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

项目摘要 在生命的前三年，儿童保健中心（WCC）的儿童预防保健访问至关重要 因为这可能是孩子进入学前班之前唯一的机会， 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，低收入家庭的儿童往往错过了这一机会。 社区.美国的WCC结构无法支持这些国家的WCC需求的广泛阵列。 弱势儿童及其家庭。关键的结构性问题包括：（a）基本医疗服务依赖医生， 常规预防保健服务，（B）限于15分钟的面对面的临床医生指导下， 需要广泛的教育和指导服务，以及（c）缺乏系统的、病人驱动的方法， 参观定制，满足家庭需求。这些结构性问题造成了 护理过程和预防性护理结果，导致WCC质量较差，健康状况可能更差 结果。我们以前使用的是严格的、结构化的、以社区为基础的参与式方法， WCC利益相关者和专家小组的方法，以开发和测试一个新的，创新的WCC交付模式， 满足低收入社区儿童的需求：以父母为中心的相遇重新设计， 新生儿教育（PANEL）。PAGRESS是一种以团队为基础的方法，使用健康教育者进行护理 （“家长教练”）提供大部分的WCC服务，解决低收入家庭面临的具体需求， 社区，并减少对临床医生作为WCC服务的主要提供者的依赖。在最初的试点中， 在两个城市地区儿科诊所的251个低收入家庭中进行的随机对照试验， 我们发现，对提供给家庭的预防保健质量的干预效果是强有力的，而且 减少急诊科（艾德）的使用。在多个诊所进行的一项更大规模的PAglutamine试验是 需要将PAGNET定位为WCC交付的基于证据的，财务上可持续的模式， 可以在全国范围内的诊所和诊所实施。在一项临床随机对照试验中， 我们将检查父母报告的护理质量和保健利用（例如，艾德利用），进行成本核算 分析，并使用直接观察来评估家长指导下医生时间分配的变化 良好的访问。该研究将与12家诊所及其健康计划支付者合作进行，并解决 以下具体目标： 目标#1：衡量PAGRENT对接受国家推荐的WCC服务和父母的影响 照顾的经验。 目的#2：确定PAglutamine对WCC、紧急护理和艾德利用率以及净成本的影响。 目的#3：检查PAglutamine对WCC和紧急护理访视的医生时间分配的影响。 目的#4：在探索性分析中评估PAglutamine对以父母为中心的结局的影响。

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.