A High-Performing System for Well-Child Care: A Vision for the Future
David Bergman, M.D., Paul Plsek, M.S., and Mara Saunders
D. Bergman, P. Plsek, and M. Saunders, A High-Performing System for Well-Child Care: A Vision for the Future, The Commonwealth Fund, October 2006
Standardization of well-child care services is intended to ensure that families receive core services and key information. But standardization also encourages a "one-size-fits-all" approach that subjects many families to unnecessary office visits. At the same time, many children at risk for physical, developmental, or behavioral problems fail to get needed services due to time and resource constraints. This report presents a vision for a high performing system of well-child care and a guide for future policy and research efforts. Based on their extensive research, the authors conclude that an ideal system would be characterized by advanced access to services, team-based care, individualized developmental and behavioral screening, care coordination through a medical home, electronic health records, and tools for information and knowledge transfer. Some reforms are ready to be implemented, while others would require additional resources, new technology, and/or policy changes.
Well-child care—the primary means of providing developmental and preventive services—is ripe for change. Despite taking great pains to be efficient providers of care, may pediatric practices struggle to fulfill the needs and expectations of families with young children. One problem is standardization in the way well-child care is both provided and reimbursed. While intended to ensure that families receive core services and key information, standardization tends to encourage a "one-size-fits-all" approach that subjects many families to unnecessary visits. At the same time, many children who are at risk for physical, developmental, or behavioral problems fail to get needed services due to time and resource constraints. Much of physicians' time is spent on providing services that could be better performed by other health professionals, infringing on time they have available to care for children with complex medical problems. Because of the poor design of well-child care, providers often fail to adopt evidence-based practices, such as the use of standardized developmental screening. These conditions lead to waste, lower-quality care, and frustration for all parties.
We need a high-performing system of well-child care designed to optimize the development of young children. New technologies and innovative clinical practices can provide the tools needed to create it. This will require transformational change; we will not be successful through efforts at the margin. In this report, we articulate changes needed to realize a high-performance system for the delivery of well-child care. We intend for it to serve as a template for implementing changes in clinical practice and a guide for further policy and research efforts.
To develop key concepts and strategies, we relied on Berwick's concept of a "change idea," or an idea that can lead to improved performance but must be detailed and adapted for a given situation. We used three approaches to develop change ideas:
- reviewing the current literature to assess key findings in well-child care research and identify important trends;
- posing discussion questions on listservs for general and academic pediatricians to generate new ways of providing well-child care (e.g., pediatricians were asked to respond to the question 'How would you deliver WCC if there were no pediatric offices?' as a way to stimulate creative thinking); and
- convening family physicians, nurse practitioners, child health advocates, researchers, grantmakers, and parents at a conference to discuss best practices and innovations.
We then developed models of high-performing practice for various well-child care scenarios. The scenarios were:
- an urban setting serving a racially and ethnically diverse population;
- a rural setting with low- to moderate-income patients who travel long distances to office visits;
- a suburban, middle-class setting;
- a system serving children with special health care needs;
- a health care system that provides reimbursement for home health visitors;
- a system with lowest possible costs, while maintaining acceptable quality;
- the most innovative system (i.e., if you did this, people would say "Wow!");
- the most technology-driven system, not centered on the physical office.
Then, drawing on the best change ideas developed for these eight scenarios, we created an overall vision for ideal well-child care. Table ES-1 organizes the change ideas according to those ready for immediate implementation; those requiring additional resources; and those requiring the use of new technology or policy development. The discussion below outlines the key elements of a high-performing system for WCC.
Advanced Access to Care
In ideal well-child care, families would be able to access health services and consult with their providers in ways that work for them. Access to care could take many different forms, apart from office visits.
- Remote encounters would be used to enhance communication between families and health care teams for situations that do not require office visits. These encounters could be created through the use of secure messaging, Web-based virtual visits, videoconferencing, or other telehealth tools.
- Systems would be implemented to allow parents to make same-day appointments, or appointments at desired times in the future.
- Home visitors would be used to deliver WCC for high-risk children.
- Developmental and educational assessment could be performed in schools, day care centers, or community and religious centers. Telehealth encounters could be used in these settings to provide access to child development expertise.
In a high-performing WCC system, a multidisciplinary team of health care professionals would offer a broad range of services to families.
- This team could include developmental and behavioral specialists, care coordinators, and home visitors. The membership of each team would be tailored to meet the specific needs of children and families. Some of the team members could be shared among multiple practices.
- Children with special health care needs would have access to a care coordinator. This individual would help families navigate complex systems, interface with payers, and develop a comprehensive plan that encompasses education and socialization as well as health care.
- Parents would be part of the health care team, helping to plan and deliver care and assess well-child care outcomes.
Individualized Developmental and Behavioral Screening
Ideal well-child care would entail continuous developmental surveillance to detect and address physical, behavioral, or learning problems and optimize child health.
- Health care professionals would assess children's development and behavior using valid screening instruments. The results of the screening would be available to clinicians prior to well-child care visits in order to identify children at risk and structure visits to meet families' expressed needs.
- Developmental and behavioral screening instruments that have been validated among different minority groups would be used for racially and ethnically diverse populations.
- Every newborn would be screened for biological, psychological, and social risk factors and stratified into groups according to risk. This could take place in the newborn nursery or during the first few well-child care visits.
