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Keim-Malpass J, Lunsford C, Letzkus LC, Scheer E, Valdez RS. Establishing the Need for Anticipatory Symptom Guidance and Networked Models of Disease in Adaptive Family Management Among Children With Medical Complexity: Qualitative Study. JMIR Form Res 2023; 7:e52454. [PMID: 37801346 DOI: 10.2196/52454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/04/2023] [Accepted: 10/06/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Caregivers of children with medical complexity navigate complex family management tasks for their child both in the hospital and home-based setting. The roles and relationships of members of their social network and the dynamic evolution of these family management tasks have been underexamined. OBJECTIVE The purpose of this study was to explore the structures and processes of family management among caregivers of children with medical complexity, with a focus on the underlying dynamic nature of family management practices and the role of members of their social network. METHODS This study used a qualitative approach to interview caregivers of children with medical complexity and members of their social network. Caregivers of children with medical complexity were recruited through an academic Children's Hospital Complex Care Clinic in the mid-Atlantic region and interviewed over a period of 1 to 3 days. Responses were analyzed using constructivist grounded theory and situational analysis to construct a new conceptual model. Only caregiver responses are reported here. RESULTS In total, 20 caregivers were included in this analysis. Caregiver perspectives revealed the contextual processes that allowed for practices of family management within the setting of rapidly evolving symptoms and health concerns. The dynamic and adaptive nature of this process is a key underlying action supporting this novel conceptual model. The central themes underpinning the adaptive family management model include symptom cues, ongoing surveillance, information gathering, and acute on chronic health concerns. The model also highlights facilitators and threats to successful family management among children with medical complexity and the networked relationship among the structures and processes. CONCLUSIONS The adaptive family management model provides a basis for further quantitative operationalization and study. Previously described self- or family management frameworks do not account for the underlying dynamic nature of the disease trajectory and the developmental stage progression of the child or adolescent, and our work extends existing work. For future work, there is a defined role for technology-enhanced personalized approaches to home-based monitoring. Due to the disparities caregivers and the children in this population already experience, technology-enhanced approaches must be built alongside key stakeholders with an equity orientation to technology co-development. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.2196/14810.
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Affiliation(s)
- Jessica Keim-Malpass
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, United States
| | - Christopher Lunsford
- Department of Physical Medicine and Rehabilitation, Duke University School of Medicine, Durham, NC, United States
| | - Lisa C Letzkus
- Division of Developmental Pediatrics, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, United States
| | - Eleanore Scheer
- Department of Systems and Information Engineering, University of Virginia School of Engineering and Applied Sciences, Charlottesville, VA, United States
| | - Rupa S Valdez
- Department of Systems and Information Engineering, University of Virginia School of Engineering and Applied Sciences, Charlottesville, VA, United States
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, United States
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Keim-Malpass J, Constantoulakis L, Shaw EK, Letzkus LC. Lagging coverage for mental health services among children and adolescents through home and community-based Medicaid waivers. J Child Adolesc Psychiatr Nurs 2023; 36:21-27. [PMID: 36075862 PMCID: PMC10087945 DOI: 10.1111/jcap.12392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 07/20/2022] [Accepted: 08/24/2022] [Indexed: 02/04/2023]
Abstract
PROBLEM Many states cover mental health home and community-based services (HCBS) for youth through 1915(c) Medicaid HCBS waivers that allow states to waive certain Medicaid eligibility criteria and define high-risk populations based on age, medical condition(s), and disability status. We sought to evaluate how States are covering children and adolescents with mental health needs through 1915(c) waivers compared to other youth waiver populations. METHODS Data elements were extracted from Medicaid 1915(c) approved waivers applications for all included waivers targeting any pediatric age range through October 31, 2018. Normalization criteria were developed and an aggregate overall coverage score and level of funding per person per waiver were calculated for each waiver. FINDINGS One hundred and forty-two waivers across 45 states were included in this analysis. Even though there was uniformity in the Medicaid applications, there was great heterogeneity in how waiver eligibility, transition plans, services covered, and wait lists were defined across group classifications. Those with mental health needs (termed serious emotional disturbance) represented 5% of waivers with the least annual funding per person per waiver. CONCLUSIONS We recommend greater links between public policy, infrastructure, health care providers, and a family-centered approach to extend coverage and scope of services for children and adolescents with mental health needs.
