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): HEALTH_CARE_PROVIDER_PRACTICE Quality Improvement/Practice-Wide Intervention HOSPITAL Policy/Guideline (Hospital) Continuing Education of Hospital Providers

Intervention Description: Implemented hospital-wide safe sleep guidelines, staff education (online modules, in-person presentations, posters, videos), appointment of unit champions, sleep sack distribution, EMR documentation templates, crib cards, crib audits (≥20 per unit per month), Safe Sleep Month campaign, and organizational strategies to keep cribs free of objects. Monthly SME meetings and iterative PDSA cycles guided interventions.

Intervention Results: Safe sleep compliance improved from 9% at baseline (2019) to 53% by 2022. Improvements observed across individual measures: head of bed elevation compliance rose from 64% to 85%; sleep area object/linen compliance from 51% to 70%; supine position compliance sustained at ~97%. Medically complex infants were less likely to adhere to safe sleep practices (33% vs. 40%, p = .027).

Conclusion: A hospital-wide QI approach, supported by multidisciplinary leadership, significantly improved safe sleep compliance across units, though challenges remain for medically complex infants. Long-term sustainability requires ongoing education, resource allocation, and cultural change.

Study Design: Hospital-wide quality improvement initiative using Plan-Do-Study-Act cycles, Lean Six Sigma, and multidisciplinary SME workgroup.

Setting: Boston Children’s Hospital, a 477-bed tertiary care pediatric hospital across 15 inpatient units.

Population of Focus: Infants aged <12 months hospitalized across inpatient units; hospital staff; caregivers (indirectly).

Sample Size: 5,045 audits collected across 15 units over 44 months; average daily census of 124 inpatient infants <12 months.

Age Range: Infants aged 0–12 months (eligibility criteria; excluded if <32 weeks gestation).

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): HEALTH_CARE_PROVIDER_PRACTICE Clinical Decision Support System Provider Reminder/Recall Systems HOSPITAL Visual Display (Hospital)

Intervention Description: - Intervention: Implementation of a smart intrapartum surveillance system. - Description: The system automatically reminds staff to apply MEWC and intrapartum care bundles, includes a fetal heart rate interpretation algorithm and electronic partogram, and operates as a CDSS analyzing EHR data to provide evidence-based care prompts. - Components: Fetal heart rate interpretation algorithm, electronic partogram, real-time data analysis, alerts based on established protocols (AIM-Maternal early warning signs protocol, FIGO-Consensus guidelines, WHO Labor Care Guide). - Frequency and Duration: Implemented in a labor and delivery unit; exact frequency and duration not specified."

Intervention Results: - The cesarean section rate for NTSV pregnancies decreased significantly from 31.0% to 23.3% after implementing the smart intrapartum surveillance system. - The primary CS rate decreased from 37.0% to 33.0%, and the overall CS rate decreased from 46.8% to 42.5%. - The smart intrapartum surveillance system reduced primary CS rates for low-risk NTSV pregnancies without affecting perinatal outcomes."

Conclusion: The study concludes that the implementation of a smart intrapartum surveillance system significantly reduces primary cesarean section rates for low-risk NTSV pregnancies without affecting perinatal outcomes. It proposes this system as a novel monitoring model for labor and delivery units, improving overall CS rates. However, the study is limited by its single-institution design and retrospective nature, which restricts understanding of algorithmic mechanisms. Future studies are needed to address these limitations, explore user perceptions, and assess long-term health effects and medical expenditure differences.

Study Design: Retrospective cross-sectional study, observational study

Setting: - Location: A local medium-sized maternity hospital in Taoyuan City, Taiwan (Hungchi Women & Children's Hospital) - Time period: April 2021 to May 2022 - Population: Parturient women admitted for delivery - Environmental factors: Labor and delivery unit with electronic medical records; hospital manages approximately 3000 births annually; staff includes 12 physicians and 32 midwives and nursing staff"

Population of Focus: Women admitted for delivery, specifically those with nulliparous, term, singleton, vertex (NTSV) status.

Sample Size: 3648

Age Range: Not mentioned (the paper does not provide specific information on the age range of the participants)

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 Active Management of Labor Labor Support

Intervention Description: - Induction of Labor (IOL): Offered starting at 41 weeks unless earlier medical or obstetric indications, or social circumstances. Antenatal testing initiated at 41 weeks and repeated at 41 3/7 or 41 4/7 weeks. Performed at various gestational ages (37th to 41st week). - Expectant Management (EM): Supported until 42 weeks, with IOL recommended at that gestation."

Intervention Results: - Cesarean birth rates did not differ significantly between induction of labor (IOL) and expectant management (EM) for weeks 37 to 40 when using inclusive EM definitions. - IOL in the 40th week was associated with lower odds of cesarean birth compared to exclusive EM, which assumes pregnancies lasting until the 41st week or later. - Neonatal outcomes, excluding macrosomia, were not significantly different between IOL and EM at any gestational age."

Conclusion: The study concludes that within a midwifery model of care, there is a low overall use of cesarean births and a low frequency of induction of labor before 41 weeks. Induction of labor in the 40th week may lower cesarean birth odds compared to expectant management that extends into later gestational ages. The study suggests that midwifery-led care, which reserves induction for medical or obstetric indications, results in positive overall outcomes and low cesarean birth rates. Future research should focus on examining components of care models that promote vaginal birth and understanding processes of care for induction of labor and expectant management.

Study Design: Retrospective observational study, multi-site

Setting: - Location: Oregon and Michigan, USA - Time period: 2007-2018 - Physical context: Hospital setting - Population: Nulliparous individuals giving birth at 37 weeks or beyond - Social context: Suburban/urban communities - Environmental factors: Midwives rotating shifts for inpatient care"

Population of Focus: Nulliparous individuals (adult women pregnant for the first time) receiving midwifery care

Sample Size: 4057

Age Range: Approximately 20 to 40 years (inferred from mean age 28.9 years and standard deviation 5.3 years)

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): HEALTH_CARE_PROVIDER_PRACTICE Data Collection Training for Staff HOSPITAL Quality Improvement STATE Perinatal Committees/Councils

Intervention Description: Hospitals implemented AAP-compliant safe sleep policies, provided staff and family education, and conducted monthly safe sleep audits. Virtual huddles and learning sessions supported implementation.

Intervention Results: Safe sleep compliance increased by 22%. Most common failure reasons: crib items (49%), unsafe bedding (27%), head-of-bed elevation (24%).

Conclusion: Statewide QI can identify and address barriers, share resources, and improve compliance with safe sleep recommendations.

Study Design: Statewide QI collaborative with monthly audits, huddles, semiannual learning sessions.

Setting: Thirteen birthing hospitals and NICUs across Tennessee (urban and rural).

Population of Focus: Infants 0–12 months hospitalized in newborn nurseries and NICUs; healthcare staff; parents.

Sample Size: 13 hospitals serving >40% of live births in Tennessee. 671 infants audited for compliance.

Age Range: Infants 0–12 months (eligibility criteria).

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.