Beyond ''Screen & Refer'': Understanding Families' Use of Resources for Health-Related Social Needs Identified via Primary Care.

OBJECTIVE: As health-related social needs (HRSN) screening increases, attention to families' resource preferences lags. This study of a pediatric primary care intervention (DULCE) with reliable HRSN screening and resource connection explored whether resources adequately addressed families' needs and, when HRSN persisted, families' reasons for declining resources. METHODS: This retrospective cohort, mixed-methods study analyzed data from 989 families that received care at seven pediatric clinics implementing DULCE in three states. DULCE screens for seven HRSN around the 1-month and 4-month well-child visits; we calculated the percent of initial and ongoing positive screens. For positive rescreens, we calculated the percent that had all eligible or wanted resources and that were interested in further resources. We also analyzed case notes, which elicited families' resource preferences, and explored demographic characteristics associated with ongoing HRSN. RESULTS: Half of enrolled families (508 of 989) initially screened positive for HRSN; 124 families had positive rescreens; 26 expressed interest in further assistance. Most families with ongoing concrete supports needs accessed all eligible resources (60-100%); 20-58% had everything they wanted. Fewer families with ongoing maternal depression and intimate partner violence accessed all eligible resources (48% and 18%, respectively); most reported having all wanted resources (76% and 90%, respectively). Families declined resources due to lack of perceived need, the HRSN resolving, or families addressed HRSN themselves. White families were more likely to rescreen positive. CONCLUSIONS: Pediatric medical homes must honor family-centered decision-making while empowering families to accept beneficial resources. Health care systems should advocate for resources that families need and want.

Primary Care-Based Housing Program Reduced Outpatient Visits; Patients Reported Mental And Physical Health Benefits.

Screening for housing instability has increased as health systems move toward value-based care, but evidence on how health care-based housing interventions affect patient outcomes comes mostly from interventions that address homelessness. In this mixed-methods evaluation of a primary care-based housing program in Boston, Massachusetts, for 1,139 patients with housing-related needs that extend beyond homelessness, we found associations between program participation and health care use. Patients enrolled in the program between October 2018 and March 2021 had 2.5 fewer primary care visits and 3.6 fewer outpatient visits per year compared with those who were not enrolled, including fewer social work, behavioral health, psychiatry, and urgent care visits. Patients in the program who obtained new housing reported mental and physical health benefits, and some expressed having stronger connections to their health care providers. Many patients attributed improvements in mental health to compassionate support provided by the program's housing advocates. Health care-based housing interventions should address the needs of patients facing imminent housing crises. Such interventions hold promise for redressing health inequities and restoring dignity to the connections between historically marginalized patient populations and health care institutions.

Participation in Pediatric Primary Care Innovation, DULCE, Increases Caregiver Agency and Resilience and Decreases Impact of Stress.

The purpose of the present study was to explore outcomes and heterogeneous effects of an evidence-based, cross-sector pediatric healthcare intervention for families with infants, Developmental Understanding and Legal Collaboration for Everyone (DULCE). DULCE is tailored to allow families' needs and desires to drive DULCE intensity. This is a longitudinal study following families involved with pediatric primary care clinics from infant's birth to 15 months. Multi-level longitudinal modeling was used to compare the program's influence on resilience, parent agency, and the impact of stress on parent functioning among program recipients (n = 172) and non-recipients (n = 170). Study participants were recruited from four health care clinics in California and Florida, and participants completed in-person survey interviews at baseline (infant age 0-6 months) and final (infant age 12-15 months) timepoints, with a minimum of 6 months between baseline and final interview required. Assignment of families to intervention (participated in DULCE) or comparison group (received clinic care as usual) varied by clinic. The cross-sector pediatric primary care intervention screened families at high rates (70-90%), along with referring and connecting families to resources. DULCE participation was associated with increases in parents' agency and resilience. DULCE's positive influence on parent agency and impact of stress was observed with low dosage, and higher-risk families saw additional improvements in resilience at high dosage (high and low risk defined with Latent Profile Analysis). Findings reinforce the importance of examining heterogeneous effects of evidence-based interventions. DULCE's influence on parent agency and impact of stress was observed with low dosage; strengthened resilience among higher-risk families was found at high dosage. These findings document the value of a universal approach to prevention services in pediatric settings with tailoring that allows families to drive their engagement with the intervention.

