Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER Patient Reminder/Invitation Enabling Services

Intervention Description: Individually randomised controlled trial. All 3 124 women in three low-resource areas in Gothenburg, due for screening during the study period, were randomised to receive an offer of a free test or the standard invitation stating the regular fee of 100 SEK (≈11 €). The study was conducted during the first six months of 2013. Attendance was defined as a registered Pap smear within 90 days from the date the invitation was sent out.

Intervention Results: Attendance did not differ significantly between women who were charged and those offered free screening (RR 0.93; CI 0.85-1.02). No differences were found within the districts or as an effect of age, attendance after the most recent previous invitation or previous experience of smear taking.

Conclusion: Abolishment of a modest screening fee in socially disadvantaged urban districts with low coverage, after previous multiple systematic interventions, does not increase attendance in the short term. Other interventions might be more important for increasing attendance in low socio-economic status areas.

Study Design: RCT

Setting: Sweden

Population of Focus: Women with no Pap smear reported in the past 3 or 5 years

Data Source: Process Registry of the Swedish National Screening Registry

Sample Size: Total (N=3,124) Intervention (n=1,562); Control (n=1,562)

Age Range: 23-63

Intervention Components (click on component to see a list of all articles that use that intervention): Education/Training (caregiver) Enabling Services PROFESSIONAL_CAREGIVER PATIENT_CONSUMER

Intervention Description: The goal of this project was to optimize team work and access to primary care services among publicly insured adolescents and young adults attending an urban primary care clinic, using a previsit screening checklist to identify patient needs and delegate tasks within a care team to coordinate access to health services at the time of the visit.

Intervention Results: The majority of patients were receptive to the previsit screening checklist; 85% of services requested were provided; nonclinician staff felt more involved in patient care; and providers’ satisfaction increased.

Conclusion: We conducted an interventional quality improvement initiative in a PDSA (Plan-Do-Study-Act) cycle format; 291 patients, 13 to 25 years old were included in the study over an 8-months period. The majority of patients were receptive to the previsit screening checklist; 85% of services requested were provided; nonclinician staff felt more involved in patient care; and providers’ satisfaction increased.

Intervention Components (click on component to see a list of all articles that use that intervention): Enabling Services Provider Training/Education Patient-Centered Medical Home PATIENT_CONSUMER HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: The Colorado Adolescent Maternity Program (CAMP) is an obstetric and pediatric medical home for pregnant and parenting adolescent girls through age 22 and their children located within Children’s Hospital Colorado. With the integration of behavioral health into CAMP, and given the prevalence of trauma histories among adolescent mothers reported in the literature, programmatic and operational changes to clinical care were made using the Substance Abuse and Mental Health Services Administration’s six key principles of a trauma-informed approach.

Intervention Results: Data showed that nearly 30% of participants reported a history of trauma. Following the inclusion of trauma-informed principles, patients had significantly higher rates of attendance at prenatal appointments (p < .001) and significantly lower rates of low birthweight babies (p = .02).

Conclusion: Future programmatic changes and long-term assessment outcomes of this trauma-informed approach in a PCMH are also discussed.

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): Enabling Services Expert Support (Provider) PATIENT_CONSUMER HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: We implemented the newborn cohort clinic (NCC) to explore the application of the patient-centered medical home (PCMH) model for infants and children with SCD from birth to age 3 years in 2011.

Intervention Results: A total of 112 patients have been managed in the NCC. All patients received penicillin prophylaxis, while 70% and 73% of patients, respectively, received the 23-valent pneumococcal vaccine and an initial transcranial Doppler by age 36 months. Most (92 of 112) of the subjects utilized the emergency department (569 encounters), with 86% of encounters for fever or other sickle cell–related complications. The majority of parents indicated satisfaction with the clinic, with 71% saying clinic providers always or usually spent enough time with their child, listened carefully to them (81%) and were sensitive to family values and customs (77%).

Conclusion: A comprehensive sickle cell clinic as a component of a PCMH is feasible and can achieve high levels of preventative care. Parents are largely satisfied with this model of care.

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE Patient-Centered Medical Home CAREGIVER Home Visit (caregiver) PATIENT/CONSUMER Home Visits Outreach (caregiver) Nurse/Nurse Practitioner Enabling Services

Intervention Description: (1) To improve connections to the medical home for infants from one low-income neighborhood (2) To increase the number of families enrolled in a local home visiting program, and (3) To improve communication between medical staff and home visitors.

Intervention Results: Outcomes were timeliness of well child care and enrollment in home visiting. Time series analyses compared patients from the intervention neighborhood with a demographically similar neighborhood. Mean age at newborn visit decreased from 14.4 to 10.1 days of age. Attendance at 2- and 4-month well child visits increased from 68 to 79% and 35 to 59 %, respectively. Rates did not improve for infants from the comparison neighborhood. Confirmed enrollment in home visiting increased. After spread to 2 more clinics, 43 % of infants in the neighborhood were reached.

Conclusion: Neighborhood-based newborn registries, proactive nursing outreach, and collaboration with a home visiting agency aligned multiple clinics in a low-income neighborhood to improve access to health-promoting services.

