Objective. To improve health outcomes of children, the US Maternal and Child Health Bureau has recommended more effective organization of preventive services within primary care practices and more coordination between practices and community-based agencies. However, applying these recommendations in communities is challenging because they require both more complex systems of care delivery within organizations and more complex interactions between them. To improve the way that preventive health care services are organized and delivered in 1 community, we designed, implemented, and assessed the impact of a health care system-level approach, which involved addressing multiple care delivery processes, at multiple levels in the community, the practice, and the family. Our objective was to improve the processes of preventive services delivery to all children in a defined geographic community, with particular attention to health outcomes for low-income mothers and infants. Design. Observational intervention study in 1 North Carolina county (population 182 000) involving low- income pregnant mothers and their infants, primary care practices, and departments of health and mental health. An interrupted time-series design was used to assess rates of preventive services in office practices before and after the intervention, and a historical cohort design was used to compare maternal and child health outcomes for women enrolled in an intensive home visiting program with women who sought prenatal care during the 9 months before the program9s initiation. Outcomes were assessed when the infants reached 12 months of age. Interventions. Our primary objective was to achieve changes in the process of care delivery at the level of the clinical interaction between care providers and patients that would lead to improved health and developmental outcomes for families. We selected interventions that were directed toward major risk factors (eg, poverty, ineffective care systems for preventive care in office practices) and for which there was existing evidence of efficacy. The interventions involved community-, practice-, and family-level strategies to improve processes of care delivery to families and children. The objectives of the community-level intervention were: 1) to achieve policy level changes that would result in changes in resources available at the level of clinical care, 2) to engage multiple practice organizations in the intervention to achieve an effect on most, if not all, families in the community, and 3) to enhance communication between, among, and within public and private practice organizations to improve coordination and avoid duplication of services. The objective of the practice-level interventions was to overcome specific barriers in the process of care delivery so that preventive services could be effectively delivered. To assist the health department in implementing the family-level intervention, we provided assistance in hiring and training staff and ongoing consultation on staff supervision, including the use of structured protocols for care delivery, and regular feedback data about implementation of the program. Interventions with primary care practices focused on the design of the delivery system within the office and the use of teamwork and data in an “office systems” approach to improving clinical preventive care. All practices ( N = 8) that enrolled at least 5 infants/month received help in assessing performance and developing systems (eg, preventive services flow sheets) for preventive services delivery. Family-level interventions addressed the process of care delivery to high-risk pregnant women ( Results. There were high levels of participation, changes in the organization of the delivery system, and improvements in preventive health outcomes. Agencies cooperated in joint contracting, staff training, and defining program eligibility. All 8 eligible practices agreed to participate and 7/8 implemented at least 1 new office system element. Of eligible women, 89% agreed to participate, and outcome data were available on 80% (180/225). After adjusting for differences in baseline characteristics, intervention group women were significantly more likely than comparison group women to use contraceptives (69% vs 47%), not smoke tobacco (27% vs 54%) and have a safe and stimulating home environment for their children. Intervention group children were more likely to have had an appropriate number of well-child care visits (57% vs 37%) and less likely to be injured (2% vs 7%). Intervention mothers also received Aid to Families with Dependent Children for fewer months after the birth of their child (7.7 months vs 11.3 months). Conclusions. We observed a number of positive effects at all 3 levels of intervention. Policy-level changes at the state and community led to lasting changes in the organization and financing of care, which enabled changes in clinical services to take place. These changes have now been expanded beyond this community to other communities in the state. We were also able to engage multiple practice organizations, reduce duplication, and improve the coordination of care. Changes in the process of preventive services delivery were noted in participating practices. Finally, the outcomes of the family-level intervention were comparable in direction and magnitude to the outcomes of previous randomized trials of the intervention. All the changes were achieved over a relatively brief 3-year study period, and many have been sustained since the project was completed. Tiered, interrelated interventions directed at an entire population of mothers and children hold promise to improve the effectiveness and outcomes of health care for families and children.

https://pediatrics.aappublications.org/content/pediatrics/108/3/e42.full.pdf

From Concept to Application: The Impact of a Community-Wide Intervention to Improve the Delivery of Preventive Services to Children

Although post traumatic stress disorder (PTSD) in children has been extensively studied during the past 15 years, little research exists regarding the efficacy of treatment interventions. This report describes an outcome-based art therapy research project currently conducted at a large urban hospital trauma center. Included are the theoretical rationale and overview of an art therapy treatment intervention called the Chapman Art Therapy Treatment Intervention (CATTI) designed to reduce PTSD symptoms in pediatric trauma patients. Used in this study, the CATTI was evaluated for efficacy in measuring the reduction of PTSD symptoms at intervals of 1 week, 1 month, and 6 months after discharge from the hospital. An early analysis of the data does not indicate statistically significant differences in the reduction of PTSD symptoms between the experimental and control groups. However, there is evidence that the children receiving the art therapy intervention did show a reduction in acute stress symptoms.

