“Milestones Matter”: One Pediatrician’s Perseverance Drives Transformative Change

Long Island City pediatrician Nancy Lee, MD, was frustrated by the hurdles non-English speaking parents faced when bringing their babies to the doctor. So, she decided to start printing educational index-sized cards for families in their native language.  

Little did she know, the idea—launched as her project with United Hospital Fund’s Pediatrics for an Equitable Developmental Start (PEDS) Learning Network Fellowship program—would lead to a much larger transformation. 

​  Nancy Lee, MD, completed the United Hospital Fund's Pediatrics for an Equitable Developmental Start (PEDS) Learning Network Fellowship.  ​
​ Nancy Lee, MD, completed the United Hospital Fund's Pediatrics for an Equitable Developmental Start (PEDS) Learning Network Fellowship. ​

“It really started with me just wanting to provide better care for my non-English speaking patients,” said Dr. Lee, who created the laminated cards with guidelines from the CDC’s “Learn the Signs, Act Early” program to help parents recognize whether their child was reaching important developmental milestones. “[But] when we looked back, we realized, ‘Oh, this is a really big problem. This is much more than educating families.’” 

The problem Dr. Lee, an assistant professor of clinical pediatrics at Weill Cornell Medicine and a pediatrician at NewYork-Presbyterian Komansky Children’s Hospital, had discovered was startling: The Community Health Care Network/Long Island City Primary Care facility where she practiced was referring patients to early intervention services at a third of the rate of the national average. This meant that providers were potentially missing signs of developmental delays or disabilities in babies and toddlers who could benefit from the free programs.  

Given this revelation, Dr. Lee’s fellowship idea evolved beyond index cards into a full-fledged quality improvement project for the clinic. But she was up for the challenge.

Dr. Lee first diagnosed two issues driving the low referral rate: clinicians weren’t successfully identifying patients who had potential delays and those they were capturing often rejected a referral, a sign the importance of early intervention might not be getting across to families.

An example of Dr. Lee's "Milestones Matter" card.
An example of Dr. Lee's "Milestones Matter" card.

Some progress in overcoming both these hurdles had already begun, thanks to Dr. Lee’s index cards, which were translated into Spanish, Bengali, and Arabic and laid out information about important milestones at each age. To help drive home the information, the cards were accompanied by small items to ensure parents could test each milestone, whether it be a rattle at two months old, a teething ring at four months old, or crayons at two years old. 

“The idea was to get parents to play a bigger role in their child’s development,” Dr. Lee said. “These screeners for developmental milestones ... rely on parents to understand what milestones are.” 

But the larger obstacle became integrating conversations about developmental milestones into the clinic’s workflow. Dr. Lee spent the next year educating clinicians about the services available so they could properly explain them, training ancillary staff on how to do the milestone check-ins, and ensuring the index cards were properly distributed. 

An example of Dr. Lee's "Milestones Matter" card.
An example of Dr. Lee's "Milestones Matter" card.

The results speak for themselves: In just over a year, the Long Island City clinic nearly doubled its referral rate, jumping from 5.5 to 10 percent. The number of those patients who were then approved for services also spiked, proving clinicians were not only making more referrals, but were becoming better at identifying patients who would benefit from them. 

These numbers represent a real difference for families who otherwise might not have received or even been aware of the intervention services, which can range from occupational therapy to speech or language help. 

“The earlier you capture a delay and the earlier you intervene, the better outcomes you’re going to have overall,” Dr. Lee said. 

Thanks to Dr. Lee’s project, the “Milestones Matter” index cards have been given to around 150 families at the Long Island City clinic and have since expanded to Manhattan’s Helmsley Tower 5 Primary Care, part of NewYork-Presbyterian’s Ambulatory Care Network, where Dr. Lee now works.  

The clinics will both see benefits that began, Dr. Lee said, with the PEDS Network fellowship. The program provided mentors, professional development resources, and a financial stipend for the project.  

“UHF’s support and funding was critical to the success of this endeavor,” she said.  

UHF's fellowship was launched in 2020 to help changemakers reimagine pediatric care in a way that reduces childhood health inequities. It is part of UHF’s Pediatrics for an Equitable Developmental Start (PEDS) Learning Network, which is funded by a grant from the Mother Cabrini Health Foundation. During the program, each fellow, like Dr. Lee, is tasked with leading an equity-focused, child health project in their workplace. 

“One of the primary goals of the PEDS Network is to highlight and share best practices throughout New York State and to support emerging clinical leaders dedicated to improving childhood development and achieving more equitable outcomes for children and their families,” said UHF senior program manager Susan Olivera, who oversees the PEDS Learning Network. “Dr. Lee’s commitment coupled with her transformative work exemplifies what the PEDS Network was created to do!”