Well-Child Care Clinical Practice Redesign for Serving Low-Income Children

Abstract

Our objective was to conduct a rigorous, structured process to create a new model of well-child care (WCC) in collaboration with a multisite community health center and 2 small, independent practices serving predominantly Medicaid-insured children. Working groups of clinicians, staff, and parents (called "Community Advisory Boards" [CABs]) used (1) perspectives of WCC stakeholders and (2) a literature review of WCC practice redesign to create 4 comprehensive WCC models for children ages 0 to 3 years. An expert panel, following a modified version of the Rand/UCLA Appropriateness Method, rated each model for potential effectiveness on 4 domains: (1) receipt of recommended services, (2) family-centeredness, (3) timely and appropriate followup, and (4) feasibility and efficiency. Results were provided to the CABs for selection of a final model to implement. The newly developed models rely heavily on a health educator for anticipatory guidance and developmental, behavioral, and psychosocial surveillance and screening. Each model allots a small amount of time with the pediatrician to perform a brief physical examination and to address parents' physical health concerns. A secure Web-based tool customizes the visit to parents' needs and facilitates previsit screening. Scheduled, non-face-to-face methods (text, phone) for parent communication with the health care team are also critical to these new models of care. A structured process that engages small community practices and community health centers in clinical practice redesign can produce comprehensive, site-specific, and innovative models for delivery of WCC. This process, as well as the models developed, may be applicable to other small practices and clinics interested in practice redesign. Pediatrics 2014;134:e229-e239 Dr Coker conceptualized and designed the study; led data acquisition, analysis, and interpretation; and drafted the initial manuscript; Ms Moreno made substantial contributions to the acquisition and analysis of data and reviewed and revised the manuscript; Drs Shekelle and Chung made substantial contributions to the study conception and design and acquisition and interpretation of data and reviewed and revised the manuscript; Dr Schuster made substantial contributions to the study conception and design and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted.www.pediatrics.org/cgi

A Parent Coach Model for Well-Child Care Among Low-Income Children: A Randomized Controlled Trial

“…16,17 Our comprehensive model (ie, the Parentfocused Redesign for Encounters, Newborns to Toddlers [PARENT]) was developed to address these key structural deficiencies in our current WCC system by decreasing reliance on the physician for routine WCC and shifting many WCC services to a health educator. 18 Our objective was to test the effectiveness of the PARENT intervention in providing comprehensive, nationally recommended WCC services, while optimizing WCC, urgent care, and emergency department (ED) utilization among low-income families.…”

Determinants of Health and Pediatric Primary Care Practices

“…To address these facilitators and barriers within practice-level strategies to improve care provided to families living in poverty, we adapted a conceptual framework previously developed for primary care practice redesign focused on low-income children (Fig 1). 16,30 The framework is based on a model first described by Donabedian, and further developed by Starfield, in which health outcomes are determined by the structures of care (ie, personnel, organization, financing, information systems), processes related to care provision (ie, diagnosis, management, reassessment), and receipt of care (ie, patient/family utilization, acceptance, understanding, compliance). [31][32][33] The present article focuses on those structures and processes that can be addressed at the practice level.…”

“…49 Some programs have been developed specifically to improve the delivery of preventive and primary care services for children in poverty. 16,[50][51][52][53] For example, the Parent-focused Encounters, Newborns to Toddlers Intervention, uses a health educator ("parent coach") to provide the bulk of well-child care (WCC) services. 16 At each visit, the parent coach provides anticipatory guidance; psychosocial screening/referral; and developmental and behavioral surveillance, screening, and guidance.…”

“…16,[50][51][52][53] For example, the Parent-focused Encounters, Newborns to Toddlers Intervention, uses a health educator ("parent coach") to provide the bulk of well-child care (WCC) services. 16 At each visit, the parent coach provides anticipatory guidance; psychosocial screening/referral; and developmental and behavioral surveillance, screening, and guidance. The intervention addresses challenges of WCC that center on common barriers to effective care delivery, including insufficient time for pediatricians to provide the level of parent guidance and education that is typically needed.…”

“…11 Thus, pediatric practices are challenged to redesign care delivery services in ways that identify and mitigate such poverty-related risks. [11][12][13][14][15][16][17][18] It is also important that as pediatric providers redesign practices, they consider the importance of building bridges to the education, public health, and policy sectors, which are similarly focused on improving children's lives.…”