Four innovations: A robust integrated behavioral health program in pediatric primary care.

The increase in behavioral health problems presenting in pediatric primary care (PPC) has led to a greater focus on the prevention and treatment of mental health concerns. As a result, care has shifted from colocation to integrated PPC models. However, the literature provides limited guidance on the development and implementation of integrated PPC models that aim to transform both PPC and the larger health care system. We developed an integrated behavioral health (IBH) approach modeled with fidelity to the Integrated Practice Assessment Tool to fully integrate behavioral health into PPC. Over the 4 years since the application of our model, we have been successful in the development of an integration process and model for practice transformation of an urban PPC center and the spread and scale of IBH services to 2 additional clinics. Four elements combine to make our integrated behavioral health program novel: (a) clear mission and vision, (b) provision of universal prevention services, (c) continuous quality improvement, and (d) emphasis on practice and systems transformation. Trends in practice and scholarly inquiry indicate the need for robust pediatric IBH models, with a clear mission and vision; articulation of how research informs the development and implementation of the model; and infrastructure to meaningfully examine the model's impact. Cognizant of these needs, Cincinnati Children's Hospital Medical Center developed an IBH program. We provide key learnings for IBH program development, PPC transformation, and innovative systems redesign. We describe these elements and make recommendations for future research and practice. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A Framework to Measure and Improve Well-Being in Primary Care.

Pediatricians aspire to optimize overall health and development, but there are no comprehensive measures of well-being to guide pediatric primary care redesign. The objective of this article is to describe the Cincinnati Kids Thrive at 5 outcome measure, along with a set of more proximal outcome and process measures, designed to drive system improvement over several years. In this article, we describe a composite measure of "thriving" at age 66 months, using primary care data from the electronic health record. Thriving is defined as immunizations up-to-date, healthy BMI, free of dental pain, normal or corrected vision, normal or corrected hearing, and on track for communication, literacy, and social-emotional milestones. We discuss key considerations and tradeoffs in developing the measure. We then summarize insights from applying this measure to 9544 patients over 3 years. Baseline rates of thriving were 13% when including all patients and 31% when including only patients with complete data available. Interpretation of results was complicated by missing data in 50% of patients and nonindependent success rates among bundle components. There was considerable enthusiasm among other practices and sectors to learn with us and to measure system performance using time-linked trajectories. We learned to present our data in ways that balanced aspirational long-term or multidisciplinary goal-setting with more easily attainable short-term aims. On the basis of our experience with the Thrive at 5 measure, we discuss future directions and place a broader call to action for pediatricians, researchers, policy makers, and communities.

The impact of the electronic health record on an academic pediatric primary care center.

Many hospitals and practices are transitioning to electronic health records (EHR), but there is little information on the impact on patient care in a busy pediatric academic setting. The objective of this study was to determine the impacts of EHR on documentation, clinical processes, billing, ancillary staff responsibilities, scheduling, and cycle time. A descriptive study to assess the impact of EHR implementation and subsequent use on documentation, clinical processes, and patient access and flow was performed in a large urban academic pediatric primary care health center. Six months and 2 years after implementation, EHR impact on documentation was collected and compared with baseline value by measuring the percentage of charts with problem lists present. Several clinical improvement processes were collected at baseline and 6 months later including medication refill turnaround time, percentage of charts without attending signature at 3 days, and type of appointment billed on ill visits. The volume of appointments and cycle time were measured at regular intervals from baseline to 2 years after implementation. The percentage of paper charts attempted to be pulled for patient visits was obtained at baseline and 1 year later. Of the 500 charts audited before implementation, and 25 charts audited 6 months and 2 years after the implementation, the percentage of the presence of problem lists improved from 29% to 84%. Medication refill turnaround time improved from an average of 48 hours to 12 hours. Charts with incomplete documentation at 3 days postvisit decreased from 3% to 1.6%. Visit coding for detailed level visits (99214) increased by 13% and for problem-focused visits (99212) decreased by 7%, resulting in increased revenue collected. Medical records support staff needs decreased from 1 full-time equivalent to 0.5 full-time equivalent. One year after the EHR implementation, the medical records staff pulled and refiled 5.2% of paper charts compared with 100% at baseline. Despite plans to return to full volume of scheduling patients by 4 weeks postimplementation, volume continued to be reduced by 10% for 3 additional months because of user inefficiency and high number of new learners/users. Patient cycle time was increased from 76 minutes preimplementation to 119 minutes immediately postimplementation and decreased to 85 to 90 minutes 2 years later. EHR can be successfully implemented in a large urban academic pediatric healthcare center. EHR implementation improved documentation of patient care, improved clinical processes, and resulted in increased revenue. However, the implementation of the EHR also led to short-term decreased appointment availability and a persistent longer cycle time. Ongoing information system training support is a key for maintaining efficiency due to the large number of new learners.

