Paediatric integrated care in the primary care setting: A scoping review of populations served, models used and outcomes measured.

BACKGROUND: Paediatric integrated care (PIC), which involves primary care and behavioural health clinicians working together with patients and families, has been promoted as a best practice in the provision of care. In this context, behavioural health includes behavioural elements in the care of mental health and substance abuse conditions, chronic illness and physical symptoms associated with stress, and addressing health behaviours. Models of and contexts in which PIC has been applied vary, as do the outcomes and measures used to determine its value. Thus, this study seeks to better understand (1) what paediatric subpopulations are receiving integrated care, (2) which models of PIC are being studied, (3) what PIC outcomes are being explored and what measures and strategies are being used to assess those outcomes, and (4) whether the various models are resulting in positive outcomes. These questions have significant policy and clinical implications, given current national- and state-level efforts aimed at promoting integrated health care. METHODS: This study utilized Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews to identify relevant articles published between January 1994 and 30 June 2020. The search utilized three databases: PubMed, PsycInfo and CINAHL. A total of 28 articles met the eligibility criteria for inclusion. RESULTS: Overall, acceptability of PIC appears to be high for patients and providers, with access, screening and engagement generally increasing. However, several gaps in the knowledge base on PIC were uncovered, and for some studies, ascertaining which models of integrated care were being implemented proved difficult. CONCLUSION: PIC has the potential to improve access to and quality of behavioural health care, but more research is needed to understand what models of PIC prove most beneficial and which policies and conditions promote cost efficiency. Rigorous evaluation of patient outcomes, provider training, institutional buy-in and system-level changes are needed.

Description of Audiologic, Developmental, Ophthalmologic, and Neurologic Diagnoses at a Primary Care Clinic for Children in Foster Care.

OBJECTIVES: This study aimed to describe the prevalence of medically diagnosed audiologic, developmental, ophthalmologic, and neurologic conditions in a foster care primary care clinic and to identify any associations among these diagnoses and patient characteristics, placement type, and maltreatment type. METHODS: This study used the electronic medical records for patients (n = 4977), aged 0 to 20 years, with at least 1 visit to an academic-affiliated medical center primary care clinic exclusively serving children in foster care between January 1, 2017, and December 31, 2020. This study was a retrospective chart review. Descriptive statistics were calculated. Bivariate logistic regression analysis was used to determine associations between the outcome variables and each independent variable. Multivariable logistic regression analysis was performed using only significant independent variables from the bivariate analysis. RESULTS: Overall, 3.5% of children had an audiologic diagnosis, 42% had a developmental diagnosis, 9.0% had an ophthalmologic diagnosis, and 4.5% had a neurologic diagnosis. There were increased odds of developmental delay with child neglect and medical complexity and decreased odds with Hispanic ethnicity, Black race, female sex, obesity, and shelter placement. CONCLUSION: These findings add to the limited data regarding medically diagnosed audiologic, developmental, ophthalmologic, and neurologic conditions for children in foster care in a primary care setting. A medical home may help children in foster care, who experience many barriers to comprehensive health care, to better identify and address these health conditions. Future studies are needed that examine health outcomes of children in foster care with these health conditions followed in a medical home.

Infectious disease screening in a dedicated primary care clinic for children in foster care.

