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Wallis KE, Guthrie W. Screening for Autism: A Review of the Current State, Ongoing Challenges, and Novel Approaches on the Horizon. Pediatr Clin North Am 2024; 71:127-155. [PMID: 38423713 DOI: 10.1016/j.pcl.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Screening for autism is recommended in pediatric primary care. However, the median age of autism spectrum disorder (ASD) diagnosis is substantially higher than the age at which autism can reliably be identified, suggesting room for improvements in autism recognition at young ages, especially for children from minoritized racial and ethnic groups, low-income families, and families who prefer a language other than English. Novel approaches are being developed to utilize new technologies in aiding in autism recognition. However, attention to equity is needed to minimize bias. Additional research on the benefits and potential harms of universal autism screening is needed. The authors provide suggestions for pediatricians who are considering implementing autism-screening programs.
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Affiliation(s)
- Kate E Wallis
- Division of Developmental and Behavioral Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; PolicyLab, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Center for Autism Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Whitney Guthrie
- Division of Developmental and Behavioral Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Center for Autism Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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2
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Lee King P, Surenian A, Odom RM, Shah K, Lee S, Jenkins E, Borders A. Using quality improvement to address social determinants of health needs in perinatal care. Semin Perinatol 2024; 48:151908. [PMID: 38692995 DOI: 10.1053/j.semperi.2024.151908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
There are unacceptable racial inequities in perinatal outcomes in the United States. Social determinants of health (SDOH) are associated with health outcomes and contribute to disparities in maternal and newborn health. In this article, we (1) review the literature on SDOH improvement in the perinatal space, (2) describe the SDOH work facilitated by the Illinois Perinatal Quality Collaborative (ILPQC) in the Birth Equity quality improvement initiative, (3) detail a hospital's experience with implementing strategies to improve SDOH screening and linkage to needed resources and services and (4) outline a framework for success for addressing SDOH locally. A state-based quality improvement initiative can facilitate implementation of strategies to increase screening for SDOH. Engaging patients and communities with specific actionable strategies is key to increase linkage to needed SDOH resources and services.
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Affiliation(s)
- Patricia Lee King
- Northwestern University, Feinberg School of Medicine, Center for Healthcare Services and Outcomes Research-Institute for Public Health and Medicine, 633N. St. Clair, 20th Fl, Chicago, IL 60611, United States; University of Chicago, Pritzker School of Medicine, Obstetrics and Gynecology, 5841 S. Maryland Avenue Chicago, IL 60637, United States; NorthShore University HealthSystem (now Endeavor Health), Maternal-Fetal-Medicine, 2650 Ridge Avenue, Evanston, IL 60201, United States.
| | - Aleena Surenian
- Northwestern University, Feinberg School of Medicine, Center for Healthcare Services and Outcomes Research-Institute for Public Health and Medicine, 633N. St. Clair, 20th Fl, Chicago, IL 60611, United States
| | - Renee M Odom
- NorthShore University HealthSystem (now Endeavor Health), Maternal-Fetal-Medicine, 2650 Ridge Avenue, Evanston, IL 60201, United States
| | - Kshama Shah
- University of Chicago, Pritzker School of Medicine, Obstetrics and Gynecology, 5841 S. Maryland Avenue Chicago, IL 60637, United States; NorthShore University HealthSystem (now Endeavor Health), Maternal-Fetal-Medicine, 2650 Ridge Avenue, Evanston, IL 60201, United States
| | - SuYeon Lee
- Northwestern University, Feinberg School of Medicine, Center for Healthcare Services and Outcomes Research-Institute for Public Health and Medicine, 633N. St. Clair, 20th Fl, Chicago, IL 60611, United States
| | - Elena Jenkins
- SSM Health St. Mary's Hospital - St. Louis, 6420 Clayton Road, Richmond Heights, MO 63117, United States
| | - Ann Borders
- Northwestern University, Feinberg School of Medicine, Center for Healthcare Services and Outcomes Research-Institute for Public Health and Medicine, 633N. St. Clair, 20th Fl, Chicago, IL 60611, United States; University of Chicago, Pritzker School of Medicine, Obstetrics and Gynecology, 5841 S. Maryland Avenue Chicago, IL 60637, United States; NorthShore University HealthSystem (now Endeavor Health), Maternal-Fetal-Medicine, 2650 Ridge Avenue, Evanston, IL 60201, United States
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Christopher D, Fresia J, Alexander J, Krenz K, Aldrich H, Hampanda K. Redesigning the First Prenatal Visit: A Quality Improvement Initiative. J Healthc Qual 2024; 46:119-129. [PMID: 38147584 DOI: 10.1097/jhq.0000000000000418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
