Family Experience of Caregiver Burden and Health Care Usage in a Statewide Medical Home Program

ObjectiveTo evaluate family-reported caregiver experiences and health care utilization of patients enrolled in the Pennsylvania Medical Home Program (PA-MHP) statewide practice network and compare results to PA-MHP practices’ Medical Home Index (MHI) scores. We hypothesized families enrolled in higher-scoring patient-and-family-centered medical homes (PCMH) on completed MHIs would report decreased caregiver burden and improved health care utilization.MethodsWe analyzed surveys completed by families receiving care coordination services in PA-MHP's network and each practice's mean MHI score. A total of 3221 caregivers completed surveys evaluating hours spent coordinating care/week, missed school/workdays, sick visits, and emergency department (ED) visits. A total of 222 providers from 54 participating PA-MHP practices completed the nationally recognized MHI. Family/practice demographics were collected. We developed multivariate logistic regression models assessing independent associations among family survey outcomes and corresponding practices’ MHI scores.ResultsFamilies enrolled in high-scoring PCMHs had decreased odds of spending >1 h/wk coordinating care (odds ratio [OR] 0.82, adjusted OR [aOR]: 0.70, 95% confidence interval [CI] 0.55–0.90), missing workdays in the past 6 months (OR 0.82, aOR: 0.72, 95% CI 0.69–0.97), and ED visits in the past 12 months (OR 0.83, aOR: 0.81, 95% CI 0.65–0.99) in comparison to families enrolled in lower-scoring PCMHs. Families enrolled in higher-scoring PCMHs did not report fewer sick visits despite fewer ED visits, indicating more appropriate health care utilization. High-scoring PCMHs had lower percentages of publicly insured and low-income children.ConclusionsHigher-scoring PCMHs are associated with decreased caregiver burden and improved health care utilization across diverse PA practices. Future studies should evaluate interventions uniformly improving PCMH quality and equity.     

Development of the Affordances in the Home Environment for Motor Development–Infant Scale

Background: The present study reports the development and application of the Affordances in the Home Environment for Motor Development–Infant Scale (AHEMD‐IS), a parental self‐report designed to assess the quantity and quality of affordances in the home environment that are conducive to motor development for infants aged 3–18 months. Methods: Steps in its development included use of expert feedback, establishment of construct validity, interrater and intrarater reliability, and predictive validity. With all phases of the project, 113 homes were involved. Results: Intraclass correlation coefficients for interrater and intrarater reliability for the total score were 1 and 0.94, respectively. In addition, results indicate that the test has the characteristic of differentiating a wide range of scores. Regression analysis for the AHEMD‐IS and motor development using the Alberta Infant Motor Scale supports preliminary evidence for predictive validity. Conclusion: Our findings suggest that the AHEMD‐IS has sufficient reliability and validity as an instrument for assessing affordances in the home environment, with clinical and research applications.     

Characteristics of High-Performing Primary Care Pediatric Practices: A Qualitative Study

ObjectivePerformance on pediatric quality measures varies across primary care practices. Health care quality is associated with organizational factors, but their effect is understudied in pediatric care. This study aimed to develop hypotheses regarding the relationship between organizational factors and composite scores on pediatric quality measures.MethodsUsing a positive deviance approach, semistructured interviews were conducted with pediatricians and staff (N = 35) at 10 purposively selected high-performing pediatric primary care practices in Massachusetts between September and December 2016. Practices were sampled to achieve diversity in geographic location, size, and organizational structure. Interviews aimed to identify organizational strategies (eg, care processes) and contextual factors (eg, teamwork) that may be associated with performance on quality measures. Interviews were audiotaped, transcribed, and analyzed using qualitative content analytic methods.ResultsWe identified 4 major themes (MTs): MT1, Practice Culture; MT2, Practice Structures and Quality Improvement Tools; MT3, Attitudes and Beliefs Related to Measuring Care Quality; and MT4, Perceived Barriers to Achieving High Performance on Quality Measures. MT1 subthemes included contextual factors such as teamwork, leadership, and feeling respected as an employee. MT2 subthemes included fixed characteristics such as practice size and strategies such as the use of an electronic medical record. MT3 and MT4 subthemes linked these constructs to factors external to the practices.ConclusionsThis study suggested that elements of organizational culture may play as important a role in the quality of care delivered as specific quality improvement strategies. Interventions to further test this relationship may aid practices seeking to improve the care they deliver.     

Benefits of Medical Home Care Reaching Beyond Chronically Ill Teens: Exploring Parent Health-Related Quality of Life

Background

Caring for teens with special health care needs places physical and mental health burdens on parents, which can be exacerbated by the stresses of transitions to independence. Medical homes can improve teen transitions to greater self-management and reduce health care–related time and financial burdens for families. We examined the association between parent-reported teen medical home status and caregiver health-related quality of life (HRQOL).

