1 Rethinking Well Child Care: Pediatric Practice and Preventive Care Edward L. Schor, MD New York Hospital Queens September 16, 2010 THECOMMONWEALTHFUND

2 Trajectory of Life Course Health and Development Children’s Well-Being Age Optimal Impaired

3 Children Ready for School Health and physical development Emotional well-being and social competence Curiosity and enthusiasm about learning Communication skills Cognition and general knowledge

4 Family Predictors At Age 2 Associated With Math And Reading Skills At Age 6-7 Minority race Maternal education < high school Language other than English Single parent Few books in house Read to <3 times per week Has named 4 colors 4 or more children Male child Forrest & Pati, 2008

5 Well Child Care/EPSDT Referral & Care Coordination Medical History Physical Exam Procedures Developmental and Behavioral Assessment Anticipatory Guidance and Parent Education Sensory Screening MeasurementsImmunizations Family Psychosocial Assessment

6 Reason for Visit to Pediatrician for Young Children 0-3 Years Commonwealth Fund analysis of MEPS 2000

7 Well Child Care Prevents Hospitalization of Children <2Yrs Avoidable hospitalizations per 1000 Medicaid children California 70.1 Georgia Michigan Children with recent preventive care visit, but not up-to-date (61) 13% (144.8) 10% (103.5) 14% Children with up- to-date preventive care (36.5) 50% (86.9) 46% (89.0) 26% RB Hakim & BV Bye, Pediatrics 2001;108:90-97

8 Children’s Receipt of Recommended Care and Quality Mangione-Smith, et al, NEJM 2007;357: Percent of Recommended Care Received

9 Children 0-5 Whose Parents Were Asked About Concerns About Learning, Development or Behavior National Survey of Child Health, 2003 VT MS X _ NY

10 Well Child Care Utilization By Insurance Status Annual Visits Ages of Children Medical Expenditure Panel Study 2000

11 Parents’ Top Reasons for Attending WCC Promoting Health Immunizations Screening Referrals Requirements School, day care, sports Reassurance Is my child okay? Am I doing okay as a parent? Opportunities for Discussion Parent priorities are key

12 Value of WCC to Parents Key elements of pediatrician- parent-child relationships Emphasis on the child Respect for parental expertise Affect and body language

13 Parent Focus Groups: Suggestions for Enhancing Well-Child Care Improve marketing about visits Improve marketing about visits Increase emphasis on development and behavior Increase emphasis on development and behavior Enhance information exchange Enhance information exchange − Preview of next visit − More efficient use of wait times − Visit summaries − Workshops (group education sessions) − with clinician and office staff − Guide to trustworthy information − Community resources

14 What Do Pediatricians Value Being able to be responsive to parent’s individual concerns and the particular child’s needs Building rapport and a therapeutic relationship with the child and family – Continuity of care – Knowledge of the family – Understand child and family’s development Designing well child care services based on assessment of risk, e.g., chronic illness, poverty Tanner, Stein & Olson, 2007

15 Rethinking Well Child Care 1. Define desired outcomes 2. Revise and individualize the schedule and content of care 3. Use personnel most efficiently 4. Adopt office redesign models and best practices 5. Implement quality improvement processes 6. Use new technologies to create new types of transactions with families 7. Focus on the families

16 Desired Outcomes at School Entry No undetected hearing or vision problem No chronic health problems without a treatment plan Immunizations complete for age No undetected congenital anomalies Good nutritional habits and no obesity No untreated dental caries No exposure to tobacco smoke Live and travel in physically safe environment Physical health and development

17 Desired Outcomes at School Entry No unrecognized or untreated delays (i.e., emotional, social, cognitive, communication) Child has good self- esteem Child recognizes relationship between letters and sounds Child has positive social behaviors with peers and adults Emotional, social and cognitive development

18 Ten Best Practices for WCC 1. Access to care that allows families to receive the care they need when they need it 2. Technology for information transfer and knowledge sharing 3. Reminder and recall systems 4. Two-stage visits with structured assessment 5. Prompting sheets 6. Negotiated care priorities and management 7. Care coordinator position in office 8. Office team approach and co-locating services 9. Monitoring effectiveness & parent surveys 10. Group well child care and parent education

19 High Performance System of Well Child Care Pre-visit assessment to tailor WCC –Development and Socio-emotional screen –Maternal depression, family violence –Child’s strengths and weaknesses –Healthy behaviors –Parent’s concerns Vary frequency and intensity of visit based on bio-psychosocial risk Health care teams Different model for different children –E-visit –Brief MD visit –Standard visit –Extended visit D. Bergman, 2010

20 Well Child Care for Children with Special Health Care Needs Care Coordinator does a pre-visit intake to –Assess current status and family resources –Update and complete the care plan –Set the agenda for visit with the family –Communicate the agenda to the provider by before the visit Care coordinator calls in at end of visit to ensure continued care coordination D. Bergman, 2010

21 Future Well Child Care Intentional, structured individualized, responsive, family-centered, efficient and effective