Bronx Health Collective (NY)
Carle Health (IL)
The CHILDS Project (VA)
Denver Health (CO)
Erie Family Health Centers (IL)
Fortify Children's Health (VA)
Jefferson County of Public Health (AL)
Johns Hopkins Pediatric Primary Care Clinics (MD)
Meharry Department of Pediatrics (TN)
Mid-America Regional Council and Swope Health Services (MO)
Nationwide Children’s Hospital Team WINS (OH)
Neighborhood Health (VA)
Northeast Valley Health Corporation (CA)
OSF HealthCare (IL)
Peninsula Community Health Services (WA)
PRIDE Community Services, Inc. (WV)
Team Pediatrics at Vista Community Clinic (CA)
ULPS General Pediatrics Clinic (TN)
UT San Antonio Wellness 360 Pediatrics (TX)
CHEC-UP: Child Health Engagement and Coaching Using Patient-centered Innovation
AllianceChicago is a network of health centers that promotes collaboration, technological innovation, research and education to improve health care services to vulnerable populations. About 82% of the population served by the Heartland Health Centers, one of the health centers in the AllianceChicago network who participated in the intervention, identify as racial or ethnic minorities. Ninety-nine percent of patients served are at or below 200% of the federal poverty line.
AllianceChicago used a chatbot messaging system to reduce disparities in well-child and immunization completions among vulnerable communities. The intervention used a text and email-based communication system to personalize text and email messages while providing one-click appointment scheduling tool via a parent’s mobile device.
The chatbot helped by:
- Reminding families of upcoming well-child visits and immunizations via text and email
- Providing families with instructions ahead of their visits
- Facilitating easy appointment scheduling via sending one-click scheduling links
- 111 well-child visits scheduled and implemented
- 27% of families who engaged with the chatbot were more likely to complete a well-child visit and immunizations compared to the control group
- 13% increase in well-child visits and immunizations in the intervention group compared to control group
Bronx Health Collective Infant Health Care Maintenance Visit Project
Background: Bronx Health Collective (BHC) is a Federally Qualified Health Center (FQHC) affiliated with the Montefiore Medical Center, located in South Bronx, New York. BHC provides medical services to the poorest congressional district in the nation.
Intervention: BHC increased rates of completed well-child visits for all current patients less than 2-years of age. Through patient registries and HOME, a BHC program serving domestic violence shelters and homeless youth, BHC identified over-due and underserved patients while using digital technology to reach and expand communications with children and the homeless.
The intervention process:
- Created automated patient lists of those in need of well-child checks
- Used administrative staff to call those in-need to schedule appointments - reaching families and homeless shelters
- Provided Metro cards, or other transportation, for patients to attend appointments to reduce barriers of receiving health care
- 10% increase in average number of completed Health Care Maintenance visits in 2021 compared to 2020
- 25% increase in infant HCM visits via the HOME program
Carle Mobile Health Services: Increasing Access to School Age Children for Physicals/Immunizations
Carle’s Mobile Health Services (MHS) provides care to Illinois residents via 40-foot, wheel-chair accessible mobile vans. Each van offers comprehensive medical services for infants, children, and adults. The care provided by MHS includes chronic condition management and education; treatment of acute illness; physicals, wellness care, and assessments; school and sports physicals and immunizations; lab testing; and referrals and applications for social services. MHS widened their scope of services to increase access to health care for all amidst the pandemic.
MHS expanded offerings to two new school districts and increased the number of events to decrease student exclusion rates. The mobile health offering expanded service dates and locations of regular operations to reach more children who needed physicals and immunizations.
The intervention process:
- Partnered with two additional school districts and the community to provide immunization/physicals for children
- Created marketing materials in three different languages
- Added three new locations and increased hours of operation
- Partnered with two new school districts
- Held Back to School immunization/physical events with six school districts
- 526 COVID-19 vaccines administered between April - September 2021
- 430 patient visits from April- September 2021
- 562 students attended Back to School events in 2021
- 5 out of 6 schools districts reported an increase in student inclusion due to lack of physicals/immunizations
Children's Health: Immunization Locally Delivered Successfully (CHILDS)
Manassas Park City Schools (MPCS) is a school district located in Manassas Park, VA. Their student health and wellness program provide a variety of support services dedicated to assisting students so they will be able to thrive in an academic environment. They have an array of mental health services ranging from bullying and suicide prevention programs to community health resources that students can access throughout the school district.
The CHILDS Project was a collaboration with MPCS, Virginia Department of Health (VDH), Virginia Department of Education (VDOE), and George Mason University Mason, and Partners (GMU MAP) Clinic. The MPCS Community Liaison worked with MPCS School Nurses and the GMU MAP Clinic to identify and refer students for immunizations.
As a result of this intervention, a new school-based collaborative partnership formed and an onsite school vaccination program took place. The CHILDS Project Framework is now being used at the state level with school districts across the state, partnering with local health departments to provide school-based vaccination clinics.
- 90 students vaccinated on Mobile Vaccine Day
- 4 new educational and clinical partnerships formed in collaboration with CHILDS Project
- 1 onsite Mobile Vaccination Day
Partnering Medicine and Dentistry to Increase Vaccination and Well-Child Check (WCC) Rates in Children Ages 9-17
Denver Health (DH) Collective is a Federally Qualified Health Center (FQHC) with 11 community based primary care centers and six community based dental clinics. Denver Health serves the greater population of Denver, Colorado by providing hospital and emergency care to the public, regardless of a patient’s ability to pay.