Pursuing perfection: an asthma quality improvement initiative in school-based health centers with community partners.

This article describes an innovative asthma quality improvement initiative conducted in school-based health centers (SBHCs) with collaboration among multiple community partners including the children's hospital, a federally qualified health center, the health department, the public school, and parents of children with asthma. The aim was to improve the health of children with asthma in these schools, as measured by minimal asthma-related activity restriction and reduction in asthma-related emergency department (ED) visits. Process measures tracked included the percent of children with (1) asthma severity classified, (2) persistent asthma with controller medication prescribed, and (3) written care plans. Data supported a statistically significant decreasing trend for the percent of SBHC children reporting activity restriction due to asthma. In addition, trend analysis demonstrated a statistically significant difference in ED visits for asthma in the SBHC group compared with a non-SBHC group. Improvements were demonstrated for all process measures. Factors contributing to success included emphasis on community engagement, transparency in sharing ideas and results, benefits outweighing human resource costs of participating, readily available data to drive improvement, and the use of multiple intervention strategies.

Access and utilization patterns of school-based health centers at urban and rural elementary and middle schools.

OBJECTIVE: We examined patterns of enrollment, use, and frequency of use in school-based health centers (SBHCs), as well as the referral, diagnosis, and disposition of SBHC visits among newly implemented SBHCs. METHODS: Four rural and four urban school districts implementing SBHCs were examined from 2000 to 2003. Total school enrollment for students was 13,046. SBHC enrollment and medical encounter data were tracked using a Web-based medical database. Descriptive analyses were conducted to evaluate primary care access and utilization patterns. RESULTS: A total of 7,460 (57.2%) students were enrolled in their SBHCs, of which 4,426 used the SBHC at least once for a total of 14,050 visits. SBHC enrollment was greater in urban districts but rate of utilization was higher in rural districts. Black students, students with public or no health insurance, and students with asthma or attention deficit disorder had higher enrollment and utilization. Rural parents referred more children to SBHCs than urban parents. Teachers referred more students who were black, had asthma, had no public or health insurance, or had acute-type health issues. Total visits increased during the three years, with the largest increase in mental health services. Students who were younger, white, attended rural schools, had public or health insurance, or had infections were more likely to be sent home. Those with chronic conditions and visits for mental health were more likely to be returned to class. CONCLUSION: Utilization patterns suggest improved access to needed health care for disadvantaged children. SBHCs are an important part of the safety net for the populations they are intended to serve.

Implementation of a Preventive Services Bundle in Academic Pediatric Primary Care Centers.

BACKGROUND AND OBJECTIVES: Previous studies have documented poor rates of delivery of preventive services, 1 of the core services provided in the primary care medical home setting. We aimed to increase the reliability of delivering a bundle of preventive services to patients 0 to 14 months of age from 58% of patient visits to 95% of visits. The bundle includes administration of routine vaccinations, offering influenza vaccination, completed lead screening, completed developmental screening tool, screening for maternal depression and food insecurity, and documentation of gestational age. METHODS: The setting was 3 academic pediatric primary care clinics that serve 31,000 patients (>90% Medicaid). Quality improvement methodology was used and key driver diagram was determined. Patient "Ideal Visit Flow" and the Responsible, Accountable, Support, Consulted, and Informed Matrix were developed to drive accountability for components of the ideal flow. Plan, Do, Study, Act cycles were used to develop successful interventions. The percent of patients seen who received all bundle elements for which they were eligible was plotted weekly on a run chart, and statistical process control methods were used to determine a significant change in performance. RESULTS: The preintervention percentage of patient visits ages 0 to 14 months receiving all preventive service bundle elements was 58%. The postintervention percentage is 92%. CONCLUSIONS: Innovative redesign led to improvement in percentage of patients age 0 to 14 months who received the entire preventive services bundle. Key elements for success were multidisciplinary site-specific teams, redesigned visit flow, effective communication, and resources for data and project management.

Pediatric faculty members' attitudes about part-time faculty positions and policies to support part-time faculty: a study at one medical center.

