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California and Vermont Strategies
- Maternal Depression Screening and Response (Learn more about this strategy)
- Child Social-Emotional Screening and Response (Learn more about this strategy)
- Risk Factor Screening and Response (Learn more about this strategy)
- IECMH in Pediatric Care (Learn more about this strategy)
IECMH in Pediatric Care with Risk Factor, Child Social-Emotional Development, and Maternal Depression Screening and Response: DULCE
DULCE (Developmental Understanding and Legal Collaboration for Everyone) is a universal program based in a pediatric primary care setting. Developed at Boston Medical Center, it supports healthy child development and addresses social and mental health needs in families with children from birth to six months. The Center for the Study of Social Policy (CSSP) has been home to the program since 2015. DULCE is currently located in 10 sites across three states: California, Florida, and Vermont. In the beginning of 2021, DULCE expanded into six additional sites, across six different states: Kentucky, Michigan, Mississippi, New Jersey, Rhode Island, and Wisconsin. Those communities are currently working toward implementation of the approach.
This profile provides an overview of DULCE and then examines variations in how DULCE is implemented in two locales: Orange County, CA, which services a Latinx population in an urban/suburban setting, and Vermont, which serves a largely white population in a rural state.
Members of an Interdisciplinary Team who deliver the DULCE intervention include: the primary care physician and/or nurse practitioner, a Family Specialist, a legal partner, a mental health lead, and an early childhood systems partner. This cross-sector, collaborative approach allows DULCE to address the full range of health, social, and economic challenges families may encounter. The Family Specialist, based in the pediatric setting, receives training on the American Academy of Pediatrics’ Bright Futures screening approach, the Brazelton Touchpoints model of child development, and the Center for the Study of Social Policy’s Strengthening Families framework to build families’ protective factors. Through collaborations with the legal partner and the early childhood systems partner, the Family Specialist helps families obtain a range of needed supports. The early childhood system partner coordinates local DULCE implementation and can influence policies that impact DULCE families. The legal partner, being well-versed in family rights, often provides legal education to build the capacity of the Family Specialists, Interdisciplinary Team, and the clinic. Initial and ongoing training for the Family Specialists is provided by the DULCE National Center at CSSP and includes quarterly professional development sessions for all sites.
The Family Specialist joins the family and pediatric provider at newborn, 1-month, 2-month, 4-month, and 6-month well-child pediatric visits. During and between visits the Family Specialist screens for maternal depression, interpersonal violence, and barriers to meeting basic needs, and uses Brazelton Touchpoints strategies to help develop a relationship with families, learn about their child’s development, and provide targeted parent-child relationship coaching. DULCE recommends the use of the Centers for Medicare & Medicaid Services Health-Related Social Needs Screening Tool or any validated tool that collects data in nine required screening domains: employment security, food security, intimate partner violence, financial supports, transportation, mental health/caregiver depression, housing stability, housing health and safety, and utilities. In the case of positive screens, the Family Specialist will help families address identified concerns with referrals to local supports and services, which have been identified in partnership with the DULCE Interdisciplinary Team. At the 6-month well-child visit the Family Specialist develops a transition plan with the family to ensure they can continue to receive needed supports within the pediatric medical practice and from outside providers, such as home visiting or early intervention.
The Interdisciplinary Team meets weekly for a case review to collaboratively solve problems and plan follow-up in cases with positive screening results. The Interdisciplinary Team, through its familiarity with DULCE families’ needs, as well as system gaps and barriers, also advocates for policy changes that impact all families in a practice. Pediatric practices offer DULCE to all patients and a Family Specialist can serve 120-140 infants per year, or 60-70 at any given time.
CSSP fully funded DULCE at five pilot sites for three years and then offered partial funding for two additional years. As these sites became more firmly established, grant funding was tapered over time. These sites and expansion sites have pursued a range of funding strategies detailed below in state implementation descriptions.
Monitoring and Evaluation
An evaluation of DULCE randomly assigned 330 families in a pediatric primary care clinic to a DULCE Family Specialist or to a control group. Family surveys completed at baseline, at the end of the intervention at six months, and at 12 months, showed significant impacts for the intervention families on a number of outcomes, including infants completing their six-month immunization schedule by seven months, having five or more routine preventive care visits by age one, and families’ access to resources such as food assistance, utility assistance, and income assistance.
Another study, of the introduction of DULCE to five sites, found that the percentage of families completing all well-child visits on time increased from 46 to 65 percent, and more than 95 percent of families were screened for health-related social needs (including maternal depression, intimate partner violence (IPV), food insecurity, housing instability, housing conditions, utilities, and employment and financial supports). Of the 70 percent of families having at least one positive screen, 86 percent received resource information for concrete supports and 71 percent received resource information for maternal depression and IPV.
