*"It doesn't matter if the cat is black or white as long as it catches
mice."*

Deng Hsaio P'ing

This a page for sharing "what works" as seen in the published literature
as well as what is done at sites that care for American Indian/Alaskan
Native children. If you have any suggestions, comments or questions
please contact Steve Holve, MD, Chief Clinical Consultant in Pediatrics
at steve.holve@tchealth.org

IHS Child Health Notes

October 2008

# Quote of the month

"The function of the imagination is not to make strange things settled,
so much as to make settled things strange."

G.K. Chesterton

**Article of Interest**

Universal screening for hearing loss in newborns: US Preventive Services
Task Force

Pediatrics. 2008 Jul;122(1):143-8.

<http://pediatrics.aappublications.org/cgi/content/full/122/1/143>

The USPSTF recommends screening for hearing loss in all newborn infants
stating that there is a high certainty that the net benefit is moderate
to substantial. This follows on the recommendations of the Joint
Committee on Infant Hearing that first recommended newborn hearing
screening in 2000.

It is estimated that 1-3/1,000 live born infants have significant
congenital hearing loss. Previous efforts with targeted screening of
high-risk newborns missed over 50% of affected infants leading to the
new recommendation for universal screening. Most programs involve a
two-step process in which the first screen is an otoacoustic emission
test and follow-up is done by auditory brainstem response. This
procedure yields a screening sensitivity of 0.92 and a specificity of
0.98

There is also substantial evidence that early identification and
intervention of hearing loss before 6 months of age will result in
marked benefits. Children that receive timely intervention services
perform 20-40 percentile points higher in vocabulary, social adjustment
and behavior at 8 years of age. Intervention can include augmentation
devices, cochlear implants or acquisition of sign language.

**Editorial Comment**

Since the first recommendation in 2000 that infants be screened for
hearing loss the percentage of infants screened at birth has increased
from 38% up to 95%. However, almost half of children who fail their
first screen do not receive appropriate or timely follow-up care.
Ensuring that all infants receive timely intervention is now our
greatest challenge in newborn hearing screening. Reviewing the results
of newborn hearing screening should be a part of the two week and six
week well child care visit.

**Recent literature on American Indian/Alaskan Native Health**

Michael L. Bartholomew, MD

Wood D, Winterbauer N, Sloyer P, Jobli E, Hou T, McCaskill Q, Livingood
WC. A Longitudinal Study of a Pediatric Practice-based Versus an
Agency-Based Model of Care Coordination for Children and Youth with
Special Health Care Needs. *Matern Child Health J*. 2008

http://www.ncbi.nlm.nih.gov/pubmed/18766431?ordinalpos=4&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

Children with Special Health Care Needs (CSHCN) is defined as "those who
have or are at increased risk for a chronic physical, developmental,
behavioral, or emotional condition and who also require health and
related services of a type or amounts beyond that required by children
generally."^1^ Recent estimates indicate that CSHCN account for
approximately 14% of all U.S. children (10.2 million) and roughly 70% of
all health care expenditures.^1,2^ The American Academy of Pediatrics
defines the characteristics of the medical home as a primary care
delivery model that is "accessible, continuous, comprehensive,
family-centered, coordinated, compassionate, and culturally
effective."^3^ Care coordination, as a part of the medical home model,
has been proven to be a vital piece of any integrated health services
system for CSHCN. Positive outcomes such as patient satisfaction,
reduced health care costs, reduced delay in care, and fewer
hospitalizations have all been shown to be related to care coordination
and the medical home model. ^1^ In 2008, Robert McSwain, Director of the
Indian Health Service, included the development of a "medical home" in
his vision statement for improving the health care for patients."^4^
Currently, tribal clinics and service units are advancing towards care
coordination and the establishment of a medical home.

This prospective cohort study compares agency-based care coordination
with practice-based models for CSHCN. Three pediatric practices that
utilize an agency based model of care coordination were compared to
three practices that utilize nurse care coordination and received
medical home training. Families of CSHCN were monitored over 18 months
through base-line and follow-up surveys. Families rated four care
coordination measures: 1.) Help with needed services 2.) Support from
the care coordinator 3.) Satisfaction with care coordination services
4.) Barriers to getting health services. Additionally, parents rated of
pediatric services including treatment by the office staff,
communication with the pediatrician, partnering in decision-making, and
connecting to outside resources. Parents with higher scale scores at
follow-up than at baseline were classified as "improved" whereas scores
lower or equal at follow-up were labeled as "not improved."

Although practiced based care coordination showed no significant
difference in mean change scores between baseline and follow-up for the
four care coordination measures, it had higher percentages of "improved"
scores than did the agency based model. Of the ratings of pediatric
services, practice based care coordination had a higher percentage of
"improved" in one measure (treatment by office staff), while the
percentages in the remaining measures were similar.

Despite the studies limitations (transient target population, lack of
randomization, and combination of the medical home training and practice
based care coordination in the participating practices possibly
influencing favorable responses), the authors conclude that practice
base care coordination leads to increased family satisfaction in the
quality of care and the reduction of barriers to care for CSHCN.

.

References:

1.  American Academy of Pediatrics. (2005). Care Coordination in the
    Medical Home: Integrating Health and Related Systems of Care for
    Children With Special Health Care Needs. Policy Statement.
    *Pediatrics*, 116, 1238-1244.

2.  American Academy of Pediatrics. (2002). The Medical Home. Policy
    Statement. *Pediatrics*, 110, 184-186.

3.  American Academy of Pediatrics. The National Center of Medical Home
    Initiatives for Children With Special Health Care Needs.
    http://www.medicalhomeinfo.org/index.html

4.  Robert G. McSwain, Indian Health Service Director. Vision for The
    Indian Healthcare System.