Courtney M. Brown

Implementation of a Preventive Services Bundle in Academic Pediatric Primary Care Centers.

BACKGROUND AND OBJECTIVES: Previous studies have documented poor rates of delivery of preventive services, 1 of the core services provided in the primary care medical home setting. We aimed to increase the reliability of delivering a bundle of preventive services to patients 0 to 14 months of age from 58% of patient visits to 95% of visits. The bundle includes administration of routine vaccinations, offering influenza vaccination, completed lead screening, completed developmental screening tool, screening for maternal depression and food insecurity, and documentation of gestational age. METHODS: The setting was 3 academic pediatric primary care clinics that serve 31 000 patients (>90% Medicaid). Quality improvement methodology was used and key driver diagram was determined. Patient “Ideal Visit Flow” and the Responsible, Accountable, Support, Consulted, and Informed Matrix were developed to drive accountability for components of the ideal flow. Plan, Do, Study, Act cycles were used to develop successful interventions. The percent of patients seen who received all bundle elements for which they were eligible was plotted weekly on a run chart, and statistical process control methods were used to determine a significant change in performance. RESULTS: The preintervention percentage of patient visits ages 0 to 14 months receiving all preventive service bundle elements was 58%. The postintervention percentage is 92%. CONCLUSIONS: Innovative redesign led to improvement in percentage of patients age 0 to 14 months who received the entire preventive services bundle. Key elements for success were multidisciplinary site-specific teams, redesigned visit flow, effective communication, and resources for data and project management.

Foster Caregivers’ Perspectives on the Medical Challenges of Children Placed in Their Care Implications for Pediatricians Caring for Children in Foster Care

Objective. To investigate, using qualitative methodology, foster caregivers’ perspectives related to the medical needs of children placed in their care. Study design. Fifteen foster caregivers were individually interviewed using a semistructured open-ended question guide. Data were coded, and the analysis was conducted in an inductive manner, allowing themes to emerge from the interviews. Results. The following 4 themes were identified: (1) the fragmented histories provided to foster caregivers and difficulty in obtaining information; (2) the unique medical complications that children in foster care experience; (3) the difference between “doing what is expected” and becoming a proactive foster caregiver; and (4) the support needs of foster caregivers. Conclusions. Foster caregivers receive insufficient information despite the evidence that these children are likely to have complex needs. It is, therefore, necessary for the pediatrician to recognize existing medical problems, identify new medical problems, educate foster caregivers, and communicate with the multidisciplinary team.

Pediatricians May Address Barriers Inadequately When Referring Low-Income Preschool-Aged Children to Behavioral Health Services

Background. Low-income parents often seek help from pediatricians for early childhood social-emotional problems but seldom follow through with referrals to behavioral health services. Objective. We sought to understand low-income parents’ experiences seeking help from pediatricians for social-emotional problems and how those experiences influenced decisions about accessing behavioral health services. Methods. We conducted 20 semi-structured interviews with low-income parents with concerns about their children’s behavior or emotions. Participants were asked about experiences seeking help from pediatricians and decision-making about accessing behavioral health services. Results. Three themes emerged: (1) Participants described reluctance to recognize social-emotional problems, which was often reinforced by doctors’ reassurance. (2) Participants reported pediatricians did not meet their expectations about testing, providing explanations/advice, or addressing behavior on-site. (3) Participants had unclear expectations of behavioral health services. Conclusions. Primary care mechanisms that reliably educate parents about behavioral trajectories and the role of behavioral health providers may improve follow-up rates.

