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Rethinking Well Child Care: Pediatric Practice and Preventive Care Edward L. Schor, MD New York Hospital Queens September 16, 2010 THE COMMONWEALTH FUND 1 Trajectory of Life Course Health and Development Children’s Well-Being Optimal Impaired Age 2 Children Ready for School • Health and physical development • Emotional well-being and social competence • Curiosity and enthusiasm about learning • Communication skills • Cognition and general knowledge 3 Family Predictors At Age 2 Associated With Math And Reading Skills At Age 6-7 • • • • • • • • • Minority race Maternal education < high school Language other than English Single parent Few books in house Read to <3 times per week Has named 4 colors 4 or more children Male child 4 Forrest & Pati, 2008 Well Child Care/EPSDT Referral & Care Coordination Medical History Anticipatory Guidance and Parent Education Developmental and Behavioral Assessment Family Psychosocial Assessment Physical Exam Procedures Immunizations Sensory Screening Measurements 5 Reason for Visit to Pediatrician for Young Children 0-3 Years 50 % 42 % 4% Preventive Visit Sick Visit Follow-up Visit Commonwealth Fund analysis of MEPS 2000 1% Psychosocial Problem 4% Other 6 Well Child Care Prevents Hospitalization of Children <2Yrs Avoidable hospitalizations per 1000 Medicaid children Children with recent preventive care visit, but not up-to-date Children with upto-date preventive care California 70.1 Georgia 160.9 Michigan 120.3 (61) (144.8) (103.5) 13% 10% 14% (36.5) (86.9) (89.0) 50% 46% 26% 7 RB Hakim & BV Bye, Pediatrics 2001;108:90-97 Children’s Receipt of Recommended Care and Quality Percent of Recommended Care Received 47% Overall Care 68% 53% 41% Preventive Care Acute Care Chronic Care 8 Mangione-Smith, et al, NEJM 2007;357:1515-23 Children 0-5 Whose Parents Were Asked About Concerns About Learning, Development or Behavior 70 66 % 60 50 48 % VT 40 _ X 30 40 % 37 % NY MS 20 10 0 High Mean New York Low 9 National Survey of Child Health, 2003 Well Child Care Utilization By Insurance Status Recommended Well Visits Insured Uninsured Annual Visits 5 4 3 2 1 0 <1 year 1-2 years 3-4 years 5-6 years Ages of Children 7-11 years 12-18 years 10 Medical Expenditure Panel Study 2000 Parents’ Top Reasons for Attending WCC • Promoting Health Immunizations Screening Referrals • Requirements School, day care, sports • Reassurance Is my child okay? Am I doing okay as a parent? • Opportunities for Discussion Parent priorities are key 11 Value of WCC to Parents • Key elements of pediatricianparent-child relationships Emphasis on the child Respect for parental expertise Affect and body language 12 Parent Focus Groups: Suggestions for Enhancing Well-Child Care • Improve marketing about visits • Increase emphasis on development and behavior • Enhance information exchange − Preview of next visit − More efficient use of wait times − Visit summaries − Workshops (group education sessions) − Email with clinician and office staff − Guide to trustworthy information − Community resources 13 What Do Pediatricians Value • Being able to be responsive to parent’s individual concerns and the particular child’s needs • Building rapport and a therapeutic relationship with the child and family – Continuity of care – Knowledge of the family – Understand child and family’s development • Designing well child care services based on assessment of risk, e.g., chronic illness, poverty 14 Tanner, Stein & Olson, 2007 Rethinking Well Child Care 1. Define desired outcomes 2. Revise and individualize the schedule and content of care 3. Use personnel most efficiently 4. Adopt office redesign models and best practices 5. Implement quality improvement processes 6. Use new technologies to create new types of transactions with families 7. Focus on the families 15 Desired Outcomes at School Entry Physical health and development • No undetected hearing or vision problem • No chronic health problems without a treatment plan • Immunizations complete for age • No undetected congenital anomalies • Good nutritional habits and no obesity • No untreated dental caries • No exposure to tobacco smoke • Live and travel in physically safe environment 16 Desired Outcomes at School Entry Emotional, social and cognitive development • No unrecognized or untreated delays (i.e., emotional, social, cognitive, communication) • Child has good selfesteem • Child recognizes relationship between letters and sounds • Child has positive social behaviors with peers and adults 17 Ten Best Practices for WCC 1. Access to care that allows families to receive the care they need when they need it 2. Technology for information transfer and knowledge sharing 3. 4. 5. 6. 7. 8. 9. 10. Reminder and recall systems Two-stage visits with structured assessment Prompting sheets Negotiated care priorities and management Care coordinator position in office Office team approach and co-locating services Monitoring effectiveness & parent surveys Group well child care and parent education 18 High Performance System of Well Child Care • Pre-visit assessment to tailor WCC – – – – – Development and Socio-emotional screen Maternal depression, family violence Child’s strengths and weaknesses Healthy behaviors Parent’s concerns • Vary frequency and intensity of visit based on bio-psychosocial risk • Health care teams • Different model for different children – – – – E-visit Brief MD visit Standard visit Extended visit D. Bergman, 2010 19 Well Child Care for Children with Special Health Care Needs • Care Coordinator does a pre-visit intake to – Assess current status and family resources – Update and complete the care plan – Set the agenda for visit with the family – Communicate the agenda to the provider by email before the visit • Care coordinator calls in at end of visit to ensure continued care coordination 20 D. Bergman, 2010 Future Well Child Care Intentional, structured individualized, responsive, family-centered, efficient and effective 21