A Pilot Randomized Controlled Trial of the Family Assessment and Feedback Intervention (FAFI): Effects on Mental Health Literacy and Attitudinal Engagement with Health Supports and Services.

This randomized controlled trial tested the Family Assessment and Feedback Intervention (FAFI), a new intervention to enhance family engagement with emotional and behavioral health services. The FAFI is a guided conversation with families about results of their multidimensional assessment that is set in the context of motivational enhancement. It differs from other assessment-with-feedback interventions by extending the focus of assessment beyond the target child to parents and the family environment, addressing parental emotional and behavioral problems and competencies, spanning a broad range of children's and parents' strengths and difficulties, and being generalizable to many settings and practitioners. Participants were 81 families in primary care pediatrics. The FAFI was associated with a significant increase in parental mental health literacy and with an increase in parental attitudinal engagement with health supports and services that closely approached statistical significance (p = .052), while controlling for children's age and gender and family socioeconomic status.

Barriers and Facilitators of High-Efficiency Clinical Pathway Implementation in Community Hospitals.

BACKGROUND: An intervention that involved simultaneously implementing clinical pathways for multiple conditions was tested at a tertiary children's hospital and it improved care quality. We are conducting a randomized trial to evaluate this multicondition pathway intervention in community hospitals. Our objectives in this qualitative study were to prospectively (1) identify implementation barriers and (2) map barriers to facilitators using an established implementation science framework. METHODS: We recruited participants via site leaders from hospitals enrolled in the trial. We designed an interview guide using the Consolidated Framework for Implementation Research and conducted individual interviews. Analysis was done using constant comparative methods. Anticipated barriers were mapped to facilitators using the Capability, Opportunity, Motivation, Behavior Framework. RESULTS: Participants from 12 hospitals across the United States were interviewed (n = 21). Major themes regarding the multicondition pathway intervention included clinician perceptions, potential benefits, anticipated barriers/challenges, potential facilitators, and necessary resources. We mapped barriers to additional facilitators using the Capability, Opportunity, Motivation, Behavior framework. To address limited time/bandwidth of clinicians, we will provide Maintenance of Certification credits. To address new staff and trainee turnover, we will provide easily accessible educational videos/resources. To address difficulties in changing practice across other hospital units, we will encourage emergency department engagement. To address parental concerns with deimplementation, we will provide guidance on parent counseling. CONCLUSIONS: We identified several potential barriers and facilitators for implementation of a multicondition clinical pathway intervention in community hospitals. We also illustrate a prospective process for identifying implementation facilitators.

The Vermont Family Based Approach in Primary Care Pediatrics: Effects on Children's and Parents' Emotional and Behavioral Problems and Parents' Health-Related Quality of Life.

This randomized controlled trial tested the Vermont Family Based Approach (VFBA) in primary care pediatrics. The VFBA is a model of healthcare delivery that shifts the focus from the individual to the family, emphasizes emotional and behavioral health, and uses evidence-based health promotion/prevention along with the treatment of emotional and behavioral problems. Participants were 81 families of 3-15-year-olds. For children, the VFBA was associated with greater reductions than the Control condition on the Child Behavior Checklist Emotionally Reactive, Withdrawn, Sleep Problems, Aggressive Behavior and Total Problems scales. For parents, the VFBA was associated with greater reductions than the Control condition on the Adult Self-Report Anxious/Depressed, Rule-Breaking Behavior, Internalizing Problems and Total Problems scales. The VFBA was also associated with greater improvement than the Control condition in the parents' health-related quality of life, as indicated by all scales of the Medical Outcomes Study Health Survey.

Follow-Up After Asthma Emergency Department Visits and Its Relationship With Subsequent Asthma-Related Utilization.

