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Primary Well-Being: Case Studies for the Growing Child

  • Deborah Kramer 0

Department of Nursing, College of Mount Saint Vincent, New York, USA

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Provides an understandable clinical context for new nurse practitioners to care for child (0-18)

Offers realistic well child visits to develop NP's thinking skills

Incorporates professional advocacy and specific child development enhancement skills

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Table of contents (32 chapters)

Front matter, preparation for the well-child visit, introduction.

Deborah Kramer

Overview of the Well-Child Visit

Role of development, health history and physical exam, the primary care provider as advocate, complementary medicine, case studies, newborn visit, two-week visit, two-month visit, four-month visit, six-month visit, nine-month visit, one-year visit, eighteen-month visit, two-year visit, thirty-month visit, three-year visit.

This book offers solutions on how to enhance the normal development of the well child incorporating complementary medicine. The primary care provider is the only healthcare professional to see every child (0-18) and their parent, and can assess the child’s health and advise parents on how to provide a healthy environment and important practices to nurture healthy children.  

The book provides realistic scenarios encountered by new nurse practitioners in their clinical training. It is structured in a question and answer framework to help practitioners critically think through the best practices to be implemented during the well child visit and develop a plan of action for the family. This book provides assessment and diagnostic criteria and tools and presents common developmental and behavioral issues for each age group. The book promotes the role of professional as advocate by making recommendations for broad social policies to help all children succeed.

  • Clinical assessment
  • Parent education
  • Child development
  • Anticipatory guidance
  • Critical clinical decision-making
  • Microbial health
  • Complementary and alternative medicine
  • Gut-brain health
  • Sensory motor integration
  • Cultural sensitivity
  • Enhancing development
  • maternal and child health

Book Title : Primary Well-Being: Case Studies for the Growing Child

Authors : Deborah Kramer

DOI : https://doi.org/10.1007/978-3-319-56708-2

Publisher : Springer Cham

eBook Packages : Medicine , Medicine (R0)

Copyright Information : Springer International Publishing AG 2017

Hardcover ISBN : 978-3-319-56707-5 Published: 24 July 2017

Softcover ISBN : 978-3-319-85979-8 Published: 13 May 2018

eBook ISBN : 978-3-319-56708-2 Published: 11 July 2017

Edition Number : 1

Number of Pages : XIV, 277

Topics : Nursing , Child Well-being , Pediatrics , Maternal and Child Health , Internal Medicine

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eReferences

  • Contextual Considerations When Interpreting Well-Child Visit Adherence Results JAMA Pediatrics Comment & Response January 1, 2023 Sarah L. Goff, MD, PhD

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Abdus S , Selden TM. Well-Child Visit Adherence. JAMA Pediatr. 2022;176(11):1143–1145. doi:10.1001/jamapediatrics.2022.2954

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Well-Child Visit Adherence

  • 1 Center for Financing, Access, and Cost Trends, Division of Research and Modeling, Department of Health and Human Services, Agency for Healthcare Research and Quality, Rockville, Maryland
  • Comment & Response Contextual Considerations When Interpreting Well-Child Visit Adherence Results Sarah L. Goff, MD, PhD JAMA Pediatrics

Well-child care, as recommended by the American Academy of Pediatrics’ Bright Futures guidelines, 1 provides children with preventive and developmental services, helps ensure timely immunizations, and allows parents to discuss health-related concerns. 2 We know from prior studies 3 , 4 that as of 2008, well-child visits were trending upward, but often fell short of recommendations among key socioeconomic groups. This article provides updated evidence on well-child visit adherence, both overall and by age, race and ethnicity, insurance coverage, family income, parent education, urbanicity, and region.

We used the Medical Expenditure Panel Survey (MEPS) 5 to conduct a cross-sectional study of children aged 0 to 18 years in 2006 and 2007 (n = 19 018) and 2016 and 2017 (n = 17 533). Sponsored by the Agency for Healthcare Research and Quality (AHRQ), MEPS provides nationally representative data on child office visits, thereby avoiding potential over reporting from questions more directly about adherence. 3 , 4 Unlike administrative or insurer data, MEPS includes uninsured children and offers extensive socioeconomic information on children and their families.

We defined adherence as the ratio of reported well-child visits during the calendar year divided by the recommended number of visits. Recommendations published in late 2007 added visits at 30 months, 7 years, and 9 years. 1 We used these recommendations throughout our study to maintain consistent adherence denominators. We compared adherence in 2006 and 2007 and 2016 and 2017 for all children and by subgroup (differences-in-differences). This study was covered under the Chesapeake Institutional Review Board protocol for AHRQ Secondary Analysis of Confidential Data from the MEPS, and followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guidelines. The eMethods in the Supplement provide additional methodological details.

