Trauma-Informed Leadership in Quality Improvement: What We Learned From Practicing in a Pandemic

In 2020, midway through the Collaborative Improvement and Innovation Network to Advance Care for Children with Medical Complexity project, the coronavirus disease 2019 pandemic erupted and caused significant disruptions for the 10 participating state teams, the project leadership, and collaborative partner organizations. Clinics shut down for in-person care, a scramble ensued to quickly leverage telehealth to fill the gap, and the trauma caused by anxiety, isolation, and exhaustion affected the health and wellbeing of children, families, and clinicians alike. We conducted a series of key informant interviews and surveys, alongside other process measures, to learn from state teams what it was like "on the ground" to try to continue improving care delivery, child quality of life, and family wellbeing under such upheaval. In this article, we synthesize qualitative and descriptive findings from these varied data sources within the framework of the trauma-informed principles we applied as a leadership team to prevent burnout, increase resilience, and maintain progress among all project participants, especially clinicians and the uniquely vulnerable family leaders. Lessons learned will be offered that can be applied to future natural and human-made emergencies that impact responsive pediatric care delivery improvement.

Factors Correlated With Successful Pediatric Post-Discharge Phone Call Attempt and Connection

OBJECTIVES

Postdischarge phone calls can identify discharge errors and gather information following hospital-to-home transitions. This study used the multisite Project IMPACT (Improving Pediatric Patient Centered Care Transitions) dataset to identify factors associated with postdischarge phone call attempt and connectivity.

METHODS

This study included 0- to 18-year-old patients discharged from 4 sites between January 2014 and December 2017. We compared demographic and clinical factors between postdischarge call attempt and no-attempt and connectivity and no-connectivity subgroups and used mixed model logistic regression to identify significant independent predictors of call attempt and connectivity.

RESULTS

Postdischarge calls were attempted for 5528 of 7725 (71.6%) discharges with successful connection for 3801 of 5528 (68.8%) calls. Connection rates varied significantly among sites (52% to 79%, P < .001). Age less than 30 days (P = .03; P = .01) and age 1 to 6 years (P = .04; P = .04) were independent positive predictors for both call attempt and connectivity, whereas English as preferred language (P < .001) and the chronic noncomplex clinical risk group (P = .02) were independent positive predictors for call attempt and connectivity, respectively. In contrast, readmission within 3 days (P = .004) and federal or state payor (P = .02) were negative independent predictors for call attempt and call connectivity, respectively.

CONCLUSIONS

This study suggests that targeted interventions may improve postdischarge call attempt rates, such as investment in a reliable call model or improvement in interpreter use, and connectivity, such as enhanced population-based communication.

The Critical Value of Maternal and Child Health (MCH) to Graduate Training in Public Health: A Framework to Guide Education, Research and Practice

Introduction

In light of persistent health inequities, this commentary describes the critical role of maternal and child health (MCH) graduate training in schools and programs of public health (SPPH) and illustrates linkages between key components of MCH pedagogy and practice to 2021 CEPH competencies.

Methods

In 2018, a small working group of faculty from the HRSA/MCHB-funded Centers of Excellence (COEs) was convened to define the unique contributions of MCH to SPPH and to develop a framework using an iterative and consensus-driven process. The working group met 5 times and feedback was integrated from the broader faculty across the 13 COEs. The framework was further revised based on input from the MCHB/HRSA-funded MCH Public Health Catalyst Programs and was presented to senior MCHB leaders in October 2019.

Results

We developed a framework that underscores the critical value of MCH to graduate training in public health and the alignment of core MCH training components with CEPH competencies, which are required of all SPPH for accreditation. This framework illustrates MCH contributions in education, research and evaluation, and practice, and underscores their collective foundation in the life course approach.

Conclusions

This new framework aims to enhance training for the next generation of public health leaders. It is intended to guide new, emerging, and expanding SPPH that may currently offer little or no MCH content. The framework invites further iteration, adaptation and customization to the range of diverse and emerging public health programs across the nation.

