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July 2015

What is Population Health: Definition and Concept
This article provides a definition for population health and clarifies the role of population health in the clinic and in public health. It is a valuable resource for pediatric health professionals looking for general information on what “population health” means and how their work—both clinical and non-clinical— can fit into initiatives focused on improving population health.

Community Pediatrics: Navigating the Intersection of Medicine, Public Health, and Social Determinants of Children’s Health
This policy statement, published in Pediatrics, outlines the role of pediatric clinicians in promoting the health and well-being of children by recognizing social determinants of health and the importance of collaborating with public health agencies to address population health issues. As such, this policy statement provides a framework for the pediatric clinician’s role in promoting population health.

Managing Populations, Maximizing Technology: Population Health Management in the Medical Neighborhood
This guide provides an overview of tools and resources available to primary care clinicians to help address population health issues. It focuses on tools available through information technology such as electronic health records, patient registries, health information exchanges, and referral tracking. The guide emphasizes the use of these tools to coordinate care with other clinical and community organizations to improve the medical home neighborhood.

Tools for Improving Population Health: Community Mapping for Health Equity
Community mapping is a technique used to evaluate patterns of health disparity among populations within a specific community. Community mapping can often help identify social determinants of health. This guide provides tools, resources, and examples of community maps that can be utilized by child health professionals, policy makers, and family advocates.

Transforming Early Development Instrument
Developed by the Transforming Early Childhood Community Systems Initiative, this instrument measures population health and development of young children. The instrument focuses on five domains which include physical health and wellbeing. Results are reported at a population level; pediatric professionals can utilize this data to plan interventions and connect families with resources. 

Parent Screening Questionnaire: A Safe Environment for Every Kid
Developed by Bright Futures, this questionnaire can be used by pediatric practices to screen families and caregivers for population health indicators, such as major psychosocial problems and risk factors for child maltreatment.

Addressing Social Determinants of Health within the Patient-Centered Medical Home: Lessons from Pediatrics
Published in JAMA, this this article provides suggestions to inform the development of patient-centered medical homes that incorporate strategies for improvement of population health. These strategies include screening for and addressing health disparities caused by social factors.

  Getting To Outcomes: A Toolkit to Help Communities Implement and Evaluate their Prevention Programs
This toolkit outlines 10 steps to help communities plan, implement, and evaluate the impact of their programs focusing on child and adolescent health. Clinicians, practices, and policy makers can utilize this resource to develop and enhance programs focused on preventive and population health among the pediatric population.

Accountable Care Organizations and Pediatricians: Evaluation and Engagement
Accountable Care Organizations (ACOs) are a vehicle for improving population health through partnerships between groups of clinicians and health care organizations working together to provide high quality care to children, adults, and families. This guidance provides information to pediatricians on challenges and successes that clinicians should consider before joining an ACO.

New Community Tools for Improving Child Health: A Pediatrician’s Guide to Local Associations
Developed in partnership with the Community Access to Child Health Program, this guide provides a comprehensive listing of community organizations—including youth groups, recreational groups, religious groups, and social advocacy organizations—that can be valuable partners in projects focused on improving population health and addressing health disparities.

MAP-IT Healthy People 2020 Guide
This electronic resource guide provides a framework for pediatric health professionals to implement public health interventions to improve population health. The guide provides links to tools and resources for community engagement, best practices, and project evaluation strategies.

Video Curriculum on Screening for the Social Determinants of Health
This collection of videos and transcripts educates pediatric resident physicians on strategies for screening of social determinants of health in the continuity clinic setting. Each video vignette includes an example of appropriate and inappropriate behavior for screening of social determinants of health with a focus on ensuring cultural competency and family-centered care.

Pediatric Public Health Curriculum
This residency curriculum helps pediatric program directors include population-based educational activities in their residency curricula to enhance clinical practice. The curriculum is adaptable for pediatric, family medicine, and medicine-pediatrics residency programs. The curriculum includes strategies to address social determinants of health for vulnerable and medically underserved populations.

For a more detailed information on Implementation Resources, click here.

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July 2015

Navigating the Affordable Care Act: Help for Families of Children with Special Health Care Needs
July, 20, 2015, Noon - 1 pm Central
Join experts from the Catalyst Center and the National Center for Medical Home Implementation as they share information, based on recently developed fact sheets, on how Affordable Care Act provisions help families raising children with special health care needs.
 Additional Information and Registration about the Navigating the Affordable Care Act Webinar

September 2015

2015 CityMatCH Annual Urban MCH Leadership Conference
September 27 – 30, 2015, Salt Lake City, UT
This annual conference brings together leaders in maternal and child health (MCH) for education and networking opportunities. The conference focuses specifically on urban populations of women, children, and families.
Additional Information about the CityMatCH Annual Urban MCH Leadership Conference

October 2015

Blazing New Trails: Innovations in State Health Policy
October 19 – 21, 2015, Dallas, Texas
This annual National Academy for State Health Policy conference provides educational opportunities for professionals interested in pediatric health policy. Sessions include those with a focus on behavioral health integration, expanded systems of care for young children and families, and policy implications of state Medicaid expansion.
Additional Information about the National Academy for State Health Policy Annual Conference