Average adherence increased from 47.9% (95% CI, 46.1%-49.7%) in 2006 and 2007 to 62.3% (95% CI, 60.1%-64.6%) in 2016 and 2017, respectively ( Table ), yet large gaps remained across race and ethnicity, poverty level, insurance, and geography. Adherence grew by 17.5 percentage points (95% CI, 11.6%-23.4%) among children ages 7 to 10 years, the group with the largest guideline increase. This increase was not, however, significantly different from adherence growth in either (1) our reference group (ages 4-6 years), selected for having unchanged guidelines and the highest initial adherence, or (2) older children, whose guidelines also remained constant.

Adherence grew unevenly across race and ethnicity, rising by 21.7 percentage points (95% CI, 17.9%-25.5%) among Hispanic children vs 15.3 percentage points (95% CI, 10.9%-19.7%) among White non-Hispanic children. Nevertheless, adherence in 2016 and 2017 among Hispanic children at 58.0% (95% CI, 55.0%-60.9%) still trailed that of White non-Hispanic children at 67.8% (95% CI, 64.3%-71.4%). Adherence among Black non-Hispanic children increased by only 5.6 percentage points (95% CI, 0.3%-11.0%), widening the Black-White adherence disparity among non-Hispanic children.

Adherence also grew unevenly across insurance status, increasing among publicly insured and privately insured children by 15.5 percentage points (95% CI, 11.8%-19.2%) and 13.9 percentage points (95% CI, 10.2%-17.6%), respectively, while not changing significantly among uninsured children. The resulting 2016 and 2017 adherence ratios for children with any private, any public (and no private), and no coverage were 66.3% (95% CI, 63.4%-69.1%), 58.7% (95% CI, 55.7%-61.7%), and 31.1% (95% CI, 23.9%-38.3%), respectively.

We found evidence of increased well-child visit adherence over our study period, which spanned increased visit recommendations, substantial macroeconomic change, and enactment of the Affordable Care Act’s coverage and preventive care provisions. Nevertheless, disturbing gaps remained. Adherence among uninsured children in 2016 and 2017 was only half the national average, and over a 20–percentage point difference still separated the highest-adherence and lowest-adherence regions. The Black non-Hispanic vs White non-Hispanic disparity widened during this period. Narrowing disparities and improving adherence among US children will require the combined efforts of researchers, policy makers, and clinicians to improve our understanding of adherence, to implement policies improving access to care, and to increase health care professional engagement with disadvantaged communities. 6

Accepted for Publication: June 22, 2022.

Published Online: August 22, 2022. doi:10.1001/jamapediatrics.2022.2954

Corresponding Author : Salam Abdus, PhD, Center for Financing, Access, and Cost Trends, Division of Research and Modeling, Department of Health and Human Services, Agency for Healthcare Research and Quality, 5600 Fishers Ln, Rockville, MD 20857 ( [email protected] ).

Author Contributions : Drs Abdus and Selden had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: All authors.

Conflict of Interest Disclosures: None reported.

Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the US Department of Health and Human Services or the Agency for Healthcare Research and Quality.

Additional Contributions: Joel Cohen, PhD, Yao Ding, PhD, and G. Edward Miller, PhD, of the Agency for Healthcare Research and Quality, provided comments on early versions of the article. and the contributors received no compensation.

Additional Information : This study was conducted by Drs Abdus and Selden as employees of the Agency for Healthcare Research and Quality (AHRQ) and as part of AHRQ’s intramural research program. AHRQ was involved with the internal peer review process.

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A case study of well child care visits at general practices in a region of disadvantage in Sydney

Affiliations.

  • 1 Department of Community Paediatrics, Liverpool Hospital, Liverpool, New South Wales, Australia.
  • 2 Specialist Disability Health Team, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.
  • 3 South Western Sydney Local Health District, Sydney, New South Wales, Australia.
  • 4 Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia.
  • 5 School of Women's and Children's Health, UNSW, Sydney, Australia.
  • 6 School of Public Health, University of Sydney, Sydney, New South Wales, Australia.
  • 7 School of Public Health, Griffith University, Gold Coast, Queensland, Australia.
  • 8 Department of Community Paediatrics, Sydney Local Health District, Croydon, New South Wales, Australia.
  • 9 School of Public Health and Community Medicine, UNSW, Sydney, Australia.
  • 10 Academic General Practice Unit, Fairfield Hospital, Fairfield, New South Wales, Australia.
  • 11 Faculty of Human Sciences Department: Department of Educational Studies, Macquarie University, Sydney, Australia.
  • PMID: 30307993
  • PMCID: PMC6181326
  • DOI: 10.1371/journal.pone.0205235

Introduction: Well-Child Care (WCC) is the provision of preventive health care services for children and their families. Prior research has highlighted that several barriers exist for the provision of WCC services.

