all of the discussions that have happened here, it has to happen in those early years: zero to five. So that’s the what, like I wanted to have true impact. And so, I’ve been at First 5 for 10 years.

The who goes back to probably my father. I have a very fond affection for health care. My father was a doctor. He came to this country from Mexico with my grandparents decades ago, went to USC, and studied to be a doctor. And he practiced in Hollywood for over 40 years as a family physician. Now back in those days, I am older than I look. Back in those days, Family Physicians did everything. They deliver babies. They took care of kids, the teenagers, the adults, and on to old age. And he did that. He also did house calls, when physicians did house calls, and I was fortunate enough to go with him as a child. Talk about integrating health and wellness in every child in every family in every community; I watched that. I experienced that with him. So, at a deeper level, at the true, true deeper level. I do that to honor him and his work.

Dr. Lisa Chamberlain 14:16

Very much appreciate that.

Dr. Coker, a good friend of mine. Tumaini is a pediatrician, and Chief of a division of General Pediatrics, and Professor of Pediatrics at the University of Washington in Seattle. We’ve tried to steal her more than once. She’s proven quite refractory, but I’m not giving up. I think today is going to help. But what’s remarkable about Tumaini, Dr. Coker, is she is a national leader in thinking about how we transform primary care. How can we take primary care and make it bigger and better? And literally on every big panel, every big all of it, she’s always the one everyone wants. So, thank you for making some time for us, and we’d love to hear your who, why, how, what.

Dr. Tumaini Coker 14:59

Awesome. Thank you, Lisa, for inviting me. I never turn down a chance to come back to Stanford. I was here for four years of probably my most formative development as a 17-year-old is to a 21-year-old, so it’s nice to be back.

My who, why, what: I’ll start with as a fellow. I was in fellowship after a pediatric residency, and I had twin boys during fellowship. And so, I had just finished; I just passed the pediatric boards, and I was doing a research fellowship. And when they were born, I was like, this is really hard. And I looked back, and I was like, what were we doing in those well-child care visits? What was I taught? Like, you know, and what I think I realized is that if it is as hard for me, and my husband, and we’ve got grandparents there… I’m literally a board-certified pediatrician. I have all the resources that one could want… What was it like for those families that I had spent all that time talking to thinking that I’m an expert in residency, and wanting to be that expert now as a as a pediatrician?

So that really, I think, shaped the rest of my career in that I became laser focused on how we are using that three years of life where we are asking parents to come to us as pediatricians, come to a well-child care visit 10 times in the three years of life, right? It’s like every couple of months we want to see them in there. We’re doing immunizations. We’re doing a physical exam, but how do we use that really precious time of theirs knowing that for so many families that are just under so many challenges and struggles? How are you using that 15 minutes? And so, what I what I’ve been studying, and thinking about, and talking to folks about — and that was 17 years ago that I had the twins, but since then — is really how do we change the structure of that we have set up within this well-child care system in pediatrics to actually meet the needs of families that are coming in to see us 10 times? We cannot waste that opportunity. And so, really changing the whole system around is nothing that’s going to happen overnight. And I can tell you, I’ve been working in this area for 17 years. Those twin boys are now 17. And I am waiting for the “center on adolescence” because that’s where I really need help right now. But I’ll leave it there. I’m really excited to be able to share this day with you all.

Dr. Lisa Chamberlain 18:03

Terrific. Thank you. And Dr. Padrez, System Professor of Pediatrics at Stanford here, a lovely colleague with me, and a community doctor as well. You heard about all of his extraordinary work. And thanks so much like we have to follow that panel, like oh, my god; that was extraordinary panel. And part of the leadership team here at the Stanford Center for Early Childhood. So fun fact: Ryan and I went to the same high school about 30 years apart. Yeah. So anyway, Ryan and I have been hanging out for a long time. So lovely to be here. So, Ryan, tell us about your who, why, what.

