A clinical process support system for primary care to address family stress

This proposal addresses the NICHD focus of specific interest for the prevention of child abuse and neglect in at risk populationsChild abuse and neglect often confers shortand long term impairment of the physicalemotionaland cognitive development of childrenThe proposed project builds on promising data from previous randomized control trialsbased on application of a screening tool in primary care pediatric practice that identifies the Family Stressors and use of harsh punishmentwhich are known to put children at risk for child abuse and neglectPediatric check ups are ideal for early identification because of nearly universal and repeated accessHoweverthese visitsalso known aschild health supervisionhave been charged with a heavy public health burden of early detection and preventive counseling for a wide variety of issues related to health riskssafetyand promoting child development during narrow time constraintsWe have previously built a system to assist with this challenge by off loading the burden of information gathering to an online previsit platform called CHADIS that has been used by over one million parents alreadyHoweverwhen the visit scope is broadened to addressing sensitive family stressorsthe challenge for PCPs becomes one of clinical interviewing skillsthatin partis best addressed with the evidence based approach known as motivational interviewingMIPCPs have not been trained for MI and it typically takes longer than the time allotted for the visitThe innovation proposed here is to collect data online before visits to not only identify problemsbut also divide the interview process so that the computer collects data in a way that guides the PCP during the visit with details and suggested wordstelepromptersfor the human elements of empathy and reflective listening that can be delivered brieflyIn additionthe innovation also reduces documentation burden and creates follow up psycho education and trackingThis new Family Stress Module supports not only a single problem visit but also acts across visits in creating the psychosocial orientation for parents of children of all ages to confide in the PCP as wellanticipatory guidancereinforced byMemoryBookand text messagesElectronic linking will be created with local referral resourcessuch as agencies or therapistsso when a referral is made two way communication is facilitated as well as tracking of appointment completion with the parent s consentThere are no other clinical process support systems of similar scope and none connected to an electronic system of care bridging medical and social domainsThe project involves first refining a prototype with parent and doctor feedback and then conducting a cluster randomized intervention trialHypothesized outcomes are lower rates of child abuse and neglect reportsless harsh punishmentas well as improved developmental and behavioral outcome in the intervention groupParent satisfaction with the enhanced clinical process and collateral benefitssuch as lower rates of missed visits and delayed vaccines will also be assessed Child maltreatmentCMinvolves aboutmillion US children placing them at risk for many shortand long term negative consequencesincluding medicaldevelopmental learningsocial and mental health problems and associated costsFamily StressorsFSsuch as parental intimate partner violencesubstance abusedepressionextreme stress and food insecurity and harsh punishment of their children are significant problems for families and also major risk factors for CMThis project is to refine and test an innovative Family Stressors Module of a web system now used by primary healthcare providersPCPof children instates to include pre visit parent report screening tools for FSACEResilience and Best Hardest parts of parenting to generate decision support teleprompters for PCPs to provide more psychosocially oriented care plus use motivational interviewing to increase accessing help by parents for their FS thereby reducing CM