Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): Continuity of Care (Caseload), Midwifery, Home Visit (caregiver),

Intervention Description: A model pilot program was established in South Australia to address the ongoing closure of regional maternity services and bring sustainable birthing services to the area with the aim of keeping birthing as close to home as safely possible. This Midwifery Caseload Model of Care (MMoC) model was an all-risk model or care whereby 12.9 full-time equivalent midwives were employed to work in collaboration with general practitioners (GP)/obstetricians across five birthing sites (Port Pirie, Crystal Brook, Wallaroo, Clare and Jamestown). In the MMoC all pregnant women in the region could be referred to the program and allocated to a known midwife once pregnancy had been confirmed. Care was then provided by the MMoC midwife and an obstetric GP or obstetrician. The service delivery model prioritized choice and interdisciplinary care. An anonymous questionnaire incorporating validated surveys and key questions from the Quality Maternal and Newborn Care (QMNC) Framework was used to assess care across the antenatal, intrapartum and postnatal period.

Intervention Results: Most women (97%) received a postnatal visit from a MMoC midwife and 84.1% reported the MMoC midwives were their main postpartum care provider. Shared care GP/MMoC midwives accounted for 8.9% (n = 17) and 6.9% (n = 13) indicated they had “other” postnatal care such as child and family health nurse, midwives and nurses at the birth hospital, and midwives at referral hospital due to baby’s prematurity. Overall women had an average of four postnatal visits. Close to a third of women (32.5%) had six or more visits. Most women (77%) reported receiving their visit in their home or a combination of home and not at home (20%). Only 3.2% of visits were not conducted at home. In addition to midwifery visits, most women (approximately 80%) also used community supports, the most frequently being child and family health nurses.

Conclusion: In this regional/rural MMoC, women were able to receive quality continuity and components of care as have been previously benchmarked against the QMNC Framework. Women embraced the new MMoC, established strong relationships with their midwives and were able to maintain good collaborative arrangements with their local GPs. The generalisability of these results should be considered for other regions which offer maternity services and have GP obstetrician support. These findings are consistent with existing evidence that supports midwifery continuity of care for women and adds to the growing body of evidence for midwifery caseload outside of metropolitan areas

Study Design: Mixed methods design using qualitative and quantitative methodologies

Setting: Five birthing sites in South Australia (Port Pirie, Crystal Brook, Wallaroo, Clare and Jamestown).

Population of Focus: Pregnant women in regional/rural areas

Sample Size: 205

Age Range: 16-42 years

Intervention Components (click on component to see a list of all articles that use that intervention): Expert Support (Provider), Continuity of Care (Caseload), Enabling Services, HEALTH_CARE_PROVIDER_PRACTICE, PATIENT_CONSUMER

Intervention Description: Using semistructured focus groups and interviews, we evaluated practices, messaging, and the prospect of integrating and coordinating care.

Intervention Results: Stakeholders supported sharing health assessment data and integrating health services as strategies to enhance the quality of care, but were concerned about security and confidentiality.

Conclusion: Overall, integrated, coordinated care was perceived to be an acceptable strategy to facilitate consistent, preventive education and improve patient-centeredness.

Intervention Components (click on component to see a list of all articles that use that intervention): Health Insurance Coverage, Continuity of Care (Caseload), Expanded Insurance Coverage,

Intervention Description: N/A

Intervention Results: Of 30,678 children, 1875 (6.1%) were classified with Asthma, 294 (1.0%) with ASD, and 15,465 (50.4%) as Controls. Overall CoC was lower for Asthma (Mean = 0.58, SD 0.21) and ASD (M = 0.57, SD = 0.20) than Controls (M = 0.66, SD = 0.21); differences in well-care CoC were minimal. In regression models, lower overall CoC was found for Asthma (aOR = 0.90, 95% CI, 0.85-0.94). Lower overall and well-care CoC were associated with public insurance (aOR = 0.77, CI, 0.74-0.81; aOR = 0.64, CI, 0.59-0.69).

Conclusion: After accounting for patient and clinical-care factors, children with asthma, but not with ASD, in this primary-care network had significantly lower CoC compared to children without chronic conditions. Public insurance was the most prominent patient factor associated with low CoC, emphasizing the need to address disparities in CoC.

