Evaluating the Implementation of the Connect for Health Pediatric Weight Management Program.

Importance: Adoption of primary care interventions to reduce childhood obesity is limited. Progress in reducing obesity prevalence and eliminating disparities can be achieved by implementing effective childhood obesity management interventions in primary care settings. Objective: To examine the extent to which implementation strategies supported the uptake of research evidence and implementation of the Connect for Health pediatric weight management program. Design, Setting, and Participants: This quality improvement study took place at 3 geographically and demographically diverse health care organizations with substantially high numbers of children living in low-income communities in Denver, Colorado; Boston, Massachusetts; and Greenville, South Carolina, from November 2019 to April 2022. Participants included pediatric primary care clinicians and staff and families with children aged 2 to 12 years with a body mass index (BMI) in the 85th percentile or higher. Exposures: Pediatric weight management program with clinician-facing tools (ie, clinical decision support tools) and family-facing tools (ie, educational handouts, text messaging program, community resource guide) along with implementation strategies (ie, training and feedback, technical assistance, virtual learning community, aligning with hospital performance metrics) to support the uptake. Main Outcomes and Measures: Primary outcomes were constructs from the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) Framework examined through parent, clinician, and leadership surveys and electronic health record data to understand the number of children screened and identified, use of the clinical decision support tools, program acceptability, fidelity to the intervention and implementation strategies, and program sustainability. Results: The program screened and identified 18 333 children across 3 organizations (Denver Health, 8480 children [46.3%]; mean [SD] age, 7.97 [3.31] years; 3863 [45.5%] female; Massachusetts General Hospital (MGH), 6190 children [33.8%]; mean [SD] age, 7.49 [3.19] years; 2920 [47.2%] female; Prisma Health, 3663 children [20.0%]; mean [SD] age, 7.33 [3.15] years; 1692 [46.2%] female) as having an elevated BMI. The actionable flagging system was used for 8718 children (48%). The reach was equitable, with 7843 children (92.4%) from Denver Health, 4071 children (65.8%) from MGH, and 1720 children (47%) from Prisma Health being from racially and ethnically minoritized groups. The sites had high fidelity to the program and 6 implementation strategies, with 4 strategies (67%) used consistently at Denver Health, 6 (100%) at MGH, and 5 (83%) at Prisma Health. A high program acceptability was found across the 3 health care organizations; for example, the mean (SD) Acceptability of Intervention Measure score was 3.72 (0.84) at Denver Health, 3.82 (0.86) at MGH, and 4.28 (0.68) at Prisma Health. The implementation strategies were associated with 7091 (39%) uses of the clinical decision support tool. The mean (SD) program sustainability scores were 4.46 (1.61) at Denver Health, 5.63 (1.28) at MGH, and 5.54 (0.92) at Prisma Health. Conclusions and Relevance: These findings suggest that by understanding what strategies enable the adoption of scalable and implementation-ready programs by other health care organizations, it is feasible to improve the screening, identification, and management of children with overweight or obesity and mitigate existing disparities.

Medical home transformation in pediatric primary care--what drives change?

PURPOSE: The aim of this study was to characterize essential factors to the medical home transformation of high-performing pediatric primary care practices 6 to 7 years after their participation in a national medical home learning collaborative. METHODS: We evaluated the 12 primary care practice teams having the highest Medical Home Index (MHI) scores after participation in a national medical home learning collaborative with current MHI scores, a clinician staff questionnaire (assessing adaptive reserve), and semistructured interviews. We reviewed factors that emerged from interviews and analyzed domains and subdomains for their agreement with MHI and adaptive reserve domains and subthemes using a process of triangulation. RESULTS: At 6 to 7 years after learning collaborative participation, 4 essential medical home attributes emerged as drivers of transformation: (1) a culture of quality improvement, (2) family-centered care with parents as improvement partners, (3) team-based care, and (4) care coordination. These high-performing practices developed comprehensive, family-centered, planned care processes including flexible access options, population approaches, and shared care plans. Eleven practices evolved to employ care coordinators. Family satisfaction appeared to stem from better access, care, and safety, and having a strong relationship with their health care team. Physician and staff satisfaction was high even while leadership activities strained personal time. CONCLUSIONS: Participation in a medical home learning collaborative stimulated, but did not complete, medical home changes in 12 pediatric practices. Medical home transformation required continuous development, ongoing quality improvement, family partnership skills, an attitude of teamwork, and strong care coordination functions.

Adapting Connect for Health pediatric weight management program for telehealth in response to the COVID-19 pandemic.

