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

项目摘要 儿童保健(WCC)在生命的头三年为儿童提供预防性保健服务是至关重要的 因为它们可能是孩子在学龄前识别和解决重要问题的唯一机会 可能产生重大影响和长期影响的社会、发展、行为和健康问题 孩子们成年后的生活。不幸的是，对于低收入家庭的孩子来说，这个机会往往被错过了。 社区。美国的WCC结构不能支持这些WCC的大量需求 弱势儿童及其家庭。主要的结构性问题包括：(A)依赖医生提供基本的、 常规预防护理服务，(B)限制15分钟面对面的临床医生指导的良好访问 需要广泛的教育和指导服务；以及(C)缺乏系统的、以病人为导向的方法 访问定制以满足家庭需求。这些结构性问题导致了 护理过程和预防性护理结果，导致WCC质量较差，可能还会导致健康状况恶化 结果。我们以前使用了一种严格的、结构化的、基于社区的参与式方法，由KEY指导 WCC利益相关者和专家小组方法，开发和测试WCC交付的新的创新模式，以 满足低收入社区儿童的需求：《邂逅》以家长为中心的重新设计， 新生儿给托德勒(父母)。家长是一种基于团队的方法，使用健康教育者进行护理 (“家长教练”)提供WCC的大部分服务，解决低收入家庭面临的具体需求 减少对临床医生作为WCC服务主要提供者的依赖。在最初的试行中 市区两个儿科诊所251个低收入家庭父母的随机对照试验， 我们发现，在向家庭提供预防性护理的质量方面，干预效果强烈且始终如一。 降低急诊科使用率。对有多家诊所的父母进行的更大规模的试验是 需要将母公司定位为基于证据的、财务上可持续的WCC交付模式 可在全国范围内通过实践和诊所实施。在一项父母的临床随机对照试验中， 我们将检查家长报告的护理质量和医疗保健利用率(例如，ED利用率)，进行成本 分析，并使用直接观察来评估在家长教练领导下医生时间分配的变化 好的访问。这项研究将与12家诊所及其医疗计划付款人合作进行，并解决 以下是具体目标： 目标1：衡量父母对接受国家推荐的WCC服务和父母的影响 护理的体验。 目的#2：确定父母对WCC、紧急护理和ED利用的影响，以及对净成本的影响。 目的#3：考察父母对WCC和紧急护理就诊医生时间分配的影响。 目的#4：在探索性分析中评估父母对以父母为中心的结果的影响。

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.