Identifying adaptations for a mindfulness program for Spanish-speaking mothers of children with chronic conditions or disabilities.

Mothers of children with chronic conditions or disabilities have benefited from mindfulness programs, yet culturally relevant mindfulness programs for Spanish-speaking mothers are lacking. We aimed to explore how this population experienced a peer-led mindfulness program to inform adaptations. Sixteen mothers attended a 6-week program and completed semi-structured interviews. Using a realist evaluation framework, we explored relationships between participants' context, the program's mechanisms and outcomes. Our thematic analysis found that four contextual factors-faith, self-concept as a woman and mother, trauma, and level of social support-influenced how participants experienced the mechanisms. Mechanisms included having positive experiences when trying practices, engaging in self-reflection, and sharing life experiences and learning in community. The mechanisms led to four outcomes: emotion regulation, savoring daily life experiences, empowerment to practice self-care and common humanity. Faith was an important enabling factor because participants had positive experiences when integrating their faith with program content. Future research should examine adaptations that invite participants to explore this synergy. Self-reflection should also be emphasized because it increased motivation to use practices and helped address barriers to engagement. Because the four contextual factors apply to many Spanish-speaking immigrants, these adaptations could enhance mindfulness programs for this population more broadly.

Pilot Evaluation of the Family Bridge Program: A Communication- and Culture-Focused Inpatient Patient Navigation Program.

OBJECTIVE: Children with low income and minority race and ethnicity have worse hospital outcomes due partly to systemic and interpersonal racism causing communication and system barriers. We tested the feasibility and acceptability of a novel inpatient communication-focused navigation program. METHODS: Multilingual design workshops with parents, providers, and staff created the Family Bridge Program. Delivered by a trained navigator, it included 1) hospital orientation; 2) social needs screening and response; 3) communication preference assessment; 4) communication coaching; 5) emotional support; and 6) a post-discharge phone call. We enrolled families of hospitalized children with public or no insurance, minority race or ethnicity, and preferred language of English, Spanish, or Somali in a single-arm trial. We surveyed parents at enrollment and 2 to 4 weeks post-discharge, and providers 2 to 3 days post-discharge. Survey measures were analyzed with paired t tests. RESULTS: Of 60 families enrolled, 57 (95%) completed the follow-up survey. Most parents were born outside the United States (60%) with a high school degree or less (60%). Also, 63% preferred English, 33% Spanish, and 3% Somali. The program was feasible: families received an average of 5.3 of 6 components; all received >2. Most caregivers (92%) and providers (81% [30/37]) were "very satisfied." Parent-reported system navigation improved from enrollment to follow-up (+8.2 [95% confidence interval 2.9, 13.6], P = .003; scale 0-100). Spanish-speaking parents reported decreased skills-related barriers (-18.4 [95% confidence interval -1.8, -34.9], P = .03; scale 0-100). CONCLUSIONS: The Family Bridge Program was feasible, acceptable, and may have potential for overcoming barriers for hospitalized children at risk for disparities.

Understanding trust between pediatric hospitalists and outpatient clinicians during hospital admissions: A multisite qualitative analysis.

BACKGROUND: During transitions between sites of care, clinicians must build trust with colleagues to make decisions that ensure safe, high-quality care. OBJECTIVES: This study explored factors that could influence trust between outpatient clinicians and pediatric hospitalists when children are referred for hospital admission. DESIGN, SETTING, AND PARTICIPANTS: We conducted an analysis of 41 semistructured interviews with outpatient clinicians and pediatric hospitalists from May 2020 through October 2021 across three healthcare systems participating in a multisite comparative effectiveness study of pediatric direct and emergency department admissions. INTERVENTION, MAIN OUTCOMES, AND MEASURES: Qualitative interviews. A conceptual model for trust between outpatient clinicians and pediatric hospitalists during hospital admission referral. Interviews were professionally transcribed, verified for accuracy, and analyzed using a combination of inductive and deductive. RESULTS: We identified two primary domains: (1) interpersonal trust and (2) trust-by-proxy. Interpersonal trust included five relational factors that influenced collaboration between clinicians: antecedent relationships, confidence in others clinical abilities, understanding others' practice culture, recognition of available resources, and power dynamic. An individual clinicians' assessment of risk and past clinical experiences also influenced trust during clinical decision-making. Trust-by-proxy represented system-level factors that could influence trust, independent of any pre-existing relationships, including communication infrastructure, guidelines and protocols, the organizational culture, and professional courtesy. CONCLUSION: Interpersonal and system-level factors influence trust between outpatient clinicians and hospitalists during decision-making encounters. System-level factors may serve as a proxy for trust when clinicians do not have pre-existing interpersonal relationships. These factors could be explored as an explicit target of interventions to improve interdisciplinary collaboration and decision-making between hospitalists and primary care clinicians.

Healthcare Quality for Acute Illness during the COVID-19 Pandemic: A Multisite Qualitative Analysis.

