Care Coordination Associated with Improved Timing of Newborn Primary Care Visits

Trade-offs in locational choices for care coordination resources in accountable care organizations

BACKGROUND

Care coordination is central to accountable care organizations (ACOs), especially in Medicaid where many patients have complex medical and social needs. Little is known about how to best organize care coordination resources in this context, particularly whether to centralize them. We examined how care coordinators' location, management, and colocation of both (within ACO headquarters, practice sites, or other organizations) relate to care quality and coordination.

METHODS

We conducted a cross-sectional analysis of surveys administered to a sample of practice sites covering all 17 Medicaid ACOs in Massachusetts ( n = 225, response rate = 64%). We applied controlled, cluster-robust regressions, adjusting the significance threshold for the number of ACO clusters, to assess how clinical information sharing across settings, care quality improvement, knowledge of social service referral, and cross-resource coordination (i.e., the ability of multiple resources to work well together) relate to where care coordinators were physically located and/or managed.

RESULTS

Centralizing care coordinators at ACO headquarters was associated with greater information sharing. Embedding care coordinators in practices was associated with greater care quality improvement. Embedding coordinators at other organizations was associated with less information sharing and care quality improvement. Managing coordinators at practice sites and other organizations were associated with better care quality improvement and cross-resource coordination, respectively. Colocating the two functions showed no significant differences.

PRACTICE IMPLICATIONS

Choosing care coordinators' locations may present trade-offs. ACOs may strategically choose embedding care coordinators at practice sites for enhanced care quality versus centralizing them at the ACO to facilitate information sharing.

Nursing Care of Childbearing Families After Previous Perinatal Loss

Nurses who care for childbearing families facilitate the family's adaptation to the arrival of a newborn through assessment of physical, emotional, and psychological needs. After experiencing a perinatal loss, such as miscarriage, stillbirth, or neonatal death, a woman's perception of pregnancy and of her sense of control in becoming a mother can include fear and anxiety, and she may have significantly different needs than a pregnant woman who has not experienced perinatal loss. In this article, we provide evidence-based information and recommendations for maternal-child nurses caring for childbearing families who are preparing to welcome a new baby (sometimes called a "rainbow baby") after a previous perinatal loss.

Academy of Breastfeeding Medicine Clinical Protocol #2: Guidelines for Birth Hospitalization Discharge of Breastfeeding Dyads, Revised 2022

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. The Academy of Breastfeeding Medicine recognizes that not all lactating individuals identify as women. Using gender-inclusive language, however, is not possible in all languages and all countries and for all readers. The position of the Academy of Breastfeeding Medicine (https://doi.org/10.1089/bfm.2021.29188.abm) is to interpret clinical protocols within the framework of inclusivity of all breastfeeding, chestfeeding, and human milk-feeding individuals.

Mother-Infant Dyad program in primary care: evidence-based postpartum care following gestational diabetes

BACKGROUND

Gestational diabetes mellitus (GDM), a common complication of pregnancy, is associated with a 10-fold increased risk of type 2 diabetes mellitus (T2DM) compared to the general population. Evidence-based guidelines recommend that patients with GDM receive postpartum care for T2DM risk reduction including an oral glucose tolerance test (OGTT) 4-12 weeks after delivery, yet half of patients with GDM did not return for their postpartum visits by 12 weeks postpartum. Additionally, only 10% utilize primary care within 12 months of delivery and one-third of GDM patients receive timely postpartum OGTT.

OBJECTIVE

To determine if the Mother-Infant Dyad postpartum primary care program provides a framework to link well-child visits with postpartum primary care visits to increase postpartum clinical interactions promoting longitudinal care, such as postpartum visit attendance and T2DM screening.

STUDY DESIGN

All patients with a diagnosis of GDM that received care at a postpartum mother-infant dyad program at a Midwestern academic medical center internal medicine and pediatrics primary care clinic were enrolled. Clinic level data was obtained by baseline and 6-month post-enrollment surveys and chart review. A comparison population was identified from Medicaid claims data using propensity score matching to enable a comparison of program participants' outcomes to a population comprised of similar individuals diagnosed with GDM that received care at sites not participating in the Dyad program. Our primary outcome was completion of T2DM screening in the 4-12 week postpartum period. The secondary outcomes were postpartum visit attendance with a prenatal provider, and prediabetes diagnoses.

RESULTS

A total of 75 mother-infant dyads were seen by the clinic. Of the enrolled women, 43% were Non-Hispanic White and 30% were Non-Hispanic Black; mean age was 30.75 years. The matched comparison group (n = 62) had a mean age of 30.75 years, were 43% Non-Hispanic White and 30% Non-Hispanic Black. Women who participated in the program were more likely to receive T2DM screenings than women who did not participate (87 vs. 79%, p<.001) and complete postpartum visits (95 vs. 58%, respectively; p<.001). Additionally, a higher rate of new prediabetes diagnoses was observed (12 vs. 6%, p < .001).