Extending the Medical Home Into the Community: A Newborn Home Visitation Program for Pediatric Residents

ObjectiveTo describe the Health Begins at Home (HBH) intervention and examine pediatric resident change in knowledge, attitudes, and self-reported behaviors after the HBH intervention.MethodsA prospective mixed-methods cohort study was conducted in 2 outpatient clinics at an urban academic pediatric residency program. Residents serving as primary care providers (n = 50) of newborn infants participated in HBH, an educational home visit intervention. Study outcomes included resident pre– and post–home visit surveys and an end-of-residency survey assessing knowledge of community, attitudes, and self-reported practice behaviors. Qualitative comments from surveys and small group post–home visit debriefing sessions were coded and themes identified.ResultsAfter intervention, residents demonstrated a significant positive change (all P < .05) in the following: adequacy of medical knowledge, understanding of home and community, excitement about home visits, and less concern about personal safety in the community. These changes were sustained in an end-of-residency survey administered 14 to 22 months after the intervention. Sixty-two percent reported a change in how they treated patients, and 94% indicated home visits should be part of the permanent curriculum.ConclusionsConducting home visits was associated with residents’ improved understanding of the community and home environment of their patients, which was sustained throughout the remainder of training. Residents reported that home visits provide an important educational experience and should be part of the permanent curriculum. Training programs should consider incorporating home visiting programs into curricula to improve resident knowledge of family home, community, and social determinants of health.     

A model to determine the feasibility of a pediatric practice

A major concern of urban and rural citizens of the United States is the availability of adequate pediatric health care in their community. Community leaders attempting to recruit health care providers and pediatricians considering locating their practice in a specific community need a method by which they can evaluate a community's potential for supporting a new primary care practice. A detailed survey was conducted in early 1988 of pediatric practices geographically dispersed throughout the state of Oklahoma. Data collected from the physicians and their administrative staff reflected the volume of office and hospital visits and practice costs over the prior 12 months. Using the capital costs and direct operating cost data with information obtained on the number of patient visits and revenue generated collected in this survey, we designed a model to project the economic feasibility of establishing a pediatric practice in a specific community. This model can be used to project the number of annual pediatric primary care visits a community can generate, the direct and indirect costs to establish and maintain a clinic, and the gross revenue and net income of the practice.     

Pediatric staff perspectives on organ donation after cardiac death in children.

OBJECTIVES: The aims of this project were to describe whether pediatric clinical staff members believe that a donation after cardiac death (DCD) program could be consistent with the mission and core values of a children's hospital and to identify what staff consider essential to the acceptability of such a program. DESIGN: Qualitative study. SETTING: Children's hospital. SUBJECTS: Pediatric clinical staff. INTERVENTIONS: Data were gathered from pediatric clinical staff during eight focus groups conducted in a children's hospital in March and April 2005. MEASUREMENTS AND MAIN RESULTS: Eighty-eight staff members participated. Six major themes emerged from qualitative analysis of the data: a) identifying children who could be candidates for DCD; b) considering the best interests of the dying child; c) approaching parents about DCD; d) preparing parents for their child's DCD; e) doing DCD well; and f) maintaining program integrity. Themes were used to construct a conceptual framework describing a model pediatric DCD program. Pediatric staff voiced numerous concerns. However, they identified "making it happen for families" who voice a desire to participate in organ donation as the primary reason for program adoption. CONCLUSIONS: This study provides a framework for understanding pediatric staff perspectives on DCD programs in children. Results suggest several possible elements that may be helpful in framing interdisciplinary dialogue and informing institutional practices in the design of a pediatric DCD program.     

The Diagnostic Interview Schedule for Children (DISC-2.1) in Spanish: Reliability in a Hispanic Population

The reliability across time, informants and interviewers of the Spanish translation of the DISC-2.1 was tested on a Puerto Rican Hispanic sample using a test-retest design. Levels of reliability between clinic ant) community samples and between younger and older children were compared to explore the sources of low reliability for certain psychiatric disorders. Parents' reports tended to be mare reliable than those of their children, although the difference was less obvious with older children. Reliability was generally higher for the externalizing disorders and when the second interviewer was a psychiatrist rather than a lay interviewer.     

Family perspectives on the quality of pediatric palliative care.

