Redesigning the well-child checkup
Sandra Contreras, a parent coach, meets with Kioki Johnson and her family during a well-child checkup at Wee Care Associates.
Well-child visits are the foundation of pediatric primary care in the U.S. Accounting for more than one-third of all outpatient visits for infants and toddlers, the appointments are intended to give doctors the opportunity to identify health, social, developmental and behavioral issues that could have a long-term impact on children's lives.
However, several studies have shown that the current system of well-child care leaves room for improvement. One major concern is that well-child care guidelines issued by the American Academy of Pediatrics call for physicians to provide more services than can realistically be completed within a 15-minute office visit. As a result, many children do not get all of the preventive care services that they need — and the problem is more acute for low-income families, thanks largely due to their greater psychosocial and developmental needs for and greater need for parenting education.
In a year-long study led by Dr. Tumaini Coker, an assistant professor of pediatrics at UCLA Mattel Children's Hospital, researchers developed a new design for preventive health care for children from birth through age 3 from low-income communities. The team partnered with two community pediatric practices and a multi-site community health center in greater Los Angeles.
"The usual way of providing preventive care to young children is just not meeting the needs of the low-income families served by these clinics and practices," said Coker, who also is a researcher with the hospital's UCLA Children's Discovery and Innovation Institute. "Our goal was to create an innovative and reproducible — but locally customizable — approach to deliver comprehensive preventive care that is more family-centered, effective and efficient."
The researchers created two working groups of pediatric clinicians, staff, clinic leadership and parents to design the new models of care. One working group was at South Bay Family Health Care, and another working group combined the efforts of two pediatric practices, the Yovana Bruno Pediatric Clinic in Duarte, California, and Wee Care Associates (led by Dr. Toni Johnson-Chavis), in Compton and Norwalk, California.
To design the new models of care, researchers gathered input from two sources. First, they solicited ideas from pediatricians, parents and health plan representatives about topics such as having non-physicians provide routine preventive care and using "alternative visit formats" — meeting with health care providers in alternative locations, meeting in groups as opposed to one-on-one, or getting providers' advice electronically instead of in person, for example. Secondly, the teams surveyed existing literature on alternative providers, locations and formats for well-child care.
Using that input, the clinic working groups developed four possible new models of care that it submitted for review by a panel of experts on preventive care practice redesign. Based on the panel's rankings, the working groups selected two models to implement and test — one for the private practices and the other for the community clinic. The private practices adopted a one-on-one visit format while the community clinic used a group-visit format, but the two models shared several characteristics:
- A trained health educator, or "parent coach," at each facility who relieves the physician of some of the more routine services and provides preventive health education and guidance, parenting education, and comprehensive but efficient preventive health services related to development, behavior and family psychosocial concerns.
- A considerably longer preventive care visit.
- A website that enables parents to customize their child's specific needs prior to their visit.
- Scheduled text messages or phone calls enabling the health care team to communicate with parents.
These findings were reported online June 16 in the journal Pediatrics.
The next stage of research is already underway: The team is testing the model selected by the two private practices in those clinical settings, with families randomly chosen to receive the care using either the new delivery model and or the old one. Researchers will compare outcomes for the two groups of children by the end of 2014. The community clinic is currently implementing its selected model, and testing will begin there in July.
"For clinics and practices that provide child preventive health care to families living in low-income communities, the process we used to develop the new models — or the new models themselves — could help them bring innovation to their own practices," Coker said.
The study was funded by grants from the National Institutes of Health's National Institute of Child Health and Development and the Health Resources and Service Administration.
The study's other authors were Dr. Paul Chung and Dr. Paul Shekelle of UCLA, Candice Moreno of the University of Illinois College of Medicine and Dr. Mark Schuster of Harvard Medical School. The authors have no financial ties relevant to this article to disclose.