BACKGROUND/PURPOSE In an era of rising maternal mortality, a thorough first prenatal visit is essential; however, in our clinic we confirmed that many important topics were not being addressed. To rectify this problem, we redesigned the first prenatal visit to improve the coverage of topics, collect social determinants of health, increase patient access, and maintain patient satisfaction. METHODS We designed a quality improvement project to improve the first prenatal visit in a faculty obstetrics and gynecology clinic. To assess effectiveness, data before and after the implementation were compared. The intervention divided the first prenatal visit into two patient encounters: a nurse-led telemedicine visit and an in-person visit with an obstetric clinician. RESULTS The median percentage of topics covered in the first prenatal visit increased from 70.0% to 95.6%, and improvements were observed for all key themes ( p < .001). Social determinants of health was routinely collected postintervention (98.8%). A reduction in no-shows (9.9%-4.2%) improved patient access for all patients. Patient satisfaction for the first prenatal visit remained unchanged ( p = .370). CONCLUSIONS Significant improvements in addressing important topics at the first prenatal visit are achievable by separating one prenatal visit into two visits while increasing patient access and maintaining high patient satisfaction.
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Arroyave Caicedo NM, Parry E, Arslan N, Park S. Integration of social determinants of health information within the primary care electronic health record: a systematic review of patient perspectives and experiences. BJGP Open 2024:BJGPO.2023.0155. [PMID: 37673433 DOI: 10.3399/bjgpo.2023.0155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 08/25/2023] [Accepted: 08/30/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND Social determinants of health (SDOH) are the non-medical factors that impact health. Although geographical measures of deprivation are used, individual measures of social risk could identify those most at risk and generate more personalised care and targeted referrals to community resources. We know SDOH are important to health care, but it is not yet known whether their collection via the electronic health record (EHR) is acceptable and useful from the patient perspective. AIM To synthesise relevant literature to explore patient perspectives on integrating information about SDOH into primary care EHRs, and the opportunities and challenges of its implementation in a general practice setting. DESIGN & SETTING Systematic review of primary care-based qualitative and mixed-method studies using thematic framework analysis. METHOD Key databases were searched for articles reporting patient perspectives of SDOH collection within the primary care EHR. Qualitative and mixed-methods studies written in English were included. A framework analysis was conducted to identify themes. RESULTS From 14 included studies, the following five main themes were identified: rationale for SDOH screening and the anticipated outcomes; impact of the provider-patient relationship on patient perceptions; data, which included privacy concerns; screening process and referral; and recommendations for future research. CONCLUSION Integration of information on SDOH into the EHR appears acceptable to patients. This review has added to the discussion of whether and how to implement SDOH screening and referral programmes into UK primary care systems.
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Affiliation(s)
| | - Emma Parry
- School of Medicine, Keele University, Staffordshire, UK
| | - Nazan Arslan
- Department of Primary Care and Population Health, University College London, London, UK
| | - Sophie Park
- Department of Primary Care and Population Health, University College London, London, UK
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Spain AK, Korfmacher J, McCrae JS. Coordination challenges and promising practices for pediatric healthcare-community partnerships: A multi-site study. JOURNAL OF COMMUNITY PSYCHOLOGY 2023; 51:2117-2132. [PMID: 36811161 DOI: 10.1002/jcop.23015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 01/16/2023] [Accepted: 02/02/2023] [Indexed: 06/14/2023]
Abstract
There have been delays integrating universal screening and referral for social needs in pediatric practice. The study investigated two frameworks for clinic-based screen-and-refer practice in eight clinics. The frameworks depict different organizational strategies to bolster family access to community resources. We conducted semi-structured interviews with healthcare and community partners at two timepoints (n = 65) to investigate start-up and ongoing implementation experiences, including continuing challenges. Results highlighted common within-clinic and clinic-community coordination challenges across diverse settings as well as promising practices supported by the two frameworks. In addition, we identified ongoing implementation challenges that face efforts to integrate these approaches and to translate screening results into activities that help children and families. Assessing the existing service referral coordination infrastructure of each clinic and community in early implementation is critical to screen-and-refer practice as this influences the continuum of supports available to meet family needs.