A three-year mixed-methods study is examining the role of pediatric primary care clinic-based interventions, one of which is DULCE, in mitigating toxic stress. Interim findings indicate that the DULCE supports strengthen families’ relationships with the clinic by introducing new screening tools conducted by a trusted Family Specialist, which helped families understand that the clinic is interested in supporting their basic needs and behavioral health. The intervention also strengthened relationships between clinics and community resources by increasing referrals and building connections with community programs through attendance at community meetings, inviting partners to visit the clinic, and similar activities.
DULCE has a data tool that collects information on family demographics, use of screeners and their results, discussion of resources, referral to services, use of Touchpoints, and quality indicators, such as the Family Specialist’s presence in the exam room 90 percent of the time. These data are presented in site-generated monthly reports that sites can use for fidelity monitoring and quality improvement. The DULCE National Center at CSSP also organizes a set of monthly coaching calls on using data to improve implementation.
The first Vermont DULCE site in Lamoille Valley was funded by CSSP as one if its five initial pilot sites, and since then DULCE has expanded to four additional sites in Vermont. At each site the Family Specialist is hired and employed by the local Parent Child Center (PCC), which also serves as the DULCE early childhood systems partner and mental health lead. The state’s 15 legislatively-designated PCCs are locally-based nonprofit organizations that provide a wide range of supports and services for parents with young children, such as parent education and referral to services that help families with basic needs, children’s development, and adult education and job readiness. Having the Family Specialist work for the PCC, rather than for the pediatric practice, ensures that DULCE sites in Vermont have robust relationships with local early childhood and family support services. The five DULCE PCCs partner with a local pediatric practice, each of which was identified and recruited through the efforts of the state’s Maternal and Child Health director. Vermont Legal Aid serves as the legal partner for each site. A statewide DULCE coordinator works as a contractor for the state Department of Health.
While the Family Specialist is not required to have a degree in a particular field or discipline, PCCs look for candidates who know the local community well, can integrate themselves into a pediatric practice unobtrusively, excel at building relationships with providers and families, and have experience caring for children, often as a parent. The Lamoille PCC runs a monthly support group for all the Family Specialists in the state, and each PCC also has trainings for staff.
At DULCE sites in Vermont, 96-98 percent of families opt to receive services, with the 2-5 families per year per site who decline typically doing so because they are having their second or third child. Rates have increased as practices participate in DULCE for longer periods of time and incorporate the expectation that families will participate into the clinic’s routines. Retention over the intervention’s six months is also very high and typically families who move away are the only ones who do not complete the full intervention. Family Specialists spend the vast majority of their time in the pediatric office, with other activities such as training, meetings, and coordination with other programs taking place at the PCC home office.
In addition to the Health-Related Social Needs Screening Tool, Vermont DULCE sites use a number of screeners including the Edinburgh Postnatal Depression Scale (EPDS), SEEK (Safe Environments for Every Kid) Parent Questionnaire, and the UNCOPE substance use screener. Family Specialists report that maternal depression and interpersonal violence are the most challenging topics to discuss, and they have learned that establishing strong relationships with parents is necessary before broaching them.
Vermont DULCE sites find that rates of positive maternal depression screens range from 15-20 percent, though this varies by site. In cases of positive screens, 75 percent of mothers engage in supports with the assistance of the Family Specialist. These supports vary by community and can include state mental health Designated Agencies, which are private, non-profit service providers responsible for delivering and coordinating adult and child mental health services in each region of the state. The Family Specialist stays up-to-date on available mental health providers.
Particularly in cases where Family Specialists identify greater needs or needs lasting beyond the six-month DULCE program, they can refer families to the state’s Children’s Integrated Services (CIS) home visiting program. Because each PCC is often the local lead CIS agency, the Family Specialist can easily refer cases to the CIS team, facilitate a warm handoff, and even conduct a joint home visit if needed. CIS offers a range of home visiting and home-based services, including Maternal Early Childhood Sustained Home-Visiting Program (MECSH), Parents As Teachers (PAT), Part C Early Intervention, specialized child care, and early childhood and family mental health.
Funding for DULCE in Vermont comes from several sources. The pilot site in Lamoille was fully funded with a grant from CSSP for three years and partially for two years. Additional sources of funding include $300,000 for three years from OneCare Vermont, the state’s accountable care organization, using Delivery Systems Reform (DSR) funds implemented under Medicaid section 1115 waiver authority. The state health department received a federal Centers for Disease Control and Prevention Overdose Data to Action grant and apportioned $250,000 to provide funding to three of the sites. DULCE Vermont has also used philanthropic funds and grants for PCC operations from the state Department of Children and Families, Child Development Division, which draw predominantly on state general revenues.
