BY LYNN PULLANO
On December 11, 2020 a novel funding opportunity was issued by the U.S. Health Resources and Services Administration (HRSA) that piqued the interest of Help Me Grow (HMG) affiliates: the Early Childhood Comprehensive Systems Health Integration Prenatal-to-Three (ECCS P-3) Program. Rarely encountering funding applications that support state-level integrated maternal and early childhood systems-building – with associated infrastructure, capacity, coordination, and policy outcomes – a number of HMG state leads earnestly began working with state Title V agencies and other collaborative partners to develop applications.
As the only evidence-based, nationally recognized early childhood system model, HMG is uniquely positioned to support the aims of states in achieving prenatal-to-three system-level goals. Identifying the potential for HMG state affiliate leads to spearhead or contribute to successful ECCS P-3 plans, the HMG National Center extended an offer of technical assistance to the National Affiliate Network through a six-week ECCS/HMG P-3 Community of Practice (CoP). The purpose of the CoP was to help applicants leverage the strong foundational work of HMG affiliates in applicant states and articulate the value of the HMG Model as a vehicle for advancing child health and development.
Eleven HMG states participated in the ECCS P-3 CoP, representing affiliates in early phases of exploration all the way through those in full implementation of the HMG Model, as well as a wide range of geographies. In five of these states, the HMG state backbone (most frequently the Title V agency), was the lead applicant. In the remaining six states, HMG affiliates contributed to or provided information about the Model to support the state’s application.
ECCS CoP: A Microcosm of the Six Conditions of Systems Change
As CoP participants proceeded through the process of developing collaborative, system-level applications, it became evident that successfully crafting ECCS P-3 proposals required attention to the very conditions needed to build the early childhood systems about which they were writing. Interestingly, the CoP experience began to mirror the Six Conditions of Systems Change articulated in The Waters of Systems Change by John Kania, Mark Kramer, and Peter Senge. Consideration of these six conditions – policies, practices, resource flows, relationships and connections, power dynamics, and mental models – help those engaged in systems change alter the conditions that hold problems in place and craft an actionable model for effecting systems reform. The same conditions applied to the creation of strong ECCS P-3 applications.
Iterative development of grant narratives, logic models, work plans, and budgets throughout the term of the CoP illustrated the Six Conditions of Systems Change in action during collaborative preparation of state proposals. A post-CoP survey conducted among participating HMG state leads further reinforced the operational prevalence of these conditions during the application process.
- HMG leads indicated the importance of relationships in developing their ECCS P-3 plans, noting opportunities to “leverage programs that we had not been able to work with, such as Medicaid,” “discuss new opportunities to partner that we hadn’t thought of before,” and “communicate and share information across partners and sectors.”
- Evidence of shifts in power dynamics within state maternal/early childhood systems emerged as grant applicants designed strategies for equity and inclusion that centered on enhancing opportunities for family leadership development, diversity of family voice in state policy development, and participation of families in evaluation of outcomes.
- With application partners working to propose efficient, effective financing and leveraging strategies to achieve systems change, innovative planning around resource flows was an integral component of each proposal.
- A wide variety of state and organizational policy and practice changes were suggested in reimagining outcomes for young children and their families. For example, engaging health care in the early childhood system was an integral objective of all states’ ECCS P-3 plans – with concomitant policy and practice changes related to statewide screening registries, centralized intake and referral systems, cross-sector data sharing, Medicaid reimbursements, and more.
- Finally, shifts in mental models surfaced over the course of the CoP. One such shift involved thinking about how to craft grant budgets appropriate to this unique, system-focused opportunity. Rather than requesting more traditional support aimed at program-level work that had a grant-period shelf life, ECCS P-3 budgets were designed to fund sustainable elements of state MEC systems such as infrastructure development (e.g., statewide Centralized Intake and Referral Systems), creation of family leadership pipelines to inform and influence state policy decisions, and strategies for increasing health care sector engagement over the long-term.
Five Lessons on Early Childhood Systems Building from the ECCS P-3 CoP
The CoP presented an opportunity to reflect upon the status of early childhood systems building within HMG states and the evolving position of HMG within those systems. Several themes emerged throughout the CoP that provide valuable lessons for those seeking to successfully implement the HMG Model to promote optimal early heath and development in children.
The experience of Help Me Grow affiliates can help move systems thinking into practical application.
The concept of “systems thinking”—mainstreamed through the dissemination of collective impact theory and strategies over the past decade—remains relatively nascent in practical application. During the CoP, it was evident that enacting the Six Conditions of Systems Change is not yet reflexive among many state and community maternal/early childhood (MEC) partners. By continually exercising systems-building “muscles” with focused intentionality, MEC collaborators have the opportunity to strengthen these six conditions in working toward system-level outcomes. HMG affiliates are often uniquely practiced in thinking and strategizing for system-level versus program-level change, ideally positioning them to inform, support, and/or lead MEC efforts. In fact, the post-CoP survey indicated the feature most attractive to state-level application partners was the systems versus program focus of HMG, which led to increased advocacy among state partners for support of the HMG Model. Five of the eleven participating affiliates indicated a somewhat to very extensive improvement in support for use of the HMG Model at the state level, five noted moderate improvement, and one perceived slight improvement.