Dr. Ryan Padrez 18:43

It’s great to be here… back up here again. I think, so because Lisa and I have a lot in common, we probably have some shared formative experiences. And, you know, it really started with me probably in residency and becoming frustrated with the systems I was encountering, you know, as a resident to support my families. And I guess, to back up, I wasn’t always a pre-med. Like Tumaini, I got to spend some formative years here as an undergraduate, and right afterwards went to Washington D.C., where I really learned a lot about our health care systems, particularly Medicaid, spending a lot of time there. So, I came into medical school and residency very much with the systems thinking about how are things getting paid for and why are certain processes of care set up this way.

I think I drove my attendings crazy because I was asking the wrong questions. I was not asking about clinical medicine. I was asking about payment. But there were a couple of patients of mine… and so my primary care clinic and training was at San Francisco General Hospital. For those who don’t know, it’s a big safety net hospital in the city. Amazing, amazing families. Amazing staff. And I couldn’t ask for a better place to train. Yet our systems there were very, very challenging, particularly in the early childhood experience.

And so, as I walked with my family to try to find speech therapy, to find mental health services, I was sending faxes on the referrals, which we still do today a lot. My mind was thinking, it’s got to be a better way. So, I think forever, I’ve tried to walk in my career this need to stay grounded in practice, but always thinking about how can we improve systems for our families. And so that’s sort of what brings me always to attract to hangout with people like yourselves up here.

Dr. Lisa Chamberlain 20:37

Terrific. Alright, so now you have a little sense of who we are here. So, for the next set of questions, the panel was designed on purpose to have these distinct perspectives that from a funder, a community leader, a leader in education and health space, and then a primary care redesign person.

From your perspective of that lens, what is the greatest opportunity or barrier — either way you want to take it, or a little of both — to integrating pediatrics into the early childhood system?

Let’s start this time with Tumaini.

Dr. Tumaini Coker 21:12

In a sense, I think the greatest opportunity is also the barrier. And I think about that, during early childhood is going back to those well-child care visits. So, a lot of the work that we’ve done, since I started the research that I’ve been working on since those boys were born 17 years ago, is really about changing the well-child care structure, because we have this wonderful process of care, right?

We know, and we have a book this big called Bright Futures, right? And so, it’s not just about the medical part. We know what kids need in terms of social emotional development. We know how to promote early relational health, which has been mentioned earlier. Thanks for coining that phrase, David Willis. We know that we need to address social needs, right? And we know what works. But all these things, that’s the process. And we also know the outcomes that we want, right? And I love the vision of the Center. I took a snap picture of that, and I see it’s on the program, too. But we want every child to reach their full potential. We want every parent to be supported.

Now, that’s the process, which we have well defined, and we have the outcomes well defined. But in well-child care, we have the wrong structure to get to either those processes or those outcomes. And so, if you wanted those processes and outcomes, why would you create a structure where a parent goes for 15 minutes every couple of months and talks to a person who spent — and I love being a pediatrician — but a person who spent three years in ICU, nursery, and some primary care? That’s just not the way that we would have created the structure for the processes and outcomes that we want.

So, what we’ve done is really been able to integrate community health workers into the team, because it’s not just… you can’t have a relationship with one pediatrician, or one family doc, or one nurse practitioner who’s going to be your everything, because they cannot take all those things that families need to reach that vision. And it works. And it’s not just the work that I’ve done in my own lab; it’s all across the country, folks are doing this: taking a team-based approach to pediatric primary care and early childhood to those preventive care visits to make them useful. So that’s the opportunity.

And I think the challenge is how do we pay for it? And how do we allow clinics to be able to do this work? And I’ve already heard from folks around the room. The barriers are not only in payment, and so I think we have to talk about Medicaid when we do this work. It has to be for Medicaid families first. Right? It has to be started with the folks that need; and that came up in another panel. We can’t trial it, and private insurance and practices that have a third Medicaid. No, we have to start it with the patients that are most vulnerable and most in need. And I’ll stop there.

