By Jennifer Fernandez
Jamestown resident Ashley Robinson’s third child arrived three months early. A micro-preemie, Milo weighed just 1 pound, 2.7 ounces, smaller than an average woman’s shoe.
At 3 weeks old, he had his first surgery. Since then, he’s had at least seven others, including for repairs to his intestines and for glaucoma, a condition where the optic nerve is damaged, usually by pressure in the eye.
Like many babies born early, Milo’s lungs were underdeveloped, which left him with chronic lung disease. The umbilical cord did not provide enough nutrients to Milo as he was growing, leading to his premature birth by cesarean section, Robinson said.
Milo was born at Moses Cone Hospital in Greensboro, but doctors transferred him at 3 weeks old to Duke Hospital for his first surgery. He stayed in the neonatal intensive care unit there for eight months.
Robinson, who had been teaching science at Andrews High School in High Point for two years, had to quit to take care of Milo.
That meant her family went from being a two-income household to a one-income household with three children, one of them with medically complex care. The financial toll left Robinson and her husband, Donte, struggling to feed their family.
Little did she know that help was waiting for her at Milo’s first visit with the family’s longtime pediatrician. When she took Milo to Atrium Health Wake Forest Baptist Pediatrics-Greensboro, the doctor recommended Robinson speak to the practice’s HealthySteps specialist.
Fourteen pediatric offices in Guilford County have embedded these specialists, who are trained to offer support for problems and concerns — common and complex — that parents might have that doctors don’t have time to address at regular patient visits.
The HealthySteps specialists provide parenting guidance, support between visits, help with referrals and care coordination. They can talk to parents about issues like behavior, sleep and parental depression, as well as social determinants of health such as access to food or transportation that could be affecting health care.
For Robinson, the HealthySteps specialist provided an opening she didn’t realize she needed.
“There was just something about her that when she asked if I was OK … I felt like I could be honest with her and tell her … I’m not OK,” Robinson recalled. “I’m doing the best I can, but I am struggling to keep my head above water here.”
Early focus
HealthySteps is a program of the nonprofit Zero to Three, which advocates for evidence-based interventions for infants and toddlers.
HealthySteps focuses on serving children in low-income families who are more at risk of health issues throughout their lives. Typically, these families are served by Medicaid, the State Children’s Health Insurance Program or are uninsured. However, all children age 3 and younger in participating clinics receive HealthySteps services.
Children receive a series of developmental, socioemotional and behavioral screenings. In addition, the HealthySteps specialists regularly check in with families for other risk factors — from maternal depression and domestic violence, to food insecurity and homelessness.
Nationally, the program has reached more than 496,000 children this year in 334 sites across 25 states, Washington, D.C., and Germany, according to the nonprofit.
In North Carolina, just over 33,000 children are in HealthySteps pediatric care, said Natalie Tackitt, the program’s state coordinator. More than 25,000 of them are in Guilford County, she said.
There are two sites in Durham and one at Fort Bragg in Fayetteville. The majority, however, are in Guilford County where the Children’s Home Society started the program in 2018 with six HealthySteps specialists, according to Brianna White, HealthySteps program supervisor.
The Children’s Home Society was already doing parent education in a handful of clinics but wanted to have a bigger impact, in part by wrapping a suite of support services around the child, White said.
The way Tackitt describes the wraparound concept is that no baby lives by themselves, and an unwell parent is not going to be able to support the healthy development of a child.
She described HealthySteps as “promoting healthy behaviors to prevent unhealthy outcomes.”
HealthySteps has a three-tiered approach to services. All children 3 years old or younger, and their families, get screened. The HealthySteps specialists check a child’s ongoing progress on reaching developmental milestones. They help connect families to services. They answer questions families have about child development and well-being.
More intensive services are available for children who need additional help, from behavioral health consults to early learning resources to ongoing, preventive team-based well-child visits.
Referrals and follow ups are a key component to ensure that children and families are getting the help they need.
One reason HealthySteps focuses on the period from birth to age 3 is that young children go to their pediatricians for well-checks a lot during this period, Tackitt said. They usually make seven visits in the first year alone.
Those first few years are also key to a child’s development, from learning motor skills to acquiring language to setting up good mental health. The brain is growing rapidly, creating nearly a million neural connections per second, absorbing information like a sponge.
The idea is that HealthySteps “becomes almost a one-stop shop for families where they’re being asked about their social, emotional, mental health, as well as being asked about their medical health,” Melissa Baron, director of quality for HealthySteps’ national office, said earlier this year at a conference on early childhood at the UNC Frank Porter Graham Child Development Institute.
‘A friendly face’
Alice Eaton, who has been a HealthySteps specialist in Guilford County for four years, said she talks to families about a variety of issues, from eating and sleeping to development and behavior. Mental health of the entire family also is discussed.
“One of the unique things about HealthySteps is that we’re hopefully there from the very beginning, whether there’s a concrete need or not,” Eaton said. “If something were to come up, we’re kind of a friendly face, especially in a lot of practices where you might see different providers every time, or different nurses every time, where there’s a lot of changing faces.”
