Vibrant and Healthy Kids Aligning Science, Practice, and Policy to Advance Health Equity (2019) / Chapter Skim
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5 Leveraging the Health Care System to Improve Outcomes and Promote Health Equity
5 Leveraging the Health Care System to Improve Outcomes and Promote Health Equity
Pages 301-388
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From page 301... ...
Furthermore, changing needs of the population, with growing diversity and greater understanding of the health impacts of social determinants of health (SDOH) , also signal the need for major changes throughout the health care system.
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•• Although health insurance coverage has grown substantially in the past few decades, mainly through Medicaid expansions and other insurance enhancements, access remains a problem for many families with young children, who experience numerous barriers to obtaining health care ser vices in addition to lack of health insurance coverage. Further efforts are with public health and other sectors, to address the social determinants that underlie many health inequities.
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The health care sector is positioned to play a crucial role in advancing health equity by providing care and services during the preconception, prenatal, postpartum, and early childhood periods. Preconception, prenatal, and pediatric care provide a point of entry into the health care system for women and men, as well as children, especially those in the first few years of life.
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. In the same year, black and Hispanic children made up 20 and 37 percent, respectively, of all children covered by Medicaid and the Children's Health Insurance Program, yet they were 14 and 25 percent, respectively, of all children (Brooks and Wagnerman, 2018)
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. Given the multigenerational impacts of toxic stress, food and housing instability, chronic disease, and parental ill health on the health of children, all family members need access to health care services across the life course.
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Rather, the health care system needs to be better leveraged to not only provide medical care but also address the SDOH (including barriers to access other than health insurance, such as lack of or inadequate transportation to medical visits, cost-sharing, and lack of culturally competent services) (Woolf, 2019)
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, non-Hispanic black women, uninsured women, and those residing in southern states, prevalence estimates of risk factor indicators were generally highest and prevalence estimates of health-promoting indicators were generally lowest. Advancing health equity in birth and child health outcomes begins with reducing preconception health disparities.
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308 TABLE 5-1 Prevalence of Preconception Health Indicators Among Nonpregnant Reproductive-Aged Women (18–44 years) , by Age Group, Race/Ethnicity, and Insurance -- Behavioral Risk Factor Surveillance System, United States, 2013–2015a Current Recommended Cigarette Normal Physical Depressionb Diabetesb,c Hypertensionb,c,d Smokinge Weightf Activityd,g (2014–2015)
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Data self-reported by women aged 18–44 years. b Self-report of ever having been told by a health care provider that they have the condition.
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f Defined as having private, Medicaid, other government plans such as TRICARE, military health care, Indian Health Service or tribal, and other kinds of health insurance during the month before pregnancy. g In chi-square tests, differences by insurance are significant at p < 0.05 for all indicators except postpartum use of effective contraception.
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. The evidence base supporting a range of services for preconception care as critical to child health has been well documented and includes folic acid supplementation; appropriate management of hyperglycemia; rubella, influenza, and hepatitis vaccination; a low phenylalanine diet; and provision of antiretroviral medications to reduce the risk for motherto-child HIV transmission (Johnson et al., 2006; Korenbrot et al., 2002)
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have been well documented, these are often not the major drivers of disparities in birth and child health outcomes. Preconception care could have a greater impact in advancing health equity if it is better set up to optimize management of chronic conditions, such as hypertension, diabetes, and obesity, that disproportionately affect low-income women and women of color; yet, for many women, the lack of access to and the episodic nature of preconception care limit its effectiveness as a population-wide strategy for advancing equity in preconception health.
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The evidence base regarding the effectiveness of preconception care is also limited by the relative dearth of research on which preconception interventions succeed in advancing health equity in birth and child health outcomes. For example, despite increasing recognition of the health impact of maternal allostatic load on not only birth and child health outcomes but also the developmental origins of health and disease, there has been a paucity of intervention research on what can be done during preconception care to reduce maternal allostatic load.
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A discussion of preconception care is incomplete if it is not centered in the broader context of U.S. history, which included concerted efforts to encourage some women to reproduce while going to great lengths to make sure other women did not.