Study Design: Retrospective cohort study of electronic health records from office visits of children <9 years, seen ≥4 times between 2015 and 2019 in 10 practices of a community-based primary health care network in California. Three cohorts were constructed: 1) Asthma: ≥2 visits with asthma visit diagnoses; 2) ASD: same method; 3) Controls: no chronic conditions. CoC, using Usual Provider of Care measure (range > 0–1), was calculated for 1) all visits (overall) and 2) well-care visits. Fractional regression models examined CoC adjusting for patient age, medical insurance, practice affiliation, and number of visits.

Setting: California

Population of Focus: Children with chronic conditions

Sample Size: 30678

Age Range: <9

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Continuity of Care (Caseload), HEALTH_CARE_PROVIDER_PRACTICE, Active Management of Labor, Midwifery

Intervention Description: To explore the relationship between the degree to which labour is established on admission to hospital and method of birth.

Intervention Results: Nulliparous women randomised to standard care were more likely to have labour augmented than those having caseload care (54.2% and 45.5% respectively, p=0.008), but were no more likely to use epidural analgesia. They were admitted earlier in labour, spending 1.1 hours longer than those in the caseload arm in hospital before the birth (p=0.003). Parous women allocated to standard care were more likely than those in the caseload arm to use epidural analgesia (10.0% and 5.3% respectively, p=0.047), but were no more likely to have labour augmented. They were also admitted earlier in labour, with a median cervical dilatation of 4 cm compared with 5 cm in the caseload arm (p=0.012). Pooling the two randomised groups of nulliparous women, and after adjusting for randomised group, maternal age and maternal body mass index, early admission to hospital was strongly associated with caesarean section. Admission before the cervix was 5 cm dilated increased the odds 2.4-fold (95%CI 1.4, 4.0; p=0.001). Augmentation of labour and use of epidural analgesia were each strongly associated with caesarean section (adjusted odds ratios 3.10 (95%CI 2.1, 4.5) and 5.77 (95%CI 4.0, 8.4) respectively.

Conclusion: These findings that women allocated to caseload care were admitted to hospital later in labour, and that earlier admission was strongly associated with birth by caesarean section, suggest that remaining at home somewhat longer in labour may be one of the mechanisms by which caseload care was effective in reducing caesarean section in the COSMOS trial.

Study Design: RCT

Setting: 1 large, tertiary maternity hospital

Population of Focus: Nulliparous women with a planned vaginal delivery who gave birth after recruitment between September 2007 and June 20102

Data Source: Not specified

Sample Size: n=1,532

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Continuity of Care (Caseload), Epidural Analgesia, Midwifery

Intervention Description: To determine if nulliparous women intending to have epidural analgesia have a similar labour profile and delivery outcome to women who intend to have their labour managed using alternative forms of pain relief.

Intervention Results: Rate of CS lower in CMS group vs. epidural group (14.2% vs. 17.2%; p>0.05)

Conclusion: The duration of labour was shorter in the CMS group compared with EPI (10.7 hours (inter quartile (IQ) 7.0,15.2) versus 11.4 hours (IQ 8.2,15.2), p = 0.039). The median duration of the first stage was 8.9 hours (IQ 6,12.5) versus 9.5 hours (IQ 7,12.7) (p = 0.069), and the median duration of the second stage was 1.33 hours (IQ 0.6,2.5) versus 1.48 hours (IQ 0.77,2.6) (p = 0.034). The requirement for oxytocin augmentation in spontaneous labour was 39.8% CMS versus 46.2% EPI (p = 0.129). There was no significant difference in the caesarean section rates. The need for any operative delivery was significantly lower in CMS (43.9% CMS versus 51.5% EPI, p = 0.019).