The coronavirus disease 2019 (COVID-19) pandemic incited substantial changes to acute care delivery, including the rapid scale-up of telehealth and numerous changes to in-person care. This study explored health system changes associated with the COVID-19 pandemic and their influences on pediatric acute care delivery and quality of care. METHODS: We conducted 38 semistructured interviews May-November 2020 with families and clinicians from 3 US regions, eliciting their perspectives and experiences regarding changes to acute care delivery during the pandemic. Interviews were analyzed using a general inductive approach to identify relationships between clinical care infrastructure, care processes, and healthcare quality. RESULTS: Emerging knowledge of COVID-19 epidemiology and associated restrictions influenced care-seeking behaviors and clinical infrastructure and processes. Infrastructure changes included the closure of some clinics, limited "sick visit" hours and locations, and increased resources for telehealth. Modified care processes included the assignment of clinicians to specific roles, limitations on sibling attendance, increased referrals to other clinics, and iterative development of procedures and protocols. Although intended to increase safety, these changes appear to have decreased access, timeliness, and equity of care. High-quality care was supported by telephone triage processes, in-person visits following initial assessments by telehealth, and identification of diagnoses and populations best-suited to telehealth versus in-person care. CONCLUSIONS: Changes in acute care delivery during the COVID-19 pandemic may have negatively impacted healthcare quality in some domains. Implementation of pediatric-specific guidelines and decision aids describing diagnoses, populations, and procedures best-suited to telehealth may improve the quality of acute care delivery.

The Role of Compassion and Mindfulness in Building Parental Resilience When Caring for Children With Chronic Conditions: A Conceptual Model.

Compassion- and mindfulness-based interventions (CMBIs) and therapies hold promise to support parent resilience by enabling adaptive stress appraisal and coping, mindful parenting, and perhaps crucially, self-compassion. These contemplative modalities have recently been expanded to parents of children with chronic illness, building on successful applications for adults facing stress, chronic pain, or mental illness, and for healthcare professionals in response to caregiver burnout resulting from their work. The design and adaptation of interventions and therapies require a conceptual model of parent resilience in the context of childhood chronic illness that integrates mindfulness and compassion. The objective of this paper is to propose and describe such a model. First, we review the need for parent support interventions for this population. Second, we introduce a Model of Compassion, Mindfulness, and Resilience in Parental Caregiving. We highlight the mindful parenting approaches, guiding theories for adaptive coping, and family resilience frameworks that informed our model. Third, we describe a case of a parent to illustrate a practical application model. Finally, we outline future directions for intervention development and research to examine the impact of CMBIs on parent resilience.

Quality of Care for Children With Medical Complexity: An Analysis of Continuity of Care as a Potential Quality Indicator.

OBJECTIVE: To examine the relationship between continuity of care for children with medical complexity (CMC) and emergency department (ED) utilization, care coordination quality, and family effects related to care coordination. METHODS: We measured ED utilization and primary care continuity with the Bice-Boxerman continuity of care index for 1477 CMC using administrative data from Minnesota and Washington state Medicaid agencies. For a subset of 186 of these CMC a caregiver survey was used to measure care coordination quality (using items adapted from the Consumer Assessment of Healthcare Providers and System Adult Health Plan Survey) and family impact (using items adapted from the National Survey of Children with Special Health Care Needs). Multivariable regression was used to examine the relationship between continuity, entered as a continuous variable ranging from 0 to 1, and the outcomes. RESULTS: The median continuity was 0.27 (interquartile range [IQR], 0.12-0.48) in the administrative data cohort and 0.27 (IQR, 0.14-0.43) in the survey cohort. Compared with children with a continuity score of 0, children with a score of 1 had lower odds of having ≥1 ED visit (odds ratio, 0.65; 95% confidence interval [CI], 0.46-0.93; P = .017) and their caregivers reported higher scores for the measure of receipt of care coordination (ß = 35.2 on a 0-100 scale; 95% CI, 11.5-58.9; P = .004). There was no association between continuity and family impact. CONCLUSIONS: Continuity of care holds promise as a quality measure for CMC because of its association with lower ED utilization and more frequent receipt of care coordination.

Using State Administrative Data to Identify Social Complexity Risk Factors for Children.

PURPOSE: Screening for social determinants of health is challenging but critically important for optimizing child health outcomes. We aimed to test the feasibility of using an integrated state agency administrative database to identify social complexity risk factors and examined their relationship to emergency department (ED) use. METHODS: We conducted a retrospective cohort study among children younger than 18 years with Washington State Medicaid insurance coverage (N = 505,367). We linked child and parent administrative data for this cohort to identify a set of social complexity risk factors, such as poverty and parent mental illness, that have either a known or hypothesized association with suboptimal health care use. Using multivariate analyses, we examined associations of each risk factor and of number of risk factors with the rate of ED use. RESULTS: Nine of 11 identifiable social complexity risk factors were associated with a higher rate of ED use. Additionally, the rate increased as the number of risk factors increased from 0 to 5 or more, reaching approximately twice the rate when 5 or more risk factors were present in children aged younger than 5 years (incidence rate ratio = 1.92; 95% CI, 1.85-2.00) and in children aged 5 to 17 years (incidence rate ratio = 2.06; 95% CI, 1.99-2.14). CONCLUSIONS: State administrative data can be used to identify social complexity risk factors associated with higher rates of ED use among Medicaid-insured children. State agencies could give primary care medical homes a social risk flag or score to facilitate targeted screening and identification of needed resources, potentially preventing future unnecessary ED use in this vulnerable population of children.