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Affiliation(s)
- Jessica Keim-Malpass
- Department of Acute and Specialty Care, School of Nursing, University of Virginia, Charlottesville, Virginia, USA.,Department of Pediatrics, School of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Leeza Constantoulakis
- Department of Acute and Specialty Care, School of Nursing, University of Virginia, Charlottesville, Virginia, USA
| | - Emily K Shaw
- Atlantic Medical Group Child Development Center, Morristown, New Jersey, USA
| | - Lisa C Letzkus
- Department of Acute and Specialty Care, School of Nursing, University of Virginia, Charlottesville, Virginia, USA.,Department of Pediatrics, School of Medicine, University of Virginia, Charlottesville, Virginia, USA
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Alonzo CJ, Letzkus LC, Connaughton EA, Kelly NL, Michel JA, Zanelli SA. High Prevalence of Abnormal General Movements in Hospitalized Very Low Birth Weight Infants. Am J Perinatol 2022; 29:1541-1547. [PMID: 33535241 DOI: 10.1055/s-0041-1722943] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Abnormal general movements (GMs) are predictive of later risk of motor impairments in preterm infants. The goals of this study are to (1) describe the implementation of the GM assessment (GMA) in a neonatal intensive care unit (NICU) and (2) investigate the prevalence and evolution of abnormal GMs in very low birth weight (VLBW) infants. STUDY DESIGN Observational study of GMs in VLBW infants (gestational age [GA] <32 weeks and/or birth weight [BW] <1,500 g) following GMA implementation in a level-IV NICU. All VLBW infants admitted between November 2017 and April 2019 were eligible for the GMA. Infants were excluded if they required high-frequency ventilation or if they could not be unbundled for video acquisition. GMAs were scored weekly by at least 2 GMA-certified providers. RESULTS The GMA was performed in 121 VLBW infants with a mean (standard deviation [SD]) GA of 28.3 (2.6) and BW of 1,113 (400 g). Only 28% of infants had normal GMs on initial assessment (32.9 ± 2.7 weeks' GA), while 61 and 11% had poor repertoire and cramped-synchronized GMs, respectively. At NICU discharge (37.6 ± 3.4 weeks corrected GA), 45 and 21% of infants were classified as having poor repertoire and cramped-synchronized GMs, respectively. Most infants with cramped-synchronized GMs on initial assessment had persistent abnormal GMs at discharge. In contrast, only one infant with normal GMs on first assessment developed cramped-synchronized GMs. CONCLUSION Abnormal GMs are common in VLBW infants, including a high prevalence of the more concerning cramped-synchronized movement pattern. The GMA can be successfully performed in VLBW infants. The GMA may be helpful in identifying infants at increased risk of later motor impairments, as well as assisting clinicians, in the stratification of infants who may benefit from additional brain imaging and/or an intensive hospital-based interventions. KEY POINTS · Abnormal GMs are common in VLBW infants.. · Poor repertoire in the most prevalent pattern observed.. · Infants at risk for abnormal motor outcomes can be identified in the NICU..
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Affiliation(s)
- Corrie J Alonzo
- Department of Pediatrics, Division of Neonatology, University of Virginia, Charlottesville, Virginia
| | - Lisa C Letzkus
- Department of Pediatrics, Division of Developmental Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Elizabeth A Connaughton
- Department of Rehabilitation services, Department of Physical Therapy, University of Virginia, Charlottesville, Virginia
| | - Nancy L Kelly
- Department of Rehabilitation services, Department of Physical Therapy, University of Virginia, Charlottesville, Virginia
| | - Joseph A Michel
- Department of Pediatrics, Division of Neonatology, University of Virginia, Charlottesville, Virginia
| | - Santina A Zanelli
- Department of Pediatrics, Division of Neonatology, University of Virginia, Charlottesville, Virginia
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Valdez RS, Lunsford C, Bae J, Letzkus LC, Keim-Malpass J. Self-Management Characterization for Families of Children With Medical Complexity and Their Social Networks: Protocol for a Qualitative Assessment. JMIR Res Protoc 2020; 9:e14810. [PMID: 32012094 PMCID: PMC7005691 DOI: 10.2196/14810] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 10/31/2019] [Accepted: 12/16/2019] [Indexed: 11/13/2022] Open
Abstract
Background Children with medical complexity (CMC) present rewarding but complex challenges for the health care system. Transforming high-quality care practices for this population requires multiple stakeholders and development of innovative models of care. Importantly, care coordination requires significant self-management by families in home- and community-based settings. Self-management often requires that families of CMC rely on vast and diverse social networks, encompassing both online and offline social relationships with individuals and groups. The result is a support network surrounding the family to help accomplish self-management of medical tasks and care coordination. Objective The goal of this study is to use a theoretically driven perspective to systematically elucidate the range of self-management experiences across families of CMC embedded in diverse social networks and contextual environments. This approach will allow for characterization of the structure and process of self-management of CMC with respect to social networks, both in person and digitally. This research proposal aims to address the significant gaps in the self-management literature surrounding CMC, including the following: (1) how