Grand Rounds September 22, 2023: Integrating Community Health Workers into Team-Based, Early Childhood Preventative Care (Tumaini Rucker Coker, MD, MBA)

Posted on by Elizabeth Mccamic

Speaker

Tumaini Rucker Coker, MD, MBA
Professor of Pediatrics
Division Head for General Pediatrics
University of Washington Department of Pediatrics
Seattle Children’s Hospital

Keywords

Pediatrics, Preventive Medicine, Community Health, Well Child Care

Key Points

  • There are 10 preventive care visits from ages 0-3, usually scheduled as 15-20 minute visits with a pediatrician. This may be the only interaction the family has with a healthcare professional, so if there are needs around behavior, health, social needs they will be addressed during these visits. This time is not used appropriately now because there is so much that needs to fit into that visit.
  • The American Academy of Pediatrics (AAP) Bright Futures guidelines for preventive visits include history, measurements, physical exam, developmental and behavioral screening, anticipatory guidance, and psychosocial and social needs screening and guidance.
  • How might we better structure preventive visits? Donabedian’s Quality Framework includes a structure that supports care, a process for the provision and receipt of care, and health outcomes, providing a process without a structure to support it. Adapted for early childhood preventive care, the structure should be team- and community-based.
  • The Parent-Focused Redesign for Encounters, Newborns to Toddlers (PARENT) study was a randomized controlled trial of PARENT verses usual care for parents with infants 12 months and younger over a 12-month study period. The PARENT group added interventions such as a community health worker “parent coach,” a pre-visit tool to help identify parent priorities, a text message service to keep in touch between visits, and a brief, focused clinician visit.
  • In the initial PARENT trial, intervention families had better performance on receipt of well child care, and patients reported better patient experience and fewer emergency department visits. Parents loved the text messaging service.
  • Based on these findings, the research team initiated a larger PARENT trial that had 3 parent coaches at federally qualified health centers. The trial was cluster randomized by clinic for usual care or intervention arms; participants were parents with infants 12 months and younger. The first year was spent allowing the clinics to make the project their own, with input from parents and clinicians.
  • Ten clinics were randomized, and 937 parents participated with 785 completing 12-month follow up. The average child age was 4 months. 93% of participants were Medicaid insured, 95% were mothers, 8% had a college degree, and 63% had a household annual income of less than $30,000. The intervention families had better performance on receipt of well child care services, better parent experiences of care, no change in Emergency Department visits, and were more likely to be up-to-date on well child care visits.
  • Integrating a community health care workers into the well child care team improves well child care for Medicaid-insured children. Evidence for PARENT, and other clinic-based interventions that utilize community health care workers in a team-based approach to early childhood well child care. Clinics and practices will need Medicaid state plan amendments that provide adequate funding for community health care workers in well child care and support for implementation.
  • The research team is in the next phase of local adaptation, having received funding from PCORI for PARENT Adaptation for Black Families: NCH-PCN Partnership. The intervention was quite strong with Latino families but did not have the power to understand what it looks like with Black families. It will be a stepped-wedge randomized trial at 12 Nationwide Primary Care Clinics with adaptations and implementation and parent, staff, and provider engagement.

 

Learn more

Read more about PARENT in JAMA.

Discussion Themes

-What did stakeholder engagement change in the process? From the beginning we did not know what the intervention was going to be. As we went to each new clinical space there were things we could not have anticipated that they wanted to change for their clinic. For example, one local clinic did not have the room space, so the coaches called the family the day before then they could pop in quickly for a brief discussion. Doing the formative work builds ownership of the intervention.

-In areas of quality improvement people often do not consider cluster randomized design or people may be disappointed if they are randomized to usual care. In the PCORI funded trial we are doing stepped wedge so everyone gets the intervention at some point, which was important to our partners. For the first small trial, we randomized at an individual level, which takes a lot of manpower to maintain. Our partners wanted to know at the end of the trial, will this make care better, and when the answer is yes, they are willing to participate. Our partners want to know the data and what it takes to collect it in a rigorous way.

Tags

#pctGR, @Collaboratory1