PURPOSE: To examine pediatric faculty members' attitudes about part-time faculty positions and policies to support part-time faculty. METHOD: In 2001, an anonymous 26-item questionnaire assessing attitudes about part-time faculty was mailed to all 441 faculty members of Cincinnati Children's Hospital Medical Center. Multivariable analyses were used to determine faculty characteristics associated with specific attitudes, and qualitative methods were used to analyze responses to an open-ended item assessing beliefs about facilitating part-time careers. RESULTS: Three hundred (68%) faculty members completed questionnaires. Twenty-nine (10%) worked part-time and an additional 88 (33%) had considered part-time work, primarily because of dependent children. Although 177 (59%) believed that part-time faculty were perceived as being less committed to their careers and the institution, 207 (69%) believed part-time faculty should be eligible for all academic tracks and 219 (73%) that they should be allowed extension of time to obtain tenure. Most reported that policy changes to support part-time faculty would enhance diversity (N = 234, 78%) and improve recruitment, retention, and promotion of female faculty. Multivariable analysis demonstrated that women and respondents with dependent children were more likely to be concerned about perceived commitment and more likely to endorse policies to support part-time faculty. Participants suggested that part-time careers for faculty would be facilitated by clarifying productivity expectations, expanding resources, and modifying existing policies. CONCLUSIONS: Although women and respondents with dependent children were concerned about perceived commitment of part-time faculty and were most supportive of policies that would support part-time faculty, pediatric faculty generally supported such policies.

Development of a bundle measure for preventive service delivery to infants in primary care.

RATIONALE, AIMS AND OBJECTIVES: In the United States, paediatric patients receive only 41% of indicated preventive services. Past improvement efforts have not bundled preventive services to measure the reliability with which infants' physical, developmental and emotional needs are all addressed. We aimed to create a comprehensive bundle measure that reflects reliable delivery of preventive services during primary care visits, as well as overall preventive service status of a population of patients served by three primary care centres. METHOD: Data were collected from electronic health records for cohorts of infants < 14 months old with at least one visit to one of three primary care centres. Immunizations, lead screening, developmental screening and screening for biopsychosocial risk factors (gestational age, parental depression, food insecurity) were chosen by local expert consensus for inclusion in the preventive services bundle measure. Monthly measures of preventive service status at 14 months of age were constructed. A visit-level bundle measure of preventive service delivery was also created. To obtain a baseline for improvement work, bundle completion rates were calculated for infants born in May 2011. Visit-level performance was measured for visits from July to August 2012. RESULTS: Among 278 patients born in May 2011, 22% of patients received the entire bundle of preventive services by 14 months of age. On a visit level, patients received all indicated services at 58% of visits. CONCLUSION: A novel bundle measure can be used to characterize delivery of preventive services and drive improvement at both an individual visit level and a population level.

Urban elementary school personnel's perceptions of student health and student health needs.

OBJECTIVE: To determine the perceptions of school personnel with regard to urban students' health and health needs as part of a planning process for development and implementation of school-linked health services. METHODS: A self-administered, close-ended questionnaire was given to 294 schoolteachers and school staff to assess school personnel perceptions of 1) health needs of students, 2) priority of need for health services or programs delivered on-site or off-site, and 3) selected factors suspected to affect implementation of new school health services. RESULTS: A total of 72% of teachers and 77% of staff completed the survey. The most highly ranked need by school personnel was mental health, followed by violence and anger management and physical abuse and domestic violence. The most commonly requested services on-site and off-site were for physical abuse or domestic violence, mental health, and drug or other substance abuse. Only 40% of teachers and staff rated current health services as excellent or good. A total of 72% of teachers and staff had some level of discomfort with their current responsibilities regarding the health of students. Parental involvement was reported to be quite low, with only 9% of teachers and staff rating it as excellent or good. CONCLUSIONS: he greatest health care need identified by these elementary school personnel was not for management of chronic or acute physical health conditions, but for mental health services and programs to meet the emotional and psychosocial needs of students. When implementing school-linked or school-based mental health services, focus needs to be placed on 3 areas: 1) education of school health and educational personnel regarding common mental health issues, 2) development of systems that improve knowledge of and connection with mental health resources inside and outside the school, and 3) development of systems that improve communication within the school and between the school and parents regarding health services.

Improvements in health-related quality of life among school-based health center users in elementary and middle school.