Study Design: RCT

Setting: 1 tertiary obstetric institution

Population of Focus: Nulliparous women who gave birth between May 1997 and October 1999

Data Source: Not specified

Sample Size: Total (n=992) Intervention (n=499) Control (n=493)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Continuity of Care (Caseload), Midwifery

Intervention Description: This retrospective cohort study compared the cesarean section rate of nulliparous women who received standard midwifery care and those who opted to participate in a caseload midwifery program (CMP) where they would see the same midwife throughout their term. This midwife would remain the “lead,” even if the patient was referred to a physician due to complications. The data was extracted from the records of 19,001 women who gave birth at the hospital from 2011 to 2014. The final study cohort included only nulliparous women and combined the total population of nulliparous women who received care from the CMP (n = 500) and the comparison group that was selected by matching for parity, country of birth, age and body mass index (BMI) on a 1:1 basis.

Intervention Results: Adjusted regression analysis for the primary outcome showed that compared with women who received SMC, women who received care through CMP had an increased rate of normal vaginal birth (69% vs. 50%, OR = 1.79, 95%, CI = 1.38-2.32). Assessment of secondary outcomes showed that the women in CMP group had decreased rates of instrumental birth (15% vs. 26%, OR = 0.48, 95% CI = 0.35-0.66), episiotomy (23% vs. 40%, OR = 0.43, 95% CI = 0.33-0.57), epidural analgesia (33% vs. 43%, OR = 0.64, 95% CI = 0.50-0.83) and amniotomy (35% vs. 50%, OR = 0.56, 95% CI = 0.43-0.72). The CMP group also had greater rates of water immersion (54% vs. 22%, OR = 4.18, 95% CI = 3.17-5.5), physiological 3rd stage (7% vs. 1%, OR = 11.71, 95% CI = 3.56-38.43) and 2nd degree tear (34% vs. 24%, OR = 1.60, 95% CI = 1.21-2.11). There were no significant differences between the two groups for rates of other secondary outcomes including Caesarean section, cervical ripening procedures, third- and fourth-degree tears, postpartum haemorrhage and neonatal outcomes.

Conclusion: CMP care is associated with increased rate of normal vaginal birth which supports wider implementation of the model. In addition, using routinely collected data and a cohort matching design can be an effective approach to evaluate maternal and neonatal outcomes.

Setting: Metropolitan tertiary hospital in Australia

Population of Focus: Nulliparous women

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Continuity of Care (Caseload), Labor Support, POPULATION-BASED SYSTEMS, STATE, Place of Birth, HEALTH_CARE_PROVIDER_PRACTICE, Midwifery

Intervention Description: The aim of this study was to investigate the effects of modified birth center care on obstetric procedures during delivery and on maternal and neonatal outcomes.

Intervention Results: The modified birth center group included fewer emergency cesarean sections (primiparas: OR: 0.69, 95% CI: 0.58-0.83; multiparas: OR: 0.34, 95% CI: 0.23-0.51), and in multiparas the vacuum extraction rate was reduced (OR: 0.42, 95% CI: 0.26-0.67). In addition, epidural analgesia was used less frequently (primiparas: OR: 0.47, 95% CI: 0.41-0.53; multiparas: OR: 0.25, 95% CI: 0.20-0.32). Fetal distress was less frequently diagnosed in the modified birth center group (primiparas: OR: 0.72, 95% CI: 0.59-0.87; multiparas: OR: 0.45, 95% CI: 0.29-0.69), but no statistically significant differences were found in neonatal hypoxia, low Apgar score less than 7 at 5 minutes, or proportion of perinatal deaths (OR: 0.40, 95% CI: 0.14-1.13). Anal sphincter tears were reduced (primiparas: OR: 0.73, 95% CI: 0.55-0.98; multiparas: OR: 0.41, 95% CI: 0.20-0.83).

Conclusion: Midwife-led comprehensive care with the same medical guidelines as in standard care reduced medical interventions without jeopardizing maternal and infant health.

Study Design: Retrospective cohort

Setting: 1 large, public hospital

Population of Focus: Nulliparous women admitted to the modified birth center between March 2004 to July 2008 who gave birth at either the modified birth center or in standard delivery ward2

Data Source: Not specified

Sample Size: Total (n=6,141) Intervention (n=1,263) Control (n=4,878)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Continuity of Care (Caseload),

Intervention Description: We identified strategies used by Community Health Centers (CHCs) to assist patients with insurance applications, and assessed patients’ receptivity to these efforts.

