Educating Physicians In Their Communities EPIC Practicing Safety Training

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Educating Physicians In Their Communities (EPIC)
Practicing SafetyTraining 1
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Statistics on Child Abuse and Neglect

• Child abuse and neglect is a significant problem
  in the U.S.
• Inconsistency in reporting.
• National Child Abuse and Neglect Data System
  (NCANDS) established in 1990.

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Background Epidemiology of Abuse and Neglect in
U.S.

• Prevalence was at its peak in 1993
  (15.3 per 1,000 children).
• Fell to 12.3 per 1,000 children in 2002.
• Fatalities rose by 8 between 1996 and 2000
  (Peddle et al. 2002).
• The fatality rate in 2002 was 1.98 deaths per
  100,000 children (Child Maltreatment 2002).

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The Importance of Prevention

• 10-15 of young children are victims of serious
  physical trauma (Finkelhor and Straus)
• Neglect is the leading cause of substantiated
  cases of abuse
• Estimates of treatment costs are 24 billion a
  year
• Long term sequelae are enormous in terms of
  psychological and functional damage, substance
  abuse, delinquency, learned aggressiveness and
  abuse potential as a parent

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Primary Care Providers Continue to Face a
Significant Dilemma

• Major morbidities of childhood not traditional
  organic illnesses.
• Issues of child abuse, discipline, behavior,
  family stressors, divorce, depression, financial
  concerns, violence, development, learning, drug
  use, etc., affect many children seen by
  Pediatricians.
• Families want their pediatricians to become
  involved in these non-traditional issues.
• Providers believe they should be involved in
  these issues.
• Providers are mostly not involved in these issues

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The Potential Role of the Primary Care
Pediatrician

• Surveys continue to rate pediatricians as
  familys most important source of information on
  child rearing (PCCA and Cheng Study)
• The well child visit is based on the value of
  anticipatory guidance.
• 22-27 of all ambulatory visits are well child
  care
• The current schedule has visits at 1 wk, 2, 4, 6,
  9 months, 1 yr, 15, 18 months, 2, 3 yrs
• Pilot studies have demonstrated improvements in
  child abuse prevention approaches after short and
  focused skill building programs.

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New National Surveys for Assessing Content of
Health Supervision for U.S. Children under 3
Years of Age

• National Survey of Early Childhood Health (NSECH)
• Periodic Survey of Fellows of the American
  Academy of Pediatrics (AAP)

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National Survey of Early Childhood Health (NSECH)

• National phone survey by National Center for
  Health Statistics through State and Local Area
  Integrated Telephone Survey (SLAITS)
• Fielded Feb-July 2000. Response rate 65.3
  (Council of American Survey Research
  Organizations-CASRO)
• Data from parents of 2,068 children age 4-35
  months, over sample of 860 African Americans and
  Hispanic households.
• Weights applied so data represent all U.S.
  children in age group.

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Nearly All Infants and Toddlers Are Connected
with Well Child Care

• Nearly all young children have a particular place
  for well child care
• Only 46 of children have a particular person for
  well child care
• Most parents of young children (86) say well
  child care is very important
• Satisfaction ratings are high (mean 8.7, on 0-10
  scale)

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Health Supervision Topics That Physicians
Discuss and Dont Discuss But Parents Would Find
Helpful
Food and feeding
Reading
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Health Supervision Topics That Physicians
Discuss and Dont Discuss But Parents Would Find
Helpful
Discussed
Not discussed
Not discussed, would have been helpful
100
14
18
17
23
25
33
30
46
28
55
50
52
43
44
35
27
0
4-9
10-18
19-35
10-18
19-35
months
months
months
months

months
Child care
Guidance/Discipline
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Periodic Survey of
Fellows of the American Academy of Pediatrics
(AAP)

• Periodic Survey National, random sample, mailed
  survey of 1600 US members of AAP
• Fielded March 2000 - August 2000
• Return rate 67
• Data reported on 811 pediatricians who provide
  health supervision to children under 36 months of
  age

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Pediatrician Perspectives on Content of Health
Supervision

• Most pediatricians say they discuss traditional
  topics with at least 70 of parents of patients
  0-9 months
• Immunizations (94), nutrition (93),
  sleeping positions (82), breastfeeding (70)
• Less frequently discussed are topics related to
  cognitive development
• Reading to child (48) and how child
  communicates (42)
• Least discussed are topics related to family and
  community needs
• Social support (28), financial needs (16),
  violence in the community (13)

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What Doctors Talk About With Their Families

• Common topics not discussed over 50 even
  though 86 of pediatricians think those topics
  are important
• discipline
• child development
• behavior
• Only 33 discuss guidance/discipline with
  parents of toddlers