BACKGROUND: To address the evolving needs and context changes due to the COVID-19 pandemic, we adapted Connect for Health, an evidence-based, primary care, pediatric weight management intervention. The objective of this study is to describe the planned adaptation process to ensure continued and equitable program uptake during the pandemic. METHODS: Guided by adaptation frameworks, we identified the core functions and forms of Connect for Health and then adapted the intervention in response to a changing healthcare context. We engaged stakeholders and surveyed parents of children with a BMI ≥ 85th percentile and pediatric clinicians and examined their experiences using telehealth for pediatric weight management and needs and preferences. Using multivariable logistic regression, we examined the preferences of parents with limited English proficiency regarding key aspects of pediatric weight management. RESULTS: We surveyed 200 parents and 43% had a primary language of Spanish. Parents wanted care to be a combination of in-person and virtual visits (80%). We found that parents with limited English proficiency had a higher odds ratio of affirming in-person visits are better than virtual visits for ensuring their child's health concern can be taken care of (OR: 2.91; 95% CI: 1.36, 6.21), feeling comfortable when discussing personal information (OR: 3.91; 95% CI: 1.82, 8.43), talking about healthy behaviors and setting goals (OR: 3.09; 95% CI: 1.39, 6.90), and talking about mental health and overall well-being (OR: 4.02; 95% CI: 1.83, 8.87) than parents without limited English proficiency. We surveyed 75 clinicians and 60% felt telehealth was a useful tool to provide care for pediatric weight management. Clinicians felt virtual visits did not pose barriers to all aspects of care. Informed by the surveys and stakeholder input, we made clinician- and family-level adaptations while retaining the program's function. CONCLUSIONS: By engaging stakeholders and adapting the program for telehealth, we optimized the reach and fit of Connect for Health to ensure its continued uptake. We have provided a real-world example of how clinical innovations can evolve and how to systematically plan adaptations in response to changing healthcare contexts. TRIAL REGISTRATION: Clinicaltrials.gov (NCT04042493), Registered on August 2, 2019.

Cost, Utilization, and Patient and Family Experience With ACO-Based Pediatric Care Management.

BACKGROUND AND OBJECTIVES: Children and Youth with Special Health Care Needs have high healthcare utilization, fragmented care, and unmet health needs. Accountable Care Organizations (ACOs) increasingly use pediatric care management to improve quality and reduce unnecessary utilization. We evaluated effects of pediatric care management on total medical expense (TME) and utilization; perceived quality of care coordination, unmet needs, and patient and family experience; and differential impact by payor, risk score, care manager discipline, and behavioral health diagnosis. METHODS: Mixed-methods analysis including claims using quasi-stepped-wedge design pre and postenrollment to estimate difference-in-differences, participant survey, and semistructured interviews. Participants included 1321 patients with medical, behavioral, or social needs, high utilization, in Medicaid or commercial ACOs, and enrolled in multidisciplinary, primary care-embedded care management. RESULTS: TME significantly declined 1 to 6 months postenrollment and continued through 19 to 24 months (-$645.48 per member per month, P < .001). Emergency department and inpatient utilization significantly decreased 7 to 12 months post-enrollment and persisted through 19 to 24 months (-29% emergency department, P = .012; -82% inpatient, P < .001). Of respondents, 87.2% of survey respondents were somewhat or very satisfied with care coordination, 56.1% received education coordination when needed, and 81.5% had no unmet health needs. Emergency department or inpatient utilization decreases were consistent across payors and care manager disciplines, occurred sooner with behavioral health diagnoses, and were significant among children with above-median risk scores. Satisfaction and experience were equivalent across groups, with more unmet needs and frustration with above-median risk scores. CONCLUSIONS: Pediatric care management in multipayor ACOs may effectively reduce TME and utilization and clinically provide high-quality care coordination, including education and family stress, with high participant satisfaction.

Screening Infants Through Adolescents for Social/Emotional/Behavioral Problems in a Pediatric Network.