BACKGROUND: Children in foster care are considered at high risk for infectious diseases, and guidelines recommend screening for tuberculosis, hepatitis B and C, syphilis, gonorrhea and chlamydia. Little is known about the prevalence of infectious disease in children in foster care. OBJECTIVES: Describe infectious disease screening practices in a primary care clinic dedicated to caring for children in foster care. PARTICIPANTS AND SETTING: Patients evaluated at a foster care primary care clinic at a southwestern academic center. METHODS: Retrospective chart review. RESULTS: From January 1, 2017 through December 31, 2018, 2868 unique patients were evaluated (53 % male, 41 % white, 30 % black, 19 % Hispanic); 1638 (57 %) had any infectious disease laboratory screening done. About 50 % of children had completed screens for tuberculosis, HIV, syphilis and hepatitis C. Tuberculosis screens were positive in 3.6 % of children, 5.5 % of adolescents were positive for chlamydia and <1 % of children were positive for HIV, syphilis or hepatitis C. Increasing age and number of visits were associated with completed tuberculosis, HIV, syphilis and hepatitis C screenings (p < 0.01); female adolescents with completed labs were more likely to be screened for gonorrhea and chlamydia than male adolescents. CONCLUSIONS: Few positive infectious disease screenings were identified in children evaluated in a dedicated foster care primary care clinic despite presence of risk factors. Multiple visits to a primary care foster care clinic may increase the likelihood of completed screenings. Targeted infectious disease screening based on age and local epidemiology may be less traumatizing but still clinically appropriate.

Agreement of injury reporting between primary care medical record and maternal interview for children aged 0-3 years: implications for research and clinical care.

OBJECTIVE: To assess agreement of injury reporting between primary care medical record and maternal interview. METHODS: Cross-sectional study of data from a randomized controlled trial of home visiting. The setting was Hawaii's Healthy Start Program (HSP). Subjects comprised a population-based sample of children in at-risk families with 3 years of primary care medical records and maternal interviews (n = 443). Outcome measures were percentage of children injured unintentionally and mean number of injuries per child in the first 3 years of life by primary care medical record and maternal interview. RESULTS: We identified 490 injuries: 48% by primary care medical record, 22% by maternal interview, and 30% in both sources. More children were reported injured by primary care medical record than maternal interview (51% vs 39%, P< .001). The mean number of injuries per child was 0.87 by primary care medical record and 0.51 by maternal interview (difference 0.36, 95% confidence interval 0.27-0.45, P< .001). Agreement between data sources was fair (kappa = 0.47). CONCLUSIONS: This study estimates that 25% of childhood injuries may not be reported in the medical record, highlighting the need for reconsideration of the use of medical records as the gold standard for unintentional injury data. Caution should be used when interpreting injury data from one source, especially from families with stressful life situations. Poor communication regarding injuries between social service, primary care and urgent care providers may contribute to decreased quality of primary care and missed opportunities for injury prevention.

Home safety in inner cities: prevalence and feasibility of home safety-product use in inner-city housing.

OBJECTIVES: Residential injuries cause significant morbidity and mortality in infants and young children. The American Academy of Pediatrics recommends initiating injury-prevention counseling during health supervision visits in the first 6 months of life. The objectives of this study were to describe and compare self-reported and observed home safety practices in urban, low-income families who were expecting or had a child <12 months old and to assess the feasibility of using safety products depending on the design and repair of urban homes. PARTICIPANTS AND METHODS: Women who were pregnant or had an infant <12 months old and who were enrolled in East Baltimore's Healthy Start home-visiting program were eligible for the study. For this pilot project, we used a prospective predesign/postdesign. Maternal self-report and investigator home observations documented the use of working smoke alarms on each level of the home, stair gates or doors blocking the top and bottom of all staircases, adult medication storage in locked cabinets, and the environmental feasibility of safety-product use. RESULTS: Home safety practices were higher by maternal self-report than by investigator observation. Fifty-five percent of families who reported a working smoke alarm on every level of the home had nonworking or absent smoke alarms noted during investigator observation. Of assessed staircases, 67% could not accommodate a wall-mounted gate at the top of the stairs, and 38% could not accommodate a pressure-mounted gate at the bottom of the stairs. Although most families reported locked storage of medications, 77% had unlocked medication storage documented during home observation. CONCLUSIONS: In this sample of urban families, implementation of American Academy of Pediatrics-recommended safety practices is low. The structural design of urban homes may be a significant barrier to home safety-product use. The American Academy of Pediatrics Injury Prevention Program sheets, manufacturers of safety products, and legislators need to address injury-prevention issues unique to urban, low-income families.