Study Design: Quasi-experimental: Nonequivalent control group

Setting: Primary care clinics and a home visiting program in a neighborhood defined by two zip codes

Population of Focus: All children born in the intervention and comparison neighborhoods

Data Source: Data from the local children’s hospital’s Emergency Department was used to identify the most common primary medical providers for children from the study zip codes • Newborn registry data (maintained manually with a Microsoft Excel spreadsheet) • Electronic health record data (with an automated newborn registry) • Manual chart review • Automated report of appointment data • Outcome measures using clinic data • Process measures using clinic and home visiting agency data

Sample Size: n=237 (cumulative number of babies on a registry); n=30 (cumulative number of families enrolled in home visiting)

Age Range: Not specified

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

Intervention Description: The purpose of this study was to pilot the feasibility of a CHW to support parental contraceptives needs within a pediatric setting serving a high number of Latino immigrant families. This article describes Mi Plan/My Plan, a CHW contraceptive counseling and resource navigation pilot program.

Intervention Results: All 311 individuals counseled were Latina mothers with median child age of 3 months. At baseline, 64.3% were using contraception and 76.5% desired to start or change their current method. Among those who desired a change, 47.9% (114/238) obtained their desired method within three months of initial counselor contact.

Conclusion: Bilingual CHW contraceptive counseling and care coordination is feasible and acceptable in a pediatric setting serving a high number of Latino immigrant families. CHWs in pediatric settings support health care access equity and are relevant to optimal maternal and child health.

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

Intervention Description: We hypothesized that addressing barriers to scheduling in-person interpreters would make FCR encounters more likely, and thus ensure more equitable care for LEP patients.

Intervention Results: There were 614 encounters with LEP patients during the intervention, 367 of which included in-person interpreters. The percentage of encounters with LEP patients involving interpreters increased from 0% to 63%. Form completion, our primary process measure, reached 87% in the most recent phase. English-proficient and LEP patients reported similar satisfaction with their rounding experience amid a modest increase in rounds duration (preintervention, 105 minutes; postintervention, 130 minutes; P = .056).

Conclusion: Using quality improvement as a framework to address key barriers, we successfully implemented a process that increased the participation of in-person interpreters on FCRs on a busy pediatric service.

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER Telephone Support Enabling Services Access to Provider through Hotline

Intervention Description: To pilot-test a Phone-based Postpartum Continuing Care (PPCC) protocol in addition to the usual care for smoking cessation for pregnant women to demonstrate the feasibility of recruitment, randomization, assessment, and implementation of the PPCC intervention.

Intervention Results: PPCC was found to be feasible and acceptable to some participants but not all. There were no significant differences in tobacco products per day at 6 months postpartum between groups; however, effect sizes differed at 6 weeks compared with 6 months postpartum. Similarly, there were no significant differences between groups in cessation rate (24% in each group) and past 90-day tobacco use (59 days vs 55 days, for Control and Experimental groups respectively).

Conclusion: The PPCC intervention did not differentially reduce tobacco use postpartum compared with a controlled comparison group, though it was found to be acceptable among a subpopulation of low-income pregnant women and feasible with regard to recruitment, randomization, assessment procedures, and implementation. Further research is needed to identify an intervention that significantly improves smoking relapse rates postpartum.

Study Design: RCT pilot

Setting: Obstetrics clinic

Population of Focus: Low-income pregnant women attending their first prenatal visit at a single academic obstetrics clinic

Data Source: Urine testing, Surveys

Sample Size: 130

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Enabling Services Expert Support (Provider) Labor Support

Intervention Description: This research used a phenomenological approach, using data from in-depth individual interviews to explore the essence of 25 Black women's experiences.

Intervention Results: We identified three major themes from the data that together, show that PSPs served as communication bridges for their clients. Clients said their PSPs helped them to understand and feel seen and heard by their medical providers during their prenatal appointments. The third theme was the deep level of trust the clients developed for their PSPs which made the first two themes possible. PSPs' intervention resulted in reduced stress and uncertainty in medical interactions and increased women's trust in their providers' recommendations.

Conclusion: Including a trusted, knowledgeable advocate like a PSP may be an important intervention in improving Black women's prenatal care experiences, reducing stress associated with medical interactions, and ultimately reducing pregnancy-related health disparities.

Study Design: Qualitative

Setting: Community-based

Population of Focus: Black women

Sample Size: 25

Intervention Components (click on component to see a list of all articles that use that intervention): Enabling Services

Intervention Description: Twenty-five women participated in interviews after their babies were born about how the organization in general, and perinatal support professionals (PSPs) in particular supported them during their pregnancies and the meaning of that support. The overall meaning of perinatal support was described as easing participants' transitions into motherhood through reducing uncertainty, social isolation, and stress.

Intervention Results: The three main themes described the meaning of perinatal support and included (a) easing the transition to motherhood through emotional support, expressed via love and help managing relationships; (b) easing the transition to motherhood through instrumental support, expressed via helping with basic needs and obtaining material goods for the baby; and (c) easing the transition to motherhood through informational support, expressed via help navigating systems and information, and gaining knowledge and skills around mothering and self-care.