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Its Not for a Lack of Trying
BRIGHT FUTURES THE FUTURE OF PEDIATRIC
EDUCATION ARTICLES IN THE MAJOR JOURNALS - PAST 5
YEARS MATERNAL DEPRESSION - 209 ARTICLES
PARENTAL SUBSTANCE ABUSE - 30 ARTICLES
DEVELOPMENTAL SCREENING - 60 ARTICLES
DOMESTIC VIOLENCE CHILDREN - 322 ARTICLES
PREVENTION OF CHILD ABUSE - 15 ARTICLES
SCHOOL ISSUES THE PEDIATRICIAN - 81 ARTICLES
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Dissemination StrategiesSome Old Approaches

• Continuing medical education
• Evidence-based guidelines
• Opinion leaders
• Audit and feedback
• Incentives and disincentives
• Academic detailing
• Patient and/or consumer activation
• Office system innovations
• Continuous quality improvement

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PRACTICING SAFETY A New Approach

• GOALS and OBJECTIVES
• Adapt materials from AAP Violence Intervention
  Program (VIPP). Develop additional culturally
  sensitive materials and tools for pediatric
  office and parents on the 7 healthy development
  indicators to prevent child abuse and neglect.
• Develop office system approaches involving
  community health services to enable the practice
  to incorporate the program into its regular
  pattern of practice to increase the competence
  and confidence of the pediatric staff to provide
  effective prevention programs.

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PRACTICING SAFETY
GOALS and OBJECTIVES contd. 3. Develop
reimbursement codes that pay appropriately for
the enhanced services of the practices. 4.
Increase collaborative efforts with other
agencies and programs working in the prevention
of abuse and neglect. 5. Disseminate the models
through publications, lectures, and the
media. 6. Implement a formal evaluation format
to measure process and outcome measures.
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PRACTICING SAFETY

• PROJECT COMPONENTS
• 0 - 3 AAP Connected Kids materials for patients
  and providers
• MAP Assessment, team process, collaborative
  interaction among sites
• Office System Tools
• Community Integration
• Social Marketing
• Resource Compendium that is site specific
• Office outreach

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7 Practicing Safety Modules Focus on Prevention

• Color coded Practice Guides
• Red Coping with Crying/SBS Prevention
• Purple Parenting
• Pink Safety in Others Care
• Blue Family and The Environment
• Orange Effective Discipline
• Green Sleeping/Eating Issues
• Aqua Toilet Training

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Practicing Safety Modules include

• Practice Guides with
• Background information about each topic
• Assessment Questions
• Anticipatory Guidance
• Parent Educational Materials
• Office Marketing Tools
• Staff tools
• Moderate Interactives/Tangibles
• Issues Management

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Incorporate the materials into your routine
patterns of practice
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Child Abuse and Neglect Prevention Begins with
YOU

• Office-based change is a TEAM effort!
• Who is here today?
• Identify roles and responsibilities
• Support your team with office policies and
  procedures promoting a child abuse and neglect
  prevention program

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Transform your plans into results!

• Create a team that is representative of your
  office
• Set regular meeting dates
• Select 2-3 goals that are specific, achievable
  interventions
• Keep in mind that small changes can have large
  effects and large interventions can result in
  minimal change!
• Communicate with each other and be reflective
• Monitor your progress
• Celebrate success!

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Questions to consider

• What are things your practice does well regarding
  child abuse and neglect prevention?
• Are there any changes youve identified that you
  would like to make but you are concerned about
  staff and other resources to accomplish them?

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Reach out to your community
Parenting Support
Preventive Care
Acute Care
Pediatric Office
Developmental Services
Chronic Care
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Create and use a Community Resource Guide
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Things to remember when creating office-based
change

• Practices are complex systems and one part cannot
  be changed without impacting the whole system
• Patterns of relationships among agents have a
  strong influence on the practice
• Self-reflection and an articulated vision can
  help guide system level change
• May need facilitated quality improvement effort
  that includes a system assessment.

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Acknowledgements
Central Evaluation Team Steven Kairys, MD,
MPHPrincipal Investigator Diane Abatemarco PhD,
MSWCo-Principal investigator Ruth Gubernick,
MPHPractice Facilitator Karen Benjamin, MPH
CHESHealth Program Analyst American Academy of
Pediatrics Staff Tammy HurleyProject
Director Charlette Nunnery, MSProject Manager

• Funding for this project has been provided by the
  Doris Duke Charitable Foundation
• This project is being coordinated by the American
  Academy of Pediatrics, in partnership with the
  University of Medicine and Dentistry of NJ-School
  of Public Health

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Next Steps

• Identify practice champion
• Identify RAP team of 5-6 people -Include
  practice champion, at least 1 member from each
  area/department of practice, and parent when
  possible
• Attend 2nd EPIC training on tool kit
  implementation and next steps