BACKGROUND: As a prelude to establishing a Pediatric Palliative Care Program, we solicited information from families about their experiences and their suggestions for improving the quality of end-of-life care. Participants were English- and Spanish-speaking family members of deceased pediatric patients who received care at Lucile Salter Packard Children's Hospital, Stanford University Medical Center, Palo Alto, Calif. METHODS: Sixty-eight family members of 44 deceased children were interviewed regarding treatment, transition to palliative care, and bereavement follow-up. Four clinical social workers and one clinical psychologist reviewed the participants' responses and identified frequently occurring themes. RESULTS: Several areas of unsatisfactory interactions with staff were identified: confusing, inadequate, or uncaring communications regarding treatment or prognosis; preventable oversights in procedures or policies; failure to include or meet the needs of siblings and Spanish-speaking family members; and inconsistent bereavement follow-up. A discrepancy emerged between the high degree of pain described by the families and parents' perceptions that pain had been managed well. Community hospice programs are frequently poorly prepared to serve pediatric patients. CONCLUSIONS: There is a need to improve pediatric palliative care. Recurring themes in the family interviews suggest useful issues to consider in the development of a palliative care program.     

Novel Transfer of Care Sign-out Assessment Tool in a Pediatric Emergency Department

Objective

Transfer of care sign-outs (TOCS) for admissions from a pediatric emergency department have unique challenges. Standardized and reliable assessment tools for TOCS remain elusive. We describe the development, reliability, and validity of a TOCS assessment tool.

International electives at the university of Minnesota global pediatric residency program: opportunities for education in all Accreditation Council for Graduate Medical Education competencies

PurposeGlobally competent pediatricians are in demand because of the increasing numbers of children from immigrant families living in the United States and the shortages of health care workers in low-income countries where the majority of the worlds' children live. This study sought to better understand the educational outcomes of international electives taken by pediatric residents training in global health.MethodsThirty-two pediatric residents who participated in an international elective as part of a global health curriculum completed reflective essays which were analyzed for themes from 2006 to 2010. During the first-order analysis, the emergent themes mapped to the Accreditation Council for Graduate Medical Education (ACGME) competencies. In response, a second-order analysis re-examined the essays with an additional researcher to support categorization consistent with the ACGME competencies.ResultsMore than 90% of essays described experiences related to medical knowledge, patient care and systems-based practice. More than 50% included reflections on practice-based learning and improvement, professionalism, and interpersonal and communication skills. Residents also described the impact on their personal and professional development.ConclusionInternational electives can provide educational opportunities for residents to develop competency in each of the 6 ACGME domains and to reevaluate their life purpose and career goals. In addition to opportunities to increase their medical knowledge, patient care and communication skills, residents find international electives rich learning environments for systems-based practice, practice-based learning/improvement, and professionalism, domains that can be challenging to teach. These findings support the importance of international electives in global health in meeting core requirements in residency training.     

Co-located Parent Coaching Services Within Pediatric Primary Care: Feasibility and Acceptability

IntroductionThis project assessed the feasibility and acceptability of Parent Connext, a positive parenting program that integrates screening and co-located parent coaching within pediatric primary care.MethodEleven practices implemented Parent Connext in phases between November 1, 2016, and July 31, 2019. Screening and surveillance for parenting and family psychosocial concerns were performed during patient visits. Providers responded with brief motivational interviewing and referral. Parenting Specialists provided individualized parent coaching to referred caregivers.ResultsScreens were completed at 13,346 (65%) targeted visits, with 26% positive for concerns. Parent coaching was provided to 1,301 of 2,711 (48%) referred families (average 2.2 sessions per family). Providers and staff felt significantly more supported, confident, and knowledgeable about addressing parenting and family psychosocial concerns after implementing Parent Connext and felt the program improved their relationships with families and quality of care.DiscussionCo-located parent coaching was found to be a feasible and worthwhile addition to pediatric primary care.     

Enhancing developmentally oriented primary care: an Illinois initiative to increase developmental screening in medical homes

In 2005, the Enhancing Developmentally Oriented Primary Care (EDOPC) project of the Illinois chapter of the American Academy of Pediatrics and the Illinois Department of Healthcare and Family Services began a project to improve the delivery and financing of preventive health and developmental services for children in Illinois. The leaders of this initiative sought to increase primary care providers' use of validated tools for developmental, social/emotional, maternal depression, and domestic violence screening and to increase early awareness of autism symptoms during pediatric well-child visits in children aged 0 to 3 years. These screenings facilitate identification of children at risk and those who need referral for further evaluation. Primary barriers to such screenings include lack of practitioner confidence in using validated screening tools. In this article we describe the accomplishments of the EDOPC project, which created training programs to address these barriers. This training is delivered by EDOPC staff and peer educators (physicians and nurse practitioners) in medical practices. The EDOPC project enhanced confidence and intent to screen among a large group of Illinois primary health care providers. Among a sample of primary care sites at which chart reviews were conducted, the EDOPC project increased developmental screening rates to the target of 85% of patients at most sites and increased social/emotional screening rates to the same target rate in nearly half of the participating practices.     

