Practicing Safety

Steve Kairys, MD, MPH, FAAPDiane Abatemarco, PhD, MSW

Practicing Safety Learning SessionMay 30, 2009

Disclosures

Steven Kairys: I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

Diane Abatemarco: I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

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 (over 60%)

Children < age 3 account for nearly 30 percent of victims.

Estimates of treatment costs are 24 billion dollars a year. Long term sequelae are enormous in terms of psycho-

logical and functional damage, substance abuse, delinquency, learned aggressiveness and abuse potential when a parent.

The Relationship of Adverse ChildhoodExperiences to Adult Health Status

A collaborative effort of Kaiser Permanente and

The Centers for Disease Control and Prevention

Vincent J. Felitti, M.D.Robert F. Anda, M.D.

The Adverse Childhood Experiences (ACE) Study

• The largest study of its kind ever done to examine the health and social effects of adverse childhood experiences over the lifespan (18,000 participants)

What do we mean by Adverse Childhood Experiences?

• Experiences that represent medical and social problems of national importance. - Childhood abuse and neglect- Growing up with domestic violence,

substance abuse or mental illness in the home

- Parental loss - Crime

ACE Study Design

Survey Wave 1 -- complete71% response (9,508/13,454) n=15,000 71% response

Survey Wave II n=15,000

All medical evaluationsabstracted

PresentHealth Status

Mortality National Death Index

Morbidity Hospital Discharge Outpatient Visits Emergency Room Visits Pharmacy Utilization

All medical evaluationsabstracted

vs. &

The Adverse Childhood Experiences (ACE) Study

Summary of Findings:• Adverse Childhood Experiences (ACEs)

are very common • ACEs are strong predictors of later

health risks and disease• This combination makes ACEs the leading determinant

of the health and social well-being of our nation

Categories of Adverse Childhood Experiences

CategoryPrevalence (%)

Abuse, by Category Psychological (by parents) 11% Physical (by parents) 11% Sexual (anyone) 22%

Household Dysfunction, by Category Substance Abuse 26% Mental Illness 19% Mother Treated Violently 13% Imprisoned Household Member 3%

What is conventionallyviewed as a problem

is actually a solution to an unrecognized prior

adversity.

Adverse Childhood Experiences determine the likelihood of the ten most common causes of death in the United States.

Top 10 Risk Factors: smoking, severe obesity, physical inactivity, depression, suicide attempt, alcoholism, illicit drug use, injected drug use, 50+ sexual partners, h/o STD.

Evidence from ACE Study Suggests:

Adverse childhood experiences are the most basic cause of health risk

behaviors, morbidity, disability, mortality, and healthcare costs.

Adverse Childhood ExperiencesAdverse Childhood Experiences

Social, Emotional, & Cognitive Impairment

Adoption ofHealth-risk Behaviors

Disease, Disability

EarlyEarlyDeathDeath

The Influence of AdverseChildhood Experiences Throughout

Life

Death

Birth

The Role Primary Care Practice in Preventing Child Abuse and

Neglect

Percent Of Children Who Saw A Pediatric Clinician In Past Year

99 %

30 %

41 %

29 %

1+ visits 1-3 visits 4-6 visits 7+ vists

Periodic Survey of Fellows of the American Academy of Pediatrics

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

Most pediatricians say they discuss traditional topics with less than 75% 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%) & how child communicates (42%)

Least discussed are topics related to family & community needs:

Social support (28%), financial needs (16%), violence in the community (13%)