Objectives: To study "real life" visits of parents and children with health professionals in order to enhance the theoretical understanding of factors affecting WCC.

Methods: Participant observations of a cross-sectional sample of 71 visits at three general practices were analysed using a mixed-methods approach.

Results: The median age of the children was 18 months (IQR, 6-36 months), and the duration of visits was 13 mins (IQR, 9-18 mins). The reasons for the visits were immunisation in 13 (18.5%), general check-up in 10 (13.8%), viral illness in 33 (49.2%) and miscellaneous reasons in 15 (18.5%). Two clusters with low and high WCC emerged; WCC was associated with higher GP patient-centeredness scores, younger age of the child, fewer previous visits, immunisation and general check-up visits, and the solo general practitioner setting. Mothers born overseas received less WCC advice, while longer duration of visit increased WCC. GPs often made observations on physical growth and development and negotiated mothers concerns to provide reassurance to them. The working style of the GP which encouraged informal conversations with the parents enhanced WCC. There was a lack of systematic use of developmental screening measures.

Conclusions: GPs and practice nurses are providing parent/child centered WCC in many visits, particularly when parents present for immunisation and general check-ups. Providing funding and practice nurse support to GPs, and aligning WCC activities with all immunisation visits, rather than just a one-off screening approach, appears to be the best way forward. A cluster randomised trial for doing structured WCC activities with immunisation visits would provide further evidence for cost-effectiveness studies to inform policy change.

Publication types

  • Multicenter Study
  • Child Health Services / economics
  • Child Health Services / organization & administration*
  • Child Health Services / statistics & numerical data
  • Child Health*
  • Child, Preschool
  • Cross-Sectional Studies
  • General Practice / economics
  • General Practice / methods
  • General Practice / organization & administration*
  • General Practice / statistics & numerical data
  • General Practitioners / organization & administration
  • General Practitioners / statistics & numerical data
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  • Preventive Health Services / statistics & numerical data
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  • Referral and Consultation / economics
  • Referral and Consultation / organization & administration
  • Referral and Consultation / statistics & numerical data

Grants and funding

Well Child Visit

The well-child/adolescent visit (wcv) is the cornerstone of pediatric care. sbhc providers should conduct these visits annually because they’re not only a chance to deliver comprehensive, evidence-based preventive care — they can also allow providers to identify health risks early and then intervene. a comprehensive wcv can improve performance in the four other national measures as well: annual risk assessment; body mass index measurement and nutrition and physical activity counseling; depression screen; and chlamydia screen., well child visit case examples.

Back to Top

Case Example 1: Converting Acute Care Visits to Comprehensive Well-Care Visits

A school-based health center in Colorado found that by converting acute care visits to comprehensive well-care visits, their providers gave more WCVs to patients, improved the relationships with those patients, and felt more satisfied in their work. The SBHC staff also witnessed an improvement in each of the other measures because the WCV was the point when risk assessments, BMI assessments, depression screens, and Chlamydia screens took place.

Case Example 2: Documenting Well-Child Visits in Electronic Health Records

An IT specialist working for an SBHC in North Carolina, designed a structured data field in an alert section of the SBHC’s EHR, eClinicalWorks, called “EXTPE” (external physical exam) to document any WCVs that occurred outside the SBHC. In that data field, SBHC providers and nurses enter the date of the student’s outside physical. With that information, SBHC staff can now run reports to see who’s had an external physical exam and who hasn’t. In a similar data field, SBHC staff can also report any WCVs they conducted at the school-based health center. Here’s a screenshot of their EHR page:

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  • Promoting Parent Engagement in School Health: A Facilitator’s Guide for Staff Development
  • Parent Engagement: Strategies for Involving Parents in School Health

Centers for Medicaid & Medicare Services:

  • Paving the road to good health: strategies for increasing Medicaid adolescent well-care visits

Frequently Asked Questions

What are some promising strategies i can use to increase the number of sbhc patients who receive an annual well-child visit.

  • Convert acute care visits and sports physicals into comprehensive WCVs by including age-appropriate components, like preventive services. If you’re unable to do a full WCV due to a complex sick visit, schedule the full WCV for another day.
  • Implement an electronic health record (EHR) tickler system to identify students due for WCVs.
  • Partner with school staff (like the school nurse and social worker) and family to identify which students need a WCV so you can schedule those visits at your school-based health center.
  • Make sure you document WCVs that happen outside of your SBHC.
  • Create a discrete field or observational term for providers to track patients who receive WCVs outside of your SBHC.

How do I document the well-child visits that happen outside of my SBHC?