CONCLUSION

The Mother-Infant Dyad postpartum primary care program improved T2DM screenings and postpartum visit attendance. In addition, a greater proportion of Dyad program participants experienced new prediabetes diagnoses that those in the comparison group. Our findings suggest that the dyad care model, in which women with GDM engage in postpartum primary care concurrent with well-child visits, can improve longitudinal postpartum care after a GDM diagnosis.

Characterization of Social Risk Factors Among Newborns Seen at an Urban Pediatric Primary Care Predictive of Appointment Nonattendance During the First 6 Months of Life

Purpose: Appointment attendance is critical in monitoring health and well-being of children. Low income Medicaid-insured families with newborns often experience social risks that may affect attendance. This project sought to characterize social risk factors present at first newborn visits predictive of future appointment nonattendance.

Methods: Retrospective cohort study of minority and Medicaid-insured population at St. Christopher's Hospital for Children using a standardized social risk screener administered at first newborn visits as part of routine clinical care. In total, 720 survey responses between December 2016 and June 2017 were correlated with electronic health record-derived sociodemographic and appointment attendance data in the first 6 months of life. Nonattendance included missed and canceled appointments. Caregiver-reported social risk factors were included as covariates in linear regressions predicting proportion nonattendance outcomes.

Results: Newborn caregivers identified many social risk factors including mental health diagnoses (14%), lack of child care support (45%), and food insecurity (9%). Approximately 74% had nonattendance with 41% missing or canceling a quarter or more appointments. Number of siblings (p<0.01) and maternal age (p<0.01) were most predictive for nonattendance, respectively. Other social risks were not significant except for maternal mental health (p=0.01) among those identifying number of risk factors above cohort average (16%).

Conclusion: Screening of newborns at first medical visits can be used to characterize social risks. Most social risk factors at first visits were not strongly predictive of nonattendance, although our results suggested associations between non-attendance and maternal demographics, mental health and household makeup.

Newborn Clinic: A Novel Model to Provide Timely, Comprehensive Care to Newborns Following Nursery Discharge

Ensuring safe and timely follow-up after well baby nursery (WBN) discharge is an ongoing challenge. This study demonstrates the efficacy of a novel model for follow-up, the Newborn Clinic (NBC), in reducing time to outpatient follow-up after WBN discharge. Our retrospective chart review of 17 952 newborns found that time to follow-up visit decreased significantly following NBC establishment. Emergency department visits, a marker of infant morbidity, were slightly increased in the post-establishment cohort. There was no difference, however, in hospital readmissions. Analysis within the post-establishment cohort showed that newborns with jaundice, a high-risk group, were much more likely to have early follow-up if their visit was scheduled with NBC. Our study demonstrates that NBC is an effective model for decreasing time from WBN discharge to follow-up visit. It should be considered as an initiative to run concurrently with expedited newborn discharge initiatives so that safe follow-up need not be sacrificed.

ACO Affiliated Hospitals Increase Implementation of Care Coordination Strategies

BACKGROUND

Hospitals affiliated with Accountable Care Organizations (ACOs) may have a greater capacity to collaborate with providers across the care continuum to coordinate care, due to formal risk sharing and payment arrangements. However, little is known about the extent to which ACO affiliated hospitals implement care coordination strategies.

OBJECTIVES

To compare the implementation of care coordination strategies between ACO affiliated hospitals (n=269) and unaffiliated hospitals (n=502) and examine whether the implementation of care coordination strategies varies by hospital payment model types.

MEASURES

We constructed a care coordination index (CCI) comprised of 12 indicators that describe evidence-based care coordination strategies. Each indicator was scored on a 5-point Likert scale from 1="not used at all" to 5="used widely" by qualified representatives from each hospital. The CCI aggregates scores from each of the 12 individual indicators to a single summary score for each hospital, with a score of 12 corresponding to the lowest and 60 the highest use of care coordination strategies.

RESEARCH DESIGN

We used state-fixed effects multivariable linear regression models to estimate the relationship between ACO affiliation, payment model type, and the use care coordination strategies.

RESULTS

We found ACO affiliated hospitals reported greater use of care coordination strategies compared to unaffiliated hospitals. Fee-for-service shared savings and partial or global capitation payment models were associated with a greater use of care coordination strategies among ACO affiliated hospitals.

CONCLUSION

Our findings suggest ACO affiliation and multiple payment model types are associated with the increased use of care coordination strategies.

Primary Care and Home Visiting Utilization Patterns among At-Risk Infants

OBJECTIVE

To describe well child care (WCC) utilization in the first year of life among at-risk infants, and the relationship to home visiting enrollment.

