WIC staff and healthcare professional perceptions of an EHR intervention to facilitate referrals to and improve communication and coordination with WIC: A qualitative study

Objectives

Participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has numerous benefits, yet many eligible children remain unenrolled. This qualitative study sought to explore perceptions of a novel electronic health record (EHR) intervention to facilitate referrals to WIC and improve communication/coordination between WIC staff and healthcare professionals.

Methods

WIC staff in three counties were provided EHR access and recruited to participate. An automated, EHR-embedded WIC participation screening and referral tool was implemented within 8 healthcare clinics; healthcare professionals within these clinics were eligible to participate. The interview guide was developed using the Consolidated Framework for Implementation Research to elicit perceptions of this novel EHR-based intervention. Semi-structured interviews were conducted via telephone. Interviews were recorded, transcribed, coded, and analyzed using thematic analysis.

Results

Twenty semi-structured interviews were conducted with eight WIC staff, seven pediatricians, four medical assistants, and one registered nurse. Most participants self-identified as female (95%) and White (55%). We identified four primary themes: (1) healthcare professionals had a positive view of WIC but communication and coordination between WIC and healthcare professionals was limited prior to WIC having EHR access; (2) healthcare professionals favored WIC screening using the EHR but workflow challenges existed; (3) EHR connections between WIC and the healthcare system can streamline referrals to and enrollment in WIC; and (4) WIC staff and healthcare professionals recommended that WIC have EHR access.

Conclusions

A novel EHR-based intervention has potential to facilitate healthcare referrals to WIC and improve communication/coordination between WIC and healthcare systems.

Coordination Between Primary Care and Women, Infants, and Children to Prevent Obesity for Infants from Low-Income Families: A Pragmatic Randomized Clinical Trial

Background: Rapid weight gain during infancy is associated with risk for later obesity, yet little research to date has examined the effect of a responsive parenting (RP) intervention with care coordination between pediatric primary care providers and Women, Infants, and Children nutritionists on infant weight. Methods: The Women, Infants, and Children Enhancements to Early Healthy Lifestyles for Baby (WEE Baby) Care study is a pragmatic, randomized clinical trial for mothers and infants (n = 288) designed to examine the effect of a patient-centered RP intervention that used advanced health information technology strategies to coordinate care to reduce rapid infant weight gain compared with standard care. General linear models examined intervention effects on infant conditional weight gain scores, weight-for-age z scores, BMI, and overweight status (BMI-for-age ≥85th percentile) from birth to age 6 months, and mothers' use of food to soothe from age 2 to 6 months. Results: There were no intervention effects on infant conditional weight gain scores or overweight status at 6 months. Infants in the RP intervention had lower mean weight-for-age z scores [M = -0.04, standard error (SE) = 0.04 vs. M = 0.05, SE = 0.04; p = 0.008] and lower mean BMI (M = 16.05, SE = 0.09 vs. M = 16.24, SE = 0.09; p = 0.03) compared with standard care. Mothers' use of emotion-based food to soothe was lower in the RP intervention compared with standard care from age 2 to 6 months [M difference = -0.32, standard deviation (SD) = 0.81 vs. 0.00, SD = 0.90; p = 0.01]. Conclusions: This pragmatic, patient-centered RP intervention did not reduce rapid infant weight gain or overweight but was associated with modestly lower infant BMI and reduced mothers' use of emotion-based food to soothe. Trial Registration: clinicaltrials.gov identifier: NCT03482908.

Women, Infants, and Children (WIC) Enrollment: Learning From Key Informants to Enhance Utilization

Enrollment in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is suboptimal, particularly for eligible children aged 1 to 4 years. We used converged data from key informants from October 2021 to January 2023 to understand the barriers to and opportunities for WIC utilization and the role of the health care provider in links to WIC. Families and WIC staff identified gaps in provider knowledge and an expressed need for improved collaboration between health providers and WIC. (Am J Public Health. 2023;113(S3):S220-S223. https://doi.org/10.2105/AJPH.2023.307443).

