Community Access to Child Health (CATCH) in the historical context of Community Pediatrics.

OBJECTIVES: As part of the evaluation of the American Academy of Pediatrics (AAP) Community Access to Child Health (CATCH), to 1) identify, retrospectively, the actual chronology of activities undertaken through CATCH, and 2) review its antecedents within the AAP, and its predecessor program-Healthy Children. METHODS: Key informant telephone interviews with 14 national leaders in CATCH were conducted. Relevant program and administrative files and other documents were reviewed. AAP staff assisted the authors in preparing a detailed chronology of Healthy Children and CATCH activities and events from spring 1988 through summer 1996. RESULTS AND CONCLUSIONS: A decade of change in the AAP, under the acronym CATCH began in the late 1980s. The formation of the AAP's Partnership for Children and the Access to Care for Children Initiative, combined with the decision by the Robert Wood Johnson Foundation to transfer the funding of Healthy Children to the AAP, underpinned the changes. The Foundation's decision provided the resources and stimulus for the expansion and increased recognition of Community Pediatrics at the national AAP office, culminating in the establishment of the Department of Community Pediatrics in mid-1994. A national program of pediatrician-led, community-based programs and supportive services was launched, other resources were attracted, and a philosophical shift in defining the role of the pediatrician was put forward. A responsibility toward all children within the community was included in the role of the pediatrician, as well as caring for the individual child within a community context.

Pediatrician-led community child health initiatives: case summaries from the evaluation of the community access to child health program.

OBJECTIVES: Case study investigations of projects identified with the Community Access to Child Health (CATCH) Program were conducted to illustrate the range of achievements of CATCH and to identify those elements related to successful or unsuccessful implementation. METHODS: We developed a purposive sample of 12 projects, selected based on time of initiation (1989-1995), level of intensity of involvement in CATCH, project locus (statewide or local), nature of program service(s), project setting, and target population(s). Two investigators spent approximately 1.5 days at each site using a preestablished case study guide that included document review and multiple in-person interviews. A total of 171 interviews were conducted with project leadership and staff, community and institutional partners, and public health officials. In seven communities, we also met with individuals receiving project services (consumers). RESULTS AND CONCLUSIONS: The premise of CATCH that with information, support, and tools, pediatricians can be agents of change in their communities was confirmed. The CATCH pediatricians with whom we met capitalize on their status in the community as physicians, their expertise, and their programmatic and political connections to create opportunities to expand and improve health and social services for children. The specific leadership of these pediatricians is often key in overcoming political and cultural barriers to implement system changes. CATCH was and continues to be an effective program strategy for stimulating and enhancing community-based child health initiatives.

Collaborative office rounds: continuing education in the psychosocial/developmental aspects of child health.

OBJECTIVES: In recent years there has been increasing emphasis on the mental health aspects of primary health care for children and adolescents. The Health Resources and Services Administration's Maternal and Child Health Bureau has contributed to efforts aimed at strengthening primary care not only in early identification and beginning intervention with mental disorders, but also in prevention of emotional and behavioral problems and in promotion of positive psychosocial development. The Collaborative Office Rounds (COR) Program is a noteworthy part of these efforts. METHODS: The COR program supports small discussion groups that meet at regular intervals over sustained periods of time to address the mental health aspects of pediatric care. The groups are jointly led by pediatricians and child psychiatrists. Although they vary in a number of ways, all are concerned with the day-to-day psychosocial issues that confront primary care providers serving children, adolescents, and their families. RESULTS: COR groups have addressed a wide range of areas including numerous problems and disorders, health supervision issues, family and community topics, personal challenges and practical complexities, and clinical management issues. Evaluation information indicates a positive response on the part of participants and moderators. This is reflected in group stability, high attendance rates, universal readiness to recommend the COR experience, and a variety of collateral accomplishments. CONCLUSIONS: Experience to date points to the COR group as a useful tool for addressing psychosocial issues in primary care. Its potential may be more fully realized by applying this approach more widely, even as further assessment is pursued.

Community pediatrics from the federal government's perspective.

Community pediatrics has enjoyed remarkable success in recent years. While I have touched on some of that progress and some of the current issues in child health care, it is apparent that many challenges continue to face the field. In the coming months, one can expect many of these issues to enter the health-care reform discussions. The questions that will arise are not unlike those about mental health care: how large will the benefits package be, what kind of reimbursement system will be used, and who will be the provider? Optimism about the answers doesn't reign every day. In the chairman's preface to Beyond Rhetoric, the final report of the National Commission on Children, Senator John D. Rockefeller IV wrote: It is time for our country to recognize the pressing need to ensure accessible, affordable health care, and take the necessary steps to enable children to be born and grow up healthy and to become able, productive adults...(H)istory will judge this generation of Americans harshly if we allow futile debate to take the place of action. For millions of children and families, the hour already is late. One can look at numerous reports on child health over the past 30 years and find similar impassioned calls to action--with little subsequent action. I hope it will be different this time.

National agenda for children with special health needs. Social policy for the 1990s through the 21st century.

The evolution in medical technology for children with special health care needs has been accompanied by an evolution in concepts of care. Broadened diagnostic categories, comprehensive concern for the whole child, and coordinated services that are family-centered and community-based have become part of the national agenda. During the 1980s this agenda was advanced both by congressional action and by joint activities of the U.S. Public Health Service and the private sector. Much remains to be accomplished. Increased parent participation and activism, an integral part of the future, will require vigilant nurturing and support.

Uses of the 1980 National Natality and Fetal Mortality Surveys for the assessment of obstetric technologies.

Because of the multipurpose utility of followback surveys, six Public Health Service (PHS) agencies including the Bureau of Health Care and Delivery Assistance (BHCDA) financially assisted the National Center for Health Statistics (NCHS), which conducted the 1980 National Natality Survey (NNS) and 1980 National Fetal Mortality Survey (NFMS). These are called "followback" surveys because NCHS uses mail questionnaires and telephone to follow back informants (mothers, hospitals, and attendants at delivery) and medical sources of radiation named by informants, identified on Certificates of Live Birth and Reports of Fetal Death from all 52 state and independent registration areas of the United States. Ten basic data applications have emerged from the 1980 NNS/NFMS, and this paper addresses these 10 purposes simultaneously, in relation to NNS/NFMS uses in assessing obstetric technologies. The five obstetric technologies that are the focus of this paper are: cesarean delivery, electronic fetal monitoring, ultrasound, X-ray, and amniocentesis--and are often examined in relation to maternal complications and conditions. Data on these technologies are highlighted with reference to each of the following 10 data applications of followback surveys: produce national estimates of unique information; establish trends; facilitate analytic and epidemiologic research; use followback surveys as anchor data bases; undertake parallel studies; link followback surveys together to calculate new vital rates; conduct comparative studies vis-à-vis other data sets; assess volume of medical care; evaluate quality of information on vital records; and generate synthetic estimates and need assessments. Finally, this paper discusses NCHS plans to measure obstetric technologies in the 1988 National Maternal and Infant Health Survey, which will include natality, fetal mortality, and infant mortality components.