Variability in Primary Care and Challenges for the Implementation of Evidence-Based Parenting Programs

Family-centered behavioral interventions are efficacious. However, such programs have not been widely implemented in systems that families can access. Primary care is a promising venue because of its reach to more than 80% of children nationwide, the perceived expertise of medical providers, and billing mechanisms supporting sustained delivery.

We use a case series approach to describe efforts to integrate a parenting program—the Family Check-Up 4 Health—to address pediatric obesity in three primary care clinics: 1) an outpatient primary care office affiliated with a regional children’s hospital, 2) a Federally Qualified Health Center (FQHC) that began as a community mental health center and is moving towards integrated health, and 3) a FQHC that has fully integrated health services using a team approach. All three clinics serve predominantly Latino and Medicaid patients in the same geographical area, however each is unique in terms of its capacity and procedures for service delivery. This presentation focuses on the establishing partnerships with each of the clinics and developing site specific implementation plans to overcome the constraints faced by each setting. We will also present data on recruitment and enrollment rates and strategies specific to each setting and overall to demonstrate the potential of primary care for engaging families and the specific challenges related to the configuration of the clinics.

The children’s hospital has a high clinic volume and pediatric residents engage families in the study. This recruitment approach has been highly successful, with 95% of eligible families choosing to engage. However, the clinic must refer to university-supported behavioral health providers to deliver the program, which creates challenges for sustainability. With a smaller volume in the FQHCs, we are supplementing this in-clinic strategy with phone-based recruitment using a list generated through the EHR. This approach has also been successful as well, with 82% of families enrolling across the two sites. In the first site, behavioral health consultants in the behavioral health side of the organization are responsible for both the conducting assessments and providing services, which has led to a delay in assessments completed (only 9% of enrolled families have competed assessments to date). In the second, Community Health Workers housed within primary care conduct assessments, which has resulted in a more streamlined approach (62% of assessments conducted to date).

The variability in primary care creates challenges for integrating evidence-based parenting programs. Multiple case study approaches, drawing from a variety of primary care clinics, are needed to inform effective implementation of behavioral health programs in primary care.