Dr. Lisa Chamberlain 24:42

Then as a policy update, the state of California has just added community health workers to something you can bill for in primary care. They are paying $26 an hour, which is not a livable wage by many definitions depending on where you are in the state, and so that is an exciting opportunity and still some work to be done. But I do see that community health worker position as someone we could build liaisons with. That if we had community health workers in our clinics at Ravenswood or Gardner, and we mapped our community’s early childhood partners who are close by, the community health worker could liaison, or we could create other models. So that’s an exciting one. I have some optimism. Okay, Kitty, we go with you next for that question: opportunities and barriers.

Kitty Lopez 25:33

I will say that, for First 5, next year, it’ll be 25 years that we’ve been in existence. And we have always looked at the holistic needs for kids. I mean, we’re very fortunate in California to have First 5s in every county of the state. The statute guides us to look holistically at health, at education, at supporting families, and then how are we improving the systems that touch kids.

So, we are constantly trying to, with limited funds, because it’s tobacco tax dollars. And it’s a great thing, people are not smoking as much, but we have limited dollars. So, we leverage dollars that exist elsewhere to try to have the best impact in those areas.

I think in San Mateo County, at least, we are very fortunate to have great collaboration, wonderful initiatives, and projects that we work on collectively. So, this is sort of in our DNA to connect folks. I have two pediatricians on my First 5 commission. I mean, I am thrilled with that. One of them is here today. So, we are, I think, as First 5s throughout all the counties in the state are looking at partnering with their health systems, their pediatricians to see what are the gaps that we can fund with our limited dollars. And how can we leverage other dollars, let’s say at the state or federal level.

I’ll say Help Me Grow is a national model. It’s not the only model for early identification and intervention. But it’s a model that we have in the county; many other counties have it. We have a physician’s advisory group. They are instrumental in trying to reach out to providers and other physicians to utilize tools and assessments that are needed for developmental assessments. So that’s just one example of how we are trying to integrate health, and I can provide some others as we as we continue talking.

Dr. Lisa Chamberlain 27:47

Thank you. Ryan, how are you thinking about this?

Dr. Ryan Padrez 27:50

I’m thinking about two things. First is bigger picture systems, so thinking about data integration, which has been brought up a few times. The exciting thing is around the country, there’s a number of states, number of communities and counties that really have some very, very progressive work on data integration, and Lisa and I got to collaborate on and learning more about some of these initiatives.

But when we dug in, many of them were cradle-to-career type initiatives, including the state of California is embarking on this. And when we talk to the colleagues across the country, most of them said, “Yeah, but we’re not going to go to healthcare,” or “we’re going to get there later; we’re going to start with other social services, other education services.” And that’s because of the HIPAA protection barriers. So, I would say a barrier to this is if we really want to think about how can we be more proactive in sharing information. For example, with our Head Start centers, who are all trying to adhere to their guidelines around awesome, preventative services that they’re making sure their patients get: those forms are really hard for them to fill out. And we’ve done it all in clinic, we just can’t share the information somehow. I think we have to look at that system barrier differently. We certainly need to keep patient protections in place, but we have to think differently about how we can make it easier on our systems to data share. So that’s big-picture data.

Then on the ground, similar to Tumaini thinking about her team-based and community workers to the clinic. As a pediatrician, what I find challenging, both a barrier and opportunity, is we know when we see a child that might need support, it’s often the family that needs that support, too. Yet I have very limited tools on what I can do to provide better support for that mom, dad, or other caregiver that’s in the room, especially around mental health support, especially around social determinants. I don’t like that term very much, and social influencers have gotten it a lot of buzz lately, but there’s more to it than just housing and finances. But as a pediatrician, I’m limited… We know that if I can support this caregiver better, I know the child is going to thrive a bit better, but we don’t have a way to pay for that yet.

Dr. Lisa Chamberlain 30:04

Excellent. Okay. And I meant it, we’re going to do questions. So, I’m going to have Ira answer our opportunity barrier question. And then if you all are thinking of questions, please do go to the mics. Ira.