Conclusion: The three main themes described the meaning of perinatal support and included (a) easing the transition to motherhood through emotional support, expressed via love and help managing relationships; (b) easing the transition to motherhood through instrumental support, expressed via helping with basic needs and obtaining material goods for the baby; and (c) easing the transition to motherhood through informational support, expressed via help navigating systems and information, and gaining knowledge and skills around mothering and self-care. Implications for practice, policy, and research are discussed.

Study Design: Qualitative

Setting: Community-based

Population of Focus: Post partum Black women

Sample Size: 25

Intervention Components (click on component to see a list of all articles that use that intervention): Enabling Services

Intervention Description: We conducted in-depth interviews with 25 Black women enrolled in a perinatal support program in Cleveland, Ohio, in late 2017 and early 2018, exploring their interactions with medical providers, the meaning of their experiences, and the roles their PSPs played.

Intervention Results: Clients broadly categorized experiences as positive or negative. When medical providers respected them, their birth plans and/or collaborated with PSPs, women reported more positive experiences. They associated negative experiences with providers having their own timelines and agendas, and women perceiving their needs were unheard and/or disrespected.

Conclusion: The findings emphasize the need for medical providers to be patient-centred, set aside assumptions, treat their patients as experts, value women's knowledge and voice, and treat patients and their supports as part of the team.

Study Design: Qualitative

Setting: Community-based

Population of Focus: Black women

Sample Size: 25

Age Range: Not disclosed

Intervention Components (click on component to see a list of all articles that use that intervention): Provider Training/Education Enabling Services Expert Support (Provider) HEALTH_CARE_PROVIDER_PRACTICE PATIENT_CONSUMER

Intervention Description: This study sought to describe the PPCC's approach to care, their guiding principles and the roles, knowledge and skills that enable them to provide exemplary care.

Intervention Results: Findings include the PPCC's position within the healthcare system, guiding principles, goals, roles and responsibilities, and knowledge and skills. Two figures enhance the understanding of the PPCCs approach to creating a safe space for the family, supporting the interdisciplinary team and facilitating coordinated birth planning.

Conclusion: Every perinatal palliative care programme should include a PPCC. Future research on clinical training could examine the effectiveness of an educational intervention, using the detailed knowledge and skills learned in this study as a curriculum.

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

Intervention Description: The current case study describes the application of Implementation Mapping to inform the selection and testing of implementation strategies to improve implementation of two behavioral health programs in a Care Coordination Program at a partnered FQHC.

Intervention Results: Results are presented by Implementation Mapping task, from Task 1 through Task 5. We also describe the integration of additional implementation frameworks (The Consolidated Framework for Implementation Research, Health Equity Implementation Framework) within the Implementation Mapping process to inform determinant identification, performance and change objectives development, design and tailoring of implementation strategies and protocols, and resulting evaluation of implementation outcomes.

Conclusion: The current project is an example of real-world application of Implementation Mapping methodology to improve care outcomes for a high priority population that is generalizable to other settings utilizing similar care models and health equity endeavors. Such case studies are critical to advance our understanding and application of innovative implementation science methods such as Implementation Mapping.

Intervention Components (click on component to see a list of all articles that use that intervention): Enabling Services Provider Training/Education Patient-Centered Medical Home HEALTH_CARE_PROVIDER_PRACTICE PATIENT_CONSUMER

Intervention Description: This article provides recommendations for adapting the pediatric medical home (PMH) model for health care needs of youth in foster care.

Intervention Results: Preliminary evidence suggests that the PMH model of care may be ideal for addressing the complex and often underserved needs of youth in foster care and their families. The present recommendations provide a logistical framework for establishing a clinic that thoughtfully considers the unique needs of this population.

Conclusion: Future research is needed to examine best practices for implementation.

Intervention Components (click on component to see a list of all articles that use that intervention): Enabling Services Expert Support (Provider) Provider Training/Education HEALTH_CARE_PROVIDER_PRACTICE PATIENT_CONSUMER

Intervention Description: This article discusses a multidisciplinary, family-centered medical home designed to address the needs of this special population.

Intervention Results: The NSP has become a primary referral source for local NICUs, with a total of 549 medically fragile infants enrolled from its inception in 2011 through 2016. Caregivers and patients experience psychosocial stressors at averages statistically significantly higher than the rest of the Commonwealth of Pennsylvania and the US. Although patients in the program use medical resources beyond that of typically developing infants, hospital utilization among this patient cohort is trending down.

Conclusion: Caring for medically fragile NICU graduates can be daunting for families given the array of necessary services, supports, and resources to maximize their potential. A multidisciplinary primary care medical home, such as the NSP, is a successful model of patient care demonstrating favorable associations with health care utilization, care coordination, and addressing/improving family functioning and their experience.

Intervention Components (click on component to see a list of all articles that use that intervention): Patient-Centered Medical Home Enabling Services PATIENT_CONSUMER HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: We report on a unique model of patient care focused on providing patient-centered care and building trusting relationships.

Intervention Results: In the first 2 years of operation, demand for services rose rapidly and there were stellar clinical outcomes, despite the fact that Luke patients are among the medically and socially highest risk populations in the nation.

Conclusion: While marginalized populations have worse birth outcomes and far more infant deaths, making care accessible and responsive to patient needs while focusing on building patient relationships is an important strategy to improve outcomes.