Intervention Results: Patients’ understanding of eligibility status, reapplication schedules, and how to apply, were major barriers to insurance enrollment. Clinic staff addressed these barriers by reminding patients when applications were due, assisting with applications as needed, and tracking submitted applications to ensure approval. Families trusted clinic staff with insurance enrollment support, and appreciated it.

Conclusion: CHCs are effective at helping patients with public health insurance. Access to insurance expiration data, tools enabling enrollment activities, and compensation are needed to support enrollment services in CHCs.

Study Design: Observational cross-sectional comparative study

Setting: Community (4 Community Health Centers in urban and rural settings, in Oregon)

Population of Focus: Low-income families

Sample Size: 26 clinic staff, 18 adult family members

Age Range: Clinic staff, parents with at least 1 child on Medicaid or CHIP

Intervention Components (click on component to see a list of all articles that use that intervention): Provider Training/Education, Other Education, Continuity of Care (Caseload), HEALTH_CARE_PROVIDER_PRACTICE, PATIENT_CONSUMER

Intervention Description: Mosquera et al provide us with pre–coronavirus disease 2019 data to reassure us that adding telemedicine access to an existing complex care medical home can be effective in improving both clinical and financial outcomes. This population of children all had ≥2 hospitalizations or ≥1 PICU admission in the previous year and a likely risk of future hospitalization at the time they were enrolled into the complex care clinic. Families were randomly selected to receive comprehensive care (experienced primary care physicians, 24/7 access by phone, same-day illness care on weekdays in clinic, hospital consult when inpatient) or comprehensive care plus audio-video telemedicine access. CMC with telemedicine access had 4 fewer days of care outside of the home per child-year, lower rates of serious illness, reduced hospital admissions, and reduced PICU admissions. The authors went further and documented a reduction in mean total health system costs of $7563 per child-year compared with a cost of only $308 per child-year to set up and conduct telemedicine visits.

Intervention Results: Experienced primary care providers who have an existing relationship with CMC and their caregivers do make a difference in the health of their most vulnerable patients. Adding telemedicine to their pediatric medical home can enhance that value even more.

Conclusion: Yet telemedicine in primary care continues to face challenges. Patients face 3 overlapping barriers to accessing telehealth: the absence of technology, digital literacy, and reliable Internet coverage. Together, these barriers comprise the digital divide, which disproportionately affects people of color, people living in rural areas, and those with low socioeconomic status. As we identify and debate solutions to the digital divide for vulnerable populations, we must partner with community agencies, schools, Internet service companies, and government leaders to overcome barriers to both technology access and digital literacy.

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Provider Training/Education, Outreach (Provider), Patient-Centered Medical Home, Expert Support (Provider), STATE, Collaboration with Local Agencies (State), Collaboration with Local Agencies (Health Care Provider/Practice), Continuity of Care (Caseload)

Intervention Description: The Illinois Child Welfare Department implemented a statewide health care system to ensure that children in foster care obtain quality health care by providing each child with a medical home.

Intervention Results: These children used the health care system more effectively and cost-effective as reflected in the higher utilization rates of primary care and well-child visits and lower utilization of emergency room care for children with chronic conditions.

Conclusion: This study demonstrates that the Medical Home model works for children in foster care providing better health outcomes in higher immunization rates.

Study Design: Observational: Cohort study; Survey

Setting: Illinois statewide health system

Population of Focus: Children in foster care between July 2001 and June 2009

Data Source: • Medicaid paid claims data

Sample Size: n=28934

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Home Visit (caregiver), Collaboration with Local Agencies (Health Care Provider/Practice), Continuity of Care (Caseload), HEALTH_CARE_PROVIDER_PRACTICE, PROFESSIONAL_CAREGIVER

Intervention Description: This report describes priority populations for home visiting programs, the capacity of programs to enroll more families, common sources of referrals to home visiting, and sources from which programs want to receive more referrals.

Intervention Results: Programs prioritized enrollment of pregnant women; parents with mental health, substance abuse or intimate partner violence concerns; teen parents; and children with developmental delays or child welfare involvement. Most respondents reported capacity to enroll more families in their programs. Few reported receiving any referrals from pediatric providers, child welfare, early care and education, or TANF/other social services. Most desired more referrals, especially from healthcare providers, WIC, and TANF/other social services.