Ira Hillman 30:17

I think the opportunity is what I said drew us to wanting to invest in this space in the first place, which is this is a universal, non-stigmatizing setting. This is not something you get a referral because of your parenting. It’s not about parenting education; everybody goes to pediatric care. So that’s the opportunity.

I think, in the eight years that I’ve been doing this, I’d say in the second half of that time, I then came to understand some barriers that, despite what you said earlier, which is pediatric healthcare is trusted. For particularly around when you want to talk about relationships, and relational health, I think many families, particularly families of color, would say: “I don’t know that I feel comfortable having these discussions with you, because you’re going to refer me to Child Protective Services.” And so, this has then helped inform our thinking. I think the solution is that the transformation that needs to happen, needs to be co-created, co-led, and co- throughout the process with families and parents.

The Pediatric Supporting Parents initiative that we and several other funders in this room are a part of, we actually pivoted just the past year or so to really move to working very closely in five communities where we’re going deep with them. But in each of those communities, there’s not just a hospital or health clinic, there are their family leaders who are working closely with them to say, what does this transformation look like? And I’ll just say even the governance of the project, which was funder driven, is now two out of the 12 votes are funders and the other 10 represent frontline clinicians and family leaders from each of those five communities. [Audience claps] Thank you.

Similarly, the work we’re doing on the collaborative effort at the Center for the Study of Social Policy’s Early Relational Health Hub; that work is being guided and driven by a family network collaborative of 66 parent leaders. So, we’ve got six parent leaders who each represent communities, I’d say, we have the most to learn from because they have been the least well served by the system. And each of those parent leaders has a network of 10 in their community to hear from, so we’re actually hearing 66 voices as we move that process forward. And so, I think, when we want to think about the transformation that’s possible, once parents are at the table, then other parents can trust it, and change can really happen.

Dr. Lisa Chamberlain 32:44

That’s extraordinary. Kitty, go ahead.

Kitty Lopez 32:46

I was just going to say, Ryan, you made me think of just that cradle-to-career model. You know, we are embarking on that in San Mateo County. That relational health, that relationship building, is so critical from the beginning to get people together in the room to think about something with you, not just to solve a problem, and that you’re needed to do X. So, our superintendent of schools is here, one of our commissioners. We are getting together with you to talk about how to integrate health from the get-go in that cradle-to-career thinking and modeling, as well as including parents and families and community. So, I’m excited about that here.

Dr. Tumaini Coker 33:35

Can I add something to what Ira said: this idea of it happens on the local level? So, I don’t think, you know, regardless of we all want generalizability, and we want to scale. But each community has to take whatever it is that we want to scale, and they have to shape it, and they have to own it. And then they are engaged. Some of the work that I’ve seen that allows that to happen is one of the things that we do, which is this model that uses a community health worker into primary care.

I work with federally qualified health centers, and usually they’re a large organization that may have multiple sites. And every time we bring this intervention into the site, we just don’t bring it in, like here’s the book, go ahead. But here is this idea that was created by parents and providers in South Los Angeles maybe 15 years ago. And so, they take just the idea, the concept of it. We bring in parents, providers, the medical assistants, the medical director, their administration: everyone who was involved in the care of in that community, which the community is that clinical space. And then they really figure out how do we make this work for us.

I’ve seen it look different in every different clinical space. Even within one FQHC organization, each clinic makes it a little bit different. But I think that has to be part of this new model for well-child care. It’s not going to be off-the-shelf, you know, go ahead and put it in every community. Every community is going to need to listen to their parents, their staff, their providers, and then their partners in the community as well.

Dr. Lisa Chamberlain 35:42

Wonderful. Well, we have a lot to learn from you, and I look forward to bringing some of those models here. Okay, this is exciting. Please go ahead.

Start of Q&A Session

Question from an audience member 35:56

Hi, thank you for this enlightening discussion. I’m Adam. I’m one of our pediatric resident physicians at the School of Medicine, which means that I get to work with Lisa and Ryan very closely on a lot of this. You know, you hinted at a lot of the broad ideas, and I wondered if there any local innovations or interventions that you are excited about that tied together a lot of these principles?

