Breakout Session: Integrating Community Engaged Research into the Patient-Centered Medical Home

Presents data from a survey of patients at four health centers in the Worcester, Mass., area on the topic of the Patient-Centered Medical Home (PCMH) model of patient care. Implications for research: The PCMH model includes a variety of interventions that have been demonstrated to be successful in some fashion. However, whether they will be effective when implemented together, whether they will be effective for the populations in question, and whether they are cost-effective uses of provider and patient time (as well as healthcare dollars) remains to be answered

Health Care for the Homeless: An Aging Demographic 2006 to 2010

Background: Homelessness in America is a growing problem. An estimated 1.59 million people spent at least one night in an emergency shelter or transitional housing program in 2010. Of this group, an estimated 2.8% were over the age of 62. The number of elderly homeless individuals is expected to increase by about 33% between 2010 and 2020 and more than double by 2050. Programs like the Health Care for the Homeless serve to both medically care for this growing population as well as collect data about their specific demographics and health care needs. Objectives: We studied demographic and health care needs unique to the rapidly growing elderly female population and reviewed current literature with the goal of identifying possible pathways to homelessness among this population as well as provider-based initiatives needed to better care for this homeless subset. Methods: Health Care for the Homeless data are collected in all fifty states, the District of Columbia, and Puerto Rico in the form of de-identified surveys completed by clinic personnel and submitted to the Uniform Data System (UDS), which compiles an aggregate report. The frequencies of key demographic variables and diagnostic and preventative health variables between 2006 and 2010 were analyzed using nonparametric Chi-square tests. Results: Between 2006 and 2010, the number of elderly female patients increased by almost a third. Chronic illness and gender-related cancer screens improved, but are well below national averages. Additionally, the housing and insurance statuses of the homeless population appear to be in flux. Fewer HCH patients are living in homeless shelters (-4.3%) and on the street (-0.7%) and more are reporting transitional housing (+1.6%) or doubling-up (+5.8%). Data further reveal fewer patients presenting without insurance (-5.3%) and more who have Medicaid (+3.7%), Medicare (+0.3%), other public insurance (+0.9%) and private insurance (+0.4%). There were no statistically significant changes between age, gender, housing, or insurance status groupings when comparing 2006 and 2010 aggregate data. Conclusion: The elderly homeless comprise a small, but growing subset of the national homeless population. This group is particularly susceptible to economic vulnerability and unmet health care needs. Elderly females are at an increased risk for common diseases and co-morbidities that affect individuals in their age group, including inability to perform activities of daily living, falls, impaired cognitive and executive function, frailty, and depression. Additionally, homelessness itself increases their risk of developing many acute illnesses and chronic conditions. This population is particularly susceptible to mental illness which may be further exacerbated by a lack of coping skills and resources to recover from their homeless situation

Educational Attainment, Non-English Language Usage, and Ability to Communicate in English in 30 Massachusetts Cities/Towns

Data regarding an individual\u27s ability, or the ability of members of a household to speak English, primary language spoken at home, educational attainment, and the level of literacy proficiency should be taken into consideration when designing and implementing policies regarding health care initiatives and the publication of health care information. This report highlights data collected from three sources: 1) The National Adult Literacy Survey; 2) The 1990 Federal Census; and 3) The Massachusetts Institute for Social and Economic Research

Together for Kids: Second Year Report : A Project of Community Healthlink, Inc.

The Together for Kids (TFK) project, now beginning its third implementation year, grew out of two years of work of over 30 childcare, health care, child welfare and social service agencies concerned about early childhood mental health issues. These concerned constituents, like others across the country, were responding to an increase in the incidence of young children exhibiting challenging behaviors that were resulting in disrupted early childhood classrooms and children being expelled from programs (Grannan et al, 1999; Swanson, 2001). Locally, there was also a concern about the growing number of public school special education students with diagnoses of emotional impairment/behaviorally disordered in the early grades. The importance of addressing the needs of these children at an early stage has been emphasized by a broad array of mental health and childcare professionals. Without appropriate services, these children end up with impaired ability to interact appropriately with family and peers; create family stress; become stigmatized as problem children; fail to develop school readiness skills and behaviors; cause disruptions to other children’s learning, socialization and safety; and contribute to burn out and turnover of preschool teachers (Grannan et al 1999; Shonkoff & Phillips, 2000). The TFK Coalition collected information from the research literature and from local day care centers about the extent of children at risk in the Worcester area. They found that 3.1% of children in four local day care centers, enrolling over 300 preschool children, were so disruptive they were expelled or would have been if the parents did not voluntarily withdraw them, with an additional 14% identified as at risk of expulsion. Based on this information, the TFK Coalition developed an intervention model that focused specifically on challenging behaviors of preschool children (ages 3 and up) enrolled in childcare centers. The first year of the project was used as a Pilot year to implement the mental health consultation model in two preschool in Worcester and a Head Start Program in South County. Results of the evaluation of this Pilot phase were encouraging and supported the initiation of an implementation phase in Year Two. This implementation phase involved providing the mental health consultation model in two additional centers that served as comparison centers during the Pilot phase. These two sites were brought on as New Intervention Sites in January 2004. This report focuses on the evaluation of the implementation phase, including the original Pilot Sites, the South County Sites and the two New Intervention Sites, as well as summarizing the findings from both of the years of intervention

