Understanding and Reducing System Barriers to Early Childhood Education Enrollment Through Quality Improvement

• In Event: Equitable Access to Childcare: Tools and Solutions

Abstract

Background: Literature suggests that high-quality early childhood education (ECE) programs can improve children’s educational, social, and health outcomes. In 2016, our city passed a $15M tax levy called Preschool Promise that provides progressive tuition assistance to 3- and 4-year-olds in high-quality ECE programs. Unfortunately, the ECE enrollment system is complex, siloed, and difficult to navigate, especially for low income families. Families must apply in person with the child’s birth certificate, medical/dental forms, proof of address and income. If no slots are available, the family must repeat the lengthy application process at another agency. Pediatric practices are invested in children’s early development and long-term health, and are positioned to play a role in improving access to ECE. In 2016, our primary care clinic created an early childhood specialist role to promote early childhood and assist families in enrolling in high quality ECE programs. To maximize impact, we took a data-driven approach to improve ECE enrollment success.

Objective: Our global aim is to leverage pediatric primary care to increase child readiness for kindergarten. Our specific aim for this project was to understand and reduce system barriers to ECE enrollment.

Methods: The setting is a large academic urban pediatric primary care center (7000 patients under age 6, 86% Medicaid-insured). We used quality improvement (QI) methods to identify burdensome aspects of the ECE enrollment process and to test potential solutions the ECE Navigator could employ. We developed and tested these solutions in partnership with community agencies. With community partners, we constructed process maps for ECE enrollment, a Key Driver Diagram capturing the true drivers of enrollment, and conducted Plan-Do Study-Act test ramps to improve enrollment. We studied failures through Pareto charts and N-of-1 stories. To study our process improvements on a granular level, we plotted the percentage of ready documents and children with completed applications on statistical process control charts to study trends over time. This allowed us to examine both small parts of a large, complex process, as well as changes in our desired outcome.

Results: The process map revealed a multi-step process to enroll, which differed slightly at each of 4 ECE agencies. With co-designed tests, the percent of required documents families were able to compile increased significantly from 40% to 100%, and the average percent of families with completed applications increased significantly from 27% to 72%. Interventions included assistance identifying ECE openings, follow-up calls, parent education, partnerships with the homeless coalition and Jobs & Family Services, an online enrollment process, and document standardization. Common barriers to enrollment included lack of transportation, prior poor customer service experience, and family stressors (homelessness, death in family). The most common barrier was that the enrollment process took much longer than originally anticipated (up to 12 months).

Conclusion: Families encounter multiple barriers to ECE enrollment that can be overcome in deep partnership with relevant community agencies. We next plan to study policy and system barriers and co-design system solutions with parents and ECE stakeholders with the global aim of reducing health inequities.

Authors

• Kristen Copeland, Cincinnati Children's Hospital
  Presenting Author

• Amy King, Division of General and Community Pediatrics Cincinnati Children's Hospital
  Non-Presenting Author

• Courtney Brown, Nationwide Children's Hospital
  Non-Presenting Author

• Alexis Amsterdam, Division of General and Community Pediatrics Cincinnati Children's Hospital
  Non-Presenting Author

• Zeina Samaan, Division of General and Community Pediatrics Cincinnati Children's Hospital
  Non-Presenting Author

• Robert Kahn, University of Cincinnati Department of Pediatrics
  Non-Presenting Author