  • Check your regional or state health information exchange/registry. Some regions and states have a health information exchange or registry where information on care received is publicly available.
  • Build relationships with providers in your community. Meet with them to tell them about the services your SBHC offers, your interest in coordinating care with them, and the specific information you’d need from them about WCVs.
  • Ask the client, the client’s family, primary care provider (PCP), school nurse and/or school record system if that client received a WCV during the past 12 months.
  • Create a process to document and extract data: If you’re entering WCVs performed outside the SBHC as a note, narrative, or comment field in your EHR, convert those to discrete fields so you can extract that data more easily.

How can I tell if a well-child visit completed outside of my SBHC was comprehensive?

  • Great question. It’s hard to tell unless another provider explicitly shared with you that it was a comprehensive WCV. Try asking specific questions to your SBHC patient or his/her family member such as, “Did the provider ask you in detail about your health history?” and use clinical judgment to determine whether or not the visit was comprehensive.
  • Build relationships with community providers so you know more about the quality of care they likely gave your patient.

Telehealth Ideas

  • When in-person care is an option, complete well-care visit in the AM, sick visits in the PM, and telehealth throughout the day
  • Complete well-care visit virtually and in-person, thereby minimizing time in office (history via telehealth and in-person for a physical exam)
  • Offer “senior transition visits” via telehealth: review each graduating 12th grader’s history and chart to ensure they are ready to transition their care

well child visit case study

Family Life

well child visit case study

AAP Schedule of Well-Child Care Visits

well child visit case study

Parents know who they should go to when their child is sick. But pediatrician visits are just as important for healthy children.

The Bright Futures /American Academy of Pediatrics (AAP) developed a set of comprehensive health guidelines for well-child care, known as the " periodicity schedule ." It is a schedule of screenings and assessments recommended at each well-child visit from infancy through adolescence.

Schedule of well-child visits

  • The first week visit (3 to 5 days old)
  • 1 month old
  • 2 months old
  • 4 months old
  • 6 months old
  • 9 months old
  • 12 months old
  • 15 months old
  • 18 months old
  • 2 years old (24 months)
  • 2 ½ years old (30 months)
  • 3 years old
  • 4 years old
  • 5 years old
  • 6 years old
  • 7 years old
  • 8 years old
  • 9 years old
  • 10 years old
  • 11 years old
  • 12 years old
  • 13 years old
  • 14 years old
  • 15 years old
  • 16 years old
  • 17 years old
  • 18 years old
  • 19 years old
  • 20 years old
  • 21 years old

The benefits of well-child visits

Prevention . Your child gets scheduled immunizations to prevent illness. You also can ask your pediatrician about nutrition and safety in the home and at school.

Tracking growth & development . See how much your child has grown in the time since your last visit, and talk with your doctor about your child's development. You can discuss your child's milestones, social behaviors and learning.

Raising any concerns . Make a list of topics you want to talk about with your child's pediatrician such as development, behavior, sleep, eating or getting along with other family members. Bring your top three to five questions or concerns with you to talk with your pediatrician at the start of the visit.

Team approach . Regular visits create strong, trustworthy relationships among pediatrician, parent and child. The AAP recommends well-child visits as a way for pediatricians and parents to serve the needs of children. This team approach helps develop optimal physical, mental and social health of a child.

More information

Back to School, Back to Doctor

Recommended Immunization Schedules

Milestones Matter: 10 to Watch for by Age 5

Your Child's Checkups

  • Bright Futures/AAP Recommendations for Preventive Pediatric Health Care (periodicity schedule)

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  • v.18(1); 2020 Jan

Caregiver and Clinician Perspectives on Missed Well-Child Visits

Elizabeth r. wolf.

1 Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia

2 Children’s Hospital of Richmond at VCU, Richmond, Virginia

Jennifer O’Neil

3 Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia

James Pecsok

Rebecca s. etz, douglas j. opel.

4 Department of Pediatrics, University of Washington, Seattle, Washington

Richard Wasserman

5 Department of Pediatrics, Larner College of Medicine, University of Vermont, Burlington, Vermont

Alex H. Krist

Despite the benefits of well-child care visits, up to one-half of these visits are missed. Little is known about why children miss them, so we undertook a qualitative study to elucidate these factors.

We interviewed 17 caregivers whose children had missed well-child visits and 6 clinicians, focusing on 3 areas: the value of well-child visits, barriers to attendance, and facilitators of attendance. Transcripts were analyzed with a grounded theory approach and thematic analysis.

Caregivers and clinicians identified similar important aspects of well-child visits: immunizations, detection of disease, and monitoring of growth and development. Both groups identified similar barriers to attendance: transportation, difficulty taking time off from work, child care, and other social stressors.

CONCLUSIONS

Further work to explore how addressing social determinants of health might improve attendance of well-child visits is needed.

