YJPDN-01185; No of Pages 2 Journal of Pediatric Nursing (2014) xx, xxx–xxx 1
HOT TOPICS DEPARTMENT Column Editor: Deborah McBride MSN
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⁎ Corresponding author.
http://dx.doi.org/10.1016/j.pedn.2014.08.003 0882-5963/© 2014 Elsevier Inc. All rights reserved.
care has expanded beyond what can be accomplished in the 38 typical visit, contributing to a wide range of quality and quantity 39 of services received by different providers. The new study builds 40 on an earlier systematic review of strategies and tools by 41 Coker et al. (2014) (http://pediatrics. 42 Q2 aappublications.org/content/131/ 43 Supplement_1/S5.full.pdf) which 44 “Providers are being examined the evidence for various 45 called on to provide models of well-child care. Coker et al. 46 more services than examined the literature on alternative 47 formats of well child care, including: 48 they can realistically
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NEW, MORE EFFICIENT and effective models of well-child care visits are needed. A recent study uses a structured process to evaluate alternative models of well-child care visits based on feasibility, acceptability to parents and clinicians, and cost. The new study is part of a long term project to design a well-child care visit model that reduces reliance on physician time, improves the quality of anticipatory guidance and more effectively addresses parental concerns. Well-child care visits are the cornerstone of pediatric primary care in the United States. They account for more than one-third of all outpatient visits for infants and toddlers and are intended to identify health, social, developmental and behavioral issues that could have a long-term impact on children's lives. However, studies have shown that the current system of well-child care leaves room for improvement. One issue of concern that was identified in the recently revised Academy of American Pediatrics guidelines on pediatric preventative care (http://pediatrics.aappublications.org/ content/133/3/568) was that providers are being called on to provide more services than they can realistically provide in a 15-minute visit. As a result, many children do not get the preventative health care that they need. This is particularly an issue in low-income neighborhoods where children may be facing a high level of unmet psychosocial and behavioral needs and a need for more parenting education. The present structure of the well-child visits in the United States calls for a healthcare provider to provide all of the recommend services in 13 face-to-face visits during the first 5 years of life. Traditionally these services are delivered during clinic visits, but providers are interested in redesigning care delivery, including offering some services outside the clinical setting. The number of recommended services for well-child
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Deborah McBride MSN ⁎
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New Models of Well-Child Care Visits
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Deborah McBride MSN
provide in a 15-minute
• Group well-child care, where four to six 49 visit. As a result, many families with similarly aged children visit 50 with a provider. children do not get 51the • Non face-to-face formats, such as a 52 preventative health Web-based system for parents to access 53 care that they need.” topics for guidance before a provider 54 visit or instead of a visit. 55 • Non-clinical locations, for example 56 home visits by a nurse practitioner or at a preschool. 57 • Services provided through an interventional program, such as combining 58 physician visits with home visits, a telephone information line and 59 monthly parent group sessions. 60 61
The review found that well-child care visits in groups are as effective in providing well-child care as 1-on-1 visits. The evidence also suggested that non-face-to-face formats, particularly Web-based tools, could enhance anticipatory guidance and possibly reduce parents' need for clinical contacts for minor concerns between well-child visits. In addition, the study found that the addition of a non-medical professional trained as a developmental specialist improved receipt of well-child care services and could enhance parenting practices. These interventions were intended to enhance usual care and some reduced acute care utilization.
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and children met with the health educator for 2 hours at each age-specific well child visit to review screening and results, address parent concern, engage in standard anticipatory guides and receive immunizations. The station-to-station model scheduled 40 minute visits and involved 10 minutes with a provider, individual anticipatory guidance with a health educator and measurements and immunizations by a medical assistant. Both types of visits were evaluated using a posttest questionnaire to identify parent concerns and schedule text or phone communication with the healthcare team. The next step is underway, where each model is tested with families randomly chosen to receive the care using either the new delivery model of the old one. The researchers will compare outcomes of the two groups of children by the end of 2014. It is hoped that this research will lead the way in improving the care to families living in low-income communities.
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The new year-long study which was carried out by physicians at Mattel Children's Hospital UCLA built on the previous paper to assess the acceptability and effectiveness of the new models of well-child visits for children in low-income communities The team partnered with two community pediatric practices and a multi-site community health center in Los Angeles. Community Advisory Boards were created to assess the four new models of care based on stakeholder data, a literature review of practice redesign, and a well childcare framework offering alternative structures. An expert panel of physicians and nurse practitioners rated each model for provision of recommended services, family-centeredness, timely follow-up, feasibility and efficiency. The Community Advisory Boards reviewed the results and selected a final model. The Community Advisory Board from the community health center selected a group-visit model and the private practice Community Advisory Board selected an individual; station to station model. Both models involved a brief physical exam with a pediatrician or nurse practitioner and relied on a health educator or “parent coach” for most routine well-child care services. In the group model parents
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Coker, T. R., et al. (2014). Well-child care clinical practice redesign for 112 serving low-income children. Pediatrics, 134, e229. 113
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HOT TOPICS DEPARTMENT Column Editor: Deborah McBride MSN
12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37
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⁎ Corresponding author.