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER Enabling Services Educational Material Community-Based Group Education Designated Clinic/Extended Hours PROVIDER/PRACTICE

Intervention Description: This paper summarizes impacts of a breast and cervical cancer screening intervention spearheaded by a Native Hawaiian community.

Intervention Results: Women in intervention community significantly more likely to be compliant with Pap smear guidelines than women in control community (X2=5.73. p=.02)

Conclusion: Positive changes in screening activities among women aware of the intervention support the importance of information diffusion by community consumers. Diffusion may occur beyond the boundaries of the community as defined.

Study Design: QE: pretest-posttest non-equivalent control group

Setting: Oahu, HI

Population of Focus: Native Hawaiian women

Data Source: Telephone survey

Sample Size: Total (N=1,260) Analysis (n=678) Intervention (n=318); Control (n=360)

Age Range: ≥18

Intervention Components (click on component to see a list of all articles that use that intervention): Enabling Services Collaboration with Local Agencies (Health Care Provider/Practice) HEALTH_CARE_PROVIDER_PRACTICE PATIENT_CONSUMER

Intervention Description: Using nationally representative data, we aimed to examine which child and family characteristics are associated with using school-based health care providers as the primary source of health care, and whether care received from these providers met the criteria for a medical home.

Intervention Results: Based on a sample of 64,710 children, 0.5% identified school-based providers as their primary source of health care. Children who were older, uninsured, or living in the Northeast were significantly more likely to report school-based providers as their usual source of care. Children whose usual source of care was a school-based provider were less likely to receive care meeting medical home criteria than children who usually received care at a doctor's office.

Conclusion: While SBHCs improve access to care, our findings indicate potential challenges with establishing a medical home for children who usually receive health care from a school-based provider.

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER Home Visits Motivational Interviewing Enabling Services Telephone Support

Intervention Description: To evaluate a web-based contingency management program (CM) and a phone-delivered cessation counseling program (Smoking Cessation for Healthy Births [SCHB]) with pregnant smokers in rural Appalachia who were ≤12 weeks gestation at enrollment.

Intervention Results: For CM, two of seven (28.57%) of the participants achieved abstinence, and three of 10 (30%) of those enrolled in SCHB were abstinent by late in pregnancy. Participants in CM attained abstinence more rapidly than those in SCHB. However, those in SCHB experienced less relapse to smoking, and a greater percentage of these participants reduced their smoking by at least 50%.

Conclusion: Based on this initial evaluation, the web-based CM and SCHB programs appeared to be feasible for use with rural pregnant smokers with acceptable program adherence for both approaches. Future researchers could explore combining these programs to capitalize on the strengths of each, for example, rapid smoking cessation based on CM incentives and better sustained cessation or reductions in smoking facilitated by the counseling support of SCHB.

Study Design: RCT pilot

Setting: Home- based smoking cessation programs

Population of Focus: English speaking pregnant women less than 12 weeks of pregnancy at the beginning in rural Appalachia

Data Source: Questionnaires, standardized scales, urinary cotinine levels

Sample Size: 17

Age Range: Not specified

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

Intervention Description: To measure pediatric preventive counseling at patient-centered medical homes (PCMHs) compared with practices that reported undertaking some or no quality-related activities.

Intervention Results: Compared with other practices, PCMHs were generally associated with greater likelihood of receiving preventive counseling. Estimates varied with the quality-related activities of the comparison practices. Counseling against smoking in the home was 10.4 to 18.7 percentage points (both P < .01) more likely for PCMHs. More associations were statistically significant for PCMHs compared with practices that undertook 1 of 2 quality-related activities examined. Among children ages 2 to 5, compared with practices undertaking both quality-related activities, those with PCMHs were more likely to receive counseling on 3 of 5 topics. Among adolescents, compared with practices undertaking both quality-related activities, those with PCMHs were more likely to receive counseling on smoking, exercise, and eating healthy.

Conclusion: PCMHs were associated with substantially greater receipt of pediatric preventive counseling. Evaluations of PCMHs need to account for the quality-related activities of comparison practices.

Intervention Components (click on component to see a list of all articles that use that intervention): Outreach (caregiver) Enabling Services PATIENT_CONSUMER PROFESSIONAL_CAREGIVER

Intervention Description: To examine effects of maternity care coordination (MCC) on perinatal health care utilization among low-income women.

Intervention Results: Maternity care coordination recipients were more likely to receive first-trimester prenatal care (p < .01) and averaged three more prenatal visits and two additional primary care visits during pregnancy; they were also more likely to participate in WIC and to receive postpartum family planning services (p < .01). Medicaid expenditures were greater among mothers receiving MCC.

Conclusion: Maternity care coordination facilitates access to health care and supportive services among Medicaid-covered women. Increased maternal service utilization may increase expenditures in the short run; however, improved newborn health may reduce the need for costly neonatal care, and by implication the need for early intervention and other supports for at-risk children.

Intervention Components (click on component to see a list of all articles that use that intervention): Provider Training/Education Expert Support (Provider) Enabling Services HEALTH_CARE_PROVIDER_PRACTICE PATIENT_CONSUMER

Intervention Description: We evaluated the benefit of embedded diagnostic consultation within primary care clinics.

