Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): Provider, Education; Hospital, Chart audit and feedback, Elective induction policy, Guideline change and implementation, Quality improvement , HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, HOSPITAL, Chart Audit and Feedback, Elective Induction Policy, Guideline Change and Implementation, Quality Improvement

Intervention Description: At a large Southern US women's hospital, new measures were made to reduce the rates of cesarian delivery at the facility. Endeavors were led by nurse / doctor leaders (VP & chief of staff). These included monitoring, benchmarking & disseminating information about CD at the facility; new protocols for oxytocin administration; Bishop's score assessment; elective CD performed only at 39 weeks; new protocols and intrapartum alternative positioning devices, the process of laboring down, and closed glottis pushing attempts in second-stage labor.

Intervention Results: Collectively, these interdisciplinary interventions have resulted in significant decreases in overall cesarean birth rates and comparable significant reductions in the NTSV cesarean rates.

Conclusion: Concerted efforts to reduce rates of nonmedically indicated cesarean birth have resulted in the development and implementation of comprehensive action plans aimed at effecting reductions and enhancing overall obstetric quality care.

Setting: One large obstetric hospital in the Southern USA

Population of Focus: NTSV births

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, PROFESSIONAL_CAREGIVER, Education/Training (caregiver), COMMUNITY, Presentation

Intervention Description: This study assessed the impact of the two-day Kansas Infant Death and SIDS (KIDS) Network Safe Sleep Instructor (SSI) train-the-trainer program on CPS staffs' knowledge of the American Academy of Pediatrics safe sleep recommendations. Training was attended by 43 participants, 27 (63%) of whom were employed by CPS. All participants completed a 10-item pre- and post-training knowledge assessment at the beginning of the training and immediately following the training, respectively. Following training, SSIs were certified to educate parents/caregivers, childcare providers, health care providers, and other members of their communities about safe sleep practices. SSIs were tasked with providing safe sleep training to at least 10 professionals and with hosting one Safe Sleep Community Baby Shower or Crib Clinic within 9 months of certification.

Intervention Results: Following SSI certification, CPS SSIs provided more safe sleep training to professionals than other SSIs (1051 vs. 165, respectively), and both groups of SSIs were able to significantly increase the knowledge of their trainees.

Conclusion: Overall, the KIDS Network SSI training was successful. The innovative partnership with CPS allowed for provision of training to a group not historically targeted for safe sleep education.

Setting: Kansas Department of Children and Families Child Protective Services (CPS)

Population of Focus: Child Protective Services staff

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Pediatric to Adult Transfer Assistance, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: This quality-improvement initiative was designed to implement a structured intervention that supports the planned transfer of care to adult primary care.

Intervention Results: Over 3 years, our PN reached out to 96% of patients (n = 226) eligible to transfer care and offered transfer assistance in person or in writing. Among those surveyed, 92% (n = 93) reported awareness of our practice transition policy, and 83% (n = 64) rated their confidence to transfer care at 3 or higher on a 5-point scale.

Conclusion: AYAs are aware of our practice transition policy, yet they welcome in-person transfer assistance. This intervention seems to improve their confidence to transfer care. However, despite PN outreach efforts, many remain empaneled in our practice and thus lack the self-care skills necessary to complete the transfer independently. Future transition interventions should address AYA's self-management skills toward transition readiness.

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage, HEALTH_CARE_PROVIDER_PRACTICE, Public Insurance (Health Care Provider/Practice), Collaboration with Local Agencies (State), Collaboration with Local Agencies (Health Care Provider/Practice), CLASSROOM_SCHOOL, PROFESSIONAL_CAREGIVER, Outreach (caregiver), Communication Tools, Distribution of Promotional Items (Classroom/School)

Intervention Description: In Michigan, a school-based outreach effort was piloted using existing school communication tools to identify children who are currently uninsured and may be eligible for state-subsidized health insurance. School districts were provided with two health insurance status collection forms to be included with the free and reduced school lunch application, and as part of the student registration packet and welcome materials for school. Completed forms were sent to a state registered application-assisting agency to ensure families can access the coverage and services they need. A final step in the process is outreach to eligible respondents by the Michigan Primary Care Association to help ensure that they receive information and access to the healthcare coverage and services they need.

Intervention Results: As a result of the survey, 156 children were identified as not having health insurance. This represents more than 44% of the 358 children who are eligible for State subsidized health insurance, in the participating school districts, but are uninsured. Integrating the collection of health insurance status into routine school communication channels is an effective way to identify children who do not have health insurance and may be eligible for state subsidized benefits.

Conclusion: 1. The Michigan Department of Community Health should lead the effort to work with the Michigan Department of Education to modify the Free and Reduced Lunch Application to capture whether or not the applicant has health insurance. 2. The Michigan Department of Community Health should lead the effort to incorporate into the direct certified free and reduced lunch eligibility process a systematic check as to whether or not the applicant has State subsidized health insurance. 3. The Michigan Department of Community Health should provide resources from the expected performance bonus to work with schools across the State to implement these changes.

Study Design: Cross-sectional pilot study

Setting: Schools (School districts in Van Buren County, Michigan)

Population of Focus: Uninsured children

Data Source: Survey data

Sample Size: 8,999 children

Age Range: School-aged children

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): HOSPITAL, Guideline Change and Implementation, HEALTH_CARE_PROVIDER_PRACTICE, Active Management of Labor

Intervention Description: This was a prospective cohort study of nulliparous women to determine how a new structured protocol of oxytocin augmentation within a single hospital obstetric department impacted labor outcomes. The new protocol instructs birth attendants to diagnose “prolonged labor” based on the World Health Organization (WHO) partograph before commencing oxytocin infusion for augmentation. Data from the hospital were collected prospectively and compared for two time-period cohorts: the historic control cohort (2009–2010) and the study period cohort (2012–2013). Nulliparous women with singleton, term deliveries (>37 weeks), cephalic presentation, and spontaneous onset of labor (Ten-Group Classification System (TGCS) group 1) were included in the analysis.

Intervention Results: The study cohort and control cohort comprised 1103 (26.2%) and 1399 (33.1%) of all laboring women, respectively (p < .01). The protocol was followed satisfactorily in 78% of the study cohort. The use of oxytocin augmentation was reduced in the study cohort versus the control cohort; 41.3 versus 48.9% (p < .01); mean oxytocin infusion duration was shorter (100 versus 123 min; p < .01); and mean total oxytocin dose decreased (1009 versus 1293 mU; p < .01). The cesarean section rate was 5.9% in the study cohort versus 8.0% in the control cohort (p = .04). The estimated mean duration of the active phase of labor increased by 47 min (p < .01) after the implementation. The frequency of estimated postpartum hemorrhage >1000 ml was higher, 4.9 versus 2.0% (p < .01), but the use of blood transfusions remained stable, 2.5 versus 2.7% (p = .78), the study cohort versus control cohort, respectively.

Conclusion: Implementation of a protocol of structured use of oxytocin augmentation reduced the frequency, dosage, and duration of oxytocin without increasing the cesarean section rate in TGCS group 1.

Setting: Obstetric Department of Sørlandet Hospital, Kristiansand, Norway

Intervention Components (click on component to see a list of all articles that use that intervention): Patient-Centered Medical Home, Notification/Information Materials (Online Resources, Information Guide), Outreach (caregiver), PROFESSIONAL_CAREGIVER, PARENT_FAMILY, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: The 2016–2018 National Surveys of Children’s Health dataset was used to identify associations among preventive care, unmet health care needs, medical home access, and emergency department (ED) use among children and adolescents with autism spectrum disorder (ASD).

Intervention Results: Results indicated that youth with ASD had higher odds of using ED services if they had unmet mental health care needs (OR = 1.58, CI: 1.04–2.39) and lower odds of using ED services if they had access to a medical home (OR = 0.79, CI: 0.63–0.98).

Conclusion: Findings suggest the importance of access to coordinated, comprehensive, and patient-centered care to address health care needs and prevent ED utilization among children and adolescents with ASD.

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): Active Management of Labor, , HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: The aim of this study was to determine whether compliance with a checklist-based protocol for oxytocin administration was associated with changes in neonatal and maternal outcomes.

Intervention Results: Among patients with complete adherence to the oxytocin administration protocol, the rate of cesarean section in the unadjusted analysis was 16.20%, compared to 18.54% for those with incomplete adherence; the rates of postpartum hemorrhage were 2.64% vs. 3.14%, respectively, and the rates of NICU admission were 3.03% vs. 3.86%, respectively. In the multivariable logistic regression, complete protocol adherence was associated with significantly lower odds of postpartum hemorrhage (adjusted odds ratio [OR] 0.85, 95% confidence interval [CI] 0.76–0.94) but higher odds of Cesarean section (adjusted OR 1.07, 95% CI 1.01–1.13); the adjusted OR for NICU admission was 0.90, which did not reach statistical significance (95% CI 0.81–1.00). Among the covariates, nulliparity and elective induction were the strongest predictors of the primary outcomes of cesarean section, postpartum hemorrhage, and NICU admission.

Conclusion: Adherence to the oxytocin administration protocol was associated with a decrease in postpartum hemorrhage but an increased risk of delivery by cesarean section.

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

Intervention Description: The City of Dallas, TA, WIC program collaborated with 3 urban hospitals and developed a training of practical techniques and information for staff to use while working with breastfeeding patients. It recognizes the powerful role that health care workers have in successful BF and the need for competent, hands-on skills to support lactation. The goals of the new collaboration with WIC were to provide staff a supervised clinical experience in a workshop format and provide a venue to practice the information they gained from the didactic education.

Intervention Results: Since implementation, 1,600 workers were trained, 1 hospital achieved Baby-Friendly designation, and all have increased BF rates by 10%.

Conclusion: The City of Dallas, TX, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program collaborated with 3 urban hospitals and developed a training of practical techniques and information for staff to use while working with BF patients. Since implementation, 1,600 workers were trained, 1 hospital achieved Baby-Friendly designation, and all have increased BF rates by 10%.

Study Design: Evaluation data

Setting: Three hospitals in Dallas, TX, and the City of Dallas WIC program

Population of Focus: Physicians, midwives, dietitians, and staff from area hospitals and clinics

Sample Size: 1600 people over three years

Age Range: Adults

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, Development/Improvement of Services, Continuing Education of Hospital Providers, HOSPITAL, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: Creation of a small baby program requires special resources and multidisciplinary engagement.

Intervention Results: While it took pre-planning to time routine exams with cares, this approach resulted in a significant decrease in apnea, bradycardia, and desaturation events than previously observed.

Conclusion: We have described benefits, challenges, and practical approaches to creating and maintaining a small baby program that could be a model for the development of special programs for other sub-populations within in the NICU.

Intervention Components (click on component to see a list of all articles that use that intervention): Provider Training/Education, Residents/Medical Students, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: Six obstetricians with significant experience in operative deliveries supervised and taught residents on labor and delivery, including the use of forceps

Intervention Results: There were 5,201 live, term, singleton, vertex deliveries under the care of residents, 1,919 (36.9%) before December 2012 and 3,282 (63.1%) December 2012 or later. The rate of forceps deliveries significantly increased from 0.6% to 2.6% (adjusted odds ratio [OR] 8.44, 95% confidence interval [CI] 3.1–23.1), and the rate of cesarean deliveries significantly decreased from 27.3% to 24.5% (adjusted OR 0.68, 95% CI 0.55–0.83). There were no statistically significant differences in the rates of third- or fourth-degree lacerations or 5-minute Apgar scores less than 7. Among nulliparous women, the forceps rate increased from 1.0% to 3.4% (adjusted OR 4.87, 95% CI 1.74–13.63) and the cesarean delivery rate decreased from 25.6% to 22.7% (adjusted OR 0.69, 95% CI 0.53–0.89). The increase in forceps deliveries

Conclusion: Having senior obstetricians supervise resident deliveries is significantly associated with an increased rate of forceps deliveries and a decreased rate of cesarean deliveries.

Setting: Mt. Sinai Hospital

Population of Focus: All patients with term singleton vertex gestrations

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, Provider Training/Education, Educational Material (Provider), Participation Incentives, Quality Improvement/Practice-Wide Intervention, Expert Support (Provider), Modified Billing Practices, Data Collection Training for Staff, Screening Tool Implementation Training, Office Systems Assessments and Implementation Training, Expert Feedback Using the Plan-Do-Study-Act-Tool, Collaboration with Local Agencies (State), Collaboration with Local Agencies (Health Care Provider/Practice), Engagement with Payers, STATE, POPULATION-BASED SYSTEMS, Audit/Attestation, HEALTH_CARE_PROVIDER_PRACTICE, Audit/Attestation (Provider)

Intervention Description: The Vermont Child Health Improvement Program (VCHIP) at the University of Vermont collaborated with state agencies and professional societies to conduct a survey of Vermont pediatric and family medicine practices regarding their developmental screening and autism screening processes, referral patterns, and barriers. The survey was administered in 2009 to 103 primary care practices, with a 65% response rate (89% for pediatric practices, 53% for family medicine practices).

Intervention Results: The survey results revealed that while 88% of practices have a specific approach to developmental surveillance and 87% perform developmental screening, only 1 in 4 use structured tools with good psychometric properties. Autism screening was performed by 59% of practices, with most using the M-CHAT or CHAT tool and screening most commonly at the 18-month visit. When concerns were identified, 72% referred to a developmental pediatrician and over 50% to early intervention. Key barriers to both developmental and autism screening were lack of time, staff, and training. Over 80% of practices used a note in the patient chart to track at-risk children, and most commonly referred to child development clinics, audiology, early intervention, and pediatric specialists.

Conclusion: The survey conducted by VCHIP revealed wide variation in developmental and autism screening practices among Vermont pediatric and family medicine practices. While most practices conduct some form of screening, there is room for improvement in the use of validated tools, adherence to recommended screening ages, and implementation of office systems for tracking at-risk children. The survey identified knowledge gaps and barriers that can be addressed through quality improvement initiatives, which most respondents expressed interest in participating in.

Study Design: QE: pretest-posttest

Setting: Pediatric and family medicine practices in Vermont

Population of Focus: Children up to age 3

Data Source: Child medical record; ProPHDS Survey

Sample Size: Chart audits at 37 baseline and 35 follow-up sites (n=30 per site) Baseline charts (n=1381) - Children 19-23 months (n=697) - Children 31-35 months (n=684) Follow-up charts (n=1301) - Children 19-23 months (n=646) - Children 31-35 months (n=655)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, HOSPITAL, Quality Improvement

Intervention Description: A hospital-wide safe sleep bundle, based on a hospital-acquired conditions (HAC) model, was implemented in September 2017. Interventions were chosen by team members during multidisciplinary team meetings. Four key time points and/or interventions across the study period were (1) nursing education on the safe sleep bundle; 2) policy update and implementation; (3) collection and sharing of audit data; and (4) peer-to-peer bundle checklist reviews during registered nurse shift handoffs and electronic medical record (EMR) input. Other notable education interventions included subject matter expert training by guest speakers from the University of Pennsylvania and education to parents through updating newborn video instruction and increased exposure to appropriate safe sleep modeling.

Intervention Results: Overall compliance improved from 9% to 72%. Head of bed flat increased from 62% to 93%, sleep space free of extra items increased from 52% to 81%, and caregiver education completed increased from 10% to 84%. The centerline for infant in supine position remained stable at 81%.

Conclusion: Using an HAC bundle safety prevention model to improve adherence to infant safe sleep guidelines is a feasible and effective method to improve the sleep environment for infants in all areas of a children's hospital.

Setting: Penn State Children's Hospital

Population of Focus: Hospital healthcare providers

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Active Management of Labor, Prolonged Second Stage of Labor

Intervention Description: RCT. Maternal and neonatal outcomes were compared among women with amniotomy versus women with intact membranes and no amniotomy at 6 2-hour time intervals: before oxytocin initiation, 0 to <2 hours after oxytocin, 2 to <4 hours after, 4 to <6 hours after, 6 to <8 hours after, and 8 to <10 hours after

Intervention Results: Of 6,106 women in the parent trial, 2,854 (46.7%) women met inclusion criteria. Of these 2,340 (82.0%) underwent amniotomy, and majority of the women had amniotomy performed between 2 and <6 hours after oxytocin. Cesarean delivery was less frequent among women with amniotomy 6 to <8 hours after oxytocin compared with women without amniotomy (21.9 vs. 29.7%; adjusted odds ratio 0.61, 95% confidence interval 0.42-0.89). Amniotomy at time intervals ≥4 hours after oxytocin was associated with lower odds of labor duration >24 hours. Amniotomy at time intervals ≥2 hours and <8 hours after oxytocin was associated with lower odds of maternal hospitalization >3 days. Amniotomy was not associated with postpartum or neonatal complications.

Conclusion: Among a contemporary cohort of nulliparous women undergoing term labor induction, amniotomy was associated with either lower or similar odds of cesarean delivery and other adverse outcomes, compared with no amniotomy.

Setting: Hospitals

Population of Focus: Nulliparous women undergoing induction of labor with oxytocin at or after 38 weeks' pregnancy.

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, HOSPITAL, Guideline Change and Implementation, Quality Improvement

Intervention Description: This quality improvement initiative used a systematic approach to reduce nulliparous cesarean birth rates, aligning with recommendations developed by the Council on Patient Safety in Women's Health Care: Patient Safety Bundle on the Safe Reduction of Primary Cesarean Births. Health care providers and nurses received education on contemporary labor management guidelines developed by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine Obstetric Care Consensus regarding safe prevention of primary cesarean deliveries and nurses were instructed on labor support techniques. The preguideline implementation period was January 1, 2015, to June 30, 2015. The postguideline implementation period was July 1, 2016, to December 31, 2016. The primary outcome measured was the nulliparous, term, singleton, vertex cesarean birth rate.

Intervention Results: There were 434 women identified in the preguideline period and 401 women in the postguideline period. The nulliparous, term, singleton, vertex cesarean birth rate decreased from 27.9% to 19.7% [odds ratio (OR) 0.63, CI 0.46-0.88]. There were improvements in health care provider compliance with following the labor management guidelines from 86.2% to 91.5% (OR 1.73, 95% CI 1.11-2.70), the use of maternal position changes from 78.7% to 87.5% (OR 1.86, 95% CI 1.29-2.68), and use of the peanut birthing ball from 16.8% to 45.2% (OR 3.83, 95% CI 2.84-5.16) as provisions for labor support.

Conclusion: Implementing a systematic approach for care of nulliparous women is associated with a decrease in term, singleton, vertex cesarean birth rates.

Setting: Two rural community hospitals and one urban community hospital in North Carolina

Population of Focus: Nulliparous women with term singleton vertex gestations

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, HEALTH_CARE_PROVIDER_PRACTICE, Data Collection Training for Staff , Provider Training/Education, Audit/Attestation (Provider)

Intervention Description: Quality improvement (QI) methodology was used to implement routine screening using an adapted version of the Survey of Well Being of Young Children (SWYC), a child behavior and social screen, for all children ages 6 months to 10 years. Rates of screen administration and documentation were assessed for 18 months. Medical records of a convenience sample (N=349) were reviewed to track referrals and follow-up for positive screens.

Intervention Results: Over 18 months, 2028 screens were administered. Screening rates reached 90% after introducing a tablet for screening. Provider documentation of screens averaged 62%. In the convenience sample, 28% scored positive for a behavioral problem, and 25% reported at least 1 social stressor. Of those with positive child behavior or social stressor screens, approximately 80% followed up with their primary medical doctor, and approximately 50% completed referrals to the clinic social worker. Further analysis indicated that referral and follow-up rates varied depending on whether the family identified child behavior or social issues. Logistic regression revealed that parental concern was independently associated with child behavior symptoms (p = 0.001) and social stressors (p = 0.002).

Conclusion: Implementing a comprehensive psychosocial screen is feasible in pediatric primary care and may help target referrals to address psychosocial health needs.

Setting: Community health center

Population of Focus: Primary care peditricians

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, HEALTH_CARE_PROVIDER_PRACTICE, ,

Intervention Description: The aims of this study were to (1) assess changes to maternity care policies in response to COVID-19, and (2) compare hospital-level breastfeeding, skin-to-skin, and rooming-in rates, at cohort hospitals, before and during the pandemic, overall and stratified by race.

Intervention Results: Twenty-six hospitals responded to the May and September 2020 surveys. Hospitals used different sources to create maternity care policies, and policies differed between institutions. Trends in rates of any and exclusive breastfeeding in the hospital cohort plateaued during the pandemic, in comparison to previous gains, and rates of skin-to-skin and hospital rooming-in decreased. No differences were evident between races.

Conclusion: Policies (Aim 1) and practices in the quality improvement cohort hospitals were inconsistent during the COVID-19 pandemic, and changes measured to practices were detrimental (Aim 2). Ongoing monitoring is recommended.

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

Intervention Description: This case study describes an innovative practice model informed by the Collective Impact Model (CIM) designed to promote breastfeeding continuity of care and community support in Central Illinois.

Intervention Results: Numerous breastfeeding support improvements were made at and between CIBPN sites. Breastfeeding rates at the birthing hospital and health center were stable, including during the COVID-19 pandemic.

Conclusion: This article contributes to the practice-based evidence for breastfeeding support by strengthening continuity of care through a successful application of the CIM by public health practitioners.

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, Planning for Transition, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: A health care transition focused quality improvement project was implemented in a large urban pediatric endocrinology clinic to evaluate the effectiveness of the administration of the Transition Readiness Assessment Questionnaire (TRAQ) by identifying barriers to implementation and creating a more sustainable format.

Intervention Results: for improved documentation and achievement of transition focused goals. Results: Several barriers were identified that minimized the effectiveness of the TRAQ tool including lack of staff trained to assist with insulin pump and meter downloads and proximity of diabetes software. Additional staff were trained, and software was relocated to a more centrally located area with greater staff accessibility to allow for discussion of transition goals with patient and family. The new process resulted in a 100% increase in documentation of transition goals and met goals (p ≤0.001).

Conclusion: The TRAQ tool is valuable for directing transition needs if implementation barriers such as staff training and accessibility to software are monitored and addressed. Frequent evaluation of the administration of the TRAQ tool protocol in the clinic setting is recommended in order to support pediatric patients' successful transition to adult care.

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

Intervention Description: All laboring individuals in this study were triaged by either a midwife or physician, and all additionally received nursing care. Each of several private practices feeding into this hospital has at least 1 midwife providing prenatal care. Midwives also provide intrapartum care in the hospital, alongside obstetrician hospitalists who provide some care during the day shift. However, once a laboring patient is admitted to a physician for intrapartum management, they do not change to a midwife provider for labor or birth. Approximately half of the individuals in this sample were admitted by a midwife (52.2%, n = 175), and the other half were admitted by a physician (47.8%, n = 160). For this study, provider type data for each participant at 2 time points were collected: during the triage visit (admitted provider type) and at birth.

Intervention Results: Patients admitted by midwives had lower odds of oxytocin augmentation (adjusted odds ratio [aOR] = 0.50, 95% confidence interval [CI] = 0.29-0.87), epidural (aOR = 0.29, 95% CI = 0.12-0.69), and cesarean birth (aOR = 0.308, 95% CI = 0.14-0.67), compared with those triaged by physicians after controlling for patient characteristics and triage timing. This study provides additional context to midwives as labor triage providers for healthy, low-risk pregnant individuals; however, challenges persisted with measurement.

Conclusion: More research is needed on the specific components of care during labor that support low-risk patients to avoid medical interventions and poor outcomes.

Setting: Community-based hospital

Population of Focus: Low risk nulliparous women

Intervention Components (click on component to see a list of all articles that use that intervention): Health_Care_Provider_Practice, Screening Tool Implementation Training, Provider Training/Education

Intervention Description: Twenty-eight pediatricians completed an in-person meeting, monthly webinars, and individualized feedback from an Expert Work Group on progress across a 3-month action period.

Intervention Results: Statistically significant increases were observed in rates of autism screening, discussions of screening results with families, and referral following abnormal results. There was no statistically significant change in rates of general developmental screening. Comparing self-report with record review, pediatricians overestimated the extent to which they conducted discussion and referral.

Conclusion: Universal screening for all children has yet to be achieved. The current project supports that practice-based improvements can be made and delineates some of the routes to success.

Setting: Clinical practice

Population of Focus: Primary care peditricians

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, Planning for Transition, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: To describe the development and pilot implementation of a transition process for youth living with human immunodeficiency virus (HIV) and to assess the perceptions of the process among youth living with HIV (YLHIV), their caregivers, and clinical staff.

Intervention Results: Our transition process was informed by our goal to provide transition support that could respond to a variety of patient factors. We developed a process focused on four stages: 1. Introduction to Transition, 2. Building Knowledge and Skills, 3. Growing in Independence, and 4. Adult Care Ready. Each stage contains competencies for the patient and tasks for the care team. The pace of proceeding through the stages is determined by completion of competencies rather than patient age. Results from youth and staff showed that the transition process and informational material were helpful.

Conclusion: We developed a transition process for YLHIV and implemented this process in an HIV clinic. Initial survey data shows that youth, caregivers, and staff found this strategy helpful. Practice implications: This pilot process may serve as a source of guidance to other clinics seeking to establish their own transition process.

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

Intervention Description: To investigate the association between one-to-one midwifery care and birth outcomes with pain relief as the primary outcome. Secondary outcomes include obs

Intervention Results: Logistic regression analysis show that nulliparous women receiving one-to-one midwifery care in the active phase of labour are less likely to have an epidural analgesia, adjusted OR of 0.81 (95% CI 0.72,0.91), less likely to be given nitrous oxide, adjusted OR of 0.77 (95% CI 0.69,0.85), and they more often received massages, adjusted OR of 1.76 (95% CI 1.47,2.11), compared with women not receiving one-to-one midwifery care. Descriptive analyses show that women receiving one-to-one midwifery care in the active phase of labour are less likely to have a caesarean section (5.8% vs. 7.2%) and they are less likely to have an operative vaginal birth (16.5% vs. 23.7%). No significant differences were observed between the groups in terms of low Apgar scores at five minutes.

Conclusion: We found that one-to-one midwifery care in the active phase of labour may be associated with birth outcomes, including decreased use of epidural analgesia and a decreased rate of caesarean sections and operative vaginal birth. The results of this study could encourage midwives to be present during the active phase of labour to promote physiological birth.

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Transition Assistance, HEALTH_CARE_PROVIDER_PRACTICE, PATIENT_CONSUMER

Intervention Description: Our aim was to assess the effect of a communication technology enhanced transition coordinator intervention compared with usual care on clinic attendance among transitioning youth with type 1 diabetes.

Intervention Results: There were no baseline differences in age, sex, HbA1c and number of follow-up visits, emergency department visits and diabetic ketoacidosis admissions in the 1 year prior to transition between the usual care (n = 101) and intervention (n = 102) groups. In the year following transfer, 47.1% in the usual care group vs 11.9% in the intervention group did not attend any outpatient diabetes appointments (p < 0.01). There were no differences in glycaemic control or diabetic ketoacidosis post transfer.

Conclusion: Our intervention was successful in improving clinic attendance among transitioning youth with type 1 diabetes. Importantly, this programme used simple, readily accessible communication technologies, which increases the sustainability and transferability of this strategy.

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): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, HOSPITAL, Chart Audit and Feedback, Guideline Change and Implementation, Quality Improvement, Policy/Guideline (State), STATE, Collaboration with Local Agencies (Health Care Provider/Practice), Collaboratives, Policy/Guideline (Hospital)

Intervention Description: Hospitals participating in the MDPQC (Maryland Perinatal-Neonatal Quality Care Collaborative) agreed to implement practices from the "Safe Reduction of Primary Cesarean Births" patient safety bundle, developed by the Council on Patient Safety in Women's Health Care. As a requirement of participation, hospital teams sent at least one team member to each collaborative event. Activities included a June 2016 in-person kick off meeting for two to three representatives from each hospital to familiarize them with the cesarean delivery bundle and the requirements of participation, followed by conference calls that occurred every month in the first year and every 2 months in the second year. Additional in-person meetings for all hospital teams took place at 12 months and at the end of the collaborative (November 2018). Nice webinars on related clinical topics were presented throughout the 30-month period. The collaborative director provided facilitation support to site teams through calls and visits when requested by the site team or when site participation lapsed.

Intervention Results: Among the 26 bundle practices that were assessed, participating hospitals reported having a median of seven practices (range 0-23) already in place before the collaborative and implementing a median of four (range 0-17) new practices during the collaborative. Across the collaborative, the cesarean delivery rates decreased from 28.5% to 26.9% (P=.011) for all nulliparous term singleton vertex births and from 36.1% to 31.3% (P<.001) for nulliparous, term, singleton, vertex inductions. Five hospitals had a statistically significant decrease in nulliparous, term, singleton, vertex cesarean delivery rates and four had a significant increase. Nulliparous, term, singleton, vertex cesarean delivery rates were significantly lower across hospitals that implemented more practices in the "Response" domain of the bundle.

Conclusion: The MDPQC was associated with a statewide reduction in cesarean delivery rates for nulliparous, term, singleton, vertex births.

Setting: 31 Maryland birthing hospitals

Population of Focus: Among the 26 bundle practices that were assessed, participating hospitals reported having a median of seven practices (range 0–23) already in place before the collaborative and implementing a median of four (range 0–17) new practices during the collaborative. Across the collaborative, the cesarean delivery rates decreased from 28.5% to 26.9% (P5.011) for all nulliparous term singleton vertex births and from 36.1% to 31.3% (P,.001) for nulliparous, term, singleton, vertex inductions. Five hospitals had a statistically significant decrease in nulliparous, term, singleton, vertex cesarean delivery rates and four had a significant increase. Nulliparous, term, singleton, vertex cesarean delivery rates were significantly lower across hospitals that implemented more practices in the “Response” domain of the bundle.

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

Intervention Description: To compare labor outcomes in women accompanied by an additional support person (doula group) with outcomes in women who did not have this additional support person (control group).

Intervention Results: Significantly shorter length of labor in the doula group, greater cervical dilation at the time of epidural anesthesia, and higher Apgar scores at both 1 and 5 minutes. Differences did not reach statistical significance in type of analgesia/anesthesia or cesarean delivery despite a trend toward lower cesarean delivery rates in the doula group.

Conclusion: Providing low-income pregnant women with the option to choose a female friend who has received lay doula training and will act as doula during labor, along with other family members, shortens the labor process.

Study Design: RCT

Setting: 1 women’s ambulatory care center at a tertiary hospital in New Jersey

Population of Focus: Nulliparous women who gave birth after enrollment between 1998 and 2002

Data Source: Not specified

Sample Size: Total (n=586) Intervention (n=291) Control (n=295)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): Referrals, Administration/Practice Management, Quality Improvement, HOSPITAL, PATIENT_CONSUMER, Patient Reminder/Invitation, HEALTH_CARE_PROVIDER_PRACTICE, EMR Reminder

Intervention Description: Researchers implemented process changes in 3 phases: phase 1, changing the screening instrument and adding decision support; phase 2, adding automatic reminders; and phase 3, adding a referral option for autism evaluations in primary care. We analyzed the proportion of visits with autism screening at 2 intervention clinics before and after implementation of process changes versus 27 community clinics (which received only automatic reminders in phase 2) with χ2 test and interrupted time series.

Intervention Results: In 12 233 visits over 2 years (baseline and phased improvements), autism screening increased by 52% in intervention clinics (58.6%-88.8%; P < .001) and 21% in community clinics (43.4%-52.4%; P < .001). In phase 1, interrupted time series trend for screening in intervention clinics increased by 2% per week (95% confidence interval [CI]: 1.1% to 2.9%) and did not increase in community clinics. In phase 2, screening in the community clinics increased by 0.46% per week (95% CI: 0.03% to 0.89%). In phase 3, the intervention clinic providers referred patients for diagnostic evaluation 3.4 times more frequently (95% CI: 2.0 to 5.8) than at baseline.

Conclusion: We improved autism screening and referrals by changing the screening instrument, adding decision support, using automatic reminders, and offering autism evaluation in primary care in intervention clinics. Automatic reminders alone improved screening in community clinics.

Setting: Pediatric and community clinics

Population of Focus: Pediatricians and staff

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, PROFESSIONAL_CAREGIVER, Education/Training (caregiver)

Intervention Description: Research staff from a single maternity ward recruited 184 mothers and their term newborns to participate in this randomized controlled trial to assess whether a patient portal could be used to provide personalized safe sleep care. The portal is capable of supporting two-way information sharing and communication between providers and families. Feasibility of the study was measured by a) the proportion of consenting mothers who enrolled in the portal and b) maternal adherence to prompts to submit photographs of their infant sleeping to the research team through the patient portal. Efficacy was determined via research assistant review of submitted photographs. The assistants were trained to detect sudden unexplained infant death risk factors, including sleep position, based on AAP guidelines. Standardized feedback was returned to mothers through the patient portal.

Intervention Results: One hundred nine mothers (59%) enrolled in the patient portal and were randomized to intervention (N = 55) and control (N = 54) groups. 21 (38, 95% CI 25-52%) intervention group participants sent photographs at 1 month and received personalized feedback. Across both groups at 2 months, 40 (37, 95% CI 28-46%) sent photographs; 56% of intervention group participants who submitted photographs met all safe sleep criteria compared with 46% of controls (difference 0.10, 95% CI - 0.26 to 0.46, p = .75). Common reasons for guideline non-adherence were sleeping in a room without a caregiver (43%), loose bedding (15%) and objects (8%) on the sleep surface.

Conclusion: Utilizing the patient portal to individualize safe infant sleep is possible, however, we encountered numerous barriers in this trial to assess its effects on promoting safe infant sleep. Photographs of infants sleeping showed substantial non-adherence to AAP guidelines, suggesting further needs for improvement to promote safe infant sleep practices.

Setting: Single maternity ward, Penn State Milton S. Hershey Medical Center

Population of Focus: Mothers and their term newborns

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage, HEALTH_CARE_PROVIDER_PRACTICE, Care Coordination, Public Insurance (Health Care Provider/Practice)

Intervention Description: The Coordinated Healthcare for Complex Kids (CHECK) model takes a broad approach to care coordination and health promotion by addressing social determinants of health, caregiver wellness, and mental health needs, in addition to chronic disease management, for children and youth with chronic health conditions. Community health workers deliver care coordination and assess individual and family needs, as well as patterns of health care utilization, to determine specific services offered to each family. The program is focused on lowering health care costs, especially regarding emergency department admissions, of pediatric patients with chronic health conditions.

Intervention Results: Overall Medicaid expenditures and utilization decreased considerably during the first year of the CHECK program for both participants and the usual care group. Notably, expenditures did not increase among CHECK participants, which has been noted in other care coordination programs. The rate of inpatient and ED utilization decreased for both groups. The mean (SD) inpatient utilization before enrollment in CHECK was 63.0 (344.4) per 1000 PYs for the intervention group and 69.3 (370.9) per 1000 PYs for the usual care group, which decreased to 43.5 (297.2) per 1000 PYs and 47.8 (304.9) per 1000 PYs, respectively, after the intervention.

Conclusion: Overall Medicaid expenditures and health care utilization (hospital and ED) decreased similarly for both CHECK participants and the usual care group.

Study Design: RCT

Setting: Community (Coordinated Healthcare for Complex Kids (CHECK) program; Illinois Medicaid)

Population of Focus: Children and young adults with chronic disease who receive public insurance

Data Source: Illinois Medicaid paid claims for CHECK participants using the Care Coordination Claims Data (CCCD) provided by the Illinois Department of Healthcare and Family Services

Sample Size: 6,245 children and young adults (3,119 in the control group and 3,126 in the intervention group)

Age Range: Children <1 and youth >18 (mean age was 11.3 years)

Intervention Components (click on component to see a list of all articles that use that intervention): Provider Training/Education, Home Visit (caregiver), PROFESSIONAL_CAREGIVER, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: This study evaluated the efficacy of a program to train home visitors to talk to clients about infant safe sleep using Motivational Interviewing and cultural sensitivity.

Intervention Results: Home visitors showed significant improvement in MI skill use and cultural sensitivity from pre- to post-test. Regarding client outcomes, our results indicate a significant group by time interaction when predicting changes in client knowledge such that the treatment group showed larger gains than the control group. There were no significant differences between groups when predicting changes in client attitudes or behavior.

Conclusion: MI may be an effective technique for home visitors to help increase families' safe sleep knowledge. Additional research is needed to examine whether such training can translate to changes in families' safe sleep behavior.

