NaturePHL

Nature of the Problem

“Children’s emotional and behavioral problems are currently an area of great national concern. The Center for Disease Control and Prevention estimates 1 out of 6 children in the United States aged 3-17 years old have a behavioral or developmental disability, such as attention-deficit hyperactivity disorder (ADHD) or autism spectrum disorder. As the prevalence of these conditions continue to rise, novel approaches that may improve the emotional and behavioral functioning of young children are needed now more than ever. In addition to the strong body of research that demonstrates the physical health benefits of nature exposure, there is emerging evidence that green recreational spaces also have a positive influence on the mental, emotional, and behavioral health of children.”- Dr. Sandhyaa Iyengar , NaturePHL The problem the NaturePHL program is trying to address is that Primary Care Providers (PCPs) are not currently equipped with the resources to counsel patient families on the emotional and behavioral health benefits associated with increased time outdoors. PCPs are poised to create change by providing effective counseling during primary care visits, but many providers in CHOP’s primary care network have reported a lack of training or resources to provide counseling that is personalized, local, and specific.

Program Description

NaturePHL is a collaborative program that currently targets patients aged 5-12 at annual well child visits and check in visits in order to reach the broadest age demographics, which includes the patient’s siblings and caregivers. Our clinical workflow -that is implemented in into the EHR of the Children’s Hospital of Philadelphia – begins with patients receiving a screening questionnaire upon their arrival to the clinic. This screening tool asks questions about current time in nature and access to local parks and green spaces. Using the screening questionnaire, providers are encouraged to provide a universal counseling message about outdoor time to patients who could benefit (with message printed in AVS), and to provide a more intensive counseling message to patients that are coming in for ADHD visits and health weight check ups. More intensive counseling includes: (a) an activity prescription bolstered by (b), the distribution of patient family education materials, as well as (c) the introduction to our website www.naturephl.org, and (d) the referral to a Nature Navigator, a community health worker who counsels patient families after their clinic visit to help them adhere to their nature prescriptions.

Disruption

NaturePHL’s clinical intervention fosters access to nature and provides pediatricians with resources for improving the emotional and behavioral well-being of children in Philadelphia. Our strategy is new and innovative as we are having pediatricians provide the messaging. Primary Care Providers are seen as trusted messengers for providing health information. Before implementing our program we held focus groups in the Philadelphia communities that CHOP serves. Through those conversations, it was made clear that if a doctor gave a prescription for their child to go outside and provide resources on why and how, everyone would follow through. The other problem NaturePHL solved through its clinical workflow at CHOP, is providers did not have the resources to talk to their patient families about the social and emotional benefits of outdoor time, and specifically how to help that patient by getting them outside. Our smartset is easy to use and accessible.

Leadership

NaturePHL is rising as a leader in behavioral health communication with it’s smartset and clinical workflow. The resources developed for patients addressing benefits and perceived barriers have proven to be a very successful tool for providers who need to counsel patients with emotional and behavioral issues. It is also a leader in the way the messaging is backed by a new body of research, associating access to green space and nature to improved mental, emotional and behavioral health of children with ADHD.

Scalability

Our toolkit can be adapted and expanded to any health care center. Our current plans for expansion start with more behavioral and specialty clinics within CHOP. We have been approached by St. Christopher’s and other Philadelphia Hospitals to implement our program in their EHR. Our patient family education materials can be edited to add or subtract different benefits depending on which patient population is being served; for example- editing our ” Health Benefits” resources to be focused on one specific area of health. Our program can also be implemented to serve a wider age range. For our pilot we chose to target 5- 12 year olds, we plan to expand to younger, adolescents, adults and older adults- as the benefits associated with spending time in nature cross generations. Our program is fully funded by PA DCNR, BARRA foundation, and are in the process of receiving funding from CHOP research lab.

Results/Outcomes

NaturePHL has a three tiered evaluation approach to measure the outcomes of our program. Our first is whether our program is proving to be a valuable resource for physicians. We measure how many messages have been given at each clinic and we also have collected self reported surveys from physicians on the ease and use of our toolkit. For 2017-2018, NaturePHL provided counseling messages to over 50% of well child visits in two of our primary care clinics totaling about 3,000 patients. Our providers reported they use the smartset all the time when in a patient visit . We are in the process of measuring our two long term outcomes of increasing time outside and improving health through access to space. We use pre and post surveys for families receiving intensive counseling to qualitatively report how much our families are increasing their time outside.