Evidence demonstrates that besides adequate financial resources, good education, and a healthful physical and social environment, the most powerful personal health improvement strategy may be establishing a regular source for health services. When a family has a trusted relationship with a knowledgeable health care provider, and these results in timely receipt of proven preventive care, the development of a personal wellness plan, and the compilation of all health records in a single location, that family has established what WHF calls a "Health Home".

WHF believes every Washington resident should have a "Health Home". To make that healthy choice the easy choice for all, WHF further believes that the health care system’s most cost-effective contribution to health improvement will be made when it supports every Washington resident in a "Health Home".

Transforming health care toward this vision will be complex and difficult. It will require a major reorientation of expectations from the patient and provider, from the policy world and into the private sector.

While WHF believes every Washingtonian should have a Health Home, WHF also acknowledges that our state should first and foremost focus on children. Not only are they our future, they offer our best hope of improving our state's health in the long term.

Research has shown that the greatest single obstacle to a regular source of care is affordability. This is why WHF supports implementation of the state's policy that all children have insurance coverage by 2010 (HB 1441) so long as this insurance creates financial incentives and accountability – not barriers – to Health Homes. This will require a combination of expanded enrollment and eligibility for publicly subsidized coverage, and encouragement of private employers to cover children in employer-sponsored health plans. These efforts must include aggressive social marketing and targeted outreach campaigns aimed at under-served populations. School nurses, public health nurses, and bi-lingual/bi-cultural community groups should be involved in this process.

WHF's Report Card tracks at least three measures to describe what can help Health Homes become universal and effective health promoting entities. These include insurance coverage, routine contact with a primary care health care provider, and timely receipt of several proven preventive services. WHF believes these measures should form the core of accountability for health services.

Insurance coverage is an indication of affordability, although its benefit design may not always promote a Health Home. The five services that comprise WHF's preventive services measure (prenatal care, childhood immunizations, cholesterol screening, colorectal cancer screening and mammograms) are sentinel, but not inclusive of the full battery of proven preventive services. An annual primary care visit indicates an ongoing relationship with a trusted health advisor, but does not guarantee a comprehensive health record, the presence of a health and wellness plan, the engagement of the parties with that plan or with one another, or the possibility that the health advisor might not be a physician.

Some 14 percent of Washington's children experience or are at increased risk for chronic physical, developmental, behavioral or emotional conditions requiring specialized care that is coordinated across several health, educational, and social services. WHF believes these children must receive this specialized care through a Medical Home, as defined by the American Academy of Pediatrics.

However, more than 80 percent of Washington's children are essentially well. These children will benefit from a Health Home that ensures their healthy development by providing regular screenings, immunizations, and health education. A variety of environments can be Health Homes, including physician practices, community clinics, developmental centers, or appropriately staffed schools or community centers. WHF believes all of these facilities will need to collaborate to provide these services in an easy, convenient and affordable way to all our children.

Primary care models and other programs that promote health at child care centers and schools assure that all children receive basic health education and services. If staffed sufficiently, proven preventive screenings, immunizations, and connections to other Health Home services can be provided in schools. In fact, evidence from other states suggests this can be part of an effective strategy to boost Washington’s comparatively low rate of childhood immunization rates.

Yet school nurses and vital school health infrastructure have eroded to alarming levels. Too few and inadequately compensated school health personnel have resulted in major deficiencies in school health and related services. Expert consultants to Washington Learns identified these deficiencies and recommended major increases in school health staffing ratios based on solid evidence of successful programs in other states. WHF adds its voice to those already urging that major increases of school health staff be provided to local schools to decrease the ratio of pupils to school nurses or health aide staff, which in some places is as high as 750:1. These resources are key to establishing needed health advice and service capacity in schools, to deliver emergency services, and to accomplish effective referrals.

In other settings too, nurses, in particular, should be seen as health partners with whom ongoing relationships can be formed. For example, even high-risk families have been shown to benefit from the Nurse-Family Partnership, a proven but under-used health partnership. This model should be made more universally available through health departments, schools and/or private clinics or provider groups.

Our state's First Steps program taught us that coverage is necessary – but not sufficient – for health improvement. Families must be reminded regularly of the value of preventive care, so they value receipt of these services highly enough to use them. Families must also have trusting relationships with their health care providers, so they will learn from their providers' experience and education. Health messages are most effective when broadcast from a trusted source. This is no less true in communities of color. Proven efforts to reach these chronically under-reached populations should be staffed and implemented through persons and facilities trusted within these communities.

Finally, we need simple, public accountability at all levels for receipt of services to all children, not simply accountability for payment if services should happen to be provided. Health care providers, state and local health departments, health insurance carriers, and state agencies each have roles to play in assessing and regularly reporting to all interested parties our success in actively engaging each of our children in a Health Home.

By 2010, every child should be receiving comprehensive, early and periodic health checks and timely treatment. The legislature should direct a lead health policy agency, to coordinate a series of activities toward this end. This effort should be conducted as an open collaboration between relevant state agencies, willing private employers, carriers, providers, community health centers, schools, local health departments and community health action agencies, making sure to include low-income and racial and ethnic minority groups. By the end of the current biennium, the state should:

• Begin tracking a specific set of health service outcomes for all Washington's children through state purchasing contracts, public health assessment activities and other means. Measurements should include enrollment in a Health Home, timely receipt of all immunizations, timely well-child visits including dental, behavioral and comprehensive developmental exams, and receipt of needed treatment;
• Implement a robust outreach and education campaign that includes both general multi-media social marketing and targeted media, and personal assistance to parents, providers and community leaders in underserved areas on the value of preventive health services and a regular source of health advice and care for children;
• Implement targeted outreach to communities of color and rural areas using community health nurses, health educators, school nurses and other health outreach workers;
• Increase the ratio of school nurses and aides toward those recommended in the Picus Report to Washington Learns;
• Encourage or require schools receiving additional school health staffing to implement coordinated school health models that include arrangements for preventive screenings, immunizations and appropriate referrals through trusted relationships with school nurses, nurse practitioners or community health providers;
• Implement training for community clinics and private practice providers statewide in practice management techniques and other means to deliver high-quality, cost-effective Health Home services and comprehensive preventive health services;
• Implement strategies to link community health action agencies with private health care providers to provide social support to patients and logistical support to these providers in continuing to see state-sponsored patients;
• Include performance incentives in state health service purchasing contracts to promote efficiency, to eliminate service receipt disparities among high-risk groups, and to improve overall outcomes; and
• Provide sufficient funds, either directly or in a dedicated reserve account, to accommodate caseload growth and improved utilization of services when they appear in state-supported children’s health programs, and eliminate waiting lists and the denial of coverage to any child eligible for state-sponsored care.