Sustaining and scaling a clinic-based approach to address health-related social needs.

Objective: Scaling evidence-based interventions (EBIs) from pilot phase remains a pressing challenge in efforts to address health-related social needs (HRSN) and improve population health. This study describes an innovative approach to sustaining and further spreading DULCE (Developmental Understanding and Legal Collaboration for Everyone), a universal EBI that supports pediatric clinics to implement the American Academy of Pediatrics' Bright Futures™ guidelines for infants' well-child visits (WCVs) and introduces a new quality measure of families' HRSN resource use. Methods: Between August 2018 and December 2019, seven teams in four communities in three states implemented DULCE: four teams that had been implementing DULCE since 2016 and three new teams. Teams received monthly data reports and individualized continuous quality improvement (CQI) coaching for six months, followed by lighter-touch support via quarterly group calls (peer-to-peer learning and coaching). Run charts were used to study outcome (percent of infants that received all WCVs on time) and process measures (percent of families screened for HRSN and connected to resources). Results: Integrating three new sites was associated with an initial regression of outcome: 41% of infants received all WCVs on time, followed by improvement to 48%. Process performance was sustained or improved: among 989 participating families, 84% (831) received 1-month WCVs on time; 96% (946) were screened for seven HRSN, 54% (508) had HRSN, and 87% (444) used HRSN resources. Conclusion: An innovative, lighter-touch CQI approach to a second phase of scale-up resulted in sustainment or improvements in most processes and outcomes. Outcomes-oriented CQI measures (family receipt of resources) are an important addition to more traditional process-oriented indicators.

Benefits of a Universal Intervention in Pediatric Medical Homes to Identify and Address Health-Related Social Needs: An Observational Cohort Study.

OBJECTIVE: Compare rates of identification of families with health-related social needs (HRSN) and connection to resources by targeted versus universal, pediatric clinic-based interventions. METHODS: This observational cohort study included 1677 families that received care (January 2017-May 2020) at 8 pediatric medical homes in 3 states implementing Developmental Understanding and Legal Collaboration for Everyone (DULCE)-a universal, evidence-based intervention that addresses HRSN for families with infants. We divided the cohort into 2 groups using 4 common risk criteria in targeted programs serving families with infants; 862 families had no high-risk characteristics (Risk Criteria Absent [RCA]); 815 families had high-risk characteristics (Risk Criteria Present [RCP]). We compared both groups by prevalence of HRSN and connection to supports and estimated the performance of high-risk criteria to identify HRSN. RESULTS: DULCE identified 990 families with HRSN, compared to an estimated 274 families, if a risk-targeted approach had been used. More than half of RCA families had HRSN, 11% used resources at enrollment, and 42.5% accessed resources through DULCE. Simultaneously, 68.8% of RCP families had ongoing HRSN although 46.0% used resources at enrollment; 63.9% accessed additional resources through DULCE. Commonly used risk criteria had a sensitivity of 55.3% (95% confidence interval [CI], 52.2%-58.5%), specificity of 61.1% (95% CI, 57.2%-64.9%), positive predictive value of 68.8% (95% CI, 65.4%-72.0%), and negative predictive value of 46.9% (95% CI, 43.5%-50.4%). CONCLUSIONS: Risk criteria commonly used to identify families for targeted interventions are imperfect proxies for HRSN. Universal, medical home-based approaches can play a key role in supporting families with infants.

Addressing Maternal Depression Through Home Visiting: One State's Experience With a Breakthrough Series Collaborative.

BACKGROUND AND OBJECTIVES: From 2013 to 2017, a national Breakthrough Series (BTS) collaborative in Maternal, Infant, and Early Childhood Home Visiting programs developed a toolkit that led to improvements in maternal depression outcomes. In 2018, Alabama's home visiting program (First Teacher) aimed to reproduce these impacts with a state-led BTS that enrolled 8 local implementing agencies (LIAs) serving more than 500 families. METHODS: LIAs tested changes in practices using Plan-Do-Study-Act cycles and tracked data regarding depression screening, referrals, service access, and symptom improvement via run charts. First Teacher administered a post-collaborative survey to assess LIA team members' satisfaction with their BTS experience. RESULTS: Alabama's BTS resulted in positive shifts in maternal depression referrals, service access, and symptom improvement. Change ideas that supported these shifts included the use of a screening script, motivational interviewing, "Mothers and Babies," and a registry. LIAs noted that BTS tools and resources helped build capacity to address the difficult and frequently stigmatized topic of maternal depression. CONCLUSION: Findings from this study indicate that evidence- and experience-based practices regarding maternal depression screening, referrals, and service access can lead to symptom improvement among mothers enrolled in a state-based home visiting program. Results of this investigation corroborate findings from previous studies while also incorporating feedback from LIAs about the BTS experience.