Narrowing Care Gaps for Early Language Delay: A Quality Improvement Study

Background and Objective. Poverty is a risk factor for both language delay and failure to access appropriate therapies. The objective of this study was to increase the percentage of children 0 to 3 years old referred from an urban primary care center who attended an initial appointment with speech pathology or audiology within 60 days from 40% to 60%. Methods. The Model for Improvement was used to develop and test the intervention, which addressed potential logistical barriers faced by low-income families. Adherence was plotted on run charts in time series to assess overall improvement, and subgroups were analyzed to identify reduction in disparities. Results. Median referral adherence improved from 40% to 60%. Families from lower income neighborhoods had lower preintervention adherence; these differences were eliminated postintervention. Conclusions. System-level changes improved access to evaluation and treatment for low-income children with language delay and narrowed the gap in access between families in lower versus higher income neighborhoods.

Area-Level Socioeconomic Factors Are Associated With Noncompletion of Pediatric Preventive Services

We examined 4872 infants born consecutively, 2011-2012, and seen at 3 primary care centers to determine whether area-based socioeconomic measures were associated with noncompletion of common preventive services within the first 15 months. Addresses were geocoded and linked to census tract poverty, adult educational attainment, and household vehicle ownership rates. The quartile of patients in the highest poverty (adjusted odds ratio [aOR] 1.25; 95% confidence interval [CI] 1.01-1.54) and lowest vehicle ownership tracts (aOR 1.32; 95% CI 1.07-1.63) had significantly increased odds of service noncompletion. There were significant spatial clusters of low completion in Cincinnati’s urban core. These findings have implications for preventive service delivery.

A Practical Guide to Conducting Quality Improvement in the Health Care Setting

Opinion statementQuality improvement uses rigorous methodology to evaluate systemic changes to patient care processes in an effort to improve patient outcomes, the patient and family experience of care, and the safety and value of the care delivered. This article introduces the Model for Improvement, which was developed by the Associates for Process Improvement in the early 1990s using an adaptation of a real-life improvement project. The example will explore how a primary care practice uses the Model for Improvement to maximize the value and safety of care they deliver for children presenting with community-acquired pneumonia with an initial focus on appropriate first-line antibiotic treatment. The three fundamental questions which form the foundation of this approach are explored through the case example: (1) What are we trying to accomplish? (2) How will we know that a change is an improvement? (3) What changes can we make that will result in improvement? Examples of many of the fundamental tools used in the course of quality improvement work, such as a key driver diagram, run chart, and plan-do-study-act (PDSA) cycle, are explored throughout the text. Finally, a discussion of implementation and sustainability of improvement gains is introduced. This article serves as a primer on quality improvement in health care and serves as a foundation for subsequent articles in this issue as well as future learning.

Primary Care and Home Visiting Utilization Patterns among At-Risk Infants

Objective To describe well child care (WCC) utilization in the first year of life among at‐risk infants, and the relationship to home visiting enrollment. Study design Retrospective cohort study using linked administrative data for infants ≥34 weeks’ gestation from 2010 to 2014, within a regional, academic primary care system. Association between WCC visits and home visiting enrollment was evaluated using bivariate comparisons and multivariable Poisson regression. Latent class analysis further characterized longitudinal patterns of WCC attendance. Multivariable logistic regression tested the association between home visiting and pattern of timeliest adherence to recommended WCC. Results Of 11 936 infants, mean number of WCC visits was 4.1 in the first 12 months of life. Of 3910 infants eligible for home visiting, 28.5% were enrolled. Among enrolled infants, mean WCC visits was 4.7 vs 4.4 among eligible, nonenrolled infants, P value < .001. After multivariable adjustment, there was no significant association between enrollment and WCC visit count (adjusted incident rate ratio 1.03, 95% CI 0.99, 1.07). Using latent class analysis, 3 WCC classes were identified: infants in class 1 (77.7%) were most adherent to recommended WCC, class 2 (12.5% of cohort) had progressively declining WCC attendance over the first year of life, and class 3 (9.8%) maintained moderate attendance. In multivariable regression, home visiting was associated with class 1 membership, aOR 1.27, 95% CI 1.04, 1.57. Conclusions A pattern of timely WCC attendance was more likely among infants in home visiting; however, most infants eligible for home visiting were not enrolled.