10 Years Later : The Impact of the Affordable Care Act on Prevention and Public Health in North Carolina.

The passage of the Affordable Care Act had a great impact on the landscape of public health programming and clinical preventive care in North Carolina. Large funding measures have supported community-based prevention efforts and led to policy, systems, and environmental changes to support a healthier population.

A Quality Improvement Intervention Bundle to Reduce 30-Day Pediatric Readmissions.

INTRODUCTION: Pediatric hospital readmissions can represent gaps in care quality between discharge and follow-up, including social factors not typically addressed by hospitals. This study aimed to reduce the 30-day pediatric readmission rate on 2 general pediatric services through an intervention to enhance care spanning the hospital stay, discharge, and follow-up process. METHODS: A multidisciplinary team developed an intervention bundle based on a needs assessment and evidence-based models of transitional care. The intervention included pre-discharge planning with a transition coordinator, screening and intervention for adverse social determinants of health (SDH), medication reconciliation after discharge, communication with the primary care provider, access to a hospital-based transition clinic, and access to a 24-hour direct telephone line staffed by hospital attending pediatricians. These were implemented sequentially from October 2013 to February 2017. The primary outcome was the readmission rate within 30 days of index discharge. The length of stay was a balancing measure. RESULTS: During the intervention, the included services discharged 4,853 children. The pre-implementation readmission rate of 10.3% declined to 7.4% and remained stable during a 4-month post-intervention observation period. Among 1,394 families screened for adverse SDH, 48% reported and received assistance with ≥ 1 concern. The length of stay increased from 4.10 days in 2013 to 4.30 days in 2017. CONCLUSIONS: An intervention bundle, including SDH, was associated with a sustained reduction in readmission rates to 2 general pediatric services. Transitional care that addresses multiple domains of family need during a child's health crisis can help reduce pediatric readmissions.

The State of North Carolina's Perinatal Health.

In working to improve the health of North Carolinians, a critical focus starts with our mothers and infants and their surrounding communities. North Carolina's perinatal outcomes, as evidenced by maternal morbidity and mortality, infant mortality, preterm births, and the larger context of lifelong physical and mental health of our citizens, offer areas for improvement and policy implications. In addition, the unacceptable disparities that remain despite some overall improvement in outcomes warrant full attention. This issue of the NCMJ highlights the state of perinatal health in North Carolina; the importance of a risk-appropriate perinatal system of care; the opportunities for supporting our parents, children, and families; and how we as a state and as a community can come together to improve the safety and experience of giving birth in North Carolina and beyond.

Redefining the Team in Team-Based Care: Role of Public Health.

In North Carolina, our public health infrastructure consists of a state health department and 85 local health departments representing all 100 counties. The state health department, local health departments, health systems, and clinical providers work literally and figuratively as a team to improve the health of our citizens. In this article, we provide examples of the critical role of public health practitioners as part of the broader team addressing health, specifically in the areas of chronic disease, communicable disease, oral health, environmental health, and maternal and child health.

Responding to Adverse Childhood Experiences: It Takes a Village.

In working to improve the health of North Carolinians, a broader emphasis has been placed on determinants of health, or non-medical drivers of health. Critical examples of health determinants are adverse childhood experiences, or ACEs, that affect early brain development and lifelong health and function. Multiple organizations and communities have come together to acknowledge the importance of prevention, address toxic stress and trauma in childhood, promote resiliency and trauma-informed care, and invest in the future of North Carolina through its children. This issue of the NCMJ highlights the prevalence and magnitude of ACEs in North Carolina and the effects on our children and the impact into adulthood, and how people and communities can come together to improve public health over the life course by addressing ACEs.

Discharge Interventions and Modifiable Risk Factors for Preventing Hospital Readmissions in Children with Medical Complexity.

BACKGROUND: Concerns about the costs and quality of hospital care have led to increased interest in hospital readmissions in children. Children with medical complexity account for high proportions of inpatient utilization and have a higher risk of hospital readmission. OBJECTIVE: To identify studies of discharge interventions to prevent hospital readmissions in children with medical complexity. METHODS: We conducted a search to identify studies of discharge interventions. Included studies 1) described an intervention or modifiable risk factor around the time of hospital discharge 2) included pediatric patients with chronic illness and/or medical complexity and 3) reported subsequent hospital utilization. RESULTS: We identified ten studies testing the following interventions: multi-faceted discharge bundle (including medication review, discharge education, and follow-up appointments) (s=1), post-discharge follow-up clinic visits (s=3), post-discharge phone calls (s=2), intensive follow-up interventions for very low birth weight infants (s=2), and education interventions in children hospitalized with asthma (s=2). Four studies reported reductions in readmissions. The discharge bundle correlated with an 11.1% decrease in 30-day readmission (9.9% vs. 8.8%, p<0.05). All three studies of post discharge follow-up clinic visits reported a decrease in 30-day readmission risk among children with follow-up scheduled within 30 days, though one study also reported that medically complex children with follow- up within three days had increased readmission risk. CONCLUSION: Evidence supporting discharge interventions for children with medical complexity is limited. Multi-faceted discharge interventions and post-discharge clinic visits may be effective.

Performance of the Modified Checklist for Autism in Toddlers in Spanish-speaking patients.

OBJECTIVE: To compare abnormal screening rates of 2 different Spanish versions of the Modified Checklist for Autism in Toddlers (M-CHAT) in US Spanish-speaking patients. METHOD: Quasi-experimental design was used with historical and English language controls. Abnormal screening rates were compared between Spain and Western-hemisphere Spanish versions, as well as to English controls during the same time periods using chi square analysis. RESULTS: M-CHAT questionnaires were scored from 589 subjects (English n = 415, Spanish n = 174). There was little difference between Spanish versions. Overall, the Spanish abnormal screening rate was double that of English (23.6% vs 11.3%, P < .001). CONCLUSIONS: Spanish M-CHAT questionnaires are abnormal more often than those in English even after changing to appropriate translation, despite lower prevalence of autism in Latinos. Issues with translation, interpretation, or cultural understanding of behaviors may contribute. Given abnormal screening rates for Latinos, the use of the M-CHAT follow-up interview in Spanish-speaking patients is beneficial but may be more time-consuming.