Children - Key Activity 2

KEY ACTIVITY #2:

Assess and Improve Reliability in Meeting Well-Child Visit (WCV) Recommendations

 

This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; proactive patient outreach and engagement; pre-visit planning and care gap reduction; care coordination; behavioral health integration; address social needs.

Overview

The American Academy of Pediatrics (AAP)/Bright Futures developed a set of comprehensive health guidelines for well-child care, known as the periodicity schedule. It is a schedule of screenings and assessments recommended at each well-child visit from infancy through adolescence. Each pediatric clinic should implement protocols to ensure all recommended activities and interventions for all children and families are addressed during WCVs.

Click here for the periodicity schedule detailing recommended activities at each well-child visit.

This foundational activity deals with assessing and then improving your practice’s reliability in implementing the guidelines in periodicity schedule. Of note, a recent thoughtful article published in Pediatrics proposes a population health framework to facilitate a redesign – with emphasis on care teams – for delivering the most evidence-based dimensions of pediatric preventive care. It doesn't solely rely on the traditional WCV as the sole venue in which key preventive services are delivered. The innovation proposed in this framework may prove impactful for patients and practices; currently, however, this approach does not align with the quality measurement framework of reporting the compliance rate with annual well-child visits.

Well-care visit activities are recommended to assess and support children’s healthy development and their ability to access needed supports to achieve their best possible health and well-being. Bright Futures compiled tables of evidence and rationale describing the high degree of certainty for guidelines included in the periodicity schedule.

It is likely that the quality and reliability of the recommended WCV activities will vary across clinics. Ensuring that every child benefits from every recommended activity across their childhood is an essential goal for pediatric clinics.

Due to racism, bias and discrimination, children of color and children from families with lower socioeconomic status are less likely to complete all WCVs and therefore benefit from all WCV activities.[1][2][3][4] Ensuring that every WCV is optimized can contribute to mitigating inequities in health and well-being experienced by children based on race, ethnicity and class.

Additionally, WCVs provide an opportunity to forge healthy, positive, strengths-based relationships with children, youth and their families. A trusted, caring relationship can provide a foundation for mitigating the deleterious and harmful effects of racism, bias and discrimination.

WCVs provide an opportunity for screening for and responding to unmet social needs as well as building the trusted relationship necessary for families to disclose unmet needs. An initial minimum standard for social need screening may be guided by the Bright Futures implementation tip sheet on integrating health-related social needs.

Relevant HIT capabilities to support this activity include electronic access to care guidelines, registries, clinical decision support, care dashboards and reports, quality reports, outreach and engagement, and care management and care coordination. See Appendix D: Guidance on Technological Interventions.

Access to outside data may be a consideration or requirement (e.g., California Immunization Registry (CAIR) immunization registry data, school health data, and data from other practices) as services received outside the health center may be part of compliance. While claims data provided by payors may be helpful in this regard, lag time may impact its usefulness. Partner Medi-Cal managed care plans (MCPs) likely already do or can provide upon request reports of children who appear overdue, based on claims and encounter data, for pediatric preventive care, such as well-child visits and lead screening. Such reports may reduce the need for health centers to generate reports from raw claims data. Patient-facing applications should be strongly considered to assure that parents, caregivers and older adolescents are informed and appreciative of the nature and importance of recommended care. Confidentiality concerns and regulatory requirements protecting emancipated adolescents can be challenging, as EHRs and other technologies may not support segmentation of information. This may need to be overcome through manual workarounds and procedures

Action steps and roles

1. Review current practices to identify key opportunities for improvement.

Suggested team member(s) responsible: QI lead with frontline staff (e.g., PCP, nurse, medical assistant, front desk staff).

Using the periodicity schedule as a guide, catalog the clinic’s current practices, processes and protocols related to WCVs. Identify how current practices align with the recommendations of the periodicity table and identify top opportunities for improvement.
Consider compiling additional data to determine the rate of completion of each of the recommended activities at each WCV, even if these data are from a small sample of WCVs (e.g., the next five to 10 WCVs for 15-month-olds). Review aggregated data to identify areas of strong performance to learn from and areas for improvement to prioritize. See more in Key Activity 3: Use Care Gap Reports or Registries to Identify all Patients Eligible and Due for Care.

Opportunities for improvement may include:

  • Improving scheduling and completion rates for WCVs at the recommended ages.
  • Introducing a practice, process or protocol that is currently not being done at all.
  • Expanding the WCVs at which a practice, process or protocol is currently being done.
  • Improving the quality or reliability of a current practice, process or protocol.

Of note, one of the more challenging Bright Futures and U.S. Preventive Services Task Force (USPSTF) recommendations is the initiation of fluoride varnish after the eruption of the first primary tooth. A new HEDIS measure in 2023 for fluoride varnish reads, “The percentage of members one to four years of age who received at least two fluoride varnish applications during the measurement year.” While federally qualified health centers (FQHCs) with colocated dental clinics may have additional resources and flexibility regarding integration of this key pediatric preventive service, practices without colocated dental clinics may need to employ new strategies.