Advancing Quality Improvement in Public Health by Exploring CQI in Alabama's Home Visiting Program.

Continuous Quality Improvement (CQI) is the use of a deliberate and defined improvement process to advance organizational systems. Quality improvement in public health is increasingly widespread, but there are still limited examples of success or descriptions of developmental trajectories for building CQI capacity. The goal of this article is to add to the extant knowledge on the topic by describing one state's implementation of evidence-based CQI in the Maternal, Infant, and Early Childhood Home Visiting program between 2014 and 2019. On the basis of a systematic review of Annual Yearly Progress reports and semistructured key informant interviews, analysis yielded 3 themes that facilitated successful implementation of CQI in Alabama: starting small and building capacity; engaging in continuous and supported learning; and establishing and maintaining a culture of quality. This project demonstrates that CQI can help public health practitioners refine processes and grow capacity to best serve clients' diverse needs.

National Home Visiting Collaborative Improves Developmental Risk Detection and Service Linkage.

OBJECTIVE: Fewer than 50% of children with developmental delay are identified before they start school, and only 10% of those identified receive services. Between May 2014 and August 2016, the Home Visiting Collaborative Improvement and Innovation Network (HV-CoIIN) aimed to improve early detection and linkage to services so that 80% of children with an identified developmental concern would receive timely, targeted developmental support. METHODS: HV-CoIIN enrolled 13 home visiting programs in 8 states and 1 tribe in a Breakthrough Series Collaborative (BTS). These programs tested interventions aligned with 5 key drivers: early detection, referral and follow-up, home visitor capacity, families engaged in developmental promotion, and data systems. Run charts were used to study measures. The main outcome was the percent of children with an identified concern who were linked to developmental support. Process measures included the percent of visits where parents were asked if they had any concerns about their child's development and the percent of children screened every 6 months. RESULTS: The percent of children with an identified developmental concern who received support increased from 70% to 82%. Parents were asked about developmental concerns at 95% of visits (baseline = 75%), and 90% of children were screened every 6 months (baseline = 51%). CONCLUSIONS: Home visiting programs can reliably execute early detection and linkage to services for at-risk populations they serve. BTS holds promise for improving implementation of federal public health programs to improve population health outcomes.

Addressing maternal depression in home visiting: Findings from the home visiting collaborative improvement and innovation network.

BACKGROUND: Maternal depression is common among low-income women enrolled in home visiting programs, yet there is considerable variability in the extent to which it is identified and addressed. This study examines outcomes related to postpartum depression screening, receipt of evidence-based services, and reductions in depressive symptoms among clients of home visiting programs in the Health Resources and Services Administration's Maternal, Infant, and Early Childhood Home Visiting Program Home Visiting Collaborative Improvement and Innovation Network (HV CoIIN), the first U.S. national application of the Institute for Healthcare Improvement's Breakthrough Series (BTS) Model in home visiting programs. METHODS AND FINDINGS: Fourteen home visiting programs in eight states, serving a geographically and racially diverse caseload of pregnant women and new mothers, took part in the HV CoIIN. Women in participating home visiting programs received the intervention strategies implemented by their program during participation in the collaborative. HV CoIIN strategies included specific policies and protocols for depression screening and home visitor response to screening results; home visitor training and supervision; delivery of prevention and treatment interventions; and tracking systems for screening, referral, and follow-up. HV CoIIN's proposed primary outcome was that 85% of women who accessed evidence-based services would experience a 25% reduction in depressive symptoms three months after accessing services. Secondary outcomes included an increased percentage of women who were screened for depression within three months of enrollment or birth, who verbally accepted a referral to evidence-based services, and who received one or more evidence-based service contacts. HV CoIIN resulted in improved symptoms among women who accessed services, from 51.1% to 59.9%. HV CoIIN also improved the percent of women screened for depression, from 83.6% to 96.3%, and those with positive depression screens who accessed evidence-based services, from 41.6% to 65.5%. Home visiting programs in this study were early adopters of quality improvement activities, which may limit the generalizability of these results to other home visiting programs. CONCLUSIONS: Home visiting programs can play an important role in closing gaps in maternal depression identification, referrals, service access, and symptom alleviation. Continuous quality improvement and BTS collaborative methods can be used to improve home visiting services in ways that advance national public health priorities and improve population health outcomes.