self-management responsibilities are distributed and negotiated among the social network and (2) how individual-, family-, and system-level factors influence self-management approaches for CMC from a theoretically driven perspective. Methods This study will encompass a qualitative descriptive approach to understand self-management practices among CMC and their social networks. Data collection and analysis will be guided by a theoretical and methodological framework, which synthesizes perspectives from nursing, human factors engineering, public health, and family counseling. Data collection will consist of semistructured interviews with children, parents, and social network members, inclusive of individuals such as friends, neighbors, and community members, as well as online communities and individuals. Data analysis will consist of a combination of inductive and deductive methods of qualitative content analysis, which will be analyzed at both individual and multiadic levels, where interview data from two or more individuals, focused on the same experience, will be comparatively analyzed. Results This study will take approximately 18 months to complete. Our long-term goals are to translate the qualitative analysis into (1) health IT design guidance for innovative approaches to self-management and (2) direct policy guidance for families of CMC enrolled in Medicaid and private insurance. Conclusions Multiple innovative components of this study will enable us to gain a comprehensive and nuanced understanding of the lived experience of self-management of CMC. In particular, by synthesizing and applying theoretical and methodological approaches from multiple disciplines, we plan to create novel informatics and policy solutions to support their care within home and community settings. International Registered Report Identifier (IRRID) PRR1-10.2196/14810
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Affiliation(s)
- Rupa S Valdez
- Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA, United States
| | - Christopher Lunsford
- Department of Orthopaedics, School of Medicine, Duke University, Durham, NC, United States
| | - Jiwoon Bae
- Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA, United States
| | - Lisa C Letzkus
- School of Nursing, University of Virginia, Charlottesville, VA, United States
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Keim-Malpass J, Constantoulakis L, Letzkus LC. Variability In States’ Coverage Of Children With Medical Complexity Through Home And Community-Based Services Waivers. Health Aff (Millwood) 2019; 38:1484-1490. [DOI: 10.1377/hlthaff.2018.05413] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Jessica Keim-Malpass
- Jessica Keim-Malpass is an assistant professor in the School of Nursing, University of Virginia, in Charlottesville
| | - Leeza Constantoulakis
- Leeza Constantoulakis is a research assistant in the School of Nursing, University of Virginia
| | - Lisa C. Letzkus
- Lisa C. Letzkus is a nurse scientist in the School of Nursing, University of Virginia and University of Virginia Medical Center
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Keim-Malpass J, Letzkus LC, Constantoulakis L. Publicly Funded Home and Community-Based Care for Children With Medical Complexity: Protocol for the Analysis of Medicaid Waiver Applications. JMIR Res Protoc 2019; 8:e13062. [PMID: 31344668 PMCID: PMC6686641 DOI: 10.2196/13062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 06/14/2019] [Accepted: 07/05/2019] [Indexed: 11/16/2022] Open
Abstract
Background Children with medical complexity are a group of children with multiple chronic conditions and functional limitations that represent the highest health care utilization and often require a substantial number of home and community-based services (HCBS). In many states, HCBS are offered to target populations through 1915(c) Medicaid waivers. To date, no standard methods or approaches have been established to evaluate or compare 1915(c) waivers across states in the United States for children. Objective The purpose of this analysis was to develop a systematic and reproducible approach to evaluate 1915(c) Medicaid waivers for overall coverage of children with medical complexity. Methods Data elements were extracted from Medicaid 1915(c) approved waiver applications for all included waivers targeting any pediatric age range through October 31, 2018. Normalization criteria were established, and an aggregate overall coverage score was calculated for each waiver. Results Data extraction occurred in two phases: (1) waivers that were considered nonexpired through December 31, 2017, and (2) the final sample that included nonexpired waivers through October 31, 2018. A total of 142 waivers across 45 states in the United States were included in this analysis. We found that the existing adult HCBS taxonomy may not always be applicable for child and family-based service provision. Although there was uniformity in the Medicaid applications, there was high heterogeneity in how waiver eligibility, transition plans, and wait lists were defined. Study analysis was completed in January 2019, and after analyzing each individual waiver, results were aggregated at the level of the state and for each diagnostic subgroup. The published results are forthcoming. Conclusions To our knowledge, this is the first study to systematically evaluate 1915(c) Medicaid waivers targeting children with medical complexity that can be replicated without the threat of missing data. International Registered Report Identifier (IRRID) RR1-10.2196/13062
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Affiliation(s)
| | - Lisa C Letzkus
- University of Virginia School of Nursing, Charlottesville, VA, United States