Understanding Caregiving and Caregivers: Supporting Children and Youth With Special Health Care Needs at Home

Caregiving encompasses the nurturing, tasks, resources, and services that meet the day-to-day needs of children and youth with special health care needs (CYSHCN) at home. Many gaps exist in the strategies currently offered by the health care system to meet the caregiving needs of CYSHCN. The work of family caregivers of CYSHCN is known to be extensive, but it is so poorly understood that it has been described as "invisible". This invisibility leads to poor communication and gaps in understanding between professional health care providers and family caregivers. To address these gaps, health care researchers must work with family caregivers to incorporate their expertise on caregiving and create meaningful and sustainable research partnerships. A growing body of research is attempting to remedy the problem of caregiving invisibility and lay better foundations for successful integration between health care settings, family caregiving, professional caregiving, and community supports for families of CYSHCN. We identify high-priority gaps in CYSHCN caregiving research and propose research questions that are designed to accelerate growth in evidence-based understanding of the work of family caregivers of CYSHCN and how best to support them.

Care team and practice-level implementation strategies to optimize pediatric collaborative care: study protocol for a cluster-randomized hybrid type III trial

BACKGROUND

Implementation facilitation is an effective strategy to support the implementation of evidence-based practices (EBPs), but our understanding of multilevel strategies and the mechanisms of change within the "black box" of implementation facilitation is limited. This implementation trial seeks to disentangle and evaluate the effects of facilitation strategies that separately target the care team and leadership levels on implementation of a collaborative care model in pediatric primary care. Strategies targeting the provider care team (TEAM) should engage team-level mechanisms, and strategies targeting leaders (LEAD) should engage organizational mechanisms.

METHODS

We will conduct a hybrid type 3 effectiveness-implementation trial in a 2 × 2 factorial design to evaluate the main and interactive effects of TEAM and LEAD and test for mediation and moderation of effects. Twenty-four pediatric primary care practices will receive standard REP training to implement Doctor-Office Collaborative Care (DOCC) and then be randomized to (1) Standard REP only, (2) TEAM, (3) LEAD, or (4) TEAM + LEAD. Implementation outcomes are DOCC service delivery and change in practice-level care management competencies. Clinical outcomes are child symptom severity and quality of life.

DISCUSSION

This statewide trial is one of the first to test the unique and synergistic effects of implementation strategies targeting care teams and practice leadership. It will advance our knowledge of effective care team and practice-level implementation strategies and mechanisms of change. Findings will support efforts to improve common child behavioral health conditions by optimizing scale-up and sustainment of CCMs in a pediatric patient-centered medical home.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04946253 . Registered June 30, 2021.

Catch it before it breaks!: managing metabolic bone disease of prematurity

PURPOSE OF REVIEW

Metabolic bone disease of prematurity, commonly referred to as osteopenia of prematurity, remains prevalent in the neonatal intensive care unit (NICU) despite recent medical advances. It is estimated that up to 60% of extreme low birth weight and 20% of very low-birth-weight infants have metabolic bone disease of prematurity. Often silent, it typically presents with poor growth, increased ventilator dependency and fractures. Clinical sequalae, such as short stature can extend into young adulthood. There is no universal consensus by neonatal intensive care unit clinicians on the screening, diagnosis, or treatment for metabolic bone disease of prematurity. The disease is often diagnosed late by radiographs or incidentally in this highly fragile population.

RECENT FINDINGS

Suggest screening using DEXA (dual-energy X-ray absorptiometry) scans or ultrasound, in combination with serum markers like alkaline phosphatase, phosphorous levels, parathyroid hormone, and tubular reabsorption of phosphate, might identify at-risk babies earlier. The use of protocol-based screenings may aid in early diagnosis.

SUMMARY

We present a review of the risk factors, recent screening methods, diagnosis and management of this prevalent, clinically relevant diagnosis, as well as propose a protocol for the early screening and management of this silent disease.

'It's common sense that an individual must eat': Advocating for food justice with people with psychiatric disabilities through photovoice

Background

People with SMI have often been excluded in advocacy efforts focused on physical health, health care and health and social policy.

Objective

Following a Photovoice project focused on barriers to healthy eating and physical activity in urban neighbourhoods, participant‐researchers were invited to present their insights in community advocacy settings. The purpose of this study was to explore the feasibility and participant–researchers’ experience of these community advocacy activities.

Design

We held four focus groups with the eight participant‐researchers after each community advocacy activity to explore their experience with public speaking, presenting their experiences and advocating.

Setting and Participants

People with serious mental illness who were overweight/obese living in supportive housing.