National Quality Improvement Initiative in Home Visiting Services Improves Breastfeeding Initiation and Duration.

OBJECTIVE: To improve breastfeeding through home visiting. METHODS: From 2013 to 2016, the Home Visiting Collaborative Improvement and Innovation Network (HV CoIIN) enrolled 15 home visiting agencies serving 1000 families in 7 states. Using the Breakthrough Series Collaborative model, HV CoIIN faculty taught a theory of change and continuous quality improvement (CQI) skills, as well as facilitating opportunities for networked learning. RESULTS: HV CoIIN improved home visitors' breastfeeding competencies and use of data to inform practice. Breastfeeding initiation increased from 47% to 61%. Exclusive breastfeeding of 3-month-old babies increased from 10% to 13.5%, and for babies 6 months old it increased from 5% to 8%. CONCLUSIONS: Home visiting programs can improve breastfeeding among participants with very low baseline breastfeeding rates. Continuous quality improvement and the Breakthrough Series Collaborative model can be used to improve home visiting services in ways that advance national public health priorities.

Using Continuous Quality Improvement Tools to Promote Tobacco Cessation Among Primary Caregivers in a Home Visiting Program in Alabama.

Alabama's Maternal, Infant, and Early Childhood Home Visiting-funded program was one of 10 state teams accepted to participate in the first wave of the Federal Home Visiting Program State and Territory Continuous Quality Improvement Practicum. This article reports methods and results of Alabama's continuous quality improvement (CQI) project and lessons learned in developing CQI capabilities among state and local public health practitioners. The Alabama team tracked CQI data weekly for the duration of the practicum using an annotated run chart. Participants included 20 identified tobacco users in 2 participating LIAs. This article highlights specific CQI tools to achieve the project aim. On the basis of CQI interventions, Alabama reached its goal; 12 of 20 primary caregivers in 2 home visiting programs made quit attempts. Alabama utilized multiple CQI tools to reach an ambitious, behavior-based aim; these same concepts could be broadly applied to quality improvement initiatives in any federal or state public health program to guide process- and outcomes-based improvement efforts.

A quality improvement project using statistical process control methods for type 2 diabetes control in a resource-limited setting.

QUALITY ISSUE: Quality improvement (QI) is a key strategy for improving diabetes care in low- and middle-income countries (LMICs). This study reports on a diabetes QI project in rural Guatemala whose primary aim was to improve glycemic control of a panel of adult diabetes patients. INITIAL ASSESSMENT: Formative research suggested multiple areas for programmatic improvement in ambulatory diabetes care. CHOICE OF SOLUTION: This project utilized the Model for Improvement and Agile Global Health, our organization's complementary healthcare implementation framework. IMPLEMENTATION: A bundle of improvement activities were implemented at the home, clinic and institutional level. EVALUATION: Control charts of mean hemoglobin A1C (HbA1C) and proportion of patients meeting target HbA1C showed improvement as special cause variation was identified 3 months after the intervention began. Control charts for secondary process measures offered insights into the value of different components of the intervention. Intensity of home-based diabetes education emerged as an important driver of panel glycemic control. LESSONS LEARNED: Diabetes QI work is feasible in resource-limited settings in LMICs and can improve glycemic control. Statistical process control charts are a promising methodology for use with panels or registries of diabetes patients.

Emotional, physical, and social needs among 0-5-year-old children displaced by the 2010 Chilean earthquake: associated characteristics and exposures.

