Well-Child Care Clinical Practice Redesign: A Parent Coach-Led Model of Care for Young Children

点击翻译按钮获取中文摘要

Project Summary Well-Child Care (WCC) visits for child preventive health care during the first three years of life are critical because they may be the only opportunity before a child reaches preschool to identify and address important social, developmental, behavioral, and health issues that could have significant impact and long-lasting effects on children's lives as adults. Unfortunately, this opportunity is often missed for children in low-income communities. The structure of WCC in the U.S. cannot support the vast array of WCC needs of these vulnerable children and their families. Key structural problems include (a) reliance on physicians for basic, routine preventive care services, (b) limitation to a 15-minute face-to-face clinician-directed well-visit for the wide array of education and guidance services needed, and (c) lack of a systematic, patient-driven method for visit customization to meet families' needs. These structural problems contribute to the wide variations in processes of care and preventive care outcomes, resulting in poorer quality of WCC and perhaps worse health outcomes. We previously used a rigorous, structured community-based participatory approach guided by key WCC stakeholders and expert panel methods to develop and test a new, innovative model of WCC delivery to meet the needs of children in low-income communities: Parent-focused Redesign for Encounters, Newborns to Toddlers (PARENT). PARENT is a team-based approach to care using a health educator (“Parent Coach”) to provide the bulk of WCC services, address specific needs faced by families in low-income communities, and decrease reliance on the clinician as the primary provider of WCC services. In an initial pilot randomized controlled trial of PARENT among 251 low-income families in two urban area pediatric practices, we found strong and consistent intervention effects on the quality of preventive care provided to families, and on reducing emergency department (ED) utilization. A larger trial of PARENT with multiple clinics is needed to position PARENT as an evidence-based, financially sustainable model for WCC delivery that can be implemented by practices and clinics nationwide. In a clinic-randomized controlled trial of PARENT, we will examine parent-reported quality of care and healthcare utilization (e.g., ED utilization), conduct a cost analysis, and use direct observations to assess changes in physician time allocation with Parent Coach-led well-visits. The study will be conducted in partnership with 12 clinics and their health plan payers, and address the following Specific Aims: Aim #1: Measure the effect of PARENT on receipt of nationally-recommended WCC services and parent experiences of care. Aim #2: Determine the effects of PARENT on WCC, urgent care, and ED utilization, and on net costs. Aim #3: Examine the effect of PARENT on physician time allocation for WCC and urgent care visits. Aim #4: Assess the effect of PARENT on parent-focused outcomes in an exploratory analysis.