Women's beliefs of pain after childbirth: Critical insight for promoting behavioral strategies to regulate pain and reduce risks for maternal mortality

OBJECTIVE

Promoting behavioral strategies to better regulate pain and decrease the use of prescription pain medications immediately after childbirth is an attractive approach to reduce risks for adverse outcomes associated with the maternal mortality crisis. This study aimed to understand women's beliefs and experiences about pain management to identify important insights for promoting behavioral strategies to control postpartum pain.

METHODS

N = 32 postpartum women participated in a semi-structured interview about beliefs/experiences with managing postpartum pain. Higher- and lower-order themes were coded; descriptive statistics were used to summarize results.

RESULTS

Major trends emerging from the data were: (1) most women used a combination of medications (e.g., oxycodone and acetaminophen) and behavioral strategies (e.g., physical activity) in the hospital (94 %) and at discharge (83 %); (2) some women reported disadvantages like negative side effects of medications and fatigue from physical activity; and (3) some women reported they would have preferred to receive more evidence-based education on behavioral strategies during prenatal visits.

CONCLUSION

Our findings showed that most women were prescribed medications while in the hospital and at discharge, and used non-prescription, behavioral strategies.

PRACTICAL IMPLICATIONS

Future research is needed to test behavioral strategies in randomized clinical trials and clinical care settings to identify impact on reducing adverse maternal health outcomes.

Comparing enhancements to well-child visits in the prevention of obesity: ENCIRCLE cluster-randomized controlled trial

BACKGROUND

Obesity disproportionally impacts rural, lower-income children in the United States. Primary care providers are well-positioned to engage parents in early obesity prevention, yet there is a lack of evidence regarding the most effective care delivery models. The ENCIRCLE study, a pragmatic cluster-randomized controlled trial, will respond to this gap by testing the comparative effectiveness of standard care well-child visits (WCV) versus two enhancements: adding a patient-reported outcome (PRO) measure (PRO WCV) and PRO WCV plus Food Care (telehealth coaching and a grocery store tour).

METHODS

A total of 2,025 parents and their preschool-aged children (20-60 months of age) will be recruited from 24 Geisinger primary care clinics, where providers are randomized to the standard WCV, PRO WCV, or PRO WCV plus Food Care intervention arms. The PRO WCV includes the standard WCV plus collection of the PRO-the Family Nutrition and Physical Activity (FNPA) risk assessment-from parents. Parents complete the PRO in the patient-portal or in the clinic (own device, tablet, or kiosk), receive real-time feedback, and select priority topics to discuss with the provider. These results are integrated into the child's electronic health record to inform personalized preventive counseling by providers. PRO WCV plus Food Care includes referrals to community health professionals who deliver evidence-based obesity prevention and food resource management interventions via telehealth following the WCV. The primary study outcome is change in child body mass index z-score (BMIz), based on the World Health Organization growth standards, 12 months post-baseline WCV. Additional outcomes include percent of children with overweight and obesity, raw BMI, BMI50, BMIz extended, parent involvement in counseling, health behaviors, food resource management, and implementation process measures.

DISCUSSION

Study findings will inform health care systems' choices about effective care delivery models to prevent childhood obesity among a high-risk population. Additionally, dissemination will be informed by an evaluation of mediating, moderating, and implementation factors.

TRIAL REGISTRATION

ClinicalTrials.gov identifier (NCT04406441); Registered May 28, 2020.

Obstetricians' prescribing practices for pain management after delivery

Aim: To examine postpartum opioid prescribing practices. Materials & methods: Obstetricians were interviewed about opioids: choice of opioid, clinical factors considered when prescribing, thoughts/beliefs about prescribing, and typical counseling provided. Inductive thematic analyses were used to identify themes. Results: A total of 38 interviews were analyzed. Several key points emerged. The choice of opioid, dosing and number of pills prescribed varied widely. The mode of delivery is the primary consideration for prescribing opioids. All providers would prescribe opioids to breastfeeding women. Some providers offered counseling on nonopioid treatment of pain. Discussion: At two large tertiary centers in Pennsylvania, the 38 physicians interviewed wrote 38 unique opioid prescriptions. Patient counseling addressed short-term pain management, but not the chronic overuse of opioids.