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. In the United States, prenatal care began with a program of nurse home visiting to pregnant women by Mrs.
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. These critiques led to a dampening of enthusiasm for prenatal care and a search for alternative strategies, such as bolstering preconception care services, to improve birth and child health outcomes in the United States.
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. Even for women who receive postpartum care, the typical 6-week postpartum visit may be too late to address some early onset issues and too limited to address other late onset or persistent problems.
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Recognizing the importance of the postpartum period as a critical time for a woman and her infant that sets the stage for their long-term health and well-being, this committee calls for a redesign of postpartum care to improve access, content, quality, delivery, and financing to better leverage its potential for advancing health equity. As will be discussed later
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Child health care has a focus on prevention and includes regular screening for a wide range of conditions, including drowning risk, lead exposure, anemia, adversity, hunger, and infectious diseases, as well as child behavior and development. Much of the work in pediatric well-child care grew from early efforts of the U.S.
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Screening is a key step in prevention and an integral part of pediatric care. Given the brief time available in a child health supervision visit, pediatric clinicians cannot do all of the recommended screening, so they make choices for their practices, based in part on the characteristics of their patient population.
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. Most child health professionals screen for growth and development, including behavioral issues and developmental delays, and for certain conditions that early treatment may ameliorate, including ASD.
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These children's hospital programs, some freestanding and others part of larger general hospitals, provide the majority of health care for children with highly specialized needs -- the groups with complex medical conditions and rarer childhood conditions. The substantial numbers of children and youth with chronic and complex health conditions, especially those with less common chronic conditions, need regular access to specialized pediatric care (e.g., specialized surgeons or pediatric cardiology)
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Similarly, prenatal and pediatric care that is primarily based on episodic, short visits to a medical clinic or office for a narrow range of clinical services scheduled when convenient for health care systems and providers is not enough to reverse the trend of centuries of inequitable health care treatment and outcomes experienced by our nation's children. Health Insurance Is Necessary But Not Sufficient Health insurance is a major facilitator to ensuring access to health care services; lack of insurance coverage is a significant barrier (Bailey et al., 2016; Choi et al., 2011; DeVoe et al., 2010, 2012a; Howell and Kenney, 2012; IOM, 2002; Sommers et al., 2015, 2017a; Tumin et al., 2019; Wallace and Sommers, 2016; Wherry et al., 2016)
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. The small percentage of children and youth without health insurance use fewer health care services and fare much worse on measures of health and health care quality (DeVoe et al., 2008a,b, 2010, 2012b)
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Data are sourced from the Commonwealth Fund Biennial Health Insurance Survey (2010, 2012, 2014, 2016)
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. In addition to access to coverage, the ACA further improved access to essential care for women, especially preconception care, by mandating coverage for women's preventive services, including all Food and Drug Administration–approved contraceptive methods and counseling and at least one well-woman preventive care visit per year with no cost-sharing (HRSA, 2018; Women's Preventive Services Initiative, n.d.)
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LEVERAGING THE HEALTH CARE SYSTEM 327 TABLE 5-3 Trimester That Prenatal Care Began, by Selected Characteristics: United States, 2016 Timing of PNC Late or No PNCa First Second Total Late Selected Characteristic Trimester Trimester Percent PNCb No PNC Total 77.1 16.7 6.2 4.6 1.6 Age of Mother Under 20 61.2 27.6 11.2 8.3 2.9 Under 15 36.7 37.6 25.7 19.2 6.5 15–19 61.5 27.5 11.0 8.2 2.9 20–24 70.3 21.7 8.0 5.9 2.1 25–29 77.8 16.3 6.0 4.4 1.5 30–34 82.1 13.1 4.8 3.6 1.2 35–39 81.7 13.5 4.8 3.6 1.2 40 and over 78.4 16.0 5.6 4.1 1.5 Race and Hispanic Origin Non-Hispanic, single-race: White 82.3 13.4 4.3 3.3 1.1 Black 66.5 23.5 10.0 7.0 3.0 merican Indian or A 63.0 24.5 12.5 9.2 3.3 Alaska Native Asian 80.6 14.0 5.4 4.6 0.8 Asian Indian 83.4 12.1 4.6 3.9 0.7 Chinese 81.2 11.4 7.4 6.9 0.5 Filipino 82.8 13.4 3.8 3.0 0.8 Japanese 85.5 10.5 4.0 3.2 0.8 Korean 85.3 10.6 4.1 3.4 0.7 Vietnamese 80.2 15.3 4.5 3.3 1.2 Other Asian 71.7 22.0 6.3 5.0 1.3 Native Hawaiian or Other Pacific Islander 51.9 28.9 19.2 14.2 5.0 Hawaiian 69.9 20.5 9.6 6.0 3.6 Guamanian 72.1 21.4 6.6 5.0 1.6 Samoan 56.9 29.1 14.0 10.4 3.6 Other Pacific Islander 43.8 31.3 24.8 18.4 6.4 continued
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. Data are sourced from the National Center for Health Statistics National Vital Statistics System.
