Engaging primary care clinicians in the selection of implementation strategies for toddler social-emotional health promotion in community health centers.

BACKGROUND: Social-emotional risk for subsequent behavioral health problems can be identified at toddler age, a period where prevention has a heightened impact. This study aimed to meaningfully engage pediatric clinicians, given the emphasis on health promotion and broad reach of primary care, to prepare an Implementation Research Logic Model to guide the implementation of a screening and referral process for toddlers with elevated social-emotional risk. METHOD: Using an adaptation of a previously published community partner engagement method, six pediatricians from community health centers (CHCs) comprised a Clinical Partner Work Group. The group was engaged in identifying determinants (barriers/facilitators), selecting and specifying strategies, strategy-determinant matching, a modified Delphi approach for strategy prioritization, and user-centered design methods. The data gathered from individual interviews, two group sessions, and a follow-up survey resulted in a completed Implementation Research Logic Model. RESULTS: The Clinical Partner Work Group identified 16 determinants, including barriers (e.g., patient access to electronic devices) and facilitators (e.g., clinician buy-in). They then selected and specified 14 strategies, which were prioritized based on ratings of feasibility, effectiveness, and priority. The highest-rated strategies (e.g., integration of the screener into the electronic health record) provided coverage of all identified barriers and comprised the primary implementation strategy "package" to be used and tested. CONCLUSIONS: Clinical partners provided important context and insights for implementation strategy selection and specification to support the implementation of social-emotional risk screening and referral in pediatric primary care. The methodology described herein can improve partner engagement in implementation efforts and increase the likelihood of success. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Trends in School Attendance for Low-Income Children with Chronic Health Conditions: Results from a Randomized Controlled Trial.

BACKGROUND: In this study, we aimed to determine how school attendance changed over time for children on Medicaid with chronic health conditions enrolled in a comprehensive care coordination program called Coordinated HEalthcare for Complex Kids (CHECK). METHODS: Medicaid beneficiaries from one managed care organization were randomized into 2 arms: CHECK program services or usual care. The final sample was 1322. RESULTS: The mean age was 10.9 (SD = 3.7) years old and children were mostly non-Hispanic Black (62.6%) or Hispanic (34.9%). The median school attendance at baseline was 94.9% (IQR 88.9, 97.9); over one-fourth of children (28.4%) were chronically absent. School attendance was not associated with race/ethnicity, risk level, and health condition. In a model including a significant time/grade interaction, school attendance increased over time for children in pre-kindergarten (OR = 1.52, 95% CI: 1.38, 1.68; p < .001) and kindergarten to 5th grade (OR = 1.21, 95% CI: 1.17, 1.26; p < .001), and decreased for children in 6th to 8th grade (OR = 0.80, 95% CI: 0.77, 0.83; p < .001). No differences were seen in school attendance or chronic absenteeism associated with enrollment in the CHECK program. CONCLUSIONS: School attendance improved for most of the low-income children with chronic health conditions in our cohort, except for children in middle school.

Development of a Community-Based Medical Neighborhood for Children with Chronic Conditions.

BACKGROUND: Children with chronic conditions have unmet health needs. Coordinated Healthcare for Complex Kids (CHECK) is a demonstration project with aims to improve health outcomes using an innovative approach to community-based health care. OBJECTIVE: We describe the development and implementation of a community-based medical neighborhood (CBMN). METHODS: The CHECK CBMN used several novel approaches to partner with clinical and community organizations, including care coordination software, advisory board participation, and an external social service referral database (SSRD). RESULTS: The CHECK CBMN executed 25 formal partnership agreements. We hosted 15 advisory board meetings, participated in 43 community events, and made 1,443 community-based social service referrals. We provided 43 trainings on pediatric chronic conditions and participated in four community in-service trainings. CONCLUSIONS: The CHECK CBMN contributes to the understanding of how innovative processes and collaboration can improve care coordination for children with chronic conditions through community and clinical partnerships.

A Real-World Community Health Worker Care Coordination Model for High-Risk Children.

Health care systems across the United States are considering community health worker (CHW) services for high-risk patients, despite limited data on how to build and sustain effective CHW programs. We describe the process of providing CHW services to 5,289 at-risk patients within a state-run health system. The program includes 30 CHWs, six care coordinators, the Director of Care Coordination, the Medical Director, a registered nurse, mental health specialists, and legal specialists. CHWs are organized into geographic and specialized teams. All CHWs receive basic training that includes oral and mental health; some receive additional disease-specific training. CHWs develop individualized care coordination plans with patients. The implementation of these plans involves delivery of a wide range of social service and coordination support. The number of CHW contacts is determined by patient risk. CHWs spend about 60% of their time in an office setting. To deliver the program optimally, we had to develop multiple CHW job categories that allow for CHW specialization. We created new technology systems to manage operations. Field issues resulted in program changes to improve service delivery and ensure safety. Our experience serves as a model for how to integrate CHWs into clinical and community systems.