BMI Data Collection and Communication Practices in a Multistate Sample of Head Start Programs

Background: Although there is a federal mandate to collect anthropometric data in Head Start (HS), little is currently known about the processes used to collect the height and weight measurements across programs and how the results are communicated to parents/guardians. The goal of this study was to understand anthropometric data collection and dissemination procedures in a sample of HS programs serving children 3-5 years. Methods: A convenience sample of HS Health or Nutrition managers were recruited via personal contacts and HS state directors to complete an electronic survey. Quantitative data were analyzed using descriptive statistics (means, standard deviations and frequencies). Open-ended questions were coded using thematic analysis. All protocols and procedures were approved by the Institutional Review Board at Miami University. Results: Approximately half of the programs reported that they have a protocol in place to guide measurements (57.1%) and those measurements are primarily taken by HS staff (64.5%). Most programs explain measurements to parents (82.3%) and report that collecting height/weight data is helpful in supporting children's health (76.0%). Most programs (80.3%) provide resources to parents of children with overweight or obesity. Four themes emerged from open-ended responses: (1) Role of Community Partners (e.g., providing information that conflicts with others); (2) Communicating Children's Weight Status with Families (e.g., using sensitive communication methods); (3) Challenges Measuring Children's Weight Status (e.g., accuracy of data, children's awareness); and (4) Family Reaction to Weight Status Communication (e.g., positive or negative experiences). Conclusion: Opportunities for quality improvement include wider use of standardized, written protocols and policies on data collection and enhanced communication practices to share information with parents.

Prenatal Provider Breastfeeding Toolkit: Results of a Pilot to Increase Women's Prenatal Breastfeeding Support, Intentions, and Outcomes

BACKGROUND

Breastfeeding rates for United States women with lower incomes fall below the government's Healthy People 2020 Goals. Breastfeeding recommendations combined with support from providers and peer counselors help women decide to begin and sustain breastfeeding, but peer counselor uptake is low.

RESEARCH AIM

To evaluate changes in referrals to Women, Infants, and Children's Supplemental Nutrition Program peer counselors, reported prenatal provider education and support, and breastfeeding outcomes (intention, initiation, 1-month duration of any and exclusive breastfeeding) after a prenatal breastfeeding promotion intervention.

METHOD

In this pre-post intervention study (2015-2016; upstate New York), providers implemented a Toolkit to discuss infant feeding recommendations and initiate peer counselor referral. We surveyed women pre- and post-implementation (after delivery; 1 month postpartum) about prenatal breastfeeding intentions, provider support, and breastfeeding outcomes. Analyses controlled for secular trends.

RESULTS

Pre-intervention (n = 71) and post-intervention (n = 70) participants were 49% Black, 61% publicly insured, and 16% uninsured. More post-intervention participants had > 1 Toolkit use (76%), peer counselor program referrals (60.0% post vs. 36.6% pre, p < .01), reported any breastfeeding intention (89% vs. 72%, p = .013), and intended to breastfeed for > 1 year (31% vs. 14%, p = .014). Post-intervention breastfeeding initiation and exclusivity were higher, but not significantly different. Post-intervention participants reported better prenatal breastfeeding support.

CONCLUSIONS

Implementing a prenatal Breastfeeding Toolkit, including facilitating peer counselor referral, was associated with increases in provider counseling, participants' breastfeeding intentions, and uptake of peer counselors. Replicating this approach may reinforce efforts to support breastfeeding in similar practices serving women with lower incomes.

Obstetric Physicians' Beliefs and Knowledge on Guidelines and Screening Tools to Reduce Opioid Use After Childbirth

OBJECTIVE

To examine obstetric physicians' beliefs about using professional or regulatory guidelines, opioid risk-screening tools, and preferences for recommending nonanalgesic therapies for postpartum pain management.

METHODS

A qualitative study design was used to conduct semi-structured interviews with obstetric and maternal-fetal medicine physicians (N=38) from two large academic health care institutions in central Pennsylvania. An interview guide was used to direct the discussion about each physicians' beliefs in response to questions about pain management after childbirth.

