Getting Pediatric Practices to
Prevent Child Abuse and Neglect
Steve Kairys, MD, MPH, FAAP, PI
Tammy Piazza Hurley, Project Director
Session Objectives
At the end of this session, participants will be able
to:
1. To detail the epidemiology and long term effects
of child abuse and neglect
2. To review the role of pediatrics in the primary
prevention of child abuse and neglect
3. To learn specific office based strategies for the
primary prevention of child abuse and neglect
The Importance of Prevention
 10-15% of young children are victims of serious
physical trauma (Finkelhor and Straus)
 Neglect is the leading cause of substantiated cases
of abuse
 Survey data demonstrate that 25% of females and
10% of males will be sexually abused by age 18
 Estimates of treatment costs are 24 billion dollars a
year
 Long term sequelae are enormous in terms of
psychological and functional damage, substance
abuse, delinquency, learned aggressiveness and
abuse potential when a parent
The Adverse Childhood Experiences
(ACE) Study
The largest study of its kind ever
done to examine the health and
social effects of adverse
childhood experiences over the
lifespan (18,000 participants)
Adverse Childhood Experiences
Are Very Common
Percent reporting types of ACEs:
Household exposures:
Alcohol abuse
Mental illness
Battered mother
Drug abuse
Criminal behavior
Childhood Abuse:
Psychological
Physical
Sexual
23.5%
18.8%
12.5%
4.9%
3.4%
11.0%
30.1%
19.9%
ACES
determine the likelihood of the
ten most common causes of
death in the United States.
Top 10 Risk Factors Are:
Smoking
Physical inactivity
Suicide attempt
Illicit drug use
50+ sexual partners
Severe Obesity
Depression
Alcoholism
Injected drug use
h/o STDs
With an ACE Score of 0, the
majority of adults have few,
if any, risk factors for these diseases.
However, with an ACE Score of 4 or
more, the majority of adults have
multiple risk factors for these
diseases or the diseases themselves.
Many chronic diseases
in adults are determined
decades earlier
in childhood.
The Role Primary Care Practice
in Preventing Child Abuse and
Neglect
Pediatric Primary Care: An Opportunity
for Preventing Child Abuse & Neglect
Well accepted, institutionalized
Goal of prevention
Concern with child, family
Special relationship with family
No stigma
Multiple visits (1st few yrs.)
An opportunity, responsibility
Percent Of Children Who Saw A Pediatric
Clinician In Past Year
99 %
41 %
30 %
1+ visits
1-3 visits
29 %
4-6 visits
7+ vists
Pediatrician Perspectives on Content of
Health Supervision

Most pediatricians say they discuss traditional topics with less
than 75% of parents of patients 0-9 months:


Less frequently discussed are topics related to cognitive
development:


Immunizations (94%), nutrition (93%),
sleeping positions (82%), breastfeeding (70%)
Reading to child (48%) & how child communicates (42%)
Least discussed are topics related to family & community
needs:

Social support (28%), financial needs (16%),
violence in the community (13%)
Parents’ Misconceptions
Parents of young children…
 57% believe a baby younger than 6 months can
be spoiled
Almost 40% believe a 12-month-old’s behavior
can be based on revenge
51% expect a 15-month-old to share
What Grown-Ups Understand About
Child Development, Civitas, 2000
Missed Opportunities
Parents concerns are often not elicited or
addressed
44-79% of parents report not discussing
important child development topics with their
pediatricians
About 57% of parents report receiving a
developmental assessment of any kind
Only half of “exemplary” practices refer children
to developmental programs
Dissemination Strategies
Continuing medical education
Evidence-based guidelines
Opinion leaders
Audit and feedback
Incentives & disincentives
Academic detailing
Patient and/or consumer activation
Office system innovations
Continuous quality improvement
A national health care
promotion and
disease prevention
initiative that uses a
developmentally
based approach to
address children’s
health needs in the
context of family and
community.
Goals
Bright Futures has four goals that will allow it to carry out its
mission of improving the health of our nation’s children,
families, and communities. These goals are to:
 Work with states to make the Bright Futures approach
the standard of care for infants, children, and
adolescents;
 Help health care providers shift their thinking to a
prevention-based, family-focused, and developmentallyoriented direction;
 Foster partnerships between families, providers, and
communities; and
 Empower families with the skills and knowledge to be
active participants in their children’s healthy
development.
Guidelines
Comprehensive health supervision guidelines:
• Developed by multidisciplinary child health experts—
providers, researchers, parents, child advocates
• Provide framework for well-child care from birth to
age 21
• Present single standard of care based on health
promotion and disease prevention model
• Include recommendations on immunizations, routine
health screening, and anticipatory guidance
• Replace the former AAP Guidelines for Health
Supervision
Features of 3rd Edition: Ten Themes
Child development
Family support
Mental health and
emotional wellbeing
Nutritional health
Physical activity
Healthy weight
Oral health
Safety and injury
prevention
Healthy sexuality
Community
resources and
relationships
Core Concepts
Prevention Works
Families Matter
Health Is Everyone’s
Business
Official AAP Policy on Prevention
The Pediatrician’s Role in Child Maltreatment
Prevention – published October 2010
Pediatrics
(http://pediatrics.aappublications.org/cgi/reprint
/126/4/8330)




Factors and characteristics placing child at risk
Protective Factors
Review of Prevention and Intervention programs
Guidance for Pediatrician
Schmidt’s 7 Deadly Sins of Childhood*
Normal developmental phases of childhood that
may cause difficulty for some:
1. Colic
2. Awakening at night
3. Separation anxiety
4. Normal exploratory behavior
5. Normal negativism
6. Normal poor appetite
7. Toilet training resistance
*Schmitt BA. Child Abuse and Neglect, 1987.
Guidance for Pediatrics
1. Obtain a thorough social history, initially and
periodically, throughout a patient’s childhood.
2. Acknowledge the frustration and anger that
often accompany parenting.
3. Talk with parents about their infant’s crying and
how they are coping with it.
4. When caring for children with disabilities, be
cognizant of their increased vulnerability and
watch for signs of maltreatment.
Guidance
5.
6.
7.
8.
Be alert to signs and symptoms of parental
intimate partner violence and postpartum
depression.
Guide parents in providing effective discipline.
Talk to parents about normal sexual development
and counsel them about how to prevent sexual
abuse.
Encourage caregivers to use the pediatric office as
a conduit to needed expertise. Become
knowledgeable about resources in the community,
and, when appropriate, refer families, especially
stressed parents, to these resources.
Advocacy
9. Advocate for community programs and
resources that will provide effective prevention,
intervention, research, and treatment for child
maltreatment and for programs that address
the underlying problems that contribute to child
maltreatment (eg, poverty, substance abuse,
mental health issues, and poor parenting
skills).
10. Advocate for positive behavioral interventions
and supports in schools.
Practicing Safety: An
Intervention to Prevent Child
Abuse and Neglect
Funded by the Doris Duke Charitable
Foundation
Practicing Safety
Overall Goal:
Decrease child abuse and neglect by increasing
screening and improving anticipatory guidance
provided by pediatric practices to parents of
children ages 0-3.
 Funded by DDCF from 2003-3007
 9 practices in NJ and PA
 Used Complex Adaptive Theory
 Toolkit consisting of 7 bundles
Toolkit Components
Toolkit included 7 modules with:
 Color coded Practice Guides:












Red: Coping with Crying/SBS Prevention
Purple: Parenting
Pink: Safety in Others’ Care
Blue: Family & The Environment
Orange: Effective Discipline
Green: Sleeping/Eating Issues
Aqua: Toilet Training
Parent Educational Materials
Office Marketing Tools
Staff tools
Moderate Interactives/Tangibles
Issues Management
Evaluation
Pre-Post staff survey
Pre-Post parent survey
Chart review
Toolkit evaluation
Physician interviews
Staff focus group interviews
Data Analysis