Intervention Results: Diagnostic clarity was determined through streamlined assessment for 59% of the children, while others required follow-up. Latency from first concern to diagnosis was 55 days and median age at diagnosis was 32 months: considerably lower than national averages or comparable tertiary clinics.

Conclusion: Findings support that embedded processes for effective triage and diagnosis within the medical home is a viable mechanism for efficient access to diagnostic services and assists in bypassing a common barrier to specialized services.

Intervention Components (click on component to see a list of all articles that use that intervention): Enabling Services

Intervention Description: This article describes a birth justice-focused volunteer birth companion program that evolved out of a multistakeholder collaboration between community birth workers, local reproductive justice organizations, and hospital-based providers, staff, and administrators in direct response to community needs. This program is unique in its collaborative development, grounding in core values, and design of a reproductive justice-focused curriculum that includes training in diversity, inclusion, and care for clients with a history of trauma or perinatal substance use.

Intervention Results: Key takeaways include recommendations to center client needs, consider sustainability, and embrace flexibility and change.

Conclusion: Discussion includes recognition of the strengths and limitations of a volunteer-based model, including acknowledgment that volunteer birth work, while filling an important gap, necessitates the privilege of having sufficient time, economic freedom, and social support. Ensuring universal insurance coverage for doula services has the potential to increase access to continuous labor support, improve birth outcomes, and diversify the birth workforce.

Study Design: Qualitative

Setting: Community-based

Population of Focus: Underserved and diverse communities

Sample Size: Unknown

Age Range: Not disclosed

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

Intervention Description: This summary describes activities conducted in the following study: A Telehealth-Enhanced Referral Process in Pediatric Primary Care: A Cluster Randomized Trial. See https://publications.aap.org/pediatrics/article/143/3/e20182738/76790/A-Telehealth-Enhanced-Referral-Process-in for a full description. Intervention: Our partners were a multisite federally qualified health center and 2 CMHCs in Los Angeles County. We randomly assigned 6 federally qualified health center clinics to the intervention or as a control and implemented a newly developed telehealth-enhanced referral process (video orientation to the CMHC and a live videoconference CMHC screening visit) for all MH referrals from the intervention clinics. Our primary outcome was CMHC access defined by completion of the initial access point for referral (CMHC screening visit). We used multivariate logistic and linear regression to examine intervention impact on our primary outcome. To accommodate the cluster design, we used mixed-effect regression models.

Intervention Results: A total of 342 children ages 5 to 12 were enrolled; 86.5% were Latino, 61.7% were boys, and the mean age at enrollment was 8.6 years. Children using the telehealth-enabled referral process had 3 times the odds of completing the initial CMHC screening visit compared with children who were referred by using usual care procedures (80.49% vs 64.04%; adjusted odds ratio 3.02 [95% confidence interval 1.47 to 6.22]). Among children who completed the CMHC screening visit, intervention participants took 6.6 days longer to achieve it but also reported greater satisfaction with the referral system compared with controls. Once this initial access point in referral was completed, >80% of eligible intervention and control participants (174 of 213) went on to an MH visit.

Conclusion: A novel telehealth-enhanced referral process developed by using a community-partnered approach improved initial access to CMHCs for children referred from primary care.

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER Other Person-to-Person Education Telephone Support Enabling Services Educational Material Motivational Interviewing Peer Counselor

Intervention Description: This study evaluated a theory-guided cognitive-behavioral counseling (CBC) intervention for smoking cessation during pregnancy and postpartum. It also explored the mediating role of cognitive-affective variables on the impact of CBC.

Intervention Results: An intent-to-treat analysis found no differences between the two groups in 7-day point-prevalence abstinence. However, a respondents-only analysis revealed a significantly higher cessation rate in the CBC (37.3 %) versus the BP (19.0 %) condition at 5-months postpartum follow-up. This effect was mediated by higher quitting self-efficacy and lower cons of quitting.

Conclusion: CBC, based on the Cognitive-Social Health Information Processing model, has the potential to increase postpartum smoking abstinence by assessing and addressing cognitive-affective barriers among women who adhere to the intervention.

Study Design: RCT

Setting: University hospital prenatal care clinic

Population of Focus: Racial and ethnically diverse urban pregnant smokers

Data Source: Standard scales, self-report, urine cotinine

Sample Size: 277, 140 in the intervention group and 137 in the control group

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Enabling Services Individual Supports Community Health Workers (CHWs)

Intervention Description: conducted a cross-sectional cohort study, measuring 3 domains of obstetric racism as defined for, by, and with Black birthing people: humanity (violation of safety and accountability, autonomy, communication and information exchange, and empathy); kinship (denial or disruption of community and familial bonds that support Black birthing people); and racism in the form of anti-Black racism and misogynoir (weaponization of societal stereotypes and scripts in service provision that reproduce gendered anti-Black racism in the hospital).

Intervention Results: Analyses were based on 806 Black birthing people, 720 (89.3%) of whom had at least 1 CSP present throughout their labor, birth, and immediate postpartum care. The presence of CSPs was associated with fewer acts of obstetric racism across all 3 domains, with statistically significant reductions in scores in the CSP group of one-third to two-third SD units relative to the no-CSP group.