RESULTS

Three trends in the data emerged from physicians' responses: 1) 71% of physicians relied on their clinical insight rather than professional or regulatory guidelines to inform decisions about pain management after childbirth; 2) although many reported that a standard opioid patient screening tool would be useful to inform clinical decisions about pain management, nearly all (92%) physician respondents reported not currently using one; and 3) 63% thought that nonpharmacologic pain management therapies should be used whenever possible to manage pain after childbirth. Key physician barriers (eg, lack time and evidence, being unaware of how to implement) and patient barriers (eg, take away from other responsibilities, no time or patience) to implementation were also identified.

CONCLUSION

These findings suggest that obstetric physicians' individual beliefs and clinical insight play a key role in pain management decisions for women after childbirth. Practical and scalable strategies are needed to: 1) encourage obstetric physicians to use professional or regulatory guidelines and standard opioid risk-screening tools to inform clinical decisions about pain management after childbirth, and 2) educate physicians and patients about nonopioid and nonpharmacologic pain management options to reduce exposure to prescription opioids after childbirth.

Agreement in Infant Growth Indicators and Overweight/Obesity between Community and Clinical Care Settings

BACKGROUND

Infants from low-income backgrounds receive nutrition care from both community and clinical care settings. However, mothers accessing these services have reported receiving conflicting messages related to infant growth between settings, although this has not been examined quantitatively.

OBJECTIVE

Describe the agreement in infant growth assessments between community (Special Supplemental Nutrition Program for Women, Infants, and Children) and clinical (primary care providers) care settings.

DESIGN

A cross-sectional, secondary data analysis of infant growth measures abstracted from electronic data management systems.

PARTICIPANTS AND SETTING

Participants included a convenience sample of infants (N = 129) from northeastern Pennsylvania randomized to the WEE Baby Care study from July 2016 to May 2018. Infants had complete anthropometric data from both community and clinical settings at age 6.2 ± 0.4 months. Average time between assessments was 2.7 ± 1.9 weeks.

MAIN OUTCOME MEASURES

Limits of agreement and bias in weight-for-age, length-for-age, weight-for-length, and body-mass-index-for-age z scores as well as cross-context equivalence in weight status between care settings.

STATISTICAL ANALYSIS PERFORMED

Bland-Altman analyses were used to describe the limits of agreement and bias in z scores between care settings. Cross-context equivalence was examined by dichotomizing infants' growth indicators at the 85th and 95th percentile cut-points and cross-tabulating equivalent and discordant categorization between settings.

RESULTS

Strongest agreement was observed for weight-for-age z scores (95% limits of agreement -0.41 to 0.54). However, the limits of agreement intervals for growth indicators that included length were wider, suggesting weaker agreement. There was a high level of inconsistency for classification of overweight/obesity using weight-for-length z scores, with 15.5% (85th percentile cut-point) and 11.6% (95th percentile cut-point) discordant categorization between settings, respectively.

CONCLUSIONS

Infant growth indicators that factor in length could contribute to disagreement in the interpretation of infant growth between settings. Further investigation into the techniques, standards, and training protocols for obtaining infant growth measurements across care settings is required.

Advanced Health Information Technologies to Engage Parents, Clinicians, and Community Nutritionists in Coordinating Responsive Parenting Care: Descriptive Case Series of the Women, Infants, and Children Enhancements to Early Healthy Lifestyles for Baby (WEE Baby) Care Randomized Controlled Trial

BACKGROUND

Socioeconomically disadvantaged newborns receive care from primary care providers (PCPs) and Women, Infants, and Children (WIC) nutritionists. However, care is not coordinated between these settings, which can result in conflicting messages. Stakeholders support an integrated approach that coordinates services between settings with care tailored to patient-centered needs.

OBJECTIVE

This analysis describes the usability of advanced health information technologies aiming to engage parents in self-reporting parenting practices, integrate data into electronic health records to inform and facilitate documentation of provided responsive parenting (RP) care, and share data between settings to create opportunities to coordinate care between PCPs and WIC nutritionists.