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, PROFESSIONAL_CAREGIVER, Education/Training (caregiver), Home Visit (caregiver)

Intervention Description: This study evaluated the efficacy of a program to train home visitors to talk to clients about infant safe sleep using Motivational Interviewing and cultural sensitivity. Conducted as part of the initiative by Cradle Kalamazoo initiative to decrease racial disparities in infant mortality, home visitors attended a 2-day training that incorporated MI skills, cultural sensitivity, and safe sleep information. The MI training was conducted by a licensed Ph.D.-level psychologist as well as a second-year doctoral student in clinical psychology with 1 year of experience conducting clinical work. Home visitor outcomes were assessed using a pre-post design that included self reporting (based on a 16-question safe sleep knowledge questionnaire) and an observational rating by a paid “community mother.” When assessing client outcomes, a quasi-experimental design was used to examine changes in knowledge, attitudes, and safe sleep practices (Fig. 1). The home visitors administered the safe sleep survey to two different groups. The intervention group included 31 clients of home visitors who completed the training. The control group included 44 clients of home visitors who had not completed the training.

Intervention Results: Home visitors showed significant improvement in MI skill use and cultural sensitivity from pre- to post-test. Regarding client outcomes, our results indicate a significant group by time interaction when predicting changes in client knowledge such that the treatment group showed larger gains than the control group. There were no significant differences between groups when predicting changes in client attitudes or behavior.

Conclusion: MI may be an effective technique for home visitors to help increase families' safe sleep knowledge. Additional research is needed to examine whether such training can translate to changes in families' safe sleep behavior.

Setting: Cradle Kalamazoo initiative in Kalamazoo, Michigan

Population of Focus: Home visitors and their clients

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage, HEALTH_CARE_PROVIDER_PRACTICE, Public Insurance (Health Care Provider/Practice), Educational Material (Provider), Collaboration with Local Agencies (State), Collaboration with Local Agencies (Health Care Provider/Practice), Nurse/Nurse Practitioner, PROFESSIONAL_CAREGIVER, Patient Navigation (Assistance), Care Coordination, STATE, Multicomponent Approach

Intervention Description: The Healthy Beginnings system of care in Atlanta, GA connects children and their families to health insurance and a medical home model of care to support children’s health and development. The main components are care management + education and parent engagement + collaborative partnerships. A registered nurse, known as the health navigator, supports parents and helps them learn how to work with health care professionals on behalf of their children; they also connect parents to the Center for Working Families to ensure that they receive public benefits for which they are eligible.

Intervention Results: Healthy Beginnings coordinated care approach has ensured that participating children and families have health insurance (97%) and receive regular immunizations (92%), ongoing health care from a primary care physician and dental health provider, and regular developmental screenings (98%) and follow-up care. Healthy Beginnings has dramatically increased children’s access to health care and forms the basis for a cost-effective approach that can be replicated in other communities.

Conclusion: By building upon the partnerships formed through the foundation’s community change effort, Healthy Beginnings has dramatically increased neighborhood children’s access to health care and forms the basis for a cost-effective approach that can be replicated in other communities.

Study Design: Program evaluation

Setting: Community (Community-based organizations in Atlanta, Georgia)

Population of Focus: Low-income young children and families

Data Source: Questionnaire data

Sample Size: 279 children

Age Range: 0-10 years

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): Educational Material, PATIENT_CONSUMER, Community Events, COMMUNITY, Nurse/Nurse Practitioner, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: The study aimed to evaluate the effectiveness of a cervical cancer prevention education program for rural Korean immigrant women. A total of 46 Korean immigrant women who had not been screened in the past three years participated. The experimental group participated in the intervention program once a week for four weeks and completed a post-program survey in week 12.

Intervention Results: The experimental group participated in the intervention program once a week for four weeks and completed a post-program survey in week 12. Compared to the control group, significant increases were detected in level of knowledge of cervical cancer prevention (p = .001), behavioral attitude toward cervical cancer prevention (p = .029) and behavioral intention regarding cervical cancer prevention (p = .005) in the experimental group. Pap screening rate of the experimental group was significantly increased (p = .029), but the rate of change in the selection of primary care providers was not significant.

Conclusion: The results suggest the need for a multilevel approach to address cultural and systemic barriers to Korean immigrant women in promotion of cervical cancer prevention behavior.

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Active Management of Labor

Intervention Description: This was a secondary analysis of the Consortium on Safe Labor data set to examine whether there is a threshold of oxytocin exposure at which the risk for primary cesarean increases among women who are nulliparous with a term, singleton, vertex fetus (NTSV) and how oxytocin interacts with other risk factors to contribute to this outcome. The sample comprised 17,331 women who were exposed to oxytocin during labor.

Intervention Results: The sample comprised 17,331 women who were exposed to oxytocin during labor. The women were predominantly white non-Hispanic (59.2%) with an average (SD) gestational age of 39.4 (1.1) weeks and an 18.5% primary cesarean rate. Exposure to greater than 11,400-milliunits (mU) of oxytocin resulted in 1.6 times increased odds of primary cesarean birth compared with less than 11,400 mU (95% CI 1.01-2.6).

Conclusion: Exposure to greater than 11,400 mU of oxytocin in labor was associated with an increased odds of primary cesarean birth in NTSV women.

Setting: Electronic medical records from 19 U.S. hospitals (Consortium on Safe Labor data set)

Population of Focus: Nulliparous women with term singleton vertex gestations

Intervention Components (click on component to see a list of all articles that use that intervention): Notification/Information Materials (Online Resources, Information Guide), Other Education, Patient-Centered Medical Home, PATIENT_CONSUMER, PARENT_FAMILY, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: The purpose of this study was to establish a healthy weight management support group in a pediatric patient-centered medical home.

Intervention Results: There was a significant improvement in fruit and vegetable intake and dining out (p = <.05), and a clinical improvement in physical activity and sugar sweetened beverage intake.

Conclusion: Setting Kids Up For Success provides a framework for patient-centered medical home's to provide a healthy lifestyle support group for SA children and their families.

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

Intervention Description: To increase consistency of breastfeeding care and interventions across a large primary care network, we established an Ambulatory Breastfeeding Consortium (ABC) focused on information sharing and discussion centered on care of breastfeeding and lactating families.

Intervention Results: The ABC has been effective in engaging primary care nurses and other clinicians and disseminating information while encouraging discussion on the importance of providing informed care to breastfeeding families.

Conclusion: Although more breastfeeding-specific education is recommended for clinicians, the ABC serves as a model for primary care clinicians to improve their knowledge and provide support for families through education, shared experience, and awareness across many pediatric primary care network sites.

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): HEALTH_CARE_PROVIDER_PRACTICE, Hospital Policies, Baby Friendly Hospital Initiative,

Intervention Description: Maternity care practices influence breastfeeding outcomes long after women leave the birth setting. We conducted this study to describe, from mothers' perspective, maternity care practices associated with breastfeeding at 3 and 6 months. Six study sites were either designated as Baby-Friendly or were in the process of achieving this designation.

Intervention Results: Our multisite study supports implementing low cost and evidence-based interventions such as immediate and uninterrupted SSC and rooming in to improve breastfeeding exclusivity.

Conclusion: Findings highlight the ongoing need to bridge the gap between hospital discharge and community breastfeeding support, including workplace accommodations.

Study Design: Cross sectional descriptive replication study

Setting: Two large academic medical centers, one in the Northeast and two in the South-central region of the US, and two smaller teaching hospitals and community hospitals in the Northeast and South-central region of the US

Population of Focus: Women who gave birth during the data collection period at each study site

Sample Size: 672 women

Age Range: Women ages 18-48

Intervention Components (click on component to see a list of all articles that use that intervention): Education on Disease/Condition, Planning for Transition, HEALTH_CARE_PROVIDER_PRACTICE, YOUTH

Intervention Description: This study aimed to evaluate the transition to adult care program instituted for liver transplant recipients (LTRs) at a large tertiary pediatric hospital in Melbourne, Australia.

Intervention Results: Twenty-eight LTRs participated in the study; 20 received the transition intervention and 8 served as controls. Within the intervention group, all domains of transition competency and reported anxiety regarding transferring had significantly improved at the conclusion of the intervention and all reported satisfaction with the transition program with most (81%) reporting readiness to transfer. There were no significant differences in rejection rates or failure to attend rates between those who did and did not receive the transition intervention.

Conclusion: A longitudinal holistic transition program has the potential to positively impact the competencies and readiness of LTRs to successful transition and transfer to adult care.

Intervention Components (click on component to see a list of all articles that use that intervention): Public Insurance (Health Care Provider/Practice), Quality Improvement/Practice-Wide Intervention, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: To evaluate child-level dental utilization and expenditure outcomes based on if and where children received fluoride varnish (FV) at quality improvement (QI) medical practices, at non-QI medical practices, at dental practices, or those who never received FV from any practice.

Intervention Results: The QI group had a significantly higher incidence of preventive dental visits than the dental (incidence rate ratio [IRR] = 0.93; 95% confidence interval [CI], 0.91-0.96) or non-QI groups (IRR = 0.86; 95% CI, 0.84-0.88). Compared with the QI group, the non-QI (adjusted odds ratio [aOR] = 2.6; 95% CI, 2.4-2.9) and dental (aOR = 2.9; 95% CI, 2.6-3.3) groups were significantly more likely to have caries-related treatment visits. The dental group children were significantly more likely to have dental treatment under GA than the QI group (aOR = 5.3; 95% CI, 2.0-14.4).

Conclusion: Children seen at QI practices appear to have an increased uptake of preventive dental services, which may explain the lower incidence of dental caries visits and GA treatment.

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): Planning for Transition, , HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: This quality improvement (QI) project aimed to improve the transition readiness process for all adolescents aged 14-18 at health care maintenance visits.

Intervention Results: Over the course of 36 months the outcome measure of provider documented transition readiness discussions increased from 19 to 64% of the time. Over the same course of time, the process measures of transition brochure distribution and completion of the readiness assessment tool increased from 0 to 94% and 0 to 84% respectively.

Conclusion: QI methodology and multidisciplinary coordinating to streamline workflow, distribution of transition information, readiness assessment and provider discussion and documentation can be successfully incorporated into a busy primary care setting. By formalizing and standardizing the transition readiness process, pediatric providers can improve young adults' readiness to transition to adult medical care.

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

Intervention Description: This study was designed to assess the impact of selected medical interventions during labor upon cesarean section rates by comparing the maternal and neonatal outcomes of obstetrician- and nurse-midwife-managed low-risk private patients.

Intervention Results: Nurse-midwife-managed patients had a significantly lower rate of cesarean section (8.5% versus 12.9%; P < .005) and operative vaginal delivery (5.3% versus 17%, P = .0001) than the physician-managed patients. Epidural anesthesia and oxytocin for induction and augmentation were used significantly more frequently in the physician-managed patients. Both interventions were associated with an increased rate of cesarean section. Fetal outcomes in the two groups were not statistically different.

Conclusion: Women cared for by nurse-midwives had a lower cesarean section rate, fewer interventions, and equally good maternal and infant outcomes when compared with those cared for by physicians.

Study Design: Retrospective cohort

Setting: 1 women’s hospital in Illinois

Population of Focus: Nulliparous women who gave birth between January 1987 and December 19902

Data Source: Not specified

Sample Size: Total (n=4,827) Intervention (n=322) Control (n=4,505)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage, HEALTH_CARE_PROVIDER_PRACTICE, Public Insurance (Health Care Provider/Practice), STATE, Perinatal Committees/Councils

Intervention Description: Numerous states have implemented policies expanding public insurance eligibility or subsidizing private insurance for parents. Under the ACA, states retain significant flexibility in terms of eligibility and program structure. Approaches to state-level expansions to parents include providing public health insurance with or without an enrollee premium and providing subsidies for private health insurance. The Oregon Experiment (Medicaid expansion) gave a subset of uninsured, low-income adults access to Medicaid through a randomized selection process.

Intervention Results: Children’s odds of having Medicaid or CHIP coverage increased when their parents were randomly selected to apply for Medicaid; findings demonstrate a causal link between parents’ access to Medicaid coverage and their children’s coverage. Children whose parents were randomly selected to apply for Medicaid had 18% higher odds of being covered in the first 6 months after parent’s selection compared with children whose parents were not selected. In the immediate period after selection, children whose parents were selected to apply for Medicaid significantly increased from 3830 (61.4%) to 4152 (66.6%) compared with a non-significant change from 5049 (61.8%) to 5044 (61.7%) for children whose parents were not selected to apply. The effect remained significant during months 7 to 12; months 13 to 18 showed a positive but not significant effect. Children whose parents were selected and obtained coverage had more than double the odds of having coverage compared with children whose parents were not selected and did not gain coverage.

Conclusion: Children’s odds of having Medicaid or CHIP coverage increased when their parents were randomly selected to apply for Medicaid. Children whose parents were selected and subsequently obtained coverage benefited most. This study demonstrates a causal link between parents’ access to Medicaid coverage and their children’s coverage.

Study Design: Randomized natural experiment; generalized estimating equation models

Setting: Policy (Oregon Medicaid expansion program)

Population of Focus: Children whose parents participated in the Oregon Experiment (Medicaid expansion program)

Data Source: The Oregon Experiment’s reservation list data; Oregon Health Plan (OHP) administrative data

Sample Size: 14,409 children

Age Range: 2-18 Years

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): HEALTH_CARE_PROVIDER_PRACTICE, Nurse/Nurse Practitioner, Planning for Transition, Pediatric to Adult Transfer Assistance, Care Coordination, Quality Improvement/Practice-Wide Intervention

Intervention Description: This quantitative descriptive study used a survey questionnaire to investigate nurses' role and responsibilities in health care transition planning (HCTP) for youth and young adults with chronic illness and/or disability. The survey looked at respondents' role in health care transition planning (HCTP), inclusion of HCTP in job description, levels of HCTP knowledge, and ratings of importance of HCTP elements.

Intervention Results: Over 64% of respondents performed HCTP activities related to complex chronic illness management. Only 18% reported specialized training in HCTP. The highest-ranking items in regard to perceived importance were educating and supporting disease self-management and speaking with families about complex needs. Predictors of perceived importance were role, inclusion of transition planning in a job description, percentage of time in direct care, caring for those aged 14 years and older, and level of knowledge about HCTP.

Conclusion: The findings highlight key aspects of the pediatric nurse role in HCTP and identify specific elements that can be addressed to support future HCTP role development.

Study Design: Quantitative descriptive methodology

Setting: Hospitals/Clinics

Population of Focus: Pediatric nurses

Sample Size: 1814

Age Range: Adults

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, , Baby Friendly Hospital Initiative

Intervention Description: In October 2012, the Maryland State Department of Health launched the Maryland Hospital Breastfeeding Policy Recommendations, which included best practices in mother-baby care, and encouraged all birthing hospitals to adopt evidence-based practices to promote breastfeeding. In 2016, four Maryland hospitals were newly designated as Baby-Friendly and were located in southern, central, and northeastern Maryland. The study evaluated whether the receipt of specific Steps was associated with breastfeeding practices through 6 months in the Maryland WIC.

Intervention Results: Reported adherence to 10-Steps policies ranged from 10%–85% (lowest for Step 9, highest for Step 10) and only Step 9 (give no pacifiers or artificial nipples to breastfeeding infants) differed according to Baby-Friendly Hospital status. Greater exposure to the 10 Steps was positively associated with exclusive breastfeeding during hospitalization. The lack of perceived adherence to Step 6 (no food or drink other than human milk), Step 9, and the International Code of Marketing of Breast-milk Substitutes (no formula, bottles, or artificial nipples) significantly decreased the likelihood of exclusive breastfeeding through 6 months.

Conclusion: Maternal perception of Baby-Friendly Step adherence was associated with exclusive breastfeeding.

Study Design: Cross-sectional 2 group comparison study

Setting: WIC Program and community hospitals in southern, central, and northeastern Maryland

Population of Focus: Postpartum women recruited through WIC clinics

Sample Size: 182 women

Age Range: Mothers older than 18 years of age

Intervention Components (click on component to see a list of all articles that use that intervention): Baby Friendly Hospital Initiative, HEALTH_CARE_PROVIDER_PRACTICE, ,

Intervention Description: (1) To compare maternal perceptions about maternity practices in Baby-Friendly Hospitals and non-Baby-Friendly Hospitals; (2) to evaluate the associations between degree of exposure to the Baby-Friendly 10 Steps and breastfeeding practices through the first 6 months; and (3) to evaluate whether the receipt of specific Steps was associated with breastfeeding practices through 6 months.

Intervention Results: Reported adherence to 10-Steps policies ranged from 10%–85% (lowest for Step 9, highest for Step 10) and only Step 9 (give no pacifiers or artificial nipples to breastfeeding infants) differed according to Baby-Friendly Hospital status. Greater exposure to the 10 Steps was positively associated with exclusive breastfeeding during hospitalization. The lack of perceived adherence to Step 6 (no food or drink other than human milk), Step 9, and the International Code of Marketing of Breast-milk Substitutes (no formula, bottles, or artificial nipples) significantly decreased the likelihood of exclusive breastfeeding through 6 months.

Conclusion: Maternal perception of Baby-Friendly Step adherence was associated with exclusive breastfeeding.

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Provider Training/Education, Educational Material (Provider), Expert Support (Provider), Participation Incentives, Modified Billing Practices, Data Collection Training for Staff, Screening Tool Implementation Training, Office Systems Assessments and Implementation Training, Expert Feedback Using the Plan-Do-Study-Act-Tool, Collaboration with Local Agencies (State), Collaboration with Local Agencies (Health Care Provider/Practice), Engagement with Payers, STATE, POPULATION-BASED SYSTEMS, Audit/Attestation, HEALTH_CARE_PROVIDER_PRACTICE, Audit/Attestation (Provider)

Intervention Description: Early identification of children with developmental and behavioral delays is important in primary care practice, and well-child visits provide an ideal opportunity to engage parents and perform periodic screening. Integration of this activity into office process and flow is necessary for making screening a routine and consistent part of primary care practice.

Intervention Results: In the North Carolina Assuring Better Child Health and Development Project, careful attention to and training for office process has resulted in a significant increase in screening rates to >70% of the designated well-child visits. The data from the project prompted a change in Medicaid policy, and screening is now statewide in primary practices that perform Early Periodic Screening, Diagnosis, and Treatment examinations.

Conclusion: Although there are features of the project that are unique to North Carolina, there are also elements that are transferable to any practice or state interested in integrating child development services into the medical home.

Study Design: QE: pretest-posttest

Setting: Partnership for Health Management, a network within Community Care of North Carolina

Population of Focus: Children ages 6 to 60 months receiving Early Periodic Screening, Diagnosis, and Treatment services

Data Source: Child medical record

Sample Size: Unknown number of charts – screening rates tracked in 2 counties (>20,000 screens by 2004)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Peer Counselor, Assessment (PATIENT_CONSUMER), Professional Support, HEALTH_CARE_PROVIDER_PRACTICE, Other (Provider Practice), COMMUNITY, Social Supports, Individual Supports,

Intervention Description: In 2014, the New York State WIC program launched the You Can Do it (YCDI) initiative in 12 WIC clinics. This multicomponent intevention, which was originally developed by the Vermont WIC program, was designed to improve participants' knowledge, attitudes, confidence, and social support to breastfeed exclusively through a screening and tailored counseling protocol combined with peer counselor and professional support spanning the prenatal and early postpartum periods. This multicomponent intervention paired with a yearlong learning community in the 12 clinics.

Intervention Results: Prevalence of exclusive BF at 7 and 30 days was significantly higher among BAPT women compared with non-BAPT or baseline cohorts. Non-Hispanic black and Hispanic women in the BAPT cohort achieved significantly higher exclusive BF rates at 30 and 60 days compared with those in non-BAPT and baseline cohorts.

Conclusion: The initiative seems to be effective at increasing exclusive BF, particularly among non-Hispanic black and Hispanic women in the New York State WIC program.

Study Design: Quasi-experimental study

Setting: 12 WIC clinics in New York State

Population of Focus: Prenatal women enrolled in WIC during the first trimester of pregnancy who intended to breastfeed or were undecided

Sample Size: Baseline cohort of 688 mother-infant dyads and two intervention cohorts: Breastfeeding Attrition Prediction Tool (BAPT) (n=362 monther-infant dyads) and non-BAPT (n=347 mother-infant dyads); 12 WIC clinics; 47 WIC staff members

Age Range: Women 18 years and older

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

Intervention Description: The aim of the present study was to compare intervention rates associated with labour in low-risk women who begin their labour in a midwife-led unit and a conventional care unit.

Intervention Results: Emergency caesarean and instrumental delivery rates in women who were admitted to the midwife-led and conventional birth wards were statistically non-different, but more women admitted to the conventional birth ward had episiotomy. More women in the conventional delivery ward received epidural analgesia, pudental nerve block and nitrous oxide, while more women in the midwife-led ward received opiates and non-pharmacological pain relief.

Conclusion: We did not find evidence that starting delivery in the midwife-led setting offers the advantage of lower operative delivery rates. However, epidural analgesia, pudental nerve block and episiotomies were less often while non-pharmacological pain relief was often used in the midwife-led ward.

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

Setting: 1 university hospital

Population of Focus: Nulliparous women who gave birth between November 2001-May 2002 (intervention group) and October 2002 (control group) and did not express desire for epidural analgesia at admission to hospital3

Data Source: Not specified

Sample Size: Total (n=453) Intervention (n=252) Control (n=201)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Training/Education, Educational Material (provider), Audit/Attestation (provider), PROFESSIONAL_CAREGIVER, Education/Training (caregiver), HOSPITAL, Quality Improvement, Crib Card

Intervention Description: This quality improvement project used an interprofessional, multimodal approach to improve sleep safety for hospitalized infants. The working group for this project included the Director of Quality Improvement for the Department of Pediatrics, a Pediatric Hospitalist, a Senior Advanced Practice Nurse in Pediatrics, Senior Associate Counsel for the Office of Counsel, and a medical student with a background in social work. The interdisciplinary group met to review and discuss improvements to communication and facilitated the development of five family interventions: a designated safe sleep web page, a clear bedside guide to safe sleep, additional training for nursing staff in motivational interviewing, a card audit system, and electronic health record smart phrases. A short survey was conducted to assess how the safe sleep toolkit has been useful to care providers in the Children’s Hospital. 

Intervention Results: With the initial pilot implementation of the K-cards, staff reported increased ease of audits. Adherence to recommended safer sleep measures was a major barrier in previous attempts to improve institutional sleep safety (1). By making adherence easier, providers may be more likely to both participate in quality improvement tracking measures and follow-up with families directly.

Conclusion: These coordinated interventions reflect advantages of an interprofessional and family-centered approach: building rapport and achieving improvements to infant sleep safety.

Setting: Golisano Children’s Hospital

Population of Focus: Hospital healthcare providers

Intervention Components (click on component to see a list of all articles that use that intervention): Other Person-to-Person Education, PATIENT_CONSUMER, Educational Material, Provider Training/Education, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: This study was a controlled trial study with longitudinal design. The sample consisted of 156 women (intervention = 78, control = 78) who registered in hearing-impaired associations in Izmir, Turkey. The education about cervical cancer and Pap smear test was given to intervention group with face-to-face interviews by using Turkish sign language. Three months later, the women were contacted and asked whether they have had a Pap smear test, and the total knowledge score of intervention groups was evaluated.

Intervention Results: There was not a statistically significant difference between the mean total score of knowledge about cervical cancer and Pap smear test in intervention (0.6 ± 1.6) and control (1.1 ± 1.9) groups. After 3 months, having a Pap smear test was found to be statistically significantly higher between groups (intervention = 29.5%, control = %1.2), and the mean cervical cancer and Pap smear knowledge score of the intervention group (9.2 ± 1.4) was found to be statistically significantly higher than the score before education (0.6 ± 1.6).

Conclusion: Education of cervical cancer and Pap smear test increased knowledge level and behaviour of Pap smear test of the women.

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): Patient Navigation , Referrals, PATIENT_CONSUMER, Educational Material (Provider), HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: We pilot tested a Perinatal Wellness Navigator (PWN) program for a group of high-risk perinatal women (N = 50; n = 42 with OUD) that consisted of (a) one-on-one tobacco treatment, (b) comprehensive assessment of cessation barriers, and (c) linkage to clinical/social services.

Intervention Results: Outcome measures were assessed at baseline and postintervention. Participants smoked 10 fewer cigarettes per day (p = .05) at postintervention and were less dependent on nicotine (p < .01). Mean postnatal depression scores (p = .03) and perceived stress (p = .03) decreased postintervention. Participants received at least one referral at baseline (n = 106 total), and 10 participants received an additional 18 referrals at postintervention to address cessation barriers.

Conclusion: The PWN program was minimally effective in promoting total tobacco abstinence in a high-risk group of perinatal women, but participants experienced reductions in cigarettes smoked per day, nicotine dependence, stress, and depression.

Intervention Components (click on component to see a list of all articles that use that intervention): Assessment, Referrals, YOUTH, PATIENT_CONSUMER, Educational Material (Provider), HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: To develop, implement, and assess implementation outcomes for a developmental monitoring and referral program for children in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

Intervention Results: In both phases, all surveyed staff (n = 46) agreed the program was easy to use. Most (≥ 80%) agreed that checklists fit easily into clinic workflow and required ≤ 5 min to complete. Staff (≥ 55%) indicated using checklists with ≥ 75% of their clients. 92% or more reported referring one or more children with potential developmental concerns. According to 80% of staff, parents indicated checklists helped them learn about development and planned to share them with healthcare providers. During the second phase, 18 of 20 staff surveyed indicated the program helped them learn when to refer children and how to support parents, and 19 felt the program promoted healthy development. Focus groups supported survey findings, and all clinics planned to sustain the program.

Conclusion: Initial implementation outcomes supported this approach to developmental monitoring and referral in WIC. The program has potential to help low-income parents identify possible concerns and access support.

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): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Quality Improvement/Practice-Wide Intervention, Baby Friendly Hospital Initiative,

Intervention Description: The Best Fed Beginnings (BFB) initiative was specifically aimed to enable 90 hospitals to earn Baby-Friendly USA assessment scheduled by the end of the collaborative project. Given the size of this initiative, BFB was conducted as 3 simultaneous Breakthrough Series collaborative projects comprising hospitals from 3 geographic regions. Hospitals assembled multidisciplinary teams that included parent partners and community representatives. Three in-person learning sessions were interspersed with remote learning and tests of change, and a Web-based platform housed resources and data for widespread sharing.

Intervention Results: By April 2016, a total of 72 (80%) of the 90 hospitals received the Baby-Friendly designation, nearly doubling the number of designated hospitals in the United States. Participation in the Best Fed Beginnings initiative had significantly high correlation with designation compared with hospital applicants not in the program (Pearson’s r [235]: 0.80; P < .01). Overall breastfeeding increased from 79% to 83% (t = 1.93; P = .057), and exclusive breastfeeding increased from 39% to 61% (t = 9.72; P < .001).

Conclusion: A nationwide initiative of maternity care hospitals accomplished rapid transformative changes to achieve Baby-Friendly designation. These changes were accompanied by a significant increase in exclusive breastfeeding.

Study Design: Evaluation data

Setting: Hospitals nationwide

Population of Focus: Hospitals across the country seeking to achieve Baby-Friendly designation

Sample Size: 90 Baby-Friendly Hospitals

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage, HEALTH_CARE_PROVIDER_PRACTICE, Public Insurance (Health Care Provider/Practice), Educational Material (Provider), PARENT_FAMILY, Training (Parent/Family), PROFESSIONAL_CAREGIVER, Outreach (caregiver), PATIENT_CONSUMER, Peer Counselor, Parent Mentors

Intervention Description: The aim of the Kids’ Health Insurance by Educating Lots of Parents (Kids’ HELP) study was to evaluate the effects of parent mentors – Latino parents with children covered by Medicaid or the Children’s Health Insurance Program (CHIP) – on insuring Latino children in a community-based trial of uninsured children from 2011-2015. Parent mentors were trained to assist families in getting insurance coverage, accessing health care, and addressing social determinants of health. The intervention group was assigned parent mentors – trained, fluently bilingual Latino parents who had at least one child insured by Medicaid or CHIP for at least one year. Parent mentors attended a two-day training and received training manuals in English and Spanish with 9 training topics and one on sharing experiences. Parents mentors provided 8 services to intervention children and families (e.g., teaching about types of insurance programs and application processes; helping parents complete and submit children’s insurance applications; acting as family advocates by liaising between families and Medicaid or CHIP agencies; and helping parents complete and submit applications for coverage renewal).

Intervention Results: The study found that parent mentors were more effective than traditional methods in insuring children (95% vs. 69%), achieving faster coverage and greater parental satisfaction, reducing unmet health care needs, providing children with primary care providers, and improving the quality of well-child and subspecialty care. Children in the parent-mentor group had higher quality of overall and specialty care, lower out-of-pocket spending, and higher rates of coverage two years after the end of the intervention (100% vs. 70%). Parent mentors are highly effective in insuring uninsured Latino children and eliminating disparities. Parent mentors, as a special category of community health workers, could be an excellent fit with and complement to current state community health worker models. This RCT documented that the Kids’ HELP intervention is significantly more efficacious than traditional Medicaid and CHIP methods of insuring Latino children. Kids’ HELP eliminates coverage disparities for Latino children, insures children more quickly and with greater parental satisfaction than among control parents, enhances health care access, reduces unmet needs, improves the quality of well-child and subspecialty care, reduces out-of-pocket spending and family financial burden, empowers parents, ad creates jobs.

Conclusion: Parent mentors are highly effective in insuring uninsured Latino children and eliminating disparities.

Study Design: RCT

Setting: Community (Communities in Dallas County, Texas with the highest proportions of uninsured and low-income minority children)

Population of Focus: Uninsured children 0-18 years old whose primary caregiver identified them as Latino and uninsured and reported meeting Medicaid/CHIP eligibility criteria for the child

Data Source: Kids’ HELP trial data; questionnaires

Sample Size: 155 subjects (children and parents); 75 in the control group and 80 in the intervention group

Age Range: 0-18 years

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage, HEALTH_CARE_PROVIDER_PRACTICE, Public Insurance (Health Care Provider/Practice), Educational Material (Provider), PARENT_FAMILY, Training (Parent/Family), PROFESSIONAL_CAREGIVER, Outreach (caregiver), PATIENT_CONSUMER, Peer Counselor, Parent Mentors

Intervention Description: This study examined the effects of parent mentors on insuring minority children in the Kids’ Health Insurance by Educating Lots of Parents (Kids’ HELP) program. Parent mentors were experienced parents with ≥1 Medicaid/CHIP-covered child who received 2 days of training, then assisted families for 1 year with insurance applications, retaining coverage, medical homes, and social needs; controls received traditional Medicaid/CHIP outreach. Parent mentors received monthly stipends for each family mentored. Parents mentors and intervention participants were matched by race/ethnicity and zip code, whenever possible. Latino families were matched with fluently bilingual Latino parent mentors. Session content for the 2-day training was based on training provided to community case managers in the research team’s previous successful RCT and addressed 9 topics (e.g., why health insurance is so important; being a successful parent mentor; parent mentor responsibilities; Medicaid and CHIP programs and the application process; the importance of medical homes).

Intervention Results: In the Kids’ HELP trial, the intervention was more effective than traditional outreach/enrollment in insuring uninsured minority children, resulting in 95% of children obtaining insurance vs. 68% of controls. The intervention also insured children faster, and was more effective in renewing coverage, improving access to medical and dental care, reducing out-of-pocket costs, achieving parental satisfaction and quality of care, and sustaining insurance after intervention cessation. This is the first RCT to evaluate the effectiveness of parent mentors in insuring uninsured children. Kids’ HELP could possibly save $12.1 to $14.1 billion. Parent mentors were more effective in improving access to primary, dental, and specialty care; reducing unmet needs, achieving parental satisfaction with care, and sustaining long-term coverage. Parent mentors resulted in lower out-of-pocket costs for doctor and sick visits, higher well-child care quality ratings, and higher levels of parental satisfaction and respect from children’s physicians.

Conclusion: PMs are more effective than traditional Medicaid/CHIP methods in insuring uninsured minority children, improving health care access, and achieving parental satisfaction, but are inexpensive and highly cost-effective.

Study Design: RCT

Setting: Community (Communities in Dallas County, Texas with the highest proportions of uninsured and low-income minority children)

Population of Focus: Primary caregiver had ≥1 child 0 to 18 years old who lacked health insurance but was Medicaid/CHIP eligible, and the primary caregiver self-identified the child as Latino/Hispanic or African-American

Data Source: Kids’ HELP trial data; questionnaires; national, state, and regional surveys

Sample Size: 237 participants; 114 in the control group and 123 in the intervention group

Age Range: 0-18 years

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, Office Systems Assessments And Implementation Training, HEALTH_CARE_PROVIDER_PRACTICE, Audit/Attestation (Provider), Data Collection Training for Staff , Provider Training/Education

Intervention Description: This 1-year national quality improvement collaborative involved 19 pediatric primary care practices. Supported by virtual and in-person learning opportunities, practice teams implemented changes to early childhood screening. Monthly chart reviews were used to assess screening, discussion, referral, and follow-up for development, ASD, maternal depression, and SDoH. Parent surveys were used to assess parent-reported screening and referral and/or resource provision. Practice self-ratings and team surveys were used to assess practice-level changes.

Intervention Results: Participating practices included independent, academic, hospital-affiliated, and multispecialty group practices and community health centers in 12 states. The collaborative met development and ASD screening goals of >90%. Largest increases in screening occurred for maternal depression (27% to 87%; +222%; P < .001) and SDoH (26% to 76%; +231%; P < .001). Statistically significant increases in discussion of results occurred for all screening areas. For referral, significant increases were seen for development (53% to 86%; P < .001) and maternal depression (23% to 100%; P = .008). Parents also reported increased screening and referral and/or resource provision. Practice-level changes included improved systems to support screening.

Conclusion: Practices successfully implemented multiple screenings and demonstrated improvement in subsequent discussion, referral, and follow-up steps. Continued advocacy for adequate resources to support referral and follow-up is needed to translate increased screening into improved health outcomes.

Setting: Pediatric primary care practices

Population of Focus: Physician leader, staff and parent partner

Intervention Components (click on component to see a list of all articles that use that intervention): Planning for Transition, Transition Assistance, PATIENT_CONSUMER, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: Young adults with intellectual/developmental disabilities (YAIDD) are a vulnerable population during HCT due to their complex care coordination and adaptive needs, yet factors associated with transition preparedness are not well defined. We aimed to determine factors associated with health care transition (HCT) preparation satisfaction for YAIDD establishing care with an adult medical home.

Intervention Results: YADD who had HCT preparation visits with a designated HCT clinic were 9 times more likely to have met all six composite HCT criteria after controlling for the number of technologies required and race/ethnicity (adj OR 9.04, 95% CI: 4.35, 18.76) compared to those referred from the community. Compared to patients who were referred from the community, the odds of feeling very prepared versus somewhat or not prepared were 3.7 times higher (adj OR 3.73, 95% CI: 1.90, 7.32) among patients referred from a designated HCT program.

Conclusion: YAIDD who participated in a structured HCT program prior to transfer to adult care experienced higher transition preparation satisfaction. Practical implications: A structured HCT clinic model to prepare adolescents with DD for transition to adult care may improve HCT preparation satisfaction for this population.

Intervention Components (click on component to see a list of all articles that use that intervention): Baby Friendly Hospital Initiative, HEALTH_CARE_PROVIDER_PRACTICE, Professional Support,

Intervention Description: We assessed the association between BF-related hospital practices (rooming-in, support from hospital staff, and provision of a pro-formula gift pack) and the odds of any or exclusive BF through 5 mo among infants and mothers enrolled in WIC.

Intervention Results: Rooming-in and strong hospital staff support were associated with higher odds of any BF at 1, 3, and 5 mo postpartum. Provision of a pro-formula gift pack was negatively associated with any BF at all time points and with exclusive BF at 1 mo. Each additional BF-friendly hospital practice experienced was associated with 47% to 85% higher odds of any BF over the first 5 mo and 31% to 36% higher odds of exclusive BF over the first 3 mo.

Conclusion: Exposure to BF-friendly hospital practices was associated with BF beyond the hospital stay. Expanding BF-friendly policies at the hospital could increase BF rates in the United States WIC-served population.

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, HOSPITAL, Quality Improvement, Visual Display (Hospital)

Intervention Description: The purpose of this study was to improve safe sleep practice (SSP) adherence by healthcare providers working with infants admitted to an inpatient pediatric unit in an urban academic center, specifically increasing compliance on five core SSP (supine, alone in the crib, no objects in crib, appropriate bundling, and flat crib). Targeted pediatric hospitalists (attending physicians who exclusively work in the hospital setting), residents, and nurses working on the general pediatric wards were invited to complete a safe sleep survey prior to receiving a brief educational intervention tailored to their specific provider group. All participants received the same basic information on the current rates of SIDS, associated disparities, current hospital practices, AAP-endorsed safe sleep practices, and the impact of healthcare provider practices on caregivers. In-person presentations, handouts, posters, and “Ask me about safe sleep” buttons for nursing staff were among the teaching tools used. Efficacy of the intervention was assessed by comparing audits of sleeping infants in hospital rooms prior to (baseline) and following (post-intervention) the education sessions.