OBJECTIVE: To assess the association between follow-up after an asthma-related emergency department (ED) visit and the likelihood of subsequent asthma-related ED utilization. METHODS: Using data from California Medicaid (2014-2016), and Vermont (2014-2016) and Massachusetts (2013-2015) all-payer claims databases, we identified asthma-related ED visits for patients ages 3 to 21. Follow-up was defined as a visit within 14 days with a primary care provider or an asthma specialist. OUTCOME: asthma-related ED revisit after the initial ED visit. Models included logistic regression to assess the relationship between 14-day follow-up and the outcome at 60 and 365 days, and mixed-effects negative binomial regression to assess the relationship between 14-day follow-up and repeated outcome events (# ED revisits/100 child-years). All models accounted for zip-code level clustering. RESULTS: There were 90,267 ED visits, of which 22.6% had 14-day follow-up. Patients with follow-up were younger and more likely to have commercial insurance, complex chronic conditions, and evidence of prior asthma. 14-day follow-up was associated with decreased subsequent asthma-related ED revisits at 60 days (5.7% versus 6.4%, P < .001) and at 365 days (25.0% versus 28.3%, P < 0.001). Similarly, 14-day follow-up was associated with a decrease in the rate of repeated subsequent ED revisits (66.7 versus 77.3 revisits/100 child-years; P < 0.001). CONCLUSIONS: We found a protective association between outpatient 14-day follow-up and asthma-related ED revisits. This may reflect improved asthma control as providers follow the NHLBI guideline stepwise approach. Our findings highlight an opportunity for improvement, with only 22.6% of those with asthma-related ED visits having 14-day follow-up.

Evidence-Informed Milestones for Developmental Surveillance Tools.

The Centers for Disease Control and Prevention's (CDC) Learn the Signs. Act Early. program, funded the American Academy of Pediatrics (AAP) to convene an expert working group to revise its developmental surveillance checklists. The goals of the group were to identify evidence-informed milestones to include in CDC checklists, clarify when most children can be expected to reach a milestone (to discourage a wait-and-see approach), and support clinical judgment regarding screening between recommended ages. Subject matter experts identified by the AAP established 11 criteria for CDC milestone checklists, including using milestones most children (≥75%) would be expected to achieve by specific health supervision visit ages and those that are easily observed in natural settings. A database of normative data for individual milestones, common screening and evaluation tools, and published clinical opinion was created to inform revisions. Application of the criteria established by the AAP working group and adding milestones for the 15- and 30-month health supervision visits resulted in a 26.4% reduction and 40.9% replacement of previous CDC milestones. One third of the retained milestones were transferred to different ages; 67.7% of those transferred were moved to older ages. Approximately 80% of the final milestones had normative data from ≥1 sources. Social-emotional and cognitive milestones had the least normative data. These criteria and revised checklists can be used to support developmental surveillance, clinical judgment regarding additional developmental screening, and research in developmental surveillance processes. Gaps in developmental data were identified particularly for social-emotional and cognitive milestones.

Weekend Versus Weekday Asthma-Related Emergency Department Utilization.

OBJECTIVE: To assess variation in asthma-related emergency department (ED) use between weekends and weekdays. METHODS: Cross-sectional administrative claims-based analysis using California 2016 Medicaid data and Vermont 2016 and Massachusetts 2015 all-payer claims databases. We defined ED use as the rate of asthma-related ED visits per 100 child-years. A weekend visit was a visit on Saturday or Sunday, based on date of ED visit claim. We used negative binomial regression and robust standard errors to assess variation between weekend and weekday rates, overall and by age group. RESULTS: We evaluated data from 398,537 patients with asthma. The asthma-related ED visit rate was slightly lower on weekends (weekend: 18.7 [95% confidence interval (CI): 18.3-19.0], weekday: 19.6 [95% CI, 19.3-19.8], P < .001). When stratifying by age group, 3- to 5-year-olds had higher rates of asthma-related ED visits on weekends than weekdays (weekend: 33.7 [95% CI, 32.6-34.7], weekday: 29.8 [95% CI, 29.1-30.5], P < .001) and 12- to 17-year-olds had lower rates of ED visits on weekends than weekdays (weekend: 13.0 [95% CI: 12.5-13.4], weekday: 16.3 [95% CI: 15.9-16.7], P < .001). In the other age groups (6-11, 18-21 years) there were not statistically significant differences between weekend and weekday rates (P > .05). CONCLUSIONS: In this multistate analysis of children with asthma, we found limited overall variation in pediatric asthma-related ED utilization on weekends versus weekdays. These findings suggest that increasing access options during the weekend may not necessarily decrease asthma-related ED use.