Conclusion: Given that most programs have the capacity to serve more families, this study provides insights regarding providers with whom home visiting programs might strengthen their referral systems.

Intervention Components (click on component to see a list of all articles that use that intervention): Outreach (Provider), Continuity of Care (Caseload), Notification/Information Materials (Online Resources, Information Guide), HEALTH_CARE_PROVIDER_PRACTICE, PARENT_FAMILY, Telehealth

Intervention Description: The purpose of this project was to determine the feasibility and effectiveness of videoconference handoffs between inpatient, case management, and home care nurses, and the patients/families during transitions of care from hospital to home care.

Intervention Results: Videoconference handoffs (n = 10) were found to be feasible and address gaps in communication, coordination of care, and patient/family engagement during transitions from hospital to home care.

Conclusion: Postpilot, nurses agreed the videoconference handoffs should continue with minimal modifications.

Intervention Components (click on component to see a list of all articles that use that intervention): Continuity of Care (Caseload), Patient-Centered Medical Home, Other Education, HEALTH_CARE_PROVIDER_PRACTICE, PATIENT_CONSUMER

Intervention Description: NCQA’s PCMH Recognition Program is the most widely adopted PCMH evaluation program in the country. Required elements for recognition include demonstrating team-based care, population care management and accountability, patient access and engagement and the skills to do performance measurement and improvement.

Intervention Results: These services allow our trainees, staff and faculty to ask the hard questions about food security and housing stability as they feel they have onsite support for families.

Conclusion: The unique needs of our families, including the social determinants that accompany poverty, and our responsibility as the primary teaching site for future pediatricians, presents challenges. However, these factors also provide us with great incentives: to assure optimal health and development for our high-risk population and provide trainees with solid training in patient-centered, team-based care, quality measurement, accountability for costs and outcomes, a focus on population health and dedication to data-driven system improvement.

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Continuity of Care (Caseload), Midwifery

Intervention Description: Midwifery group practice (MGP) also known as caseload midwifery, was introduced and embedded in a Western Australian (WA) tertiary maternity hospital. A study conducted between July 2013 and June 2014 assessed the obstetric and neonatal outcomes by parity, women's satisfaction by mode of delivery, and perceptions of care. The study also compared the MGP women against the 2012 WA tertiary hospital birthing population (before the midwife practice was initiatived)

Intervention Results: Phase one included 232 MGP women; 87% achieved a vaginal birth. Phase two included 97% (226 of 232) women, finding 98% would recommend the service. Phase three analysis of 62 interviews revealed an overarching theme ‘Continuity with Midwives’ encompassing six sub-themes: only a phone call away; home away from home; knowing me; a shared view; there for me; and letting it happen. Phase four compared the MGP cohort to 33,393 WA women. Intrapartum MGP women were more likely than the WA population to have a vaginal birth (87% vs 65%, P ≤ 0.001) and intact perineum (49% vs 36%, P ≤ 0.001) and less likely to use epidural/spinal analgesia (34% vs 59%, P ≤ 0.001), or have a caesarean (13% vs 35%, P ≤ 0.001).

Conclusion: Mixed methods enabled systematic examination of this new ‘no exit’ MGP confirming safety and acceptability. Findings contribute to our knowledge of MGP models.

Setting: Tertiary maternity hospital in western Australia

Population of Focus: Primiparous and multiparous women attending MGP (midwifery group practice)

Intervention Components (click on component to see a list of all articles that use that intervention): Collaboration with Local Agencies (State), Expert Support (Provider), Continuity of Care (Caseload), STATE, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: This study aimed to examine the association between care-management and birth outcomes (low birthweight and preterm birth rates) among high-risk non-Hispanic White and Black pregnant people enrolled in the North Carolina Pregnancy Medical Home.

Intervention Results: From January 1, 2016 to December 31, 2017, a total of 3564 singleton pregnancies occurred among non-Hispanic Black and White pregnant Medicaid beneficiaries, who were a part of the Pregnancy Medical Home in North Carolina. White pregnant people comprised 57% and Black pregnant people comprised 43% of the sample. In the Method 1 analysis, intensive care management was significantly associated with reductions in preterm birth and low birthweight among Black and White pregnant people whereas in the Method 2 analysis, the implementation of a risk-stratification score only resulted in a significant reduction among Black pregnant people. In multivariable logistic modeling, race, number of prenatal visits, and intensive care management were all significantly associated with the outcomes of interest.