 

2. Test new and adapted practices and processes to develop improved workflows and standard protocols for implementing recommended activities during WCVs, focusing first on prioritized areas for improvement.

Suggested team member(s) responsible: QI lead with frontline staff, as appropriate for the WCV activity of focus; patients and their families.

Consider how to use registries, the pre-visit planning process, and daily huddles to support this key activity. (Note: Other key activities are included in this guide to support these aspects.) Use the individual WCV resource pages at AAP Schedule of Well-Child Care Visits – HealthyChildren.org to design, organize and improve each WCV. Consider how to integrate a trauma-informed approach as your practice creates and tests new or adapted processes and enlist caregivers as partners in ensuring WCV activities are provided on time. HealthyChildren.org provides a caregiver-friendly version of the AAP Schedule of Well-Child Care Visits that clinics can share with parents so they know what to expect.

 

3. Continuously improve approach to WCVs, both overall and for key subpopulations.

Suggested team member(s) responsible: QI lead with frontline staff, as above.

Track data on completion of WCVs in real time and collect disaggregated data by race and ethnicity, as well as by language spoken and geographies, whenever possible. Advocate for strategies that address the challenges specific to subgroups, particularly those with low WCV completion rates, to drive optimal WCVs for all children and families. See more in Key Activity 10: Implement Trauma-Informed Care Approach Across the Patient Journey and Key Activity 4: Use a Systematic Approach to Decrease Inequities.

Implementation tips

Below are examples of quality improvement efforts to improve reliability of meeting WCV recommendations:

  • Sonoma Valley Community Health Center created a training booklet to both train new staff and act as a reference guide for existing staff. Updated annually, it contains many of the health center’s key workflows, including childhood immunizations.
  • Shasta Community Health Center conducted an improvement project centered around increasing the rate of pediatric patients who leave an acute care visit with a scheduled well child visit from the baseline of 30%.
  • Marin Community Clinics undertook a multipronged improvement effort for completing required immunizations for all patients by their second birthday by creating a culture of vaccinations at the practice.
  • Hill Country Health & Wellness Center conducted a quality improvement project where they tested a new workflow for Childhood Health and Disability Prevention (CHDP) visits with one provider to optimize the use of provider time by segmenting the 40-minute appointment slot into two sessions. The first 20 minutes is with the licensed vocational nurse (LVN) or registered nurse (RN) for education, and the remaining 20 minutes is with the provider. This change was designed to increase access to well-child visits and deliver education on immunizations, thereby increasing immunization rates according to accepted periodicity schedules.

Endnotes

  1. Maria Trent, Danielle G. Dooley, Jacqueline Dougé, SECTION ON ADOLESCENT HEALTH, COUNCIL ON COMMUNITY PEDIATRICS, COMMITTEE ON ADOLESCENCE, Robert M. Cavanaugh, Amy E. Lacroix, Jonathon Fanburg, Maria H. Rahmandar, Laurie L. Hornberger, Marcie B. Schneider, Sophia Yen, Lance Alix Chilton, Andrea E. Green, Kimberley Jo Dilley, Juan Raul Gutierrez, James H. Duffee, Virginia A. Keane, Scott Daniel Krugman, Carla Dawn McKelvey, Julie Michelle Linton, Jacqueline Lee Nelson, Gerri Mattson, Cora C. Breuner, Elizabeth M. Alderman, Laura K. Grubb, Janet Lee, Makia E. Powers, Maria H. Rahmandar, Krishna K. Upadhya, Stephenie B. Wallace; The Impact of Racism on Child and Adolescent Health. Pediatrics August 2019; 144 (2): e20191765. 10.1542/peds.2019-1765 
  2. Garg A, Wilkie T, LeBlanc A, Lyu R, Scornavacca T, Fowler J, Rhein L, Alper E. Prioritizing Child Health: Promoting Adherence to Well-Child Visits in an Urban, Safety-Net Health System During the COVID-19 Pandemic. Jt Comm J Qual Patient Saf. 2022 Apr;48(4):189-195. doi: 10.1016/j.jcjq.2022.01.008. Epub 2022 Jan 26. PMID: 35216919; PMCID: PMC8789396. 
  3. Tom JO, Tseng C-W, Davis J, Solomon C, Zhou C, Mangione-Smith R. Missed well-child care visits, low continuity of care, and risk of ambulatory care-sensitive hospitalizations in young children. Arch Pediatr Adolesc Med. 2010;164(11):1052–1058. 
  4. Evans EJ, Arbeit CA. What's the difference? Access to health insurance and care for immigrant children in the US. Int Migr. 2017;55(5):8–30.