Well-Child Care Clinical Practice Redesign for Serving Low-Income Children

Coker TR(1), Moreno C(2), Shekelle PG(3), Schuster MA(4), Chung PJ(5).

Pediatrics. 2014 Jul;134(1):e229-39. doi: 10.1542/peds.2013-3775. Epub 2014 Jun

Our objective was to conduct a rigorous, structured process to create a new model of well-child care (WCC) in collaboration with a multisite community health center and 2 small,   independent practices serving predominantly Medicaid-insured children. Working groups of clinicians, staff, and parents (called “Community Advisory Boards” [CABs]) used (1) perspectives of WCC stakeholders and (2) a literature review of WCC practice redesign to create 4 comprehensive WCC models for children ages 0 to 3 years. An expert panel, following a modified version of the Rand/UCLA Appropriateness Method, rated each model for potential effectiveness on 4 domains: (1) receipt of recommended services, (2) family-centeredness, (3) timely and appropriate follow-up, and (4) feasibility and efficiency. Results were provided to the CABs for selection of a final model to implement. The newly developed models rely heavily on a health educator for anticipatory guidance and developmental, behavioral, and psychosocial surveillance and screening. Each model allots a small amount of time with the pediatrician to perform a brief physical examination and to address parents' physical health concerns. A secure Web-based tool customizes the visit to parents' needs and facilitates previsit screening. Scheduled, non–face-to-face methods (text, phone) for parent communication with the health care team are also critical to these new models of care. A structured process that engages small community practices and community health centers in clinical practice redesign can produce comprehensive, site-specific, and innovative models for delivery of WCC. This process, as well as the models developed, may be applicable to other small practices and clinics interested in practice redesign.

Group Well-Child Care: An Analysis of Cost.

• Hiromi Yoshida, 
• Ada M. Fenick, 
• and Marjorie S. Rosenthal

CLIN PEDIATR 0009922813512418, first published on December 10, 2013  doi:10.1177/0009922813512418
Objective.To determine if group well-child visits (WCV) can be cost neutral compared with individual WCV by varying health care providers, group size, and physician salary.Method. We created 6 economic models to evaluate the costs of WCV: 3 for individual WCV delivered by (1) advanced practice registered nurse (APRN), (2) resident, and (3) attending and 3 for group WCV delivered by (4) APRN with a nurse and social worker; (5) resident with an attending, nurse, and child life specialist; and (6)attending with a nurse. For group WCV, we performed sensitivity analyses on group size and duration of provider participation. Results. We achieved cost-neutrality at 4 families in the APRN group WCV model; at 3, 4, 5, and 6 families in the resident model with 30, 45, 60, and 90 minutes of attending supervision, respectively; and at 4 and 5 families in the low and high attending salary model, respectively. Conclusion. Group WCV can be delivered in a cost-neutral manner by optimizing group size and provider participation.

Well-Child Care Clinical Practice Redesign for Young Children: A Systematic Review of Strategies and Tools

PEDIATRICS 2013 Vol. 131 No. Supplement 1 March 1, pp. S5 -S25

Tumaini R. Coker, MD, MBA^a,^b,^c, 

Annika Windon, AB^d,

Candice Moreno, MD, MPH^a,^b, 

Mark A. Schuster, MD, PhD^e,^f, and

Paul J. Chung, MD, MS^a,^b,^c,^g

1. BACKGROUND AND OBJECTIVE: Various proposals have been made to redesign well-child care (WCC) for young children, yet no peer-reviewed publication has examined the evidence for these. The objective of this study was to conduct a systematic review on WCC clinical practice redesign for children aged 0 to 5 years.
   METHODS: PubMed was searched using criteria to identify relevant English-language articles published from January 1981 through February 2012. Observational studies, controlled trials, and systematic reviews evaluating efficiency and effectiveness of WCC for children aged 0 to 5 were selected. Interventions were organized into 3 categories: providers, formats (how care is provided; eg, non–face-to-face formats), and locations for care. Data were extracted by independent article review, including study quality, of 3 investigators with consensus resolution of discrepancies.
   RESULTS: Of 275 articles screened, 33 met inclusion criteria. Seventeen articles focused on providers, 13 on formats, 2 on locations, and 1 miscellaneous. We found evidence that WCC provided in groups is at least as effective in providing WCC as 1-on-1 visits. There was limited evidence regarding other formats, although evidence 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. The addition of a non–medical professional trained as a developmental specialist may improve receipt of WCC services and enhance parenting practices. There was insufficient evidence on nonclinical locations for WCC.
   CONCLUSIONS: Evidence suggests that there are promising WCC redesign tools and strategies that may be ready for larger-scale testing and may have important implications for preventive care delivery to young children in the United States.