STUDY DESIGN

Retrospective cohort study using linked administrative data for infants ≥34 weeks' gestation from 2010 to 2014, within a regional, academic primary care system. Association between WCC visits and home visiting enrollment was evaluated using bivariate comparisons and multivariable Poisson regression. Latent class analysis further characterized longitudinal patterns of WCC attendance. Multivariable logistic regression tested the association between home visiting and pattern of timeliest adherence to recommended WCC.

RESULTS

Of 11 936 infants, mean number of WCC visits was 4.1 in the first 12 months of life. Of 3910 infants eligible for home visiting, 28.5% were enrolled. Among enrolled infants, mean WCC visits was 4.7 vs 4.4 among eligible, nonenrolled infants, P value < .001. After multivariable adjustment, there was no significant association between enrollment and WCC visit count (adjusted incident rate ratio 1.03, 95% CI 0.99, 1.07). Using latent class analysis, 3 WCC classes were identified: infants in class 1 (77.7%) were most adherent to recommended WCC, class 2 (12.5% of cohort) had progressively declining WCC attendance over the first year of life, and class 3 (9.8%) maintained moderate attendance. In multivariable regression, home visiting was associated with class 1 membership, aOR 1.27, 95% CI 1.04, 1.57.

CONCLUSIONS

A pattern of timely WCC attendance was more likely among infants in home visiting; however, most infants eligible for home visiting were not enrolled.

Newborn follow-up after discharge from the maternity unit: Compliance with national guidelines

BACKGROUND

In the context of shorter hospital stays in maternity units, in 2014 the French health authorities issued guidelines for newborn follow-up after discharge from maternity units. A medical visit is recommended between the 6th and 10th day of life, as are home visits from midwives. This study was designed to evaluate compliance with these guidelines.

METHODS

The study was observational, prospective, multicenter, and was conducted in March and April 2015 in three maternity units in northern France that participate in the Baby Friendly Hospital Initiative (BFHI). Follow-up practices (medical visit between the 6th and 10th day, home visits from a midwife) and demographic, social, and medical data were recorded during the stay in the maternity unit, and through a phone interview 1 month later, in singleton term-born infants.

RESULTS

The study population included 108 mother-infant pairs. The recommended medical visit was effectively performed by a physician between the 6th and 10th day of life for 20 newborns (19%) (95% CI: [11; 26]). During the 1st month, at least one home visit from a midwife was recorded for 96 mother-infant pairs (89%). The only factor positively correlated with a medical visit between the 6th and 10th day was the mother's choice, made early during the hospital stay and independently of the real length of stay, for early discharge from the maternity unit.

CONCLUSION

Compliance with national guidelines was poor for the recommended medical visit between the 6th and 10th day of life. Information needs to be improved.

Newborn follow-up after discharge from a tertiary care hospital in the Western Cape region of South Africa: a prospective observational cohort study

Background

Current practice in the Western Cape region of South Africa is to discharge newborns born in-hospital within 24 h following uncomplicated vaginal delivery and two days after caesarean section. Mothers are instructed to bring their newborn to a clinic after discharge for a health assessment. We sought to determine the rate of newborn follow-up visits and the potential barriers to timely follow-up.

Methods

Mother-newborn dyads at Tygerberg Hospital in Cape Town, South Africa were enrolled from November 2014 to April 2015. Demographic data were obtained via questionnaire and medical records. Mothers were contacted one week after discharge to determine if they had brought their newborns for a follow-up visit, and if not, the barriers to follow-up. Factors associated with follow-up were analyzed using logistic regression.

Results

Of 972 newborns, 794 (82%) were seen at a clinic for a follow-up visit within one week of discharge. Mothers with a higher education level or whose newborns were less than 37 weeks were more likely to follow up. The follow-up rate did not differ based on hospital length of stay. Main reported barriers to follow-up included maternal illness, lack of money for transportation, and mother felt follow-up was unnecessary because newborn was healthy.

Conclusions

Nearly 4 in 5 newborns were seen at a clinic within one week after hospital discharge, in keeping with local practice guidelines. Further research on the outcomes of this population and those who fail to follow up is needed to determine the impact of postnatal healthcare policy.

Parental Opioid Abuse: Barriers to Care, Policy, and Implications for Primary Care Pediatric Providers

Parental opioid use is affecting the physical, developmental, and mental health of the pediatric population nationwide and raises questions of safety when these children remain in the care of opioid-addicted parents. Pediatric providers face many barriers to identifying and caring for children beyond the neonatal period who have been affected by parental opioid abuse both in utero and in the home. These barriers include communication between providers and services, identification of intrauterine exposure, parental opioid abuse screening, and knowledge of child protective services involvement. In addition, understanding current state and national health policy regarding parental opioid abuse helps providers navigate these barriers. The purpose of this article is to identify barriers to care of children affected by parental opioid abuse both in utero and in the home, to discuss current health policy surrounding the issue, and to identify implications for the care of these children in the primary care pediatric setting.