Monitoring and evaluation
Each Vermont DULCE site uses a data collection tool housed at the pediatric practice site, and Family Specialists enter relevant data after each visit. The team conducts a monthly continuous quality improvement meeting to review the data to improve implementation fidelity. For example, the data have suggested the need to address troubling trends across patients (e.g., high rates of maternal depression) and gaps in community resources.
Orange County DULCE
DULCE in Orange County, California, is in three of the five pediatric clinics operated by Children’s Health Orange County (CHOC). Ninety-eight percent of the families served by the three DULCE pediatric clinics identify as Latinx or Hispanic, and many are bilingual or non-English-speaking. The Family Specialist is part of CHOC’s broader community education team, and DULCE’s mental health lead is the social work department within CHOC’s population health division. The early childhood partner is First 5 Orange County, which uses state tobacco tax dollars to fund early childhood services and programs in Orange County, and the legal partner is Public Law Center.
The DULCE Family Specialist is classified by CHOC’s personnel system as a Community Health Worker, which is a role that does not require the incumbent to hold a bachelor’s degree. The three DULCE Family Specialists have extensive experience working with families, including in home visiting programs, and are fluent in Spanish. In addition to the CSSP DULCE training, the Family Specialists have participated in CHOC trainings on early relational health, mitigating toxic stress, and ACEs (adverse childhood experiences).
Despite the COVID pandemic, the Family Specialists have maintained their full caseload of 60-75 families. DULCE uptake among CHOC pediatric clinic families is high, with very few parents declining DULCE. The program’s high retention over the six months of the intervention is aided by the effective integration of the DULCE intervention into the clinics’ workflow and Family Specialists’ ability to engage families.
Because of the strong relationships formed with the Family Specialists, parents are willing to discuss sensitive issues concerning mental health, substance use, and violence, and are receptive to referrals. To establish these strong relationships, Family Specialists find ways to engage with parents during and outside of the time they spend with the physician. Family Specialists have access to the patient scheduling system, which tells them when current and potential DULCE participants will be visiting. Once the family has been roomed, the Family Specialist introduces themself, establishes a rapport, and offers the program. The Family Specialist will typically remain in the room to support the family during and after the physician encounter. The Family Specialists check in with the families between visits and talk with them when they come in for sick visits or for sibling visits. They can serve as a resource during a crisis, which was especially common during the early months of the pandemic. For example, DULCE organized transportation for a grandmother after she took custody of her three young grandchildren. DULCE also gives grocery cards when families disclose food insecurity.
Common referrals to DULCE’s legal partner in Orange County, made by the Family Specialist with a personal introduction, are related to immigration, housing and intimate partner violence. The Family Specialists use the Edinburgh Postnatal Depression Scale (EPDS) and receive guidance from CHOC’s social workers and psychiatry department about maternal depression screening and referral practices. The Family Specialists refer parents with positive Edinburgh screens to CHOC social workers for additional screening and connection with mental health services. These include a perinatal mood disorder program developed as part of the county’s behavioral health system.
Family Specialists also refer families to an array of home visiting models through the county’s Bridges Maternal Child Health Network. First 5 Orange County is the county’s largest funder of home visiting services, which include Nurse Family Partnership, Parents as Teachers, and community-designed models such as MOMS Orange County. The DULCE Interdisciplinary Team’s weekly meetings are joined by a Help Me Grow liaison, who can serve the Family Specialist and families as a source of referrals to services for child developmental and behavioral concerns and to parent education. Other than English, the most common language spoken by DULCE parents is Spanish. All service providers to whom DULCE refers employ bilingual and bicultural, Spanish-speaking providers who work with the family in their preferred language.
DULCE funding, which covers the Family Specialists’ salaries and training, comes from Medicaid funds for unreimbursed care made available to CHOC through the county’s managed care plan (CalOptima), with a match provided by Orange County First 5 from state First 5 tobacco tax funds.
Monitoring and Evaluation
DULCE in Orange County will be introducing a streamlined, user-friendly data dashboard by the end of 2021, which will simplify documentation and patient tracking by the Family Specialists and make data entry more efficient and less time-consuming. Because the dashboard is connected to CHOC’s electronic medical record (EMR) system, it will facilitate improved comparisons of quality metrics across the three program sites; analysis of trends and gaps at the overall program level; and identification of effective practices at the individual Family Specialist level for training purposes.
Special thanks to the following individuals for providing information for and reviewing this profile: Azieb Ermias, Senior Program Analyst, Center for the Study of Social Policy; Scott Johnson, Vermont DULCE Coordinator; Breena Holmes, pediatrician and senior faculty at the Vermont Child Health Improvement Program in Department of Pediatrics at University of Vermont; and Ilia Rolón, Director, Community Clinical Outreach, CHOC.
Last updated December 2021