Intervention Results: This Quality Improvement project evaluated a staff education intervention using a pre- and post-design. Surveys of providers determined baseline SSP knowledge. Adherence to SSP in the hospital was audited before and after education. One hundred pre-intervention infant sleep placement observations were recorded and 123 were collected post-intervention.

Conclusion: This quality improvement project suggests that the inpatient setting provides opportunities for providers to demonstrate SSP but that healthcare providers often do not follow SSP in practice. Continued education can lead to improvements in SSP adherence ensuring that hospitals are modeling SSP for the families of infants.

Setting: The University of Chicago Medicine Comer Children’s Hospital

Population of Focus: Pediatric healthcare providers

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Quality Improvement/Practice-Wide Intervention

Intervention Description: Teams participated in a 7-month virtual learning collaborative to implement immunization delivery best practices at their SHCs. A pre-post-intervention design was used to compare vaccination coverage in May 2017 to May 2018 among students who were unvaccinated at the start of the academic year.

Intervention Results: Data were compared from 29 SHCs and 152,648 students (2017) and from 18 SHCs and 122,315 students (2018). Percent of newly vaccinated students increased for ≥1 dose of flu vaccine by 14.3 percentage points to 32.3% (p < .01), ≥1 dose of HPV vaccine by 3.9 points to 7.8% (p < .05) and ≥3 doses of HPV vaccine by 0.7 points to 1.5% (p < .05).

Conclusion: Participating in a learning collaborative may help SHCs improve vaccination delivery.

Setting: Student health clinics

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage, HEALTH_CARE_PROVIDER_PRACTICE, Public Insurance (Health Care Provider/Practice), PROFESSIONAL_CAREGIVER, Education/Training (caregiver), Collaboration with Local Agencies (State), Educational Material (caregiver), STATE, Multicomponent Approach

Intervention Description: In New York, to maximize comprehensive insurance coverage for CYSHCN, a Service Integration Model was formed between the Office of Health Insurance Services and the Early Intervention Program. The 3 key components include educational messaging (jointly prepared messages about health insurance benefits and enrollment assistance offered by the Office of Health Insurance Services through the Early Intervention Program) + data from program databases (data matching with the Early Intervention Program) + individual counseling using program staff (incorporation of the Office of Health Insurance Services program staff—child benefit advisors—to work directly with parents of children in the Early Intervention Program to facilitate enrollment and renewal. The model overcomes enrollment barriers by using consumer friendly enrollment materials and one-on-one assistance, and shows the benefits of a comprehensive and collaborative approach to assisting families with enrollment into public health insurance.

Intervention Results: Since 2008, more than 5,000 children in the Early Intervention Program have been successfully enrolled and coverage renewed in Medicaid through the Service Integration Model. In 2008, the study team found that children in the Early Intervention Program had a 34% churning rate for Medicaid because of enrollment barriers and misconception of the Early Intervention Program as a replacement for Medicaid. By 2010, the churning rate for clients assisted through Office of Health Insurance Services was reduced from 34% to 8%. The Office of Health Insurance Services will modify the Service Integration Model to respond to New York State’s implementation of the Health Insurance Exchange required by the 2010 ACA. Partnerships across government programs and agencies offer opportunities to enroll hard-to-reach populations into public health insurance. The model reflects how government programs can work together to improve rates of enrollment and retention in public health insurance. The key elements of integration of program messages, data matching, and staff involvement allow for the model to be tailored to the specific needs of other government programs.

Conclusion: The model overcomes enrollment barriers by using consumer-friendly enrollment materials and one-on-one assistance, and shows the benefits of a comprehensive and collaborative approach to assisting families with enrollment into public health insurance.

Study Design: Program evaluation

Setting: Community (New York City Department of Health and Mental Hygiene's Office of Health Insurance Services and the Early Intervention Program)

Population of Focus: Uninsured and underinsured young children with special health care needs in New York City participating in the Early Intervention Program

Data Source: Evaluation data

Sample Size: 6,500 children in early intervention with a Medicaid number

Age Range: 0-3 years

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

Intervention Description: To compare the benefits of one-to-one nurse labor support with the benefits of usual intrapartum nursing care in women stimulated with oxytocin.

Intervention Results: A beneficial trend because of one-to-one nurse support, with a 56% reduction in risk of total cesarean deliveries [RR of experimental vs. control = 0.44 (95% confidence interval = 0.19 to 1.01)].

Conclusion: The beneficial trend in reducing cesarean deliveries attributed to one-to-one nursing in women stimulated with oxytocin suggests that continuous support by intrapartum nursing staff may benefit women stimulated with oxytocin during labor.

Study Design: RCT

Setting: 1 women’s hospital

Population of Focus: Nulliparous women who gave birth between January 17, 1993 and July 17, 1994

Data Source: Not specified

Sample Size: Total (n=413) Intervention (n=209) Control (n=204)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Labor Support, Midwifery, HOSPITAL, Peer Review, Quality Improvement

Intervention Description: In efforts to help reduce the primary C-section rate, the hospital participated in the American College of Nurse-Midwives Healthy Birth Initiative. Strategies employed included use of intermittent auscultation, upright labor positioning, an early labor lounge, one-to-one labor support, and team huddles.

Intervention Results: The baseline nulliparous, term, singleton, vertex cesarean rate in 2015 was 29.3%. In 2016, after 1 year of implementation of the project, the hospital decreased nulliparous, term, singleton, vertex cesarean rate to 26.1%-a reduction of 10%. In 2017, the rate was decreased to 25.3%-a reduction by 3.7%.

Conclusion: The multicomponent bundle incorporated proven quality improvement strategies and engaged numerous champions and stakeholders, including midwifery students.

Setting: Urban academic hospital in the Midwest

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: After discovering racial/ethnic disparities in adherence to well-child visits, UMass Memorial Health worked to identify and mitigate barriers to adherence for patients and families across 53 primary care practices in central Massachusetts.

Intervention Results: For patients who identified as Hispanic/Latinx, adherence rose from 64.3% at baseline to 74.1% (p < 0.001); and for patients who identified as Black/African American, adherence rose from 58.7% at baseline to 71.9% (p < 0.001). The gap in adherence to well-child visits for Black/African American and Hispanic/Latinx children compared to White children narrowed (12.4 percentage points to 5.1; p < 0.001; 6.8 percentage points to 2.9; p < 0.001).

Conclusion: Through a unique partnership between health system leaders, frontline staff, and the system's informatics team and by engaging caregivers to identify and address barriers to well-child visits, UMass Memorial Health was able to improve adherence to well-child visits among patients who identify as Black/African American or Hispanic/Latinx.

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Prolonged Second Stage of Labor, HOSPITAL, Guideline Change and Implementation, Quality Improvement, Collaboratives, Policy/Guideline (Hospital)

Intervention Description: Standardized second-stage labor evidence-based practice recommendations were structured into an interdisciplinary “5 Ps practice bundle” (patience, positioning, physiologic resuscitation, progress, preventing urinary harm) and implemented across 34 birthing hospitals. The second-stage labor practices were derived from the Association of Women's Health, Obstetric and Neonatal Nurses and the American College of Nurse-Midwives professional guidelines. The recommendations are designed to support the laboring woman's normal physiologic processes and avoid unnecessary interventions.

Intervention Results: Significant improvements were observed in second-stage practices. Association of Women's Health, Obstetric and Neonatal Nurses' perinatal nursing care quality measure Second-Stage of Labor: Mother-Initiated Spontaneous Pushing significantly improved [pre-implementation 43% (510/1,195), post-implementation 76% (1,541/2,028), p < .0001]. Joint Commission Perinatal Care-02: nulliparous, term, singleton, vertex cesarean rate significantly decreased (p = 0.02) with no differences in maternal morbidity, or negative newborn birth outcomes. Unexpected complications in term births significantly decreased in all newborns (p < 0.001), and for newborns from vaginal births (p = 0.03). Birth experience satisfaction rose from the 69th to the 81st percentile.

Conclusion: Clinical implications: Implementing 13 evidence-based second-stage labor practices derived from the Association of Women's Health, Obstetric and Neonatal Nurses and the American College of Nurse-Midwives professional guidelines achieved our goals of safely reducing primary cesarean birth among low-risk nulliparous women, and optimizing maternal and fetal outcomes associated with labor and birth. By minimizing routine interventions, nurses support physiologic birth and improve women's birth satisfaction.

Setting: 34 birthing hospitals in the Trinity Health System

Population of Focus: Nulliparous women with term singleton vertex gestations

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): 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): 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): Notification/Information Materials (Online Resources, Information Guide), Referrals, Educational Material (Provider), HEALTH_CARE_PROVIDER_PRACTICE, PATIENT_CONSUMER

Intervention Description: To improve Early Head Start/Head Start (EHS/HS) screening, referral, and enrollment for children from diverse, low-income communities.

Intervention Results: The preintervention group included 223 patients. The postintervention group included 235 patients. EHS/HS screening improved significantly after the intervention, rising from 8% in the preintervention period to 46% in the postintervention period (odds ratio [OR] 10.5, 95% confidence interval [CI] [5.9, 19.4]). EHS/HS documented referral rates increased from 1% in the preintervention period to 20% in the postintervention period (OR 18.3, 95% CI [5.7, 93.6]). Thirty-two of the 42 patients in the postintervention group referred to EHS/HS were reached to determine enrollment status. Six children (14%) had enrolled in EHS/HS.

Conclusion: With use of existing resources, a medical home–Head Start partnership can build an integrated system that significantly improves screening and referral rates to early learning programs.

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Provider Training/Education, Expert Support (Provider), Modified Billing Practices, Screening Tool Implementation Training, Office Systems Assessments and Implementation Training, Expert Feedback Using the Plan-Do-Study-Act-Tool, Engagement with Payers, STATE, POPULATION-BASED SYSTEMS, Collaboration with Local Agencies (State), Collaboration with Local Agencies (Health Care Provider/Practice), HEALTH_CARE_PROVIDER_PRACTICE, Audit/Attestation (Provider)

Intervention Description: This report evaluates the impact of Phase II of Maine's First STEPS initiative

Intervention Results: Average percentage of documented use of a developmental screening tool increased substantially from baseline to followup for all three age groups (46% to 97% for children under one; 22% to 71% for children 18-23 months; and 22% to 58% for children 24-35 months). Rate of developmental screening based on MaineCare claims increased from the year prior to intervention implementation to the year after implementation for all three age groups (5.3% to 17.1% for children age one; 1.5% to 13.3% for children age two; and 1.2% to 3.3% for children age 3).

Conclusion: The authors summarize lessons learned in implementing changes in practices and challenges in using CHIPRA and IHOC developmental, autism, and lead screening measures at the practice-level to inform quality improvement.

Study Design: QE: pretest-posttest

Setting: Pediatric and family practices serving children with MaineCoverage

Population of Focus: Children ages 6 to 35 months

Data Source: Child medical record; MaineCare paid claims

Sample Size: Unknown number of chart reviews from 9 practice sites completing follow-up

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Baby Friendly Hospital Initiative, HEALTH_CARE_PROVIDER_PRACTICE, ,

Intervention Description: The purpose of this study was to evaluate whether Baby Friendly Hospital (BFH) designation in Maryland improved breastfeeding practices among Special Supplemental Nutrition Program for Women, Infants and Children (WIC) participants.

Intervention Results: From pre to post intervention no differences in breastfeeding initiation or any breastfeeding at 6 months were attributable to BFH status. There was some evidence that BFH designation in 2016 was associated with an absolute percent change of 2.4% (P = 0.09) for any breastfeeding at 3 months.

Conclusion: Few differences in breastfeeding outcomes among WIC participants were attributable to delivery in a BFH. Results from this study inform policy about maternity practices impacting WIC breastfeeding outcomes. More study needed to determine the impact of BFH delivery on differences in breastfeeding outcomes between sub-groups of women.

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage, HEALTH_CARE_PROVIDER_PRACTICE, Public Insurance (Health Care Provider/Practice), NATIONAL, Policy/Guideline (National)

Intervention Description: Numerous states have implemented policies expanding public insurance eligibility or subsidizing private insurance for parents. Under the ACA, states retain significant flexibility in terms of eligibility and program structure. This study assessed the impact of parental health insurance expansions from 1999 to 2012 on the likelihood that parents are insured; their children are insured; both the parent and child within a family unit are insured; and the type of insurance. Cross-state and within-state multivariable regression models estimated the effects of health insurance expansions targeting parents using 2-way fixed effect modeling and difference-in-difference modeling.

Intervention Results: Cross-state analyses demonstrate that public expansions without premiums and special subsidized plan expansions had the largest effects on parental coverage and increased the likelihood of jointly insuring the parent and child. Expansions increased parental coverage by 2.5 percentage points and increased the likelihood of both parent and child being insured by 2.1 percentage points. Substantial variation was observed by type of expansion. Public expansions without premiums and special subsidized plan expansions had the largest effects on parental coverage and increased the likelihood of jointly insuring both the parent and child. Higher premiums were a substantial deterrent to parents’ insurance. Our findings suggest that premiums and the type of insurance expansion can have a substantial impact on the insurance status of the family. The most effective expansions for parental insurance coverage were those for traditional Medicaid coverage without premiums and for special subsidized plans that subsidized costs for individuals to purchase state-sponsored plans. These findings can help inform states as they continue to make decisions about expanding Medicaid under the Affordable Care Act to cover all family members.

Conclusion: Our findings suggest that premiums and the type of insurance expansion can have a substantial impact on the insurance status of the family. These findings can help inform states as they continue to make decisions about expanding Medicaid under the Affordable Care Act to cover all family members.

Study Design: Cross-sectional analysis of data

Setting: Policy (States)

Population of Focus: Parents ≤ 300% FPL who were eligible for insurance expansions in selected states

Data Source: 2000–2013 March supplements to the Current Population Survey, with data from the Medical Expenditure Panel Survey—Insurance Component and the Area Resource File

Sample Size: 19 expansion states (representing 28 expansions) and 22 control states without a parental expansion during the study period

Age Range: Parents and children; specific ages not stated

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Planning for Transition, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: We assessed the effectiveness of a transition protocol that aimed to improve the transfer of adolescents to adult primary care. Chart reviews were conducted on 21- and 22-year-old patients seen 18 months before and after protocol implementation. Completion of an adult medicine appointment scheduled within 6 months from the last pediatric visit was the primary outcome of interest.

Intervention Results: In pre-implementation period, 20.9% of patients versus 39.3% in post-implementation period were transferred. Transfer was higher in patients who had a dedicated transition visit, had a transition order placed, and were tracked during the transfer process.

Conclusion: Implementing a transition protocol in pediatric clinics can improve the transition of adolescents aging out of pediatric care and may diminish gaps in medical care that can be associated with poor health outcomes.

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): PAYER, Expanded Insurance Coverage, HEALTH_CARE_PROVIDER_PRACTICE, Public Insurance (Health Care Provider/Practice), PROFESSIONAL_CAREGIVER, Educational Material (caregiver), Patient Navigation (Assistance), Outreach (Provider), Enrollment Assistance

Intervention Description: Community Health Centers (CHCs) serving low-income populations are well-positioned to support patients navigating the complexities of the public health insurance application process and prevent lapses in coverage. Specialized staff, called enrollment assistants, can help to determine insurance eligibility and/or guide patients through application processes, including assistance with completing application forms, understanding requirements, and providing appropriate documentation.

Intervention Results: Enrollment assistants are valuable resources, and CHCs are effective at helping patients with public health insurance. The enrollment assistants helped families understand the process and avoid mistakes and delays while patients valued their advice and their pragmatic, hands-on application assistance.

Conclusion: 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. 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-case comparison

Setting: Community (Community-health centers in Oregon)

Population of Focus: Practice members (e.g., managers, clinical and non-clinical staff, enrollment assistants) and families using community health centers

Data Source: Observations and interviews

Sample Size: 4 Community Health Centers (CHCs) in Oregon; 26 practice members; 18 adult family members who had at least one pediatric patient

Age Range: Parents and children; specific ages not stated

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Labor Support, POPULATION-BASED SYSTEMS, State — Place of Birth, STATE, Place of Birth, Childbirth Education Classes, Midwifery, PATIENT_CONSUMER, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: We evaluated the effect on perinatal outcomes of an interdisciplinary program designed to promote physiologic birth and encourage active involvement of women and their families in maternity care.

Intervention Results: Compared with women receiving standard care, those in the birth program were more likely to be delivered by a midwife (41.9% v. 7.4%, p < 0.001) instead of an obstetrician (35.5% v. 69.6%, p < 0.001). The program participants were less likely than the matched controls to undergo cesarean delivery (relative risk [RR] 0.76, 95% confidence interval [CI] 0.68-0.84) and, among those with a previous cesarean delivery, more likely to plan a vaginal birth (RR 3.22, 95% CI 2.25-4.62). Length of stay in hospital was shorter in the program group for both the mothers (mean ± standard deviation 50.6 ± 47.1 v. 72.7 ± 66.7 h, p < 0.001) and the newborns (47.5 ± 92.6 v. 70.6 ± 126.7 h, p < 0.001). Women in the birth program were more likely than the matched controls to be breastfeeding exclusively at discharge (RR 2.10, 95% CI 1.85-2.39).

Conclusion: Women attending a collaborative program of interdisciplinary maternity care were less likely to have a cesarean delivery, had shorter hospital stays on average and were more likely to breastfeed exclusively than women receiving standard care.

Study Design: Retrospective cohort

Setting: 1 women’s hospital

Population of Focus: Nulliparous women who gave birth between April 2004 to October 20102

Data Source: Not specified

Sample Size: Total (n=1,660) Intervention (n=830) Control (n=830)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): Education on Disease/Condition, Notification/Information Materials (Online Resources, Information Guide), Planning for Transition, PARENT_FAMILY, YOUTH, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: This quality improvement project focused on improving transition to adult health care by creating varied supports for the patient, family, and the health care team and putting them into action within a pediatric medical practice that serves over 250 adolescent and young adult patients with autism spectrum disorder.

Intervention Results: Before the supports were put into place, patients and families received limited and inconsistent communication to help them with transition. While the supports helped increase the amount and quality of help patients and families received, medical providers skipped or put off transition discussion in approximately half of well visits for targeted patients. Challenges in implementing the transition process included finding time to discuss transition-related issues with patients/families, preference of medical providers to have social workers discuss transition, and difficulty identifying adult health care providers for patients.

Conclusion: This suggests more work is needed to both train and partner with patients, families, and health staff to promote smooth and positive health transitions.

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Patient Reminder/Invitation, Incentives, HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Residents/Medical Students

Intervention Description: Phase 1 lasted 9 months and implemented CCS patient outreach, patient financial incentives, and clinic staff education. Phase 2 lasted 9 months and involved a workflow change in which MAs identified candidates for CCS during patient check-in. Feedback spanned the entire study period.

Intervention Results: After interventions, the average number of monthly Pap tests increased from 35 to 56 in phase 1 and to 75 in phase 2. Of 385 patients contacted in phase 1, 283 scheduled a Pap test and 115 (41%) completed it. Compared to baseline, both interventions improved cervical cancer screening (phase 1 relative risk, 1.86; 95% CI, 1.64–2.10; P < 0.001; phase 2 relative risk, 2.70; 95% CI, 2.40–3.02; P < 0.001). Our clinic’s CCS rate improved from 70% to 75% after the 18-month intervention.

Conclusion: The rate of CCS increased by 5% after a systematic 2-phase organizational intervention that empowered MAs to remind, identify, and prepare candidates during check-in for CCS.

Setting: Urban academic internal medicine clinic

Population of Focus: Women ages 21-64 eligible for cervical cancer screening

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): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Chart Audit and Feedback, Quality Improvement

Intervention Description: The aim of this study was to evaluate pregnancy outcomes before, during, early post and late post introduction of the nine‐item list. The list included the following: 1) monitoring of obstetric results, 2) a midwife coordinator, 3) risk 4) classification of women according to the Robson Classification, 5) three midwife-competence levels, 6) obstetric morning round, 7) fetal monitoring skills, 8) obstetric skills training, and 9) teamwork with a midwife, obstetrician and nurse working together with the common goal of a normal delivery. The target group for the intervention was nulliparous women at term with spontaneous onset of labor and cephalic presentation (Robson group 1).

Intervention Results: Apgar score <7 at 5 minutes, Apgar score <4 at 5 minutes and umbilical cord arterial pH <7 did not differ significantly between the four time periods. Between before introduction and early post introduction, instrumental vaginal delivery decreased from 19.8% to 12.2% and cesarean section from 9.6% to 4.5%. The late post introduction period showed a maintained effect with 10.7% instrumental deliveries and 3.9% cesarean sections. Obstetric anal sphincter injury grade III decreased instantly during the introduction of the nine-item list from 7.8% to 5.1% and thereafter remained unchanged.

Conclusion: Implementation of the nine-item list increased the proportion of spontaneous vaginal deliveries by reducing the number of instrumental deliveries and cesarean sections without affecting the neonatal outcomes in nulliparous women with spontaneous onset of labor. The nine-item list intervention seems to provide long-term sustainable results.

Setting: Delivery unit in Linköping, Sweden

Population of Focus: Nulliparous women at term with spontaneous onset of labor and cephalic presentation

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

Intervention Description: Patient-centered medical homes (PCMHs) seek to provide primary care that is comprehensive, patient-centered, coordianted, accessible, and high quality. PCMHs have the potential to improve receipt of preventive services by automating reminders to patients, measuring adherence to recommended services, giving feedback to physicians about adherence rates, using clinical decision support embedded in electronic health record (EHR) systems, and other quality-related activities. The objective of this study was to measure pediatric preventive counseling at PCMHs compared with practices that reported undertaking some or no quality-related activities. We focus on 2 activities most directly related to the provision of recommended counseling by physicians: 1) whether the practice regularly gave physicians reports on the clinical quality of their care, and 2) if the practice had an EHR system, whether the system routinely reminded practitioners to provide guideline-based care or screening tests.

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.

Study Design: Secondary data analysis

Setting: Patient-centered medical homes

Population of Focus: Children and adolscents who visited their office-based usual sources of care

Sample Size: 4814 children and adolescents

Age Range: Ages 0-17

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): 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): PAYER, Expanded Insurance Coverage, HEALTH_CARE_PROVIDER_PRACTICE, Public Insurance (Health Care Provider/Practice), Medicaid

Intervention Description: The Massachusetts Medicaid Buy-In program, called MassHealth CommonHealth, allows families of children with disabilities to buy into the state’s Medicaid program to cover more services and to defray costs that private insurance does not cover. Children with disabilities who do not have other insurance can use the program as their sole insurance; Children with disabilities who have other insurance can use the program as a secondary payer to supplement coverage and reduce families’ out-of-pocket costs due to the deductible, co-payments, and coinsurance for the child. Adopting a Medicaid Buy-In program may be an effective way for states to create a pathway to Medicaid for children with disabilities whose family income is too high for Medicaid and who have unmet needs and/or whose families incur high out-of-pocket costs for their care.

Intervention Results: This study suggests that the MassHealth CommonHealth Buy-In program improves access to care for children with disabilities by providing the benefits that were limited in scope or unavailable through other insurance before enrollment and by making available services more affordable. Parents reported that this increased access resulted in improvements in their child’s health or functioning, reduced stress on the parents and families, and reduced financial strain. Overall, many respondents appreciated the CommonHealth program. Despite these benefits, other families reported that they continued to face barriers in access to care for their children with disabilities. They reported difficulty in finding mental health or dental care, as many of these providers (as well as other specialists) did not accept MassHealth. Even with CommonHealth, families still had high out-of-pocket costs due to services that are not covered or high CommonHealth premiums. Families also struggled with complex paperwork requirements. Policy and administrative changes could improve the program and further increase access to care for children with complex, costly conditions. Adopting a Medicaid Buy-In program may be an effective way for other states to create a pathway to Medicaid for children with disabilities whose family income is too high for Medicaid and who have unmet needs and/or whose families incur high out-of-pocket costs for their care.

Conclusion: Data suggest that CommonHealth improves access to care for children with disabilities by providing the benefits that were limited in scope or unavailable through other insurance before enrollment and by making available services more affordable. Policy and administrative changes could improve the program and further increase access to care for children with complex, costly conditions. Adopting a Medicaid Buy-In program may be an effective way for states to create a pathway to Medicaid for children with disabilities whose family income is too high for Medicaid and who have unmet needs and/or whose families incur high out-of-pocket costs for their care.

Study Design: Survey

Setting: Policy (CommonHealth, Massachusetts's Medicaid Buy-In program)

Population of Focus: Parents and caregivers of Massachusetts children with disabilities enrolled in CommonHealth

Data Source: Survey data

Sample Size: 615 families

Age Range: 0-18 years

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

Intervention Description: A social worker coordinated medical care for children in foster care in a foster care medical home (FCMH) and tracked care coordination (CC) activities using a modified Care Coordination Measurement Tool© (mCCMT).

Intervention Results: The CC prevented 11 emergency department (ED) visits, 9 placement disruptions, and 42 patient privacy violations.

Conclusion: Children assigned to a FCMH have diverse CC needs and benefit from social workers’ specialized skills.

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Provider Training/Education, HEALTH_CARE_PROVIDER_PRACTICE, Audit/Attestation

Intervention Description: Use of formal developmental screening tools in the pediatric medical home improves early identification of children with developmental delays and disorders, including Autism Spectrum Disorders.

Intervention Results: Percentage of screening at 18-month well-child visits increased (P<.05) in all intervention practices. Average screening percentages were 70.8% for intervention practices, 46% for control practices. One intervention practice had a lower screening % than matched control practice (P=.37). Number of screens performed on the same day as a well-child visit increased from 3,442 in 2008 to 12,533 in 2009.

Conclusion: These pilot study results indicate the potential of academic detailing as an effective strategy for improving rates of developmental screening.

Study Design: QE: pretest-posttest nonequivalent control group

Setting: Pediatric and family medicine practice (5 intervention and 5 control) sites in Connecticut

Population of Focus: Children at 18-month well-child visits

Data Source: Child medical record; Medicaid claims

Sample Size: Baseline Chart Audits3 : - Intervention (n=200) - Control (n=100) Follow-Up Chart Audits: - Intervention (n=196) - Control (n=100)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Transition Assistance, HEALTH_CARE_PROVIDER_PRACTICE, PATIENT_CONSUMER

Intervention Description: To assess participation with a structured transition programme for adolescents with diabetes.

Intervention Results: Five hundrend and twelve adolescents who were to be transferred to adult care (476 type 1 (T1D) and 36 type 2 (T2D)), overall participation rate of 83%, 86% (408/476) with T1D compared to 47% (17/36) with T2D. Within the cohort of T1D, participation rates for Māori and Pacific were lower (74% and 77%, respectively) than New Zealand Europeans (88%, p = 0.020 and p = 0.039, respectively). Lower socio-economic status was associated with reduced participation (77%) compared to higher socio-economic status (90%, p = 0.002). Of the 476 T1D who participated, 408 (96%) subsequently attended at least one adult service clinic ("capture"). 42% attended an adult clinic within the planned 3 months, 87% at 6 months and retention in adult clinics over 5 years of follow-up was 78%. By contrast, the 68 young people with T1D who did not participate in the structured transition had a capture rate of 78% (p < 0.001) and retention of 63% (p = 0.036).

Conclusion: In adolescents with diabetes, a formal transition from a paediatric service was associated with high rates of adult capture and subsequent retention in adult care over a 5-year follow-up period. Low socio-economic status, Māori or Pacific ethnicity and T2D were associated with reduced participation in the structured transition programme.

Intervention Components (click on component to see a list of all articles that use that intervention): Baby Friendly Hospital Initiative, HEALTH_CARE_PROVIDER_PRACTICE, ,

Intervention Description: We sought to evaluate posthospital breastfeeding outcomes among women who deliver at a baby friendly hospital (BFH) by (1) estimating exclusive breastfeeding rates at the postpartum visit (PPV), (2) quantifying the exclusive breastfeeding discontinuation rate, and (3) identifying which factors are associated with breastfeeding discontinuation.

Intervention Results: At hospital discharge, 71.1% of the participants were EBF, 21.7% were CF, and 7.2% were EFF. At the PPV, the frequency of the primary outcome of EBF was 31.6% (95% confidence interval: 25.2–38.8); 34.6% (28.0–41.9) were CF, and 33.8% (27.3–41.1) were EFF. Therefore, the EBF absolute and relative discontinuation rates were 39.5% and 55.6%, respectively. No demographic factors, delivery characteristics, or maternal medical morbidities were associated with EBF in the multivariable logistic regression. However, women in the EBF group were more likely to report a workplace environment conducive to breastfeeding and partner and friend support.

Conclusion: Significant breastfeeding discontinuation rates occur even among women who deliver at a BFH. Our findings suggest that multifactorial interventions, including a focus on the prevention of formula introduction, are needed in the early postpartum period to achieve higher EBF rates at the PPV.

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Integration into Adult Care, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: We tested the hypothesis that individuals who participated in the co-located model have greater retention in adult care compared to those who only received pediatric transition services.

Intervention Results: Individuals who participated in the co-location model were 1.9 times more likely to remain in adult care 12 (95%CI: 1.01, 3.47) and 24 (95%CI: 1.01, 3.70) months post pediatric care compared to those who did not participate. Individuals with HbSS/HbSβ0-thalassemia were 1.9 times more likely to be retained at 12 months compared to those with HbSC/HbSβ+-thalassemia/HbS/HPFH (95%CI: 1.12, 3.09). For every clinic encounter in the last 2 years of pediatric care, the odds of being retained at least 24 months after initiating adult care increased 1.1 times (95%CI: 1.02, 1.13).

Conclusion: Continuity of providers from pediatric to adult care may increase long-term retention in adult care. Longitudinal monitoring of adult outcomes is critical to identifying the efficacy of transition services

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement, Provider Training/Education, Crib Card, HOSPITAL, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: This project aimed to improve infant sleep practices in a 10-bed level I nursery using visual cues (crib cards) and nursing education.

Intervention Results: safe sleep practices improved from 32% (30/95) preintervention to 75% (86/115) postintervention (P < 0.01).

Conclusion: This study demonstrates that implementing a quality improvement initiative to improve infant sleep practices in a low-volume nursery is feasible and impactful.

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

Intervention Description: The study examines patients cared for by a co-practice of nurse midwives and family physicians at a rural hospital. Data were collected through a retrospective chart audit for all patients whose prenatal care, labor, or delivery was managed by members of the practice in 1990 and 1991.

Intervention Results: Few differences were noted between nurse midwives and family physicians in the management of labor or delivery. The only consistent finding was that family physicians were more likely than midwives to use an episiotomy for delivery (40% vs 30% in primiparous women, P = .02; and 20% vs 10% in multiparous women, P = .007). Despite seemingly similar management styles, primiparous women managed by family physicians were more likely to undergo cesarean section (14% vs 8%, P = .05) resulting from the diagnosis of dystocia. When practice specialty was included in a logistic regression model with parity and the number of preexisting risk factors, the effect of specialty on cesarean sections remained significant with a relative risk of 2.79 for cesarean section if patients had their labor managed by a family physician (P < .001).

Conclusion: Family physicians and nurse midwives managed patients in labor similarly, but nurse midwives were more likely to achieve a vaginal delivery in primiparous women and do so without an episiotomy. Although the differences found would not interfere with a collaborative practice, subtle differences in patient management do exist. Further exploration of these differences may be helpful in understanding the impact of these differences on mixed-specialty practices.

Study Design: Retrospective cohort

Setting: 1 hospital in Kentucky

Population of Focus: Random sample of nulliparous women who gave birth between 1990 and 19912

Data Source: Not specified

Sample Size: Total (n=371) Intervention (n=185) Control (n=186)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational material, HEALTH_CARE_PROVIDER_PRACTICE, Quality Improvement/Practice-Wide Intervention, Hospital Policies, Provider Training/Education,

Intervention Description: The purpose of this system-wide quality improvement project was to create a breastfeeding-friendly pediatric practice. This breastfeeding support initiative was implemented at a multisite rural Illinois pediatric practice. The policy included: (a) breastfeeding promotion recommendations; (b) provider, nurse, and staff roles; (c) patient education and resources; and (d) breastfeeding-friendly atmosphere guidelines. An evidence-based breastfeeding policy was developed, staff education sessions were conducted, private lactation rooms were created, and breastfeeding photographs/posters were displayed throughout the offices. Lactation support services were publicized throughout the offices. Lactation support services were publicized via signs and social media postings.

Intervention Results: Overall breastfeeding rates were higher at each time point after implementation. Statistically significant increases occurred at the newborn and 1-month visits, with a modest improvement at 2 and 4 months.

Conclusion: This project demonstrated an improvement in breastfeeding duration rates. It is anticipated that this practice-wide standard of care change will promote breastfeeding throughout the first 12 months of life.

Study Design: Pre-post intervention

Setting: Multisite rural IL pediatric practice

Population of Focus: Mothers with breastfeeding infants from newborn to 4 months seen for well-child visits at a pediatric practice

Sample Size: 71 infants preintervention and 18 infants postintervention

Age Range: Newborn to infants 4 months old

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage, HEALTH_CARE_PROVIDER_PRACTICE, Public Insurance (Health Care Provider/Practice), Provider Training/Education, Nurse/Nurse Practitioner, CLASSROOM_SCHOOL, Teacher/Staff Training, PROFESSIONAL_CAREGIVER, Outreach (caregiver), Outreach (School Staff)

Intervention Description: Healthy and Ready to Learn is a targeted, school-based CHIP and Medicaid outreach initiative for identifying and enrolling eligible and uninsured children entering kindergarten in North Carolina’s highest need counties. School nurses and administrative staff attend regional trainings on how to use a required health assessment form, submitted at school entry, to identify uninsured children who could be eligible but are not enrolled in public insurance. Continuous community-based outreach (e.g., attending community events, providing outreach materials in various languages, contacting local organizations and leaders to help inform families about CHIP and Medicaid) is also utilized.

Intervention Results: With increased enrollment rates and well-child exam rates, findings demonstrate the potential benefits of using schools as a point of intervention in enrolling young children in public health insurance and as a source of trusted information for parents from low-income backgrounds. The initiative increased enrollment rates by 12.2% points and increased well-child exam rates by 8.6% points in the regression discontinuity design models, but not differences-in-differences, and did not significantly increase well-child visits. Findings demonstrate the potential benefits of using schools as a point of intervention in enrolling young children in public health insurance and as a source of trusted information for low-income parents.

Conclusion: Findings demonstrate the potential benefits of using schools as a point of intervention in enrolling young children in public health insurance and as a source of trusted information for low-income parents.

Study Design: Quasi-experimental difference-in-difference and regression discontinuity

Setting: Schools (Elementary schools in North Carolina)

Population of Focus: Uninsured kindergarten-aged children in high economic need counties in North Carolina

Data Source: Medicaid and CHIP administrative data, focus groups, key informant interviews

Sample Size: 300 children; 16 counties were selected as intervention sites that included 278 elementary schools in 22 districts; in the second year, expanded to 32 counties

Age Range: 4-6 years

Intervention Components (click on component to see a list of all articles that use that intervention): Education on Disease/Condition, Notification/Information Materials (Online Resources, Information Guide), Planning for Transition, HEALTH_CARE_PROVIDER_PRACTICE, PARENT_FAMILY, YOUTH

Intervention Description: This study evaluated the impact of establishing a transition clinic in a regional Australian setting on the lives of young adults living with severe chronic kidney disease and their families.

Intervention Results: Four key themes were identified as follows: The Model of Care; Peer support; Transition towards self-management: Building life skills; Suggestions for improvement and limitations of the service model. The non-institutional, informal clinic setting and social/educational activities facilitated engagement, self-management and peer support for young people and parents. Suggestions for improvement included involvement of older peers, additional life skills sessions and a youth worker.

Conclusion: This regional transition clinic is valued by the young people and their parents for generating peer support, building self-management and life skills. Sustainability of the clinic depends upon having the appropriate expertise available, access to a suitable venue and offering a program that meets the needs of young people.

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): HEALTH_CARE_PROVIDER_PRACTICE, Hospital Policies, Baby Friendly Hospital Initiative,

Intervention Description: This study examines changes in Baby-Friendly hospital practices, breastfeeding outcomes, and their relationships with Baby-Friendly hospital status among WIC-enrolled children in Los Angeles County.

Intervention Results: In 2017, mothers surveyed were more likely to engage in Baby-Friendly hospital practices compared with 2008. Any and exclusive breastfeeding outcomes at 1 and 3 months significantly increased since 2014, and breastfed infants were more likely to have mothers who participated in Baby-Friendly hospital practices. The more Baby-Friendly hospital practices mothers met, the better the breastfeeding outcomes. However, there is room for improvement in the uptake of Baby-Friendly hospital practices in Baby-Friendly hospitals.

