Children Guide

Preventive screenings and care for children and adolescents reduce the risk of disease that can lead to disabilities and premature mortality. However, many in the United States do not utilize suggested preventive healthcare services.^[1]

In the case of children, regular well-child check-ups are essential to monitor growth and identify potential health issues at early stages when intervention is often more effective. Screenings and vaccinations play a pivotal role in upholding the well-being of individuals spanning various age brackets.^[2][3]

This guide provides practices with detailed guidance, examples, resources and tools to develop, test, refine, bring to scale, and continually improve protocols around children’s immunization and well-child visits (WCVs). This document uses existing evidence, bright spots and examples from the field to offer practical guidance on improving the effectiveness of your child health strategy, keeping in mind that it will be adapted to your practice’s unique context.

Key activities in this guide are organized into three categories:

• Foundational activities: The core activities that all practices must implement as part of their children’s immunization and WCV protocol.
• Going deeper activities: More advanced activities that build off the foundational activities and further your efforts to achieve equitable improvement in your children’s immunization and WCV rates.

Where to Start: While we recommend following the sequence of the key activities in this guide, the activities can be used individually or adapted to fit your practice’s priorities.

Trying it Out then Making it Habit: For each activity, we provide guidance on how to plan, try, and implement the activity along with links to other resources, technology considerations and examples. Consider trying different versions of the action steps and roles with a smaller group before fully implementing at your practice.

Maintaining Progress: Ongoing review and continual improvement are important for your practice to maintain your progress in population health management and help you stay nimble in adapting to changing patient demographics, new clinical best practices, new payment policies, workforce changes, and other changes at your practice. For many activities we have also provided tips for periodically reviewing and making improvements to key workflows even after initially implementing the change.

If you implement the Foundational Activities in this guide, your practice should be able to achieve the following objectives:

1. Engage patients served by your practice to validate any proposed process improvements and to learn alternative methods to improve quality in your focus area.
2. Analyze core quality measures to identify disparities and improvement opportunities for adherence to American Academy of Pediatrics (AAP) preventive care guidelines year over year among attributed patients.
3. Incorporate AAP preventive care guidelines into well-child visit protocols for infancy and early childhood (up to 30 months).
4. Create an outreach protocol to reach and engage all attributed patients due for care.
5. Prepare for integrating behavioral health follow-up services as needed.
6. Create a health-related social needs screening process that informs patients’ treatment plans.
7. Assess current capabilities and develop a plan for ongoing improvement in data utilization, care team workflows and efficiency that includes sustainable health information technology (HIT) strategies and continuous staff training on technology.

This guide also includes sections on measurement, equity, social health, behavioral health integration and an appendix including helpful tools and resources. We have included information about California Medi-Cal covered benefits and services that were up-to-date at the time of publishing, but benefits and billing guidance change over time. Nothing in this guide should be considered formal guidance, and anyone using this guide should check with the appropriate authorities on benefits and billing guidance.

This is a living document and will change based on continued learning on this topic and may include additional activities, examples, resources and sections in the future.

Additional Information can be found in Getting Started: Introduction to the PHMI Implementation Guides, and Aligning PHM Principles with Community Health Clinic Strategic Planning.

Improving the health of a population impacts everyone in a practice. Critical roles needed to engage in the work outlined in this guide and support practice change include:

• Quality improvement leadership, like a director of quality improvement (QI) or additional team leads (e.g., clinical, front office, etc.), to support cultural changes.
• Coaches or practice facilitators who are partnered with teams to help identify areas for improvement and support change through change management strategies.

PHMI’s approach emphasizes four foundational areas for PHM: a reimagined care team, empanelment, the business case, and data quality and reporting (DQ&R). These areas provide the foundation for the sustainable delivery of person-centered, population-based care and improving outcomes for a population of focus; see Building the Foundations for Population Health Management: Talking Points for Engagement for a concise overview and talking points for why these areas are important.

In addition, practices can reference specific Building the Foundations key activities to go deeper into specific challenges related to advancing equity, social health, behavioral health integration, and access and outreach for their population of focus:

Equity

• Business Case Guide: Advancing Equity Through Your Business Case
• Empanelment Guide: Advancing Equity Through Empanelment
• Data Quality and Report Guide: Advancing Equity Through Data Quality and Reporting
• Care Teams and Access Guide: Advancing Equity Through Care Teams and Workforce
• In this guide: Key Activity 5: Use a Systematic Approach to Decrease Inequities and Key Activity 23: Strengthen a Culture of Equity

Social Health

• Care Teams and Workforce Guide: Key Activity 1: Develop and test a core team structure
• In this guide: Key Activity 9: Screen for and Attend to Pediatric Behavioral and Social Needs, Including ACEs

Behavioral Health

• People with Behavioral Health Conditions Guide
• Care Teams and Workforce Guide: Key Activity 1: Develop and test a core team structure and Key Activity 2: Identify gaps in staffing and decide how to address them
• In this guide: Key Activity 9: Screen for and Attend to Pediatric Behavioral and Social Needs, Including ACEs

Access and Outreach

• Empanelment Guide: Going Deeper: Connecting Empanelment with Patient-Centered Access
• Care Teams and Workforce Guide: Key Activity 2: Identify Gaps in Staffing and Decide How to Address Them
• In this guide: Key Activity 18: Provide Proactive Inreach and Outreach to Help Adolescents Engage in Behavioral Health Care