Staff and physician report of raised awareness about
child abuse and neglect.
Staff and parent reports of a significant increase in
maternal depression screening.
Toolkit data identified use of Infant crying, discipline
and toilet training tools with families.
Staff report that maternal drug and alcohol issues were
generally difficult for practices to address although
those with established referral systems to social
workers fared better.
Most practices noted that the intervention program
contained too much information.
Lessons Learned
1. Some type of facilitation is needed to help the
practices make change.
2. Efforts need to be made to spread intervention
throughout practice.
3. AAP brochures, posters and screening tools
were of most use to practices.
4. Need to get the materials into an electronic
format as well culturally diverse for ease of
building the materials into the core of the
practice style.
5. Strong need for better connection to
community resources.
Changes in practice
 Raised awareness about child abuse and neglect.
 Maternal depression screening was adopted by 4
of the 5 pediatric practices. .
 Infant crying, discipline and toilet training modules
were also implemented by the practices.
 Maternal drug and alcohol issues were generally
difficult for practices to address although those
with established referral systems to social workers
fared better.
 Most practices noted that the intervention
program contained too much information.
Weaknesses
Focus Groups
 Too much information (and cost of materials)
 Lack of feedback loop – from docs back to staff and
from parents back to staff – staff discontent with not
knowing impact of PS materials/efforts
 No change in roles; staff wanted to play a bigger
role
Physician Interviews
 Too many meetings
 Materials too wordy, language barriers
Practicing Safety:
Phase II
Revised Toolkit
3 Bundles
Infant: coping with crying
 Mother/Caregiver: maternal depression,
bonding/attachment
 Toddler: effective discipline, toilet training