Conclusion: Effort is needed to ensure Baby-Friendly hospitals have support to continuously comply with all steps to maintain Baby-Friendly designation, and non-Baby-Friendly hospitals have support to incorporate these practices into hospital protocols.

Study Design: Triennial cross-sectional survey

Setting: Los Angeles County hospitals

Population of Focus: Infants born in Los Angeles County hospitals, no older than 2 years of age at the time of the survey whose mothers were interviewed

Sample Size: 6,449 infants and their mothers

Age Range: Infants under 2 years of age

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Quality Improvement, Policy/Guideline (State)

Intervention Description: A quality improvement course was introduced to reduce the caesarean section rate among nulliparas women and to find out which group of women reduced the cesarean section rate following attendance at the course. The course was dedicated to delivery-related staff from all Lithuanian hospitals providing obstetrical care. All hospitals had their representatives attending the course. They included not only obstetricians and gynecologists but also midwives, neonatologists and nurses. The aim of the course was to ensure that all Lithuanian hospitals providing obstetrical care had the same obstetrical knowledge and provided standardized care in managing the same obstetrical situations. The course consisted of educational sessions and practice drills. The core of educational sessions was a file of evidence-based obstetrical guidelines that were distributed nationally.

Intervention Results: Nulliparas accounted for 43% (3746/8718) and 44.6% (3585/8046) of all the deliveries in 2012 and 2014 years, respectively. The CS rate among nulliparas decreased from 23.9% (866/3626) in 2012 to 19.0% (665/3502) in 2014 (p < 0.001).The greatest decrease in absolute contribution to the overall CS rate was recorded in groups 1 (p = 0.005) and 2B (p < 0.001). Perinatal mortality was 3.5 in 2012 and 3.1 in 2014 per 1000 deliveries (p = 0.764).

Conclusion: The TGCS can work as an audit intervention that could help to reduce the CS rate without a negative impact on perinatal mortality.

Setting: Lithuanian hospitals

Population of Focus: Nulliparous low risk women

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Quality Improvement, Policy/Guideline (State)

Intervention Description: A quality improvement course was introduced to reduce the caesarean section rate among nulliparas women and to find out which group of women reduced the cesarean section rate following attendance at the course. The course was dedicated to delivery-related staff from all Lithuanian hospitals providing obstetrical care. All hospitals had their representatives attending the course. They included not only obstetricians and gynecologists but also midwives, neonatologists and nurses. The aim of the course was to ensure that all Lithuanian hospitals providing obstetrical care had the same obstetrical knowledge and provided standardized care in managing the same obstetrical situations. The course consisted of educational sessions and practice drills. The core of educational sessions was a file of evidence-based obstetrical guidelines that were distributed nationally.

Intervention Results: Nulliparas accounted for 44.6% (3585/8046) and 42.9% (3628/8460) of all the deliveries in 2014 and 2016 years, respectively. The CS rate among nulliparas decreased from 19.0% (665/3502) in 2014 to 16.8% (593/3526) in 2016 (p = 0.018). The greatest decrease in absolute contribution to the overall CS rate was recorded in group 1 (p = 0.08). Perinatal mortality was 3.1 in 2014 and 3.9 in 2016 per 1000 deliveries (p = 0.569).

Conclusion: The QIC has helped to reduce the CS rate among nulliparas without a negative influence on perinatal mortality. The greatest decrease in the overall CS rate was recorded among nulliparous women who were treated with oxytocin and managed to reach a full cervical dilatation.

Setting: Lithuanian hospitals

Population of Focus: Nulliparous low risk women

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Hospital Policies, Baby Friendly Hospital Initiative, Provider Training/Education, Expert Support (Provider),

Intervention Description: In 2010, the Hawaii State Department of Health received support from the CDC to launch the Baby-Friendly Hawaii Project to increase the number of Hawaii hospitals that provide maternity care consistent with the Ten Steps to Successful Breastfeeding and increase the rate of women who remain exclusively breastfeeding throughout their hospital stay. The BFHP employed six strategies based on a model developed by the New York City Department of Health and Mental Hygiene: engage hospitals, enlist support, recruit champions, assess hospitals, conduct site visits and trainings, and monitor outcomes. Populations targeted for BFHP were registered nurses, lactation consultants, and other hospital staff, as well as expectant mothers at all 11 Hawaii maternity hospitals during the project period.

Intervention Results: Since 2010, 52 hospital site visits, 58 trainings, and ongoing technical assistance were administered, and more than 750 staff and health professionals from BFHP hospitals were trained. Hawaii’s overall quality composite Maternity Practices in Infant Nutrition and Care score increased from 65 (out of 100) in 2009 to 76 in 2011 and 80 in 2013, and Newborn Screening Data showed an increase in statewide exclusive breastfeeding from 59.7% in 2009 to 77.0% in 2014.

Conclusion: Implementation and findings from the BFHP can inform future planning at the state and federal levels on maternity care practices that can improve breastfeeding.

Study Design: Program evaluation

Setting: Maternity hospitals in Hawaii

Population of Focus: Registered nurses, lactation consultants, and other hospital staff and expectant mothers at all 11 Hawaii maternity hospitals

Sample Size: 750 staff and health professionals

Age Range: N/A

Intervention Components (click on component to see a list of all articles that use that intervention): Referrals, Provider Training/Education, Outreach (caregiver), PATIENT_CONSUMER, PROFESSIONAL_CAREGIVER, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: This invited article is one of several comprising part of a special issue of Child Abuse and Neglect focused on child trafficking and health. The purpose of each invited article is to describe a specific program serving trafficked children.

Intervention Results: Serving 62 youth during its first year, the medical home has begun to improve access to high-quality healthcare to a very vulnerable population.

Conclusion: Featuring these programs is intended to raise awareness of innovative counter-trafficking strategies emerging worldwide and facilitate collaboration on program development and outcomes research.

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, HEALTH_CARE_PROVIDER_PRACTICE, ,

Intervention Description: Our specific aims were two-fold: 1) Accurately measure breastfeeding indicators and 2) Implement AAP Breastfeeding-Friendly Pediatric Office Practice Recommendations.

Intervention Results: Since initiation of the data analytic tool, breastfeeding data has been analyzed from over 30,000 visits (86% Medicaid-insured, 82% Black race). Currently, 80% of providers use default templates that allow standardized data capture. At first newborn visit, 74% of infants were breastfed. At six months, 36% of infants were breastfed; 23% exclusively. Standardized documentation of infant feeding status improved and has remained consistent. Breastfeeding duration did not significantly improve despite practice interventions.

Conclusion: Pediatric primary care measurement tools are feasible and critical to understand breastfeeding continuation. Increased resources and interventions to support breastfeeding in Primary Care are necessary to improve outcomes.

Intervention Components (click on component to see a list of all articles that use that intervention): Telephone Support, Adult-led Spport/Counseling/Remediation, PATIENT_CONSUMER, Educational Material (Provider), HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: The purpose of this study is to conduct moderator analyses using pooled data from three randomized controlled trials of the intervention conducted in collaboration with 2-1-1 contact centers in Atlanta, North Carolina and Houston. 2-1-1 is a strategic partner for tobacco control as it connects over 15 million clients, largely socio-economically disadvantaged, to social and health resources each year.

Intervention Results: Intervention effectiveness was not moderated by race/ethnicity, education, income, children in the home or number of smokers in the home. Smoking status of the participant, however, did moderate program effectiveness, as did time to first cigarette. Number of cigarettes per day and daily versus nondaily smoking did not moderate intervention effectiveness.

Conclusion: The intervention was effective across socio-demographic groups and was effective without respect to daily versus nondaily smoking or number of cigarettes smoked per day, although smoking status and level of nicotine dependence did influence effectiveness.

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Patient Reminder/Invitation, Provider/Patient Communication Portal, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: Secondary, cross-sectional data from the 2011-2015 National Health Interview Survey were combined and analyzed. For each cancer screening, inclusion criteria were based on the age of screening recommendations and prior history of cancer diagnosis (n=35,912 for breast, n=48,512 for cervical, and n=45,884 for colon). The independent variable was whether adults used email PPC in the past 12 months (yes or no). The dependent variables were whether (1) women (aged ≥40 years) received a mammogram in the past 12 months; (2) women (aged 21-65 years) received a Pap test in the past 12 months; and (3) individuals (aged ≥50 years) received a colon cancer screening in the past 12 months. Bivariate and multivariable logistic regression analyses were conducted.

Intervention Results: Adults who reported receiving all three cancer screenings in the past 12 months were more likely to be non-Hispanic White; be married or living with a partner; have a bachelor’s degree or higher education level; have health insurance coverage; and perceive their health as excellent, very good, or good (all P<.001). Men were more likely to receive colon cancer screenings than women (P<.001). Multivariable logistic regression models showed women who used email to communicate with their health care providers had greater odds of receiving breast (odds ratio [OR] 1.32, 95% CI 1.20-1.44) and cervical (OR 1.11, 95% CI 1.02-1.20) cancer screenings than women who did not use email PPC. Adults who used email to communicate with their health care providers had 1.55 times greater odds (95% CI 1.42-1.69) of receiving a colon cancer screening than those who did not use email PPC.

Conclusion: Our results demonstrate that email PPC is a marker of increased likelihood of adults completing age-appropriate cancer screenings, particularly breast, cervical, and colon cancer screenings. More research is needed to examine other factors related to the reasons for and quality of email PPC between patients and health care providers and determine avenues for health education and intervention to further explore this association.

Setting: Primary care setting

Population of Focus: Women ages 21-64 who received primary care within the past 12 months

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Provider Training/Education, Educational Material (Provider), Expert Support (Provider), Participation Incentives, Quality Improvement/Practice-Wide Intervention, Data Collection Training for Staff, Screening Tool Implementation Training, Audit/Attestation, HEALTH_CARE_PROVIDER_PRACTICE, Audit/Attestation (Provider)

Intervention Description: To assess the degree to which a national sample of pediatric practices could implement American Academy of Pediatrics (AAP) recommendations for developmental screening and referrals, and to identify factors that contributed to the successes and shortcomings of these efforts.

Intervention Results: At the project's conclusion, practices reported screening more than 85% of patients presenting at recommended screening ages. They achieved this by dividing responsibilities among staff and actively monitoring implementation. Despite these efforts, many practices struggled during busy periods and times of staff turnover. Most practices were unable or unwilling to adhere to 3 specific AAP recommendations: to implement a 30-month visit; to administer a screen after surveillance suggested concern; and to submit simultaneous referrals both to medical subspecialists and local early-intervention programs. Overall, practices reported referring only 61% of children with failed screens. Many practices also struggled to track their referrals. Those that did found that many families did not follow through with recommended referrals.

Conclusion: A diverse sample of practices successfully implemented developmental screening as recommended by the AAP. Practices were less successful in placing referrals and tracking those referrals. More attention needs to be paid to the referral process, and many practices may require separate implementation systems for screening and referrals.

Study Design: QE: interrupted timeseries design

Setting: Sixteen pediatric primary care practices from 15 different states

Population of Focus: Children ages 8 to 36 months at wellchild visits

Data Source: Child medical record

Sample Size: Chart audits: - Baseline and Follow-Up: (n=30) per practice in July 2006 and March 2007; total charts audited (n= 960) - Intervention period: (n=10) per practice per month for 7 months; total charts audited (n=1,120)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Transition Assistance, Care Coordination, HEALTH_CARE_PROVIDER_PRACTICE, PATIENT_CONSUMER

Intervention Description: The objective was to evaluate healthcare outcomes (continuity of care and healthcare utilization) for clients enrolled in LIFEspan.

Intervention Results: Prospective enrolment comprised 30 ABI, 48 CP, and 21 SB participants. Retrospective enrolment comprised 15 ABI and 18 CP participants. LIFEspan participants demonstrated significantly greater continuity of care (45% had engagement with adult services in the year following discharge at 18 years), compared to the prospective SB group (14%). Healthcare utilization data were inconsistent with no significant changes in frequency of physician office visits, emergency department visits, or hospitalizations for clients enrolled in LIFEspan in the year following discharge, compared to the 2 years prior to discharge.

Conclusion: Introduction of the LIFEspan model increased continuity of care, with successful transfer from pediatric to adult services for clients enrolled. Data on longer-term follow-up are recommended for greater understanding of the degree of adult engagement and influence of LIFEspan on healthcare utilization following transfer.

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Material, Patient Reminder/Invitation, HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Quality Improvement/Practice-Wide Intervention, Nurse/Nurse Practitioner

Intervention Description: Improving cervical cancer screening rates was identified as a priority in a federally qualified health center when only 40% of eligible women were properly screened in 2016. Forty-five percent of the population the clinic serves is uninsured and 60% are Hispanic. The aim of this quality improvement project was to have 75% of the women 21 to 65 years of age who sought care at this clinic during the 60-day project period receive Pap test eligibility screening, enrollment in a state and federal screening program, and case management. Four rapid plan–do–study–act cycles were used. Tests of change included team engagement, patient engagement, eligibility screening, and case log management. Data were analyzed using run charts to evaluate the impact of interventions on outcomes. The interventions consisted of team meetings, a patient engagement tool, an eligibility screening tool, and case log management.

Intervention Results: Among the women who completed care at the clinic during the 60-day project period, 80% were uninsured and 86% were Hispanic. A total of 87% of women received effective care, which consisted of same-day Well Woman Health Care Program enrollment and a same-day Pap test or an appointment to return for a well-woman visit.

Conclusion: A multicomponent approach led to underserved women receiving equitable access to cervical cancer screening and timely enrollment in a cervical cancer screening program.

Setting: Federally qualified health center (FQHC) in Tucson, Arizona,

Population of Focus: Uninsured and underserved women ages 21-65

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Hospital Policies, Baby Friendly Hospital Initiative,

Intervention Description: To evaluate the impact of transition to Baby-Friendly certification on underserved populations at the University of New Mexico hospital. The journey towards Baby Friendly designation proceeded in four phases. The study team examined inpatient breastfeeding related clinical practices and short-term breastfeeding duration rates among patients of the midwifery service during the transition to Baby Friendly status. The purpose was twofold: (a) to evaluate the impact of BFHI implementation on the short-term duration of both any breastfeeding and exclusive breastfeeding, and (b) to determine the impact of exposure to the inpatient Ten Steps on short-term breastfeeding duration, both individually and cumulatively.

Intervention Results: Implementation of the BFHI and cumulative exposure to the Ten Steps increased short-term duration of any breastfeeding and exclusive breastfeeding at 2-6 weeks postpartum. Exposure to all six of the inpatient Ten Steps increased the odds of any breastfeeding by 34 times and exclusive breastfeeding by 24 times. Exposure to Step 9 (“Give no pacifiers or artificial nipples”) uniquely increased the likelihood of any breastfeeding at 2-6 weeks postpartum by 5.7 times, whereas Step 6 (“Give infants no food or drink other than breastmilk”) increased the rate of exclusive breastfeeding by 4.4 times at 2-6 weeks postpartum.

Conclusion: These findings demonstrate that the Baby Friendly Hospital Initiative can have a positive impact on breastfeeding among underserved populations.

Study Design: Quasi-experimental, retrospective cohort design

Setting: University of New Mexico Hospital

Population of Focus: Mother-baby pairs pre-BFHI and post-BFHI delivering at the hospital

Sample Size: 1004 mother-infant pairs (449 in the pre-BFHI cohort & 555 in the post-BFHI cohort)

Age Range: Mothers age 20-33 and their infants at 2-6 weeks postpartum

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): Quality Improvement/Practice-Wide Intervention, HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Educational Material

Intervention Description: To equitably increase exclusive breastfeeding at hospital discharge among obstetrician/gynecologist resident service clients by 20% over 8 weeks. Design

Intervention Results: Rates of exclusive breastfeeding at hospital discharge were 7% at baseline and 13% after implementation. Rates of exclusive breastfeeding among Black clients were 0% at baseline and 16% after implementation. Clients demonstrated Baby-Friendly knowledge (teach-back average, 89%) but continued to supplement with formula, most often related to supply concerns (65%).

Conclusion: Intentionally equitable implementation of the Baby-Friendly steps may ameliorate racial disparities in breastfeeding during the early postpartum period. Preparing families to exclusively breastfeed should begin prenatally.

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

Intervention Description: Data was collected electronically from over 3400 pregnant women during a three-month period in 2017.

Intervention Results: Dental appointments were upheld by 87.3% of referred women and by 56.9% of those without a referral (OR = 5.20 (4.05–6.67); p < 0.001). Among those who were referred, dental appointments were upheld in 91.7% of cases when further asked to provide oral health feedback and in 83.5% of cases in absence of such further request (OR = 2.19 (1.3–3.66); p = 0.003).

Conclusion: It was determined that referrals from a gynaecologist, and associated oral health feedback requests increase the frequency of abiding to dental appointments during pregnancy. As such, it is necessary to increase the involvement of gynaecologists in the promotion and maintenance of perinatal oral health.

Setting: Clinic/Medical provider office

Population of Focus: Pregnant people

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): PROVIDER/PRACTICE, Provider Training/Education, Provision of Safe Sleep Item, HOSPITAL, Policy/Guideline (Hospital), Sleep Environment Modification, CAREGIVER, Education/Training (caregiver), Educational Material (caregiver), HEALTH_CARE_PROVIDER_PRACTICE, Audit/Attestation

Intervention Description: The purpose of this study was to improve safe sleep practices for infants in nonneonatal pediatric units with implementation of specific interventions.

Intervention Results: Safe sleep was observed for 4.9% of 264 infants at baseline and 31.2% of 234 infants postintervention (P<.001). Extra blankets, the most common of unsafe items, were present in 77% of cribs at baseline and 44% postintervention. However, the mean number of unsafe items observed in each sleeping environment was reduced by >50% (P=.001).

Conclusion: Implementation of site-specific interventions seems to improve overall safe sleep in inpatient pediatric units, although continued improvement is needed. Specifically, extra items are persistently left in the sleeping environment.

Study Design: QE: pretest-posttest

Setting: Eight children’s hospitals

Population of Focus: Infants aged 0 to 6 months admitted to the general pediatric unit (excluding infants in the NICUs, PICUs, and maternal fetal units)

Data Source: Crib audit/infant observation

Sample Size: Baseline (n=234) Follow-up (n=210)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Provider Training/Education, Educational Material (Provider), Expert Support (Provider), Quality Improvement/Practice-Wide Intervention, Data Collection Training for Staff, Office Systems Assessments and Implementation Training, Expert Feedback Using the Plan-Do-Study-Act-Tool, POPULATION-BASED SYSTEMS, STATE, Collaboration with Local Agencies (State), Collaboration with Local Agencies (Health Care Provider/Practice), Audit/Attestation, HEALTH_CARE_PROVIDER_PRACTICE, Audit/Attestation (Provider)

Intervention Description: The objectives of this study were to assess the feasibility of implementing a bundle of strategies to facilitate the use of Bright Futures recommendations and to evaluate the effectiveness of a modified learning collaborative in improving preventive and developmental care.

Intervention Results: Office system changes most frequently adopted were use of recall/reminder systems (87%), a checklist to link to community resources (80%), and systematic identification of children with special health care needs (80%). From baseline to follow-up, increases were observed in the use of recall/reminder systems, the proportion of children's charts that had a preventive services prompting system, and the families who were asked about special health care needs. Of 21 possible office system components, the median number used increased from 10 to 15. Comparing scores between baseline and follow-up for each practice site, the change was significant. Teams reported that the implementation of office systems was facilitated by the perception that a component could be applied quickly and/or easily. Barriers to implementation included costs, the time required, and lack of agreement with the recommendations.

Conclusion: This project demonstrated the feasibility of implementing specific strategies for improving preventive and developmental care for young children in a wide variety of practices. It also confirmed the usefulness of a modified learning collaborative in achieving these results. This model may be useful for disseminating office system improvements to other settings that provide care for young children.

Study Design: QE: pretest-posttest

Setting: Primary care practices (15 at baseline, 8 at follow- up) throughout the US (9 states total), with most in the Midwest

Population of Focus: Children from birth through 21 years of age

Data Source: Child medical record

Sample Size: Unknown number of chart audits from 8 practice sites completing follow-up

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Planning for Transition, Transition Assistance, HEALTH_CARE_PROVIDER_PRACTICE, PATIENT_CONSUMER

Intervention Description: The research aimed to analyse the implementation in an initial cohort of patients of a new programme of transition to adult care based on a case

Intervention Results: The cohort included 500 patients, with malignant brain tumour (n = 56 (11%)), obesity (n = 55 (11%)), type 1 diabetes (n = 54 (11%)), or other disease (n = 335 (67%)). Their median age at transfer was 19, and the sex ratio was 0.5. At median 21 months of follow-up, 439 (88%) had a regular follow-up in or outside the hospital, 47 (9%) had irregular follow-up (absence at the last appointment or no appointment scheduled within the time recommended), 4 had stopped care on doctor's advice, 4 had died, 3 had moved, and 3 had refused care. The programme involved 9615 case management actions; 7% of patients required more than 50 actions. Patients requiring most support were usually those affected by a rare genetic form of obesity.

Conclusion: Case managers successfully addressed the complex needs of patients. Over time, the cohort will provide unprecedented long-term outcome results for patients with various conditions who experienced this form of transition.

Intervention Components (click on component to see a list of all articles that use that intervention): Baby Friendly Hospital Initiative, HEALTH_CARE_PROVIDER_PRACTICE, Hospital Policies, Other Education

Intervention Description: Identify practices associated with breastfeeding maintenance, examine breastfeeding-related hospital practices by hospital designation level (Baby Friendly vs. Gift vs. none), and assess racial disparities in hospital practices and breastfeeding maintenance.

Intervention Results: Breastfeeding in the hospital, infant only receiving breast milk, and breastfeeding within one hour after birth were positively associated and receiving a gift pack with formula was negatively associated with breastfeeding maintenance in both NHW and NHB women. Associations were stronger in NHW compared to NHB mothers.

Conclusion: We identified several practices significantly associated with breastfeeding maintenance. However, racial disparities indicate a need for population-specific supportive practices.

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Quality Improvement, Crib Card, HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Nurse/Nurse Practioner, Audit/Attestation

Intervention Description: A multi-pronged, safe sleep quality improvement initiative was introduced in three inpatient pediatric hospitals. The intervention included: 1) nursing education, 2) identification of nurse "safe sleep" champions, 3) crib cards, 4) crib audits, and 5) weekly reporting of data showing nursing unit ABC compliance via tracking boards. A pre/post analysis of infants <12 months old was performed using a convenience method of sampling. The goal was ABC compliance of ≥25% for the post-intervention period.

Intervention Results: There were 204 cribs included pre-intervention and 274 cribs post-intervention. Overall, there was not a significant change in sleep position/location (78.4 to 76.6%, p = 0.64). There was a significant increase in the percent of infants sleeping in a safe sleep environment following the intervention (5.9 to 39.8%, p < 0.01). Overall ABC compliance, including both sleep position/location and environment, improved from 4.4% pre-intervention to 32.5% post-intervention (p < 0.01). There was no significant variability between the hospitals (p = 0.71, p = 1.00).

Conclusion: The AAP's safe sleep recommendations are currently not upheld in children's hospitals, but safer sleep was achieved across three children's campuses in this study. Significant improvements were made in sleep environment and overall safe sleep compliance with this multi-pronged initiative.

Setting: Three children's hospital campuses

Population of Focus: Hospital staff

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Material, Professional Support, HEALTH_CARE_PROVIDER_PRACTICE, Baby Friendly Hospital Initiative, COMMUNITY, Individual Supports,

Intervention Description: The Westside Healthy Start Program (WHS), located in Chicago, Illinois, developed an ongoing multilevel approach to breastfeeding promotion. Key elements of the WHS breastfeeding model include individual education and counseling from pregnancy to 6 months postpartum and partnership with a local safety-net hospital to implement the Baby Friendly Hospital Initiative and provide lactation support to delivering patients. All WHS participants receive general breastfeeding education from case managers throughout pregnancy (such as information about breastfeeding benefits) and one face-to-face visit from a BFC in the third trimester for more personalized and comprehensive support. WHS collaborates with the largest delivering hospital in the service area, a safety-net provider, to improve the breastfeeding environment and systems of care.

Intervention Results: In the year our model was implemented, 44.6% (49/110) of prenatal WHS participants reported that they planned to breastfeed, and 67.0% (183/273) of delivered partici- pants initiated. Among participants reaching 6 months postpartum, 10.5% (9/86) were breastfeeding. WHS also had 2667 encounters with women delivering at our partner hospital during breastfeeding rounds, with 65.1% of contacts initiating. Community data was not available to assess the efficacy of our model at the local level. However, WHS participants fared better than all delivering patients at our partner hospital, where 65.0% initiated in 2015.

Conclusion: Healthy Start programs are a promising vehicle to improve breastfeeding initiation at the individual and community level. Additional evaluation is necessary to understand barriers to duration and services needed for this population.

Study Design: Evaluation data

Setting: Westside Healthy Start program located in Chicago, IL

Population of Focus: Low-income, African-American women who are pregnant

Sample Size: 652 women

Age Range: Women <17 to 45 years old

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, , HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: The aim of this quality improvement project (QIP) was to improve the engagement of adolescents and young adults (AYAs), aged 14-20, in the process of transitioning from pediatric to adult care.

Intervention Results: Eighty-five AYAs and 40 parents/caregivers completed readiness assessments twice. Scores improved overall, reaching statistical significance with a small change in AYA mean scores for importance (.94) and confidence (.75). Provision of a transition policy and completion of readiness assessments by AYAs and parents/caregivers met the 70% goal. Patient portal enrollments increased from 4.2% to 12.5%, although did not meet the 30% goal.

Conclusion: Engagement of AYAs and parents/caregivers was improved as a result of this QIP. Successful routine implementation of transition process measures demonstrated improved clinic-wide communication.

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): HEALTH_CARE_PROVIDER_PRACTICE, Hospital Policies, Baby Friendly Hospital Initiative,

Intervention Description: The environment in which a women gives birth may be an important determinant of breastfeeding initiation. The impact of the Baby-Friendly Hospital Initiative (BFHI) is not well characterized in the southeastern region of the US where significant breastfeeding disparities persist. The study aimed to evaluate the impact of the BFHI on breastfeeding initiation in North Carolina, with special attention to rural areas.

Intervention Results: Birth at a Baby-Friendly hospital was associated with increased odds of breastfeeding initiation, adjusted odds ratio = 1.7, 95% confidence interval [1.65, 1.89]. Model residuals showed significant clustering by county, with some rural areas’ rates systematically overestimated. Whereas presence of a Baby-Friendly hospital in a mother’s community of residence was not associated with increased initiation, birth at a Baby-Friendly hospital was associated with smaller disparities in initiation between rural and urban births.

Conclusion: Birth at a Baby-Friendly hospital is associated with improved breastfeeding initiation and reduced disparities in initiation between rural and urban counties in North Carolina.

Study Design: Secondary data analysis

Setting: Hospitals in North Carolina

Population of Focus: Mothers with North Carolina residence delivering in a hospital

Sample Size: 137,738 women

Age Range: Mothers older than 18 years of age

Intervention Components (click on component to see a list of all articles that use that intervention): PROFESSIONAL_CAREGIVER, Education/Training (caregiver), Educational Material (caregiver), HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Home Visit (caregiver), Audit/Attestation

Intervention Description: The Maternal Infant Health Outreach Worker (MIHOW) program is an early-childhood home visiting program that uses community health workers (CHWs) to improve health outcomes in underserved communities. To be a MIHOW home visitor, women must be from the target community, be of the same culture and/or language group of families served, have completed all MIHOW training, and use the MIHOW curriculum. This randomized clinical trial evaluated the impact of MIHOW’s use of CHWs on selected maternal/infant outcomes up to 15 months postpartum. All study participants received the minimal education intervention (MEI), which consisted of printed educational materials about health and child development, compared to the intervention group that also received MIHOW home visitation services. Data was collected during interviews conducted by trained data collectors who were fluent in Spanish, also spoke English, and were from the same community.

Intervention Results: Enrolled women (N = 132) were randomly assigned, with 110 women completing the study (MEI = 53; MIHOW = 57). Positive and statistically significant (p < .01) effects of MIHOW were observed on breastfeeding duration, safe sleep practices, stress levels, depressive symptoms, emotional support, referral follow through, parental confidence, and infant stimulation in the home.

Conclusion: Findings provided strong evidence of the effectiveness of MIHOW for improving health outcomes in this sample. Using trained CHWs makes programs such as MIHOW a viable option for providing services to immigrant and underserved families.

Population of Focus: Pregnant Hispanic women living in middle Tennessee

Intervention Components (click on component to see a list of all articles that use that intervention): Nurse/Nurse Practitioner, Planning for Transition, Pediatric to Adult Transfer Assistance, Integration into Adult Care, YOUTH, Education on Disease/Condition, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: A cluster randomized clinical trial was conducted of a nurse-led transition intervention for 16- to 17-year-olds with moderate or complex CHD versus usual care. The intervention group received two 1-h individualized sessions targeting CHD education and self-management skills. The primary outcome was excess time to adult CHD care, defined as the interval between the final pediatric and first adult cardiology appointments, minus the recommended time interval, analyzed by using Cox proportional hazards regression accounting for clustering. Secondary outcomes included scores on the MyHeart CHD knowledge survey and the Transition Readiness Assessment Questionnaire.

Intervention Results: A total of 121 participants were randomized to receive the intervention (n = 58) or usual care (n = 63). At the recommended time of first adult appointment (excess time = 0), intervention participants were 1.8 times more likely to have their appointment within 1 month (95% confidence interval: 1.1 to 2.9; Cox regression, p = 0.018). This hazard increased with time; at an excess time of 6 months, intervention participants were 3.0 times more likely to have an appointment within 1 month (95% confidence interval: 1.1 to 8.3). The intervention group had higher scores at 1, 6, 12, and 18 months on the MyHeart knowledge survey (mixed models, p < 0.001) and the Transition Readiness Assessment Questionnaire self-management index (mixed models, p = 0.032).

Conclusion: A nurse-led intervention reduced the likelihood of a delay in adult CHD care and improved CHD knowledge and self-management skills.

Study Design: Cluster randomizedclinical trial

Setting: Clinic-based (Outpatient clinic)

Population of Focus: Adolescents attending outpatient clinics in 1 of 2 tertiary care pediatric cardiology programs in Canada

Data Source: Questionnaires

Sample Size: 121 (58 intervention, 63 control)

Age Range: 16-17 years

Intervention Components (click on component to see a list of all articles that use that intervention): Nurse/Nurse Practitioner, Education on Disease/Condition, Planning for Transition, HEALTH_CARE_PROVIDER_PRACTICE, YOUTH

Intervention Description: To evaluate the impact of a novel nurse-led transition intervention program designed for young adolescents (age 13-14 years) with congenital heart disease (CHD). We hypothesized that the intervention would result in improved self-management skills and CHD knowledge.

Intervention Results: We randomized 60 participants to intervention (n = 30) or usual care (n = 30). TRANSITION-Q score (range 0-100) increased from 49 ± 10 at baseline to 54 ± 9.0 at 6 months (intervention) vs 47 ± 14 to 44 ± 14 (usual care). Adjusted for baseline score, TRANSITION-Q scores at 1 and 6 months were greater in the intervention group (mean difference 5.9, 95% CI 1.3-10.5, P = .01). MyHeart score (range 0-100) increased from 48 ± 24 at baseline to 71 ± 16 at 6 months (intervention) vs 54 ± 24 to 57 ± 22 (usual care). Adjusted for baseline score, MyHeart scores at 1 and 6 months were greater in the intervention group (mean difference 19, 95% CI 12-26, P < .0001). Participants aged 14 years had a greater increase in TRANSITION-Q score at 6 months compared with 13-year-old participants (P < .05).

Conclusion: A nurse-led program improved transition readiness and CHD knowledge among young adolescents. This simple intervention can be readily adopted in other healthcare settings.

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Training/Education, PROFESSIONAL_CAREGIVER, Education/Training (caregiver), HOSPITAL, Quality Improvement, Promotional Event, Audit/Attestation (Provider)

Intervention Description: Physicians from various units within the hospital system created and led multidisciplinary safe sleep teams. After attending a kickoff event to learn more about infant mortality and sleep related deaths, safe sleep champions from four teams were encouraged to work with their teams to tailor interventions, both specific to the needs of their areas and to address the global aim of county-wide sleep-related death reduction. The teams collaborated and produced a hospital-wide key driver diagram, highlighting the importance of screening, family education, staff education, and hospital reporting interventions. They were encouraged to complete as many Plan-Do-Study-Act (PDSA) cycles as necessary to improve safe sleep practices in both hospital and home settings.

Intervention Results: Our teams have significantly increased compliance with safe sleep practices in the inpatient and neonatal intensive care unit settings (P < 0.01). We have also increased screening and education on appropriate safe sleep behaviors by ED and primary care providers (P < 0.01). Our county's sleep-related death rate has not significantly decreased during the collaborative.

Conclusion: Our collaborative has increased American Academy of Pediatrics-recommended safe sleep practices in our institution, and we decreased sleep-related deaths in our primary care network. We have created stronger ties to our community partners working to decrease infant mortality rates. More efforts will be needed, both within and outside of our institution, to lower our community's sleep-related death rate.

Setting: Nationwide Children’s Hospital and delivery hospitals throughout Columbus Ohio

Population of Focus: Hospital healthcare providers

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Audit/Attestation (provider), PROFESSIONAL_CAREGIVER, Education/Training (caregiver), HOSPITAL, Quality Improvement

Intervention Description: This study evaluates a quality improvement program to improve compliance with appropriate safe sleep practices in both children’s and birthing hospitals. Hospitalists from both settings were recruited to join the Ohio American Academy of Pediatrics’ EASE (Education and Sleep Environment) injury prevention collaborative to increase admitted infant safe sleep behaviors. The collaborative leadership team required hospitalist physician champions at each institution to form and lead multidisciplinary groups composed of other physicians and trainees, nursing leadership, hospital administrators, child life specialists, and other health care providers as deemed necessary. The leadership team educated participating hospital teams about safe sleep evidence-based guidelines, local statistics, quality improvement principles, and the use of Plan Do-Study-Act cycles within their institutions via interactive exercises. Multidisciplinary interventions in the areas of physician and/or nursing staff education, environmental management strategies, policy creation/revisions, and parental support and education were among the interventioned encourages. The Ohio AAP chapter instructed teams to collect data by conducting random audits, using a standardized tool (available by request).

Intervention Results: A total of 37.0% of infants in children's hospitals were observed to follow the current American Academy of Pediatrics recommendations at baseline; compliance improved to 59.6% at the project's end (P < .01). Compliance at birthing centers was 59.3% and increased to 72.5% (P < .01) at the collaborative's conclusion.

Conclusion: This study demonstrates that a quality improvement program in different hospital settings can improve safe sleep practices. Infants in birthing centers were more commonly observed in appropriate sleep environments than infants in children's hospitals.

Setting: 3 Children's hospitals and 6 birthing hospitals in Ohio

Intervention Components (click on component to see a list of all articles that use that intervention): Adult-led Support/Counseling/Remediation, Assessment, YOUTH, HEALTH_CARE_PROVIDER_PRACTICE, EMR Reminder

Intervention Description: This study aimed to assess the feasibility of a CDSS to address caregivers' tobacco use and child tobacco smoke exposure (TSE).

Intervention Results: We screened 185 caregivers whose children were exposed to TSE for study inclusion; 155 (84%) met the eligibility criteria, and 149 (80.5%) were included in the study. Study nurses advised 35.2% of the caregivers to quit, assessed 35.9% for readiness to quit, and assisted 32.4%. Of the 149 participants, 83.1% were female; 47.0% were white and 45.6% African American; 84.6% had public insurance or were self-pay; 71.1% were highly nicotine dependent; 50.0% and 50.7% allowed smoking in the home and car, respectively; and 81.3% of children were biochemically confirmed to be exposed to tobacco smoke. At follow-up (86.6% retention), 58.9% reported quit attempts at 3 months. There was a significant decrease in nicotine dependence and a significant increase in motivation to quit. Self-reported quit rate was 7.8% at 3 months.

Conclusion: An electronic health record-embedded CDSS was feasible to incorporate into busy UC nurses' workloads and was associated with encouraging changes in the smoking behavior of caregivers. More research on the use of CDSS to screen and counsel caregivers who smoke in the UC and other acute care settings is warranted.

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Active Management of Labor, Labor Support, HOSPITAL, STATE, Quality Improvement, Policy/Guideline (State), Collaboratives, Policy/Guideline (Hospital)

Intervention Description: California hospitals whose nulliparous, term, singleton, vertex cesarean delivery rates were above the Healthy People 2020 goal of 23.9% in 2015 were invited to participate in the Supporting Vaginal Birth collaborative led by the California Maternal Quality Care Collaborative (CMQCC). The participating hospitals were organized into small teams of six to eight hospitals each led by a physician and a nurse mentor who provided clinical expertise and quality-improvement coaching. The mentors were from other hospitals and had experience in prior CMQCC quality collaboratives. The collaborative focused on implementation of ACOG–SMFM guidelines for labor management and on increasing nursing labor support. A modified Institute for Healthcare Improvement Breakthrough Series collaborative model was used with monthly team check-in phone calls and sharing of implementation ideas and materials. Hospitals received training materials, Grand Rounds for physicians and nurses, educational webinars, and on-site assistance from their mentors.