Conclusion: findings suggest that CSPs may be an effective way to reduce obstetric racism as part of quality improvement initiatives, emphasizing the need for democratizing the birthing experience and birth space, and incorporating community members as a way to promote the safety of Black birthing people in hospital settings.

Study Design: Crossectional Cohort Study

Setting: Clinical

Population of Focus: Black birthing people

Sample Size: 806

Age Range: 24-36

Intervention Components (click on component to see a list of all articles that use that intervention): Home Visits Enabling Services

Intervention Description: MGMC's multipronged approach addresses the complex interactions among social determinants of health, societal drivers of inequity, health care systems, implicit bias for health professionals and the importance of engaging with the community. The 4 evidence‐based strategies of MGMG are (1) racial concordance between Black midwives and patients, (2) group prenatal care, (3) nurse navigation, and (4) one year of in‐home postpartum doula support.

Intervention Results: Racial concordance among care providers and patients, group prenatal care, perinatal nurse navigation, and 12 months of in-home postpartum doula support are 4 evidence-based interventions that are bundled in MGMC.

Conclusion: We posit that a model that restructures maternity care to increase health system accountability and aligns with the needs and desires of Black pregnant and postpartum people will increase trust in the health care system and result in better clinical, physical, emotional, and social outcomes.

Study Design: Multicomponent

Setting: Community-based

Population of Focus: Black birthing community

Sample Size: Not disclosed

Age Range: Not disclosed

Intervention Components (click on component to see a list of all articles that use that intervention): Collaboration with Local Agencies (State) Patient-Centered Medical Home Enabling Services STATE HEALTH_CARE_PROVIDER_PRACTICE PATIENT_CONSUMER

Intervention Description: This study assessed the Collaborative’s impact on access to coordinated care within patient-centered medical homes (PCMH).

Intervention Results: After algorithm implementation, there has been a significant decrease in the time required to establish care in PCMHs, increased provider acknowledgment of refugee status, and decreased emergency department (ED) visits. Multi-disciplinary, organized collaboration can facilitate enhanced access to care for refugee families at the population level.

Conclusion: After algorithm implementation, there has been a significant decrease in the time required to establish care in PCMHs, increased provider acknowledgment of refugee status, and decreased emergency department (ED) visits. Multi-disciplinary, organized collaboration can facilitate enhanced access to care for refugee families at the population level.

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER Educational Material Community-Based Group Education Enabling Services Other Media COMMUNITY POPULATION-BASED SYSTEMS

Intervention Description: A 48-month community intervention was conducted to improve breast and cervical cancer (BCC) screening among Korean American (KA) women in Alameda County (AL), California. KA women in Santa Clara (SC) County, California served as a comparison group.

Intervention Results: After adjusting for all covariates, no significant difference in Pap smear rates between intervention and comparison counties.

Conclusion: Although our overall intervention did not appear to enhance screening practices at the community-level, attendance at a women's health workshop appears to have increased cervical cancer screening.

Study Design: QE: pretest-posttest non-equivalent control group

Setting: Alameda County and Santa Clara County, CA

Population of Focus: Korean American women

Data Source: Telephone survey

Sample Size: Total (N=2,176) Baseline (n=1,093); Follow-up (n=1,083) Analysis (participated in baseline or follow-up) (n=1,902) Baseline (n=818) Intervention (n=404); Control (n=414) Follow-up (n=1,084) Intervention (n=418); Control (n=458)

Age Range: ≥18

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER Educational Material Community-Based Group Education Patient Navigation Enabling Services PROVIDER/PRACTICE Provider Reminder/Recall Systems Provider Education Designated Clinic/Extended Hours Female Provider COMMUNITY Television Media Other Media POPULATION-BASED SYSTEMS

Intervention Description: Development and implementation of a multifaceted intervention using community-based participatory research (CBPR) methodology and evaluated with a quasi-experimental controlled design with cross-sectional pre-intervention (2000) and post-intervention (2004) telephone surveys. Data were analyzed in 2005.

Intervention Results: Significantly greater odds of Pap smear for women in intervention county than in control county (OR=2.02, 95% CI: 1.37-2.99)

Conclusion: A multifaceted community-based participatory research (CBPR) intervention was associated with increased Pap test receipt among Vietnamese-American women in one community.

Study Design: QE: pretest-posttest non-equivalent control group

Setting: Santa Clara County, CA and Harris County, TX

Population of Focus: Vietnamese women living in either county

Data Source: Computer-assisted telephone interviewing system

Sample Size: Baseline(n=1,566) Intervention (n=798); Control (n=768) Follow-up (n=2,009) Intervention (n=1,004); Control (n=1,005)

Age Range: ≥18

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

Intervention Description: We evaluated how revisits and costs of care varied in a 12-month period between children in a care coordination program at our center (enrolled after hospital discharge with a tracheostomy or on a ventilator) and children with complex chronic condition discharges who were not enrolled.

Intervention Results: Seventy patients in the program were compared with 56 patients in the control group. On bivariate analysis, the median combined number of hospitalizations and ED visits in 2018 was lower among program participants (0 vs 1; P = .033), and program participation was associated with lower median total costs of care in 2018 ($700 vs $3200; P = .024). On multivariable analysis, care coordination program participation was associated with 59% fewer hospitalizations in 2018 (incidence rate ratio: 0.41; 95% confidence interval: 0.23 to 0.75; P = .004) but was not significantly associated with reduced ED visits or costs.

