Video Abstract
Pediatricians hope to help children and families flourish. However, the typical approach of providing episodic care to individuals rarely addresses the fundamental drivers of population-level health outcomes. Moreover, this approach typically ignores outcomes for individuals without access to care, who miss out on opportunities for episodic care and are not usually captured in accountability measures.
To better understand the health of the population and to promote the development and uptake of interventions that might lead to more meaningful and sustained improvements and reduce inequities in health outcomes, the Maternal and Child Health Bureau, the National Academy of Medicine, and the Center for Medicare and Medicaid Services have called for new accountability metrics for child population health.1–3 For example, the National Academy of Medicine report, “Vital Signs: Core Metrics for Health and Health Care Progress,” proposed that health systems be accountable for healthier communities, high-quality care, affordable care, and engaged people.1 These reports highlight that improving population-health for children now can have a multigenerational impact.
In response to this call, we began a “Pediatric Vital Signs” project in 2020 with the goal to measure and improve population health by decreasing infant mortality, increasing kindergarten readiness, increasing high school graduation, decreasing teenage pregnancy, decreasing obesity, decreasing suicide, decreasing child mortality, and increasing preventive services delivery for all children and adolescents living in Franklin County, Ohio, which is served by our institution, Nationwide Children’s Hospital, with specific 10-year goals to be achieved by 2030.4 We felt emboldened to publish our goals in 2020 based on having a large and well-established Medicaid accountable care organization and two well-established place-based community development initiatives aimed at child and family outcomes in racially and ethnically minoritized communities. As described in the articles in the supplement, many of these individual areas were targeted for improvement before grouping them all under the Vital Signs umbrella. Grouping the projects together allowed us to clearly communicate how all of these projects fit together to improve population health and to share resources across somewhat disparate projects. Since this publication, the Vital Signs project has expanded to other counties served by our accountable care organization, Partners for Kids.
We believe at this point it is important to share our progress and what we plan to do next. We hope that our experience, including successes and challenges, helps others address critical population-health needs. As described in the supplement, some of the projects are focusing on interventions within health care settings (eg, suicide prevention, prevention of unintended pregnancy, improving Kindergarten readiness), with plans to move to a broader population-health focus if these health care-based initiatives proved to be successful while others are focusing on community-level initiatives (eg, infant mortality prevention, obesity prevention).
We anticipated that there would be internal (ie, hospital) resistance to our plans when we developed the Vital Signs project in 2019 because our focus on improving outcomes for all children, regardless of whether they are our patients might reduce investment in hospital services. We also anticipated external (ie, community) resistance as a large health care system took a more active role in public health initiatives and social sector programs usually seen as the purview of others. As described in the articles in this supplement, we prepared for these concerns. There was one key challenge we did not anticipate: a global pandemic that would begin as soon as the work was scheduled to start.
The projects vary in the degree of maturity and influence that they are having on population-health outcomes. For example, the work to improve Kindergarten readiness is still a small clinical quality-improvement project, but in contrast the work to reduce infant mortality involves many community partners that have worked together for years. Increasing high school graduation rates and decreasing all-cause child mortality has been difficult for several of our partners following the pandemic, and so we have decided to share our experience later rather than in this supplement. We have made significant improvement in the delivery of preventive services in the clinics directly affiliated with Nationwide Children’s Hospital, but we are still working on finding a sustainable approach to gather this information from all pediatric clinics in Franklin County, and so will also describe this work in a future publication. We have also added another area of focus, using tax credits to help families address poverty, which is described in this supplement. Poverty is a driver of poor population health and inequities in all health outcomes. Therefore, addressing poverty has emerged as a key activity to improve each Vital Sign. As a cross-cutting and seemingly intransigent challenge, reducing poverty requires separate leadership and institutional commitment.
We chose all of these areas of focus because we believe that together they are necessary to improve population health. Regardless of topic area and degree of success, several overarching lessons emerged:
Multisector collaboration is essential.
Community engagement is critical for decreasing inequities and implementing sustainable change.
Value-based contracting by an accountable care organization is necessary to align the delivery of clinical services with population health outcomes.
A large hospital system with project management, expertise in quality improvement, and ability to integrate clinical data can act as a “backbone” institution to help community organizations and social service agencies improve the efficiency of their service delivery.
Community organizations and social service agencies provide the insight necessary to the hospital system to understand the threats and opportunities to improving population health.
Recruiting community members disproportionately impacted by disparities in outcomes related to the Vital Signs as partners in this work leads to novel and effective interventions that might not be identified by the clinicians who usually have the responsibility for improvement.
We hope our experience, as shared within this supplement, encourages you to develop a Vital Signs project for your community. We obviously cannot anticipate what external events might happen between now and our 2030 target date for our goals (hopefully not another pandemic!). Although there have been challenges along the way, the impact of our ongoing efforts and the community partnerships that have developed are beginning to improve the health of children and adolescents in Franklin County. To provide perspective about the Vital Signs project, the supplement concludes with a commentary by Jennifer W. Kaminski, PhD, Debra Houry, MD, MPH, from the Centers for Disease Control and Prevention that provides a national perspective on why Vital Signs projects are needed and lessons to help promote this important work.5
Dr Kemper drafted the initial manuscript and reviewed and revised the manuscript. Ms Sander and Dr Kelleher contributed to the initial draft of the manuscript and critically revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
CONFLICT OF INTEREST DISCLOSURES: None of the authors have a commercial association that might pose or create a conflict of interest with the information presented in this manuscript.
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