Coker Tumaini R, Moreno Candice, Shekelle Paul G, Schuster Mark A, Chung Paul J
UCLA Children's Discovery and Innovation Institute, Mattel Children's Hospital, andRAND, Santa Monica, California;
University of Illinois College of Medicine, Chicago, Illinois;
Pediatrics. 2014 Jul;134(1):e229-39. doi: 10.1542/peds.2013-3775. Epub 2014 Jun 16.
Our objective was to conduct a rigorous, structured process to create a new model of well-child care (WCC) in collaboration with a multisite community health center and 2 small, independent practices serving predominantly Medicaid-insured children. Working groups of clinicians, staff, and parents (called "Community Advisory Boards" [CABs]) used (1) perspectives of WCC stakeholders and (2) a literature review of WCC practice redesign to create 4 comprehensive WCC models for children ages 0 to 3 years. An expert panel, following a modified version of the Rand/UCLA Appropriateness Method, rated each model for potential effectiveness on 4 domains: (1) receipt of recommended services, (2) family-centeredness, (3) timely and appropriate follow-up, and (4) feasibility and efficiency. Results were provided to the CABs for selection of a final model to implement. The newly developed models rely heavily on a health educator for anticipatory guidance and developmental, behavioral, and psychosocial surveillance and screening. Each model allots a small amount of time with the pediatrician to perform a brief physical examination and to address parents' physical health concerns. A secure Web-based tool customizes the visit to parents' needs and facilitates previsit screening. Scheduled, non-face-to-face methods (text, phone) for parent communication with the health care team are also critical to these new models of care. A structured process that engages small community practices and community health centers in clinical practice redesign can produce comprehensive, site-specific, and innovative models for delivery of WCC. This process, as well as the models developed, may be applicable to other small practices and clinics interested in practice redesign.
我们的目标是开展一个严谨、结构化的过程，与一个多站点社区健康中心以及两家主要为医疗补助保险儿童服务的小型独立诊所合作，创建一种新的儿童健康照护（WCC）模式。由临床医生、工作人员和家长组成的工作小组（称为“社区咨询委员会”[CABs]）运用（1）WCC利益相关者的观点以及（2）对WCC实践重新设计的文献综述，为0至3岁儿童创建了4种全面的WCC模式。一个专家小组按照兰德/加州大学洛杉矶分校适宜性方法的修改版，在4个领域对每个模式的潜在有效性进行评分：（1）接受推荐服务的情况，（2）以家庭为中心的程度，（3）及时且恰当的随访，以及（4）可行性和效率。将结果提供给CABs以选择最终实施的模式。新开发的模式在很大程度上依赖于一名健康教育工作者进行预期指导以及发育、行为和社会心理监测与筛查。每个模式都分配了少量时间让儿科医生进行简短的体格检查并处理家长对身体健康的担忧。一个安全的基于网络的工具根据家长的需求定制就诊，并便于就诊前筛查。家长与医疗团队沟通的预定非面对面方式（短信、电话）对这些新的照护模式也至关重要。让小型社区诊所和社区健康中心参与临床实践重新设计的结构化过程能够产生全面、针对具体地点且创新的WCC提供模式。这个过程以及所开发的模式可能适用于其他对实践重新设计感兴趣的小型诊所。