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. As demonstrated above, Medicaid is an important source of insurance coverage and facilitator of basic access to women's health care services, particularly for low-income women.
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children and youth currently have health insurance, children who are low income or from racial and ethnic minority populations face problems with lack of access to ongoing, comprehensive health care services (McCormick et al., 2001; Weinick and Krauss, 2000)
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. Many Factors Affect Access to Health Care Services A complex array of factors beyond insurance coverage influence preconception, prenatal, and pediatric care use (Heaman et al., 2014; Kalmuss and Fennelly, 1990)
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In the state, CCOs cover a distinct geographic area and have broad budgeting authority for Medicaid and CHIP funding within that area, along with incentives to improve quality and broaden attention to social determinants of care in part through active collaboration with schools and community agencies (Oregon Health Authority, 2018; Stecker, 2013)
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increasing access to presumptive Medicaid eligibility, which provides pregnant women with access to immediate prenatal care; and (4) increasing continuity of coverage for low-income women who become pregnant (Association of Maternal & Child Health Programs, 2016)
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(See the sections that follow for discussion on the need to integrate health care services across the life course.) • Supporting comprehensive access across the life course.
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For example, adoption of a measure to assess disparities in timely and adequate access to well woman care, prenatal, and pediatric care as a national performance measure by the Title V Maternal and Child Health Block Grant. PROMOTING QUALITY OF CARE Quality health care is timely, equitable, safe, patient centered, efficient, and effective (IOM, 2001)
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. The reauthorization of CHIP in 2009 provided the first major support for quality measurement in public health insurance programs for children and youth and led to substantial growth in pediatric care measures and ongoing efforts to expand and refine these measures (AHRQ, 2018; Perrin, 2012)
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Often, these assessments are done at a population level and do not highlight disparities or account for practices caring for populations with different characteristics. Thus, in addition to traditional methods to assess performance and QI, there are a number of other areas that are receiving increased attention in efforts to attain equitable health care practices, including developing new metrics and measurement methods to account for child development and well-being in the context of an intersectional and multidimensional view of health and health equity and enhanced workforce education and training (including training to recognize and address implicit bias)
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. Even having clear standards for screening does not ensure that all child health practitioners screen for all relevant issues.
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. As the science advances regarding contributors to child health equity, new measures that capture the SDOH, including indicators of cumulative adversity and family issues that may impact health and development, have become available.
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The increased attention to identifying and addressing social, economic, and environmental factors adversely impacting the health of children and families has led to enhanced curricula in the training programs for child and family health care providers. These additional components strengthen the emphasis on learning about the social and community aspects of care for patients and families, implicit bias and unequal treatment, and how to more effectively collaborate with community organizations to improve care and outcomes.
