A Quality Improvement Approach to Decreasing Postdischarge Acute Care Reuse Among Children With Asthma.

OBJECTIVES: To reduce 7-day acute care reuse among children with asthma after discharge from an academic children's hospital by standardizing the delivery of clinical care and patient education. METHODS: A diverse group of stakeholders from our tertiary care children's hospital and local community agencies used quality improvement methods to implement a series of interventions within inpatient, emergency department (ED), and outpatient settings. These interventions were designed to improve admission, inpatient care, and discharge processes for children hospitalized because of asthma and included a focus on (1) resident education, (2) patient access to medication and asthma education, and (3) gaps in existing asthma clinical care pathways in the ED and ICU. The primary outcome was the rate of 7-day acute care reuse (combined hospital readmissions and ED revisits) after discharge from an index hospitalization for asthma, measured through a monthly review of electronic health record data and compared with a 6-month baseline period of reuse data. RESULTS: The mean 7-day reuse rate for asthma after discharge was 3.7% during the 6 months baseline period (n = 107) and 1.0% during the 15-month intervention period (n = 302). This included a shift in our median from 3.3% to 0% with an 8-month period of no 7-day reuse. CONCLUSIONS: An interprofessional quality improvement team successfully achieved and sustained a 73% reduction in mean 7-day asthma-related acute care reuse after discharge by standardizing provider training, care processes, and patient education.

Teaching community pediatrics to pediatric residents: strategic approaches and successful models for education in community health and child advocacy.

To improve child health at a community level, pediatricians require knowledge and skills that have not been traditionally included in residency training. Recent policy statements from the American Academy of Pediatrics and requirements from Accreditation Council for Graduate Medical Education Residency Review committees emphasizing the importance of community pediatrics training have provided additional incentive for pediatric residency programs to actively explore methods of teaching the principles and promoting the practice of community pediatrics to resident trainees. With a growing number of diverse educational models in various stages of practice or development, common themes and approaches to promote successful teaching of community health and child advocacy can be described. This article defines strategies for 2 critical elements of community pediatrics training, engaging residents and building strong community partnerships, then highlights a number of educational models that illustrate key curricular components and methods. Published results from evaluations of some programs suggest that community pediatrics training of this caliber will cultivate a cadre of pediatricians (academic and community based, generalists and subspecialists, researchers and practitioners) who understand child health in the context of community and have the leadership and collaborative skills to improve the health of children in their communities.

A block rotation in community health and child advocacy: improved competency of pediatric residency graduates.

CONTEXT: Despite increasing recognition of the importance of community health and child advocacy activities by pediatricians, residency programs have had little experience providing this education. There are no known reports examining the effects of such training on residency graduates. OBJECTIVE: To determine whether a program for educating residents in community health and child advocacy, Pediatric Links With the Community (PLC), improved attitudes and competencies of residency graduates. DESIGN: Survey of all graduates of the Rochester Pediatric Residency Program from 1991-2001. Graduates before institution of PLC (pre-PLC) were compared with graduates after institution of PLC (post-PLC). PARTICIPANTS: A total of 137 (81%) of 169 graduates participated; 78 (85%) of 92 were in the pre-PLC group and 59 (77%) of 77 were in the post-PLC group. INTERVENTION: PLC provides all pediatric residents with a 2-week rotation working with multiple community-based organizations. OUTCOME MEASURES: Differences between pre-PLC and post-PLC graduates in self-reported attitudes and competencies in multiple community health and child advocacy activities on 4-point Likert scales. RESULTS: The pre-PLC and post-PLC groups' attitudes toward community health activities were equally positive (3.4 vs 3.5, P =.08). The post-PLC group rated its competency higher in 8 of 12 activities (P <.05); its overall rating of competency was also higher (2.8 vs 2.3, P <.001). CONCLUSIONS: Although all pediatricians surveyed had positive attitudes toward community health and child advocacy activities, those who participated in PLC had higher self-perceived competency in most activities. Residency training programs can increase graduates' competence in community health skills.

Evaluation of a community-based pediatrics residency rotation using narrative analysis.

PURPOSE: To evaluate the extent to which a community pediatrics rotation in disadvantaged neighborhoods provided residents with a self-assessed change in knowledge, attitudes, and skills useful for improving the health of children at the community level. METHOD: All pediatrics and medicine-pediatrics residents at the University of Rochester Medical Center participate in a two-week community-based rotation. At the end of each rotation, residents were asked to write a short essay on what they learned during the experience. An interdisciplinary team conducted a retrospective, qualitative analysis of residents' essays looking for recurring themes. Essays were also examined for narrative plot elements that would indicate a causal sequence of events indicating some transformation of the learner. RESULTS: Of the 25 essays reviewed, each gave evidence of at least one of three themes: increased knowledge of lives in poverty, renewed enthusiasm for advocacy, and increased skill in making referrals. Although many residents expressed initial skepticism of the value of a community rotation, none noted any negative final impression. The narrative structure of residents' essays also showed evidence of some transformation of the learner. CONCLUSIONS: A community pediatrics rotation can be a successful educational experience for providing residents with knowledge of how pervasive poverty impacts children and families. Reported changes in attitudes and skills require further evaluation to demonstrate that they can be applied in practice.