http://dx.doi.org/10.1016/j.pedn.2014.08.003 0882-5963/© 2014 Elsevier Inc. All rights reserved.
care has expanded beyond what can be accomplished in the 38 typical visit, contributing to a wide range of quality and quantity 39 of services received by different providers. The new study builds 40 on an earlier systematic review of strategies and tools by 41 Coker et al. (2014) (http://pediatrics. 42 Q2 aappublications.org/content/131/ 43 Supplement_1/S5.full.pdf) which 44 “Providers are being examined the evidence for various 45 called on to provide models of well-child care. Coker et al. 46 more services than examined the literature on alternative 47 formats of well child care, including: 48 they can realistically
E
10
T
9
C
8
E
7
NEW, MORE EFFICIENT and effective models of well-child care visits are needed. A recent study uses a structured process to evaluate alternative models of well-child care visits based on feasibility, acceptability to parents and clinicians, and cost. The new study is part of a long term project to design a well-child care visit model that reduces reliance on physician time, improves the quality of anticipatory guidance and more effectively addresses parental concerns. Well-child care visits are the cornerstone of pediatric primary care in the United States. They account for more than one-third of all outpatient visits for infants and toddlers and are intended to identify health, social, developmental and behavioral issues that could have a long-term impact on children's lives. However, studies have shown that the current system of well-child care leaves room for improvement. One issue of concern that was identified in the recently revised Academy of American Pediatrics guidelines on pediatric preventative care (http://pediatrics.aappublications.org/ content/133/3/568) was that providers are being called on to provide more services than they can realistically provide in a 15-minute visit. As a result, many children do not get the preventative health care that they need. This is particularly an issue in low-income neighborhoods where children may be facing a high level of unmet psychosocial and behavioral needs and a need for more parenting education. The present structure of the well-child visits in the United States calls for a healthcare provider to provide all of the recommend services in 13 face-to-face visits during the first 5 years of life. Traditionally these services are delivered during clinic visits, but providers are interested in redesigning care delivery, including offering some services outside the clinical setting. The number of recommended services for well-child
R R
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O
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Deborah McBride MSN ⁎
C
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Q1 3
New Models of Well-Child Care Visits
U
2
F
Deborah McBride MSN
provide in a 15-minute
• Group well-child care, where four to six 49 visit. As a result, many families with similarly aged children visit 50 with a provider. children do not get 51the • Non face-to-face formats, such as a 52 preventative health Web-based system for parents to access 53 care that they need.” topics for guidance before a provider 54 visit or instead of a visit. 55 • Non-clinical locations, for example 56 home visits by a nurse practitioner or at a preschool. 57 • Services provided through an interventional program, such as combining 58 physician visits with home visits, a telephone information line and 59 monthly parent group sessions. 60 61
The review found that well-child care visits in groups are as effective in providing well-child care as 1-on-1 visits. The evidence also suggested that non-face-to-face formats, particularly Web-based tools, could enhance anticipatory guidance and possibly reduce parents' need for clinical contacts for minor concerns between well-child visits. In addition, the study found that the addition of a non-medical professional trained as a developmental specialist improved receipt of well-child care services and could enhance parenting practices. These interventions were intended to enhance usual care and some reduced acute care utilization.
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77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94
and children met with the health educator for 2 hours at each age-specific well child visit to review screening and results, address parent concern, engage in standard anticipatory guides and receive immunizations. The station-to-station model scheduled 40 minute visits and involved 10 minutes with a provider, individual anticipatory guidance with a health educator and measurements and immunizations by a medical assistant. Both types of visits were evaluated using a posttest questionnaire to identify parent concerns and schedule text or phone communication with the healthcare team. The next step is underway, where each model is tested with families randomly chosen to receive the care using either the new delivery model of the old one. The researchers will compare outcomes of the two groups of children by the end of 2014. It is hoped that this research will lead the way in improving the care to families living in low-income communities.
95
Reference
111
F
76
The new year-long study which was carried out by physicians at Mattel Children's Hospital UCLA built on the previous paper to assess the acceptability and effectiveness of the new models of well-child visits for children in low-income communities The team partnered with two community pediatric practices and a multi-site community health center in Los Angeles. Community Advisory Boards were created to assess the four new models of care based on stakeholder data, a literature review of practice redesign, and a well childcare framework offering alternative structures. An expert panel of physicians and nurse practitioners rated each model for provision of recommended services, family-centeredness, timely follow-up, feasibility and efficiency. The Community Advisory Boards reviewed the results and selected a final model. The Community Advisory Board from the community health center selected a group-visit model and the private practice Community Advisory Board selected an individual; station to station model. Both models involved a brief physical exam with a pediatrician or nurse practitioner and relied on a health educator or “parent coach” for most routine well-child care services. In the group model parents
D E T C E R R N C O
96 97 98 99 100 101 102 103 104 105 106 107 108 109 110
Coker, T. R., et al. (2014). Well-child care clinical practice redesign for 112 serving low-income children. Pediatrics, 134, e229. 113
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