The effectiveness of art therapy interventions in reducing post traumatic stress disorder (PTSD) symptoms in pediatric trauma patients

Although Medicaid is the largest public payer of behavioral health services, information on access and utilization of services is lacking, and no data on the frequency of service use or types of services provided for children with autism spectrum disorders (ASDs) are available. As states move toward managed care approaches for their Medicaid program, services information is critical. Behavioral health service data for children with autism spectrum disorders were collected from a state Medicaid Managed Care (MMC) program and analyzed from fiscal years 1995 through 2000. Findings revealed that the number of children who received services over time increased significantly; however, the rate of service use was only one tenth of what should be expected based on prevalence rates. The mean number of service days provided per child decreased significantly, about 40%, and the most prevalent forms of treatment changed. Day treatment vanished and medication and case management increased disproportionately to the number of children served. Explanations and implications of the findings are presented as well as recommendations for future research.

/pdf/access-and-service-use-by-children-with-autism-spectrum-kab8kdfke6.pdf

Access and service use by children with autism spectrum disorders in Medicaid Managed Care.

The global impact

https://www.academicpedsjnl.net/article/S1876-2859(08)00314-8/pdf

Early Childhood Health Promotion and Its Life Course Health Consequences

The twentieth century saw huge successes in health care in the United States. Immunizations, antibiotics, and public health initiatives have combined to lower the infant mortality rate and lengthen life span. Unlocking the secrets of the human genome promises more advances. Despite these advances, we remain stymied by the steady drumbeat of death and disfigurement attributable to childhood injuries. Injuries, both violent and unintentional, are one of the most significant public health issues facing children today, but public outrage is absent. As a result, proven solutions go unused, and thousands of children die each year.

Unintentional injuries in childhood: analysis and recommendations.

In recent years, states have increasingly turned to managed care arrangements for financing and delivering health services to Medicaid beneficiaries. In 1996, approximately 40% of all Medicaid recipients were enrolled in some form of managed care. The rapid escalation of managed care in this population has been fueled by states' desire to slow the growth of Medicaid expenditures and by the trend toward managed care enrollment in the private health insurance industry. The effect of managed care on cost containment in the Medicaid program may be limited, however, because 85% to 90% of Medicaid managed care enrollees are women of childbearing age and children, who together account for 69% of Medicaid recipients, but only 26% of program costs. Nonetheless, the increase in managed care enrollment in this population may have a profound impact on health service delivery and health outcomes for U.S. children, approximately 20% of whom received health benefits through the Medicaid program in 1995. In the future, the proportion of Medicaid-eligible children enrolled in managed care will likely increase as a result of recent legislation that relaxed the requirement that states seek federal approval prior to mandating managed care enrollment for Medicaid beneficiaries. More states are relying on fully capitated arrangements as the preferred type of managed care for Medicaid recipients, despite the relative lack of experience many of these plans have in serving this low-income population. Moreover, managed care organizations have few incentives to enroll chronically or disabled children with higher-than-average expected costs. Without mechanisms in place that adequately adjust capitated rates to account for these higher-cost enrollees, managed care organizations may lose money, and children with the greatest health care needs may be underserved. As mandatory managed care enrollment for Medicaid recipients increases nationwide, states should carefully monitor changes in program costs and quality as well as implications for the delivery of pediatric health services and health outcomes.

Medicaid Managed Care and Children: An Overview.

Arevolution in health care has taken place during the past decade in the United States. The revolution was ignited by skyrocketing health care costs1 and fueled by the widespread public sentiment that the high cost of health care was the most important problem in the health care industry.2 The health insurance industry and providers responded to the public’s outcry by creating lower-cost health care insurance alternatives—managed health care plans. Managed health care is a vast array of financing and health care delivery systems that are designed to limit costs and ration health care. Employers and individuals seized the opportunity to lower their health care costs and began to buy these managed health care plans. Today, managed care plans are pervasive; 85% of all employed families and a growing number of those covered by Medicaid are in managed health care plans.3,4 By choosing managed health care, U.S. employers and consumers have changed the nation’s health care system.

Lisa W. Deal

Papers

Unintentional injuries in childhood: analysis and recommendations.

Medicaid Managed Care and Children: An Overview.

Children and managed health care: analysis and recommendations.