INTRODUCTION

The American Academy of Pediatrics recommends 13 well-child visits before the age of 6 years. 1 These visits are an opportunity to deliver immunizations, provide anticipatory guidance, and identify and treat disease. 2 Attendance of well-child visits has been associated with reduced hospitalizations and emergency department use. 3 , 4 Despite these benefits, children miss between 30% to 50% of well-child visits. 3 – 6 Poor, uninsured, and African American children miss a greater proportion of these visits compared with upper-income, privately insured, and white counterparts. 5 – 7 Many states support safety-net practices to promote access. Despite these efforts, it is not fully understood why more disadvantaged patients miss a disproportionately larger share of well-child visits.

Few studies have explored patient and clinician perspectives on why pediatric visits are missed. Studies conducted more than 15 years ago identified transportation, 8 , 9 work, 9 wait times, 8 and lack of understanding about the reason behind the visits 8 as reasons for missed visits. Clinicians in England also identified social reasons and family belief systems as reasons. 10 Because clinicians are not always aware of the nonmedical aspects of patients’ lives, they may not fully understand or may have different perspectives on why well-child visits are missed. It is also unclear whether clinician and caregiver perspectives on missed well-child visits align. We aimed to assess current US caregiver and clinician perspectives regarding missed well-child visits in an urban, underserved health care system with a large proportion of African Americans.

We selected a purposive sample of 17 caregivers and 6 clinicians (family practice and pediatric physicians) for children aged 0 to 6 years who missed 2 or more well-child visits at Virginia Commonwealth University Health System (VCUHS) between January 1, 2011, and January 1, 2016. We chose 2 or more missed well-child visits as the cutoff in order to include caregivers of young children as well as those of older children. We hypothesized that using a higher threshold of missed visits would disproportionately select families with older children. We excluded patients without any well-child visits recorded as this group may have used a different health system as their primary care medical home. Well-child visits were identified by relevant International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) or International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes (eg, V20.2, Z00.129) and Current Procedural Terminology (CPT) claims codes (eg, 99381). Because Spanish-speaking children make up about one-third of the pediatric population at VCUHS, we also included Spanish-speaking caregivers in this study.

Caregivers were contacted through direct mailings, while clinicians serving pediatric patients in VCUHS were contacted through e-mail. Individuals who did not respond to the initial mailings were sent another invitation.

Our research team developed a semistructured guide before the study. The included questions focused on 3 domains: the value of well-child visits (eg, “What are important aspects of well-child visits?”), barriers to attendance (“What makes it hard to attend well-child visits?”), and facilitators of attendance (eg, “What would make attendance easier?”). Interviews were conducted by telephone between November 2016 and March 2017 without the use of field notes. Two female interviewers (J.O. and Martha Gonzalez [M.G.]) conducted all the interviews; the former is a medical student, and the latter is a Spanish-speaking qualitative researcher. Both interviewers were trained in interview techniques and the use of the interview guide before the study and completed the interviews in a standardized way (ie, questions were asked in a similar manner to all of the participants). Neither interviewer had relationships with the caregivers before starting the study.

Verbal consent was obtained before the start of the interview. Participants were briefed on the goals of the study before the interviews. We did not the record demographics of the participants in order to protect their privacy and encourage forthright dialog between the participant and the interviewer. Interviews lasted between 10 and 20 minutes, and none were repeated. Interviews were conducted until saturation was reached. At the completion of each interview, caregivers were mailed a $25 gift card. Clinicians were not compensated for participation.

Interviews were digitally recorded and transcribed. Spanish-speaking families were interviewed by a native Spanish speaker (M.G.) and transcripts were translated into English for interpretation. Transcripts were not made available to participants for review after the interviews were complete.

We used a grounded theory approach when analyzing the interviews. After reviewing 5 interviews independently, the research team (E.R.W., J.O., and J.P.) met and created an initial codebook based on the interview guide and topics raised by participants. As a group, the sample of interviews was reviewed with the initial codebook, and the codebook was adjusted based on consensus. With use of an editing style of coding, 11 this final codebook was applied to the full data set (J.O., J.P., and E.R.W.) using Word (Microsoft Corp). Coded data were reviewed by coauthors (J.O., J.P., and E.R.W.) and grouped into 3 categories: (1) valuable aspects of well-child visits, (2) barriers to well-child visit attendance, and (3) facilitators of well-child visit attendance. The team then used thematic analysis 12 to highlight the significance of each grouping from the perspective of caregivers and clinicians. Participants did not provide feedback on the results of the analysis. Our study was approved by the institutional review board of Virginia Commonwealth University.

Of 205 English-speaking caregivers and 95 Spanish-speaking caregivers who were mailed invitations, 12 English-speaking and 5 Spanish-speaking caregivers agreed to participate. Of the 23 clinicians practicing at VCUHS who were contacted, 6 agreed to participate.