Conclusion: Care management is associated with reductions in preterm birth and low birthweight in the Medicaid-managed Pregnancy Medical Home in North Carolina. This study contributes to a growing body of literature on the role of state-based initiatives in reducing perinatal morbidity. These results are significant as it demonstrates the importance of care coordination and management, in identifying and providing resources for high-risk pregnant people. In the United States, where pregnancy-related outcomes are poor, programs that address the multitude of economic, social, and clinical complexities are becoming increasingly crucial and necessary.

Intervention Components (click on component to see a list of all articles that use that intervention): Home Visits, Continuity of Care (Caseload), Expert Support (Provider), HEALTH_CARE_PROVIDER_PRACTICE, PATIENT_CONSUMER

Intervention Description: The goal of this study was to evaluate the impact of integrating CHWs into the medical teams of children with HL and identify the social needs associated with their caregivers at a large urban hospital center.

Intervention Results: Of the 30 charts reviewed, 93% demonstrated social needs including food insecurity (24%) and educational service needs (45%). Eighty-seven percent of caregivers reported a sense of control over the child's condition, yet 73% reported a stress level of four or greater on the distress thermometer scale. At 3 months follow-up, 70% of patients completed referrals; a significant number of patients had obtained hearing aids and cochlear implants compared to baseline (p = 0.017).

Conclusion: Caregivers of children with HL face multiple social obstacles, including difficulties connecting to educational and financial resources. CHWs are instrumental in identifying social needs and connecting caregivers to services.

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Patient-Centered Medical Home, Continuity of Care (Caseload), PATIENT/CONSUMER, Enabling Services

Intervention Description: In light of the transition of the Alabama Medicaid program to a primary care case management model, we assessed the level to which children had access to a medical home before and after implementation of that model.

Intervention Results: In general, Medicaid-enrolled children in Alabama did not meet our definition of medical home either before or after implementation of a primary care case management model. Only 11.8% of children saw a single provider and had a well child visit from that provider during the baseline year. A majority of children (49.9%) however had both a primary care provider and received a well child visit. Sixteen percent of children saw a primary care physician but received no identifiable well visit, while 11% had well child care but did not see a primary care physician. Of particular concern, 23% neither saw a primary care physician nor had a well child visit during the baseline year. These figures changed only slightly in the 26 counties examined before and after implementation of the primary care case management model.

Conclusion: State Maternal and Child Health programs are required to report as a performance measure “the percent of children with special health care needs in the state who have a medical/health home” as part of their Block Grant application. Using Medicaid data, this simple measurement strategy can provide an indication of the extent to which at least one population of children receive care through a medical home.

Study Design: Quasi-experimental: Pretestposttest

Setting: Alabama Medicaid-financed primary care

Population of Focus: Children with Medicaid in 26 counties

Data Source: Medicaid administrative/claims data

Sample Size: n=60752 (enrolled during baseline); n=64789 (enrolled during postimplementation period)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Medicaid, Access, Continuity of Care (Caseload), Community Health Centers

Intervention Description: N/A

Intervention Results: We found the probability of unmet need for medical and dental care to be lower among HRSA HC patients than individuals whose usual source of care were not HRSA HCs.

Conclusion: HRSA HC patients have lower probabilities of unmet need for medical and dental care. This is likely because HRSA HCs provide accessible, affordable, and comprehensive primary care services. Expanding capacity of these organizations will help reduce unmet need and its consequences.

Study Design: We used logistic regression models to compare the predicted probabilities of unmet need for uninsured and Medicaid individuals whose usual source of care is HRSA HCs versus clinics in general or private physicians.

Setting: Nationally representative survey of low income, adult patients who identified HRSA HCs as their usual source of care

Population of Focus: HRSA HC patients

Sample Size: ?