Analysis approach

Qualitative analysis of the focus group transcripts, using a modified grounded theory approach followed by structured coding focused on empowerment, participation and non‐discrimination.

Results

Participant‐researchers gave three oral presentations of their photographs at a variety of community‐based programmes and settings and participated in a rally to advocate for SNAP benefits. Two themes emerged from analysis: (a) Empowerment (the level of choice, influence and control that users of mental health services can exercise over events in their lives) and (b) Barriers to Empowerment (obstacles to participation and well‐being).

Conclusions

This evaluation strengthens the evidence that it is feasible for participant‐researchers in Photovoice projects to engage in robust advocacy activities, such as presentations and discussions with local policymakers. During focus groups, participant‐researchers demonstrated realistic optimism towards their roles as change agents and influencers in spite of acknowledged systemic barriers.

The Experience of Latina Mothers of Children and Youth With Special Health Care Needs: A Qualitative Study

Children and youth with special health care needs (CYSHCN) comprise a growing proportion of the pediatric population; the patient- and family-centered medical home provides a comprehensive model for caring for these patients. Given the limited literature available as well as extreme patient vulnerability, we sought to understand the experience of Latino parents in caring for their CYSHCN within our patient-centered medical home in an urban neighborhood in North Philadelphia. A convenience sample of 14 mothers or grandmothers of CYSHCN participated in semistructured interviews, which were analyzed using a thematic, constant comparative approach to identify common themes. Themes identified included “Waiting,” “Communication/Trust,” “All-Consuming Requirements of Care/Sacrifice,” and “Fate/Faith/Blessings.” These themes corresponded with identified goals of the patient-centered medical home. Our findings suggest that the principles of the patient-centered medical home can be applied in unique ways to caring for this unique patient population.

Integrated Pediatric Health Care in Pennsylvania: A Survey of Primary Care and Behavioral Health Providers

This study reports on a statewide survey of medical and behavioral health professionals to advance the knowledge base on the benefits and obstacles to delivering integrated pediatric health care. Surveys distributed in 3 statewide provider networks were completed by 110 behavioral health specialists (BHSs) and 111 primary care physicians (PCPs). Survey content documented their perceptions about key services, benefits, barriers, and needed opportunities related to integrated care. Factor analyses identified 8 factors, and other items were examined individually. We compared responses by specialty group (BHS vs PCP) and integrated care experience (no vs yes). The findings revealed differences across domains by specialty subgroup. In several cases, BHS (vs PCP) respondents, especially those with integrated care experience, reported lower benefits, higher barriers, and fewer resource requests. The implications of these results for enhancing care integration development, delivery, training, and research are discussed along with the study's limitations and empirical literature.

Vaccine Hesitancy in Pediatric Primary Care Practices

Understanding how pediatric practices handle parental vaccine hesitancy is important as it impacts the efficiency and effectiveness of pediatric practices. In total, 21 semi-structured interviews with pediatric practice staff within a primary care network were conducted between May 2012 and March 2013. Thematic analysis focused on the barriers and challenges of vaccine hesitancy and strategies to reduce the burden at the practice level. Barriers and challenges of vaccine hesitancy included time constraints, administrative challenges, financial challenges and strained patient-provider relationships. Strategies to minimize the burden of vaccine hesitancy included training for vaccine counseling, screening for vaccine hesitancy prior to immunization visits, tailored vaccine counseling, and primary care provider visits for follow-up immunization. Pediatric practices reported many challenges when caring for vaccine-hesitant families. Multiple strategies were identified to reduce the burden of vaccine hesitancy, which future studies should explore to determine how effective they are in increasing vaccine acceptance in pediatric practices.

Care Coordination for Children and Youth With Special Health Care Needs: National Survey Results

We analyzed findings from the 2009-2010 National Survey of Children with Special Health Care Needs to identify associations between families with children and youth with special health care needs (CYSHCN) reporting adequate care coordination (CC) with family-provider relations, shared decision making (SDM), and child outcomes. Eligible subjects were the 98% of families asked about CC, service use, and communication. Bivariate analysis using χ² tests were performed on binary outcome variables to determine the strength of the associations between CC and independent and dependent variables. Weighted, multivariate logistic regression models were constructed to assess independent associations of adequate CC with child outcomes and associations of SDM on adequate CC. Among families of CYSHCN asked about CC, 72% reported receiving help with CC. Of these, 55% reported receiving adequate CC. Family report of adequate CC was favorably associated with family-provider relations, child outcomes, and report of provider participation in SDM.