OBJECTIVE: To assess changes in screening completion in a diverse, 7-clinic network after making annual screening for social/emotional/behavioral (SEB) problems the standard of care for all infant through late adolescent-aged patients and rolling out a fully automated screening system tied to the electronic medical record and patient portal. METHODS: In 2017, the Massachusetts General Hospital made SEB screening using the age-appropriate version of the Pediatric Symptom Checklist the standard of care in its pediatric clinics for all patients aged 2.0 months to 17.9 years. Billing records identified all well-child visits between January 1, 2016 and December 31, 2019. For each visit, claims were searched for billing for an SEB screen and the electronic data warehouse was queried for an electronically administered screen. A random sample of charts was reviewed for other evidence of screening. Chi-square analyses and generalized estimating equations assessed differences in screening over time and across demographic groups. RESULTS: Screening completion (billing and/or electronic) significantly increased from 2016 (37.2%) through 2019 (2017 [46.2%] vs 2018 [66.8%] vs 2019 [70.9%]; χ2 (3) =112652.33, P < .001), with an even higher prevalence found after chart reviews. Most clinics achieved screening levels above 90% by the end of 2019. Differences among demographic groups were small and dependent on whether data were aggregated at the clinic or system level. CONCLUSIONS: Following adoption of a best-practice policy and implementation of an electronic system, SEB screening increased in all age groups and clinics. Findings demonstrate that the AAP recommendation for routine psychosocial assessment is feasible and sustainable.

Pediatric Practice Transformation and Long-Acting Reversible Contraception (LARC) Use in Adolescents.

OBJECTIVE: Long acting reversible contraceptives (LARCs) are recommended as highly effective for adolescents. Although the uptake of LARCs has increased, overall use remains low due to barriers for both providers and patients. We evaluate whether pediatric medical home transformation, including implant placement in pediatrics, may increase LARC use or decrease adolescent pregnancy rates. METHODS: Retrospective interrupted time-series analysis of adolescents ages 11 to 19 years at 2 pediatric practices in academically affiliated community health centers during 2005-2015. The intervention practice underwent medical home transformation including team-based care with family planning and health coaching, youth-friendly policies, and contraceptive implant placement. The control practice continued usual care. Differential changes in population event rates were evaluated using a segmented longitudinal regression model. RESULTS: The study population included 4946 adolescent females at the intervention practice and 1992 at the control practice. Following practice transformation, LARC use increased significantly more at the intervention practice compared to the control (1.73 versus 0.28 events per 1000 patients quarterly P = 0.004). Pregnancy rate declined at both practices without temporal correlation to the LARC intervention. During the medical home transformation period, the intervention practice showed a greater decline in pregnancy rate, though this difference did not reach statistical significance (2.01 versus 0.81 events per 1000 patients quarterly P = 0.090). CONCLUSIONS: Adolescents had higher LARC use where implant placement was offered within the pediatric practice as part of medical home transformation. Although LARC did not impact pregnancy rate, the process of practice transformation may have accelerated its decline through heightened adolescent health focus.

Implementation Evaluation of HUGS/Abrazos During the COVID-19 Pandemic: A Program to Foster Resiliency in Pregnancy and Early Childhood.

Early life adversity can significantly impact child development and health outcomes throughout the life course. With the COVID-19 pandemic exacerbating preexisting and introducing new sources of toxic stress, social programs that foster resilience are more necessary now than ever. The Helping Us Grow Stronger (HUGS/Abrazos) program fills a crucial need for protective buffers during the COVID-19 pandemic, which has escalated toxic stressors affecting pregnant women and families with young children. HUGS/Abrazos combines patient navigation, behavioral health support, and innovative tools to ameliorate these heightened toxic stressors. We used a mixed-methods approach, guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, to evaluate the implementation of the HUGS/Abrazos program at Massachusetts General Hospital from 6/30/2020-8/31/2021. Results of the quality improvement evaluation revealed that the program was widely adopted across the hospital and 392 unique families were referred to the program. The referred patients were representative of the communities in Massachusetts disproportionately affected by the COVID-19 pandemic. Furthermore, 79% of referred patients followed up with the initial referral, with sustained high participation rates throughout the program course; and they were provided with an average of four community resource referrals. Adoption and implementation of the key components in HUGS/Abrazos were found to be appropriate and acceptable. Furthermore, the implemented program remained consistent to the original design. Overall, HUGS/Abrazos was well adopted as an emergency relief program with strong post-COVID-19 applicability to ameliorate continuing toxic stressors while decreasing burden on the health system.

Twelve-Month Outcomes of the First 1000 Days Program on Infant Weight Status.