An 8.8-magnitude earthquake occurred off the coast of Chile on 27 February 2010, displacing nearly 2,000 children aged less than five years to emergency housing camps. Nine months later, this study assessed the needs of 140 displaced 0-5-year-old children in six domains: caregiver stability and protection; health; housing; nutrition; psychosocial situation; and stimulation. Multivariate regression was applied to examine the degree to which emotional, physical, and social needs were associated with baseline characteristics and exposure to the earthquake, to stressful events, and to ongoing risks in the proximal post-earthquake context. In each domain, 20 per cent or fewer children had unmet needs. Of all children in the sample, 20 per cent had unmet needs in multiple domains. Children's emotional, physical, and social needs were associated with ongoing exposures amenable to intervention, more than with baseline characteristics or epicentre proximity. Relief efforts should address multiple interrelated domains of child well-being and ongoing risks in post-disaster settings.

Choosing the best child assessment instrument for a specific context: a methodology for engaging local experts applied in Chile.

OBJECTIVE: Chile is considering expanding its system for early childhood development to include 5- to 7-year olds, but it has no consensus about how to identify at-risk children. This study facilitated a process for incorporating local priorities and best practices to choose a child assessment instrument. METHODS: Using the priority-setting method of the Child Health and Nutrition Research Initiative (CHNRI), 21 Chilean experts defined and weighted ideal assessment instrument characteristics; 130 instruments were scored according to how closely they matched experts' ideal definitions. Instruments were ranked by score under different inclusion criteria. RESULTS: Experts weighted instrument quality highest (95 on 1-100 scale), followed by administration site (87), domains assessed (82), cost (80), administrator (76), Spanish version (75), time (75), and prior use in Chile (53). Experts agreed that an ideal instrument (1) would reliably assess language, socioemotional well-being, mental health, and parenting abilities, (2) could be administered at schools or home, and (3) could be administered by teachers or parents. No single instrument matched all Chilean priorities. Three instruments met 11 of 13 priorities (age; quality; administration at school, home, or waiting rooms; assess language and socioemotional domains; administered by teachers, parents, or psychologists; time ≤30 minutes). Including mental health or parenting abilities ranked instruments whose composite scores were 35% lower. CONCLUSION: Decisions about how to assess children at developmental risk should be informed by local context. The CHNRI method provided a useful process that made explicit mutually exclusive priorities, quantified trade-offs of different assessment strategies, and identified 3 of the instruments that best met local needs and priorities.

Aftershocks of Chile's earthquake for an ongoing, large-scale experimental evaluation.

Evaluation designs for social programs are developed assuming minimal or no disruption from external shocks, such as natural disasters. This is because extremely rare shocks may not make it worthwhile to account for them in the design. Among extreme shocks is the 2010 Chile earthquake. Un Buen Comienzo (UBC), an ongoing early childhood program in Chile, was directly affected by the earthquake. This article discusses (a) the factors the UBC team considered for deciding whether to put on hold or continue implementation and data collection for this experimental study; and (b) how the team reached consensus on those decisions. A lesson learned is that the use of an experimental design for UBC insured that the evaluation's internal validity was not compromised by the earthquake's consequences, although cohort comparisons were compromised. Other lessons can be transferred to other contexts where external shocks affect an ongoing experimental or quasi-experimental impact evaluation.

Lessons from the Chilean earthquake: how a human rights framework facilitates disaster response.

The earthquake of 2010 in Chile holds important lessons about how a rights-based public health system can guide disaster response to protect vulnerable populations. This article tells the story of Chile Grows With You (Chile Crece Contigo), an intersectoral system created three years before the earthquake for protection of child rights and development, and its role in the disaster response. The creation of Chile Grows With You with an explicit rights-oriented mandate established intersectoral mechanisms, relationships, and common understanding between governmental groups at the national and local levels. After the earthquake, Chile Grows With You organized its activities according to its founding principles: it provided universal access and support for all Chilean children, with special attention and services for those at greatest risk. This tiered approach involved public health and education materials for all children and families; epidemiologic data for local planners about children in their municipalities at-risk before the earthquake; and an instrument developed to assist in the assessment and intervention of children put at risk by the earthquake. This disaster response illustrates how a rights-based framework defined and operationalized in times of stability facilitated organization, prioritization, and sustained action to protect and support children and families in the acute aftermath of the earthquake, despite a change in government from a left-wing to a right-wing president, and into the early recovery period.