A primary care learning collaborative to improve office systems and clinical management of pediatric asthma.

OBJECTIVE: Pediatric asthma is a common, relapsing-remitting, chronic inflammatory airway disease that when uncontrolled often leads to substantial patient and health care system burden. Improving management of asthma in primary care can help patients stay well controlled. METHODS: The Vermont Child Health Improvement Program (VCHIP) developed a quality improvement (QI) learning collaborative with a primary objective to improve clinical asthma management measures through improvement in primary care office systems to support asthma care. Seven months of medical record review data were evaluated for improvements on eight clinical asthma management measures. Pre and post office systems inventory (OSI) self-assessments detailing adherence to improvement strategies were analyzed for improvement. Logistic regressions were used to test for associations between OSI strategy post scores and the corresponding clinical asthma management measures by month seven. RESULTS: This study found significant improvement from baseline to month seven on seven of the eight clinical asthma management measures and between pre and post OSI for seven of the nine strategies assessed (N = 19 practices). Additionally, one point higher average OSI scores on the assessment and monitoring of asthma severity, asthma control, asthma action plans, and asthma education strategies were associated with significantly greater odds of improvement in their respective clinical asthma management measures. CONCLUSIONS: A QI learning collaborative approach in primary care can improve office systems and corresponding clinical management measures for pediatric patients with asthma. This suggests that linking specific office systems strategies to clinical measures may be a helpful tactic within the learning collaborative model.

Statewide Asthma Learning Collaborative Participation and Asthma-Related Emergency Department Use.

BACKGROUND: Quality improvement (QI) efforts can improve guideline-recommended asthma care processes in the pediatric office setting. We sought to assess whether practice participation in an asthma QI collaborative was associated with decreased asthma-related emergency department (ED) visits. METHODS: A statewide network of practices participated in a pediatric asthma QI collaborative from 2015 to 2016. We evaluated asthma-related ED visit rates per 100 child-years for children ages 3 to 21 years with asthma, using the state's all-payer claims database. We used a difference-in-differences approach, with mixed-effects negative binomial regression models to control for practice and patient covariates. Our main analysis measured the outcome before (2014) and after (2017) the QI collaborative at fully participating and control practices. Additional analyses assessed (1) associations during the intervention period (2016) and (2) associations including practices partially participating in QI collaborative activities. RESULTS: In the postintervention year (2017), participating practices' (n = 20) asthma-related ED visit rate decreased by 5.8 per 100 child-years, compared to an increase of 1.8 per 100 child-years for control practices (n = 15; difference in differences = -7.3; P = .002). Within the intervention year (2016), we found no statistically significant differences in asthma-related ED visit rates compared to controls (difference in differences = -4.3; P = .17). The analysis including partially participating practices yielded similar results and inferences to our main analysis. CONCLUSIONS: Participation in an asthma-focused QI collaborative was associated with decreased asthma-related ED visit rates. For those considering implementing this type of QI collaborative, our findings indicate that it takes time to see measurable improvements in ED visit rates. Further study is warranted regarding QI elements contributing to success for partial participants.

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. METHODS: In 2013, a total of 20 primary care practices completed a 7-month QI project aimed to increase immunization coverage among early childhood (29-33 months), school-age (6 years), and adolescent (13 years) age groups. For this study, we examined random cross-sectional medical record reviews from 12 of the 20 practices within each age group in 2012, 2013, and 2014 to measure improvement in immunization coverage over time using chi-squared tests. We repeated these analyses on population-level data from Vermont's immunization registry for the 12 practices in each age group each year. We used difference-in-differences regressions in the immunization registry data to compare improvements over time between the 12 practices and those not participating in QI. RESULTS: Immunization coverage increased over 3 years for all ages and all immunization series (P ≤ .009) except one, as measured by medical record review. Registry results aligned partially with medical record review with increases in early childhood and adolescent series over time (P ≤ .012). Notably, the adolescent immunization series completion, including human papillomavirus, increased more than in the comparison practices (P = .037). CONCLUSIONS: Medical record review indicated that QI efforts led to increases in immunization coverage in pediatric primary care. Results were partially validated in the immunization registry particularly among early childhood and adolescent groups, with a population-level impact of the intervention among adolescents.