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Affiliation(s)
- Angeline K Spain
- Chapin Hall at the University of Chicago, Chicago, Illinois, USA
| | - Jon Korfmacher
- Chapin Hall at the University of Chicago, Chicago, Illinois, USA
| | - Julie S McCrae
- Chapin Hall at the University of Chicago, Chicago, Illinois, USA
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Brown J, Ahmed N, Biel M, Patchen L, Rethy J, Thomas A, Arem H. Considerations in implementation of social risk factor screening and referral in maternal and infant care in Washington, DC: A qualitative study. PLoS One 2023; 18:e0283815. [PMID: 37053233 PMCID: PMC10101493 DOI: 10.1371/journal.pone.0283815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/17/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND The District of Columbia (DC) has striking disparities in maternal and infant outcomes comparing Black to White women and babies. Social determinants of health (SDoH) are widely recognized as a significant contributor to these disparities in health outcomes. Screening for social risk factors and referral for appropriate services is a critical step in addressing social needs and reducing outcome disparities. METHODS We conducted interviews among employees (n = 18) and patients (n = 9) across three diverse, urban clinics within a healthcare system and one community-based organization involved in a five-year initiative to reduce maternal and infant disparities in DC. Interviews were guided by the Consolidated Framework for Implementation Research to understand current processes and organizational factors that contributed to or impeded delivery of social risk factor screening and referral for indicated needs. RESULTS We found that current processes for social risk factor screening and referral differed between and within clinics depending on the patient population. Key facilitators of successful screening included a supportive organizational culture and adaptability of more patient-centered screening processes. Key barriers to delivery included high patient volume and limited electronic health record capabilities to record results and track the status of internal and community referrals. Areas identified for improvement included additional social risk factor assessment training for new providers, patient-centered approaches to screening, improved tracking processes, and facilitation of connections to social services within clinical settings. CONCLUSION Despite proliferation of social risk factor screeners and recognition of their importance within health care settings, few studies detail implementation processes for social risk factor screening and referrals. Future studies should test implementation strategies for screening and referral services to address identified barriers to implementation.
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Affiliation(s)
- Jason Brown
- Medstar Health Research Institute, Healthcare Delivery Research, Washington, DC, United States of America
| | - Naheed Ahmed
- Medstar Health Research Institute, Healthcare Delivery Research, Washington, DC, United States of America
| | - Matthew Biel
- Department of Psychiatry, Georgetown University School of Medicine, Washington, DC, United States of America
- Department of Psychiatry, MedStar Georgetown University Hospital, Washington, DC, United States of America
| | - Loral Patchen
- MedStar Washington Hospital Center, Women and Infant Services, Washington, DC, United States of America
- MedStar Washington Hospital Center, Obstetrics/Gynecology, Washington, DC, United States of America
| | - Janine Rethy
- Department of Pediatrics, MedStar Georgetown University Hospital, Washington, DC, United States of America
| | - Angela Thomas
- Medstar Health Research Institute, Healthcare Delivery Research, Washington, DC, United States of America
| | - Hannah Arem
- Medstar Health Research Institute, Healthcare Delivery Research, Washington, DC, United States of America
- Department of Oncology, Georgetown University School of Medicine, Washington, DC, United States of America
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Arbour M, Fico P, Floyd B, Morton S, Hampton P, Murphy Sims J, Atwood S, Sege R. Sustaining and scaling a clinic-based approach to address health-related social needs. FRONTIERS IN HEALTH SERVICES 2023; 3:1040992. [PMID: 36926501 PMCID: PMC10012656 DOI: 10.3389/frhs.2023.1040992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 01/25/2023] [Indexed: 02/19/2023]
Abstract
Objective Scaling evidence-based interventions (EBIs) from pilot phase remains a pressing challenge in efforts to address health-related social needs (HRSN) and improve population health. This study describes an innovative approach to sustaining and further spreading DULCE (Developmental Understanding and Legal Collaboration for Everyone), a universal EBI that supports pediatric clinics to implement the American Academy of Pediatrics' Bright Futures™ guidelines for infants' well-child visits (WCVs) and introduces a new quality measure of families' HRSN resource use. Methods Between August 2018 and December 2019, seven teams in four communities in three states implemented DULCE: four teams that had been implementing DULCE since 2016 and three new teams. Teams received monthly data reports and individualized continuous quality improvement (CQI) coaching for six months, followed by lighter-touch support via quarterly group calls (peer-to-peer learning and coaching). Run charts were used to study outcome (percent of infants that received all WCVs on time) and process measures (percent of families screened for HRSN and connected to resources). Results Integrating three new sites was associated with an initial regression of outcome: 41% of infants received all WCVs on time, followed by improvement to 48%. Process performance was sustained or improved: among 989 participating families, 84% (831) received 1-month WCVs on time; 96% (946) were screened for seven HRSN, 54% (508) had HRSN, and 87% (444) used HRSN resources. Conclusion An innovative, lighter-touch CQI approach to a second phase of scale-up resulted in sustainment or improvements in most processes and outcomes. Outcomes-oriented CQI measures (family receipt of resources) are an important addition to more traditional process-oriented indicators.