Dr. Lisa Chamberlain 36:22

Great question, what are we going to do locally, our center? So, Ryan, do you have some ideas or Kitty?

Dr. Ryan Padrez 36:29

Well, I have fun in the sense of working with First 5, Kitty, and our county partners. There’s exciting movements and collaborations with our home visiting programs here in our county. And I know some folks in the audience are leaders of that in our county, and that’s a really beautiful nexus of established funded programs that are working with families, and how can pediatrics be a better partner in connecting those teams with families.

There are different approaches to home visiting. I think COVID has brought a lot of innovations to that space in regards to telemedicine, video connections, and how we can connect with families more frequently and often, especially those that might be a little hesitant to have visitors in the home. And so, I’m excited about playing on those interventions in that partnership there. There’s a lot more money coming from the federal government and states to support these and excited that that’s going to be a possibility down the line.

Kitty Lopez 37:26

I will just highlight: it’s not even in our county, but because we’re at Stanford, this includes the, the design thinking school. One of my colleagues in Humboldt County wanted to improve the birthing center at one of the hospitals for Native Americans because they were not having a really good experience. And so, the design, with some consultants that we work with and folks from the, talked with parents, talked with community. They did this whole process, as they do, to rethink how you deliver children at this hospital up in Humboldt, so parents and family members feel welcome. They feel a part of that hospital in that community, and they did it. Those things are happening all the time throughout the state. And First 5 is able to help fund those, incubate those, start those, and leverage other dollars for that.

I’ll also say we have a great partnership locally with Ravenswood Health Center for the virtual dental home model. In the classroom, they are in 19 early learning sites. Over 400 kids were helped last year. I’ve seen those little chairs in the classroom. The hygienist is there, right in the classroom, so the kids can feel that that’s a welcoming experience. You know, tooth decay and cavities is the number one problem for kids missing school. And so, they can see the hygienists, connect back virtually with a dentist at an office, and we’ve been funding that and investing that in for over 10 years. Yes, we need to do things better at the state level, but we need to do support models like that, that help kids right now.

Dr. Lisa Chamberlain 39:17

It’s terrific.

Question from an audience member 39:20

Hi, my name is Anthony Queen. One of the things that I’ve come to hear from the parents who I work with nationwide in the African American community is the healthcare system has hijacked healthcare. In other words, they don’t trust doctors. The most stressful time that they ever have is when they went to a wellness visit or just to get a physical. They leave the office feeling worse off than when they went in. And I just want to know what would you say to that?

And then secondly, one of the ways that I’m trying to work with healthcare providers in Lake County in Michigan is by using doulas, because they are already accepted in the African American community and you already have that acceptance. As I tell a lot of these programs, you can have all the bells and whistles, but if the families don’t trust you, it’s not going to work. And I always tell them collaboration is going to move at the speed of trust.

Dr. Tumaini Coker 40:14

Amen. I think the answer is right there, you know. Who else can be part of the team? When you think about a Black family going into having that relationship… We’ll go back to COVID and the vaccination: part of that is, if you had this awesome, trusting relationship with your primary care provider, you can go to them and say, “What do you think I should do?” “Should my child get this vaccination or not?” And just by sheer numbers, Black families don’t have that ability to have that level of trusting relationship with their PCP, their primary care provider, as white families do. Why?

Well, we can go back to the historical damage that has been done. So just by the fact of me being a Black woman who grew up in, I won’t mention the decade, but whatever… [Laughter] My parents, my experience is based on their experience. And so, if they didn’t have a good experience, and so that that colors that there. And then on top of that, we just don’t have as the numbers or representation for Black physicians, Black pediatricians, Black family docs, Black MPs, who are going to be PCPs. So, we don’t have that opportunity to build that trusting, long relationship that maybe multiple generations have built. We can’t change that today, but there are things that we should be doing to change the workforce.