Both caregivers and clinicians identified immunizations, the detection of illness, and the monitoring of growth and development as important aspects of well-child care ( Table 1 ). The long-term relationship and interaction between the clinician and family was also important to both groups. Clinicians thought that their relationships with the families played a role in determining whether the family would attend future visits, as the following representative quote illustrates:

We have seen time and again that relationship and, like, connection matters for everyone when it comes to the people who take care of them and the system that takes care of them, and so if you can enhance the relationship, I think you increase your chances of helping the patients who are least likely to show up to maybe, like, improve that. (clinician participant)

Selected Quotations on the Value of Well-Child Visits

Caregivers and clinicians cited lack of transportation and difficulty taking time off from work as reasons for missed well-child visits ( Table 2 ). Caregivers said that underlying financial stress made these logistics even more difficult. Caregivers and clinicians also discussed competing priorities, such as caring for young children, older children’s school schedules, and the scheduling of the caregivers’ own medical appointments. Clinicians also thought that caregivers may prioritize attending well-child visits in which vaccinations are typically given. Clinicians expressed concern that immigration and language differences may be barriers to attendance. Spanish-speaking caregivers thought that availability of language services made them more interested in attending well-child visits.

Selected Quotations on the Barriers to Well-Child Visit Attendance

We found that this sample of caregivers and clinicians from an urban underserved health system understood the need for and valued well-child visits. Caregivers and clinicians thought these visits were important to give vaccinations, identify disease, monitor growth and development, and build the relationship between family and clinician. Caregiver and clinician perspectives on reasons behind missed well-child visits were aligned. Both groups thought that transportation, financial stress, taking time off from work, and difficulty with child care were barriers to attendance. Clinicians identified language differences and immigration status as barriers to attendance, and Spanish-speaking families thought the presence of language services facilitated attendance.

Similar to findings of older studies, 8 – 10 both groups primarily described structural and social barriers as contributing to missed well-child visits. The VCUHS is considered a safety-net health system with a large proportion of publicly insured children. Richmond also has a high proportion of single parents and parents working in low-wage jobs who may find it more difficult to take time off from work. The clinics that see pediatric patients are centrally located and on major bus lines; however, some families may feel unsafe waiting at bus stops in areas with high rates of violent crime. It should be noted that since conducting these interviews, parking has become free for patients, although we have not yet studied how this change has affected attendance.

One limitation to our study is the reliance on mailings, which may have resulted in the exclusion of families with low levels of literacy or unstable housing. In addition, the relatively low response rate (although typical for studies of this type) may have biased our sample toward those who valued well-child visits to a greater degree than those who did not respond. We plan to elicit additional perspectives from hard-to-reach families in future studies.

Our findings suggest there is a need to further explore the potential relationship between well-child visit attendance and social determinants of health. Although the importance of social determinants of health has been known to the scientific community for some time, attempts to address these determinants have been limited. There may be ways to reduce bar riers to attendance through interventions at the level of the family (eg, transportation, child care), the health care system (eg, appointment reminders, care coordination, screening for and addressing of social determinants of health), and the payer (value-based care rather than fee for service). Future research emphasis could be placed on understanding and helping the children missing the greatest number of visits.

Acknowledgments

We would like to acknowledge Martha Gonzalez, Julia Rozman, and Paulette Lail Kashiri for their assistance with the project.

Conflicts of interest: authors report none.

To read or post commentaries in response to this article, see it online at http://www.AnnFamMed.org/content/18/1/30 .

Funding support: This work was supported by a 2016 Bright Futures Young Investigator Award from the Academic Pediatric Association and by a Clinical and Translational Science Awards grant (UL1TTR002649).

Previous presentation: Qualitative Methods for Identifying Reasons Behind Missed Well Child Care Visits. Presented at the Practice Based Research Network Conference; June 22, 2017; Bethesda, Maryland.

Delayed Milestones in Children: A 14-Month Well-Child Visit Case Study

Mr. Zee presents to the clinic with his son Eric for a 14-month well-child visit. He expresses concern that Eric is not walking yet. The APRN reviews Eric’s past medical and birth history in the electronic medical record. Max was born at 34.5 weeks’ gestation via emergency C-section and was discharged 2 weeks later.

Introduction

Well-child visits are essential for monitoring a child’s growth and development . During these visits, healthcare providers assess various milestones to ensure a child’s healthy progression. In this case study, we explore the scenario of Mr. Zee’s concerns about his 14-month-old son, Eric, who is not yet walking. We will review Eric’s past medical and birth history, discussing the potential causes of delayed milestones and the importance of addressing parental concerns.