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Affiliation(s)
- MaryCatherine Arbour
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Placidina Fico
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Baraka Floyd
- Department of Pediatrics, Stanford School of Medicine, Stanford, CA, United States
| | | | - Patsy Hampton
- Center for the Study of Social Policy, Washington, D.C., United States
| | - Jennifer Murphy Sims
- Early Intervention Services, UCSF Benioff Children's Hospital, Oakland, CA, United States
| | - Sidney Atwood
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Robert Sege
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, United States
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Brennan L, Evans M, Michaeli G, Pandita P, Patel S, Powell K, Putnam-Johnson H, Chong A, Stelzner S, Casavan K. Completion of Social Drivers of Health Screenings in Pediatric Practices Participating in a Quality Improvement Initiative. J Dev Behav Pediatr 2022; 43:472-479. [PMID: 35994262 DOI: 10.1097/dbp.0000000000001114] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 05/22/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The Indiana Chapter of the American Academy of Pediatrics (INAAP) participated in a national quality improvement project led by the AAP called Addressing Social Health and Early Childhood Wellness, which sought to screen for and address social drivers of health (SDoH), socioemotional development, and perinatal depression in pediatric practices through practice and system improvement. This project aims to evaluate positive SDoH screenings and subsequent referrals from participating Indiana practices. METHODS Ten pediatric practices in mid-central Indiana participated in this collaboration between July 2020 and July 2021 and submitted information about clinic resources, patient demographics, and process measures. Monthly chart reviews of well-child visits assessed completion of SDoH screenings, discussion of screening results with families, and referrals for positive screens. Composite measures of performance were developed from chart review. RESULTS Measures showed significant improvements in SDoH screening and identified opportunities for improvement in the care continuum. SDoH screenings of eligible patients significantly increased from 21% to 62% on average ( p = 0.0002). Needed referrals fulfilled increased from 37% to 57% ( p = 0.003) on average. Interestingly, no significant improvement was seen in referring patients who screened positive (81% vs 89%, p = 0.0949). CONCLUSION This project provided a framework for successful development and efficient integration of screening and referral processes into clinic workflow. Implementing Plan-Do-Study-Act cycles, monthly chart reviews, and collaborative meetings facilitated increased documentation of screening, counseling, and referral for positive SDoH screens in participating practices. Future analysis should measure health outcomes and social and community capital derived by health systems and patients from such interventions.