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Keim-Malpass J, Letzkus LC, Kennedy C. Parent/caregiver health literacy among children with special health care needs: a systematic review of the literature. BMC Pediatr 2015; 15:92. [PMID: 26242306 PMCID: PMC4525748 DOI: 10.1186/s12887-015-0412-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Accepted: 07/28/2015] [Indexed: 11/10/2022] Open
Abstract
Background Children with special health care needs (CSHCN) are children with medical or behavioral diagnoses that require services beyond those generally needed by pediatric populations. They account for a significant portion of pediatric health care expenditures and often have complicated treatment regiments. Health literacy has recently been recognized as a key indicator of quality chronic disease self-management and parental/caregiver health literacy of CSHCN is an understudied area. The purpose of this systematic review was to assess the available evidence of studies investigating parent/caregiver health literacy of CSHCN. Methods Databases were searched to retrieve relevant articles for inclusion (dating from 1998 to 2014). Only studies that assessed the relationship between parent/caregiver health literacy on outcomes pertinent to CSHCN were included. Because of the limited number of studies, there were no restrictions placed on type of outcome. Results Thirteen studies were included in the final review with a range of health literacy assessments and outcome ascertainment. The majority of studies; (1) focused on the relationship between parental/caregiver health literacy and asthma outcomes, (2) were cross-sectional study designs, and (3) included samples recruited from pediatric clinics in academic medical settings. Conclusions There were several gaps in the literature where future research is needed including; (1) direct assessment of child/adolescent health literacy, (2) inclusion of children with co-morbid conditions, (3) further assessment of the relationship between health literacy and health care utilization and cost, and (4) assessment of parental/caregiver health literacy in the inpatient care setting.
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Affiliation(s)
- Jessica Keim-Malpass
- University of Virginia School of Nursing, P.O. Box 800782, Charlottesville, 22908, VA, USA.
| | - Lisa C Letzkus
- University of Virginia School of Nursing, P.O. Box 800782, Charlottesville, 22908, VA, USA. .,University of Virginia Children's Hospital, Charlottesville, VA, USA.
| | - Christine Kennedy
- University of Virginia School of Nursing, P.O. Box 800782, Charlottesville, 22908, VA, USA.
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Keim-Malpass J, Letzkus LC, Kennedy C. Health literacy and the Affordable Care Act: a policy analysis for children with special health care needs in the USA. Risk Manag Healthc Policy 2015; 8:31-6. [PMID: 25897270 PMCID: PMC4396417 DOI: 10.2147/rmhp.s80699] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Children with special health care needs (CSHCN) represent populations with chronic health conditions that are often high utilizers of health care. Limited health literacy has emerged as a key indicator of adverse health outcomes, and CSHCN from limited health literacy families are particularly vulnerable. The purpose of this policy analysis is to outline key provisions in the Affordable Care Act (ACA) that incorporate health literacy approaches for implementation and have implications for CSHCN in the USA. Several key provisions are incorporated in the ACA that involve health literacy and have implications for CSHCN. These include: expansion of public insurance coverage and simplifying the enrollment process, provisions assuring equity in health care and communication among all populations, improving access to patient-centered medical homes that can offer care coordination, ensuring enhanced medication safety by changing liquid medication labeling requirements, and provisions to train health care providers on literacy issues. More research is needed to determine how provisions pertaining to health literacy in the ACA are implemented in various states.
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Affiliation(s)
| | - Lisa C Letzkus
- University of Virginia School of Nursing, Charlottesville, VA, USA ; University of Virginia Children's Hospital, Charlottesville, VA, USA
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Erickson JM, Adelstein KE, Letzkus LC. A Feasibility Study to Measure Physical Activity, Fatigue, Sleep-Wake Disturbances, and Depression in Young Adults During Chemotherapy. J Adolesc Young Adult Oncol 2014; 3:37-41. [PMID: 24669357 DOI: 10.1089/jayao.2013.0028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Little is known about the physical activity (PA) of young adults (YAs) during cancer therapy. In this feasibility study, 14 YAs (20-34 years old) completed a six-minute walk test, recorded their steps per day for one week, and answered weekly self-reports about physical activity, fatigue, sleep-wake disturbances, and depression during one cycle of chemotherapy. Findings suggest YAs are willing to complete a PA study during chemotherapy and have variable sleep and activity schedules. Their symptoms varied in severity, with highest scores for fatigue. Studies to improve PA in YAs during chemotherapy are warranted to manage short- and long-term treatment effects.
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Affiliation(s)
- Jeanne M Erickson
- University of Virginia School of Nursing , Charlottesville, Virginia
| | | | - Lisa C Letzkus
- University of Virginia School of Nursing , Charlottesville, Virginia
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