OBJECTIVES: To examine the effects of the First 1000 Days intervention on the prevalence of infant overweight and maternal postpartum weight retention and care. METHODS: Using a quasi-experimental design, we evaluated the effects of the First 1000 Days program among 995 term, low-income infants and their mothers receiving care in 2 intervention community health centers and 650 dyads in 2 comparison health centers. The program includes staff training, growth tracking, health and behavioral screening, patient navigation, text messaging, educational materials, and health coaching. Comparison centers implemented usual care. Infant outcomes were assessed at 6 and 12 months, including weight-for-length z score and overweight (weight for length ≥97.7th percentile). We also examined maternal weight retention and receipt of care 6 weeks' post partum. RESULTS: The mean birth weight was 3.34 kg (SD 0.45); 57% of infants were Hispanic; 66% were publicly insured. At 6 months, infants had lower weight-for-length z scores (ß: -.27; 95% confidence interval [CI]: -.39 to -.15) and lower odds of overweight (adjusted odds ratio [OR]: 0.46; 95% CI: 0.28 to 0.76) than infants in comparison sites; differences persisted at 12 months (z score ß: -.18; 95% CI: -.30 to -.07; adjusted OR for overweight: 0.60; 95% CI: 0.39 to 0.92). Mothers in the intervention sites had modestly lower, but nonsignificant, weight retention at 6 weeks' post partum (ß: -.51 kg; 95% CI: -1.15 to .13) and had higher odds (adjusted OR: 1.50; 95% CI: 1.16 to 1.94) of completing their postpartum visit compared with mothers in the comparison sites. CONCLUSIONS: An early-life systems-change intervention combined with coaching was associated with improved infant weight status and maternal postpartum care.

Fostering Resilience in Pregnancy and Early Childhood During the COVID-19 Pandemic: The HUGS/Abrazos Program Design and Implementation.

Pregnancy and early childhood pose unique sensitivity to stressors such as economic instability, poor mental health, and social inequities all of which have been magnified by the COVID-19 pandemic. In absence of protective buffers, prolonged exposure to excessive, early adversity can lead to poor health outcomes with significant impact lasting beyond the childhood years. Helping Us Grow Stronger (HUGS/Abrazos) is a community-based program, designed and launched at the time of the COVID-19 surge in the Spring of 2020, that combines emergency relief, patient navigation, and direct behavioral health support to foster family resilience and mitigate the negative impacts of COVID-related toxic stress on pregnant women and families with children under age 6. Through a targeted referral process, community health workers provide resource navigation for social needs, and a social worker provides behavioral health support. The use of innovative tools such as a centralized resource repository, community health workers with specialized knowledge in this age range, and a direct referral system seeks to assist in streamlining communication and ensuring delivery of quality care. We aim to serve over 300 families within the 1st year. The HUGS/Abrazos program aims to fill an important void by providing the necessary tools and interventions to support pregnant women and young families impacted by adversity exacerbated by the COVID-19 pandemic.

Association of the First 1,000 Days Systems-Change Intervention on Maternal Gestational Weight Gain.

OBJECTIVE: To examine the associations of a clinical and public health systems-change intervention on the prevalence of excess gestational weight gain among high-risk, low-income women. METHODS: In a quasi-experimental trial, we compared the prevalence of excess gestational weight gain among women before (n=643) and after (n=928) implementation of the First 1,000 Days program in two community health centers in Massachusetts. First 1,000 Days is a systematic program starting in early pregnancy and lasting through the first 24 months of childhood to prevent obesity among mother-child pairs. The program includes enhanced gestational weight gain tracking and counseling, screening for adverse health behaviors and sociocontextual factors, patient navigation and educational materials to support behavior change and social needs, and individualized health coaching for women at high risk for excess gestational weight gain based on their prepregnancy body mass index (BMI) or excess first-trimester weight gain. The primary outcome was gestational weight gain greater than the 2009 Institute of Medicine (now known as the National Academy of Medicine) guidelines according to prepregnancy BMI. RESULTS: Among 1,571 women in the analytic sample, mean (SD) age was 30.0 (5.9) years and prepregnancy BMI was 28.1 (6.1); 65.8% of women started pregnancy with BMIs of 25 or higher, and 53.2% were Hispanic. We observed a lower prevalence (55.8-46.4%; unadjusted odds ratio [OR] 0.69, 95% CI 0.49-0.97), similar to results in a multivariable analysis (adjusted OR 0.69, 95% CI 0.49-0.99), of excess gestational weight gain among women with prepregnancy BMIs between 25 and 29.9. Among women who were overweight at the start of pregnancy, the lowest odds of excess gestational weight gain were observed among those with the most interaction with the program's components. Program enrollment was not associated with reduced excess gestational weight gain among women with prepregnancy BMIs of 30 or higher. CONCLUSIONS: Implementation of a systems-change intervention was associated with modest reduction in excess gestational weight gain among women who were overweight but not obese at the start of pregnancy. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03191591.