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Affiliation(s)
- Luke Brennan
- Indiana University School of Medicine, Indianapolis, IN
| | | | | | - Pooja Pandita
- Indiana University School of Medicine, Indianapolis, IN
| | - Shraya Patel
- Indiana University School of Medicine, Indianapolis, IN
| | - Kayla Powell
- Indiana University School of Medicine, Indianapolis, IN
| | | | | | - Sarah Stelzner
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN; and
| | - Kara Casavan
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN; and
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Meurer J, Rohloff R, Rein L, Kanter I, Kotagiri N, Gundacker C, Tarima S. Improving Child Development Screening: Implications for Professional Practice and Patient Equity. J Prim Care Community Health 2022; 13:21501319211062676. [PMID: 34986680 PMCID: PMC8743928 DOI: 10.1177/21501319211062676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION AND OBJECTIVES A pediatric group with 25 clinics and 150 providers used multifaceted approaches to implement workflow processes and an electronic health record (EHR) flowsheet to improve child developmental screening. The key outcome was developmental screening done for every patient during 3 periods between ages 8 and 36 months. Identification of developmental concerns was the secondary study outcome. Screening rates and referrals were hypothesized to be optimized for children regardless of demographic backgrounds. METHODS During preventive visits, developmental screens targeted patients in age groups 8 to 12, 13 to 24, and 25 to 36 months. EHRs were analyzed for screening documentation, results, and referrals by patient demographics. Fifteen pediatric professionals were interviewed about their qualitative experiences. Quality improvement interventions included appointing clinic champions, training staff about the screening process and responsibilities, using a standardized tool, employing plan-do-study-act cycles, posting EHR prompts, providing financial incentives, and monitoring screening rates using control charts. RESULTS Within 25 months, screening rates improved from 60% to >95% within the 3 preventive visit age groups for a total of more than 30 000 children. Professionals valued the team process improvements. Children enrolled in Medicaid, black children, and those living in lower income zip codes had lower screening rates than privately insured, white children, and those living in higher income areas. Ages and Stages Questionnaire 3rd edition results were significantly different by gender, race/ethnicity, insurance, and income categories across all groups. Referral rates varied by race/ethnicity and zip code of residence. CONCLUSIONS This project resulted in an effective and efficient process to improve child developmental screening that was valued by pediatric professionals. Analyses of patient demographics revealed disparities in services for the most vulnerable families. Ongoing quality improvement, health services research, and advocacy offer hope to improve health equity.
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Affiliation(s)
- John Meurer
- Medical College of Wisconsin (MCW), Milwaukee, WI, USA
| | | | - Lisa Rein
- Medical College of Wisconsin (MCW), Milwaukee, WI, USA
| | | | | | | | - Sergey Tarima
- Medical College of Wisconsin (MCW), Milwaukee, WI, USA
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Fitzhugh CD, Pearsall MS, Tully KP, Stuebe AM. Social Determinants of Health in Maternity Care: A Quality Improvement Project for Food Insecurity Screening and Health Care Provider Referral. Health Equity 2021; 5:606-611. [PMID: 34909527 PMCID: PMC8665789 DOI: 10.1089/heq.2020.0120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2021] [Indexed: 12/30/2022] Open
Abstract
Purpose: This quality improvement project evaluated implementation of social determinants of health screening and referral for food insecurity. Methods: Four obstetric providers used study-developed resources to screen and refer English-speaking patients (n=14) during clinic visits. Providers and patients completed post-visit questionnaires. Provider feedback informed improvements to the intervention approach for consecutive study shifts. Results: Providers and patients reported high satisfaction with encounters. Referrals were made for four patients. Challenges to implementation included resource organization, time constraints, and integration into clinic workflow. Conclusion: Processes for universal screening and tailored information provision are areas to continue to strengthen for establishing equitable health care.
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Affiliation(s)
- Chelsea D Fitzhugh
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | | | - Kristin P Tully
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Alison M Stuebe
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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Arbour MC, Floyd B, Morton S, Hampton P, Sims JM, Doyle S, Atwood S, Sege R. Cross-Sector Approach Expands Screening and Addresses Health-Related Social Needs in Primary Care. Pediatrics 2021; 148:peds.2021-050152. [PMID: 34706903 DOI: 10.1542/peds.2021-050152] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/24/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES During infancy, the American Academy of Pediatrics Bright Futures fourth edition health supervision guidelines recommend frequent well-child visits (WCVs) in which providers are expected to screen for and address maternal depression, intimate partner violence (IPV), and health-related social needs (HRSN). We spread an evidence-based approach that implements these recommendations (Developmental Understanding and Legal Collaboration for Everyone; DULCE) with 3 aims for 6-month-old infants and their families: 75% receive all WCVs on time, 95% are screened for 7 HRSNs, and 90% of families with concrete supports needs and 75% of families with maternal depression or IPV receive support. METHODS Between January 2017 and July 2018, five DULCE teams (including a community health worker, early childhood system representative, legal partner, clinic administrator, pediatric and behavioral health clinicians) from 3 communities in 2 states participated in a learning collaborative. Teams adapted DULCE using Plan-Do-Study-Act cycles, reported data, and shared learning monthly. Run charts were used to study measures. The main outcome was the percent of infants that received all WCVs on time. RESULTS The percentage of families who completed all WCVs on time increased from 46% to 65%. More than 95% of families were screened for HRSNs, 70% had ≥1 positive screen, and 86% and 71% of those received resource information for concrete supports and maternal depression and IPV, respectively. CONCLUSIONS Quality improvement-supported DULCE expansion increased by 50% the proportion of infants receiving all WCVs on time and reliably identified and addressed families' HRSNs, via integration of existing resources.
