The current models of primary care don’t meet the needs of children in low-income communities. New structures, formats and processes could improve these children’s health and well-being by providing high quality care that more effectively addresses the multitude of needs among families in low-income communities. The Innovation in Child Healthcare Delivery Lab (Coker Lab) is working to improve care through research that includes:
Comparing Two Models of Well-Child Care for Black Families
Pediatric preventive care visits, or "Well-Child Care," are an essential aspect of ensuring that social, developmental, behavioral and health concerns are addressed before a child enters preschool. However, low-income families may not have their preventive care needs met under the current Well-Child Care visit model. To address this, an innovative Well-Child Care model was developed in partnership with clinics that serve low-income families. The model was designed to provide comprehensive and family-centered Well-Child Care services while also reducing reliance on clinicians as the sole providers of preventive care services. This model is known as Parent-focused Redesign for Encounters, Newborns to Toddlers (PARENT), a team-based approach that utilizes a parent coach (i.e., health educator) as a member of the Well-Child Care team.
The PARENT model was previously tested in a randomized controlled trial (RCT) at two pediatric practices serving low-income families, and in a larger trial conducted among ten federally-qualified health centers (FQHCs). While PARENT demonstrated improved health outcomes for the predominantly Latino population within the RCTs, further investigation is required to understand intervention impact among clinics serving a largely Black/African American population.
The goal of this research is to use a stakeholder-engaged approach to adapt, implement, and test a new model of PARENT that is designed to meet the needs of Black families. Researchers at Seattle Children's Research Institute are partnering with 12 of the Nationwide Children's Hospital Primary Care Networks (NCH-PCN), which serve a patient population that is over 96% publicly insured, 50% Black, and 16% Latinx, to implement this randomized stepped wedge study of PARENT.
Each of the 12 NCH-PCN sites will begin the study in the control group and, in a randomly assigned order, sequentially join the intervention group, where they will implement the PARENT model for all Well-Child Care visits for ages 0-15 months. Electronic Health Record and administrative data will be collected on all eligible children, ages 9-15 months, every 9 months throughout the study. This data, representing either the control or intervention state, will be compared to assess the effectiveness of the adapted PARENT model in better meeting the needs of Black families.
This research is funded by the Patient-Centered Outcomes Research Institute.
Community Health Workers Improve Early Childhood Preventive Care for Medicaid-Insured Families
Parent-focused Redesign for Encounters, Newborns to Toddlers (PARENT) is a model for early childhood well-child care that utilizes a community health worker (CHW) to provide early childhood preventive care services as a part of the well-child care (WCC) visit. Our objective was to examine the effectiveness of PARENT in a cluster randomized trial of children ages 0-2 years.
PARENT Intervention Description
- Overview: The Coach (CHW) provides anticipatory guidance, psychosocial assessment and referral, and developmental/behavioral surveillance, screening, and guidance at each well-visit during early childhood.
- Visit Process: The Coach meets with the parent/family during the WCC visit to:
- Discuss parent-identified concerns for anticipatory guidance.
- Identify social needs and make community referrals.
- Conduct developmental surveillance, address any developmental or behavioral concerns, and complete a standardized screening instrument for developmental delay or autism (at AAP-recommended visits).
- Coach Training: The Coach is a CHW with training in comprehensive early childhood preventive care.
Cluster randomized controlled trial (March 2019-July 2022) of PARENT compared with usual care, with 12-month follow-up period. Intervention clinics implemented PARENT, a team-based approach to care that utilizes a CHW in the role of a Coach (i.e., health educator) as part of the WCC team to provide comprehensive preventive care services. Control clinics used usual care.
We partnered with 10 clinics from two federally-qualified health centers in Washington and California. 1,283 parents with a child ≤12 months of age for a well-visit at one of the clinic sites were approached; 937 were enrolled. Of the 914 who remained eligible and enrolled, 785 completed the 12-month follow-up interview. Our primary outcomes were receipt of recommended anticipatory guidance and emergency department (ED) utilization, and secondary outcomes were psychosocial screening, developmental screening, healthcare utilization, and experiences of care.
Of 914 enrolled parent participants, 95% were mothers, 73% were Latino, and 63% reported annual income <$30,000; infants were mostly Medicaid-insured, with mean age of 4.4 months at enrollment. 785 (86%) completed the 12-month survey. Parents in intervention clinics reported receiving more anticipatory guidance than those in control clinics (mean score 73.9 vs. 63.3; adjusted regression coefficient 11.01 (95% CI 6.44-15.59)). There was no difference in ED utilization between intervention and control (ED use was lower than expected across both groups due to the pandemic). Intervention impact included greater receipt of psychosocial assessments, and having developmental/behavioral concerns elicited and addressed, attendance at WCC visits, and greater helpfulness of care.
The PARENT intervention resulted in improvements in the receipt of preventive care services for Medicaid-insured families, by incorporating CHWs as part of the WCC team. Our findings inform evidence for PARENT, and other innovative interventions that utilize non-clinicians in a team-based approach to early childhood WCC.
Implications for Policy and Practice
At least 21 states now allow Medicaid payment for CHW services, and some of these states have enacted state plan amendments to allow provision of CHW services within primary care settings. Interventions such as PARENT can ensure that practices providing pediatric primary care can leverage these changes in Medicaid to improve early childhood preventive care services to families.
We are grateful to the families, staff, and providers of Community Health Care and Northeast Valley Health Corporation for their engagement in this study. This project was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health under award number R01HD088586.
Our main study findings are reported in a 2023 JAMA publication. Additional work is ongoing to understand the cost implications of the PARENT intervention.
- April 30, 2023: Publication Q&A: Community Health Workers in Early Childhood Well-Child Care for Medicaid-Insured Children: A Randomized Clinical Trial
Other publications from this study include:
- Hurst R, Liljenquist K, Lowry SJ, Szilagyi PG, Fiscella KA, Weaver MR, Porras-Javier L, Ortiz J, Sotelo Guerra LJ, Coker TR. A Parent Coach–Led Model of Well-Child Care for Young Children in Low-Income Communities: Protocol for a Cluster Randomized Controlled Trial. JMIR Res Protoc 2021;10(11):e27054
- Liljenquist K, Hurst R, Sotelo Guerra L, Szilagyi PG, Fiscella K, Porras-Javier L, Coker TR. Time Spent at Well-Child Care Visits for English- and Spanish-Speaking Parents. Academic Pediatrics, 2023. doi: 10.1016/j.acap.2022.06.009
- Liljenquist K, Coker TR. Transforming Well-Child Care to Meet the Needs of Families at the Intersection of Racism and Poverty. Academic Pediatrics, 2021. doi: 10.1016/j.acap.2021.08.004
- Sotelo Guerra LJ, Ortiz J, Liljenquist K, Szilagyi PG, Fiscella K, Porras-Javier L, Johnson G, Friesema L and Coker TR (2023). Implementation of a community health worker focused team-based model of care: What modifications do clinics make? Front. Health Serv. 3:989157. doi: 10.3389/frhs.2023.989157