Eric’s Medical and Birth History

Eric was born prematurely at 34.5 weeks’ gestation through an emergency C-section. Premature birth can be associated with a range of developmental challenges due to the incomplete development of vital organs and systems. It’s not uncommon for premature infants to reach developmental milestones, such as walking, at a slightly different pace than full-term babies.

Potential Causes of Delayed Milestones

Premature Birth: Eric’s premature birth is a significant factor to consider. Preterm infants often require more time to catch up to their full-term peers in terms of developmental milestones.

Adjusted Age: When evaluating milestones in premature infants, it’s crucial to consider their “adjusted age.” This age reflects the time elapsed since birth, minus the number of weeks Eric was premature. For Eric, at 14 months of chronological age, his adjusted age would be approximately 12 months. Therefore, his walking progress should be compared to the milestones expected of a one-year-old.

Variability: Children develop at their own pace, and there is a wide range of “normal” when it comes to developmental milestones. Not all children will reach each milestone at the same time.

Addressing Parental Concerns

It’s essential for healthcare providers, like the Advanced Practice Registered Nurse (APRN) in this scenario, to address parental concerns and provide guidance and reassurance. Here are some steps to consider:

Assessment: Conduct a thorough developmental assessment, including Eric’s motor skills, communication, and social development. Evaluate whether he is achieving other age-appropriate milestones.

Education: Explain to Mr. Zee the concept of adjusted age and that Eric’s developmental progress should be compared to what is expected for his adjusted age, not his chronological age.

Monitoring: Keep track of Eric’s progress and encourage parents to keep a developmental journal. If there are still concerns at Eric’s next well-child visit, further evaluation may be necessary.

Early Intervention: If there are ongoing concerns about delayed milestones, consider an early intervention program to support Eric’s development. Early intervention services can provide therapies and strategies to help him catch up.

Parental Support: Offer emotional support to Mr. Zee, as parental concerns can be overwhelming. Encourage open communication and provide resources for further information.

Delayed milestones in children, especially those born prematurely, are not uncommon. Understanding the unique circumstances of each child, addressing parental concerns, and providing guidance and support are essential aspects of well-child visits. By assessing Eric’s development, educating his father about adjusted age, and monitoring his progress, the APRN can ensure that Eric receives appropriate care and support to reach his developmental milestones.

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Medicaid Coverage of Maternal Depression Screenings during Well-Child Visits: Case Study of Alaska and Arizona

Maternal mental health plays a critical role in improving birth outcomes and addressing maternal mortality and morbidity. Despite the prevalence of maternal depression during and after pregnancy, the condition often goes undiagnosed and untreated.[1],[2]

Nearly all state Medicaid programs are working to improve maternal health through early identification of depression during well-child visits and connecting mothers to follow-up services, as depicted in NASHP’s updated Medicaid Policies for Caregiver Depression Screening during Well-Child Visits by State .

This case study explores how Alaska and Arizona structure Medicaid coverage of maternal depression screenings during well-child visits as part of a two-generational approach to support maternal mental health.

A mother and father with their baby in a sling

Medicaid Policies for Caregiver and Maternal Depression Screening during Well-Child Visits, by State

Overview of maternal depression and the importance of medicaid.

Maternal depression during and after pregnancy is common, with one in eight women reporting symptoms after giving birth.[3] Rates of postpartum depression are disproportionately higher among lower-income women.[4] Despite the prevalence of maternal depression, the condition often goes undiagnosed and untreated.[5] This may be, in part, due to providers missing opportunities to ask women about depression. According to the Centers for Disease Control and Prevention, about one in five women were not asked about depression during a prenatal visit and over half of women with depression were not treated.[6]

Postpartum depression can last long after giving birth and may include intense feelings of sadness, anxiety, and hopelessness that can interfere with daily functioning.[7] When left untreated, postpartum depression can negatively affect the health of the mother and child, including the child’s development.[8] Relatedly, mental health conditions (including suicide) are a leading underlying cause of maternal mortality, accounting for nearly 9 percent of pregnancy-related deaths.[9]

Given the serious implications of maternal depression, there is a growing recognition of the importance of identifying the condition and connecting mothers to needed follow-up services, particularly for Medicaid beneficiaries. In 2016, the Centers for Medicare & Medicaid Services (CMS) issued a bulletin underscoring the importance of Medicaid reimbursement for maternal depression screenings maternal depression screenings during well-child visits . As of 2023, 45 states and Washington, DC allow, recommend, or require maternal depression screenings during well-child visits, up from 43 states and DC in February 2020.[10],[11] The most recent states to implement maternal depression screenings during well-child visits are Arizona and Alaska — each structuring the Medicaid benefit differently.  