A favorite part of the job for Eaton is watching families change and grow, especially parents, who grow in their confidence.
“Parents are really appreciative when they know that there’s someone that they can call or talk to even between visits,” she said.
Even parents who’ve already had children often find themselves with questions about something they didn’t encounter with their other children, or that was easier with a previous child, Eaton said.
Everyone has access to the HealthySteps specialist. Families don’t have to sign up or meet any qualifications to get services.
Even if one child ages out, many times families will have another child young enough to be part of HealthySteps, so they continue to get those support services, said Samantha Prior, Zero to Three’s senior communications director.
That’s the case for Robinson, whose family will still be served by the program when Milo ages out because her 1-year-old daughter, Malia, qualifies.
She said HealthySteps has been invaluable to her family. It has been a lifeline for her.
Moms are supposed to be like superheroes, Robinson said.
“We’re supposed to do all the things,” she said. “And we do do all the things, but we need support and help too, and sometimes it’s not easy to say that, or to even know where you can go to get that type of support.”
Funding
There’s been a lot of interest in expanding the program in the state, including creating sites in Charlotte and Goldsboro, as well as eastern and western North Carolina, Tackitt said. The main holdup is often funding.
In Guilford County, financial backing has come from philanthropic groups. The Duke Endowment and Blue Meridian Partners supported the launch, but once that initial money dries up, other sources will need to be found, Tackitt said. She said that was the plan all along and that the HealthySteps national office is working with the Children’s Home Society on finding ways to support the program once the initial money is gone. (Disclaimer: NC Health News also receives grant funding from the Duke Endowment. NC Health News funders have no input into editorial decisions.)
The Lincoln Community Health Center site in Durham got initial funding from a federal grant through the Health Resources and Services Administration.
A lot of the work that Zero to Three does with partners launching HealthySteps is to look at creating sustainable funding, Prior said.
Many programs start with philanthropic funding or grants, but they need consistent support to continue, she said.
In New York, grants through that state’s Office of Mental Health covered startup and implementation costs. South Carolina used federal pandemic aid through the state’s Education Department with a goal of school readiness because there is evidence that HealthySteps can improve school readiness, Tackitt said.
Some states have turned to Medicaid reimbursement as a sustainable funding source.
In Maryland, practices get an extra $15 Medicaid payment for every well-child visit.
Arkansas passed legislation in 2023 and this year to funnel Medicaid funding to support the program, Anna Strong, executive director of the Arkansas chapter of the American Academy of Pediatrics, told NC Health News.
The first bill that passed required Arkansas Medicaid to provide a supplemental reimbursement rate per patient for physician practices participating in HealthySteps that were part of Medicaid’s patient-centered medical home program, Strong said.
A bill passed earlier this year in that state allows reimbursement in the medical home for breastfeeding and lactation services, she said.
Other steps have also helped financially bolster the program in Arkansas.
“Some of the foundational work of HealthySteps is ensuring that screenings happen at a universal level in their practice, and Arkansas was not reimbursing in the medical home for maternal depression screenings or developmental screenings,” Strong said. “And so we were able to get both of those turned on at Medicaid … and that was really helpful.”
‘Every mom needs some support’
North Carolina doesn’t have a sustainable funding source for HealthySteps lined up yet, according to Tackitt and others.
Using Medicaid could be a tough sell. It took the N.C. General Assembly a decade to pass Medicaid expansion, which is now in jeopardy of being clawed back due to federal cuts under the One Big Beautiful Bill Act.
And in the “mini-budget” passed in July, legislators failed to extend funding for the state’s Healthy Opportunities Pilot, which sought to improve health outcomes of Medicaid recipients by covering nonmedical health needs of rural residents.
HealthySteps supporters argue that the program offers a great return on investment.
In North Carolina, for every $1 invested in HealthySteps, state Medicaid saves an estimated $4.79 annually, according to data that Tackitt shared with NC Health News.
Since Milo’s birth, Ashley Robinson has become an advocate for the program. Last year, she joined the HealthySteps Family Advisory Group. Members are parents or caregivers who share their insights with the national organization on how it can improve the program. She has been asked to stay on the advisory group for a second term, which starts in October.
Joining the group opened up another level of advocacy and a wealth of knowledge, she said.
The experience spurred her on to other advocacy work. She has been involved with Little Lobbyists, which focuses on advocating for children with disabilities. And she was featured in an ad earlier this year advocating for Medicaid funding.
Having access to HealthySteps has been great, Robinson said.
“I don’t have to bear it all alone,” she said. “I can ask someone for help.”
“It should be in every … pediatrician’s office,” Robinson added, “because every mom needs some support in some way.”
Correction: This article has been changed to correct an error. According to Natalie Tackitt, North Carolina’s HealthySteps coordinator, HealthySteps has reached more than 25,000 children in Guilford County, not 6,000 as previously reported.
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