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Changing the model for well child care – how can we serve families better? :

February 23, 2016

In a study being released this month in Pediatrics, Dr. Tumaini Coker et al. (10.1542/peds.2015-3013) challenge us to consider a fundamentally different approach to well child care.

In a study being released this month in Pediatrics, Dr. Tumaini Coker et al. (10.1542/peds.2015-3013) challenge us to consider a fundamentally different approach to well child care.(1) Their study describes a non-blinded randomized controlled trial of a parent coach model for provision of well child care, in which most of the “business” of the visit is guided by the family, and provided by a master’s level coach, rather than by a pediatrician or other health care professional.

Their intervention, whose appropriate acronym is PARENT (Parent Focused Redesign for Encounters, Newborns to Toddlers), was created via a 12 months long stakeholder-engaged process in which parents, pediatricians and Medical Assistants (MAs) collaborated. The driving concern for the intervention trial, as expressed by the authors, is that, “Our current WCC [well child care] structure has difficulty supporting the vast array of preventive care needs among low-income families.”

The 4 major components of PARENT are 1) a health educator, called a parent coach, who is the primary provider, 2) a web-based tool that parents use to prioritize and select issues for the visit, 3) a text messaging service with brief age-specific reminders, and 4) a short problem-based visit with a pediatric clinician that includes a physical exam. The bulk of the interactions and visit with each family are with the parent coach.

The authors are able to show that PARENT, as compared to routine well child care, led to statistically significant improvements in parent-reported outcomes, such as receipt of anticipatory guidance and psychosocial assessment, in completion of structured developmental screening, and in parent satisfaction. I congratulate the authors on a remarkably successful trial of an innovative and collaborative intervention. Where to from here? Should all practices serving low-income families adopt this new method?

Clearly well child care is intended for the family and index child, so parent reported outcomes are highly relevant and appropriately serve as the primary outcome of the study. It is interesting, however, that the satisfaction level of the pediatric clinicians, whose role in PARENT is relatively truncated and circumscribed, was not measured. I understand that the core content of well child care can easily be delivered by non-physicians, but speaking personally I would not want this method for my own practice. Many of us serving low-income families have long-term relationships with parents and extended family, treasure these enduring bonds, and provide pediatric care for the next generation, that is, for children whose parents were our patients.

It is hard for me to envision the same level of satisfaction with practice when (even the best and most empathic) parent coach conducts the bulk of the well care interactions, and unintentionally trivializes my role to simply needing to perform a physical exam and following up on concerns identified on screening. Is this a selfish view? Yes, it likely is, but to enjoy one’s profession is a wonderful thing, and I don’t know if the pediatric clinicians who serve as part of PARENT will love their job over time as much as I do. (I certainly welcome their response to this blog and hope they prove me wrong.) Would pediatric trainees, who are new to continuity of care, perhaps prefer the PARENT physician role? A comparison of satisfaction between trainees and experienced clinicians in the PARENT program might also be of interest.

The work of Coker and colleagues has potential to become a true “game-changer.” Using parent report and satisfaction as a primary outcome is optimal, and the authors have shown their intervention makes a difference. But rather than simply replicating the PARENT model, hopefully this work spurs other primary care clinicians and researchers to innovate, create and collaborate on other new potential “best practice” approaches to well child care. Even the best can always become better, and how much more satisfying will it be for pediatricians to participate in change rather than sit out on the sidelines!

1- Coker et al A Parent Coach model for well-child care among low-income children: a randomized controlled trial
2 - Mittal P. Centering Parenting: Pilot Implementation of a Group Model for Teaching Family Medicine Residents Well-Child Care. The Permanente Journal. 2011;15(4):40-41.
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