A longitudinal study of a pediatric practice-based versus an agency-based model of care coordination for children and youth with special health care needs.

BACKGROUND: Care coordination has been shown to improve the quality of care for children and youth with special health care needs (CYSHCN). However, there are different models for structuring care coordination in relation to the medical home and most Title V agencies use an agency-based model of care coordination. No studies have prospectively compared a practice-based care coordination model to a Title V agency-based care coordination model. OBJECTIVE: Report the results of a prospective cohort study comparing a practice-based nurse care coordinator model with Title V agency-based care coordination model. DESIGN/METHODS: Three pediatric practices received the intervention, placement of a nurse care coordinator onsite within the practice, along with training and quality improvement on the principles of the medical home. Three practices continued to rely on agency-based care coordination services. CYSHCN in the practices were identified, interviewed at baseline, and re-interviewed after 18 months. We interviewed 262 families/children at baseline and 144 families/children (76 in the intervention and 68 in the comparison group) at 18 months. Families rated the quality of services they received from the care coordinator and the pediatric practice, and their experience of barriers to services for their CYSHCN. RESULTS: Families in the practice-based care coordination group were more likely to report improvement in their experience with the care coordinator (P = 0.02), fewer barriers to needed services (P = 0.003), higher overall satisfaction with care coordination (P = 0.03), and better treatment by office staff (P = 0.04). CONCLUSIONS: We found that for families of CYSHCN, practice-based care coordination in the medical home led to increased satisfaction with the quality of care they received and a reduction of barriers to care. The practice-based care coordination model is utilized by a minority of State Title V agencies and should be considered as a potentially more effective model than the agency-based approach.

A multi-method assessment of satisfaction with services in the medical home by parents of children and youth with special health care needs (CYSHCN).

OBJECTIVE: To assess satisfaction of parents of children with special health care needs with treatment by office staff, communication with the pediatrician, involvement in decision-making and coordination of services outside the practice. PATIENTS AND METHODS: We used a mixed-method (qualitative and quantitative) approach to collect parental perceptions of the Medical Home services provided by their pediatricians. Six practices were selected to participate in the study based on geographic and patient demographic characteristics. In total, 262 (75% response rate) families completed surveys, and 28 families of these participated in focus groups. The Family Survey collected information (corroborated and enriched with focus group interviews) on parent and child demographics, severity of the child's condition and the burden on parents. We assessed parental satisfaction with treatment by office staff, communication with the pediatrician, involvement in decision-making, and connection to services outside the practice. Survey responses were analyzed using SAS with all associations considered significant at the P < 0.05 level. Focus groups were recorded, transcribed into EZ-Text and analyzed by a team of three researchers to identify patterns and themes inherent in the data. RESULTS: Families reported in focus group interviews that they experienced significant stress due to the demands of caring for a child with special health care needs. Overall, only a small percentage of families reported being dissatisfied with their treatment by office staff (13-14%), communication with the pediatrician (10%), and involvement in decision-making (15-16%). However, a majority of families (approximately 58%) were dissatisfied with the ability of the pediatrician and his/her office to connect the families with resources outside the pediatric office. Families whose children had more severe conditions, or whose conditions had more of an impact on the families, reported being less satisfied with all aspects of communication and care coordination Families of youth with special health care needs (>12 years of age) were less satisfied than families of younger children with the practice's ability to connect them to resources outside the practice. CONCLUSIONS: Both the focus groups and surveys demonstrated that families of children with special needs are under very significant stress. Pediatricians must become better equipped to identify and communicate more proactively with families of CYSHCN that are experiencing significant parent burden. Pediatricians and their staff also need to improve their knowledge of community resources and proactively make referrals to community services needed by families of CYSHCN.

Immunization levels among inner city children enrolled in subsidized childcare.

PURPOSE: Measure immunization rates in subsidized child care and determine whether the population is representative of inner city preschool children. METHODS: We identified 156 children, ages 0-60 months, in 14 inner-city child care centers enrolled in subsidized care and obtained demographic and immunization information. ZIP-code distribution of sample children was correlated with similarly aged children from the 2000 Census (family incomes .150% of poverty). RESULTS: The overall subsidized child care population was geographically similar to all low-income children, ages 0-5, in Jacksonville (r.0.94). Only 73.3% were up-to-date at 3 months and 44.2% at 12 months of age (3 DTaP, 2 HIB, 2 IPV, 3 Hep B). DISCUSSION: Our findings support the contention that children in subsidized child care are geographically representative of low-income, inner city preschool children. This study suggests that children enrolled in subsidized child care are both potentially underserved and an accessible window into the inner-city preschool population.

Evaluating Medical Home constructs for children with special needs: integrating theory and logic models.

The Medical Home model for providing services to children with special healthcare needs has strong philosophical foundations, but the science supporting this theoretical model is not as well developed. The use of logic models and mixed method design provide systematic and rigorous approaches to observation while retaining the complexity, which tends to be lost with research designs intended to control and reduce the number of variables impacting a desired outcome, such as randomized controlled trials. This application provides a historical basis for applying logic models of evaluation and illustrates the utility of logic models.

USMLE step 1 scores as a significant predictor of future board passage in pediatrics.

PURPOSE: To explore the relationship(s) between USMLE, In-Training Exam, and American Board of Pediatrics (ABP) board-certifying exam scores within a Pediatric residency-training program. METHODS: Data were abstracted from records of graduating residents from the Pediatric residency program at the University of Florida College of Medicine Jacksonville from 1999 to 2005. Seventy (70) residents were identified and their files reviewed for the following information: USMLE Step 1 and 2 scores, in-training exam results and eventual board scores as reported by the ABP. Correlation and regression analyses were performed and compared across all tests. RESULTS: The correlation coefficients between the three types of tests were all statistically significant. Using logistic regression, however, only USMLE Step 1 scores (compared to Step 2) had a statistically significant association with board performance. Interestingly, none of the three in-training exam scores had any additional impact on predicting board performance given one's USMLE Step 1 score. USMLE Step 1 scores greater than 220 were associated with nearly a 95 per cent passage rate on the board-certifying exam. CONCLUSIONS: The data suggests that performance on USMLE Step 1 is an important predictor of a resident's chances of passing the pediatric boards. This information, which is available when a resident initiates training, can be used to identify those at risk of not passing the boards. While Step 1 scores should not be used as a sole determinant in the recruiting process, individual learning plans can be developed and implemented early in training to maximize one's ability to pass the certifying exam.

Educating the next generation of pediatricians in urban health care: the Anne E. Dyson Community Pediatrics Training Initiative.

To improve the health of children who are exposed to urban health risks, there has been a national recognition of the need for better models of training pediatricians. In 2000, in response to this need, the Dyson Foundation launched a new residents-training model that focuses on community health and advocacy, The Anne E. Dyson Community Pediatrics Training Initiative (the Initiative). The Initiative is made up of 12 programs at ten sites, which are working in their communities to improve the health of the children. At its core are five objectives: to equip residents with tools and knowledge to provide community-based health care, to make use of community resources so that residents learn to practice as medical home providers, to engage residents in the communities in which they work, to develop meaningful partnerships between departments of pediatrics and their communities, and to enhance pediatrics training through interdisciplinary collaborations among schools and departments. Curricular approaches at the participating sites differ slightly, but all have explicitly incorporated teaching community pediatrics into their standard rotations and continuity clinics. The authors showcase the programs of the Initiative and explore how the programs have sought buy-in from their parent institutions, faculty, residents, and communities.