Provider Perspectives of High-Quality Pediatric Hospital-to-Home Transitions for Children and Youth With Chronic Disease.

OBJECTIVE: The objective of this study was to describe health care providers' and hospital administrators' perspectives on how to improve pediatric hospital-to-home transitions for children and youth with chronic disease (CYCD). METHODS: Focus groups and key informant interviews of inpatient attending physicians, primary care physicians, pediatric residents, nurses, care coordinators, and social workers were conducted at a tertiary care children's hospital. Key informant interviews were performed with hospital administrators. Semistructured questions were used to elicit perceptions of transitional care quality and to identify key structures and processes needed to improve transitional care outcomes. Transcripts of discussions were coded to identify emergent themes. RESULTS: Participants (N = 22) reported that key structures needed to enhance transitional care were a multidisciplinary team, inpatient provider-patient continuity, hospital resource availability, an interoperative electronic health record, and availability of community resources. Key processes needed to achieve high-quality transitional care included setting individualized transition goals, involving parents in care planning, establishing parental competency with home care tasks, and consistently communicating with primary care physicians. Providers identified a lack of reliable roles and processes, insufficient assessment of patient and/or family psychosocial factors, and consistent 2-way communication with community providers as elements to target to improve transitional care outcomes for CYCD. CONCLUSIONS: Many key structures and processes of care perceived as important to achieving high-quality transitional care outcomes for CYCD have the opportunity for improvement at the institution studied. Engaging key stakeholders in designing quality improvement interventions to address these deficits in the current care model may improve transitional care outcomes for this vulnerable population.

Development and Validation of a Method to Identify Children With Social Complexity Risk Factors.

OBJECTIVES: We sought to develop and validate a method to identify social complexity risk factors (eg, limited English proficiency) using Minnesota state administrative data. A secondary objective was to examine the relationship between social complexity and caregiver-reported need for care coordination. METHODS: A total of 460 caregivers of children with noncomplex chronic conditions enrolled in a Minnesota public health care program were surveyed and administrative data on these caregivers and children were obtained. We validated the administrative measures by examining their concordance with caregiver-reported indicators of social complexity risk factors using tetrachoric correlations. Logistic regression analyses subsequently assessed the association between social complexity risk factors identified using Minnesota's state administrative data and caregiver-reported need for care coordination, adjusting for child demographics. RESULTS: Concordance between administrative and caregiver-reported data was moderate to high (correlation range 0.31-0.94, all P values <.01), with only current homelessness (r = -0.01, P = .95) failing to align significantly between the data sources. The presence of any social complexity risk factor was significantly associated with need for care coordination before (unadjusted odds ratio = 1.65; 95% confidence interval, 1.07-2.53) but not after adjusting for child demographic factors (adjusted odds ratio = 1.53; 95% confidence interval, 0.98-2.37). CONCLUSIONS: Social complexity risk factors may be accurately obtained from state administrative data. The presence of these risk factors may heighten a family's need for care coordination and/or other services for children with chronic illness, even those not considered medically complex.

Impact of English proficiency on care experiences in a pediatric emergency department.

OBJECTIVE: To compare emergency department care experiences of Spanish-speaking, limited-English-proficient (SSLEP) and English-proficient (EP) parents and to assess how SSLEP care experiences vary by parent-perceived interpretation accuracy. METHODS: The National Research Corporation Picker Institute's Family Experience Survey (FES) was administered from November 26, 2010, to July 17, 2011, to 478 EP and 152 SSLEP parents. Problem scores for 3 FES dimensions were calculated: information/education, partnership with clinicians, and access/coordination of care. Adjusted associations between language proficiency (SSLEP vs EP) and dimension problem scores were examined by multivariate Poisson regression. Unadjusted Poisson regression analysis was used to examine the association between perceived interpretation accuracy and FES problem scores for SSLEP parents who received interpretation. RESULTS: SSLEP parents had a higher risk of reporting problems with access/coordination of care compared to EP parents (risk ratio 1.6, 95% confidence interval 1.2, 2.1). There were no differences in reported care experiences related to information/education or partnership with clinicians. Among SSLEP parents who received professional interpretation, those reporting poor accuracy had a higher risk of also reporting problems with information/education (risk ratio 2.1, 95% confidence interval 1.2, 3.6). CONCLUSIONS: In a pediatric emergency department with around-the-clock access to professional interpretation, SSLEP parents report poorer experiences than EP parents with access/coordination of care, including perceived wait times. Their experiences with provision of information/education and partnership with clinicians approximate those of EP parents. However, SSLEP parents who perceive poor interpretation accuracy report more problems understanding information provided about their child's illness and care.