Intervention Results: Among collaborative hospitals, the nulliparous, term, singleton, vertex cesarean delivery rate fell from 29.3% in 2015 to 25.0% in 2017 (2017 vs 2015 adjusted OR [aOR] 0.76, 95% CI 0.73-0.78). None of the six safety measures showed any difference comparing 2017 to 2015. As a sensitivity analysis, we examined the tercile of hospitals with the greatest decline (31.2%-20.6%, 2017 vs 2015 aOR 0.54, 95% CI 0.50-0.58) to evaluate whether they had greater risk of poor maternal and neonatal outcomes. Again, no measure was statistically worse, and the severe unexpected newborn complications composite actually declined (3.2%-2.2%, aOR 0.71, 95% CI 0.55-0.92).

Conclusion: Mothers and neonates participating in a large-scale Supporting Vaginal Birth collaborative had no evidence of worsened birth outcomes, even in hospitals with large cesarean delivery rate reductions, supporting the safety of efforts to reduce primary cesarean delivery using American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine guidelines and enhanced labor support.

Setting: 56 California hospitals

Population of Focus: Nulliparous women with term singleton vertex gestations

Intervention Components (click on component to see a list of all articles that use that intervention): Baby Friendly Hospital Initiative, HEALTH_CARE_PROVIDER_PRACTICE, ,

Intervention Description: We aimed to evaluate the effects of the implementation of the Baby-Friendly Hospital Initiative for a proportion of mothers who exclusively breastfed during a 6-month period, including breastfeeding problems, and maternal breastfeeding attitudes.

Intervention Results: The implementation of the Baby-Friendly Hospital Initiative had no effect on the proportion of mothers who exclusively breastfed, and we found no significant differences in exclusive breastfeeding at 6 months (41.3 % vs 52.9 %, p =.435). The intervention did not influence the reported number of breastfeeding problems (p =.260) or maternal breastfeeding attitudes (p =.354). More favourable breastfeeding attitudes (p <.001) and less problematic breastfeeding (p <.001) were associated positively with exclusive breastfeeding.

Conclusion: Exclusive breastfeeding rates did not increase after the intervention; however, the rates at baseline were already high. Ensuring the Baby-Friendly Hospital Initiative practices through pre- and postnatal periods and preparing mothers to manage common breastfeeding problems might improve breastfeeding rates.

Intervention Components (click on component to see a list of all articles that use that intervention): Baby Friendly Hospital Initiative, HEALTH_CARE_PROVIDER_PRACTICE, ,

Intervention Description: To determine healthcare professionals’ breastfeeding attitudes and hospital practices before and after the implementation of the Baby-Friendly Hospital Initiative.

Intervention Results: The healthcare professionals’ breastfeeding attitude scores increased significantly after the implementation of the Baby-Friendly Hospital Initiative, difference = 0.16, (95% CI [0.13, 0.19]) and became breastfeeding favorable among all professional groups in each study unit. Positive changes in breastfeeding-supportive hospital practices were achieved. The infants had significantly more frequent immediate and uninterrupted skin-to-skin contact with their mothers. The rate of early breastfeeding, as well as the number of exclusively breastfed infants, increased.

Conclusion: After the Baby-Friendly Hospital Initiative and Baby-Friendly Hospital Initiative for neonatal wards (Neo-BFHI) interventions were concluded, we found significant improvements in the breastfeeding attitudes of healthcare professionals and in breastfeeding-related care practices.

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Provider Training/Education, Educational Material (Provider), Expert Support (Provider), Participation Incentives, Quality Improvement/Practice-Wide Intervention, Data Collection Training for Staff, Expert Feedback Using the Plan-Do-Study-Act-Tool, Collaboration with Local Agencies (State), Collaboration with Local Agencies (Health Care Provider/Practice), STATE, POPULATION-BASED SYSTEMS, Audit/Attestation, HEALTH_CARE_PROVIDER_PRACTICE, Audit/Attestation (Provider)

Intervention Description: Seven pediatric primary care practices participated in New Mexico's Developmental Screening Initiative in a year-long quality improvement project with the goal of implementing standardized developmental screening tools.

Intervention Results: At baseline, there were dramatic differences among the practices, with some not engaged in screening at all.

Conclusion: Overall, the use of standardized developmental screening increased from 27% at baseline to 92% at the end of the project.

Study Design: QE: pretest-posttest

Setting: Seven primary care practices in a large urban area and small regional community in New Mexico

Population of Focus: Children ages 1 through 60 months

Data Source: Child medical record

Sample Size: Total medical records reviewed at baseline and follow-up (n=1139)

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), 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): Care Coordination, Planning for Transition, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: The study objective was to characterize the feasibility, acceptability, and short-term efficacy of a protocolized transition navigator (TN) intervention in AYA with SCD.

Intervention Results: Ninety-three percent (56/60) of enrolled individuals completed the intervention. Participation in the TN program was associated with significant improvement in mean transition readiness scores (3.58-4.15, P < .0001), disease knowledge scale (8.91-10.13, P < .0001), Adolescent Medication Barriers Scale (40.05-35.39, P = .003) and confidence in both disease (22.5-23.96, P = .048) and pain management (25.07-26.61, P = .003) for youth with SCD.

Conclusion: The TN intervention was acceptable to youth with SCD, feasible to implement at an urban academic medical center, and addressed barriers to transition identified by the youth. Longer-term assessment is needed to determine if the TN intervention improved successful transfer to and retention in adult care.

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Hospital Policies, Baby Friendly Hospital Initiative, HOSPITAL, Policy/Guideline (Hospital)

Intervention Description: The Baby-Friendly Hospital Initiative (BFHI), developed by the World Health Organization (WHO) and United Nations Children's fund, is a global program aimed at promoting, protecting, and supporting breastfeeding. Hospitals in the BFHI community must develop clear policies related to staff training and breastfeeding promotion from pregnancy until hospital discharge following childbirth. The aim of this study was to compare women in non-BFHI-accredited hospitals in a socio-economically homogeneous region of southern Italy (Campania region) with a "baby-friendly hospital," as recognized by UNICEF, in Verbania in the Piedmont region of northern Italy (Castelli Hospital) in terms of 1) breastfeeding in the days following childbirth; 2) the information provided by health personnel before and after childbirth; 3) knowledge about breastfeeding before and during hospitalizations; and 4) participation in antenatal classes.

Intervention Results: In general, both groups showed good basic knowledge about different aspects of breastfeeding. In both regions, about 90% reported that the information received during the antenatal classes simplified the breastfeeding experience.

Conclusion: Our study confirms the importance of systematic promotion of breastfeeding and subsequent delivery of adequate support to maternity departments, in accordance with international guidelines.

Study Design: Evaluation data

Setting: Ten accredited and non-accredited hospitals in the Piedmont region of northern Italy

Population of Focus: Women receiving care at the ten participating hospitals

Sample Size: 786 women (580 in Campania + 206 women in Piedmont)

Age Range: Not reported

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

Intervention Description: N/A

Intervention Results: Although most US adolescents had a usual source of care (91%), only about one-half (51%) had access to a PCMH. Disparities in the prevalence of PCMHs were seen by race/ethnicity, poverty, and having special health care needs. There were lower adjusted odds in having a PCMH for Hispanic (aOR, 0.56; 95% CI, 0.45-0.68) and black adolescents (aOR, 0.55; 95% CI, 0.46-0.66) compared with white adolescents. Those living below 4 times the poverty level had lower adjusted odds of PCMH access. Adolescents with 3-5 special health care needs had lower adjusted odds (aOR, 0.43; 95% CI, 0.35-0.52) of having a PCMH compared with adolescents without any special health care needs. Other than receiving family centered care, every component of PCMH was slightly lower in 2011-2012 compared with 2007.

Conclusion: PCMH access was lower among minorities, those living in poverty, and those with multiple special health care needs. These disparities in PCMH access among these typically underserved groups call for further study and interventions that would make PCMHs more accessible to all adolescents.

Study Design: Data on adolescents ages 12-17 years (n = 34 601) from the 2011-2012 National Survey of Children's Health were used in this cross-sectional study to determine what proportion had access to a PCMH. Multivariable logistic regression was used to calculate the odds of having a PCMH, adjusting for sociodemographic characteristics and special health care needs. Comparisons were made to distribution of PCMH in 2007.

Setting: NSCH survey; United States

Population of Focus: Adolescents

Sample Size: 34601

Age Range: 12/17/2024

Intervention Components (click on component to see a list of all articles that use that intervention): Nurse/Nurse Practitioner, Patient-Centered Medical Home, Notification/Information Materials (Online Resources, Information Guide), PARENT_FAMILY, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: We aimed to integrate nurse care managers to coordinate care for such patients, and then evaluate, if this improved health care utilization.

Intervention Results: Three medical home-based nurse care managers were integrated into four pediatric hospital affiliated practices in a large, urban center. The number of ED visits and inpatient admissions were statistically significantly decreased post-intervention (p < 0.05).There was also a decrease in the number of subspecialty visits, but it was close to the threshold of significance (p = 0.054). There was no impact noted on primary care visits.

Conclusion: This quality improvement project demonstrates that nurse care managers who are integrated into the medical home of CSHCN can potentially decrease the utilization of ED visits and hospital admissions as well as subspecialty visits. Practice implications Nurse care managers can play a pivotal role in medical home redesign for the care of CSHCN.

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): Health_Care_Provider_Practice, Screening Tool Implementation Training, Provider Training/Education

Intervention Description: The ECHO Autism STAT model was designed to provide diagnostic training for PCPs. At the outset of the program, participants attended a 1.5 day training, which included an orientation to the program, an overview of autism symptoms, and specific interactive and hands-on training on administration and interpretation of the STAT. Following the in-person training, PCPs participated in bimonthly 90-min ECHO Autism STAT clinics for 12 months, during which additional training in diagnosis and management of autism was provided through didactics and case-based learning, with an emphasis on evidence-based care and best-practice guidelines for screening, diagnosis, and management.

Intervention Results: Results indicated improvements in PCP practice and self-efficacy, and feasibility of the model for enhancing local access to care.

Conclusion: By combining hands-on training in standardized techniques with ongoing virtual mentorship and practice, the program emphasized both timely diagnosis and appropriate referral for more comprehensive assessment when necessary.

Setting: Pediatric practice

Population of Focus: Primary care peditricians

Intervention Components (click on component to see a list of all articles that use that intervention): Pediatric to Adult Transfer Assistance, Care Coordination, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: To evaluate the impact of structured transition from pediatric to adult inflammatory bowel disease (IBD) services on objective patient outcomes, including disease flares, admission rates, and healthcare resource use.

Intervention Results: A total of 129 patients were included: 95 transition patients and 34 non-transition patients. In the 12 months post-index visit, transition patients had fewer disease flares (P = 0.05), were more likely to be steroid-free (71% vs 41%, P < 0.05), and were less likely to have an emergency department visit leading to hospital admission (5% vs 18%, P < 0.05). During this period, the mean estimated overall cost of care per patient was £1644.22 in the transition group and £1827.32 in the non-transition group (P = 0.21).

Conclusion: Structured transition from pediatric to adult IBD care services was associated with positive and cost-neutral outcomes in patients with pediatric IBD.

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

Intervention Description: The objective of this randomized controlled trial was to examine the perinatal effects of doula support for nulliparous middle-income women accompanied by a male partner during labor and delivery.

Intervention Results: The doula group had a significantly lower cesarean delivery rate than the control group (13.4% vs 25.0%, p = 0.002), and fewer women in the doula group received epidural analgesia (64.7% vs 76.0%, p = 0.008). Among women with induced labor, those supported by a doula had a lower rate of cesarean delivery than those in the control group (12.5% vs 58.8%, p = 0.007). On questionnaires the day after delivery, 100 percent of couples with doula support rated their experience with the doula positively.

Conclusion: For middle-class women laboring with the support of their male partner, the continuous presence of a doula during labor significantly decreased the likelihood of cesarean delivery and reduced the need for epidural analgesia. Women and their male partners were unequivocal in their positive opinions about laboring with the support of a doula.

Study Design: RCT

Setting: University Hospitals in Ohio

Population of Focus: Nulliparous women who gave birth after enrollment in childbirth education classes between 1988 and 2002

Data Source: Not specified

Sample Size: Total (n=420) Intervention (n=224) Control (n=196)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Provider Training/Education, Provision of Safe Sleep Item, HOSPITAL, Quality Improvement, Policy/Guideline (Hospital), Crib Card, Visual Display (Hospital), Sleep Environment Modification, Promotional Event, CAREGIVER, Education/Training (caregiver), Educational Material (caregiver), Attestation (caregiver), HEALTH_CARE_PROVIDER_PRACTICE, Audit/Attestation

Intervention Description: The purpose of this quality improvement project was to promote the AAP safe sleep recommendations and provide appropriate role modeling of these recommendations for hemodynamically stable infants throughout their hospital stay.

Intervention Results: Observations noted an improvement from 70% to 90% (p< 0.01) of infants in a safe sleep position when comparing pre- and postintervention results. There were some improvements in knowledge of and agreement with the AAP guidelines after the educational intervention, but not as much as expected.

Conclusion: There was inconsistency between nursing knowledge and practice about safe infant sleep. Nurses were aware of the AAP recommendations, but it took time to achieve close to full compliance in changing clinical practice. Observation was an important part of this initiative to reinforce knowledge and role model best practice for parents.

Study Design: QE: pretest-posttest

Setting: Golisano Children’s Hospital at the University of Rochester in NY

Population of Focus: Hemodynamically stable infants less than 1 year of age in the mother-baby unit and nine pediatric units

Data Source: Crib audit/infant observation

Sample Size: Baseline (n=65) Follow-up (n=60)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Health_Care_Provider_Practice, Screening Tool Implementation Training, Provider Training/Education

Intervention Description: Each EAE Hub, including clinicians and staff, participated in an on-site multiday intensive training on ASD evaluation. Included in the didactic curriculum were education on developmental screening, structured developmental history and interviewing techniques (including the assessment of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5] ASD symptoms), medical and psychological differential diagnosis and common comorbid concerns, communication skills for delivery of diagnosis, and current evidence regarding ASD interventions.

Intervention Results: Our findings suggest that developing a tiered system of developmental screening and early ASD evaluation is feasible in a geographic region facing health care access problems. Through targeted delivery of education, outreach, and intensive practice-based training, large numbers of young children at risk for ASD can be identified, referred, and evaluated in the local primary care setting.

Conclusion: The EAE Hub model has potential for dissemination to other states facing similar neurodevelopmental health care system burdens. Implementation lessons learned and key system successes, challenges, and future directions are reviewed.

Setting: Intervention sites ranged from large health systems to private pediatric practices

Population of Focus: Clinicians and staff of pediatric practices

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, Hospital Policies, Baby Friendly Hospital Initiative, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: Using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework, this study assessed CHAMPS, which used a Quality Improvement intervention at hospitals, and engaged intensively with local community partners.

Intervention Results: Average hospital breastfeeding initiation rates rose from 56% to 66% (p < 0.05), the proportion of hospitals designated Baby-Friendly or attaining the final stages thereof rose from 15% to 90%, and 80% of Mississippi Special Supplemental Programme for Women, Infants, and Children districts engaged with CHAMPS. CHAMPS also maintains a funded presence in Mississippi, and all designated hospitals have maintained Baby-Friendly status. These findings show that a breastfeeding-focused public health initiative using broad-based strategic programming involving multiple stakeholders and a range of evaluation criteria can be successful.

Conclusion: More breastfeeding promotion and support programmes should assess their wider impact using evidence-based implementation frameworks.

Intervention Components (click on component to see a list of all articles that use that intervention): Residents/Medical Students, Provider Training/Education, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: Medical personnel play a critical role in caregiver safe infant sleep education. However, training outcomes in the safe infant sleep training literature have been mixed. Promising approaches that warrant further investigation are the use of behavioral skills training and pyramidal training. The current study consisted of two experiments.

Intervention Results: Experiment 1 extended Carrow et al. (2020) and Vladescu et al. (2020) by teaching medical students safe infant sleep practices using behavioral skills training. Discriminated responding was examined across trained and untrained environmental arrangements using a multiple-baseline design. All participants arranged safe sleep environments following behavioral skills training. In Experiment 2, we used pyramidal behavioral skills training to train medical students to teach others safe sleep practices. Results indicated high procedural integrity scores following training and generalization of skills.

Conclusion: All participants arranged safe sleep environments following behavioral skills training. In Experiment 2, we used pyramidal behavioral skills training to train medical students to teach others safe sleep practices. Results indicated high procedural integrity scores following training and generalization of skills.

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Residents/Medical Students, PROFESSIONAL_CAREGIVER, Education/Training (caregiver)

Intervention Description: This study consisted of two experiments: 1) Medical students were taught safe sleep practices using behavioral skills training (BST) with an emphasis on sleep positioning (supine), surface, and items in the crib). The training included instruction, modeling, rehearsal, and feedback. 2) Using a pyramidal BST, medical students were trained to teach others safe sleep practices.

Intervention Results: Results indicated high procedural integrity scores following training and generalization of skills.

Conclusion: Pyramidal BST participants were provided with a training manual that included a written protocol of the training procedures, a checklist of the training components, data sheets, a safe infant sleep brochure, and a list of common questions about safe infant sleep with corresponding answers. Responses were examined pre- and post-training using a multiple-baseline design.

Setting: Urban university

Population of Focus: Medical students

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, Provider Training/Education, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: A pediatric group with 25 clinics and 150 providers used multifaceted approaches to implement workflow processes and an electronic health record (EHR) flowsheet to improve child developmental screening.

Intervention Results: Within 25 months, screening rates improved from 60% to >95% within the 3 preventive visit age groups for a total of more than 30 000 children. Professionals valued the team process improvements. Children enrolled in Medicaid, black children, and those living in lower income zip codes had lower screening rates than privately insured, white children, and those living in higher income areas. Ages and Stages Questionnaire 3rd edition results were significantly different by gender, race/ethnicity, insurance, and income categories across all groups. Referral rates varied by race/ethnicity and zip code of residence.

Conclusion: This project resulted in an effective and efficient process to improve child developmental screening that was valued by pediatric professionals. Analyses of patient demographics revealed disparities in services for the most vulnerable families. Ongoing quality improvement, health services research, and advocacy offer hope to improve health equity.

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): Quality Improvement/Practice-Wide Intervention, Peer Counselor, HEALTH_CARE_PROVIDER_PRACTICE, PATIENT_CONSUMER

Intervention Description: A breastfeeding-friendly physician’s office that applies the 13 recommendations of the Academy of Breastfeeding Medicine can help increase the exclusivity and duration of breastfeeding. Having already published the results up to five months of age of this intervention in our pediatric practice, we now report on the follow up to 36 months.

Intervention Results: The rates of any breastfeeding at discharge and at 1, 3 and 5 months (n = 252) were 95.2, 95.8, 89.3 and 86.5%, respectively. At 8, 12, 18, 24 and 36 months of age, the rates of breastfeeding were 70.6% (163/231), 59% (135/229), 35% (78/224), 24.6% (55/224) and 7.2% (16/224), respectively.

Conclusion: The rates of any breastfeeding recorded in our pediatric practice up to age 36 months, are much higher than those reported elsewhere in high income countries and are likely to be associated with our baby-friendly and biological nurturing approach.

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, PROFESSIONAL_CAREGIVER, Education/Training (caregiver), Provision of Safe Sleep Item, HOSPITAL, Quality Improvement, Sleep Environment Modification, Policy/Guideline (Hospital), Audit/Attestation

Intervention Description: The hospital’s safe sleep task force (SSTF) implemented targeted interventions using the American Academy of Pediatrics (AAP) policy statement as the gold standard and based on hospital data/crib audits to address areas of greatest nonadherence to recommendations. The SSTF created a standalone Infant Safe Sleep Policy for all infants admitted to the hospital; provided education on safe sleep to health care providers; created a patient education video for parents of all hospitalized infants; increased its Halo sleep sack allotment; and revised the room set-up to encourage adherence to AAP’s safe sleep guidelines. A safe sleep audit tool was used by clinical assistant or nurse (per hospitalized sleeping session) to assess adherence to safe sleep guidelines. The overall aim of the initiative was to increase the average weekly adherence to the AAP-recommended safe sleep practices for hospitalized infants to ≥95% over 12 months.

Intervention Results: There was a significant improvement in overall adherence to safe sleep recommendations from baseline (M = 70.8%, SD 21.6) to end of study period (M = 94.7%, SD 10.0) [t(427) = -15.1, P ≤ 0.001]. Crib audits with 100% adherence increased from a baseline (M = 0%, SD 0) to the end of the study period M = 70.4%, SD = 46) [t(381)= -21.4, P ≤ 0.001]. This resulted in two trend shifts on the p-chart using Institute for Healthcare Improvement control chart rules.

Conclusion: Targeted interventions using QI methodology led to significant increases in adherence to safe sleep guidelines. Notable improvements in behavior indicated significant changes in safe sleep culture. We also noted continued adherence in follow-up audits reflecting sustainability.

Setting: Tertiary children's hospital

Population of Focus: Hospital healthcare providers

Intervention Components (click on component to see a list of all articles that use that intervention): Technology-Based Support, PATIENT_CONSUMER, Midwifery, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: One specific form of support that is under researched is the use of Breastfeeding Support Facebook (BSF) groups that are aimed at supporting women in specific local areas, often with links to face to face support. Initial research highlights that mothers’ value these groups but the role that midwives play in offering support to local mothers through these groups has not been examined. The aim of this study was therefore to examine mothers’ perceptions of midwifery support for breastfeeding delivered through these groups, specifically when midwives played an active role in being a group ‘moderator’ or leader.

Intervention Results: Moderation was an important factor in mothers’ experiences, with trained support associated with greater engagement and more frequent visits, impacting on perceptions of group ethos, reliability and inclusivity. Midwife moderation was uncommon (5% of groups) but valued: midwife moderators offered a high level of support to mothers in their groups, with 87.5% having received midwife support often or sometimes and 97.8% rating this useful or very useful. Access to a midwife moderated group was also associated with viewing local face to face midwifery support for breastfeeding more positively. This is a significant finding, highlighting that online support complements face-to-face support in local settings (67% of groups were linked to a physical group), and improves continuity of care (14% of mothers who had midwife moderators received care from them). As such midwife moderated or supported groups have the potential to add value to local face to face services and improve breastfeeding experiences in communities.

Conclusion: The findings have important implications to support the development of integrated online interventions to improve public health.

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Transition Assistance, HEALTH_CARE_PROVIDER_PRACTICE, PATIENT_CONSUMER

Intervention Description: This study evaluated the services delivered within a care coordination program at a transition consultation center for CSHCN. It also compared the advancement of youth by age group toward graduation criteria.

Intervention Results: The comparison of services for those with diagnoses of autism spectrum disorder, cerebral palsy and Down syndrome were uniformly high in supporting primary care and health care financing. Medicaid waiver assistance was provided more frequently to younger adolescents while older adolescents more commonly received support in all other graduation criteria, including primary and specialty care, healthcare financing and decision-making supports.

Conclusion: Youth served in a transition care coordination program receive a high volume and broad array of services. There are some variations in the types of services by diagnosis and level of support need. Older youth show greater advancement toward graduation criteria. Practice implications: This in-depth chart review provides a valuable description of the activities of care coordinators serving CSHCN enduring transition. It enables development of targeted strategies for building care coordination programming and sets an example for the design of future research studies on this topic.

Intervention Components (click on component to see a list of all articles that use that intervention): Nurse/Nurse Practitioner, Quality Improvement/Practice-Wide Intervention, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: The purpose of this study was to develop and implement a transition process planning and communication tool to facilitate transition planning among multiple, pediatric subspecialties within a system-wide transition program.

Intervention Results: Implementation of the tool was feasible and corresponded with increased transition planning documentation post-implementation. Nurses represented 33% of the sample that utilized the tool. Survey results revealed barriers to documentation and utilization of the tool, along with strategies for improvement.

Conclusion: This study demonstrates that health professionals, especially pediatric nurses and nurse practitioners, are willing to adopt new, electronic documentation tools to enhance multidisciplinary transition planning consistent with best practices. Future studies should address identified barriers, assess the effectiveness of the tool on improving transition outcomes, and consider implications for integration into global health care models. System-wide implementation of such tools may improve multidisciplinary communication and coordination of care for youth with special health care needs.

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, EMR Reminder, PATIENT_CONSUMER, Telephone Support

Intervention Description: Parents completed the PSC-17P electronically before the visit and the scored data were immediately available in the patient's chart. Using billing and screening data, the study tracked rates of overall and positive screening during the first-year baseline (4 months) and full implementation phases of the project in the first (8 months) and second (12 months) year.

Intervention Results: A total of 35,237 patients completed a WCV in the first year. There was a significant improvement in PSC-17P screening rates from the first-year baseline (26.3%) to full implementation (89.3%; P < .001) phases. In the second year, a total of 40,969 patients completed a WCV and 77.9% (n = 31,901) were screened, including 18,024 patients with screens in both years. PSC-17P screening rates varied significantly across the 18 locations and rates of PSC-17P risk differed significantly by practice, insurance type, sex, and age.

Conclusion: The current study demonstrated the feasibility of routine psychosocial screening over 2 years using the electronically administered PSC-17P in a network of pediatric practices. This study also corroborated past reports that PSC-17 risk rates differed significantly by insurance type (Medicaid vs commercial), sex, and age group.

Setting: Pediatric practies

Population of Focus: Parents and caregivers

Intervention Components (click on component to see a list of all articles that use that intervention): Adult-led Support/Counseling/Remediation, Referrals, Educational Material, YOUTH, PATIENT_CONSUMER, HEALTH_CARE_PROVIDER_PRACTICE, Screening Tool Implementation

Intervention Description: The obective of this study was to describe innovations added to the CEASE intervention and to track 2 year post-intervention implementation data on families who were screened for tobacco use.

Intervention Results: Electronic screening was used to routinely identify tobacco users, leading to increased potential for offering cessation assistance to all household members who smoke.

Conclusion: Improved delivery of smoking cessation services to families may be achieved by integrating technological innovations into routine pediatric practice.

Intervention Components (click on component to see a list of all articles that use that intervention): School-Based Dental Services, CLASSROOM_SCHOOL, HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education

Intervention Description: This community intervention study compared the changes in oral health knowledge, attitude, practices (KAP), and oral health indicators among 12-14-year-old children who received a school based oral health promotion delivered by auxiliaries in a rural setting in India.

Intervention Results: The improvement in total KAP score, oral hygiene, and gingival bleeding from baseline to follow up was higher in the intervention arm (p < 0.05). The prevented fraction for net caries increment were 23.33% and 20.51% for DMFT and DMFS, respectively. Students in the intervention group had a higher dental attendance (OR 2.92, p < 0.001). The change in treatment index, restorative index, and care index were significantly higher in the intervention arm (p < 0.001).

Conclusion: Inclusion of available primary care auxiliaries like school health nurses and teachers in oral health promotion is a novel, effective, and sustainable strategy to improve oral health indicators and utilization in rural areas in low resource settings.

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

Intervention Description: Low-risk nulliparous women gave birth at interprofessional centers with both midwives and physicians, and this data was compared to low-risk women who gave birth at noninterprofessional centers without midwives. The study is based on Consortium on Safe Labor data from low-risk nulliparous women who birthed in interprofessional (n = 7393) or noninterprofessional centers (n = 6982).

Intervention Results: There was concordance across logistic regression models, the most restrictive and conservative of which were propensity-matched models. With this approach, women at interprofessional medical centers, compared with women at noninterprofessional centers, were 74% less likely to undergo labor induction (risk ratio [RR] 0.26; 95% CI 0.24-0.29) and 75% less likely to have oxytocin augmentation (RR 0.25; 95% CI 0.22-0.29). The cesarean birth rate was 12% lower at interprofessional centers (RR 0.88; 95% CI 0.79-0.98). Adverse neonatal outcomes occurred in only 0.3% of births and were thus too rare to be modeled.

Conclusion: The care processes and birth outcomes at interprofessional and noninterprofessional medical centers differed significantly. Nulliparous women receiving care at interprofessional centers were less likely to experience induction, oxytocin augmentation, and cesarean than women at noninterprofessional centers. Labor care and birth outcome differences between interprofessional and noninterprofessional centers may be the result of the presence of midwives and interprofessional collaboration, organizational culture, or both.

Setting: Interprofessional care centers with midwifes; non-interprofessional care centers

Population of Focus: Low-risk nulliparous pregnant women

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Referrals, HEALTH_CARE_PROVIDER_PRACTICE, PATIENT_CONSUMER, Telephone Support

Intervention Description: Children ages 12 to 42 months old who receive well-child care at a community health center serving predominantly Hispanic families were recruited and randomly assigned to intervention and control groups. Families in the intervention group were connected with 2-1-1, in which a trained care coordinator conducted developmental screening over the phone using the Parental Evaluation of Development Status Online system and made referrals to intervention services on the basis of developmental risk. The 2-1-1 care coordinator then followed-up with families to assist with connections to evaluations and services.

Intervention Results: One hundred and fifty-two children were randomly assigned to intervention (n = 77) and control (n = 75) groups. On the basis of intention-to-treat analyses, significantly more children assigned to the intervention group were referred (32% vs 9%; P = .001) and were receiving services (16% vs 1%; P = .002) within 6 months compared with children assigned to usual care alone.

Conclusion: Telephone-based developmental screening and care coordination through 2-1-1 appears to be an effective approach for increasing the numbers of young children referred to, and receiving, intervention services for developmental delays.

Setting: Community-based

Population of Focus: Children and families

Intervention Components (click on component to see a list of all articles that use that intervention): Baby Friendly Hospital Initiative, HEALTH_CARE_PROVIDER_PRACTICE, ,

Intervention Description: (1) To determine the breastfeeding rate during the first 6 months of life in children of mothers diagnosed with COVID-19 infection at the time of birth; and (2) to assess the possible influence of being born in a center with Baby-Friendly Hospital Initiative accreditation.

Intervention Results: A total of 117 (47.3%) newborns were born in Baby-Friendly Hospital Initiative (BFHI) accredited centers. These centers applied skin-to-skin contact with greater probability (OR = 1.9; 95% CI [1.18, 3.29]) and separated the newborns from their mothers less frequently (OR = 0.46; 95% CI [0.26, 0.81]) than non-accredited centers. No differences were observed in relation to the presence of a companion at the time of birth. At discharge, 49.1% (n = 57) of newborns born in BFHI-accredited centers received exclusive breastfeeding versus 35.3% (n = 46) in non-accredited centers (p = .03). No differences were observed in breastfeeding rates throughout follow-up.

Conclusion: The exclusive breastfeeding rate at discharge in children of mothers with COVID-19 infection at birth was higher in Baby-Friendly Hospital Initiative accredited centers, which most frequently applied skin-to-skin contact at birth as well as rooming-in.

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Hospital Policies, Baby Friendly Hospital Initiative,

Intervention Description: A recent effort exists to increase the number of Baby-Friendly designated hospitals in Los Angeles County (LAC). At the time that data for this study were collected (August 2014), 16 hospitals had obtained the designation. Sixteen months later (December 2015), another 11 joined the ranks, bringing the total number of Baby-Friendly designated hospitals in LAC to 27. With such a drastically changing scene in birthing hospitals, it is important to document whether there have been corresponding increases in Baby-Friendly hospital practices in LAC and whether being born in a Baby-Friendly designated hospital is associated with improved breastfeeding outcomes in the low-income population in the county.

Intervention Results: The rates of Baby-Friendly hospital practices have improved since 2008. Although no association existed with rates of any breastfeeding, being born in a hospital designated Baby-Friendly or in the process of obtaining this designation was significantly associated with an increased odds of exclusive breastfeeding at 1 and 3 months.

Conclusion: The BFHI may help achieve recommended exclusive breastfeeding rates, especially for low-income populations. Additional strategies are needed to support low-income mothers in LAC with all levels of breastfeeding.

Study Design: Parent reported phone survey

Setting: Los Angeles County hopsitals

Population of Focus: 5,000 WIC families living in Los Angeles County completing the LAC WIC survey

Sample Size: 4,873 infants

Age Range: Infants under 2 years of age

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Nurse/Nurse Pratitioners, HOSPITAL, Quality Improvement, Crib Card, Audit/Attestation

Intervention Description: This quality improvement pilot program used a bundle approach to create a safe sleep program that consisted of safe sleep education for NICU nurses, the creation and implementation of safe sleep cards, and revision of the institution’s safe sleep policy. To assess safe sleep practices, sleep environment audits were completed pre- and post-safe sleep program. To assess nurses’ safe sleep knowledge, a safe sleep questionnaire was delivered pre- and post-education.

Intervention Results: The change in SSP (ΔSSP) following safe sleep program implementation and change in nurses' safe sleep knowledge (ΔKnowledge) following education.

Conclusion: SSP increased from 25 percent to 61 percent compliance, and nurses' knowledge scores increased from 83 percent to 97 percent.

Setting: Level III NICU

Population of Focus: Hospital staff

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Labor Support, Midwifery, HOSPITAL, Chart Audit and Feedback, Peer Review, Quality Improvement

Intervention Description: This quality improvement initiative involved multiple interventions that were monitored over time by statistical process control charts. Components included a nested case-control review of local risk factors, provider and patient education, multidisciplinary reviews based on published guidelines with feedback, provider report cards, commitment to labor duration guidelines, and a focus on natural labor. The nursing team received training and certification in holistic nursing, and certified nurse-midwives were employed and given delivery privileges. The six-bed Karmanos Center for Natural Birth (NBC) was opened in November 2014 for low-risk women who were managed without continuous fetal monitoring, epidural analgesia, and obstetrical interventions.

Intervention Results: Control chart analysis demonstrated that the institutional cesarean delivery rate was due to culture and not "outlier" obstetricians. The primary singleton vertex cesarean rate decreased from 23.4% to 14.1% and the NTSV rate decreased from 34.5% to 19.2% (both p < .0001). There was a decrease in NICU admission but no significant changes in postpartum hemorrhage, chorioamnionitis, stillbirth, or neonatal mortality.

Conclusion: Structured quality improvement initiatives may decrease primary cesarean deliveries without increasing maternal or perinatal morbidity.

Setting: Beaumont Hospital, Royal Oak, an academic-community hybrid facility in southeastern Michigan

Population of Focus: Nulliparous women with term singleton vertex gestations

Intervention Components (click on component to see a list of all articles that use that intervention): Integration into Adult Care, Transition Assistance, Care Coordination, PATIENT_CONSUMER, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: In 2018, we initiated a transition clinic structure, integrating an Internal Medicine - Pediatrics trained Adult Rheumatologist in a Pediatric Rheumatology clinic to guide this transition. Our goal was to improve transition outcomes. We report the methods of this clinic and its preliminary outcomes.

Intervention Results: The transition clinic Adult Rheumatologist saw 177 patients in 2 years, and 57 patients were eligible for, approached, and successfully enrolled in the registry. From this registry, all patients reviewed the Transition Policy with the Adult Rheumatologist and 45 (78.9%) completed at least one Transition Readiness Assessment. Of the 22 patients for whom transition was indicated, all were successfully transitioned to an Adult Rheumatologist. 17 (77.3%) continued care post-transition with the transition clinic Adult Rheumatologist, and 5 (22.7%) continued care post-transition with a different Adult Rheumatologist. The median time between the last transition clinic visit and first Adult clinic visit was 5.1 months.

Conclusion: Our results are an improvement over transition rates reported elsewhere that did not implement our model. We believe that this structure could be applied to other primary care and subspecialty clinics.

Intervention Components (click on component to see a list of all articles that use that intervention): Transition Assistance, Pediatric to Adult Transfer Assistance, Integration into Adult Care, PATIENT_CONSUMER, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: The transition of patients with Prader-Willi syndrome (PWS) to adult life for medical care is challenging because of multiple comorbidities, including hormone deficiencies, obesity and cognitive and behavioral disabilities. To assess endocrine management, and metabolic and anthropometric parameters of PWS adults who received (n = 31) or not (n = 64) transitional care, defined as specialized pediatric care followed by a structured care pathway to a multidisciplinary adult team.