But in the meantime, we have to start bringing in folks like doulas into care. We have to bring in community health workers. We have to bring in early childhood specialists. We have to expand the workforce, and get out of this mindset that you have to have this particular degree to do this particular thing and prevention, because you don’t. We can train lots of folks to do the work, to build that trust. And to then allow families to have that relationship.

Ira Hillman 42:40

I just want to add that what gives me some promise, because I agree with everything all of you have just said. This is again the barrier that I’m concerned about. It is in a pilot that we’ve begun, leveraging Reach Out and Read that we’ve talked about earlier as a platform, to reach more of these docs who are interacting with families who are already taking a different tack, right? They’re already saying, “Well, early literacy is now maybe part of my job.” They’re wanting to embed early relational health training, and so we’ve piloted this lens of emotional connection where they tune in, and they actually pay attention to the dyad. And what I’ll say is I’m heartened by the reaction we’ve heard from some pediatricians already who have said, “I didn’t think I could do it, because I didn’t have the time. I was very skeptical. But now that I’ve done it, I can’t imagine not doing this as part of my visit.” And the bonus was, they said, actually tuning into the relationship and finding the strengths that were present in the room and lifting them up opened up the trusting relationship, that then they were able to have other conversations with the family that they had not had access to previously, because they were tuning into something that the family really valued.

Dr. Lisa Chamberlain 43:49

That’s wonderful. Okay, yeah. Come over to the side, please.

Question from an audience member 43:52

Hi, I’m Carol Thompson, and I ran a small early childhood education program. Given 15 minutes, 10 times during the first three years of a child’s life, pediatricians then spend on average 150 minutes with each child acknowledging the pediatrician’s deep health expertise, which you all have talked about. The direct contact is incredibly limited compared to early childhood educators who are spending 40 to 50 hours per week with young children between the ages of zero and five. What are the structural changes that can happen to support health professionals partnering with and trusting ECE providers insights?

Dr. Lisa Chamberlain 44:34

It’s a great question. I can say really quickly that I totally hear it. We have these intermittent touches. And so, one of the things that I’ve worked on with Dr. Loeb, she spoke earlier today, was an intervention where we can text families from the clinic. So, we talked to them about the different aspects of say early literacy. And so, if the family is interested, we sign them up. And then on Monday, Wednesday, Friday, for weeks until they see us again, they get a text that says doc says, and then it talks to them quickly about early childhood development. And we studied it; in seven months, children who had these texts gained three months of literacy faster than the control group. So, we have to figure out and leverage opportunities, technology, other things. Matt Glickman inspires me constantly to think about how do we increase our touch between those visits. But you had an important other part of your question, which is: how do we kind of connect a little bit more? So, I’m wondering if my panelists have any other?

Dr. Ryan Padrez 45:42

The only thing I’d add — and it’s a great question, Carol — is I’m a big believer in building relationships. And so, it’s not possible to, of course, have that relationship with every single ECE provider in the community or every single pediatrician. But we can start by picking up the phone and having a phone conversation. We can start by, you know… now with video, I think there’s so much possibility to build that relationship. And so, the times that I’ve been most moved is when I see the ECE provider and clinician actually just talking for a minute, and that moves mountains in a… Sounds very odd, but it really is true.

Dr. Lisa Chamberlain 46:20

How we can be better partners. Wonderful. I did two over there, so I’m going to do two over here. Go ahead.

Question from an audience member 46:26

Hi, I’m a PhD student in education, and I have a background in developmental psychology. So, my question is actually related to that, but more also incorporating theory building from the developmental psychologists, where the traditional textbook theories of learning are actually done by inviting parents to lab spaces, which is also more restrained than having the natural family visits and the pediatricians in well-care environment. So, I was wondering, do you think there are opportunities to conduct research and theory-building work in the natural-family visits in the pediatric environment? And also, how can you incorporate that knowledge from the healthcare practitioners into the theory-building process?

Dr. Lisa Chamberlain 47:19

Okay, research in the clinic, because we’re just so bored, and there’s so much space there.