Age Range: 18+

Intervention Components (click on component to see a list of all articles that use that intervention): Notification/Information Materials (Online Resources, Information Guide), Continuity of Care (Caseload), Enabling Services, HEALTH_CARE_PROVIDER_PRACTICE, PATIENT_CONSUMER, PARENT_FAMILY

Intervention Description: To identify the diverse services required by families of children with special health care needs (CSHCN) and identify the specific care coordination (CC) efforts associated with the most common types of observed diagnoses. Requested services were categorized into specific sectors, and CC efforts were quantified by observed diagnoses and defined sectors.

Intervention Results: A total of 2682 CSHCN records were reviewed. The majority (59%) required services/resources in 1 to 2 sectors, 24% required services/resources in 3 to 5 sectors, and 17% required services/resources in 6 or more sectors. Including informational service, the most frequently required sectors across the study population were education, financial, medical/dental, social connections, and advocacy. Children diagnosed with autism spectrum disorder had the highest needs across all sectors

Conclusion: Most CSHCN and their families use a substantial amount of CC time and effort to secure services from diverse sectors. High-quality and efficient CC requires an understanding of the specific needs of these CSHCN and their families and how to link them to a diverse array of services and resources.

Intervention Components (click on component to see a list of all articles that use that intervention): Continuity of Care (Caseload), Policy/Guideline (State), Care Coordination,

Intervention Description: N/A

Intervention Results: Persons with complex disabilities more frequently experienced continuity (83.7%) than persons without disabilities and those with basic disabilities (60.7% and 65.6%, respectively, p < 0.001). Seldom or never being sick was the most frequently reported reason for not having a usual provider; more persons without disabilities (64%) reported this reason than persons with disabilities (basic: 41.9%, p < 0.001; complex: 26.6%, p = 0.001). Persons with disabilities more frequently reported visiting different providers for different needs and not having a usual provider due to the costs of medical care than persons without disabilities.

Conclusion: Future research needs to examine the influence of continuity on healthcare disparities among persons with complex disabilities. Policies and practice must be attentive to how proposed changes to the healthcare system potentially reduce access to care among persons with disabilities.

Study Design: Pooled 2-year data from panels 14-16 (2009-2012) of the Medical Expenditure Panel Survey were examined. Working-age adults (18-64) were categorized as having no disability, basic disabilities, or complex disabilities. Persons were categorized having provider continuity (provider throughout the period) or discontinuity (gaining or losing providers during the period). χ2 and multinomial logistic regressions were used to examine outcomes by disability status.

Setting: Medical Expenditure Panel Survey

Population of Focus: Persons with disabilities

Sample Size: 26867

Age Range: 18-64

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Labor Support, Continuity of Care (Caseload), HOSPITAL, Chart Audit and Feedback, Quality Improvement

Intervention Description: Using data from Robson classification, a novel labor–ward management protocol termed Comprehensive Management (CM) was carried out at the Obstetric Unit of the Cà Granda Niguarda Hospital in Milan, Italy, from 1 January 2012 to 31 December 2013. CM included regular labor monitoring, documentation of events, audit and feedback, the use of intrapartum ultrasound, mobility in labor and birth posture of choice, a partograph conceived as a screening tool, continuity of care; respectful labor and childbirth care; oral fluid and food intake, and emotional support from a person of choice. The CM “framework” provides tools to make medical interventions performed during childbirth quantitatively measurable and comparable.

Intervention Results: Following CM a substantial reduction was observed in the Overall Treatment Ratio, as well as in the ratios for augmentation (amniotomy and synthetic oxytocin use) and for caesarean section ratio, without any increase in neonatal and maternal adverse outcomes. The key component of this reduction was the dramatic decline in the proportion of women progressing to augmentation, which resulted not only the most practiced intervention, but also the main door towards further treatments.

Conclusion: The proposed framework, once combined with Robson Classification, provides useful tools to make medical interventions performed during childbirth quantitatively measurable and comparable. The framework allowed to identifying the key components of interventions reduction following CM. In its turn, CM proved useful to reduce the number of medical interventions carried out during childbirth, without worsening neonatal and maternal outcomes.