Conclusion: The care coordination program is a robust service spanning the continuum of patient care. We found program participation to be associated with reduced rehospitalization, which is an important driver of costs for children with medical complexity.

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): Home Visit (caregiver) Enabling Services Outreach (Provider) PATIENT_CONSUMER HEALTH_CARE_PROVIDER_PRACTICE PROFESSIONAL_CAREGIVER

Intervention Description: The purpose of this study was to describe how each practice operationalized clinical–community linkage strategies that best suited their setting and to determine if efforts resulted in improved MIHP participation and other service use.

Intervention Results: When compared with similar women from the rest of the state, the Federally Qualified Health Center observed a 9.1 absolute percentage points (APP; 95% confidence interval [CI], 8.1–10.1) increase in MIHP participation and 12.5 APP (95% CI, 10.4–14.6) increase in early first trimester enrollment. The obstetrics and gynecology residency practice experienced increases of 4.4 APP (95% CI, 3.3–5.6) in overall MIHP participation and 12.5 APP (95% CI, 10.3–14.7) in first trimester enrollment. Significant improvements in adequate prenatal care, emergency department use, and postpartum visit completion were also observed.

Conclusion: Clinical–community linkages can significantly improve participation of Medicaid-insured women in an evidence-based home visiting program and other prenatal services. This work is important because health providers are looking for ways to create clinical–community linkages.

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): Enabling Services Patient-Centered Medical Home Expert Support (Provider) HEALTH_CARE_PROVIDER_PRACTICE PATIENT_CONSUMER

Intervention Description: To compare perspectives of caregivers of children with autism receiving care at the Neurobehavior Healthy Outcomes Medical Excellence (HOME) Program, an interdisciplinary clinic that provides primary care and behavioral/mental health services for patients with autism and other developmental disabilities, with those responding to the 2016 National Survey of Children’s Health (NSCH). We focused on ratings related to shared decision making, care coordination, family-centered care, and care within a medical home.

Intervention Results: Compared with the NSCH cohort (n=1,151), children enrolled in HOME (n=129) were older, more often female, had severe autism, and had co-occurring intellectual disability. Caregivers perceived that children receiving care within HOME more often received family-centered, coordinated care within a medical home compared with a national sample of children with autism. HOME enrollees also reported increased access to behavioral treatments and adult transition services with less financial burden compared to the national sample.

Conclusion: An interdisciplinary clinic model may best serve children with autism, especially those with higher severity symptoms and co-occurring conditions.

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER Educational Material Patient Navigation Enabling Services Home Visits

Intervention Description: A randomized controlled trial to evaluate the effectiveness of two alternative cervical cancer screening interventions for Chinese women living in North America.

Intervention Results: Women in both intervention groups significantly more likely to have Pap smear than women in control group (39% in outreach worker group vs 15% in control, p<.001; 25% in direct mail group vs 15% in control, p=.03)

Conclusion: Culturally and linguistically appropriate interventions may improve Pap testing levels among Chinese women in North America.

Study Design: RCT

Setting: Seattle, WA and Vancouver, British Columbia

Population of Focus: Women who spoke Cantonese, Mandarin, or English, with no history of cervical cancer or hysterectomy, who were defined as underutilizers of cervical cancer screening (no Pap test in the past 2 years and/or did not intend to have a Pap test in the next 2 years)

Data Source: Self-report through personal interviews and verified through medical record review

Sample Size: Total (N=402) Intervention Group 1 (n=129); Intervention Group 2 (n=139); Control (n=134)

Age Range: 20-69

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER Educational Material Patient Navigation Enabling Services COMMUNITY Community Events POPULATION-BASED SYSTEMS Home Visits

Intervention Description: A group-randomized controlled trial to evaluate a cervical cancer screening intervention program targeting Seattle’s Cambodian refugee community.

Intervention Results: The proportion of women in the intervention group reporting recent cervical cancer screening increased from 44% at baseline to 61% at follow-up (+17%). The corresponding proportions among the control group were 51 and 62% (+11%). These temporal increases were statistically significant in both the intervention (P < 0.001) and control (P = 0.027) groups.

Conclusion: This study was unable to document an increase in Pap testing use specifically in the neighborhood-based outreach intervention group; rather, we found an increase in both intervention and control groups. A general awareness of the project among women and their health care providers as well as other ongoing cervical cancer screening promotional efforts may all have contributed to increases in Pap testing rates.

Study Design: Cluster RCT

Setting: Seattle, Washington

Population of Focus: Cambodian women

Data Source: Self-report through personal interviews and verified through medical record review

Sample Size: Total (N=370) Analysis (n=289) Intervention (n=144); Control (n=145)

Age Range: ≥18

Intervention Components (click on component to see a list of all articles that use that intervention): Enabling Services

Intervention Description: Using a matched cohort design, birth certificate records for By My Side participants from 2010 through 2017 (n = 603) were each matched to three controls who also lived in the program area (n = 1809). Controls were matched on maternal age, race/ethnicity, education level, and trimester of prenatal- care ini-tiation, using the simple random sampling method.