OBJECTIVE: To examine the role of school-based health centers (SBHCs) on changes in student health-related quality of life (HRQOL) over a 3-year period among elementary and middle school students. DESIGN: Three-year longitudinal prospective study. SETTING: Four elementary schools with newly implemented SBHCs and 4 elementary comparison schools matched for rural/urban and state, percentage of nonwhite students, and percentage of free or reduced-price lunch-eligible students. PARTICIPANTS: Randomly selected student-parent dyads (n = 579) who responded in all 3 years from 4 intervention schools and 4 comparison schools randomly selected from school enrollment lists. Students in intervention schools were further divided into SBHC users and nonusers. INTERVENTION: SBHC. MEASURES: The outcome, HRQOL, was measured annually by student self-reported and parent proxy-reported scores using the PedsQL 4.0. School covariates included region and state; individual covariates included child age, gender, race, health insurance, chronic health conditions, family income, and parental marital status. RESULTS: Adjusting for school- and individual-level covariates, there was a significant improvement in student-reported HRQOL over the 3 years for the SBHC user group compared with the comparison school group. Other significant predictors of student-reported HRQOL included student age, gender, health insurance, and household income. There were no differences across groups by using parent proxy reports of HRQOL. CONCLUSIONS: The SBHC model of health care delivery improves student-reported HRQOL among younger, elementary, and middle school children. Moreover, it appears to have more influence on those children that generally have impeded access to care and who can most benefit from it, specifically those without private health insurance and with lower income levels.

Trends in otitis media among children in the United States.

BACKGROUND: The prevalence of repeated otitis media (OM) increased during the 1980s, but it is unknown if the increase has continued. OBJECTIVES: To determine trends in the prevalence of OM, early-onset OM, and repeated OM among US children from 1988 to 1994 and to identify factors that may explain any observed changes. METHODS: The Third National Health and Nutrition Examination Survey was administered in 2 phases: phase I (1988-1991) and phase II (1991-1994), each comprising a national probability sample. OM (ever having had OM), early-onset OM (first episode at <12 months of age), and repeated OM (>or=3 episodes) were assessed for 8261 children <6 years of age. RESULTS: After controlling for risk factors for OM, the prevalence of OM from phase I to phase II increased from 66.7% to 69.7% (odds ratio [OR] = 1.1; 95% confidence interval [CI] =.99, 1.1), early-onset OM increased from 41.1% to 45.8% (OR = 1.1; 95% CI = 1.03, 1.2), and repeated OM increased from 34.8% to 41.1% (OR = 1.2; 95% CI = 1.1, 1.4). This observed increase corresponds to 561,000 and 720,000 more children having early-onset OM and repeated OM, respectively. Child care use, early breastfeeding termination, asthma, and access to health care did not significantly increase from phase I to phase II. The prevalence of early-onset OM and repeated OM was higher for affluent children, but the greatest increase in prevalence was among impoverished children. There was an increase in allergic conditions from phase I to phase II for poor children (22.6% to 30.2%). CONCLUSIONS: The prevalence of early-onset OM and repeated OM continued to increase among preschool children in the United States. Further research to investigate this increasing prevalence should explore changes in management practice and an increase in prevalence of allergic conditions among poor children.

Health-related quality of life in urban elementary schoolchildren.

BACKGROUND: Health disparities between children from urban minority backgrounds and children from more affluent backgrounds are well-recognized. Few studies specifically address urban children's perceptions of their health-related quality of life (HRQOL) or the factors that contribute to these perceptions. Since schools are pivotal to children's intellectual, social, and emotional development, school connectedness may be a factor that contributes to their perception of HRQOL. OBJECTIVE: To examine children's perceptions of HRQOL in an elementary school-based population of urban children. METHODS: The study population consisted of 2nd, 3rd, and 5th graders from 6 urban kindergarten to 8th grade schools and their parents. Children completed a survey that included questions on HRQOL and school connectedness. Parents completed a telephone survey that assessed demographics, the child's health, health care usage, and parental health status. Data on school absences and mobility from the computerized school database were linked to survey data. Bivariate analyses were used to evaluate the association between child report of HRQOL and collected variables, including school connectedness. Multivariable linear regression was conducted to identify the factors best predicting HRQOL in these urban children. RESULTS: Of the 1150 eligible students, parent and child survey data were available for 525 (45.6%). Fifty-one percent of students were male and 89% were black. Ninety-four percent of parents were female, 29% were married, and 62% had family incomes below 20,000 dollars per year. The mean total score for HRQOL was 67.2, with a possible range of 0 to 100 (higher scores reflecting better HRQOL). In the multivariable analysis, child grade, the relationship of the " parent" to the child, employment, family income, type/presence of insurance, and school connectedness were significantly associated with the HRQOL total score. CONCLUSIONS: Young urban children self-report low HRQOL scores and do so as early as the 2nd grade. These low scores, which reflect children's own perceptions of impaired psychological and physical health, have potential implications for the success of urban children in their learning environments. The association between HRQOL and school connectedness might suggest that health and educational programs that improve a child's attachment to school could result in improved perceptions of health by urban children.