Setting: Obstetric Unit of the Cà Granda Niguarda Hospital in Milan, Italy

Population of Focus: Nulliparous or multiparous women, at term, with single cephalic baby in either spontaneous or induced labor

Intervention Components (click on component to see a list of all articles that use that intervention): PARENT/FAMILY, Notification/Information Materials (Online Resources, Information Guide), PROVIDER/PRACTICE, Patient-Centered Medical Home, Educational Material (Provider), Continuity of Care (Caseload), CAREGIVER, Education/Training (caregiver), Educational Material (caregiver), PATIENT/CONSUMER, Referrals, Other Education

Intervention Description: This study examines the effect of a provider alliance on service utilization, satisfaction , self efficacy, and attachment to a regular source of care for participating low income urban children and their families.

Intervention Results: The use of Physician Assistants and community health workers to expand community outreach, primary care services, pediatric sub-specialty care, and service coordination within and between care settings improved health services utilization, satisfaction with health services, parental self efficacy in navigating the health care system for their children, and service convenience for an at-risk population. Also, the use of Physician Assistants to provide pediatric sub-specialty services did not have a negative effect on parental satisfaction with a child's care.

Conclusion: Parents were slightly more satisfied with services received from a Physician Assistant in comparison with the physician sub- specialists in cardiology and nephrology clinics.

Study Design: Prospective quasiexperimental; Survey

Setting: South Central Los Angeles primary and specialty care clinics

Population of Focus: Children between the ages of 0-18 (“or are adolescents”) who reside within the geographic area of South Los Angeles

Data Source: A 30 item parent survey to assess parents’ perceived difficulty in accessing services and their satisfaction with the services received • Patient database was used to collect service utilization and financial data from operational and administrative tracking instruments and reports at both the primary and specialty care sites

Sample Size: Estimated 727,000 children in the service area; n=11,533 children reach during outreach events; n=80,000 (10% of children in service area) children attached to a medical home; n=8545 children enrolled in available payer sources

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Continuity of Care (Caseload), Labor Support, Midwifery

Intervention Description: a cross sectional study examining the risk profile, birth outcomes and cost of care for women booked into one of the three available models of care in a tertiary teaching hospital in Australia between July 1st 2009 December 31st 2010.

Intervention Results: First time ‘low risk’ mothers who received caseload care were more likely to have a spontaneous onset of labour and an unassisted vaginal birth 58.5% in midwifery group practices (MGP) compared to 48.2% for Standard hospital care and 30.8% with Private obstetric care (p < 0.001). They were also significantly less likely to have an elective caesarean section 1.6% with MGP versus 5.3% with Standard care and 17.2% with private obstetric care (p < 0.001). From the public hospital perspective, over one financial year the average cost of care for the standard primipara in MGP was $3903.78 per woman. This was $1375.45 less per woman than those receiving Private obstetric care and $1590.91 less than Standard hospital care per woman (p < 0.001). Similar differences in cost were found in favour of MGP for all women in the study who received caseload care.

Conclusion: Cost reduction appears to be achieved through reorganising the way care is delivered in the public hospital system with the introduction of Midwifery Group Practice or caseload care. The study also highlights the unexplained clinical variation that exists between the three models of care in Australia.

Study Design: Retrospective cohort

Setting: 1 large teaching hospital

Population of Focus: Nulliparous women who gave birth between July 2009 and December 20102

Data Source: Not specified

Sample Size: Total (n=1,406) Intervention (n=482) Control (n=674)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): Collaboration with Local Agencies (State), Home Visit (caregiver), Continuity of Care (Caseload), STATE, PROFESSIONAL_CAREGIVER, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: This study examined state-level supports and barriers for coordination of home visiting with other entities within the early childhood system of care.

Intervention Results: Forty-two (75%) of the MIECHV administrators participated in the survey. States and territories varied widely within and across the 5 domains of support for coordination. MIECHV leadership was an area of relative strength, whereas data systems and finance showed the most room for improvement. State leadership and shared goals were associated with stronger perceptions of state-level coordination.

Conclusion: The findings indicate opportunities for shared learning among states to enhance coordination infrastructure. Such efforts should include multiple stakeholder perspectives and consideration of local and organizational contexts. This work could be facilitated using the service coordination toolkit developed as part of this project.