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.

Pediatric-Informed Facilitation of Patient-Centered Medical Home Transformation.

Patient-centered medical home (PCMH) transformation has been challenging for pediatric practices, in part because of the National Committee for Quality Assurance (NCQA) PCMH focus on conditions and processes specific to adult patients. Realizing the potential challenges faced by pediatric practices, Vermont supported pediatric-informed facilitators to help practices during PCMH transformation. This study characterizes the impact of pediatric-informed facilitators; provides benchmark data on NCQA scores, number of facilitation meetings, and the time between facilitation start and end; and compares pediatric- and adult-serving practices. We found no difference between pediatric and matched adult-serving practices in NCQA score, number of facilitation meetings, or weeks to NCQA scoring. These results suggest that pediatric-informed facilitators can help pediatric practices achieve NCQA PCMH recognition on par with practices serving adult patients. Supporting primary care practices with specialty-informed facilitators can assist integration into health care reform efforts.

Effects of Patient-centered Medical Home Transformation on Child Patient Experience.

INTRODUCTION: Patient experience, 1 of 3 aims for improving health care, is rarely included in studies of patient-centered medical home (PCMH) transformation. This study examines the association between patient experience and National Committee on Quality Assurance (NCQA) PCMH transformation. METHODS: This was a cross-sectional study of parent-reported child patient experience from PCMH and non-PCMH practices. It used randomly sampled experience surveys completed by 2599 patients at 29 pediatric and family medicine PCMH (n = 21) and non-PCMH (n = 8) practices in Vermont from 2011 to 2013. Patient experiences related to child development and prevention were assessed using the Consumer Assessment of Health care Providers and Systems (CAHPS). RESULTS: A 10-point increase in NCQA score at PCMH practices is associated with a 3.1% higher CAHPS child prevention score (P = .004). Among pediatric practices, PCMH recognition is associated with 7.7% (P < .0005) and 7.2% (P < .0005) higher CAHPS child development and prevention composite scores, respectively. Among family medicine practices, PCMH recognition is associated with 7.4% (P = .001) and 11.0% (P < .0005) lower CAHPS child development and prevention composite scores, respectively. CONCLUSIONS: Our results suggest that PCMH recognition may improve child patient experience at pediatric practices and worsen experience at family medicine practices. These findings warrant further investigation into the differential influence of NCQA PCMH transformation on family medicine and pediatric practices.

Improving delivery of Bright Futures preventive services at the 9- and 24-month well child visit.

OBJECTIVES: To determine if clinicians and staff from 21 diverse primary care practice settings could implement the 2008 Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd edition recommendations, at the 9- and 24-month preventive services visits. METHODS: Twenty-two practice settings from 15 states were selected from 51 applicants to participate in the Preventive Services Improvement Project (PreSIP). Practices participated in a 9-month modified Breakthrough Series Collaborative from January to November 2011. Outcome measures reflect whether the 17 components of Bright Futures recommendations were performed at the 9- and 24-month visits for at least 85% of visits. Additional measures identified which office systems were in place before and after the collaborative. RESULTS: There was a statistically significant increase for all 17 measures. Overall participating practices achieved an 85% completion rate for the preventive services measures except for discussion of parental strengths, which was reported in 70% of the charts. The preventive services score, a summary score for all the chart audit measures, increased significantly for both the 9-month (7 measures) and 24-month visits (8 measures). CONCLUSIONS: Clinicians and staff from various practice settings were able to implement the majority of the Bright Futures recommended preventive services at the 9- and 24-month visits at a high level after participation in a 9-month modified Breakthrough Series collaborative.

The national improvement partnership network: state-based partnerships that improve primary care quality.