Alaska’s Maternal Depression Screening under Medicaid

Alaska’s state Medicaid program began covering pregnant and postpartum depression screenings in April 2021.[12] Under the benefit, postpartum women eligible for Medicaid may receive up to two standardized depression screenings per episode under the current procedural terminology (CPT) code 96127 (i.e., brief emotional/behavioral assessment). Postpartum women who are not eligible for Medicaid may receive up to one standardized depression screening per episode under the CPT code 96161 (i.e., health and hazard assessment), which is billed under the infant’s Alaska Medicaid identification number. Postpartum women not enrolled in Medicaid may receive these screenings up to one year after their child’s birth.[13] Other caregivers who are enrolled in Medicaid may also receive coverage of depression screenings.

Providers eligible to bill for these services include physicians, physician assistants, advance practice registered nurses, psychologists, and behavioral health aids. School-based service providers may also bill for maternal depression screening under CPT code 96127. The reimbursement rate varies depending on which provider type is billing. For example, physicians claiming reimbursement under 96127 receive $6.10 whereas physicians billing under 96161 receive $3.60. While providers are not required to report whether a screen is positive or negative, providers are instructed to refer those identified as being at-risk for depression to an appropriate behavioral health provider for follow-up services.[14]

Arizona’s Maternal Depression Screening under Medicaid

Alaska and Arizona are the most recent states to cover maternal depression screenings under their Medicaid programs to better identify maternal depression during well-child visits and connect mothers to needed follow-up services. With maternal depression screenings available in at least 45 states and DC, the approaches detailed in this case study may inform other state Medicaid programs’ efforts to support maternal mental health as part of a two-generational approach.

  • Identifying Maternal Depression, Centers for Disease Control and Prevention, May 2, 2022. https://www.cdc.gov/reproductivehealth/vital-signs/identifying-maternal-depression/index.html
  • Ko, Jean., et al., Depression Treatment Among U.S. Pregnant and Nonpregnant Women of Reproductive Age, 2005-2009 , Journal of Women’s Health, June 2012. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4416220/

Identifying Maternal Depression , May 2022.

Bordy, Debra., et al., Prevalence of Depression Among Adults Aged 20 and Over: United States, 2013-2016, Centers for Disease Control and Prevention, 2018. https://www.cdc.gov/nchs/products/databriefs/db303.htm#ref4

Depression Treatment Among U.S. Pregnant and Nonpregnant Women of Reproductive Age, 2005-2009, June 2012.

Prevalence of Depression Among Adults Aged 20 and Over: United States, 2013-2016, 2018.

Maternal Depression Can Undermine the Development of Young Children: Working Paper No. 8, Center on the Development Child, Harvard University, 2009. https://developingchild.harvard.edu/wp-content/uploads/2009/05/Maternal-Depression-Can-Undermine-Development.pdf

Davis, Nicole, et al., Pregnancy-related Deaths: Data from 14 U.S. Maternal Mortality Review Committees, 2007-2017 , Centers for Disease Control and Prevention. https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/MMR-Data-Brief_2019-h.pdf

Rebecca Cooper and Carrie Hanlon, NASHP Finds More States Screening for Maternal Depression during Well-Child Visits , National Academy for State Health Policy, April 2021.

Medicaid Policies for Caregiver and Maternal Depression Screening during Well-Child Visit by State, National Academy for State Health Policy, February 25, 2023. https://nashp.org/maternal-depression-screening/

Alaska Medicaid Policy Clarification Depression Screening, Counseling, and Interventions for Adolescents and Postpartum Women , Department of Health and Human Services, April 2021. https://manuals.medicaidalaska.com/docs/dnld/Update_Policy_Clarification_Depression%20Screening_Adolescents_Postpartum.pdf

Alaska Medicaid Policy Clarification Depression Screening, Counseling, and Interventions for Adolescents and Postpartum Women , April 2021.

Chapter 430-Early and Periodic Screening, Diagnostic and Treatment Services, Chapter 400 Medical Policy for Maternal and Child Health, Arizona Health Care Cost Containment System, 2022. https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/400/430.pdf

Rachael Salley. (Arizona Health Care Cost Containment System). Email. February 21, 2023.

Chapter 430-Early and Periodic Screening, Diagnostic and Treatment Services, 2022.

Physician Fee Schedule, Arizona Health Care Cost Containment System. Accessed February 21, 2022. https://azahcccs.gov/PlansProviders/RatesAndBilling/FFS/Physicianrates/FFSCodes.aspx?schedule=2022OctoberPhysicianRates

Acknowledgements

This case study is a publication of the National Academy for State Health Policy (NASHP). This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under the Supporting Maternal and Child Health Innovation in States Grant No. U1XMC31658; $398,953. This information, content, and conclusions are those of the authors’ and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. government.  

NASHP wishes to thank Kathy Berry from the Alaska Department of Health and Dr. Eric Tack and Rachael Salley from the Arizona Health Care Cost Containment System for their time and insights.

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