Pediatrician Perspectives on Content of Health Supervision

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

What Doctors Talk About With Their Families

Percent of Pediatricians Screening Young Children for Developmental Problems

96 %

71 %

15 %23 %

Any Screening Always OnlyClinical

Assessment

Sometimes OnlyClinical

Assessment

StandardizedInstrument

AAP Periodic Survey #53, 2002

Parents With Concerns About Their Children Ages 4-35 Months

48 %45 %

42 % 41 %38 %

Behavior Communication Emotional well-being

Getting alongwith others

Learningpreschool skills

National Survey of Early Childhood Health, 2000

Parents’ Misconceptions

Parents of young children…

57% believe a baby younger than 6 months can

be spoiled

Almost 40% believe a 12-month-old’s behavior

can be based on revenge

51% expect a 15-month-old to share

What Grown-Ups Understand About Child Development, Civitas, 2000

Missed Opportunities

Parents concerns are often not elicited or addressed

44-79% of parents report not discussing important child development topics with their pediatricians

About 57% of parents report receiving a developmental assessment of any kind

Only half of “exemplary” practices refer children to developmental programs

What Child Health Professionals Should Do

Screening: Identify risk factors that could lead to a problem, and initiate treatment to reduce or remove the risk

Educate: Anticipate potential problems, and initiate treatment to promote resilience in the child and family

Treat and Refer: Newly identify a problem, diagnose, initiate treatment or referral and provide care coordination

PRACTICING SAFETYPHASE I

Overall Goal: Decrease child abuse and neglect by

increasing screening and improving anticipatory guidance provided by pediatric practices to parents of children ages 0-3.

TOOLKIT7 Color coded Modules:

Red: Coping with Crying/SBS Prevention

Purple: Parenting

Pink: Safety in Others’ Care

Blue: Family & The Environment

Orange: Effective Discipline

Green: Sleeping/Eating Issues

Aqua: Toilet Training

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

Practicing Safety Modules include…Practicing Safety Modules include…

Practice GuideA tool for the clinician

Explanation of topic

Stages to introduce and reinforce information

Assessment Questions

Anticipatory Guidance

Materials for the office, parents, and staff

Issues Management

Practice Guide - Utilization A tool for the clinician

Assessment Questions

Anticipatory Guidance

Incorporate the materials into your routine patterns of practice

Create and use a Community Resource Guide

Data Analysis: Phase 1

AgreeDisagree

It's hard to make any changes in this practice because we're so busy seeing patients.

100.0%

80.0%

60.0%

40.0%

20.0%

0.0%

Pe

rce

nt

Follow-up

Baseline

data collected at baseline or follow-up

Pre-Post Test Significance: Staff Responses

Difficulty making changes in practice

Pre-Post Test Significance: Staff Responses

At least occasionallyNever or rarely

How often do you use a health risk assessment (HRA) protocol or questionnaire to identify parents or

patients who may benefit from counseling or other interventions for the following - Maternal depression

80.0%

60.0%

40.0%

20.0%

0.0%

Perc

ent

Follow-up

Baseline

Data collected at baseline or follow-up

At least occasionallyNever or rarely

How often do you use nurses or health educators, within your practice, for individual counseling to your

patients with - Maternal depression

80.0%

60.0%

40.0%

20.0%

0.0%

Per

cent

Follow-up

Baseline

Data collected at baseline or follow-up

Use of screening tool for depression Counseling for maternal depression

No Yes

In the last 12 months, have your child’s doctors or office providers in this practice asked you: If you ever feel depressed, sad, or have crying spells

80.0%

60.0%

40.0%

20.0%

0.0%

Pe

rce

nt

Follow up

Baseline

data collected at baseline or follow up

Pre-Post Test Significance: Parent Responses

Asked about depression

More than once a day

About once a day

Several Times

Once or Twice

Not at all

How many times in the past week did you look at or read a book with your child?

