Redesigning Health Care Practices to Address Childhood Poverty.

Child poverty in the United States is widespread and has serious negative effects on the health and well-being of children throughout their life course. Child health providers are considering ways to redesign their practices in order to mitigate the negative effects of poverty on children and support the efforts of families to lift themselves out of poverty. To do so, practices need to adopt effective methods to identify poverty-related social determinants of health and provide effective interventions to address them. Identification of needs can be accomplished with a variety of established screening tools. Interventions may include resource directories, best maintained in collaboration with local/regional public health, community, and/or professional organizations; programs embedded in the practice (eg, Reach Out and Read, Healthy Steps for Young Children, Medical-Legal Partnership, Health Leads); and collaboration with home visiting programs. Changes to health care financing are needed to support the delivery of these enhanced services, and active advocacy by child health providers continues to be important in effecting change. We highlight the ongoing work of the Health Care Delivery Subcommittee of the Academic Pediatric Association Task Force on Child Poverty in defining the ways in which child health care practice can be adapted to improve the approach to addressing child poverty.

Determinants of Health and Pediatric Primary Care Practices.

More than 20% of children nationally live in poverty. Pediatric primary care practices are critical points-of-contact for these patients and their families. Practices must consider risks that are rooted in poverty as they determine how to best deliver family-centered care and move toward action on the social determinants of health. The Practice-Level Care Delivery Subgroup of the Academic Pediatric Association's Task Force on Poverty has developed a roadmap for pediatric providers and practices to use as they adopt clinical practice redesign strategies aimed at mitigating poverty's negative impact on child health and well-being. The present article describes how care structures and processes can be altered in ways that align with the needs of families living in poverty. Attention is paid to both facilitators of and barriers to successful redesign strategies. We also illustrate how such a roadmap can be adapted by practices depending on the degree of patient need and the availability of practice resources devoted to intervening on the social determinants of health. In addition, ways in which practices can advocate for families in their communities and nationally are identified. Finally, given the relative dearth of evidence for many poverty-focused interventions in primary care, areas that would benefit from more in-depth study are considered. Such a focus is especially relevant as practices consider how they can best help families mitigate the impact of poverty-related risks in ways that promote long-term health and well-being for children.

Associations between housing instability and food insecurity with health care access in low-income children.

OBJECTIVE: Homelessness and hunger are associated with poor health care access among children. Housing instability and food insecurity represent milder and more prevalent forms of homelessness and hunger. The aim of this study was to determine the association between housing instability and food insecurity with children's health care access and acute health care utilization. METHODS: We conducted a cross-sectional analysis of 12,746 children from low-income households included in the 2002 National Survey of America's Families (NSAF). In multivariate models controlling for important covariates, we measured the association between housing instability and food insecurity with 3 health care access measures: 1) no usual source of care, 2) postponed medical care, and 3) postponed medications. We also measured 3 health care utilization measures: 1) not receiving the recommended number of well-child care visits, 2) increased emergency department visits, and 3) hospitalizations. RESULTS: Our analysis showed that 29.5% of low-income children lived in households with housing instability and 39.0% with food insecurity. In multivariate logistic regression models, housing instability was independently associated with postponed medical care, postponed medications, and increased emergency department visits. Food insecurity was independently associated with no usual source of care, postponed medical care, postponed medications, and not receiving the recommended well-child care visits. CONCLUSION: Families that experience housing instability and food insecurity, without necessarily experiencing homelessness or hunger, have compromised ability to receive adequate health care for their children. Policy makers should consider improving programs that decrease housing instability and food insecurity, and clinicians should consider screening for housing instability and food insecurity so as to provide comprehensive care.

Evening continuity clinic: preserving primary care education in the face of duty hour limitations?

OBJECTIVE: Residency programs with postcall afternoon continuity clinics violate the new Accreditation Council for Graduate Medical Education (ACGME) limitations on resident duty hours. We evaluated housestaff experience with a pilot intervention that replaced postcall continuity clinics with evening continuity clinics. METHODS: We began this pilot program at one continuity clinic site for pediatric residents. Instead of postcall clinics, residents had evening continuity clinic added to a regular clinic day when they were neither postcall nor on call. At 5 and 11 months, we surveyed housestaff satisfaction and experience with the evening clinics, particularly in comparison to postcall clinics. RESULTS: Nineteen of 23 pediatric residents participated in the pilot program. Twenty-two and 17 residents completed the 5- and 11-month follow-up surveys, respectively. A significantly greater proportion of residents rated their overall satisfaction with evening clinic as good/outstanding (16/18, 89%) compared with postcall clinic (2/19, 11%) at the 5-month survey (P<.01). Resident preference for evening clinic over postcall clinic persisted but was not statistically significant at 11 months (P =.05), and overall satisfaction with evening clinic was unchanged from the 5- and 11-month surveys (P =.64). All areas of patient care, medical education, and clinic infrastructure were better or equal in evening clinic in comparison to postcall clinic except for continuity of preceptors and access to medical services. CONCLUSION: Housestaff had greater satisfaction and a better clinic experience with evening clinic versus postcall clinic. Evening continuity clinic is a viable solution to meeting the ACGME work hour limitations while preserving housestaff primary care education.