Each bundle includes a practice guide as
well as tools for each topic
Infant Bundle
Infant Bundle: Coping with Crying
Practice Guide: includes care management plan, assessment/screening questions,
anticipatory guidance.
Green light:
Assessment/
Screening
Anticipatory
Guidance
-Example: How often does your baby cry and how do
you handle it?
-Provide anticipatory guidance
-Welcome to the World of Parenting brochure
-Guide for parents: Swaddling 101
-Crying poster
Yellow light:
Parent concerns
-Example: Who can you call to help when you need a
break?
-Provide anticipatory guidance
-Refer to family strengthening organization
Red light:
Possible safety
concerns for infant
Referral to Child Protective Services for evaluation
and care management
Introduce at 2 weeks to 4 weeks; Reinforce at 2 months
**Tools are identified by purple font
Mother/Caregiver Bundle
Mother/Caregiver Bundle: Maternal Depression/Bonding/Attachment
Practice Guide: includes care management plan, assessment/screening questions,
anticipatory guidance.
Green
light:
Assessment/Screening
Anticipatory Guidance
-Edinburgh Postnatal Depression Scale (EPDS)
-Example: Is the mom’s partner available for support?
-Example: What do you enjoy doing with your baby?
-Provide anticipatory guidance
-Postpartum Depression Brochure
-Refresh. Renew. Recharge Poster
-Have you Read to Your Baby today button
Yellow
light:
At risk for
depression/<9* but have
concerns/early signs
Referral to support system, including PCP, OB,
Behavioral health agency, home visiting program
Red
light:
Depression/≥9* or ≥1 on
Q#10*/potential risk to
self and/or infant
Referral to Child Protective Services and/or
Behavioral Health agency
*Refers to the EPDS
Introduce at 2 weeks to 4 weeks; Reinforce at 2 and 3 months
**Tools are identified by purple font
Toddler Bundle: Discipline
Toddler Bundle: Discipline
Practice Guide: includes care management plan, assessment/screening questions,
anticipatory guidance.
Green light:
Assessment/
Screening
Anticipatory
Guidance
-Example: What makes you lose it with your
baby/child? How do you handle it?
-How were you disciplined as a child?
-Provide anticipatory guidance
-Teaching Good Behavior-Tips on Discipline
-Play is How Toddlers Learn
-Reading. Routine. Relationships. Rewards poster
Yellow light:
Evidence help is
needed/parental
frustration/unrealis
tic expectations
-Example: How do you handle temper tantrums?
-Provide anticipatory guidance
-Temper Tantrum brochure
-Refer to family strengthening organization
Red light:
Possible safety
concerns for child
Referral to Child Protective Services for evaluation
and care management
Introduce at 6 months; Reinforce at 12, 15, 18, 24, 36 months
**Tools are identified by purple font
Toddler Bundle: Toilet Training
Toddler Bundle: Toilet Training
Practice Guide: includes care management plan, assessment/screening questions,
anticipatory guidance.
Green light:
Assessment/
Screening
Anticipatory
Guidance
-Example: Have you thouhgt about or started toilet
training? How is it going?
-Provide anticipatory guidance
-AAP Toilet Training brochure
Yellow light:
Evidence help is
needed/parental
frustration/unrealis
tic expectations
-Provide anticipatory guidance
-Potty Chart
-Bedwetting Brochure
-Refer to family strengthening organization
Red light:
Possible safety
concerns for child
Referral to Child Protective Services for evaluation
and care management
Introduce at 18 months; Reinforce at 2 and 3 years
**Tools are identified by purple font
Practicing Safety Project Aims
Improve assessment/screening and anticipatory
guidance by pediatric physicians and staff with
parents/caregivers on topics of crying, maternal
depression, toilet training, and discipline (to
100% by November 2009).
Test use of the Practicing Safety tools for
education by pediatric physicians and staff with
parents/caregivers on topics of crying, maternal
depression, toilet training, and discipline.
Test the usefulness of the Practicing Safety tools
and ease of use of the tools; and determine
strategies for use of the tools.
Practicing Safety Project Methods
 Modified Learning Collaborative with 14 teams (lead physician plus
2 others from practice)
 Model for Improvement; Plan, Do, Study, Act; small tests of change
 Prework period (April 2009)


Baseline chart review
Pre-Inventory Survey
 Learning Session 1(May 2009)
 Action Period (June-November 2009)




Monthly Chart Review/Chart Documentation Forms
 10 charts of patients at the 2-month visit (infant and mother/caregiver
bundles)
 10 charts of patients at the 18-month visit (toddler bundle)
Monthly Progress Reports
Monthly Team Calls
Review of Run Charts to guide improvements (posted to a Project Workspace
Web site)
 Follow-up (November 2009)



