Improving adolescent access and services in a large primary care network: report of a 10 year project.

This report describes a decade long initiative to bring a unified approach and improved quality to the process and content of adolescent health care in a large and complex urban primary care network within an academic health system. The moving force was a voluntary multidisciplinary group who comprised the Montefiore Adolescent Primary Care Initiative, known as MAPCI, led by a physician subspecialist in Adolescent Medicine. A series of needs assessments formed the basis for a multipronged effort to create policies and procedures, educational activities and materials, changes in record-keeping and billing practices, and modification of staff attitudes and behavior that would enhance access and ensure confidentiality of services for the adolescent age group. The commitment of medical center leadership contributed to overall progress which was accelerated in the second half of the decade by the addition of a full-time staff member, with the title Adolescent Program Manager. Progress in various arenas was assessed with a series of planned studies, whose positive results provided encouragement for continuing efforts. The example of this initiative and its accomplishments should provide useful and replicable methods that could be adapted for improvement of adolescent health services in some of the other large primary care networks that are an ever-expanding presence in the current health care environment.

Redesigning Health Care Practices to Address Childhood Poverty.

Child poverty in the United States is widespread and has serious negative effects on the health and well-being of children throughout their life course. Child health providers are considering ways to redesign their practices in order to mitigate the negative effects of poverty on children and support the efforts of families to lift themselves out of poverty. To do so, practices need to adopt effective methods to identify poverty-related social determinants of health and provide effective interventions to address them. Identification of needs can be accomplished with a variety of established screening tools. Interventions may include resource directories, best maintained in collaboration with local/regional public health, community, and/or professional organizations; programs embedded in the practice (eg, Reach Out and Read, Healthy Steps for Young Children, Medical-Legal Partnership, Health Leads); and collaboration with home visiting programs. Changes to health care financing are needed to support the delivery of these enhanced services, and active advocacy by child health providers continues to be important in effecting change. We highlight the ongoing work of the Health Care Delivery Subcommittee of the Academic Pediatric Association Task Force on Child Poverty in defining the ways in which child health care practice can be adapted to improve the approach to addressing child poverty.

Determinants of Health and Pediatric Primary Care Practices.

More than 20% of children nationally live in poverty. Pediatric primary care practices are critical points-of-contact for these patients and their families. Practices must consider risks that are rooted in poverty as they determine how to best deliver family-centered care and move toward action on the social determinants of health. The Practice-Level Care Delivery Subgroup of the Academic Pediatric Association's Task Force on Poverty has developed a roadmap for pediatric providers and practices to use as they adopt clinical practice redesign strategies aimed at mitigating poverty's negative impact on child health and well-being. The present article describes how care structures and processes can be altered in ways that align with the needs of families living in poverty. Attention is paid to both facilitators of and barriers to successful redesign strategies. We also illustrate how such a roadmap can be adapted by practices depending on the degree of patient need and the availability of practice resources devoted to intervening on the social determinants of health. In addition, ways in which practices can advocate for families in their communities and nationally are identified. Finally, given the relative dearth of evidence for many poverty-focused interventions in primary care, areas that would benefit from more in-depth study are considered. Such a focus is especially relevant as practices consider how they can best help families mitigate the impact of poverty-related risks in ways that promote long-term health and well-being for children.