METHODS

Parents and newborns (dyads) who were eligible for WIC care and received pediatric care in a single health system were recruited and randomized to a RP intervention or control group. For the 6-month intervention, electronic systems were created to facilitate documentation, data sharing, and coordination of provided RP care. Prior to PCP visits, parents were prompted to respond to the Early Healthy Lifestyles (EHL) self-assessment tool to capture current RP practices. Responses were integrated into the electronic health record and shared with WIC. Documentation of RP care and an 80-character, free-text comment were shared between WIC and PCPs. A care coordination opportunity existed when the dyad attended a WIC visit and these data were available from the PCP, and vice versa. Care coordination was demonstrated when WIC or PCPs interacted with data and documented RP care provided at the visit.

RESULTS

Dyads (N=131) attended 459 PCP (3.5, SD 1.0 per dyad) and 296 WIC (2.3, SD 1.0 per dyad) visits. Parents completed the EHL tool prior to 53.2% (244/459) of PCP visits (1.9, SD 1.2 per dyad), PCPs documented provided RP care at 35.3% (162/459) of visits, and data were shared with WIC following 100% (459/459) of PCP visits. A WIC visit followed a PCP visit 50.3% (231/459) of the time; thus, there were 1.8 (SD 0.8 per dyad) PCP to WIC care coordination opportunities. WIC coordinated care by documenting RP care at 66.7% (154/231) of opportunities (1.2, SD 0.9 per dyad). WIC visits were followed by a PCP visit 58.9% (116/197) of the time; thus, there were 0.9 (SD 0.8 per dyad) WIC to PCP care coordination opportunities. PCPs coordinated care by documenting RP care at 44.0% (51/116) of opportunities (0.4, SD 0.6 per dyad).

CONCLUSIONS

Results support the usability of advanced health information technology strategies to collect patient-reported data and share these data between multiple providers. Although PCPs and WIC shared data, WIC nutritionists were more likely to use data and document RP care to coordinate care than PCPs. Variability in timing, sequence, and frequency of visits underscores the need for flexibility in pragmatic studies.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03482908; https://clinicaltrials.gov/ct2/show/NCT03482908.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12887-018-1263-z.

A patient-centered, coordinated care approach delivered by community and pediatric primary care providers to promote responsive parenting: pragmatic randomized clinical trial rationale and protocol

Background

Economically disadvantaged families receive care in both clinical and community settings, but this care is rarely coordinated and can result in conflicting educational messaging. WEE Baby Care is a pragmatic randomized clinical trial evaluating a patient-centered responsive parenting (RP) intervention that uses health information technology (HIT) strategies to coordinate care between pediatric primary care providers (PCPs) and the Special Supplemental Nutrition Program for Women, Infant and Children (WIC) community nutritionists to prevent rapid weight gain from birth to 6 months. It is hypothesized that data integration and coordination will improve consistency in RP messaging and parent self-efficacy, promoting shared decision making and infant self-regulation, to reduce infant rapid weight gain from birth to 6 months.

Methods/design

Two hundred and ninety mothers and their full-term newborns will be recruited and randomized to the “RP intervention” or “standard care control” groups. The RP intervention includes: 1) parenting and nutrition education developed using the American Academy of Pediatrics Healthy Active Living for Families curriculum in conjunction with portions of a previously tested RP curriculum delivered by trained pediatric PCPs and WIC nutritionists during regularly scheduled appointments; 2) parent-reported data using the Early Healthy Lifestyles (EHL) risk assessment tool; and 3) data integration into child’s electronic health records with display and documentation features to inform counseling and coordinate care between pediatric PCPs and WIC nutritionists. The primary study outcome is rapid infant weight gain from birth to 6 months derived from sex-specific World Health Organization adjusted weight-for-age z-scores. Additional outcomes include care coordination, messaging consistency, parenting behaviors (e.g., food to soothe), self-efficacy, and infant sleep health. Infant temperament and parent depression will be explored as moderators of RP effects on infant outcomes.

Discussion

This pragmatic patient-centered RP intervention integrates and coordinates care across clinical and community sectors, potentially offering a fundamental change in the delivery of pediatric care for prevention and health promotion. Findings from this trial can inform large scale dissemination of obesity prevention programs.

Trial registration

Restrospective Clinical Trial Registration: NCT03482908. Registered March 29, 2018.