Intervention Results: Among the entire cohort, 35.8% received growth hormone (GH) during childhood and 16.8% had a GH stimulation test after completion of growth. In adulthood, 14.7% were treated with GH, 56.8% received sex-hormone therapy, whereas 91.1% were hypogonadic and 37.9% had undergone valid screening of the corticotropic axis. The main reason for suboptimal endocrine management was marked behavioral disorders. Patients receiving transitional care were more likely to have had a GH stimulation test and hormonal substitutions in childhood. They also had a lower BMI, percentage of fat mass, improved metabolic parameters and fewer antidepressant treatments. Transitional care remained significantly associated with these parameters in multivariate analysis when adjusted on GH treatment.

Conclusion: A coordinated care pathway with specialized pediatric care and transition to a multidisciplinary adult team accustomed to managing complex disability including psychiatric troubles are associated with a better health status in adults with PWS.

Study Design: Retrospective cohort study

Setting: Hospital/clinicbased

Population of Focus: Age 16 or older with Prader-Willi syndrome

Data Source: Medical records, survey

Sample Size: 95; 31 Intervention group, 64 Non- intervention group

Age Range: 16-19 years

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Labor Support, Provider Training/Education, HOSPITAL, Guideline Change and Implementation, Quality improvement

Intervention Description: This was a quality improvement project and practice change was part of the Reducing Primary Cesarean Learning Collaborative from the American College of Nurse-Midwives. It was designed to increase nurse self-efficacy and the use of continuous labor support and to reduce the rate of primary cesarean births among nulliparous women with low-risk pregnancies. The multi-component intervention, called the “Comfort in Labor Safety Bundle,” included updating existing labor policies, providing nurse education and training workshops, modifying the documentation of care, and procuring labor support equipment. Nurse confidence and skill in labor support techniques was measured using the Self-Efficacy Labor Support Scale. The study also tracked how many women were provided continuous labor support and the primary cesarean birth rate among women who were nulliparous and low risk.

Intervention Results: Nurses' mean self-efficacy scores increased from 76.67 in 2016 to 86.96 in 2019 (p < .001). The proportion of women who were provided continuous labor support increased from a baseline of 4.38% (47/1,074) in January 2015 through March 2016 to 18.06% (82/454) in July through December 2019 (p < .001). The primary cesarean birth rate for nulliparous women with low-risk pregnancies remained stable, at approximately 18% from 2015 to 2019.

Conclusion: Implementation of the Comfort in Labor Safety Bundle improved nurse self-efficacy in labor support techniques and increased the frequency of continuous labor support.

Setting: Level II regional hospital in Virginia

Population of Focus: Nulliparous women with low risk pregnancies

Intervention Components (click on component to see a list of all articles that use that intervention): Patient-Centered Medical Home, Nurse/Nurse Practitioner, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: To examine the workforce transformation occurring in community health centers that have achieved PCMH status, and to assess the relationship of those changes to utilization, as measured by the number of visits.

Intervention Results: We found that adopting a PCMH model was significantly associated with a growth in use of advanced practice staff (nurse practitioners and physician assistants) [0.53 full-time equivalent (FTE), 8.77%; P<0.001], other medical staff (medical assistants, nurse aides, and quality assurance staff) (1.23 FTE, 7.46%; P=0.001), mental health/substance abuse staff (0.73 FTE, 17.63%; P=0.005), and enabling service staff (case managers and health educators) (0.36 FTE, 6.14%; P=0.079), but not primary care physicians or nurses. We did not observe a significant increase in utilization, as measured in total number of visits per year. However, the visits marginally attributed to advanced practice staff (539 FTE, 0.89%; P=0.037) and mental health/substance abuse staff (353 FTE, 0.59%; P=0.051) significantly increased.

Conclusion: Our findings suggest that the implementation of PCMH actively reengineers staff composition and this, in turn, results in changes in marginal utilization by each staff type.

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): Collaboration with Local Agencies (State), Patient-Centered Medical Home, STATE, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: This issue of the Rhode Island Medical Journal (RIMJ) chronicles the development and implementation of a statewide initiative, Patient-Centered Medical Homes for Kids (PCMH-Kids), which now impacts the health care of nearly 100,000, or half of the children living in Rhode Island.

Intervention Results: integration of behavioral health (BH) into pediatric primary care was a key focus of PCMH-Kids. BH needs in children present as pre-clinical or subclinical findings, and presents emerging social-emotional challenges for children and parents.

Conclusion: This issue of the Rhode Island Medical Journal (RIMJ) chronicles the development and implementation of a statewide initiative, Patient-Centered Medical Homes for Kids (PCMH-Kids), which now impacts the health care of nearly 100,000, or half of the children living in Rhode Island.

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, HEALTH_CARE_PROVIDER_PRACTICE, STATE

Intervention Description: Each participating practice was paired with a transformation coach who assessed the practice and, with the office team, crafted a work plan to facilitate practice transformation. Plans included clarification of roles/job descriptions, team building, data capturing and reporting systems, behavioral health integration plans and care coordination needs and capabilities. All practices reported their quality metrics quarterly, uploading their data to a shared data repository. Additionally, all practices participated in collaborative learning, sharing best practices and lessons learned in quarterly meetings for care coordination, data reporting, integrated behavioral health and practice transformation.

Intervention Results: Through shared learning and practice coaching the cohort 1 practices implemented work flows and data and analysis metrics that address the contracted measures. Supported by strong transformation coaching and support, all practices achieved NCQA 3 recognition within the first contract year. In year two, 100% of the cohort 1 practices met both quality metrics for developmental screening and growth monitoring and counseling and posted improvement over time. [Figures 1 and 2] Patient and family satisfaction was high at baseline and 67% of the practices met the improvement benchmarks for customer service measure for access, communication and office staff. PCMH-Kids practices successfully decreased Emergency Department (ED) utilization and had a 2.5% reduction in ED usage compared to the peer group (rate for 1,000-member-months, excluding ERISA members).

Conclusion: PCMH-Kids practices successfully decreased Emergency Department (ED) utilization and had a 2.5% reduction in ED usage compared to the peer group (rate for 1,000-member-months, excluding ERISA members).

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Nurse/Nurse Practitioner, PROFESSIONAL_CAREGIVER, Education/Training (caregiver), HOSPITAL, Quality Improvement, Crib card, Audit/Attestation

Intervention Description: A multidisciplinary team developed a quality improvement initiative to create a hospital-based safe sleep environment for all newborns and infants prior to discharge. The safe sleep initiative included two key elements: (1) parent education about safe infant sleep that included verifying their understanding of safe sleep, and (2) modeling of safe infant sleep environment by hospital staff. To monitor compliance, documentation of parent education, caregiver surveys, and hospital crib check audits were tracked monthly. A visual safe sleep “crib ticket”—a checklist of safe sleep guidelines-- was placed at the bedside of newborns who were ready for supine positioning. Investigators used Plan-Do-Study-Act (PDSA) cycles to evaluate the impact of the initiative from October 2015 through February 2018.

Intervention Results: Safe sleep education was documented for all randomly checked records (n = 440). A survey (n = 348) revealed that almost all caregivers (95.4%) reported receiving information on safe infant sleep. Initial compliance with all criteria in WBN (n = 281), NICU (n = 285), and general pediatric inpatient units (n = 121) was 0%, 0%, and 8.3%, respectively. At 29 months, WBN and NICU compliance with all criteria was 90% and 100%, respectively. At 7 months, general pediatric inpatient units' compliance with all criteria was 20%.

Conclusion: WBN, NICU and general pediatric inpatient unit collaboration with content experts led to unit-specific strategies that improved safe sleep practices.

Setting: Well-baby nursery (WBN) and NICU in an academic, quaternary care, regional referral center

Population of Focus: Hospital staff

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Nurse/Nurse Practitioner, HOSPITAL, Quality Improvement

Intervention Description: The primary goals of the initiative were to improve nurses' adherence to the 2016 AAP safe sleep recommendations, including the supine infant sleep position, and to increase role modeling of a safe infant sleep environment. The initiative included a slide-show presentation on SUID, the AAP 2016 recommendations for infant safe sleep, rationale behind the recommendations, and common barriers to following the safe sleep guidance. The post-intervention evaluation included testing of nurses' knowledge, infant crib audits, and nurses' evaluation of the intervention.

Intervention Results: A significant improvement was found in overall nurse education scores. Crib audits demonstrated a significant improvement in the following elements: use of multiple blankets, swaddling of the infant, and parent teaching. Nursing surveys reported an increase in confidence to practice safe sleep recommendations and educate and redirect parents.

Conclusion: Implementing a safe sleep initiative can increase nurses' knowledge, improve adherence to recommendations with modeling safe sleep practices, and increase parent awareness of safe sleep recommendations, potentially positively affecting adherence after discharge.

Setting: Community hospital in a women's services unit

Population of Focus: Full-time nurses and infant care technicians

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Nurse/Nurse Practitioner

Intervention Description: The purpose of this quality improvement initiative was to increase the percentage of eligible infants being placed in safe sleep environments by registered nurses in a NICU. An evidence-based safe sleep bundle was developed and implemented in a level IV NICU at an academic medical center in the Southeastern United States. Data were subsequently collected for 5 months via biweekly crib audits.

Intervention Results: Of the 744 infants audited in the QI period, 604 were observed in a safe sleep environment. From the pre- to postintervention period, SSPs increased by 68% (preintervention: 13%, postintervention: 81%, P value < .001). Adherence to the varying components of SSPs also reflected statistically significant improvements.

Conclusion: SSPs should be endorsed and modeled in all NICUs. Introducing proper SSPs in the hospital setting may lead to better compliance at home by the infants' caregivers.

Setting: Academic medical institution in Southeast U.S.

Population of Focus: Registered nurses in NICU

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement, Provider Training/Education, HOSPITAL, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: The purpose of this QI initiative was to increase the percentage of eligible infants being placed in safe sleep environments by registered nurses in a NICU.

Intervention Results: Of the 744 infants audited in the QI period, 604 were observed in a safe sleep environment. From the pre- to postintervention period, SSPs increased by 68% (preintervention: 13%, postintervention: 81%, P value < .001). Adherence to the varying components of SSPs also reflected statistically significant improvements.

Conclusion: SSPs should be endorsed and modeled in all NICUs. Introducing proper SSPs in the hospital setting may lead to better compliance at home by the infants' caregivers.

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage, HEALTH_CARE_PROVIDER_PRACTICE, Collaboration with Local Agencies (State), PROFESSIONAL_CAREGIVER, Outreach (caregiver), PATIENT_CONSUMER, Referrals, STATE, Mini Grants, Public Insurance (State)

Intervention Description: Small grants to community-based organizations have been shown to be effective in garnering the involvement of the local community in health promotion efforts. The Georgia Utilization Mini-grant Program leveraged modest funding and resources to promote community involvement to improve enrollment and utilization of Medicaid and CHIP services for children. It demonstrates how a state Medicaid agency can step outside its usual administrative role to play an important part in supporting local outreach and marketing efforts to promote Medicaid/CHIP enrollment and utilization.

Intervention Results: Funded community-based organizations improved utilization of children’s health services by developing innovative staffing patterns, creating new data systems for scheduling appointments and maintaining records, and forging new collaborative relationships to leverage financial support. Responses suggest that the program improved levels of enrollment, appointment-setting and referrals for social and other services. Common facilitators and barriers to success and ways to address them were also identified.

Conclusion: Elaboration on each of the facilitators of success led to the development of several recommendations as guidance for future outreach funding programs such as: staffing, data systems, collaboration and how to address incentives and barriers.

Study Design: Participatory approach

Setting: Community (Community-based organizations)

Population of Focus: Children enrolled in Medicaid and PeachCare

Data Source: Questionnaires, telephone interviews, one-on-one counseling, application assistance, home visits

Sample Size: 6 organizations

Age Range: Children; specific ages not stated

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, STATE, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: This article summarizes the key, consensus-based financing elements to providing quality, effective, comprehensive care in the pediatric medical home: (1) first dollar coverage without deductibles, copays, or other cost-sharing for necessary preventive care services as recommended by Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents; (2) adoption of a uniform definition of medical necessity across payers that embraces services that promote optimal growth and development and prevent, diagnose, and treat the full range of pediatric physical, mental, behavioral, and developmental conditions, in accord with evidence-based science or evidence-informed expert opinion; (3) payment models that promote appropriate use of pediatric primary care and pediatric specialty services and discourage inappropriate, inefficient, or excessive use of medical services; and (4) payment models that strengthen the patient- and family-physician relationship and do not impose additional administrative burdens that will only erode the effectiveness of the medical home.

Intervention Results: Some programs are demonstrating positive results.43 On the other hand, pay-for-performance programs are still evolving. Many adult programs have features that are not pertinent to improving care provided to children or that cannot easily be translated into pediatric equivalents.

Conclusion: For a medical home for children to be both effective and fiscally viable, payers must adequately finance the full range of services required to optimize the physical, developmental, emotional, and behavioral well-being of children, which critically influence health throughout the life course. Some support is required to engage families initially with the medical home. Once engaged, appropriate support is needed for encounters, care coordination, continuous quality improvement, implementation of an effective electronic health record system, and innovative efforts to improve community health. This support should not impose additional administrative burdens that will erode the effectiveness of the medical home. Payers should consider how best to achieve better health care value without encouraging fragmented care outside the medical home.

Intervention Components (click on component to see a list of all articles that use that intervention): Planning for Transition, Pediatric to Adult Transfer Assistance, Care Coordination, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: We identified and treated young adults with type 1 diabetes who had been lost to follow-up during their transfer from pediatric to adult care, comparing their clinical, psychosocial, and health care utilization outcomes to participants receiving continuous care (CC) throughout the transition to adult care. Individuals in their last year of pediatric care (CC group, n = 51) and individuals lost to follow-up in the transfer to adult care ("lapsed care" [LC] group, n = 24) were followed prospectively for 12 months. All participants were provided developmentally tailored diabetes education, case management, and clinical care through a structured transition program.

Intervention Results: At baseline, LC participants reported lapses in care of 11.6 months. Compared with CC participants, they had higher hemoglobin A1C (A1C; p = .005), depressive symptoms (p = .05), incidence of severe hypoglycemia (p = .005), and emergency department visits (p = .004). At 12-month follow-up, CC and LC participants did not differ on the number of diabetes care visits (p = .23), severe hypoglycemia (no events), or emergency department visits (p = .22). Both groups' A1C improved during the study period (CC: p = .03; LC: p = .02). LC participants' depressive symptoms remained elevated (p = .10), and they reported a decline in life satisfaction (p = .007). There was greater loss to follow-up in the LC group (p = .04).

Conclusion: Our study suggests that, for young adults with a history of lapses in care, a structured transition program is effective in lowering A1C, reducing severe hypoglycemia and emergency department utilization, and improving uptake of routine diabetes care. Loss to follow-up and psychosocial concerns remain significant challenges in this population.

Study Design: Prospective cohort

Setting: Hospital-based

Population of Focus: Young people with type 1 diabetes

Data Source: Surveys, A1c readings, medical records

Sample Size: Continuous care = 51; Lapsed care = 24

Age Range: 19-25 years of age

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): HEALTH_CARE_PROVIDER_PRACTICE, Active Management of Labor, Labor Support, Midwifery, Prolonged Second Stage of Labor, HOSPITAL, Chart Audit and Feedback, Guideline Change and Implementation

Intervention Description: 419 consecutive patients were divided into two groups, with one group (216 patients) receiving “standard management” (with medical acceleration of labor commencing at the ‘‘action line’’ in the case of arrested or protracted labor) and the other group (203 patients) receiving “comprehensive management” (CM) where arrested or protracted labor was considered a warning sign promoting further diagnostic assessment prior to considering intervention. Comprehensive management included the daily audit and discussion of clinical cases by medical and midwifery staff; the introduction of intrapartum ultrasonography alongside traditional clinical assessment to determine fetal head and trunk position accurately; one-on-one labor support facilitated by midwives and/or labor partners; and attention to the psychological well-being of the patient throughout labor and delivery.

Intervention Results: his study included 3283 and 3068 women in the before and after periods, respectively. The groups had similar general and obstetric characteristics. The global cesarean delivery rate decreased significantly from 9.4% in the preguideline to 6.9% in the postguideline period (odds ratio, 0.71; 95% confidence interval, 0.59-0.85; P < .01). The cesarean delivery rate for arrest of first-stage labor fell by half, from 1.8% to 0.9% (odds ratio, 0.51; 95% confidence interval, 0.31-0.81; P < .01) but was significant only among nulliparous women. The cesarean delivery rate for second-stage arrest of labor decreased but not significantly between periods (1.3% vs 1.0%; odds ratio, 0.73; 95% confidence interval, 0.44-1.22; P = .2), and the cesarean delivery rate for failure of induction remained similar (3.7% vs 3.5%; odds ratio, 1.06; 95% confidence interval, 0.06-13.24; P = .88). The median duration of labor before cesarean delivery also became significantly longer among nulliparous women during the later period. Maternal and neonatal outcomes did not differ between the 2 periods, except that the rate of 1 minute Apgar score <7 fell significantly in the later period (8.4% vs 6.9%; odds ratio, 0.80; 95% confidence interval, 0.66-0.97; P = .02).

Conclusion: The modification of our protocol by implementing the new consensus recommendations was associated with a reduction of the rate of primary cesarean delivery performed for arrest of labor with no apparent increase in immediate adverse neonatal outcomes in nulliparous women at term with singleton pregnancies in vertex presentation and with epidural anesthesia. Further studies are needed to assess the long-term maternal and neonatal safety of these policies.

Setting: Obstetric Unit of Sesto San Giovanni Hospital, Milan, Italy, an urban community hospital

Population of Focus: nulliparous women with a single fetus in cephalic presentation, in spontaneous labor at term or induced labor post term.

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage, HEALTH_CARE_PROVIDER_PRACTICE, Collaboration with Local Agencies (State), Public Insurance (Health Care Provider/Practice), PROFESSIONAL_CAREGIVER, Outreach (caregiver), STATE, Data Collection System

Intervention Description: Florida Covering Kids & Families (FL-CKF) is dedicated to developing outreach methods for enrolling and retaining eligible children in the state’s CHIP. FL-CKP developed a strong data system that allows it to evaluate the effectiveness and success of statewide enrollment and retention efforts. Community and school outreach partners enter data each month on all completed CHIP applications via a secure interface, and data are then transmitted to the state. The data system is an outreach method for enrolling and retaining coverage; it can also monitor outcomes and provide feedback to community outreach partners. Organizations helping uninsured children apply for health insurance may benefit from creating data collection systems to monitor project efficacy and modify outreach and enrollment strategies for greater effectiveness.

Intervention Results: The highest number of application submissions were through outreach at a child’s school or childcare facility, through a community-based organization, or through targeted outreach events. However, even though those strategies resulted in the largest number of application, approval and denial rates show which of these strategies (through a CHIPRA grant partner site or government agency) yielded the highest enrollments. This information can be further stratified by individual project partner to show which strategies are working best in that region. The improved data collection system of Cycle II enables FL-CKF to better monitor the efforts of project partners by tracking monthly progress toward grant deliverable goals.

Conclusion: Organizations helping uninsured children apply for health insurance may benefit from creating data collection systems to monitor project efficacy and modify outreach and enrollment strategies for greater effectiveness.

Study Design: Evaluation assessment

Setting: Community (Community-based organizations and schools in Florida)

Population of Focus: Eligible children in Florida's CHIP

Data Source: Checkbox Survey Solutions data system

Sample Size: 502,866 children in Florida who are uninsured

Age Range: 0-17 years

Intervention Components (click on component to see a list of all articles that use that intervention): Education on Disease/Condition, YOUTH, Planning for Transition, Pediatric to Adult Transfer Assistance, Integration into Adult Care, Care Coordination, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: Children's hospitals must provide developmentally appropriate care to increasing numbers of young adults with complex healthcare needs as they transition to adult-oriented care. This article describes the patients, service, and short-term outcomes of an interprofessional healthcare transition (HCT) consult team comprised of nurses, social workers, a community health worker, and physicians. The Adult Consult Team's tiered population framework stratifies patients by medical complexity. The team coordinates HCT services for patients with the highest complexity. Patients at least 18 years old are eligible if they have at least two specialists or an intellectual or developmental disability (IDD). Through a comprehensive medical and psychosocial assessment, the team prepares patients/families for adult-oriented healthcare.

Intervention Results: The Adult Consult Team received 197 referrals from July 2017 to June 2018. Patients had at least two specialists (73%), IDD (71%), technology dependence (e.g., gastrostomy tube, 37%) and Medicaid insurance (57%). The team assisted patients seen in its outpatient clinic with navigating mental health services (39%), insurance issues (13%), IDD services (15%), and the guardianship process (37%) and creating comprehensive care plans.

Conclusion: The Adult Consult Team transferred 30 patients with medical complexity to adult primary and specialty care, significantly improving pediatric inpatient and outpatient capacity for pediatric-aged patients. A broad range of young adult medical, psychosocial, legal, educational, and vocational needs were addressed.

Study Design: Cohort pilot evaluation

Setting: Hospital/clinicbased (Large tertiary-care children’s hospital and ambulatory) network located in an East Coast urban community

Population of Focus: Patients aged 18 and older who had not transitioned from pediatric to adult care who need specialty care from at least two specialties and/or had an intellectual or developmental disability

Data Source: Medical records

Sample Size: 197 patient referrals; at analysis, 97 were seen in consultation

Age Range: Mean age 20.4 years

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

Intervention Description: We aimed to test the feasibility of co-locating dermatology services within primary care and increase the proportion of patients treated for basic skin complaints within the medical home while decreasing wait times.

Intervention Results: Fifty-eight percent of patients referred for a dermatologic complaint were scheduled in RASH clinic. Wait times for new patient appointments in RASH clinic were significantly shorter than for new dermatology appointments in the previous 12 months (mean 36 days vs 65 days, P < .001). The monthly number of referrals to dermatology also decreased significantly after the RASH clinic opened (24/month vs 12/month, P < .001). Ten percent of RASH patients were referred on to dermatology. In a survey of PCPs (N = 67), 76% said the RASH clinic was “extremely/very helpful.”

Conclusion: Providing dermatologic care to low or moderate complexity patients within the medical home is feasible and leads to better access to care. This innovative model could be spread to other clinics and subspecialties.

Intervention Components (click on component to see a list of all articles that use that intervention): Education on Disease/Condition, Planning for Transition, YOUTH, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: We assessed the efficacy of our transition clinic on patient education and empowerment and identified correlates of successful transition.

Intervention Results: Overall, 592 patients were seen at least once in our transition service between 2015 and 2022 (age 15.2 ± 1.8 years, 47.5% female). Most adolescents (53%) had moderate CHD, followed by simple (27.9%) and severe (19.1%) CHD. Learning disability (LD) was present in 18.9% and physical disability (PD) in 4.7%. In patients without LD, knowledge of their cardiac condition improved significantly from the first to the second visit (naming their condition: from 20 to 52.3%, P < 0.0001; describing: 14.4-42.7%, P < 0.0001; understanding: 26.1-60.7%, P < 0.0001), and from the second to the third (naming: 67.4%, P = 0.004, describing: 61.4%, P < 0.001, understanding: 71.1%, P = 0.02;). Patients with LD did not improve their disease knowledge over time (all P > 0.05). Treatment adherence and management involvement, self-reported anxiety, and dental care awareness did not change over time. Successful transition (attendance of ≥ 2 clinics) was achieved in 49.3%. Younger age at the first visit, simpler CHD, and absence of PD were associated with successful transition.

Conclusion: A transition service positively impacts on patient education and empowerment in most CHD adolescents transitioning to adult care. Strategies to promote a tailored support for patients with LD should be sought, and earlier engagement should be encouraged to minimize follow-up losses.

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): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Quality Improvement/Practice-Wide Intervention

Intervention Description: Partners For Kids (PFK) is an accountable care organization caring for pediatric Medicaid beneficiaries in Ohio. PFK QI specialists recruited practices to develop QI projects around increasing well care visit rates (proportion of eligible children with well care visits during calendar year) for children aged 3-6 years and adolescents. The QI specialists supported practice teams in implementing interventions and collecting data through monthly or bimonthly practice visits.

Intervention Results: Ten practices, serving more than 26 000 children, participated in QI projects for a median of 8.5 months (IQR 5.3-17.6). Well care visit rates in the QI-engaged practices significantly improved from 2016 to 2018 (P < .001 for both age groups). Over time, well care visit rates for 3- to 6-year-old children increased by 11.8% (95% CI 5.4%-18.2%) in QI-engaged practices, compared with 4.1% (95% CI 0.1%-7.4%) in non-engaged practices (P = .233). For adolescents, well care visit rates increased 14.3% (95% CI −2.6% to 31.2%) compared with 5.4% (95% CI 1.8%-9.0%) in QI-engaged vs non-engaged practices over the same period (P = .215). Although not statistically significant, QI-engaged practices had greater magnitudes of rate increases for both age groups.

Conclusion: Through practice facilitation, PFK helped a diverse group of community practices substantially improve preventive visit uptake over time. QI programs in primary care can reach patients early to promote preventive services that potentially avoid costly downstream care.

Setting: Clinic/Medical provider office

Population of Focus: Patients in participating pediatric practices, ages 3-6 and 12-18

Intervention Components (click on component to see a list of all articles that use that intervention): Provider Training/Education, PATIENT_CONSUMER, HEALTH_CARE_PROVIDER_PRACTICE, Educational Material (Provider), Peer Counselor

Intervention Description: To evaluate changes in referrals to Women, Infants, and Children’s Supplemental Nutrition Program peer counselors, reported prenatal provider education and support, and breastfeeding outcomes (intention, initiation, 1-month duration of any and exclusive breastfeeding) after a prenatal breastfeeding promotion intervention.

Intervention Results: Pre-intervention (n = 71) and post-intervention (n = 70) participants were 49% Black, 61% publicly insured, and 16% uninsured. More post-intervention participants had > 1 Toolkit use (76%), peer counselor program referrals (60.0% post vs. 36.6% pre, p < .01), reported any breastfeeding intention (89% vs. 72%, p = .013), and intended to breastfeed for > 1 year (31% vs. 14%, p = .014). Post-intervention breastfeeding initiation and exclusivity were higher, but not significantly different. Post-intervention participants reported better prenatal breastfeeding supp

Conclusion: Implementing a prenatal Breastfeeding Toolkit, including facilitating peer counselor referral, was associated with increases in provider counseling, participants’ breastfeeding intentions, and uptake of peer counselors. Replicating this approach may reinforce efforts to support breastfeeding in similar practices serving women with lower incomes.

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, HOSPITAL, Chart Audit and Feedback, Quality Improvement, Policy/Guideline (Hospital), Collaboratives

Intervention Description: This was a multifaceted quality improvement initiative designed to decrease the cesarean delivery rates for NTSV births in California. From 2016 to 2019, the California Maternal Quality Care Collaborative partnered with Smart Care California to implement multiple approaches to decrease the rates of cesarean delivery. Guided by the Consolidated Framework for Implementation Research, efforts were aimed at both the internal (hospital level) and the external (statewide) environment. Hospitals with rates of cesarean delivery greater than 23.9% for NTSV births were invited to join 1 of 3 cohorts for an 18-month quality improvement collaborative between July 2016 and June 2019. Within the collaborative, multidisciplinary teams implemented multiple strategies supported by mentorship, shared learning, and rapid-cycle data feedback. Partnerships among nonprofit organizations, state governmental agencies, purchasers, and health plans addressed the external environment through transparency, award programs, and incentives.

Intervention Results: A total of 7 574 889 NTSV births occurred in the US from 2014 to 2019, of which 914 283 were at 238 hospitals in California. All California hospitals were exposed to the statewide actions to reduce the rates of cesarean delivery, including the 149 hospitals that had baseline rates of cesarean delivery greater than 23.9% for NTSV births, of which 91 (61%) participated in the quality improvement collaborative. The rate of cesarean delivery for NTSV births in California decreased from 26.0% (95% CI, 25.8%-26.2%) in 2014 to 22.8% (95% CI, 22.6%-23.1%) in 2019 (relative risk, 0.88; 95% CI, 0.87-0.89). The rate of cesarean delivery for NTSV births in the US (excluding California births) was 26.0% in both 2014 and 2019 (relative risk, 1.00; 95% CI, 0.996-1.005). The difference-in-differences analysis revealed that the reduction in the rate of cesarean delivery for NTSV births in California was 3.2% (95% CI, 1.7%-3.5%) higher than in the US (excluding California). Compared with the hospitals and the periods not exposed to the collaborative activities, and after adjusting for patient characteristics and time using a modified stepped-wedge analysis, exposure to collaborative activities was associated with a lower odds of cesarean delivery for NTSV births (24.4% vs 24.6%; adjusted odds ratio, 0.87 [95% CI, 0.85-0.89]).

Conclusion: In this observational study of NTSV births in California from 2014 to 2019, the rates of cesarean delivery decreased over time in the setting of the implementation of a coordinated hospital-level collaborative and statewide initiatives designed to support vaginal birth.

Setting: 238 nonmilitary hospitals providing maternity services in California

Population of Focus: Nulliparous women with term singleton vertex gestations

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

Intervention Description: To determine, among a sample of young CSHCN with developmental conditions, (1) characteristics associated with receipt of both patient-centered medical home (PCMH) and Part C early intervention, (2) the association between each PCMH criterion and receipt of Part C generally, and (3) for CSHCN with disabilities versus delays.

Intervention Results: 19% of our sample received both PCMH and Part C. Black, non-Hispanic children had lower odds [OR 0.44, 95% CI (0.20, 0.97)] and CSHCN with more severe developmental conditions had higher odds [OR 2.13, 95% CI (1.22, 3.17)] of receiving both services. CSHCN with a PCMH were no more likely to be receiving Part C than those without a PCMH [OR 0.85, 95% CI (0.49, 1.49)]. Receiving any one of the PCMH criterion was not associated with receiving Part C, with one exception. Among CSHCN with delays, effective care coordination was associated with lower odds of Part C [OR 0.46, 95% CI (0.21, 0.97)].

Conclusion: Concurrent PCMH and Part C access was low for young CSHCN with developmental conditions affecting their function. Given the overlapping mandates for PCMH and Part C, integrated efforts are warranted to identify if lack of concurrent services in fact reflects unmet service needs.

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Provider Training/Education, HOSPITAL, Quality Improvement, Policy/Guideline (Hospital), Sleep Environment Modification, CAREGIVER, Educational Material (caregiver), HEALTH_CARE_PROVIDER_PRACTICE, Audit/Attestation

Intervention Description: A quality improvement project for implementing safe sleep practices (SSP) was conducted at a large, U.S children's hospital.

Intervention Results: Audit data showed that 72% and 77% of infants were asleep supine at baseline and follow-up respectively (p=0.07).

Conclusion: Infant safe sleep practices have the potential to reduce infant mortality.

Study Design: QE: pretest-posttest

Setting: A tertiary care children’s hospital in AR

Population of Focus: Infants 0-12 months in intensive care and medical-surgical units caring asleep at the time of the audit

Data Source: Crib audit/infant observation

Sample Size: Baseline (n=398) Follow-up (n=498)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Planning for Transition, Integration into Adult Care, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: We describe HCT outcomes within the University of Maryland STEP Program, which is built upon integration of an adult HIV provider and navigator into the pediatric clinic, and coordinated collaboration between pediatric and adult HIV multi-disciplinary care teams.

Intervention Results: In the STEP cohort, linkage to adult care was 94% and 12 month retention in adult care (95%) was statistically higher compared to the historical cohort. Rates of viral suppression did not differ pre- and post-HCT among STEP Program patients.

Conclusion: These results support the concept of an integrated pediatric and adult HIV HCT model though the ability to achieve sustainable HCT success will require further study.

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

Intervention Description: To test whether a policy of active management of nulliparous labour would reduce the rate of caesarean section and prolonged labour without influencing maternal satisfaction.

Intervention Results: Active management of labour did not reduce the rate of caesarean section 30/320 (9.4%), compared with 32/331 (9.7%) for routine care, but did shorten the length of first stage of labour (median 240 min vs 290 min; P = 0.02), and reduce the relative risk of prolonged labour (RR 0.39; 95% CI 0.22, 0.71). There were no differences between groups in the rates of newborn nursery admission, neonatal acidosis, low Apgar scores, or postpartum haemorrhage. Satisfaction with labour care was high (77%) and did not differ between groups.

Conclusion: Active management of labour reduced the duration of the first stage of labour without affecting the rate of caesarean section, maternal satisfaction, or other maternal or newborn morbidity.

Study Design: RCT

Setting: 1 women’s hospital

Population of Focus: Nulliparous women who gave birth after recruitment between June 1993 and August 1997

Data Source: Not specified

Sample Size: Total (n=651) Intervention (n=320) Control (n=331)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Assessment (Provider), Provider Training/Education, PROFESSIONAL_CAREGIVER, Education/Training (caregiver), Crib Card, HOSPITAL, Quality Improvement, Policy/Guideline (Hospital)

Intervention Description: This was a pre/post quality improvement study conducted at a single quaternary care medical center from 2015 to 2019. Infants <12 months were observed in their sleeping environment pre- and post-implementation of multiple hospital-wide interventions to improve the sleep safety of hospitalized infants. Following baseline data collection, a multidisciplinary team reviewed the hospital’s infant sleep practices and developed and implemented a care bundle that included the following: A new safe sleep hospital policy; online-learning modules for all hospital staff who interact with infants; educational updates to physicians; an educational handout for volunteers; infant safe sleep education in the nursing admission and/or discharge education for infants; infant safe sleep education in the electronic health record; and various forms of education for families/caregivers in English and Spanish. The primary outcome measure was adherence to the ABCs of safe sleep (Alone in the sleep environment, on their Back on a firm sleep surface, and in an empty Crib).

Intervention Results: Only 1.3% of 221 infants observed preintervention met all ABCs of safe sleep; 10.6% of 237 infants met the ABCs of safe sleep postintervention. Significant improvements in the post-intervention cohort included sleeping in a crib (94% versus 80% preintervention; P < 0.001), avoidance of co-sleeping (3% versus 15% preintervention; P < 0.001), absence of supplies in the crib (58% versus 15% preintervention; P < 0.001), and presence of an empty crib (13% versus 2% preintervention; P < 0.001).

Conclusion: Most infants hospitalized at our institution do not sleep in a safe environment. However, the implementation of a care bundle led to improvements in the sleep environment in the hospital. Further research is necessary to continue improving in-hospital safe sleep and to assess whether these practices impact the home sleep environment.

Setting: A single quaternary care medical center

Population of Focus: Hospital healthcare providers

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, PROFESSIONAL_CAREGIVER, Education/Training (caregiver), Provision of Safe Sleep Item

Intervention Description: The Georgia state department of public health trained facilitators at 28 sites across the state to facilitate a group safe sleep education and crib distribution program. The program consisted of a one-time educational session (approximately 30-45 minutes) using a PowerPoint presentation that included talking points for the session facilitator. At the end of the education session, participants received a portable crib—which also served as a cue to action—and instructions for and demonstration of crib set-up and take-down. A prospective, matched pre- and post-test cohort design with follow-up was used to evaluate changes in self-reported knowledge, intentions, and practices.

Intervention Results: The final sample included 615 matched pre- and post-test surveys, and 66 matched follow-up surveys. The proportion of correct responses on all knowledge and intended practice items increased significantly from pre- to post-test. When asked where their babies would have slept if they had not received the portable crib, 66.1% of participants planned to use a recommended sleep location (e.g., crib or bassinet). At post-test, 62.3% planned to change something about their infant's sleep based on what they learned. At follow-up, knowledge was maintained for all but two items and practices and for half of practice items. The results suggest that participating in the education program was associated with increased knowledge and intended adherence, but that these changes were not maintained at follow-up.

Conclusion: These results are in line with the research literature that finds a difference in intentions and actual practices after the baby is born.

Setting: Multiple facilities in Georgia

Population of Focus: Expectant and new parents demonstrating financial need

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Outreach (Provider), Diet/Exercise, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: The NFFD trial was a population-based antenatal combined lifestyle intervention consisting of dietary counseling and supervised exercise classes, evaluated in a randomized controlled trial. Normal weight, overweight and obese participants were recruited by midwifes from eight healthcare clinics in the southern part of Norway, encompassing both cities and rural areas, between September 2009 and February 2013. The intervention group had access to a twice-weekly standardized exercise program. Classes were provided for groups at five different fitness centers, led by qualified instructors and consisted of 10 min of warm-up, 40 min of cardiovascular and strength exercises at moderate intensity, with emphasis on core and pelvic floor musculature, and finally 10 min of stretching. Exercise intensity was measured by ratings of perceived exertion set to 12–14 (somewhat hard) on the 6–20 Borg rating scale 18. Additionally, the participants were encouraged to undertake at least 30 min of cardio exercises at moderate intensity at least three times a week, in accordance with current physical activity recommendations 19. The dietary component of the intervention consisted of 10 dietary recommendations designed by the NFFD team

Intervention Results: The intervention group had a longer first stage of labor compared with the control group (293 ± 202 min vs. 257 ± 181 min, p = 0.030). No differences between the randomization groups were seen for time spent in second stage of labor, prolonged labor or mode of delivery. In the total sample, women with the highest physical activity level had lower odds ratio (OR) of acute cesarean delivery (OR 0.33, 95% CI 0.11-0.97, p = 0.044) than did those with the lowest physical activity-level.