Post-Inventory Survey
Post Toolkit Evaluation Survey
Post-Telephone Interviews
Thank you to the 14
Practicing Safety
Teams!
Longview,
WA
Child and
Adolescent
Clinic
Grand Rapids, MI
Helen DeVos Children’s
Hospital General
Pediatrics
Dayton, OH
Children’s
Health Clinic
Brooklyn, NY
Maimonides
Infants and
Children’s
HospitalNewkirk Family
Health Center
Flushing, NY
Flushing Hospital
Medical Center
New Haven, CT
Hospital of Saint
Raphael Pediatric
Primary Care Center
Midlothian, VA
Pediatric &
Adolescent Health
Partners
West Reading, PA
All About Children
Pediatric Partners
PC
Bluefield, WV
Dr Frazer’s Office
Charlotte, NC
CMC-Myers Park
Pediatrics
Houston, TX
Lyndon B. Johnson
Pediatric Clinic
Tuscaloosa, AL
University Medical
Center
Brewton, AL
Lower Alabama
Pediatrics
Greenville, SC
Center for
Pediatric Medicine
Practicing Safety Results:
Assessment/Screening and
Anticipatory Guidance
Infant
Mother/Caregiver
Toddler: Discipline
Toddler: Toilet Training
Practicing Safety Results:
Usefulness of Tools
Average Respondent Ratings of “Practicing Safety Tool
Evaluation: Infant Bundle”
Information/ Content
Cultural Sensitivity
Swaddling 101
World of Parenting
Coping with
Crying
Hug, Hold, Comfort,
Cuddle
Appropriate Information
3.9
4.6
4.3
4.2
Adequately Comprehensive/ Thorough
4.0
4.4
4.3
4.1
Aids in Patient Care
3.9
4.5
4.3
4.2
Literacy Level is Appropriate
3.5
3.9
4.5
4.4
Culturally Appropriate
3.8
4.2
4.4
4.4
Free of Bias
4.5
4.5
4.6
4.6
Readability
3.5
4.1
4.6
4.5
Relevant Information
3.9
4.2
4.4
4.4
Purpose is Clear
3.9
4.3
4.4
4.4
Effective
3.9
4.2
4.3
4.3
3.9
4.3
4.4
4.3
Usefulness
Total (average)
Key:
1 = Poor
5 = Excellent
Average Respondent Ratings of “Practicing Safety Tool
Evaluation: Mother/Caregiver Bundle”
Information/
Content
Post Partum
Depression
Refresh, Renew, Recharge
Edinburgh Postnatal
Scale
Read to Baby Button
Appropriate Information
4.5
4.1
4.4
3.4
Adequately Comprehensive/
Thorough
4.3
4.1
4.2
3.4
Aids in Patient Care
4.5
4.1
4.5
3.4
Literacy Level is Appropriate
3.7
4.2
3.6
4.3
Culturally Appropriate
4.1
4.4
4.1
4.2
Free of Bias
4.5
4.6
4.3
4.6
Readability
4.1
4.2
3.9
4.1
Relevant Information
4.2
4.2
4.2
4.2
Purpose is Clear
4.6
4.2
4.4
4.3
Effective
4.1
4.1
4.4
3.9
4.3
4.2
4.2
4.0
Cultural Sensitivity
Usefulness
Total (average)
Key:
1 = Poor
5 = Excellent
Average Respondent Ratings of “Practicing
Safety Tool Evaluation: Toddler Bundle”
Toilet
Training
Information/
Content
Potty
Chart
BedWetting
Teaching
Good
Behavior
Temper
Tantrum
Playing is
Learning
Reading,
Routine, etc.
Appropriate Information
4.7
4.6
4.2
4.8
4.9
4.7
4.5
Adequately Comprehen-sive/
Thorough
4.6
4.3
4.2
4.7
4.7
4.6
4.5
Aids in Patient Care
4.7
4.5
4.1
4.7
4.8
4.5
4.4
Literacy Level Appropriate
4.1
4.6
4.3
4.3
4.2
4.4
4.3
Culturally Appropriate
4.4
4.5
4.4
4.5
4.6
4.6
4.3
Free of Bias
4.7
4.7
4.6
4.8
4.8
4.7
4.5
Readability
4.5
4.7
4.1
4.6
4.6
4.6
4.5
Relevant Information
4.7
4.5
4.1
4.7
4.8
4.8
4.4
Purpose is Clear
4.8
4.8
4.3
4.8
4.8
4.8
4.6
Effective
4.5
4.6
4.0
4.6
4.7
4.6
4.2
4.6
4.6
4.2
4.6
4.7
4.6
4.4
Cultural
Sensitivity
Usefulness
Total (average)
Key:
1 = Poor
5 = Excellent
Practicing Safety Results: Office
Systems Inventory
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POLICIES Our practice has policy/policies in place to support the following
(check all that apply):
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Pre-inventory
Post-inventory
DOCUMENTATION SYSTEMS Our practice has a system in place to
(check all that apply):
100.0%
80.0%
60.0%
40.0%
20.0%
0.0%
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Pre-inventory
Post-inventory
Average Time spent at 2- and 18-month well
child visits from pre to post intervention
Pre-test Average
(n=13 practices)
On average, how
much time is spent at
a 2-month well child
visit (in minutes)
On average, how
much time is spent at
a 18-month well child
visit (in minutes)
Post-test Average
(n=13 practices)
Change in minutes
(average)
19.2 minutes
20.6 minutes
+1.4 minutes
21.7 minutes
22.3 minutes
+0.6 minutes
Practicing Safety Results:
Qualitative Themes
Qualitative Themes
Consistent use of PS toolkit
Systemization of risk
Changes to chart documentation
Community resource linkages
Initiation of meetings
Improved medical education
Implementation of QI methodology
Increased awareness
Challenges
Unanticipated positive outcomes
Practicing Safety Lessons Learned
 Practices need guidance in order to incorporate practicebased protocols that address child abuse and neglect
prevention as part of well-child care
 Pediatricians, once supported and mentored, are excited
to offer families more concrete and systematic guidance
in these areas
 Practicing Safety can inform more successful
implementation of enhanced care and assists practices
in establishing a medical home
 Parents are receptive to guidance on these topics and
believe these issues are of significant concern
 Practicing Safety provided an opportunity for enhanced
clinical education for physicians, nurses, residents, etc
Practicing Safety Lessons Learned (con’t.)
 Practices tailored tools to fit their patient population.