30.0%

20.0%

10.0%

0.0%

Pe

rce

nt

Follow up

Baseline

data collected at baseline or follow up

Pre-Post Test Significance: Parent Responses

Reading to your child

Tool Evaluation Summary

0

10

20

30

40

50

60

70

80

90

Overall usefulness of modules (Percentage of respondents

who rated module as 3 or 4)Module 1: Coping with Crying Module 2: Parenting Module 3: Safety in Others’ Care Module 4: Family & the Environment Module 5: Effective Discipline Module 6: Sleeping and Feeding Module 7: Toilet Training

Tool Evaluation by Module Tools Rated most useful

Coping with Crying Module “Coping with Crying” posters (95% rated 3

or 4) “World of Parenting” brochure (83% rated 3

or 4)

Parenting Module “Post-partum Depression” brochure (89%

rated 3 or 4) “Bonding With Your Child” booklet (88%

rated 3 or 4)

Safety in Others’ Care ModuleSupport telephone numbers magnet (82% rated

3 or 4) “Choosing Child Care: What’s Best for

Your Family” (59% rated 3 or 4)

Family and the Environment ModuleSupport phone #s magnet (88% rated 3-4) Domestic violence shoe card (74% rated 3-

4)

Effective Discipline Module “Teaching Good Behavior—Tips on

Discipline” brochure (88% rated 3 or 4) “Temper Tantrums: A Normal Part of

Growing Up” brochure (87% rated 3 or 4)

Sleeping and Feeding Module  “Sleep Problems in Children” brochure

(75% rated 3 or 4) “Feeding Kids Isn’t Always Easy” brochure

(75% rated 3 or 4)

Toilet Training Module “Toilet Training” brochure (95% rated 3 or 4) “Bed-wetting” brochure (89% rated 3 or 4)

Further Assessment

Focus group discussion sessions were conducted with 5-8 members of the practice staff, including members and non-members of the Reflective Adaptive Process (RAP) team.

In-depth telephone interviews were conducted with a physician in each of the practices.

Qualitative data collected were reflexively coded by 3 members of the research team separately. Inter-rater reliability was checked.

Changes in practice Raised awareness about child abuse and neglect. Maternal depression screening was adopted by 4

of the 5 pediatric practices. The practice that did not adopt screening identified lack of a referral source for depressed mothers within the community.

Infant crying, discipline and toilet training modules were also implemented by the practices.

Maternal drug and alcohol issues were generally difficult for practices to address although those with established referral systems to social workers fared better.

Most practices noted that the intervention program contained too much information.

Strengths of Practicing Safety

Staff focus groups Raised staff and MD awareness of issues and

approach to patients/parents. Helped institute depression screening and discussion

of toilet training. Provided opportunity for practice to reflect Materials and helping identify parents at risk

Physician interviews Increased awareness of problems leading to child

abuse & neglect Developed more systematic ways of sharing

information

WeaknessesFocus Groups Too much information (and cost of materials) Not targeted to varied audience Lack of feedback loop – from docs back to staff and

from parents back to staff – staff discontent with not knowing impact of PS materials/efforts

No change in roles; staff wanted to play a bigger role

Physician Interviews Too many meetings Materials too wordy, language barriers Staff complained of too much work

Revisions

5 Points to Practicing Safety1. Reflective Practice Change

2. Infant

3. Mother

4. Toddler

5. Community

Toolkit Revision

Infant Mother Toddler

BUNDLES

Team Expectations

Submit 20 Monthly Chart Documentation Forms on 30th of every month (June-November)

Submit Monthly Progress Report on 30th of every month Share lessons learned and problem-solve with other participating

practices through monthly conference calls and e-mail. Complete a post-Inventory survey in November Complete a Tool Evaluation survey in November A selected number of practices will be asked to participate in

telephone interviews at the conclusion of the project Work with other members of your practice’s clinical team to improve

care processes related to maternal depression screening, counseling about crying, counseling about toilet training, and counseling about effective discipline.

Test innovations in care delivery to prevent child abuse and neglect.

Agenda For Day

Baseline Data ResultsToolkit Bundles (Infant,

Mother/Caregiver, Toddler)Model for ImprovementData Collection and

MeasurementTeam Planning TimeTeam SharingWrap Up and Next Steps

Ask Questions!

Share Experiences!

Plan for Testing!