Conclusion: A significantly longer first stage of labor was observed in the intervention group than in the control group. A high physical activity level in late pregnancy was associated with lower odds of acute cesarean delivery compared with a low physical activity level.

Setting: Southern Norway

Population of Focus: Healthy nulliparous women with a singleton pregnancy

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, , HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: We aimed to improve the prevalence of EIBF among teenage mothers to at least 90% through a quality improvement (QI) initiative.

Intervention Results: The prevalence of EIBF among adolescent mothers was 28.5% during the pre-intervention baseline phase. QI team meeting was held and the barriers to EIBF among the adolescent mothers were discussed and depicted in the form of a fish-bone analysis model. The prevalence of EIBF increased during each intervention cycle to 50%, 60%, 62.5%, 72.7%, 88%, and 100%. At the end of six months follow-up phase, the prevalence of EIBF sustained at around 100%.

Conclusion: This QI initiative has proven to be effective in improving the prevalence of EIBF with simple but effective measures. Adolescent women comprise of a vulnerable sub-population of high-risk mothers. Proper counseling and respectful maternity care will help them face the challenges of motherhood boldly.

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Pediatric to Adult Transfer Assistance, Planning for Transition, Integration into Adult Care, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: Developing and evaluating effective transition interventions for young people (16-25 years) with inflammatory bowel disease (IBD) is a high priority. While transition clinics (TCs) have been recommended, little is known about their operating structures and outcomes. This study aimed to gain insight into the value of a TC compared with direct handover care. Data collection included: semistructured interviews with professionals (n=8), observations during consultations with young people (5×4 hours), medical chart reviews of patients transferred 2 to 4 years prior to data collection (n=56 in TC group; n=54 in control group) and patient questionnaires (n=14 in TC group; n=19 in control group).

Intervention Results: At the TC, multidisciplinary team meetings and alignment of care between paediatric and adult care providers were standard practice. Non-medical topics received more attention during consultations with young people at the TC. Barriers experienced by professionals were time restrictions, planning difficulties, limited involvement of adult care providers and insufficient financial coverage. Facilitators experienced were high professional motivation and a high case load. Over the year before transfer, young people at the TC had more planned consultations (p=0.015, Cohen's d=0.47). They showed a positive trend in better transfer experiences and more satisfaction. Those in direct handover care more often experienced a relapse before transfer (p=0.003) and had more missed consultations (p=0.034, Cohen's d=-0.43) after transfer.

Conclusion: A TC offer opportunities to improve transitional care, but organisational and financial barriers need to be addressed before guidelines and consensus statements in healthcare policy and daily practice can be effectively implemented.

Study Design: Controlled mixed-methods evaluation (control group and other controls)

Setting: Clinic-based (2 outpatient IBD (Inflammatory Bowel Disease) clinics)

Population of Focus: Young people with IBD transitioning to adult care

Data Source: Semi-structured interviews, observations during consultations, medical charts, and patient questionnaires

Sample Size: 54 patients

Age Range: 16-25 years of age

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Integration into Adult Care, Pediatric to Adult Transfer Assistance, Planning for Transition, Nurse/Nurse Practitioner, YOUTH, Education on Disease/Condition, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: We compared the clinical long-term course of 24 patients with and 11 patients without structured transition care within 24 months before and 24 months after transfer from paediatric to adult health care. Socio-economic parameters and quality of life were assessed by IBD Questionnaire (IBDQ-32) and additional items. Treatment costs were calculated for medication, surgery and hospitalisation.

Intervention Results: The percentage of transfer group patients with an IBD-related intestinal complication was higher compared to the transition group (64% vs. 21%, p = 0.022). We also found a tendency towards a higher number of IBD-related surgery in the transfer group compared to the transition group (46% vs. 13%, p = 0.077). Transfer group patients received higher mean cumulated doses of radiation compared with the transition group (4.2 ± 5.3 mSv vs. 0.01 ± 0.01 mSv, p = 0.036). Delayed puberty was only noted in the transfer group (27%, p = 0.025). Mean expenditures for surgeries and hospitalisation tended to be lower in the transition group compared to transfer group patients (744 ± 630€ vs. 2,691 ± 4,150€, p = 0.050). Sexual life satisfaction was significantly higher (p = 0.023) and rates of loose bowel movements tended to be lower (p = 0.053) in the transition group.

Conclusion: Structured transition of adolescents with IBD from paediatric into adult health care can lead to important clinical and economic benefits.

Study Design: Retrospective study design

Setting: Clinic-based (Pediatric department of a health clinic)

Population of Focus: Patients with IBD transferring to adult care

Data Source: Medical records, patient questionnaires

Sample Size: 24 patients with transition care

Age Range: 17-22 years of age

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, PROFESSIONAL_CAREGIVER, Training/Education (caregiver) , Audit/Attestation, Audit/Attestation (Provider)

Intervention Description: Pediatricians were recruited to participate in a a virtual quality improvement learning collaborative (QILC) that promoted screening for safe sleep practices in the home and counseling families on the ABCs of safe sleep during visits. Monthly hour-long learning collaborative webinars allowed practices to view their progress, share current plan-do-study-act cycles, review safe sleep best practices, and learn about quality improvement topics. Participants collected data on safe sleep documentation in a newborn discharge or well-child visit note, which was submitted at baseline and in subsequent phases.

Intervention Results: Thirty-four pediatricians from 4 inpatient and 9 outpatient practices participated in the QILC. At baseline, documentation of safe sleep practices varied greatly (0%-98%). However, by the end of the QILC, all participating practices were documenting safe sleep guidance in over 75% of patient encounters. Aggregate practice data show a significant, sustained improvement. The 12-month follow-up data were submitted from 62% of practices, with sustainment of improvement in 75% of practices.

Conclusion: A facilitated, virtual QILC is an effective methodology to improve safe sleep counseling among a diverse group of pediatric practices. It is one step in improving consistent messaging around safe sleep by healthcare providers as pediatricians work to decrease sleep-related infant deaths.

Setting: Online community of practice

Population of Focus: Inpatient and outpatient pediatricians

Intervention Components (click on component to see a list of all articles that use that intervention): PROFESSIONAL_CAREGIVER, Educational Material (caregiver), Provision of Safe Sleep Item, HOSPITAL, Quality Improvement, Crib Card, Policy/Guideline (Hospital), HEALTH_CARE_PROVIDER_PRACTICE, Educational Material (Provider), Nurse/Nurse Practitioner, Audit/Attestation, Audit/Attestation (Provider)

Intervention Description: This hospital quality improvement initiative performed a series of Plan-Do-Study-Act cycles designed to increase the proportion of infants placed in a “perfect sleep” environment that met all of the American Academy of Pediatrics’ infant safe sleep guidelines. The initiative took place while the hospital was preparing for Baby Friendly certification, with increased emphasis on rooming in and skin to skin at the same time. Initial cycles targeted nurse and parental education, while later cycles focused on providing sleep sacks/wearable blankets for the infants. The goal was to achieve 70% “perfect sleep” compliance among infants cared for in the hospital.

Intervention Results: While we did not meet our goal, the percentage of infants with 'perfect sleep' increased from a baseline of 41.9% to 67.3%, and we also saw improvement in each of the individual components that contribute to this composite measure. Improvements were sustained over 12 months later, suggesting that QI interventions targeting infant safe sleep in this inpatient setting can have long-lasting results.

Conclusion: This project also suggests that infant safe sleep QI initiatives and preparation towards Baby Friendly Hospital Certification can be complementary.

Population of Focus: Hospital healthcare providers

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, Planning for Transition, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: The Six Core Elements of Transition have been advocated to guide transition, but little is published about their use with liver transplant patients. We started a liver transplant transition program in August 2015 using quality improvement (QI) methods and by linking the Six Core Elements of Transition to process measures.

Intervention Results: Overall RTQ scores improved from 23.7 to 30.5 (+28.7%, P = .009) prior to transfer. Nearly two-thirds (63%) of patients were seen by adult transplant hepatology within 6 months, and one patient was lost to follow-up after the first adult visit. Tacrolimus-level standard deviations were <2.0 in 45% of patients in pediatric care and 72% of patients in adult care. Three patients had undergone immunosuppression withdrawal in pediatric care, with one restarted on immunosuppression prior to transfer to adult care due to late acute rejection.

Conclusion: The Six Core Elements of Transition can be translated into patient- and system-level transition milestones to serve as potential quality metrics in the implementation of transition programs.

Intervention Components (click on component to see a list of all articles that use that intervention): Baby Friendly Hospital Initiative, HEALTH_CARE_PROVIDER_PRACTICE, ,

Intervention Description: To examine the influence of the BFHI on breastfeeding by comparing breastfeeding outcomes in a study cohort recruited before the implementation of the BFHI and a cohort recruited after its implementation.

Intervention Results: A higher proportion of participants from the post-implementation cohort breastfed and breastfed exclusively at all follow-up periods. Participants in the pre-BFHI cohort, on average experienced 3.10 (SD = 1.42) of the BFHI steps, whereas the participants in the post-BFHI cohort experienced 3.59 (1.09) of the BFHI steps. Half of the participants discontinued any breastfeeding by 13 weeks in the pre-BFHI cohort; more than half in the post-BFHI cohort were still breastfeeding at 6 months postpartum (p < .001). Giving only human milk in the first 48 hr of delivery and not providing pacifiers or bottles were associated with lower risk of not exclusive breastfeeding in both cohorts.

Conclusion: Implementation of the BFHI was associated with improvements in breastfeeding practices and outcomes.

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, HOSPITAL, Collaboratives, Residents/Medical Students

Intervention Description: In accordance with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists Training Program guidelines, residents were required to develop competency in outlet, low, midcavity, and rotational instrumental birth. In 2010, the Monash Health Centre in Victoria Australia implemented a formalized lecture series and mannequin simulation training preceding mandatory instrumental credentialing for all obstetric residents. Credentialing required residents to be directly supervised by senior obstetricians in human instrumental birth until assessed as competent for unsupervised practice (remote supervision). Residents could only be credentialed in vacuum birth after being first credentialed in forceps birth. All residents were required to meet with training supervisors at 3-monthly intervals to review credentialing documents and implement remedial pathways if credentialing was not achieved in an appropriate timeframe.

Intervention Results: There were 72,490 births from 2005 to 2014 at Monash Health, of which 8,789 (12%) were attempted instrumental vaginal births. After the intervention, rates of forceps births increased [autoregressive integrated moving average coefficient (β) 1.5, 95% confidence interval (CI) 1.03-1.96; P<.001], and vacuum births decreased (β -1.43, 95% CI -2.5 to -0.37; P<.01). Rates of postpartum hemorrhage decreased (β -1.3, 95% CI -2.07 to -0.49; P=.002) and epidural use increased (β 0.03, 95% CI 0.02-0.05; P<.001). There was no change in rates of unsuccessful instrumental births (β -0.39, 95% CI -3.03 to 2.43; P=.83), intrapartum cesarean delivery (β -0.29, 95% CI -0.55 to 0.14; P=.24), third- and fourth-degree tears (β -1.04, 95% CI -3.1 to 1.00; P=.32), or composite neonatal morbidity (β -0.18, 95% CI -0.38 to 0.02, P=.08). Unsuccessful instrumental births were more likely to be in nulliparous women (P<.001), less likely to have a senior obstetrician present (P<.001), be at later gestation (P<.001), and involved larger birth weight neonates (P<.001).

Conclusion: A policy of ensuring obstetric forceps competency before beginning vacuum training results in more forceps births, fewer postpartum hemorrhages, and no increase in third- and fourth-degree perineal injuries or episiotomies.

Setting: Monash Health, an academic health science center in Melbourne, Australia

Population of Focus: All patients with attempted instrumental births

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage, HEALTH_CARE_PROVIDER_PRACTICE, Public Insurance (Health Care Provider/Practice), NATIONAL, Policy/Guideline (National)

Intervention Description: In 2006, Massachusetts passed major health reform legislation, including an individual mandate for adults (who were required to purchase insurance or face a penalty); Medicaid expansion (i.e., children’s eligibility for the state’s Medicaid-CHIP increased from 200 to 300% of the FPL and adult eligibility for Medicaid increased to 100% FPL), and minimum essential benefits for private insurance (e.g., coverage of basic specialty services, no co-pay or deductible for preventive care visits).

Intervention Results: Massachusetts health reform, the model for the ACA, reduced uninsurance and improved access to some types of care for children in the state. Expanding adult-oriented health access policies in MA was associated with a trend toward reduced uninsurance and improved access to specialty care for children overall at 5 years post-reform. For low-income children, health reform was associated with increased access to a personal doctor for children previously Medicaid-eligible and increased access to specialty care for children newly Medicaid-eligible.

Conclusion: Adult-oriented health reforms may have reduced uninsurance and improved access to some types of care for children in Massachusetts. Repealing the ACA may produce modest detriments for children.

Study Design: Quasi-experimental difference-in-difference

Setting: Policy (Data from 2003, 2007, and 2011-2012 waves of the National Survey of Children's Health)

Population of Focus: Families with children in Massachusetts

Data Source: National Survey of Children’s Health (NSCH

Sample Size: 5,760 children in the intervention group (MA), 28,183 children in the comparison group (other New England states)

Age Range: 0-17 years

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

Intervention Description: Births to women in centers with interprofessional care that included midwives (n = 48,857) were compared with births in non-interprofessional centers (n = 47,935) using the Robson 10-group classification system that stratifies cesarean birth rates using maternal characteristics. The Robson system categorizes all cesarean birth rates by 6 fixed maternal and/or fetal criteria important to perinatal care decision making: gestational age, parity, fetal lie, number of fetuses, previous cesarean birth, and onset of spontaneous labor.

Intervention Results: Women were less likely to have a cesarean birth (26.1% vs 33.5%, P < .001) in centers with interprofessional care. Nulliparous women with singleton, cephalic, term fetuses (category 2) were less likely to have labor induced (11.1% vs 23.4%, P < .001), and women with a prior uterine scar (category 5) had lower cesarean birth rates (73.8% vs 85.1%, P < .001) in centers with midwives. In centers without midwives, nulliparous women with singleton, cephalic, term fetuses with induction of labor (category 2a) were less likely to have a cesarean birth compared with those in interprofessional care centers in unadjusted comparison (30.3% vs 35.8%, P < .001), but this was reversed after adjustment for maternal comorbidities (adjusted odds ratio, 1.21; 95% CI, 1.12-1.32; P < .001). Cesarean birth rates among women at risk for complications (eg, breech) were similar between groups.

Conclusion: Interprofessional care teams were associated with lower rates of labor induction and overall cesarean utilization as well as higher rates of vaginal birth after cesarean. There was consistency in cesarean rates among women with higher risk for complications.

Setting: Interprofessional care centers with midwifes; non-interprofessional care centers

Population of Focus: 48,857 women in interprofessional care group; 47,935 in the non-interprofessional care group

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Midwifery, HOSPITAL, Quality Improvement, Collaboratives

Intervention Description: Midwives provide intrapartum care to low-risk nulliparous women in hospital settings where obstetricians also care for women during childbirth. This model of care is one of the measurable components of the Obstetrical Care Outcomes Assessment Program, a quality improvement initiative that uses clinical data from maternal and newborn medical records to evaluate the care given to pregnant women during labor, delivery and the postpartum period as the basis for exploring actionable and sustainable improvements. The program uses health care provider specific, chart-abstracted data for quality improvement from all births at participating sites. Multiple hospitals in the Northwest United States, including urban, suburban, and rural centers supported by I, II, III, and IV levels of maternal care participate in this quality improvement collaborative.

Intervention Results: The study cohort comprised 23,100 births (3,816 midwife and 19,284 obstetrician). Compared with obstetricians, midwifery patients had significantly lower intervention rates, an approximately 30% lower risk of cesarean delivery in nulliparous patients (adjusted relative risk [aRR] 0.68; 95th% CI 0.57-0.82), and an approximately 40% lower risk of cesarean in multiparous patients (aRR 0.57; 95th% CI 0.36-0.89). Operative vaginal birth was also less common in nulliparous patients (aRR 0.73; 95th% CI 0.57-0.93) and multiparous patients (aRR 0.30; 95th% CI 0.14-0.63). Shoulder dystocia was more common in multiparous patients receiving midwifery care (aRR 1.42; 95th% CI 1.04-1.92).

Conclusion: In low-risk pregnancies, midwifery care in labor was associated with decreased intervention, decreased cesarean and operative vaginal births, and, in multiparous women, an increased risk for shoulder dystocia. Greater integration of midwifery care into maternity services in the United States may reduce intervention in labor and potentially even cesarean delivery, in low-risk pregnancies. Larger research studies are needed to evaluate uncommon but important maternal and newborn outcomes.

Setting: Hospitals participating in a multi-center quality improvement collaborative (the Obstetrical Care Outcomes Assessment Program)

Population of Focus: Low-risk nulliparous pregnant women

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Hospital Policies, Baby Friendly Hospital Initiative,

Intervention Description: The study team examined whether Baby Friendly Hospital accreditation in the past, as indicated by a former BFH designation, had a sustained impact on national breastfeeding rates and duration and that breastfeeding success remains particularly high when BFHs comply closely with monitored BF practices.

Intervention Results: We compared exclusive and any breastfeeding according to BFH designation over the first year of life, using Kaplan-Meyer Survival curves. Logistic regression models were applied to analyse breastfeeding prevalence, and Cox-regression models were used for exclusive (0–6 months) and continued (6–12 months) breastfeeding duration. Average duration of exclusive breastfeeding (13.1 weeks, 95% confidence interval [12.0, 17.4]) and any breastfeeding (32.7 weeks, 95% confidence interval [30.5, 39.2]) were the longest for babies born in currently accredited BFHs. Exclusive breastfeeding was associated with high compliance with monitored BF practices in current BFHs and with the number of BF practices experienced in all hospitals. Continued breastfeeding was significantly longer when babies were born in current BFHs (cessation hazard ratio 0.60, 95% confidence interval [0.42, 0.84]) or in former BFHs (cessation hazard ratio 0.68, 95% confidence interval [0.48, 0.97]).

Conclusion: Overall, the results support continued investment into BFHs, because babies born in current BFHs are breastfed the most and the longest, whereas a former BFH designation shows a sustained effect on continued breastfeeding.

Study Design: Cross-sectional study

Setting: Baby-Friendly hospitals in Switzerland

Population of Focus: Mother-child dyads randomly selected by Swiss Parent Counselors from a list of births registered in the previous 11 months

Sample Size: 1,326 mother-child dyads

Age Range: Infants under 12 months and their mothers

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Planning for Transition, Pediatric to Adult Transfer Assistance, Care Coordination

Intervention Description: The transition program was designed to provide additional support during transition of care and was introduced 6 months prior to referral to adult diabetes care. The intervention was 18 months long and spanned six clinic visits (three pediatric and three adult). There were also two clinic visits in the 12 months of follow-up, so the total number of study visits was eight. Central to the program were transition coordinators (TCs) at each site who provided a link between pediatric and adult diabetes care. The TCs were Certified Diabetes Educators who provided transitional education and clinical support where appropriate. The role of the TC was to assist participants during the visits in the first 18 months, maintain contact with participants between the visits (by phone, text messages, or e-mail), facilitate support for insulin adjustments and sick day/hypoglycemia management during regular hours, send reminders and help reschedule appointments, and assess needs and facilitate referrals to other services (e.g., psychology, social work, nurse educator, or dietitian). The TCs also provided specific transition-related education and education materials and at the last pediatric visit a bio sketch of the adult endocrinologist to whom the participant had been referred as well as written instructions and maps to navigate adult diabetes centers.

Intervention Results: We randomized 205 participants, 104 to the transition program and 101 to standard care. Clinic attendance was improved in the transition program (mean [SD] number of visits 4.1 [1.1] vs. 3.6 [1.2], P = 0.002), and there was greater satisfaction with care (mean [SD] score 29.0 [2.7] vs. 27.9 [3.4], P = 0.032) and less diabetes-related distress (mean [SD] score 1.9 [0.8] vs. 2.1 [0.8], P = 0.049) reported than in standard care. There was a trend toward improvement in mean HbA1c (8.33% [68 mmol/mol] vs. 8.80% [73 mmol/mol], P = 0.057). During the 12-month follow-up, there was no difference in those failing to attend at least one clinic visit (P = 0.846), and the mean change in HbA1c did not differ between the groups (P = 0.073). At completion of follow-up, the groups did not differ with respect to satisfaction with care or diabetes-related distress and quality of life.

Conclusion: Transition support during this 18-month intervention was associated with increased clinic attendance, improved satisfaction with care, and decreased diabetes-related distress, but these benefits were not sustained 12 months after completion of the intervention.

Study Design: RCT

Setting: Hospitals/Clinics

Population of Focus: Young adults with type 1 diabetes

Sample Size: 205

Age Range: 17-20 years

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, HEALTH_CARE_PROVIDER_PRACTICE, Midwifery

Intervention Description: We explored breast feeding outcomes of women having a First Nations infant at three sites that introduced a culturally specific continuity of midwife care model.

Intervention Results: Most women (298, 87%) received the culturally specific model. Breast feeding initiation (96%, 95% CI 0.93 to 0.98) was high. At 3 months, 71% were giving ‘any’ (95% CI 0.65 to 0.78) and 48% were giving ‘only’ breast milk (95% CI 0.41 to 0.55). Intending to breast feed 6 months (Adj OR ‘any’: 2.69, 95% CI 1.29 to 5.60; ‘only’: 2.22, 95% CI 1.20 to 4.12), and not smoking in pregnancy (Adj OR ‘any’: 2.48, 95% CI 1.05 to 5.86; ‘only’: 4.05, 95% CI 1.54 to 10.69) were associated with higher odds. Lower education (Adj OR ‘any’: 0.36, 95% CI 0.13 to 0.98; ‘only’: 0.50, 95% CI 0.26 to 0.96) and government benefits as the main household income (Adj OR ‘any’: 0.26, 95% CI 0.11 to 0.58) with lower odds.

Conclusion: Breast feeding rates were high in the context of service-wide change. Our findings strengthen the evidence that culturally specific continuity models improve breast feeding outcomes for First Nations women and infants. We recommend implementing and upscaling First Nations specific midwifery continuity models within mainstream hospitals in Australia as a strategy to improve breast feeding.

Intervention Components (click on component to see a list of all articles that use that intervention): Screening Tool Implementation Training, HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education

Intervention Description: Forty-six PCPs from 10 diverse practices across four counties in Washington State participated. PCPs attended a 2-hour training workshop on early recognition and care for toddlers with ASD and use of a REDCap-based version of the Modified Checklist for Autism in Toddlers–Revised with Follow-up (webM-CHAT-R/F) that provided automated presentation and scoring of follow-up questions. Data were collected at baseline and 6 months following each county's training window. PCPs’ screening methods and rates and perceived self-efficacy regarding ASD care were measured by self-report and webM-CHAT-R/F use was measured via REDCap records.

Intervention Results: At follow-up, 8 of the 10 practices were using the webM-CHAT-R/F routinely at 18-month visits. The proportion of PCPs reporting routine M-CHAT screening increased from 82% at baseline to 98% at follow-up (16% increase, 95% confidence interval [CI] 3%-28%; McNemar exact P = .02). The proportion using the M-CHAT-R/F follow-up interview questions increased from 33% to 82% (49% increase, 95% CI 30%-68%, exact McNemar test, P < .001). Significant increases in self-efficacy were found for all seven areas assessed (Ps ≤ .008).

Conclusion: This brief intervention increased PCPs' self-reported valid use of the M-CHAT-R/F at 18 months and their self-efficacy regarding ASD care. Combining educational information with a web-based ASD screen incorporating the M-CHAT-R/F follow-up questions may increase universal ASD screening with improved fidelity.

Setting: Clinical practice

Population of Focus: Primary care peditricians

Intervention Components (click on component to see a list of all articles that use that intervention): Provider Training/Education, Educational Material (Provider), HEALTH_CARE_PROVIDER_PRACTICE, Screening Tool Implementation

Intervention Description: To determine whether an intervention addressing both logistical and knowledge barriers to early screening for autism spectrum disorder (ASD) increases evidence-based screening during 18-month well-child visits and primary care providers' (PCPs') perceived self-efficacy in caring for children with ASD.

Intervention Results: At follow-up, 8 of the 10 practices were using the webM-CHAT-R/F routinely at 18-month visits. The proportion of PCPs reporting routine M-CHAT screening increased from 82% at baseline to 98% at follow-up (16% increase, 95% confidence interval [CI] 3%-28%; McNemar exact P = .02). The proportion using the M-CHAT-R/F follow-up interview questions increased from 33% to 82% (49% increase, 95% CI 30%-68%, exact McNemar test, P < .001). Significant increases in self-efficacy were found for all seven areas assessed (Ps ≤ .008).

Conclusion: This brief intervention increased PCPs' self-reported valid use of the M-CHAT-R/F at 18 months and their self-efficacy regarding ASD care. Combining educational information with a web-based ASD screen incorporating the M-CHAT-R/F follow-up questions may increase universal ASD screening with improved fidelity.

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement, Nurse/Nurse Practitioner, HOSPITAL, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: To facilitate implementation, clinical nurses were educated as Subject Matter Experts (SMEs) to empower them to transform and sustain outcomes-driven QI for infant safe sleep nursing practice.

Intervention Results: Immediate posteducation surveys completed by SMEs indicated that over 98% of respondents strongly agreed or agreed they were able to effectively demonstrate communication strategies, identify SME role components, provide environment surveillance, and demonstrate best practices in infant safe sleep. To allow time for assimilation of the of SME role, a survey was initiated at 6 months to capture progress made. Seventy-eight SMEs responded to the survey and reported exceptional or substantial progress in 10 areas for SME responsibilities.

Conclusion: Use of the SME role for program implementation led to highly favorable SME-reported outcomes in leading a hospital-based QI program.

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Nurse/Nurse Practitioner, Hospital, Quality Improvement, Audit/Attestation

Intervention Description: This descriptive study examined outcomes from 268 clinical nurses who received comprehensive education on infant safe sleep and their role as subject matter experts (SMEs). SME nurses completed two interactive learning modules addressing safe sleep guidelines and teaching strategies and attended a workshop to acquire skills for program implementation. Key competencies included data collection and dissemination, policy development, and communication techniques. Likert-type scale surveys measured knowledge gained and progress made in practice following education.

Intervention Results: Immediate posteducation surveys completed by SMEs indicated that over 98% of respondents strongly agreed or agreed they were able to effectively demonstrate communication strategies, identify SME role components, provide environment surveillance, and demonstrate best practices in infant safe sleep. To allow time for assimilation of the of SME role, a survey was initiated at 6 months to capture progress made. Seventy-eight SMEs responded to the survey and reported exceptional or substantial progress in 10 areas for SME responsibilities.

Conclusion: Use of the SME role for program implementation led to highly favorable SME-reported outcomes in leading a hospital-based QI program.

Setting: 25 birthing hospitals in Pennsylvania

Population of Focus: Nurses trained as subject matter experts (SMEs)

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): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Designated Clinic/Extended Hours

Intervention Description: The objective of this study was to demonstrate long-term retention of HPV knowledge and positive attitudes towards HPV vaccination after attending our novel HPV workshop, with a focus on knowledge of oropharyngeal cancer. A follow-up survey was administered to medical students 1.5 years after the initial completion of the workshop. HPV vaccination records from the student-led clinic were collected from the immunization information system.

Intervention Results: Awareness that HPV causes oropharyngeal cancer was present in 33% of medical students pre-curriculum; immediate and long-term post-curricular awareness of this association remained at 90% or higher (p < 0.0001). Comfort with HPV counseling, having enough information to recommend the vaccine, and knowledge of HPV malignancies, symptoms, transmission, and vaccination schedule remained persistently elevated over pre-curriculum scores (p < 0.05). Long-term knowledge scores were also higher than a control group of medical students at the same stage of training who had never participated in the workshop (p < 0.05). HPV vaccination rates at the medical school’s student-run clinic also increased after the curriculum, from an average of 1.89 HPV vaccines given per clinic to 3.55 (p = 0.001).

Conclusion: This study demonstrates that knowledge and positive attitudes were maintained 1.5 years after participating in this HPV curriculum during students’ preclinical years of medical school. Additionally, an increase in HPV vaccination rates occurred at a student-led clinic, indicating a positive clinical impact on the curriculum.

Setting: Reno school of medicine, University of Nevada

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): PAYER, Expanded Insurance Coverage, HEALTH_CARE_PROVIDER_PRACTICE, Public Insurance (Health Care Provider/Practice), NATIONAL, Policy/Guideline (National), STATE, Prenatal Care Access

Intervention Description: Prenatal care is an important component of preventive health care with multigenerational consequences for women and their families. For low-income immigrant women, Emergency Medicaid, a federal safety net program for those poor enough to qualify for Medicaid but who cannot meet the citizenship requirements, covers the cost of a birth but not prenatal care or postpartum contraception. An “unborn child” option enacted in CHIP and CHIPRA gave states new options to provide prenatal care coverage with federal matching funds for extending coverage to immigrant children and pregnant women, regardless of their legal status or date of entry to the U.S. The study leveraged a natural experiment where unauthorized immigrant women eligible for Emergency Medicaid gained access to prenatal care coverage by the expansion of the Emergency Medicaid Plus program in Oregon.

Intervention Results: Expanding access to prenatal care coverage increased both utilization and quality of prenatal care, and women were more likely to receive adequate care and recommended preventive health services. After expansion of access to prenatal care, there was an increase in prenatal visits (7.2 more visits, 95% CI 6.46 to 7.98), receipt of adequate prenatal care (28% increased rate, CI 26 to 31), rates of diabetes screening (61% increased rate, CI 56 to 65) and fetal ultrasounds (74% increased rate, CI 72 to 77). Maternal access to prenatal care was also associated with an increased number of well-child visits (0.24 more visits, CI 0.07 to 0.41), increased rates of recommended screenings and vaccines, and reduced infant mortality (-1.04 per 1000, CI -1.45 to -0.62) and rates of extremely low birth weight (<1000g) (-1.5 per 1000, CI -2.58 to -0.53).

Conclusion: Our results provide evidence of increased utilization and improved health outcomes for unauthorized immigrants and their children who are United States citizens after introduction of prenatal care expansion in Oregon. This study contributes to the debate around reauthorization of the Children's Health Insurance Program in 2017.

Study Design: Quasi-experimental difference-in-difference

Setting: Policy (Oregon Health Authority)

Population of Focus: Pregnant low-income immigrant women and their infants

Data Source: Medical claims data from January 1, 2003 through October 1, 2015

Sample Size: 210,200 mothers and infants

Age Range: Pregnant women: 12-51 years; Infants: 0-1 years

Intervention Components (click on component to see a list of all articles that use that intervention): Counseling (Parent/Family), EMR Reminder, Care Coordination, Integration into Adult Care, Pediatric to Adult Transfer Assistance, Planning for Transition, PARENT_FAMILY, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: The Multidisciplinary Intervention Navigation Team (MINT) was developed to decrease variations in pediatric to adult medical transitions. System-level goals were to (1) increase provider and leadership engagement, (2) increase transition tools, (3) increase use of electronic medical record-based clinical decision supports, (4) improve transition practices through development of transition policies and clinical pathways; (5) increase transition education for patients and caregivers; (6) increase the adult provider referral network; and (7) implement an adult transition consult service for complex patients (MINT Consult).

Intervention Results: Between July 2015 and March 2017, MINT identified 11 transition champions, increased the number of divisions with drafted transition policies from 0 to 7, increased utilization of electronic medical record-based transition support tools from 0 to 7 divisions, held seven psychoeducational events, and developed a clinical pathway. MINT has received more than 70 patient referrals. Of patients referred, median age is 21 years (range, 17-43); 70% (n = 42) have an intellectual disability. Referring pediatric providers (n = 25) reported that MINT helped identify adult providers and coordinate care with other Children's Hospital of Philadelphia specialists (78%); and that MINT saved greater than 2 hours of time (48%).

Conclusion: MINT improved the availability, knowledge, and use of transition-related resources; saved significant time among care team members; and increased provider comfort around transition-related conversations.

Study Design: Cohort pilot evaluation

Setting: Hospital-based (Free-standing tertiary pediatric academic hospital (Children’s Hospital of Philadelphia (CHOP))

Population of Focus: Patients aged 17-43 who had not transitioned from pediatric to adult care for medically complex patients

Data Source: Transition Readiness Assessment Questionnaire; electronic medical records; surveys

Sample Size: Total number not given, but there were 80 consults given over 2 years; 74 were deemed appropriate referrals

Age Range: 17-43 years (median age 20)

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, HOSPITAL, Chart Audit and Feedback, Quality Improvement

Intervention Description: The aim of this initiative was to implement an evidence-based bundle at an urban community teaching hospital in at least 50% of labors in 60 days in order to reduce early labor admissions and increase adherence to evidence-based labor management guidelines shown to decrease cesarean birth. Chart audits, root-cause analysis, and staff engagement informed bundle development. An early labor triage guide, labor walking path, partograph, and pre-cesarean checklist were implemented to drive change. Four Rapid Cycle Plan Do Study Act cycles were conducted over 8 weeks

Intervention Results: The bundle was implemented in 58% of births. The bundle reduced early labor admissions labor from 41% to 25%. Team knowledge reflecting current guidelines in labor management increased 35% and 100% of cesareans for labor arrest met criteria. Patient satisfaction scores exceeded 98%.

Conclusion: Implementing an evidenced-based bundle was effective in reducing early labor admissions and increasing utilization of and adherence to labor management guidelines.

Setting: Urban community teaching hospital

Population of Focus: Nulliparous women with term singleton vertex gestations

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Active Management of Labor, HOSPITAL, Guideline Change and Implementation, Quality Improvement

Intervention Description: Hospital protocol was modified to align with the new consensus recommendations from the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM). In the new protocol, the cutoff point between the latent and active phases of the first stage of labor was changed from 4 to >6 cm and the definitions of arrest of labor, lack of progress, and failed induction were revised to allow laboring women more time to progress before additional medical interventions were indicated.

Intervention Results: This study included 3283 and 3068 women in the before and after periods, respectively. The groups had similar general and obstetric characteristics. The global cesarean delivery rate decreased significantly from 9.4% in the preguideline to 6.9% in the postguideline period (odds ratio, 0.71; 95% confidence interval, 0.59–0.85; P < .01). The cesarean delivery rate for arrest of first-stage labor fell by half, from 1.8% to 0.9% (odds ratio, 0.51; 95% confidence interval, 0.31–0.81; P < .01) but was significant only among nulliparous women. The cesarean delivery rate for second-stage arrest of labor decreased but not significantly between periods (1.3% vs 1.0%; odds ratio, 0.73; 95% confidence interval, 0.44–1.22; P = .2), and the cesarean delivery rate for failure of induction remained similar (3.7% vs 3.5%; odds ratio, 1.06; 95% confidence interval, 0.06–13.24; P = .88). The median duration of labor before cesarean delivery also became significantly longer among nulliparous women during the later period. Maternal and neonatal outcomes did not differ between the 2 periods, except that the rate of 1 minute Apgar score <7 fell significantly in the later period (8.4% vs 6.9%; odds ratio, 0.80; 95% confidence interval, 0.66–0.97; P = .02).

Conclusion: The modification of our protocol by implementing the new consensus recommendations was associated with a reduction of the rate of primary cesarean delivery performed for arrest of labor with no apparent increase in immediate adverse neonatal outcomes in nulliparous women at term with singleton pregnancies in vertex presentation and with epidural anesthesia. Further studies are needed to assess the long-term maternal and neonatal safety of these policies.

Setting: University referral hospital in Poissy, France

Population of Focus: All women with a singleton pregnancy at term (!37 weeks of gestation), in vertex presentation, with spontaneous or induced labor, and with epidural anesthesia

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Assessment (provider), Provider Training/Education, Nurse/Nurse Practitioner, PARENT/FAMILY, Education/Training (caregiver), Provision of Safe Sleep Item, HOSPITAL, Quality Improvement

Intervention Description: The purpose of our safe sleep initiative was to improve parental and staff knowledge of safe sleep practices and to achieve increased compliance with infant safe sleep in the hospital setting. A multidisciplinary team of health professionals was created to address poor compliance with safe sleep guidelines, investigate barriers, and identify primary drivers for improvement. Subsequent interventions included parent education, staff education, and improvements in system processes. Members of the hospitals nurse residency program conducted multidisciplinary surveys before and after the quality improvement initiative to assess staff knowledge of safe sleep practices. The data were collected prospectively.