Urban college student self-report of hookah use with health care providers

OBJECTIVE

This study's purpose was to describe urban college students' communication about hookah with health care providers.

PARTICIPANTS

Participants included a random sample of undergraduate urban college students and health care providers.

METHODS

Students surveyed determined the epidemiology of hookah use in this population, how many health care providers asked about hookah, and how many students admitted hookah use to a physician.

RESULTS

Of 375 students surveyed, 78 (20.8%) had never tried it, 284 (75.7%) had smoked hookah at least once, and 64 students (22.6%) were classified as frequent hookah smokers. Only 15 (4.7%) reported a health care provider asking about hookah during visits, whereas 36 (12.7%) admitted their hookah use to a health care provider.

CONCLUSION

Hookah use was found to be highly prevalent among students in one urban university. This study supports the hypothesis that few health care providers broach the topic with patients. Additional research on health consequences of hookah use, education, and improved screening is warranted.

A Narrative Review of Patient and Family Engagement: The "Foundation" of the Medical "Home"

BACKGROUND

Patient and family engagement (PFE) is vital to the spirit of the medical home. This article reflects the efforts of an expert consensus panel, the Patient and Family Engagement Workgroup, as part of the Society of General Internal Medicine's 2013 Research Conference.

OBJECTIVE

To review extant literature on PFE in pediatric and adult medicine and quality improvement, highlight emerging best practices and models, suggest questions for future research, and provide references to tools and resources to facilitate implementation of PFE strategies.

METHODS

We conducted a narrative review of relevant articles published from 2000 to 2015. Additional information was retrieved from personal contact with experts and recommended sources from workgroup members.

RESULTS

Despite the theoretical importance of PFE and policy recommendations that PFE occurs at all levels across the health care system, evidence of effectiveness is limited, particularly for quality improvement. There is some evidence that PFE is effective, mostly related to engagement in the care of individual patients, but the evidence is mixed and few studies have assessed the effect of PFE on health outcomes. Measurement issues and the lack of a single comprehensive conceptual model pose challenges to progress in this field. Recommendations for future research and a list of practical tools and resources to facilitate PFE are provided.

CONCLUSIONS

Although PFE appeals to patients, families, providers, and policy-makers, research is needed to assess outcomes beyond satisfaction, address implementation barriers, and support engagement in practice redesign and quality improvement. Partnering with patients and families has great potential to support high-quality health care and optimize outcomes.

Factors influencing physical activity in children and youth with special health care needs: a pilot study

Background. Evidence suggests that children and youth with special health care needs (CYSHCN) have decreased physical activity compared to peers. This study describes weight status and physical activity in CYSHCN and identifies factors associated with physical activity and community resources to promote physical activity. Methods. Parents (n = 21) and CYSHCN (n = 23) were recruited from a pediatric clinic. The most prevalent diagnoses were autism (n = 7, 30%) and cerebral palsy (n = 3, 13%). Interviews were conducted with parents for information on physical activity and community resources. Children's height and weight were measured to calculate body mass index (BMI). Results. The majority of CYSHCN (n = 13, 59%) were obese. CYSHCN did not meet recommended levels of 60 minutes of daily physical activity and engaged in more screen time than recommended. More children with cognitive/behavioral/emotional diagnoses were obese compared to children with physical/medical diagnoses. A majority of parents (n = 16, 73%) indicated their CYSHCN need more supervision to participate in physical activity in community programs. Conclusion. The majority of CYSHCN in this study were obese and sedentary. Resources to promote physical activity are needed for this population.

[The curative action of Monticelli Term's water in upper respiratory tract diseases (author's transl)]

The Authors study the action of the sodio bromide-iodic water of Monticelli Terme in upper respiratory tract disease and particularly assert that is not to neglect the organic ground on which establishes mucosa's disease. Therman treatment gives the best therapeutic results in every patient presenting chronic inflammatory processes of the upper respiratory trach alternating periods of quiescency and of activity, and poor therapeutic action in patients presenting chronic inveterate diseases with great alterations in vascular and glandular components of the mucosa.