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It also requires explicit training on eliminating implicit bias and unequal treatment in health care. Unequal preconception, prenatal, and pediatric care based on race, ethnicity, and SES has been well documented (Brett et al., 1994; Kogan et al., 1994;
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Ad ministered by the Health Resources and Services Administration and Maternal and Child Health Bureau, the Community-Based Doula Program is a model that provides culturally appropriate peer-to-peer support based on the life course ap proach during the perinatal and early postpartum periods. The program serves women and families in communities with high levels of health and social needs (the majority of participants are black or Hispanic, and a small number are from tribal communities)
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. Advancing health equity in birth and child health outcomes will require addressing implicit bias and unequal treatment in health care (see Chapters 7 and 8 for more on implicit bias training)
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Improving Quality of Care Based on its review of the evidence the committee concludes: Conclusion 5-3: Strategies to improve the quality of preconception, pre natal, and child health care have included developing and implementing new measures, including for adversity and social determinants, along with efforts to strengthen the training of the health care workforce to better understand diversity and implicit bias and to address equity in health care. To improve the quality of care provided in the preconception through early childhood periods, the committee recommends: Recommendation 5-2: To expand accountability and improve the quality of preconception, prenatal, postpartum, and pediatric care, • Public and private payers should include new metrics of child and family health and well-being that assess quality using a holistic view of health and health equity.
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Metrics for accountability include • Social determinants and risk measures: Measures that reflect whether risks were identified early and whether families received needed help, with key drivers of health inequities that lie beyond traditional clinical purview but profoundly impact their health, such as housing instability, food security, and exposure to adver sity or trauma. • Cross-sector developmental measures: Measures that move beyond common indicators of child development, such as immunizations and management of acute infections or common chronic conditions, to address an expanded set of clinical indicators crucial for children and caretakers, including MBH.
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Nonetheless, the multiple scheduled health supervision visits during the prenatal and early childhood periods can serve to connect families with trusted health advisors. For young children who have frequent pediatric care visits in the first years of life, health care provides a main entry point to health and many other services that can support the promotion of health for preschool children and their families (Garg et al., 2015; Patient-Centered Primary Care Collaborative, n.d.; Stille et al., 2010)
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This model is especially promising in the reconceptualization of postpartum care, which would move away from a single clinical encounter toward more comprehensive, ongoing support for the postpartum transition. While initial observational studies (Thielen, 2012)
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. Research shows that CenteringPregnancy has led to improved birth outcomes, including significantly lower risk of preterm birth, low birth weight (LBW)
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child health providers in supporting and encouraging father involvement, with special attention to fathers' involvement across childhood ages and the influence of fathers' physical and mental health on their children. Given the growing diversity of families, similar attention is needed to engaging partners of all types across the health system.
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. One such program embeds mental health workers in several community health center pediatric practices so that they can see patients jointly or transfer them easily and immediately.11 These personnel both see patients directly and help to train the primary care practitioners to hone their own mental health skills.
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. It has been shown to improve child health outcomes in a random ized trial (Gottlieb et al., 2016)
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Home visiting 10. Trainings/child quality improvement SOURCE: CSSP, 2018.
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. For prenatal care, enhanced care models have been designed to deliver coordinated, augmented, enabling, enriched, comprehensive, or "wraparound" prenatal care services -- particularly for low-income populations.
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. In his systematic review of three types of enhanced prenatal care -- home visiting programs, comprehensive care programs, and preterm prevention programs -- Fiscella (1995)
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. These examples all apply developmental science and aim to advance health equity during the preconception through early childhood periods.
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. These innovative efforts together promise ways to strengthen preconception, prenatal, and pediatric care, help it move to team care and improve use of new technologies, and strengthen integration with other community services to enhance child health and well-being.
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. Family-centered care can lead to improved child health and behavioral outcomes (Dunst and Trivette, 2009; Dunst et al., 2007; Kuo et al., 2012)
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, and several single-site evaluations have also taken place. Findings from the evaluations suggest that the model can help to achieve improved outcomes in child health and development, breastfeeding and early nutrition, con nections to resources, child safety, parenting knowledge and practices, parent and physician satisfaction, maternal depression, and early literary and school readiness (Zero to Three, 2017)
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CMS recently released a request for proposals to address similar opportunities at the child health level, with a strong emphasis on MBH and building community coalitions to improve outcomes based on social determinants criteria (CMS, 2019)
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Such data, collected from the comfort of a woman's own home throughout her pregnancy, may include not only information on blood pressure or urine protein but also nutrition and physical activities, stress and sleep, and occupational, environmental, and other exposures that affect pregnancy outcomes and developmental origins of health and disease. With remote home monitoring, it is possible to continuously transmit data to the Cloud, which, with the aid of artificial intelligence and machine learning, could be used to improve predictive analytics.
