Impact on Dental Utilization of the Integration of Oral Health in Pediatric Primary Care Through Quality Improvement.

OBJECTIVES: To evaluate child-level dental utilization and expenditure outcomes based on if and where children received fluoride varnish (FV) at quality improvement (QI) medical practices, at non-QI medical practices, at dental practices, or those who never received FV from any practice. DESIGN: Retrospective claims-based analysis cohort study. SETTING: Children with Medicaid insurance through an Ohio pediatric accountable care organization. PARTICIPANTS: Children aged 1 to 5 years with 1 or more well-child visits between 2015 and 2017. INTERVENTION: FV receipt versus no FV. Among children who received FV, categorized if FV delivered by a QI-participating medical provider, a non-QI-participating medical provider, and a dental provider. MAIN OUTCOME MEASURE: Dental claims from 2014 to 2019 were collected for preventive dental visits, caries-related treatment visits, dental general anesthesia (GA) visit, and emergency department visit for a dental problem to examine utilization patterns, expenditures, and dental outcomes. RESULTS: The QI group had a significantly higher incidence of preventive dental visits than the dental (incidence rate ratio [IRR] = 0.93; 95% confidence interval [CI], 0.91-0.96) or non-QI groups (IRR = 0.86; 95% CI, 0.84-0.88). Compared with the QI group, the non-QI (adjusted odds ratio [aOR] = 2.6; 95% CI, 2.4-2.9) and dental (aOR = 2.9; 95% CI, 2.6-3.3) groups were significantly more likely to have caries-related treatment visits. The dental group children were significantly more likely to have dental treatment under GA than the QI group (aOR = 5.3; 95% CI, 2.0-14.4). CONCLUSIONS: Children seen at QI practices appear to have an increased uptake of preventive dental services, which may explain the lower incidence of dental caries visits and GA treatment.

Practice Facilitation Improves Adolescent Reproductive Health Preventive Services in Primary Care.

OBJECTIVES: Provision of reproductive health preventive services to adolescents is critical given their high rates of sexually transmitted infections and unintended pregnancies. Pediatricians are well positioned to provide these services but often face barriers. With this project, we aimed to build quality improvement (QI) capacity within pediatric practices to improve adherence to national guidelines for adolescent reproductive health preventive services. METHODS: In 2016, an accountable care organization overseeing health care delivery for low-income children in the Midwestern United States used practice facilitation, a proven approach to improve health care quality, to support pediatric practices in implementing reproductive health QI projects. Interested practices pursued projects aimed at providing (1) sexual risk reduction and contraceptive counseling (reproductive health assessments [RHAs]) or (2) etonogestrel implants. QI specialists helped practices build key driver diagrams and implement interventions. Outcome measures included the proportion of well-care visits with RHAs completed and number of etonogestrel insertions performed monthly. RESULTS: Between November 1, 2016, and December 31, 2019, 6 practices serving >7000 adolescents pursued QI projects. Among practices focused on RHAs, the proportion of well-care visits with completed RHAs per month increased from 0% to 65.8% (P < .001) within 18 months. Among practices focused on etonogestrel implant insertions, overall insertions per month increased from 0 to 8.5 (P < .001). CONCLUSIONS: Practice facilitation is an effective way to increase adherence to national guidelines for adolescent reproductive health preventive services within primary care practices. Success was driven by practice-specific customization of interventions and ongoing, hands-on support.

Promoting Pediatric Preventive Visits Through Quality Improvement Initiatives in the Primary Care Setting.

OBJECTIVE: To evaluate whether quality improvement (QI) capacity-building in affiliated primary care practices could increase well care visit uptake. STUDY DESIGN: Partners For Kids (PFK) is an accountable care organization caring for pediatric Medicaid beneficiaries in Ohio. PFK QI specialists recruited practices to develop QI projects around increasing well care visit rates (proportion of eligible children with well care visits during calendar year) for children aged 3-6 years and adolescents. The QI specialists supported practice teams in implementing interventions and collecting data through monthly or bimonthly practice visits. RESULTS: Ten practices, serving more than 26 000 children, participated in QI projects for a median of 8.5 months (IQR 5.3-17.6). Well care visit rates in the QI-engaged practices significantly improved from 2016 to 2018 (P < .001 for both age groups). Over time, well care visit rates for 3- to 6-year-old children increased by 11.8% (95% CI 5.4%-18.2%) in QI-engaged practices, compared with 4.1% (95% CI 0.1%-7.4%) in non-engaged practices (P = .233). For adolescents, well care visit rates increased 14.3% (95% CI -2.6% to 31.2%) compared with 5.4% (95% CI 1.8%-9.0%) in QI-engaged vs non-engaged practices over the same period (P = .215). Although not statistically significant, QI-engaged practices had greater magnitudes of rate increases for both age groups. CONCLUSIONS: Through practice facilitation, PFK helped a diverse group of community practices substantially improve preventive visit uptake over time. QI programs in primary care can reach patients early to promote preventive services that potentially avoid costly downstream care.

Using Practice Facilitation to Improve Depression Management in Rural Pediatric Primary Care Practices.

INTRODUCTION: Depression is a common and serious mental health condition frequently encountered in pediatric primary care. Pediatricians report discomfort in managing depression due in part to limited training and limited access to mental health care, which is accentuated in rural areas. METHODS: We developed an evidence-based, quality improvement project designed to help pediatricians increase screening and initial management of depression in the primary care setting. We recruited practices from a pediatric accountable care organization as part of a larger quality improvement portfolio that used a practice facilitation model to support practices with data collection and project management. Practitioners received training on quality improvement, depression screening, and a depression management plan (referred to as the depression management bundle). Practices completed Plan-Do-Study-Act cycles to improve their performance. RESULTS: We recruited 4 practices in rural Ohio to participate. Screening increased from 0% to 81% within 6 months. All 4 practices measured documentation of the depression management bundle for patients diagnosed with depression. Composite data from these practices showed an increase in documentation from 59% to 86% by month 6. CONCLUSIONS: This study provides preliminary support for the use of practice facilitation combined with skills training to increase screening and improve documentation of depression management in rural primary care practices, where specialty mental health resources may be limited. Further research is needed to determine if this approach can be successfully disseminated and if patient outcomes improved.

Improving Pediatrician's Behavioral Health Competencies Through the Project ECHO Teleconsultation Model.

Project ECHO (Extension for Community Healthcare Outcomes) is a teleconsultation model for enhancing the treatment of underserved patients in primary care. Previous behavioral health (BH) adaptations of Project ECHO have primarily focused on adults or specific diagnoses and have relied on self-reported outcomes. The purpose of this pilot was to adapt Project ECHO to support pediatric primary care providers in addressing common BH needs and to conduct an initial evaluation of its effectiveness. Overall, participants reported high levels of satisfaction and a statistically significant improvement in their overall knowledge and skills (P = 0.001). Participation was also associated with a reduction in the use of psychotropic polypharmacy. This pilot adds to a growing body of literature suggesting that Project ECHO is a promising workforce development approach to build competencies for the management of BH issues in primary care.