Screening for Toxic Stress Risk Factors at Well-Child Visits: The Addressing Social Key Questions for Health Study.

OBJECTIVES: To determine the prevalence of and demographic characteristics associated with toxic stress risk factors by universal screening, the impact of screening on referral rates to community resources, and the feasibility and acceptability of screening in a medical home setting. STUDY DESIGN: We developed the Addressing Social Key Questions for Health Questionnaire, a 13-question screen of adverse childhood experiences (ACEs) and unmet social needs. Parents/guardians of children 0-17 years of age received this questionnaire at well-child visits at 4 academic clinics from August 1, 2016 to February 28, 2017. Providers reviewed the tool and referred to community resources as needed. A subset of families completed demographic and satisfaction surveys. Prevalence of ACEs and unmet social needs, community referral rates at 1 site with available data, and family acceptability data were collected. Analyses included frequency distributions, χ2 tests, and Poisson regression. RESULTS: Of 2569 families completing an Addressing Social Key Questions for Health Questionnaire, 49% reported ≥1 stressor; 6% had ≥1 ACE; 47% had ≥1 unmet social need. At 1 site, community referral rates increased from 2.0% to 13.3% (P < .0001) after screening implementation. Risk factors for having a stressor include male sex and African American or Hispanic race. 86% of 446 families want clinics to continue screening. CONCLUSIONS: Universal screening for toxic stress risk factors in pediatric primary care improved identification and management of family needs. Screening was feasible and acceptable to families. Prevalence of unmet social needs but not ACEs was comparable with prior studies. Further evaluation and modification of the screening protocol is needed to increase screening and identification.

Chicago Public School nurses examine barriers to school asthma care coordination.

OBJECTIVE/DESIGN: Well documented asthma disparities in Chicago pose a continual challenge for the Chicago Public Schools (CPS). Coordinated Healthcare for Complex Kids (CHECK) is a health care demonstration project funded by a Centers for Medicare and Medicaid Services Health Care Innovation Award. A collaborative partnership was formed between CHECK and CPS. With CHECK support, CPS administered a survey to 160 nurses to understand the asthma problems nurses perceived and interest in intervention. RESULTS: Seventy-five per cent (n = 120) completed the survey. While asthma was the top diagnosis managed by 95%, 72% reported gaps in asthma understanding. Appropriate communication between school nurses and providers occurred 33% of the time; 18% believed they received sufficient support to follow-up on deficient paperwork. The barriers mentioned were lack of medications (73%), time (67%), and communication with providers (61%). When asked their opinions on potential interventions, 78% of nurses supported web-based applications, 66% community health workers (CHW), and 66% stock albuterol in schools. CONCLUSIONS: The greatest barriers for CPS nurses with asthma management are time and communication. Potential interventions such as web-based communication applications and CHW in schools were well received.

Formative research implications on design of a randomized controlled trial for oral health promotion in children.

BACKGROUND: The COordinated Oral health Promotion (CO-OP) Chicago trial will test the efficacy of a community health worker (CHW) intervention to improve oral health behaviors for children at high risk for early childhood caries. Before implementing the cluster-randomized controlled trial, we conducted a formative assessment to determine the final design. We used qualitative methods to assess the feasibility and acceptability of the proposed recruitment, data collection, and intervention plan. METHODS: Key informant interviews (N = 37) and site observations were conducted at 10 pediatric primary care clinics and 10 Special Supplemental Nutrition Program for Women Infant and Children (WIC) centers to gain insight from providers and administrators at the locations where recruitment and intervention will occur. Eight focus groups (N = 68) were conducted with caregivers of children to capture the parent perspective. Conceptual coding methods from grounded theory were applied to organize the data into the final themes. RESULTS: Families, clinics, and WIC centers were all very interested in additional supports for oral health and were enthusiastic about CHWs. Challenges included competing family priorities that might interfere in study enrollment and intervention efficacy. Physical space for enrollment and intervention delivery was a major barrier for some sites. Home visits for data collection and intervention delivery would be unacceptable for some families. These challenges and barriers prompted us to make major changes in our trial design. We opened the option for data collection to occur in multiple locations. We eliminated the home-only arm of the trial. Clinics and WIC centers that are randomized to the non-intervention arm will now have CHWs available at the study conclusion. Finally, we aligned the CHW oral health topics to the needs of families. CONCLUSIONS: We conducted this comprehensive formative assessment to determine the feasibility and acceptability of the CO-OP Chicago trial. While overall acceptance of the trial was high, the results highlighted specific issues with the proposed trial implementation plan and led to several critical design changes. This type of formative work requires a significant upfront investment but we expect it will translate into savings through better recruitment, retention, intervention implementation and adherence, and result dissemination.