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For example, reminders generated by electronic medical records can be used to encourage prenatal providers to prescribe progesterone to eligible patients with a documented history of spontaneous preterm delivery, to tell pediatric care providers about overdue immunizations, or to prompt follow-up on abnormal lab results, which can sometimes be missed in busy, understaffed clinics, especially in underresourced communities. Health education materials are accessible on the Internet and through smartphone apps.
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Many women lose their pregnancyrelated Medicaid coverage at 60 days postpartum. Payers often do not recognize the care provided to parents in pediatric and family medicine care settings.
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provide most of the subspecialty care for children and youth with more complex and less common health conditions. Insofar as many children have public health insurance -- with even higher rates among children with chronic health conditions -- children's hospitals rely substantially on public financing.
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(See Box 5-9 for more on population health payments.) Organization and Integration of Health Care Services Based on its review of the evidence, the committee concludes: Conclusion 5-4: Recent efforts to transform health care to address social determinants, early adversity, and mental and behavioral health integra tion and to develop community-based health care teams have increas ingly addressed the changing needs of young families and children.
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Promote the adoption and spread of multigenera tional, team-based care models that support patients with a mix of traditional clinical professionals, such as doctors, nurses, social workers, and pharmacists, with mental health professionals, as well as community health workers or peer support specialists. Team activities include chronic disease management, integrated MBH, family support in early childhood, including access to par ent training, and referral/connection to needed community ser vices (housing, food, etc.)
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Shared governance structures should promote collaboration, including investment in administrative infrastructure and back bone organizations to manage collaboratives, thereby ensuring the flow of information and funding across sectors, and other strategies for sharing efforts and savings. THE FUTURE OF PRECONCEPTION THROUGH PEDIATRIC CARE Vision: To advance health equity, reduce health disparities, and improve birth and child health outcomes, the committee calls for a health care system that ensures access for all to high-quality health care across the life course.
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To expand the content of preconception to pediatric care to address key drivers of health inequities better, specific actions include • Recognize the impact of both adverse and enriching experi ences across the life course and cumulative effects on health and well-being. Address transitions between care providers and move from disjointed episodic care to an integrated continuum of longitudinal health care designed to optimize health production across the life course.
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Clinicians and clinical staff should have ongoing training and accountability in areas of implicit bias and equity in evaluation and treatment. CONCLUSION Applying the science of early development to transform preconception, prenatal, postpartum, and pediatric care has the potential to advance health equity.
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2016. Poverty and child health in the United States.
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2013. Effectiveness of home visiting in improving child health and reducing child maltreatment.
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Maternal and Child Health Journal 15(6)
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: Rationale and design of a random ized controlled trial of CenteringPregnancy and birth outcomes. BMC Pregnancy and Childbirth 17(1)
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2015. Patterns of health insurance coverage around the time of preg nancy among women with live-born infants -- Pregnancy Risk Assessment Monitoring System, 29 States, 2009.
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2009. Children's receipt of health care services and family health insurance patterns.
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Maternal and Child Health Journal 19(4)
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to reduce infant mortality. Maternal and Child Health Journal 21(6)
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Maternal and Child Health Journal 22(Suppl 1)
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Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau.
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2019. Title V Maternal and Child Health Services Block Grant Program.
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2006. Recommendations to improve preconception health and health care -- United States: A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care.
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Maternal and Child Health Journal 16(2)
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2004. Integrating the environment, the economy, and community health: A community health center's initiative to link health benefits to smart growth.
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2017. Communities in action: Pathways to health equity.
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2015. Reported child health status, Hispanic ethnicity, and language of interview: United States, 2011–2012.
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Maternal and Child Health Journal 23(8)
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2017a. Health insurance coverage and health -- what the recent evidence tells us.
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Maternal and Child Health Journal 23(5)
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Maternal and Child Health Journal 17(2)
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