Intervention Results: Compliance with safe sleep improved to >80% in both units. Tracking of process measures revealed NICU parents received safe sleep education 98-100% of the time. No change was observed in the balancing measures. Transfers from the NN to the NICU for temperature instability did not increase. Parent satisfaction with discharge preparedness did not change (98.2% prior to and 99.6% after).

Conclusion: We achieved improved compliance with safe sleep practices in our NN and NICU through education of staff and parents and improved system processes. We believe this will translate to improved safe sleep practices used by parents at home.

Setting: Truman Medical Center in Kansas City

Population of Focus: Infants admitted to newborn nursery and NICU

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Nurse/Nurse Practitioner, HOSPITAL, Quality Improvement, Sleep Environment Modification, Crib Card, Visual Display, Audit/Attestation

Intervention Description: A quality improvement (QI) model was developed to introduce the AAP guidelines on safe sleep (SS) practices into the NICU nursing practice in a consistent and sustainable method. The project team included the NICU hospitalist, a neonatologist, the Director of Newborn Services at the Wakefield Division, the nurse manager, two nurses, and a nurse practitioner. The team members met at monthly QI meetings to discuss progress for the duration of the project. Key drivers were identified, and the team used PDSA cycles to target interventions, which included a crib check tool and presentations by SS experts. One of the team’s main concerns during the initial deliberation sessions was the suboptimal temperature control in the NICU, and after meeting with the engineering staff, more sensors were placed in the NICU to eliminate the wide variations of temperatures throughout the day. The primary aim of the project was a 20% improvement in the SS compliance rates (from 7% to 27%) by December, 2017.

Intervention Results: Approximately 600 crib checks (CC) were performed over the duration of this project. At baseline, 7% of infants were placed in a SS position in the NICU. Following the QI project, SS position increased to 96% of infants.

Conclusion: Multifactorial interventions significantly improved SS compliance among NICU nurses. Cultivating personal motivation among nurses, consistent empowerment and dedication to culture change by the entire team was crucial for the sustainability of the project.

Setting: Wakefield neonatal service, Montefiore Medical Center

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Lactation Consultant, Other Education, Technology-Based Support, HEALTH_CARE_PROVIDER_PRACTICE, Other (Provider Practice),

Intervention Description: Telelactation is one tool that can be leveraged to increase access to International Board Certified Lactation Consultants (IBCLCs) in rural settings. Telelactation services connect breastfeeding women to remotely located IBCLCs through audio-visual technology. The Telehealth for Mothers to Improve Lactation Confidence (Tele-MILC) randomized controlled trial evaluated the feasbility and impact of telelactation via personal electronic devices on breastfeeding duration and exclusivity among rural mothers. Participants randomized to the telelactation arm were given an orientation to Pacify Health's telelactation app by hospital nurses. The nurses showed participants how to download the app on a personal device (smartphone or tablet), provided a coupon code for free, umlimited video calls, and encouraged participants to conduct a test call on their own device or on a demonstration device. After the orientation, participants could request umlimited, on-demand video calls with IBCLCs through the app for as long as they desired. The app used in the trial aimed to provide video calls within seconds of a visit request by a mother. The app is also HIPAA-compliant, and the telelactation services it provides involves a large network of geographically dispersed IBCLCs available to take video calls 24 hours a day.

Intervention Results: Among participants in the telelactation arm, 50% (47/94) reported participating in video calls. At 12 weeks, 71% of participants in the telelactation arm versus 68% of control participants were breastfeeding in the ITT model (3% difference, P = .73), whereas 73% of participants in the telelactation arm versus 68% of control participants were breastfeeding in the IV model (5% difference, P = .74). Among participants who were still breastfeeding at 12 weeks, 51% participants in the telelactation arm were breastfeeding exclusively versus 46% of control participants in the ITT model (5% difference, P = .47), whereas 56% of participants in the telelactation arm were breastfeeding exclusively versus 45% of control participants in the IV model (11% difference, P = .48). In all models, participants in the telelactation arm were breastfeeding at higher rates; however, differences were not statistically significant.

Conclusion: This trial demonstrated that telelactation can be implemented with a rural underserved population. Though this trial was not powered to detect differences in breastfeeding duration and exclusivity, and none were observed, telelactation remains a promising approach for further investigation. ClinicalTrials.gov Identifier: NCT02870413.

Study Design: RCT

Setting: Critical Access Hospital in North-Central PA/Online

Population of Focus: Postpartum women who had initiated breastfeeding and planned to contine after hospital discharge

Sample Size: 203 women (102 for intervention and 101 for control)

Age Range: Women 18 years and older

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Active Management of Labor, HOSPITAL, Chart Audit and Feedback, Quality Improvement,

Intervention Description: From 2008 through 2015, a multi-strategy approach that included provider education, provider feedback, and implementation of new policies was used to target evidence-based and inferred factors that influence the cesarean delivery rate among nulliparous patients with term singleton vertex gestations. This quality improvement initiative included the standardization of fetal heart rate tracing, provider training based on consensus guidelines, and the implementation of audits and provider feedback.

Intervention Results: More than 20,000 NTSV deliveries were analyzed, including more than 15,000 during the intervention period. The NTSV cesarean delivery rate declined from 35% to 21% over eight years. The total cesarean delivery rate declined as well. Increase in meconium aspiration syndrome and maternal transfusion were observed.

Conclusion: Quality improvement initiatives can decrease the NTSV cesarean delivery rate. Any increased incidence of fetal or maternal complications associated with decreased NTSV cesarean delivery rate should be considered in the context of the risks and benefits of vaginal delivery compared to cesarean delivery.

Setting: A single tertiary care academic medical center

Population of Focus: Nulliparous women with term singleton vertex gestations

Intervention Components (click on component to see a list of all articles that use that intervention): Nurse/Nurse Practitioner, Counseling (Parent/Family), Care Coordination, Integration into Adult Care, Pediatric to Adult Transfer Assistance, Planning for Transition, PARENT_FAMILY, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: Reaching a certain age, juvenile idiopathic arthritis (JIA) patients in paediatric care are transferred to adult care. An increased disease activity after transfer and increased dropout has been suggested, however, evidence is scarce. Our aim is to determine whether the process of transition is associated with increased disease-activity and dropout, and to identify associated factors. During a 3-year prospective transition cohort study, paediatric patients (14-17yrs) were transferred to adult care. Paediatric (10-13yrs) and adult JIA patients (18-27yrs) were used as control groups. Demographic and disease-related items were obtained yearly. Non-parametric tests were used to compare differences between the groups and mixed models to evaluate disease activity over time, measured by JADAS27 and DAS28. Dropout was defined as not attending the clinic for 2 consecutive visits.

Intervention Results: Groups did not differ regarding baseline variables of subtype, gender, uveitis, ANA-, RF- or HLA B27-positivity and current or past DMARD use. Median disease activity was not different between groups during follow-up. Transfer was not associated with disease activity. Dropout rate was 12%, and was significantly higher in patients under transition (22%) compared with paediatric (3%) and adult care (10%). Patients who dropped out had significantly lower disease activity at baseline and were using less MTX, but did not differ regarding subtype, ANA, RF and HLA-B27.

Conclusion: The process of transition in JIA is not associated with an increase in disease activity, however, this period carries a risk for drop out especially in patients with low disease activity.

Study Design: e Longitudinal transition cohort study

Setting: Clinic-based (Out-patient clinics of university hospitals)

Population of Focus: Juvenile idiopathic diabetes 1 patients transferring to adult care

Data Source: Medical records

Sample Size: 64 patients

Age Range: 14-17 years of age

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Quality Improvement/Practice-Wide Intervention

Intervention Description: Researchers designed a multi-pronged pilot intervention to address barriers to care for pregnant women and young children in dental safety net settings. Pilot intervention components were: (1) Business assessment to evaluate and enhance safety net dental practice financial stability; (2) Quality improvement (QI) training to test and implement improved office access and efficiency; and (3) Evidence-based education for dental providers on care for pregnant women and young children.

Intervention Results: All mean measures improved, including: higher monthly revenue ($28,380–$33,102, p = 0.37), decreased no-show rate (17.7–14.3%, p = 0.11), higher monthly dental health encounters (283–328, p = 0.08), and higher monthly encounters for young children (8.8–10.5, p = 0.65), and pregnant women (2.8–9.7, p = 0.29). Results varied by practice, with some demonstrating largest increases in encounters for young children and others pregnant women. Focus group participants reported that the collaborative improved access for pregnant women and young children, and that QI methods were often new and difficult.

Conclusion: A learning collaborative among dental practices increased dental encounters and access for young children and pregnant women. Participation by safety net dental practices in a QI collaborative is feasible and acceptable. Individual sites saw greater improvements in different outcomes areas, based on their own structures and needs. Future efforts should focus on specific needs of each dental practice and should offer additional QI training.

Setting: Safety net dental practices

Population of Focus: Pregnant people

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

Intervention Description: Telehealth simulation has shown to be acceptable and helpful in teaching clinical reasoning, increasing exposure to telehealth experiences, and preparing nursing students for real interaction experiences with patients.

Intervention Results: A total of 205 students completed the evaluation. Most students (n = 136, 66.3%) were not familiar with telehealth prior to the simulation. Most students (n = 199, 97.1%) also found the simulation helpful for supporting breastfeeding mothers and wanted more telehealth simulations in the future (n = 162, 79%). Feedback for improving the simulations included: improving the technical setup (n = 17, 8.3%), increasing the time that students interacted with the mother (n = 16, 7.8%), and observing the correct performance of the simulation after debriefing (n = 16, 7.8%).

Conclusion: Telehealth simulation is a promising modality for clinical competency assessment, thus it is essential to integrate telehealth education into nursing curriculum. It is evident that telehealth-based breastfeeding simulations can be used to address the exposure/knowledge gap among nursing students who are missing or have limited exposure to breastfeeding content and telehealth use in their nursing curriculum.

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

Intervention Description: Continuing education for Nevada WIC professionals with the online HUG Your Baby course Roadmap to Breastfeeding Success was implemented.

Intervention Results: Results showed significant improvement in knowledge about infant behavior and development, confidence in identifying and responding to infant behavior, and the positive integration of HUG resources into the professionals’ work.

Conclusion: Lack of knowledge on the impact of infant development and behavior on breastfeeding affects both professionals and the clients they serve. Continuing education for Nevada WIC professionals with the online HUG Your Baby course Roadmap to Breastfeeding Success was implemented.

Intervention Components (click on component to see a list of all articles that use that intervention): School-Based Dental Screening, Teledentistry, HEALTH_CARE_PROVIDER_PRACTICE, CLASSROOM_SCHOOL

Intervention Description: The purpose of this paper was to describe how two school-based teledentistry programs increased access to oral health services for children and adolescents living in rural areas.

Intervention Results: Both MCHS and CDS reported that over 99 percent of encounters were successfully completed using telehealth technology. Both grantees reported that 99.4 percent of students received an oral health evaluation/screening, primarily through a dental hygienist traveling to the school site connected to a dentist or advanced dental therapist through telehealth. One half of the students had dental caries (50.6 % MCHS; 48.6% CDS). Both grantees referred all students with dental caries for oral health follow-up care.

Conclusion: By utilizing dental hygienists traveling to school sites and connecting with centrally located dental professionals through telehealth, both grantees increased access to needed oral health care services for rural children. Oral health screening in school settings using dental hygienists with teledentistry can provide an efficient way to identify students at high risk for dental caries and offer a valuable strategy for oral disease prevention and control.

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Provider Training/Education, Quality Improvement/Practice-Wide Intervention,

Intervention Description: In Tennessee, a statewide, multidisciplinary development team reviewed evidence from the "Ten Steps to Successful Breastfeeding" to create a consensus toolkit of process indicators. The Tennessee Initiative for Perinatal Quality Care (TIPQC) is a statewide perintatal quality collaborative seeking to improve health outcomes for mothers and infants through large-scale quality improvement (QI) initiatives. All teams met in monthly webinar huddles (online group discussions), semiannual regional learning sessions, and an annual statewide TIPQC collaborative meeting. Monthly webinar meetings for the participating hospitals were held online, hosted and led by TIPQC and state leaders.

Intervention Results: Thirteen hospitals accounting for 47% of live births in Tennessee submitted data on 31,183 mother–infant dyads from August 1, 2012, to December 31, 2013. Aggregate monthly mean PC-05 demonstrated “special cause” improvement increasing from 37.1% to 41.2%, an 11.1% relative increase. Five hospitals reported implementation of ≥5 of the Ten Steps and two hospitals reported ≥90% reliability on ≥5 of the Ten Steps using locally designed process audits.

Conclusion: Using large-scale improvement methodology, a successful statewide collaborative led to >10% relative increase in breastfeeding exclusivity at discharge in participating Tennessee hospitals. Further opportunities for improvement in implementing breastfeeding supportive practices were identified.

Study Design: Evaluation data

Setting: Hospitals in TN

Population of Focus: Hospitals located in the Mississippi River Delta or Appalachia in TN

Sample Size: 13 hospitals with data on 31,183 mother-infant dyads

Intervention Components (click on component to see a list of all articles that use that intervention): Education on Disease/Condition, Planning for Transition, HEALTH_CARE_PROVIDER_PRACTICE, YOUTH

Intervention Description: The objective of this study was to design, implement and evaluate a novel transitions program for adolescents with Inflammatory Bowel Disease and their parents, and to assess the impact of this program on transition readiness skills, self-efficacy and participant satisfaction.

Intervention Results: Over 60% of participants found the workshop helpful and 92% would recommend it to other teens with IBD. The average adolescent transition readiness score (TRAQ) significantly increased by 5.00 points following the workshop (SD = 7.49, p = 0.04), while total parent scores increased by 10.55 points (SD = 11.15, p = 0.011). As was expected, this demonstrates increased transition readiness skills. The average total adolescent IBD-SES score decreased by 6.75 (SD = 8.95, p = 0.024).

Conclusion: This novel transition program resulted in increased participant transition readiness, as reported by adolescent and parents, indicating the workshop's utility in promoting tangible skill development. Self-efficacy scores did not increase; self-efficacy is a delayed measure of program success and is tied to disease status and other stressors which also changed across time points. Practice implications: Future directions include continuing the virtual program for increased participation and dissemination, integrating feedback and increasing interdisciplinary involvement.

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Material, HEALTH_CARE_PROVIDER_PRACTICE, Midwifery, Labor Support

Intervention Description: A hospital in Belgium introduced "the cocoon," an alongside midwifery-led care unit. Low-risk pregnant women had the option of choosing the midwifery pathway or attending the traditional care pathway. Patients who chose the Cocoon pathway (62.2 percent nulliparous and 37.8% multiparous) had their pregnancy followed up almost exclusively by midwives, and their care was reviewed by a gynecologist at least twice during their pregnancy. The visits at the Cocoon lasted 45 minutes instead of the standard 20 minutes in the “classic” clinic. Women and their birth partners were encouraged to attend classes provided by midwives from the Cocoon and were given the opportunity to participate in a maximum of seven classes, six of which were group classes.

Intervention Results: In this setting, the cesarean birth rate was 10.3% compared with 16.0% in the traditional care pathway (adjusted odds ratios [aOR] 0.42 [95% CI 0.25-0.69]), the induction rate was 16.3% compared with 30.5% (0.46 [0.30-0.69]), the epidural analgesia rate was 24.9% compared with 59.1% (0.15 [0.09-0.22]), and the episiotomy rate was 6.8% compared with 14.5% (0.31 [0.17-0.56]). There was no increase in adverse neonatal outcomes. Intrapartum and postpartum transfer rates to the traditional pathway of care were 21.1% and 7.1%, respectively.

Conclusion: Women planning their births in the midwifery-led unit, the Cocoon, experienced fewer interventions with no increase in adverse neonatal outcomes. Our study gives initial support for the introduction of similar midwifery-led care pathways in other hospitals in Belgium.

Setting: Alongside midwifery‐led unit within a Belgian hospital

Population of Focus: Nulliparous and multiparous women with low-risk pregnancies

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

Intervention Description: We are now offering the Pfizer/BioNTech COVID-19 vaccine to any eligible individual in the office during our regularly scheduled clinic hours and are also offering unique vaccination clinics during our evening back-to-school physical nights in the late summer and early fall. Through our experience offering the COVID-19 vaccine to caregivers in our practice, we have found the following: (1) in addition to adolescent and young adult patients receiving the COVID-19 vaccine in the practice, we have provided the vaccine to several caregivers each day (more than 60 doses administered in 1 month); (2) a number of caregivers have reported appreciation for the convenience afforded by getting the vaccine while they were already at a visit for their child; (3) some caregivers have taken the opportunity to receive the vaccine together with their children in solidarity; and (4) several caregivers have stated that they appreciate the comfort and trust of getting the vaccine in the pediatric practice.

Intervention Results: Logistically, vaccinating family members and other nonpatients in our practice required some preparation and additional staffing. We needed a method for scheduling vaccine encounters in the electronic medical record (even for those not previously registered), securing adequate and appropriate vaccine supply and storage, ensuring adequate nursing resources, and developing workflow protocols. We also encouraged all team members who interact with patients and families in the practice (eg, physicians, nurse practitioners, nurses, social workers, behavioral health specialists) to ask about the COVID-19 vaccine, offer the opportunity for discussion with a clinician, and inform them of the opportunity to receive the vaccine in the office if desired (with second booster doses scheduled 3 weeks later for the Pfizer vaccine). In addition to the effort from our dedicated practice staff, the institution was able to support additional part-time nursing coverage (4 hours per day) for vaccination efforts using their COVID-19 emergency funds.

Conclusion: We also encouraged all team members who interact with patients and families in the practice (eg, physicians, nurse practitioners, nurses, social workers, behavioral health specialists) to ask about the COVID-19 vaccine, offer the opportunity for discussion with a clinician, and inform them of the opportunity to receive the vaccine in the office if desired (with second booster doses scheduled 3 weeks later for the Pfizer vaccine). In addition to the effort from our dedicated practice staff, the institution was able to support additional part-time nursing coverage (4 hours per day) for vaccination efforts using their COVID-19 emergency funds.

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.

Intervention Components (click on component to see a list of all articles that use that intervention): Integration into Adult Care, Pediatric to Adult Transfer Assistance, Planning for Transition, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: We did a randomised, open-label, controlled trial of patients aged 17-19 years with type 1 diabetes. Participants were recruited from a tertiary paediatric diabetes service at the Royal Children's Hospital (Melbourne, VIC, Australia) and had to be scheduled for transition to adult services at one of eight centres in Melbourne. We randomly assigned participants (1:1), using sequential sealed opaque envelopes, to either appointment management (intervention) or current care (control). The appointment manager acted as the point of contact between intervention group participants and the relevant adult clinics, and provided personalised pre-appointment telephone and short message service (SMS) reminders with automatic rebooking of missed appointments. No contact was initiated with the control group after recruitment, and any self-initiated contact with the investigating team was directed to the participant's previous treating paediatric physician. The intervention continued throughout the trial until at least 12 months of follow-up data were obtained for all participants. We assessed the mean frequency of adult clinic attendance and disengagement from services during 0-12 months after transition (primary outcomes) and 12-24 months after transition (secondary outcomes), analysed by intention to treat. We used regression analyses, adjusted for clinic attendance and glycated haemoglobin concentration pre-transition, to analyse the effect of the intervention. This study is registered with the Australian New Zealand Clinical Trials Registry (number ACTRN12611001012965).

Intervention Results: Between Jan 4, 2012, and Dec 31, 2014, we randomly assigned 120 individuals, 60 to the intervention and 60 to control. During 0-12 months after transition, the mean number of clinics attended was 2·3 (SD 1·1) in the intervention group and 2·3 (1·4) in the control group (p=0·84; adjusted β 0·1, SE 0·2, p=0·88); three (6%) of 49 participants in the intervention group and six (11%) of 55 in the control group disengaged from services (p=0·38; adjusted odds ratio [OR] 0·5, 95% CI 0·1-2·3, p=0·36). At 12-24 months post-transition, mean clinic attendance was 2·5 (SD 1·3) in the intervention group and 1·4 (SD 1·8) in the control group (p=0·001; adjusted β 0·9, SE 0·4, p=0·009); two (6%) of 32 in the intervention group and 18 (49%) of 37 in the control group disengaged from services (p=0·001; adjusted OR 0·1, 95% CI 0·1-0·2, p=0·001). Neither the intervention nor pre-transition clinic attendance had an independent effect on glycated haemoglobin after transition.

Conclusion: Appointment management did not increase clinic attendance and did not decrease disengagement with services 0-12 months after transition to adult services, but had a positive effect during 12-24 months after transition.

Study Design: RCT

Setting: Hospital/clinic- based (One hospital and 8 clinics)

Population of Focus: Young adults with type 1 diabetes transferring from pediatric care to adult clinics

Data Source: Medical records

Sample Size: 60 patients

Age Range: 17-19 years of age

Intervention Components (click on component to see a list of all articles that use that intervention): CLASSROOM_SCHOOL, School-Based Health Centers, Planning for Transition, HEALTH_CARE_PROVIDER_PRACTICE, Pediatric to Adult Transfer Assistance, Care Coordination, Quality Improvement/Practice-Wide Intervention

Intervention Description: This pilot study implemented and assessed the use of a structured HCT process, the Six Core Elements of HCT, in two school-based health centers (SBHCs) in Washington, DC. The pilot study examined the feasibility of incorporating the Six Core Elements into routine care and identified self-care skill gaps among students. Quality improvement methods were used to customize, implement, and measure the Six Core Elements and HCT supports.

Intervention Results: After the pilot, both SBHCs demonstrated improvement in their implementation of the structured HCT process. More than half of the pilot participants reported not knowing how to find their doctor’s phone number and not knowing what a referral is.

Conclusion: These findings indicate the need for incorporating HCT supports into SBHCs to help students build self-care skills necessary for adulthood.

Study Design: Cohort pilot evaluation

Setting: Schools

Population of Focus: High school students

Sample Size: 560

Age Range: Grades 9-12

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, , HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: This pilot study implemented and assessed the use of a structured HCT process, the Six Core Elements of HCT, in two school-based health centers (SBHCs) in Washington, DC. The pilot study examined the feasibility of incorporating the Six Core Elements into routine care and identified self-care skill gaps among students.

Intervention Results: After the pilot, both SBHCs demonstrated improvement in their implementation of the structured HCT process. More than half of the pilot participants reported not knowing how to find their doctor's phone number and not knowing what a referral is.

Conclusion: These findings indicate the need for incorporating HCT supports into SBHCs to help students build self-care skills necessary for adulthood.

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Planning for Transition, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: At a medium-sized pediatric hospital with no formal transition support program, we developed and evaluated the use of a single-session transfer clinic as an initial quality improvement intervention to improve patient satisfaction, clinic attendance, and knowledge of transition related issues.

Intervention Results: All patients and parents who attended reported high levels of satisfaction with the clinic. Providers were also mostly positive regarding their participation. Feedback from the first clinic was used to modify the structure of the second clinic to better meet the needs of participants and to allow the clinic to run more efficiently. The use of group sessions and adapting resources developed by other diabetes programs were viewed favourably by participants and lessened the burden on staff who delivered the clinic.

Conclusion: A half-day transfer clinic is a viable step towards improving patient and parent satisfaction during the transition into adult care without requiring additional staff or significant expenditures of new resources. This type of clinic can also be incorporated into a larger program of transition supports or be adopted by programs serving young adults with other chronic diseases

Intervention Components (click on component to see a list of all articles that use that intervention): Home Visit (caregiver), Outreach (Provider), HEALTH_CARE_PROVIDER_PRACTICE, PROFESSIONAL_CAREGIVER

Intervention Description: To assess the degree to which nurses in a national public health home visiting program collaborate with interprofessional providers to serve families experiencing adversity.

Intervention Results: Relational coordination scores, which are relative measures, ranged from 1 to 5; highest with supplemental nutrition for Women, Infants & Children (M = 3.77) and early intervention (M = 3.44); and lowest with housing (M = 2.55). The greatest sharing of resources was with supplemental nutrition (sum = 12.95) and mental health providers (sum = 11.81), and least with housing (sum = 7.26); with a range of 1–30 where higher scores indicated greater resource-sharing.

Conclusion: Home visiting nurses collaborate with interprofessional providers with variation in the degree of collaboration between agencies and by provider type within an agency. Collaboration was a function of two interrelated domains: interpersonal relationships supported by organizational and contextual factors at the systems-level.

Intervention Components (click on component to see a list of all articles that use that intervention): Guideline Change and Implementation, HOSPITAL, POPULATION-BASED SYSTEMS, NATIONAL, Policy/Guideline (National), PROFESSIONAL_CAREGIVER, Consensus Guideline Implementation, HEALTH_CARE_PROVIDER_PRACTICE, Active Management of Labor

Intervention Description: To evaluate the rate of primary cesarean delivery after adopting labor management guidelines.

Intervention Results: Among women delivering after induction or augmentation, the cesarean delivery rate decreased from 35.5% to 24.5% (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.38-0.91). The overall cesarean delivery rate decreased from 26.9% to 18.8% (adjusted OR 0.59, CI 0.38-0.92). Composite maternal morbidity was reduced (adjusted OR 0.66, CI 0.46-0.94). The frequency of cesarean delivery documenting arrest of dilation at less than 6 cm decreased from 7.1% to 1.1% postguideline (n=182 and 176 preguideline and postguideline, respectively, P=.006) with no change in other indications.

Conclusion: Postguideline, the cesarean delivery rate among nulliparous women attempting vaginal delivery was substantially reduced in association with decreased frequency in the diagnosis of arrest of dilation at less than 6 cm.

Study Design: Retrospective cohort

Setting: 1 public university hospital in Pennsylvania

Population of Focus: Nulliparous women who gave birth between September 13, 2013 and February 28, 2014 and between May 1, 2014, to September 28, 2014

Data Source: Not specified

Sample Size: Total (n=567) Pre-intervention (n=275) Post-intervention (n=292)

Age Range: Not Specified

Intervention Components (click on component to see a list of all articles that use that intervention): HEALTH_CARE_PROVIDER_PRACTICE, Active Management of Labor, Provider Training/Education, HOSPITAL, Quality Improvement, Chart Audit and Feedback, Guideline Change and Implementation,

Intervention Description: This quality improvement project was planned, implemented, and evaluated over an 8‐month time period from July 2018 through March 2019. Within this time frame, 7 weeks from October through December were devoted to four plan‐do‐study‐act (PDSA) cycles. The tests of change implemented during the PDSA cycles included both team engagement (interdisciplinary team huddles) and process changes (pilot of a best practices checklist (based on evidence-based guidelines) and audits of unplanned cesarean births). Interdisciplinary teams met regularly (53 times during the study period) to review individual cases, checklists, and audit data, and contribute to the decision-making process with the aim of reducing C-section rates.

Intervention Results: Over 7 weeks, 13 of 55 NTSV patients gave birth by cesarean, resulting in an NTSV CB rate of 23.6%. Fifty-three huddles were held by 218 staff members for 28 patients. Team engagement scores improved from 85% to 98%. Although the effective care CB scores trended upward, the overall mean was 51%.

Conclusion: Interdisciplinary team huddles, coupled with the use of a best practices checklist and feedback from audits, achieved a more effective use of CB in the NTSV patient population.

Setting: Community hospital in Mid-atlantic state

Population of Focus: Nulliparous patients with term singleton vertex gestations

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage, HEALTH_CARE_PROVIDER_PRACTICE, Public Insurance (Health Care Provider/Practice), NATIONAL, Policy/Guideline (National)

Intervention Description: Dependent coverage expansion (DCE) policies on the state and federal level have been enacted to target the high rates of uninsurance and unique barriers to obtain coverage among adolescents and young adults (AYA). DCE, a component of the ACA, requires private insurance policies that cover dependents to offer coverage for policyholders’ children through age 26. Several states, including Massachusetts, New Hampshire, and Maine, adopted state DCE policies that extended dependent coverage, with the Massachusetts policy accompanied by other health reforms later incorporated into the ACA, including an individual mandate, a Medicaid expansion, creation of a health insurance exchange with subsidies, and prohibition of pre-existing condition exclusions. State and federal health reforms may modify the effects of a DCE by altering the coverage options and incentives for AYA.

Intervention Results: Findings suggest that an individual mandate and other reforms may enhance the effect of DCE in preventing loss of coverage among AYA. Implementation of DCE with other reforms was significantly associated with a 23% reduction in exit from dependent coverage among AYA compared to the reduction observed for DCE alone. Additionally, comprehensive reforms were associated with over two additional years of dependent coverage for the average AYA and a 33% increase in the odds of regaining dependent coverage after a prior loss. Findings suggest that an individual mandate and other reforms may enhance the effect of DCE in preventing loss of coverage among AYA. The joint effect of these policy levers is also associated with maintenance of dependent coverage until an older age and increased likelihood of regaining dependent coverage after an initial disenrollment. In addition to reductions in the odds of and time to dependent coverage exit, DCE was associated with further coverage gains for AYA in the form of regained dependent coverage.

Conclusion: Findings suggest that an individual mandate and other reforms may enhance the effect of DCE in preventing loss of coverage among AYA.

Study Design: Retrospective cohort with a pre- to post-comparison

Setting: Policy (Insurance consortium in 3 states: Massachusetts, Maine, and New Hampshire)

Population of Focus: Harvard Pilgrim Health Care members who were enrolled continuously as a dependent for at least 1 year between the ages of 16 and 18, from January 2000 to December 2012

Data Source: Enrollment and claims data from Harvard Pilgrim Health Care (HPHC), a large not-for-profit health plan with over 1 million members in commercial plans concentrated in Massachusetts, New Hampshire, and Maine

Sample Size: 131,542 individuals

Age Range: 16-18 years

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT_CONSUMER, Educational Materials, Lactation Consultant, Other Education, Professional Support, HEALTH_CARE_PROVIDER_PRACTICE, Other (Provider Practice),

Intervention Description: A team-based, integrated lactation consultant (LC) and primary care provider (PCP) program improves breastfeeding rates in some outpatient settings, but only a limited number of studies have assessed efficacy in socioeconomically and racially diverse communities. The study intervention implemented routine LC/PCP visits for families at their first newborn visit to the FQHC following hospital discharge. A typical team-based visit was scheduled for 40 minutes with the RN/LC present for the entire visit and the PCP joining for about 10 minutes to examine the infant and coordinate the plan of care. The remaining 30 minutes was dedicated to lactation support, including addressing latch, milk supply, decreasing maternal pain, and breastfeeding anticipatory guidance.

Intervention Results: Among patients who initiated breastfeeding, those who received a LC/PCP visit were significantly more likely to be breastfeeding at 2 weeks (94% versus 80%, p = 0.004) and 4 months (68% versus 45%, p = 0.01). However, breastfeeding rates for the whole practice were not significantly different before and after implementation. Seventy-two percent of breastfeeding families saw a LC (n = 204). Median LC visit per breastfeeding patient was 1.18 (standard deviation [SD] +1.2). Patient survey reported that the three most commonly helpful aspects of the visit were “latch instruction” (60%), “breastfeeding questions answered” (80%) and “learning about massage and hand expression” (50%).

Conclusion: Team-based LC/PCP care is feasible at a FQHC. Patients found it helpful. Among families who initiated breastfeeding, receiving LC/PCP care was associated with increased breastfeeding duration through 4 months.

Study Design: Retrospective chart review

Setting: Federally Qualified Health Center in Cleveland, OH

Population of Focus: Women and infants receiving care at a Federally Qualified Health Center

Sample Size: Pre (n=197 women) and post (n=245 women)

Age Range: Women 18 years and older

Intervention Components (click on component to see a list of all articles that use that intervention): EMR Reminder, , HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: This study's purpose was to increase provider HCT services engagement through implementation of a transition-specific CDS and participation in a transition-focused Learning Collaborative (LC).

Intervention Results: From July 2018 through June 2019, providers at LC-participating sites engaged in HCT services at 8.0% (n = 480) and 5.3% (n = 145) of eligible patient visits compared to the control's 3.1% (n = 69). Engagement was highest for ≥18-year-olds at the LC-participating sites, 26.0% (n = 263) and 12.0% (n = 80), compared to the control's 7.2% (n = 31). After expanding from ≥16 to ≥14-year-olds, engagement decreased by 9.5% at ≥16-year-old visits. LC-participating sites reported increased HCT guideline adherence.

Conclusion: Quality improvement activities and transition clinical decision supports can improve provider engagement in recommended transition services for adolescents and young adults.

Intervention Components (click on component to see a list of all articles that use that intervention): YOUTH, Education on Disease/Condition, Counseling (Parent/Family), Planning for Transition, Pediatric to Adult Transfer Assistance, PARENT_FAMILY, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: There is no model for the process of transition of adolescents with inflammatory bowel diseases (IBD) to the adult care protocol. We recently established a transition clinic where 17-year-old to 18-year-old IBD patients are seen by a multidisciplinary team including pediatric and adult gastroenterologists with expertise in IBD treatments, an IBD nurse, and a psychologist. We quantitatively describe this model and its benefits, and correlate demographic and transition parameters to self-efficacy in IBD adolescent patients before and after transition. All adolescent IBD patients enrolled in our transition clinic between January 2013 and December 2015 were included. They completed a self-efficacy questionnaire ('IBD-yourself') before and after the transition. The scores were correlated to demographic, disease, and transition parameters.

Intervention Results: Thirty of the 36 enrolled patients (mean age: 19±1.8 years, range: 17-27) had Crohn's disease. Twenty-seven patients completed the transition protocol, which included an average of 3-4 meetings (range: 2-8) over 6.9±3.5 months. Self-efficacy scores in all domains of the questionnaire were significantly higher after completion of the transition. The weighted average score of the questionnaire's domains was 1.85±0.3 before and 1.41±0.21 after transition (P<0.0001). Age, sex, disease duration, duration of transition, and the number of meetings in the clinic correlated with the questionnaire's scores in the domains of coping with IBD, knowledge of the transition process, and medication use.

Conclusion: A well-planned adolescent IBD transition clinic contributes significantly toward improved self-efficacy in IBD. We recommend its implementation in IBD centers to enable a personalized transition program tailored to the needs of adolescents with IBD in specific domains.

Study Design: Quasi- experimental pre post

Setting: Hospital-based (Pediatric and adult IBD centers in a hospital)

Population of Focus: 36 IBD patients who started the transition process (January 2013-December 2015) in the adolescent transition clinic in the institute/hospital

Data Source: Questionnaires

Sample Size: 36 patients

Age Range: 17-27 years of age (median: 18.5)

Intervention Components (click on component to see a list of all articles that use that intervention): STATE, Public Insurance (State), HEALTH_CARE_PROVIDER_PRACTICE, Public Insurance (Health Care Provider/Practice)

Intervention Description: Researchers used data on individuals 12 years of age and older from the Canadian Health Survey to esitmate the marginal effects (ME) of having dental insurance including increased dental attendance.

Intervention Results: Having dental insurance increased the proportion of participants who visited the dentist in the past year (56.6 to 79.4%, ME: 22.8, 95% confidence interval (CI): 20.9–24.7) and who reported very good or excellent oral health (48.3 to 57.9%, ME: 9.6, 95%CI: 7.6–11.5).

Conclusion: Findings suggest that dental insurance is associated with improved dental visiting behaviours and oral health status outcomes. Policymakers could consider universal dental coverage as a means to support financially vulnerable populations and to reduce oral health disparities between the rich and the poor.

Setting: Community

Population of Focus: Children 12 years of age and older

Intervention Components (click on component to see a list of all articles that use that intervention): Health_Care_Provider_Practice, Screening Tool Implementation Training, Provider Training/Education

Intervention Description: The REAL-START intervention aimed to increase primary care provider adherence to ASD and developmental screening guidelines, and to increase Early Intervention (EI) referral for children at developmental risk in primary care clinics serving Latinos. This quasi-experimental study enrolled 6 Oregon primary care clinics. Clinic staff attended one initial and three follow-up trainings.

Intervention Results: Initially, 2357 18- and 24-month visit records (1157 18-month and 1200 24-month visits) were reviewed. Of these, 134 records were excluded because the child was previously identified as having a developmental disability, missing language or ethnicity information, or no provider name recorded, resulting in a final analytic sample of 2224 records. Although the overall percentage of Latino children in the study was relatively high (39%), two clinics had unexpectedly lower rates of Latino children of screening age (10% and 18%, respectively) than predicted from baseline data. A total of 20% (n = 436) of families spoke Spanish as a primary language. EI referral data were followed for 381 children, of whom 216 were new referrals for “screening age” (15–28 month) children. Among children referred to EI, 47% were Latino and 30% spoke Spanish as a primary language. In total, 63% were Medicaid-insured, and 37% were female. Median age at EI referral was 19 months.

Conclusion: REAL-START, a yearlong screening intervention, was effective in increasing screening for autism spectrum disorder and general developmental delays, increasing therapy referrals, and shortening time for developmental assessment in primary care clinics with Latino patients.

Setting: Primary care clinics

Population of Focus: Primary care providers and staff