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Affiliation(s)
| | - Baraka Floyd
- Stanford School of Medicine, Stanford, California
| | | | - Patsy Hampton
- Center for the Study of Social Policy, Washington, DC
| | | | | | | | - Robert Sege
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
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Spain AK, Monahan EK, Alvarez K, Finno-Velasquez M. Latinx Family Perspectives on Social Needs Screening and Referral during Well-Child Visits. MCN Am J Matern Child Nurs 2021; 46:143-149. [PMID: 38019058 DOI: 10.1097/nmc.0000000000000710] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To understand Latinx parent perspectives on screening and referral approaches to identify social determinants of health and address social and material needs during well-child visits and to identify techniques that promote their engagement with these approaches. STUDY DESIGN We investigated parent perspectives and engagement with social needs screening and referral practices during well-child visits using focus group methodology. RESULTS We conducted 17 focus groups (n = 134 parents and other primary caregivers) with families receiving care at sites operated by eight pediatric primary care clinics. Adding social needs screening and referral shifted the social context of well-child visits for Latinx parents. Participants reported greater engagement with the practices where they perceived an emotional connection with nurses and other clinicians and cultural brokering to ensure their screening responses accurately reflected family needs and priorities. Participants highlighted the importance of having a personal patient-provider relationship as many preferred to discuss social needs outside of the exam room. CLINICAL IMPLICATIONS Nurses and other clinicians play a critical role in establishing systems needed to systematically screen and refer families for social needs. Future policy development should consider implications for nursing practice and leadership in adopting these approaches.
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McCrae JS, Robinson JAL, Spain AK, Byers K, Axelrod JL. The Mitigating Toxic Stress study design: approaches to developmental evaluation of pediatric health care innovations addressing social determinants of health and toxic stress. BMC Health Serv Res 2021; 21:71. [PMID: 33468104 PMCID: PMC7814628 DOI: 10.1186/s12913-021-06057-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 01/02/2021] [Indexed: 11/26/2022] Open
Abstract
Background Health care administrators must establish and promote effective partnerships with community agencies to address social determinants of health, including reducing exposure of infants and young children to chronic stress. Because infants’ experiences are inextricably tied to their caregivers, an important target for mitigating “toxic” stress exposure in early childhood is through reducing parents’ experiences of chronic stress in addition to protecting children from direct experiences of harm such as physical or sexual abuse. Conducting screening to identify when children are exposed to early life adversity is a first step; connecting families to needed support services is an essential component to addressing identified challenges. This paper presents the methodology of a three-year study of health care systems innovations designed to engage and support parents of infants to prevent and mitigate children’s toxic stress exposures. Methods Key study features included: 1) multi-component study in five U.S. communities and nine pediatric health care clinics and the families they serve, 2) a developmental evaluation approach to describe how innovations are experienced over time at three levels—community systems, pediatric providers, and families, and 3) rapid cycle feedback conducted with communities, clinics and families to co-interpret data and findings. Data sources included: 1) focus groups and interviews with community stakeholders, clinic staff, and families, 2) electronic health record and Medicaid services data extracted to assess health care quality, utilization, and financial impact, and 3) clinic-recruitment of 908 parents of infants in a longitudinal survey. Results. The sample is briefly characterized based on responses to the enrollment phase of the parent survey. Conclusions We discuss the study design elements’ contribution to generating evidence needed by innovators, communities, and clinics to modify and sustain investments in these innovations to prevent or mitigate the effects of exposure to toxic stress on young children.
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Affiliation(s)
- Julie S McCrae
- Chapin Hall at the University of Chicago, 1313 E. 16th Street, Chicago, IL, 60637, USA.
| | - Jo Ann L Robinson
- University of Connecticut, 348 Mansfield Road U1058, Storrs, CT, 06269-1058, USA
| | - Angeline K Spain
- Chapin Hall at the University of Chicago, 1313 E. 16th Street, Chicago, IL, 60637, USA
| | - Kaela Byers
- University of Kansas, 1545 Lilac Lane, Lawrence, KS, 66045, USA
| | - Jennifer L Axelrod
- The Chicago Community Trust, 225 N, Michigan Avenue, Suite 2100, Chicago, IL, 60601, USA
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