Challenge

The first six months of a child’s life are a critical time of development. Stress early in life can create negative short and long term health effects. Many conditions contribute to stress, including poverty, inadequate housing, and lack of adequate nutrition. Unfortunately, these are more likely to impact families with low income, families of color, and immigrants.

DULCE (Developmental Understanding and Legal Collaboration for Everyone) employs a strength-based approach to help parents navigate the challenges of caring for babies, raising healthy children, and advocating for what they need. Starting with baby’s first medical visit, families develop a relationship with a DULCE family specialist who helps them navigate community resources and create the conditions for healthy development. A cross-sector team located at a pediatric clinic—including a physician or nurse practitioner, a medical-legal partner, an early childhood system representative, a mental health lead, and the DULCE family specialist— work together to provide holistic care, drawing upon their respective areas of expertise. By prioritizing parent-identified needs, connecting them to supports, and building trusting relationships, parents are better equipped to raise healthy children and advocate for well-being.

DULCE is grounded in a community’s local early childhood system, with implementation led by a local back-bone organization that engages pediatric and legal partners and holds responsibility for supporting and aligning a broader set of early childhood interventions, strategies, and policies. DULCE enables CSSP’s county-level partners to reach virtually all of the families of newborns within participating clinical sites, and it provides the opportunity for the health system to better connect with broader community services and supports for children and families. 

Data gathered from six clinic sites over two years during initial implementation nationally showed that DULCE had reached over 1,500 families. Nearly all families (98%) accept DULCE services and 87% of these families continue through the full six months (most non-completions are due to relocation). DULCE currently operates in seven clinic sites in five communities across the United States.

Overview

DULCE approached Root Cause with questions about how best to reach more families and communities. The model, co-developed by Robert Sege, MD, Ph.D., now at Tufts Medical Center, and Samantha Morton, CEO, MLPB, was grounded in the compelling findings from a randomized controlled trial (RCT) conducted at Boston Medical Center showing that the DULCE model has a statistically significant impact on enrolled children and families, as well as the clinics that serve them.

The communities involved in the first expansion cohort—Palm Beach County, FL, Lamoille Valley, VT and Alameda, Los Angeles and Orange Counties, CA—were demonstrating strong signs of early success. Their clinical sites were showing  increased patient retention, increase of on-time immunizations, decreased no-show rates for well-child visits, and early identification and resolution of family housing, income, nutritional and mental/behavioral health needs. Physicians and clinic staff were crediting DULCE with improving the work environment and reducing burnout, and emerging evidence suggested that DULCE was paving the way for families to engage in other interventions when needed. In addition, communities were embarking on policy and system changes based on their experience with DULCE and related effort to address the social determinants of health (e.g., addressing family transportation needs). The pilot communities were starting to think about expansion locally, and CSSP, along with its partners, were interested in making DULCE available to new communities

Root Cause and CSSP partnered to create a business plan for effective and sustainable replication of the DULCE model.

Root Cause and DULCE developed a business plan that answered key questions for DULCE related to replication and expansion. 

Root Cause worked with DULCE team members to articulate what it would take for DULCE to grow, both within current communities and in new communities. The process included summarizing learning from expansion efforts to date, and mapping a set of goals and activities to enable local communities and the national office to increase reach and impact. 

Together with the DULCE team, Root Cause created the following resources for CSSP to support DULCE’s future expansion: 

• A business plan document to serve as a road map for spread and scale, and to edit as appropriate to share with others to gain additional support. The plan includes sections on:
  • The need and opportunity for the DULCE program model
  • Learning through expansion and implications for DULCE’s future
  • Goals and action plan for the next three years and beyond
  • Leadership and team
  • Investment required
• A financial model to guide budgeting as the work evolves
• A model local budget as communities get started with DULCE, which can be adjusted to use with communities as they are expanding
• The DULCE Stages of Implementation Framework to guide local activities, technical assistance (TA), and the development of TA tools/infrastructure for communities implementing DULCE
• A timeline and mapping of the new approach to delivering TA
• A summary of benchmarking research