Together for Kids: First Year Report: A Project of Community Healthlink, Inc.

The Together for Kids (TFK) project grew out of two years of work of over 30 childcare, health care, child welfare, and social service agencies concerned about early childhood mental health issues. These concerned constituents, like others across the country, were responding to an increase in the incidence of young children exhibiting challenging behaviors that were resulting in disrupted early childhood classrooms and children being expelled from programs (Grannon et al, 1999; Swanson, 2001). The importance of addressing the needs of these children at an early stage has been emphasized by a broad array of mental health and childcare professionals. Without appropriate services, these children end up with impaired ability to interact appropriately with family and peers; create family stress; become stigmatized as problem children; fail to develop school readiness skills and behaviors; cause disruptions to other children’s learning, socialization and safety; and contribute to burn out and turnover of preschool teachers (Grannan et al 1999; Shonkoff & Phillips, 2000). The TFK Coalition collected information from the research literature and from local day care centers about the extent of children at risk in the Worcester area. They found that 3.1% of children in four local day care centers, enrolling over 300 preschool children, were so disruptive they were expelled or would have been if the parents did not voluntarily withdraw them, with an additional 14% identified as at risk of expulsion. They also anecdotally connected the increasing difficulty in managing classrooms with high staff turnover, ranging up to 46% in one year. At the same time, only one Center reported access to early childhood mental health services. Based on this information, the TFK Coalition began to develop an intervention model. The specific focus of the project is on challenging behaviors of preschool children (ages 3 and up) enrolled in childcare centers

Together for Kids: Three-Year Project Report: A Project Administered by Community Healthlink, Inc.

The Together for Kids (TFK) project, funded by The Health Foundation of Central Massachusetts and the United Way of Central Massachusetts, has been the result of the dedicated work of over 30 childcare, health care, child welfare and social service agencies concerned about early childhood mental health issues. These concerned constituents formed a coalition to address the increasing incidence of young children exhibiting challenging behaviors in preschool classrooms, as reflected nationally with current estimates ranging from 7% to 25% (Raver & Knitzer, 2002; Webster-Stratton & Hammond, 1997). These challenging behaviors typically include biting, hitting, throwing things, defying adults, or becoming withdrawn and unable to interact with others, and result in disrupted early childhood classrooms and children being expelled from programs (Grannan et al, 1999; Swanson, 2001). The problem of preschool expulsions has received national attention in recent years, and in fact a very recent national study confirmed that more children are being expelled from preschool than for all other grades (Gilliam, 2005). In Worcester, Massachusetts, there was also a concern about the growing number of public school special education students with diagnoses of emotional impairment or behavioral disorders in the early grades. The first year of the project intervention began as a Pilot to implement a mental health consultation model in two preschools and a Head Start Program, and to use two additional centers as comparison sites. In Year 2, these two additional centers that served as comparison centers during the Pilot phase also received the intervention. The results of the Years 1 and 2 showed behavioral improvement in children receiving the consultation services, as well as suggestive evidence for broader classroom positive effects. In Year 3, some modifications to the model were implemented. Families were allowed to continue with services when necessary beyond the 3 to 6 month intensive intervention. A Family Liaison was also added to the model to facilitate family engagement in the child care programs. The basic model of services, however, remained the same over the three years. This report is a summary of the results of the project, combing data from all three years to increase sample size and provide additional statistical power and confidence. We have determined there is sound evidence for clinical benefits of the TFK mental health consultation model, and the next step will be to sustain the model in child care programs using public resources. Thus, going forward, adaptations to the model will focus on how to establish universal screening and consultation for preschool families, using a ratio of one FTE clinician to 200 preschool children. Future evaluation activities will focus on sustainability issues, and documenting service delivery approaches for a generalizable model

