Embracing the complexity of modifiable risk reduction: A registry of modifiable risks for 0-12 month infants.

Despite relatively high medical expenditures, the United States performs poorly on population health indicators relative to many other countries. A key step in addressing this situation involves determining impactful and cost-effective interventions for at-risk populations. This requires an understanding of medical, social, behavioral health and safety domains of risk. Of immediate interest are those risks that are modifiable at the individual and family levels and could be reduced through intervention and broader care coordination efforts. Unfortunately, a comprehensive list of such risks does not exist in the published literature. Using multiple interrelated methods, including clinical, social, and care coordination experience, expert elaboration and validation, and reviews of existing assessments and literature, we present what we believe to be the most comprehensive listing of individually modifiable risk factors (IMRFs), relevant to care coordination, available for individuals aged 0-12 months. The list addresses IMRFs within four broad domains of risk (medical, social, behavioral health, and safety). Comprehensive risk registries such as the one presented here can enhance our collective efforts to identify and mitigate risks for specific populations. Such registries can also support research to build understandings of the impact of risks, individually and in interconnected signature combinations. The risk registry presented here and the enhanced understandings flowing from it may yield useful insights for clinicians, social service providers and researchers seeking a whole person approach to care, as well as for payers and policymakers seeking to enable health policy and payment reforms to improve population health.

Using a Clinical Decision Support Tool to Increase Chlamydia Screening Across a Large Primary Care Pediatric Network.

We aim to demonstrate increased chlamydia screening across a large pediatric network using an electronic health record-based intervention. We developed a pop-up notification that alerted providers that chlamydia screening was recommended during a well adolescent visit, when appropriate. We compared chlamydia screening rates before and after the implementation of the alert. The screening rate for chlamydia improved from 2.40% in the year before intervention to 5.01% in the year after intervention ( P < .01). In conclusion, an electronic health record intervention was successfully able to significantly increase rates of chlamydia screening across a large pediatric network.

Pathways community care coordination in low birth weight prevention.

The evidence is limited on the effectiveness of home visiting care coordination in addressing poor birth outcome, including low birth weight (LBW). The Community Health Access Project (CHAP) utilizes community health workers (CHWs) to identify women at risk of having poor birth outcomes, connect them to health and social services, and track each identified health or social issue to a measurable completion. CHWs are trained individuals from the same highest risk communities. The CHAP Pathways Model is used to track each maternal health and social service need to resolution and CHWs are paid based upon outcomes. We evaluated the impact of the CHAP Pathways program on LBW in an urban Ohio community. Women participating in CHAP and having a live birth in 2001 through 2004 constituted the intervention group. Using birth certificate records, each CHAP birth was matched through propensity score to a control birth from the same census tract and year. Logistic regression was used to examine the association of CHAP participation with LBW while controlling for risk factors for LBW. We identified 115 CHAP clients and 115 control births. Among the intervention group there were seven LBW births (6.1 %) compared with 15 (13.0 %) among non-CHAP clients. The adjusted odds ratio for LBW was 0.35 (95 % confidence interval, 0.12-0.96) among CHAP clients. This study provides evidence that structured community care coordination coupled with tracking and payment for outcomes may reduce LBW birth among high-risk women.