Does a residents' continuity clinic provide primary care?

Pediatric residents are required to care for a group of children over a period of time. For many, this "continuity" experience is in a hospital outpatient department that may or may not provide primary care. We applied a measure of primary care to the Primary Care Clinic, the continuity clinic at The Johns Hopkins Hospital, Baltimore, Md, and found that it compared favorably with private pediatric practices in the Baltimore area, providing significantly more "principal care" (93% vs. 84.5% of encounters), and to the Harris Lane Home walk-in clinic, where only 51% of encounters were "principal care". The Primary Care Clinic scored higher on a primary care index, a measure of the extent to which the facility serves as a primary care source for patients, suggesting that hospital-based training can provide residents with an opportunity to provide primary care.     

Successful Integration of Pediatrics Into State Health Care Reform Efforts

Health care reform in Vermont promotes patient-centered medical homes (PCMH) and multi-disciplinary community health teams to support population health. This qualitative study describes the expansion of Vermont's health care reform efforts, initially focused on adult primary care, to pediatrics through interviews with project managers and facilitators, CHT members, pediatric practitioners and care coordinators, and community-based providers. Analyses used grounded theory, identifying themes confirmed by repeat occurrence across respondents. Respondents believed that PCMH recognition and financial and community supports would improve care for pediatric patients and families. Respondents shared three main challenges with health care reform efforts: achieving PCMH recognition, adapting community health teams for pediatric patients and families, and defining roles for care coordinators. For health care reform efforts to support pediatric patients and be family-centered, states may need additional resources to understand how pediatric and adult primary care differ and how best to support pediatrics during health care reform efforts.     

Medical Home and Pediatric Primary Care Utilization Among Children With Special Health Care Needs

IntroductionThe medical home model seeks to improve health care delivery by enhancing primary care. This study examined the relationship between the presence of a medical home and pediatric primary care office visits by children with special health care needs (CSHCN) using the data from 2005-2006 National Survey of Children with Special Healthcare Needs.MethodSurvey logistic regression was used to analyze the relationship.ResultsWhen CSHCN age, gender, ethnicity/race, functional status, insurance status, household education, residence, and income were included in the model, CSHCN with a medical home were 1.6 times more likely to have six or more annual pediatric primary care office visits than were children without a medical home [odds ratio = 1.60, 95% confidence interval = (1.47, 1.75)]. Female CSHCN, younger CSHCN, children with public health insurance, children with severe functional limitations, and CSHCN living in rural areas also were more likely to have a larger number of visits.DiscussionBy controlling for child sociodemographic characteristics, this study provides empirical evidence about how medical home availability affects primary care utilization by CSHCN.     

The Baby Pediatric Symptom Checklist: Development and Initial Validation of a New Social/Emotional Screening Instrument for Very Young Children

ObjectiveTo develop and validate the Baby Pediatric Symptom Checklist (BPSC), a brief social/emotional screening instrument for children less than 18 months. The BPSC is modeled after the Pediatric Symptom Checklist (PSC) and is part of the Survey of Wellbeing of Young Children, a comprehensive, freely available screening instrument designed for use in pediatric primary care.MethodBPSC items were developed by a team of experts who reviewed existing assessment instruments and relevant research literature. Scale construction and initial validation were conducted with 205 families from pediatric primary care sites and 54 families from referral clinics. A replication sample of 146 additional families were enrolled from an independent set of primary care practices.ResultsExploratory factor analysis revealed 3 dimensions of the BPSC: irritability, inflexibility, and difficulty with routines. Factor structure was confirmed in the replication sample. Retest reliability and internal reliability were adequate (intraclass correlation coefficient >0.70) across subscales, with the exception of the “irritability” subscale’s internal reliability in the replication sample. Construct validity of the “irritability” and the “difficulty with routines” subscales is supported by correlations with the Parenting Stress Index and the Ages & Stages Questionnaire: Social/Emotional, but the “inflexibility” subscale seems to be distinct from performance on these instruments. Tests of differential item functioning revealed no significant effects for race/ethnicity, child gender, parent education, or family income. Age-based normative data were calculated for each subscale.ConclusionThe BPSC assesses 3 domains of behavior for very young children and shows promise as a social/emotional screening instrument for pediatric primary care.     

Quality Improvement to Immunization Coverage in Primary Care Measured in Medical Record and Population-Based Registry Data

Objectives

Despite the proven benefits of immunizations, coverage remains low in many states, including Vermont. This study measured the impact of a quality improvement (QI) project on immunization coverage in childhood, school-age, and adolescent groups.