American Academy of Pediatrics National Conference and Exhibition
October 24 – 27, 2015, Washington, DC
This annual conference brings together the nation’s experts in pediatric care. The 2015 conference will feature over 350 educational sessions, including training on family-centered care and family engagement within pediatric medical homes. Plenary sessions include information on pediatric education, telemedicine, and advocacy.
Additional Information about the American Academy of Pediatrics National Conference and Exhibition

November 2015

Association of University Centers on Disabilities Annual Conference: Growing Leaders, Driving Change
November 16 – 18, 2015, Washington, DC
This annual conference brings together over 700 community leaders, researchers, policy makers, and clinicians advocating for individuals with disabilities and their families. Sessions include information on family support and communication. Multiple networking opportunities are provided.
Additional information about the Association of University Centers on Disabilities Annual Conference

Patient-Centered Primary Care Collaborative Annual Fall Conference
November 11-13, 2015, Washington, DC
This annual conference focuses on state and federal investments in primary care and their impact on patients, professionals, and payment. A special award will be given to Calvin CJ Sia, MD, FAAP, for his outstanding work as a champion in pediatric medical home implementation.
Additional Information about the Patient-Centered Primary Care Collaborative Annual Fall Conference

For a more detailed listing of upcoming conferences, webcasts, and other educational offerings, click here.

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Healthy People 2020
This national 10-year program that sets measurable objectives for population health in the United States includes specific objectives related to maternal, infant, child, and adolescent health. Many pediatric health initiatives at the state and federal level that have the potential to impact implementation of pediatric medical home reference Healthy People 2020 objectives throughout their work plans.

The Patient-Centered Medical Home: A Path toward Health Equity?
Published by the Institute of Medicine, this discussion paper summarizes key points from a roundtable discussion on health equity and elimination of health disparities. The discussion focuses on the patient-centered medical home as a pathway to eliminate health access disparities and improve population health.

A Randomized Trial on Screening for Social Determinants of Health: The iScreen Study
Published in Pediatrics, this article describes a randomized trial of electronic versus face-to-face social screening formats in emergency departments. The purpose of this study was to determine which method facilitated easier screening for social determinants of health in order to improve population health of children and youth.

Preventing Chronic Disease Special Collection: Mobilizing Action towards Community Health
This special edition of Preventing Chronic Disease presents a compilation of peer-reviewed articles focusing on population health indicators, measurement, evaluation, and payment. This compilation also describes lessons learned from population health initiatives throughout the country. 

For a more detailed information on National Pediatric Medical Home Initiatives, click here.

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Community Access to Child Health Planning, Implementation, and Resident Grants
A program of the American Academy of Pediatrics, these grants support pediatricians in collaborative efforts with their communities to ensure that all children have access to health care services within a medical home. The grants place a special emphasis on improving population health.

Healthy Tomorrows Partnership for Children Program
Funded through the Maternal and Child Health Bureau, these 5-year community-based projects focus on improving population health, eliminating health disparities, and serving vulnerable and marginalized pediatric populations to improve population health.

American Academy of Pediatrics Council on Community Pediatrics
A membership group of the American Academy of Pediatrics, this council develops education and policy to promote community pediatrics. Special Interest Groups of the council focus on policy and practice to promote population health for immigrant populations and rural areas.

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Special Feature: An Interview with Healthy Tomorrows Partnership for Children Program Grantees
The Get Healthy! Obesity Treatment and Prevention Program is a Healthy Tomorrows Partnership for Children Program (HTPCP) located in a suburban community of South Adams County, Colorado. The program, based out of Kids First Health Care, includes four school-based health centers and two community health centers that collectively serve children from birth to 21 years of age. Over 65% of the project’s population are Medicaid beneficiaries and approximately 60% are Spanish language speakers.  

The project utilizes patient navigators to screen children for obesity, food security, and other social determinants of health. Children identified as obese are enrolled in a Healthy Living program, focused on obesity reduction and healthy lifestyle promotion. In a recent interview with the National Center for Medical Home Implementation (NCMHI), Medical Director Sarah Winbourn, MD, and Devra Fregin, Director of Practice Management, explained that patient navigators utilize the HeartSmart Screening Tool to identify patients eligible for the Healthy Living program. Additionally, patients are given vouchers to participate in recreational programs throughout the community. Patient navigators ensure that patients and families are proactively engaged in their care through frequent follow-up phone calls. These phone calls ensure families receive referrals to community services, help families overcome any challenges (such as accessibility) in attending follow-up appointments with clinicians, and answer any questions related to the treatment plan.

Preliminary results from the first year of the grant show that 49% of patients have improved their Body Mass Index. Additionally, the number of patients who receive recreational vouchers and attend the Healthy Living program has increased. Dr Winbourn explained that reaching out to “patients who aren’t already reaching out to us” is the key to improving population health within the community. In the future, the project team plans to incorporate Bright Futures guidelines into the clinic’s electronic health records to enhance coordinated screening for social determinants of health. For more information, visit the Colorado NCMHI State page and the HTPCP Web site.

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