A Clinical Process Support System for Primary Care to Address Family Stress

This project is to create and test a "clinical process support system" that will improve the
ability of primary child health care providers (PCPs) to screen for and address family
stressors during routine child health visits that are associated with negative child outcomes
in a manner that is feasible and acceptable to both clinicians and parents. The family
stressors assessed include: intimate partner violence (IPV), parental depression, parental
stress, food insecurity, parental substance use and harsh punishment of the child. The system
is designed to overcome known obstacles to addressing these issues during routine well child
visits. These obstacles include: lack of PCP training in an evidence-based approach to the
interview (e.g., motivational interviewing); lack of time; low parental expectations for
addressing sensitive family issues during routine child "physicals"; and the usual absence of
co-located mental health providers. The new Family Stress module will build on two
foundations: 1) previous studies of screening using the Safe Environment for Every Kid (SEEK)
tool, which showed reduced child maltreatment outcomes in two Randomized Control Trials; and
2) an existing online screening and decision support system (CHADIS). The goals are to
support parents in reducing family risk and the exposure of the young child to their own
Adverse Childhood Experiences (ACE), including child maltreatment.

The innovations in this method of addressing family stressors and overcoming the above
obstacles include:

1. Time efficiencies. Time is saved through pre-visit online data collection, saving both
interview and clinical documentation time and staff time saved for patient education and
needed referrals.

2. Creating the environment for psychosocial care. This is done through a combination of
pre-visit questionnaires with agenda broadening questions (best and hardest parts of
parenting), inclusion of parental background from Adverse Childhood Experiences (ACE)
and Positive Childhood Experiences inquiries in clinical discussions; individualized
text and resources for the family in the Care Portal; milestones to "celebrate" in each
child's "MemoryBook"; and empathetic and reflective responses from the PCP.

3. Efficient training. Training is done using innovative "moment of care" teleprompters
created instantly in response to the individual parent issues from the pre-visit tools
to support the difficult conversations and a motivational interview begun by the
computer needed to move families towards services.

4. Care communication. Practices will be able to share data with their own colocated
services or be linked electronically with outside local resources using a unique online
"consent to share information" functionality that also facilitates determining if the
referral appointment was completed. Visit notes and documentation of attendance at a
consultation will be shared with consent between the PCP and referral agency or
professional to facilitate two-way communication for coordinated care.

Design: A cluster randomized quality improvement intervention using the clinical process
support family stress module in routine care for children 0-3 years will be conducted in 30
primary care practices. The project will enroll as many 0-4 month olds as possible and follow
them to age 24 months and a cohort of 18-24 month olds as controls using online consent (not
requiring staff time). For this 2.5 year project the study staff will ask physicians and
office staff to complete a one hour online training, offices to notify parents to complete
CHADIS when scheduling well-child visits for children 0-3 years old with the questionnaire
assignments for the project including Family Assessment of Safety and Stress (FASS), and
primary care clinicians to use the CHADIS Family Stress module including the care
coordination functionality during the visits when that site is randomized to the intervention
period. At the end of the project the study requires clinicians to complete a survey and
provide information from the medical records for participating children about immunization
completion and missed visits. This information can be collected in a variety of ways
depending on each electronic record.

Outcomes: The outcomes anticipated for the proposed study include improved parent connection
to services and parent-child relationships, and reduced family stressors, child behavior
problems, harsh punishment, and Child Protection referrals for abuse and neglect. Expected
outcomes include that higher parent satisfaction with the enhanced clinical process will
result in lower rates of missed visits and delayed immunizations. These results should
provide evidence of the effectiveness of PCP screening and referral to reduce family
stressors and the evidence needed for full United States Preventive Services Task Force
endorsement of this clinical process support tool for reducing child maltreatment.

Inclusion Criteria:

- Parents and their children 1 month to 4 months at enrollment.

- Parents and their children 16-20 months for comparison group.

- Primary Care Providers of any age.

Exclusion Criteria:

-Unable to speak and read English.