Some practices incorporated tools for more than the project
prescribed well-child visit based on age.
Some practices collapsed the suggested “green” and “yellow”
assessment questions and anticipatory guidance and used
both levels routinely as primary prevention topics at well-visits
for all of their families with children in the targeted age ranges
 Some practices found a need for multi-lingual, low
literacy and more graphic materials for parents
 Just participating in PS raised awareness of child abuse
and neglect issues for all roles in the pediatric office
 Chart documentation is key to determining
improvements in care
Practicing Safety Lessons Learned (con’t.)
 It is important to have an engaged practice champion to
succeed & leadership support, teams enhance practice
change
 Some practices found it challenging to promote the
bigger picture of their work to the rest of the practice
physicians and staff – the importance of testing and
measuring prior to full-on implementation
 Administrative and clinical priorities compete with making
change (H1N1, EMR implementation, staff turnover)
 Coding and reimbursement remain a challenge
 The project motivated practices to link with community.
 Lastly, practices would like more info on diffision.
Additional Resources
Practicing Safety QuIIN Web Page:
http://www.aap.org/qualityimprovement/quiin/
PracticingSafety.html
Project Staff
Jill Healy, QuIIN Project Manager jhealy@aap.org
 Tammy Hurley, Manager, Child Abuse and Neglect
Prevention Activities
thurley@aap.org