Intervention Results: By My Side participants had lower odds of having a preterm birth (5.6% vs 11.9%, P< .0001) or a low- birthweight baby (5.8% vs 9.7%, P= .0031) than controls. There was no statistically significant difference in the odds of cesarean delivery.

Conclusion: Participation in the By My Side Birth Support Program was associ-ated with lower odds of preterm birth and low birthweight for participants, who were predominantly Black and Hispanic. Investing in doula services is an im-portant way to address birth inequities among higher risk populations such as birthing people of color and those living in poverty. It could also help shape a new vision of the maternal- health system, placing the needs and well- being of birthing people at the center.KEYWORDSbirth justice, doula support, health equity, Healthy Start, low birthweight, preterm birth

Study Design: Quasi-experimental, matched cohort design

Setting: Community-based

Population of Focus: Pregnant individuals who live in Brooklyn New York and meet the income-eligibility requirements for the Women, Infants, and Children nutrition program (WIC)

Sample Size: 2400

Age Range: 18-40

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER Other Person-to-Person Education Enabling Services Other Media Community Events COMMUNITY POPULATION-BASED SYSTEMS

Intervention Description: In a randomized controlled trial of 20 communities, the study examined whether a comprehensive intervention influenced cancer screening behaviors and lifestyle practices in rural communities in Eastern Washington State. Cross-sectional surveys at baseline and post-intervention included interviews with a random sample of approximately 100 households per community. The interview included questions on ever use and recent use of Pap test, mammogram, and fecal occult blood test (FOBT) and sigmoidoscopy/colonoscopy, fruit and vegetable consumption and smoking practices.

Intervention Results: The study found few significant changes in use of screening services for cervical (Pap test), breast (mammogram) or colorectal cancer (fecal occult blood test (FOBT) or sigmoidoscopy/colonoscopy) between intervention and control communities. Results showed no significant differences in fruit and vegetable consumption nor in smoking prevalence between the two groups. We found more awareness of and participation in intervention activities in the treatment communities than the control communities.

Conclusion: Our null findings might be attributable to the low dose of the intervention, a cohort effect, or contamination of the effect in non-intervention communities. Further research to identify effective strategies to improve cancer prevention lifestyle behaviors and screening practices are needed.

Study Design: Cluster RCT

Setting: Twenty communities in the Lower Yakima Valley of WA

Population of Focus: Women

Data Source: Self-report through personal interviews

Sample Size: Total (N=1,962) Analysis (n=1,851) Intervention (n=894); Control (n=957)

Age Range: ≥18

Intervention Components (click on component to see a list of all articles that use that intervention): Enabling Services

Intervention Description: In addition to literature and policy reviews, researchers conducted 16 semistructured interviews from March to August 2020 with key informants from organizations involved in training, certifying, advocating for, and employing doulas, and informants involved in state policy making.

Intervention Results: The landscape of organizations involved in doula training and certification is diverse. In discussing their training and curriculum, interviewees from large organizations and community-based organizations (CBOs) stressed the importance of incorporating a focus on structural racism in maternal health into training curricula. CBOs specifically offered three areas of systems-level change that can help equitably grow doula services: the importance of addressing structural racism, changing the balance of power in decision making and policy making, and a cautious approach to Medicaid reimbursement.

Conclusion: This study provides evidence of how doula organizations move the field toward better serving the specific needs of underserved populations. It recognizes the expertise of CBOs in developing policy to expand doula services to communities in need. The information from this study highlights the complexities of facilitating consistency across doula training and certification requirements and implementing a sustainable funding mechanism while also meeting communities' unique needs.

Study Design: Qualitative

Setting: Community-based

Population of Focus: Individuals and organizations involved in the provision of birth doula services, as well as policymakers and advocates working to address health inequities in maternal and perinatal care.

Sample Size: 16

Age Range: Not disclosed

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER Patient Reminder/Invitation Enabling Services Designated Clinic/Extended Hours PROVIDER/PRACTICE

Intervention Description: (1). to assess the cost-effectiveness of three interventions to deliver breast and cervical cancer screening to women unscreened for >or=3 years and (2). to determine the relation of an invasive cervical cancer diagnosis to the interval since the last true screening test.

Intervention Results: Significantly greater odds of Pap smear for women in phone/phone and letter/phone intervention groups than in control group (phone/phone OR=4.77, letter/phone OR=5.57, p<.0001)

Conclusion: Letter reminder, followed by a telephone appointment call, was the most cost-effective approach to screening rarely screened women. Lack of accurate information on prior hysterectomy adds substantial unnecessary costs to a screening reminder program.

Study Design: RCT

Setting: Portland, OR metropolitan area

Population of Focus: Women who were members of Northwest Kaiser Permanente (NWKP) for at least 3 years, with no history of cervical cancer or hysterectomy, who had not received a Pap smear in the same 3 years they had been members of NWKP

Data Source: Radiology and cytology database

Sample Size: Total (N=1,200) Intervention Group 1 (n=288); Intervention Group 2 (n=308); Intervention Group 3 (n=303); Control (n=301)

Age Range: 18-70