- The results from behavioral and developmental screenings would be used to customize the content of the well-child care visit and include appropriate members of the health care team.
Cultural Beliefs and Practices of Racial and Ethnic Minority Groups
An ideal well-child care system would accommodate patients' communication needs as well as their preferences, values, and expectations.
- Children and families would have access to language and other cultural interpretation services in cases where English is not the language spoken at home.
- Health care organizations would consider providing some components of well-child care in sites such as day care centers, churches, or homes. Some families might find community settings more familiar or comfortable than health clinics or physician offices.
- Health care teams would include members who are familiar with the beliefs and practices of their patient populations.
Care Coordination in the Context of a Medical Home
In an ideal well-child care system, each child would have a medical home to coordinate care among multiple pediatric specialists, schools, and community agencies.
- Pediatric clinicians would form partnerships with community and government agencies. Such partnerships could focus on population-based health initiatives, such as obesity prevention.
- For children with special health care needs, community pathways would be developed to bring together the health care system, schools, and other community agencies and provide a clear path for children who need a wide array of services.
- Videoconferencing would be used to enhance care coordination between families and health care providers.
Knowledge Transfer and Electronic Health Records
To care for their children and participate in the medical decision-making process, families need access to accurate information and effective systems for knowledge transfer. In an ideal well-child care system:
- Health care organizations would commit to implementing electronic health records (EHRs) and eliminating costly and inefficient paper transactions.
- Each parent/child would have a personal health record (PHR) that was closely integrated with his or her EHR. Through the PHR, each family would be able to engage in secure electronic communications with their clinicians, view test results and visit summaries, input health information, and share information with other health care professionals.
- Families would have access to a repository of information about child development and behavior, health promotion, and illness that is evidence-based and up to date—a "Bright Futures" for parents. The repository would be appropriately indexed so that distinct modules could be linked to PHRs.
- Health care information would be integrated across communities, states, and the nation using common standards for electronic databases and tools.
- Creation of regional health information organizations would be encouraged. These organizations would be able to integrate information across providers to create a community health record and a regional and national database to facilitate disease surveillance and outcomes assessment.
Health Care Financing
Effective well-child care would depend on a health care financing system that provides universal access to health care for children.
- Ideally, the United States would pass legislation to provide universal health care coverage for children. Because the health of the child is often dependent on the health of the family, this coverage should be extended to mothers and fathers.
- Short of universal health coverage, intermediate steps should be implemented to provide: 1) appropriate reimbursement for transactions other than face-to-face encounters; 2) levels of reimbursement based on the degree of risk of the child and family (i.e., tiered capitation); and 3) reimbursement for the work of non-physician members of health care teams, such as mental health professionals and child development specialists.
WCC as it exists today is in need of transformational change. The current system does not meet the needs of families or the aspirations of providers. This report puts forth a template for the future direction of well-child care. To move forward, we will need to engage in a stepwise process to bring about incremental and transformational change. We will not be successful unless we pair changes in practice with changes in reimbursement. In particular, provider incentives need to be aligned to promote best practices in preventive and developmental care. Effecting change will also require strong leadership from organizations and agencies such as the American Academy of Pediatrics, the American Academy of Family Practice, and the Maternal and Child Health Bureau.
Table ES-1. Well-Child Care Change Ideas: Readiness for Implementation
|Change Ideas Ready for Implementation||Change Ideas Requiring Additional Resources||Change Ideas Requiring New Technology or Policy Development|
|Assign children into risk categories and customize their screening and developmental/ preventive services||Provide advance access; ensure that visits can take place on the day requested||Give parents access to vetted Web sites; automatically direct them to sites from electronic or personal health records|
|Focus well-child care visits with the help of structured assessments prior to the visits||Use public health nurses or other child health professionals to make home visits||Create interactive health care information programs to teach child development and health promotion skills; possible partnerships with media companies|
|Use of parents as consultants to answer questions and impart information||Use multidisciplinary teams to ensure families are offered broad range of services, including developmental and mental health services||Send group e-mails or text messages with health information, e.g., allergy alerts|
|Enable parents of children with special health care needs to partner with practices, participate in planning care||Deliver screening and developmental and preventive services at preschools and day care centers||Install kiosks at places of employment or other central locations to provde information about community resources|
|Pediatricians serve as consultants to schools, community agencies, and other settings||Forge partnerships between practices and communities agencies for population-based initiatives, such as obesity prevention||Create electronic health records linked to regional health information organizations to track outcomes and perform needs assessment|
|Give parents customized calendars with schedule and description of well-child visits (like tear-off tickets for mortgage payments or car maintenance)||Enable "one-stop shopping": co-location of health, mental health, education, and social services||Use electronic prompts and reminders for clinicians and parents to ensure appropriate and timely well-child care|
|Set up specific office hours for behavioral and developmental problems||Perform population-based screening in schools, churches, or community agencies to identify health care needs||Set up Web-based tracking/ monitoring systems linked to a child's electronic health record, e.g., immunization registry, specialty referrals, and disease management|
| ||Use a care coordinator in conjunction with team-directed care||Use a personal health record derived from an electronic health record|
D. Bergman, P. Plsek, and M. Saunders, A High-Performing System for Well-Child Care: A Vision for the Future, The Commonwealth Fund, October 2006