The Safe Environment for Every Kid
(SEEK) Model: Pediatricians
Preventing Child Maltreatment
Howard Dubowitz, MD, MS
Wendy Lane, MD, MPH
Cindy Weisbart, PsyD
University of Maryland School of Medicine
The SEEK Model
Specially trained physicians
Parent Screening Questionnaire (PSQ)
Brief assessment of problems
Initial management
Physician - social worker team
Referral to community agencies
Introduction to the PSQ
Provides context: “We want to help families
have a safe environment for kids”
Builds on what’s accepted: injury prevention
Universal: “We’re asking everyone …”
Empathic: “Being a parent is not easy”
Parent Screening Questionnaire (PSQ)
 brief
 easy to read
 answer yes/no
 convenient, time to complete
 voluntary
PSQ
Examples of PSQ Questions
Intimate partner violence: In the past
year, have you been afraid of a partner?
Substance abuse: In the past year,
have you felt the need to cut back on
drinking or drug use?
Depression: Lately, do you often feel
down, depressed, or hopeless?
If screen +
PSQ : 1-2 questions per problem
Brief assessment
Initial management, refer
A positive screen is not a diagnosis
SEEK Study Design
Model Care (Intervention)
Trained pediatricians, Parent Screening Questionnaire,
+ social worker. All patients receive Model Care
Randomly
assign
practices
Subset of
mothers
recruited
Initial
Survey
6 Mo.
Survey
12 Mo.
Survey
Medical
Chart &
CPS
Record
Review
Standard Care (Control)
All patients receive standard pediatric primary care
SEEK HPs
• SEEK I: Residents’ continuity clinics
• SEEK II: Private practices in central
Maryland
•
•
Agreed for practice to be randomized to
intervention or control group
If in intervention group, agreed to attend
training and implement SEEK
SEEK Study Samples
SEEK I
SEEK II
 558 families
 1121 families
 Low income, urban
 Middle class, mostly
suburban
 Mostly African American
 Pediatric resident clinic
 92 residents
 Mostly white
 18 pediatric private practices
 101 pediatricians & pediatric
nurse practitioners
Hypothesis 1
Training physicians to address risk factors
for CM will significantly improve their:
Attitudes
Knowledge
Comfort level
Perceived competence
Practice
SEEK I: Practice Behavior
Intervention vs. Control Residents
Mean Score
5
4
Intervention
Control
3
2
Range: 0 - 5
α =.72
Pre-test
6 months
18 months
p = .03 (pretest - 18 months)
SEEK I: Rates that Problems were Screened for
During Regular Checkups
% based on chart review
35
30
25
20
Before
During
15
10
5
0
SEEK
Control
Depression
SEEK
Control
Partner Violence
SEEK I & II PSQ: Conclusions
 Very good test - retest reliability
 High sensitivity – depression, stress
 Low sensitivity – acceptable?
 High specificity - all risk factors
except food insecurity
In Summary
Improved physician sense of competence
and screening for risk factors, based on:

Self-report

Medical chart review

Direct observation
In SEEK I and II
Sustained 18 months after initial training
Hypothesis 2
The SEEK model will help
prevent child maltreatment
Parent-Child Conflict Tactics Scale (CTS –
PC)
Parent’s report of psychological and physical
aggression in disciplining a child
Starts with positive approaches, escalates
with increasingly violent behaviors
Adequate reliability, validity
Straus et al, Child Abuse & Neglect. 1998;22:249-70
%
Medical Neglect: Non-compliance†
based on chart review (SEEK I)
10
9
8
7
6
5
4
3
2
1
0
Intervention
Control
Before
†
After*
MD documented “non-compliance”
* P = 0.05
%
Medical Neglect: Delayed Immunizations†
based on chart review (SEEK I)
10
9
8
7
6
5
4
3
2
1
0
Intervention
Control
Before
†
MD documented
After*
* P = 0.002
Child Protective Services Reports for Abuse or Neglect
(SEEK I)
25
20
15
%
Intervention
Control
10
5
0
Before
After*
* P = 0.03
SEEK II CPS Results
Group
No CPS
Reports
Pre-SEEK
CPS
Reports
Only
During
SEEK CPS
Reports
Only
Pre and
During
SEEK CPS
Reports
n (row %)
n (row %)
n (row %)
n (row %)
Intervention
579 (95)
15 (3)
8 (1)
7 (1)
Control
519 (98)
6 (1)
3 (0.6)
2 (0.4)
P = 1.0 using Fisher’s exact test
Closing thoughts
 Practices can incorporate screening and
guidance into their practices
 Focused engagement in child abuse
prevention shows promise
 Reimbursement issues need to be
addressed
 It appears that more than one model on
practice improvement can be effective
The Road Ahead ……….
Further replication, evaluation, refinement
Prioritize resident continuity clinics
Begin pre-natally
SEEKING SAFETY- combine the elements
of the two models
Broad outcomes based study of at least
100 practices
Thank you!
Questions