Implementing an Intervention to Address Social Determinants of Health in Pediatric Practices

项目摘要 众所周知，社会决定因素影响儿童的健康轨迹，特别是对低收入儿童。 儿科初级保健为解决儿童的社会状况提供了独特的机会；然而，最近 国家数据显示，很少有供应商在访问时例行筛选未得到满足的需求。我们之前的工作是 重点是发展以儿科初级保健为基础的干预措施，“我们关心”，旨在解决贫困问题 家庭的物质需求--粮食安全、就业、父母教育、住房稳定、家庭供暖、 和儿童保育--通过系统地筛选这些需求并将家庭转介到现有的以社区为基础的 服务。到目前为止，我们主要在社区卫生中心(CHC)测试了我们的护理；我们的RCT 证明了我们关怀对父母接受社区资源的有效性。尽管演示了 我们关怀在这种环境中的影响是重要的，超过80%的低收入儿童得到了提供者的关怀 传统的儿科做法(即非儿童保健中心)。鉴于《平价医疗法案》对高价值、患者- 以初级保健和儿科专业指南为中心，以及WE CARE的疗效数据，我们认为 我们处于有利地位，可以在传统的儿科实践中测试和实施我们的护理。我们提议一个大型的- 规模，混合型2有效性-在美国28个儿科实践中的实施试验。一级台阶 楔形研究集群RCT设计将用于在所有实践中实施We Care，使用两个常见的 用于将以系统为基础的干预措施整合到初级保健中的战略--我们以前协助的“现场” 内容专家提供培训课程和持续咨询的战略；以及自我指导的 “基于网络”的方法模仿美国儿科学会的实践转型战略。这个 提出的研究的具体目的是：1)证明自我导向的、基于网络的 实施我们关怀的战略，与促进现场战略相比较；2)展示我们 CARE在增加父母获得社区资源方面的有效性；以及3)评估可持续性 我们在儿科实践中所关心的。我们假设我们关心的人将通过这两种方式具有同等的保真度 战略。根据我们之前的工作，我们假设我们关心的人会显著增加父母的收入 与常规护理相比，访问后六个月社区资源的减少。我们也希望我们会关心 在实施后持续1年、2年和3年。我们预计将从9000多份图表审查中收集数据， 2800名亲子二人组，150名提供者和办公室工作人员。我们的建议是创新的，因为它挑战 在就诊时处理社会决定因素的当前儿科实践。这项提议引起了公众的广泛关注。 向低收入儿童提供初级保健对健康的影响，并与儿童基金会的使命相一致 NICHD。我们的长期目标是传播循证干预措施，系统地解决 健康的社会决定因素与为全美低收入儿童提供护理的儿科实践有关。

Project Summary It is known that social determinants influence children’s health trajectories, particularly for low-income children. Pediatric primary care provides a unique opportunity to address children’s social conditions; however, recent national data demonstrates that few providers routinely screen for unmet needs at visits. Our prior work has focused on developing a pediatric primary care-based intervention, “WE CARE,” aimed at addressing poor families’ material needs – food security, employment, parental education, housing stability, household heat, and childcare – by systematically screening for these needs and referring families to existing community-based services. To date, we have tested WE CARE primarily in community health centers (CHCs); our RCT demonstrated WE CARE’s efficacy on parental receipt of community-based resources. Although demonstrating WE CARE’s impact in this setting is important, over 80% of low-income children receive care from providers in traditional pediatric practices (i.e. non-CHCs). Given the Affordable Care Act’s mandate for high-value, patient- centered primary care and pediatric professional guidelines, along with WE CARE’s efficacy data, we believe we are well-positioned to test and implement WE CARE in traditional pediatric practices. We propose a large- scale, Hybrid Type 2 effectiveness-implementation trial in twenty eight pediatric practices in the US. A stepped wedge study cluster RCT design will be used to implement WE CARE in all practices using two common strategies used to integrate systems-based interventions into primary care – our previously facilitated “on-site” strategy in which content experts provide training sessions and on-going consultation; and a self-directed “web-based” method modeled after the American Academy of Pediatrics’ practice transformation strategy. The proposed study’s specific aims are to: 1) demonstrate the non-inferiority of the self-directed, web-based strategy for implementing WE CARE, in comparison to the facilitated on-site strategy; 2) demonstrate WE CARE’s effectiveness on increasing parental receipt of community resources; and 3) assess the sustainability of WE CARE in pediatric practices. We hypothesize that WE CARE will have equivalent fidelity via the two strategies. Based on our prior work, we hypothesize that WE CARE will significantly increase parental receipt of community resources six months post-visit compared to usual care. We also expect WE CARE to be sustained 1-, 2-, and 3-years post-implementation. We expect to gather data from over 9,000 chart reviews, 2,800 parent-child dyads, and 150 providers and office staff. Our proposal is innovative because it challenges current pediatric practice for addressing social determinants at visits. This proposal has significant public health implications for the delivery of primary care to low-income children and is aligned with the mission of the NICHD. Our long-term goal is to disseminate an evidence-based intervention that systematically addresses the social determinants of health to pediatric practices that provide care to low-income children throughout the US.