Preparing Future Leaders: An Integrated Quality Improvement Residency Curriculum

BACKGROUND AND OBJECTIVES: The Accreditation Council for Graduate Medical Education (ACGME) has recognized the importance of quality improvement (QI) training and requires that accredited residencies in all specialties demonstrate that residents are integrated and actively participate in interdisciplinary clinical quality improvement and patient safety activities. However, competing demands in residency training may make this difficult to accomplish. The study\u27s objective is to develop and evaluate a longitudinal curriculum that meets the ACGME requirement for QI and patient safety training and links to patient-centered medical home (PCMH) practices. METHODS: Residents in the Worcester Family Medicine Residency (WFMR) participated in a faculty-developed quality improvement curriculum that included web-based tutorials, quality improvement projects, and small-group sessions across all 3 years of residency. They completed self-evaluations of knowledge and use of curricular activities annually and at graduation, and comparisons were made between two graduating classes, as well as comparison of end of PGY2 to end of PGY3 for one class. RESULTS: Graduating residents who completed the full 3 years of the curriculum rated themselves as significantly more skilled in nine of 15 areas assessed at end of residency compared to after PGY2 and reported confidence in providing future leadership in a focus group. Five areas were also rated significantly higher than prior-year residents. CONCLUSIONS: Involving family medicine residents in a longitudinal curriculum with hands-on practice in implementing QI, patient safety, and chronic illness management activities that are inclusive of PCMH goals increased their self-perceived skills and leadership ability to implement these new and emerging evidence-based practices in primary care

Pathways to Kindergarten Readiness: The Roles of Second Step Early Learning Curriculum and Social Emotional, Executive Functioning, Preschool Academic and Task Behavior Skills

Efforts to improve the achievement gap between low-income children and their more affluent peers has led to the development of classroom interventions and curricula to increase executive functioning (EF) and social-emotional skills (SE), thought to be foundational for learning. The Second Step Early Learning (SSEL) curriculum is a commercially available curriculum designed to improve school readiness by building EF and SE skills. However, although widely used, it has not been widely studied. Modeling SSEL’s underlying theory of change, structural equation modeling (SEM) was used to longitudinally examine the effects of the curriculum on low-income preschool children’s kindergarten school readiness through the hypothesized mediating role of EF and SE skills in improving pre-academic skills and task behavior in preschool. In a cluster randomized trial, 972 children attending 63 preschool classrooms within 13 low-income Head Start or community preschools were individually tested at the beginning (T1) and end of preschool (T2, n = 836) and followed into kindergarten. Children’s average age at T1 was 53 months, with 51% male, 42% Anglo-American, 26% African–American, and 40% Hispanic-American. Children’s EF, social skills, pre-literacy/language, and pre-math skills were assessed by trained child assessors blind to study conditions at T1 and T2. Assessors also rated children’s task behavior in the testing situation at T1 and T2. School records of children’s kindergarten screening scores were obtained on 345 children at T3. It was expected that SSEL would have both direct and indirect effects on kindergarten readiness through improvements in children’s SE and EF skills preschool academic skills and on-task behavior. We found no direct effects of SSEL on either pre-academic or on-task behavior outcomes in preschool, nor on later kindergarten readiness. However, SSEL significantly increased EF, and as expected by SSEL’s theory of change, growth in EF predicted gains in both pre-academics (particularly pre-math), and on-task behavior in preschool. End-of-year pre-academic skills and on task behavior in turn predicted better kindergarten readiness. Further, SE (although not impacted by SSEL) had direct and indirect effects on kindergarten readiness. Thus, overall, our findings largely support SSEL’s theory of change, particularly in relation to EF

Access to Educational Opportunities for Latino Students in Four Massachusetts School Districts

This report was prompted by the pressing concerns over the high failure rates of Latino students on the Massachusetts Comprehensive Assessment System (MCAS) exam. While 27% of White students failed the English portion of the MCAS test and 38% failed the Mathematics portion in 2000, the corresponding rates for Latino students were 66% and 79% respectively (Massachusetts Department of Education, 2000a). There is a great urgency to understand why Latino students score substantially behind students from other racial/ethnic groups. This urgency stems from the reality that students currently enrolled in the 10th grade will be required to pass this exam in order to receive a high school diploma in 2003

You Want Us to Do What? How to Conduct Community-engaged Research Studies from the Perspective of the Community Organizations: Evidence from the Kidsteps II Study

Voices of community partners can help guide future community engaged research partnerships. Drs. Upshur and Wenz-Gross have been working with a Worcester community coalition for almost 15 years to create, document and research issues of at risk preschool children. Their first work, funded by the Health Foundation of Central Massachusetts, developed and tested a model of early childhood mental health consultation to child care programs. This led to testing of a primary prevention curriculum funded by the National Institute of Mental Health, and subsequently to a large randomized intervention study funded by the US Department of Education. Community partners will describe their experiences in this community driven research