Improvement partnerships (IPs) are a model for collaboration among public and private organizations that share interests in improving child health and the quality of health care delivered to children. Their partners typically include state public health and Medicaid agencies, the local chapter of the American Academy of Pediatrics, and an academic health care organization or children's hospital. Most IPs also engage other partners, including a variety of public, private, and professional organizations and individuals. IPs lead and support measurement-based, systems-focused quality improvement (QI) efforts that primarily target primary care practices that care for children. Their projects are most often conducted as learning collaboratives that involve a team from each of 8 to 15 participating practices over 9 to 12 months. The improvement teams typically include a clinician, office manager, clinical staff (nurses or medical assistants), and, for some projects, a parent; the IPs provide the staff and local infrastructure. The projects target clinical topics, chosen because of their importance to public health, local clinicians, and funding agencies, including asthma, attention-deficit/hyperactivity disorder, autism, developmental screening, obesity, mental health, medical home implementation, and several others. Over the past 13 years, 19 states have developed (and 5 are exploring developing) IPs. These organizations share similar aims and methods but differ substantially in leadership, structure, funding, and longevity. Their projects generally engage pediatric and family medicine practices ranging from solo private practices to community health centers to large corporate practices. The practices learn about the project topic and about QI, develop specific improvement strategies and aims that align with the project aims, perform iterative measures to evaluate and guide their improvements, and implement systems and processes to support and sustain those improvements. Since 2008, IPs have offered credit toward Part 4 of Maintenance of Certification for participants in some of their projects. To date, IPs have focused on achieving improvements in care delivery through individual projects. Rigorous measurement and evaluation of their efforts and impact will be essential to understanding, spreading, and sustaining state/regional child health care QI programs. We describe the origins, evolution to date, and hopes for the future of these partnerships and the National Improvement Partnership Network (NIPN), which was established to support existing and nurture new IPs.

Improvement in adolescent screening and counseling rates for risk behaviors and developmental tasks.

BACKGROUND: High-quality preventive services for youth aged 11 to 18 include assessment and counseling regarding health behavior risks and developmental tasks/strengths of adolescence. Nationally, primary care health behavior risk screening and counseling rates lag considerably behind other preventive health services. The purpose of this project was to assist pediatric and family medicine practices to make office systems-based changes that promote comprehensive screening and counseling for risks and developmental tasks/strengths during adolescent preventive services visits. METHODS: Over a 9-month period, 7 pediatric and 1 family medicine primary care practices (13 physicians and 3 nurse practitioners) participated in a modified Breakthrough Series Collaborative. This project was designed to support primary care practitioner efforts to implement comprehensive screening and counseling for risk behaviors and developmental tasks/strengths for their adolescent patients and increase the rate of brief office intervention and referral. Composite variables were designed to reflect whether screening and counseling were documented for risks and developmental tasks. Statistical comparisons were made by using the nonparametric Wilcoxon matched-pairs signed rank test. RESULTS: There were increases in the composite measures of screening and counseling for risk behaviors (all 6 risks: 26%-50%, P = .01) and 3 of 4 developmental tasks/strengths (32%-66%, P = .01). Documentation of office interventions for identified risks and out-of office referral rates did not change. CONCLUSIONS: With the use of an office systems-based approach, screening and counseling for all critical risk behaviors and developmental tasks/strengths during adolescent preventive services visits can be improved in primary care practices.

Health literacy and child health promotion: implications for research, clinical care, and public policy.

The nation's leading sources of morbidity and health disparities (eg, preterm birth, obesity, chronic lung disease, cardiovascular disease, type 2 diabetes, mental health disorders, and cancer) require an evidence-based approach to the delivery of effective preventive care across the life course (eg, prenatal care, primary preventive care, immunizations, physical activity, nutrition, smoking cessation, and early diagnostic screening). Health literacy may be a critical and modifiable factor for improving preventive care and reducing health disparities. Recent studies among adults have established an independent association between lower health literacy and poorer understanding of preventive care information and poor access to preventive care services. Children of parents with higher literacy skills are more likely to have better outcomes in child health promotion and disease prevention. Adult studies in disease prevention have suggested that addressing health literacy would be an efficacious strategy for reducing health disparities. Future initiatives to reduce child health inequities should include health-promotion strategies that meet the health literacy needs of children, adolescents, and their caregivers.