The perceived value of the Help Me Grow Model includes and extends beyond its unique system focus.
The ECCS P-3 grant construction process offered participating HMG affiliates a valuable view on what their state-level application partners found most appealing about HMG. While the systems focus of the HMG Model was considered the most attractive element, its evidence base, the learning community available through the National Affiliate Network, and the Core Component of a Centralized Access Point or “Centralized Intake and Referral System (CIRS)” were all reported to be benefits and assets associated with the Model In this case, the Centralized Access Point was particularly desirable to partners, as it was a component required in HRSA’s Notice of Funding Opportunity.
System outcomes are not simple to identify and measure.
Help Me Grow data collection and analysis efforts can support systems evaluation.
While welcoming the rare systems-focused opportunity presented through the ECCS P-3 grant, CoP teams confronted challenges in articulating related measures of success. “The evaluation component was tricky for us to navigate,” noted one HMG state lead. The question of how to measure and articulate systems change was a daily topic as logic models and evaluation plans were drafted and redrafted. To help articulate appropriate systems-level evaluation strategies, cohort members drew from the Six Conditions of Systems Change to develop potential progress and outcome indicators. In addition, resources from the HMG National Center provided direction. These included the Help Me Grow Business Case and ROI Calculator, which leverages financial modeling of early childhood programs/interventions to quantify the additional value-add of HMG implementation, as well as the recent HMG Positive Deviance project, a Network-wide research study that identifies the enabling conditions for sustainability of HMG systems. Awareness grew around the data collection and analysis work already being done by HMG affiliates as a foundational contribution to state-level maternal/early childhood systems evaluation.
Achieving equity, diversity, and inclusiveness is both a high priority and a complex journey. Targeted universalism can help chart a course.
As CoP teams considered how to optimally embed equity, diversity, and inclusiveness when building out state maternal/early childhood system strategies, it became obvious that positive intentions surpassed confidence in how to best manage approaches to achieve desired levels of impact and authentic change. The “targeted universalism” approach espoused by the HMG National Center—articulated in the Haas Institute’s Targeted Universalism Primer—provided a framework from which to draw actionable methods of ensuring that all families with young children in a given state have access to maternal/early childhood supports to the extent each family needs. Succinctly, the Primer describes the concept of targeted universalism as, “setting universal goals pursued by targeted processes to achieve those goals.” HMG is and has always been intended to support and serve all families, but local systems across the country carry out targeted strategies, approaches, and initiatives to specifically address the various and unique needs of families affected by racism, poverty, isolation, discrimination, and other inequities. It was noted by a state partner that, “HMG is ahead of the curve with thinking about targeted universalism.”
Explaining the Help Me Grow Model remains a
challenge and an opportunity.
The complexity of systems building—and its relative infancy in practical application—means that fostering understanding of a systems model like HMG can be a similarly complicated endeavor. While support for use of HMG as a framework or key approach for state MEC systems expanded throughout the CoP, it was at times challenging for partners to understand the nuances of HMG as a systems model rather than a program. Yet, the CoP illustrated that focused efforts to achieve understanding of the HMG Model among state-level partners can yield positive results. As a result of the ECCS application process, all participating HMG CoP affiliates perceived improved understanding of HMG among their state-level partners. Nine of the eleven affiliates sensed a moderate to very extensive increase in comprehension of the Model among their grant partners.
Implications for the National Affiliate Network
The lessons and themes which emerged from the ECCS P-3 CoP echo and validate the mutually reinforcing priorities detailed in the newly released, five-year HMG National Strategic Growth Plan, which outlines strategies for accelerating the HMG Network’s growth and impact as an asset for communities and states pursuing early childhood system building. As the only national, evidence-based early childhood model that focuses at the systems-level, HMG has immense potential to shift “the waters of systems change” as an approach to advancing healthy development of all children aged birth through five and their families. In working to implement HMG with fidelity at the community- and state-levels, affiliate leaders and their collaborative partners can benefit from intentional consideration of the Six Conditions of Systems Change and emergent resources from the HMG National Center to help navigate the challenging seas of systems development.
Help Me Grow National Center Strategic Growth Plan
|1. Further validate HMG’s impact model and measure Network performance towards equitable outcomes (including those defined by communities).|
|2. Accelerate the network’s ability to use data to achieve community change at the state and system-levels (including investment in services that are culturally appropriate).|
|3. Clearly define how the HMG Model can be used to advance racial equity (through the components of targeted universalism).|
|4.Secure robust funding for early childhood systems infrastructure in several key states to build momentum for a parallel national policy and advocacy agenda.|
|5. Pursue ~3x growth, emphasizing equitable growth within existing states to serve populations that mirror racial/ethnic demographics of communities.|
Stay tuned for our forthcoming report exploring the various innovative ways Help Me Grow affiliates designed the Help Me Grow Model to be a key piece of their proposed approach to the Early Childhood Comprehensive Systems (ECCS): Health Integration Prenatal-to-Three Program.
Lynn Dobmeier Pullano is a Help Me Grow National Implementation Expert and President/Owner of All Good, a New York-based consulting firm that specializes in collective impact, system building, and strategic implementation for social value causes.