Ira Hillman 47:26

We are leveraging the Reach Out and Read network who has a strong research component, and so they’ll be working with other research partners to actually test this out in the setting where it’s happening, because the research around it has always been in the sort of lab that was just described.

Dr. Lisa Chamberlain 47:43

So yes, it’s possible. Go ahead.

Question from an audience member 47:48

David Willis from the Center for the Study of Social Policy. This is a thrilling conversation, one, about bringing early learning and health together and looking at that partnership…The health foundations of early learning are well established. But how can we be very intentional on this effort? And I wanted to raise the urgency question. And the urgency of what we all know is our children are suffering, and the mental health crisis begins early. The stress in families is well documented now. We’re in the post-COVID trying to recover in very uncertain times. There’s an urgency issue about every day, there’s new babies born. They start very rapidly down a path towards kindergarten readiness and towards well-being, and mental health is in the middle of this. So how do we think about the health platform and the urgency issue to advance this work in the moment, because it’s really an urgent issue nationally. Thanks.

Dr. Lisa Chamberlain 48:43

Appreciate that, David. I just would quickly say, we get it. I mean, we are seeing kids; we’ve continued to see them through the pandemic, and it is urgent. The mental health crisis is real. We’ve never seen such high rates of adolescent depression and anxiety. The kids, right now you’re hearing, there are no pediatric beds anywhere. Kids are really sick for a reason that’s a separate panel. We share your urgency. And I do feel like we’ve come through a time where we feel like we are open to new ideas: telehealth, other opportunities. But I’ll just say, you don’t have to convince us. We see the loss of development and how we’re behind the eight ball.

Kitty Lopez 49:32

I think conversations are happening. I mean, I’m looking at my Commissioner, Nancy McGee, the superintendent and our Health Chief, who is talking about this very issue. One of our commissioners is a mental health counselor at one of the high schools. I think Alexis is 300% over the number of visits that she is seeing kids, so we know it, and I do think I don’t have any answers up here today. But I think there are conversations happening right now on the ground to try to figure out what we can do collectively.

Dr. Tumaini Coker 50:07

The other piece I want to just quickly add is: it is urgent, and I want to take us back to Medicaid just for a moment because it drives so much of what we can do in pediatrics for low-income children in low-income communities. And so just going back to something that Ryan mentioned about hearing that pediatrician talk to an early childhood educator — and the surprise, but the joy in that — but how little of that can happen in our system? And so, if we are visit to visit to visit, and there is no incentive to connect with early childhood education from a pediatric perspective, because Medicaid doesn’t incentivize that, it’s not going to happen for the most part. And so, if we don’t get the change and the restructuring of what Medicaid pays for, then I don’t think we’re going to meet the goal.

Dr. Lisa Chamberlain 51:09

Thank you. Okay, let me sum it up for you. The Center for Early Childhood is going to tackle that problem. We are earnest about this. We believe it is important. We believe transdisciplinary work is absolutely central to solving these complex problems. You’re hearing us talk about how pediatrics is moving to team-based care. We need diverse care. We need a diverse team to address the structural racism; there is structural racism in clinic. Medicine is not exempt for the problems of racism. And so, we need diverse teams that people can trust. We need co-development of interventions.

Medicaid is changing in California. We’ve got a pediatrician who’s the Secretary of Health. It’s wonderful, and Dr. Ghaly is investing in community health workers. There’s incredible opportunities and timing right now to do innovative things in California. We need to address the data issue. Imagine if we could share data with Head Start. You wouldn’t have to check their eyes. We’re doing it. We’re doing it in clinic. We’re doubling the work that’s needed, so we could do that.

I think technology is unleashing opportunities. We need leadership. We need energy and commitment to making big changes. So, we’re in it for you. And I will just say, if you are an early childhood provider: if you call us, we will call you back. We would welcome that call, so don’t hesitate to pick up the phone.

All right. Thank you for the opportunity.

Ira Hillman leads Einhorn Collaborative’s Bonding strategy. Learn more about our work in Bonding and more about Ira. Sign up to receive our monthly newsletter and be the first to read Ira’s blog posts.