The goal was to increase adolescent vaccination and well-child checkups through Medical Dental Integration (MDI). Medical Dental Integration educated and trained dentists on vaccines and notified patients via email and phone outreach to schedule well-child checks and vaccinations.
DH produced automated daily reports, so the dental staff could notify patients who had overdue vaccines while providing dental updates, allowing overdue patients to visit the primary care clinic, which is in the same building, in the same time window as their dental appointment, to increase likelihood of delivering the vaccination.
The intervention process:
- Educated and trained dentists on vaccines and vaccine hesitancy
- Produced automated daily reports of patients that were overdue on vaccines or well-child checks
- Notified patients of overdue vaccines at the time of visit and well-child checks via email to schedule appointments
- 122 patients received a vaccination due to MDI, this is a 5% increase from the 2,438 vaccines given in 2020 vaccinations when compared with the 2,560 vaccines given in 2021
Watch a video displaying this innovative intervention
The P-4 Well Child Project
Erie Family Health Centers (EFHC) serves high-need families and patients in the broader Chicago area by offering medical, oral, and behavioral health care for patients of all ages.
The goal was to increase both well-child visits and vaccination rates of children 0 to 2 years old.
EFHC implemented a comprehensive care approach by offering telehealth visits. EFHC provided tools to help families assess their unique health needs and match them to specialized service, such as case management for mothers with newborns. EFHC used phone outreach and pop-up reminders to alert parents and guardians about pediatric visits and upcoming vaccination dates.
The intervention process:
- Implemented telehealth visits to reduce barriers of care
- Provided tailored support and recommendations to address the unique health concerns of families
- Provided case management for mothers with newborns
- Contacted families whose children were overdue for vaccines via phone outreach
- Created pop-up reminders in EFHC’s Electronic Health Record System so providers could notify patients and families about upcoming vaccination dates
- 3,550 telehealth visits implemented
- 21,780 total visits
- 1,017 vaccinations given
Increasing Well Visit Rates Among Teens Living in Poverty
Fortify Children’s Health focuses on pediatric health care by serving children of Virginia through clinical statewide networks.
The intervention goal was to improve adolescent care through their HEDIS Adolescent Well Care (AWC) Program. Fortify chose to focus on adolescents living in poverty because of their increased risk of other health concerns. Fortify used a Peer-to-Peer Social Media Campaign by recruiting teen patients to create TikTok videos reminding peers to schedule well-visit appointments. Fortify engaged 43 practices to help doctors identify patients who had yet to receive a well-child visit.
Fortify used a variety of intervention methods to demonstrate a rate of improvement in Adolescent Well Care (AWC) performance.
The intervention process:
- Recruited teens to create original TikTok videos to remind peers to visit doctor’s offices for well-child visits
- Implemented a Peer-to-Peer Social Media Campaign
- Provided 43 practices with patient outreach sheets on a monthly basis to identify patients that are overdue for well-visits
- 1,220 more adolescent well-child visits given in 2021 than 2020
- 26.5% increase in well-child visits in 2021 compared with 2020
- 43 practices engaged to help doctors identify over-due patients
Promoting Pediatric Primary Prevention (P4) Challenge
Jefferson County Department of Health (JCDH) is a public health institution dedicated to investing resources, responding to needs, and empowering citizens and visitors of Jefferson County to attain their best health.
The intervention goal was to increase well-child visits and immunizations through JCDH’s “Back to School Clinic.” The “Back to School Clinic” enhanced access program for patients aged 0 to 18 years, who identified as overdue for service. The "Back to School Clinic" used partnerships with the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), Head Start, Maternal and Child Health (MCH) programs, Roundtables, dental offices, and social workers to evaluate and educate overdue patients while call center staff scheduled appointments for patients and used digital reminders for upcoming appointments.
The intervention process:
- Identified patients who are overdue for well-child visits and immunizations
- Engaged with patients and families through local partnerships
- Facilitated appointment scheduling via call center staff and digital reminders
Phreesia Software was used to digitally engage targeted patients before, during, and after their scheduled visit.
- 1,465 well-child and immunization exams administered
- 1,432 routine vaccine doses administered
- 30% increase in well-child visits and immunizations compared to FY2020
- 79% increase in child immunizations
- 87% increase in adolescent immunizations (11-12 years)
Improving Well-Child Visits and Immunizations and Social Determinants of Health in Pediatric Patients Impacted by COVID-19
Johns Hopkins Harriett Lane and Bayview Clinics serve minority populations in the East Baltimore Area. Harriett Lane serves minority and publicly insured families and patients. Bayview Clinics serves a majority population of Latino Americans.
The goal was to increase catch-up measles immunizations for children aged birth to 2 years, and increase well-visits of children aged birth to 15 months, specifically working with those children who are disabled and receive Supplemental Security Income (SSI).
Johns Hopkins increased access to well-visits and immunizations through phone and mail outreach to educate and arrange transportation services for families and patients. Johns Hopkins addressed barriers to healthcare by providing families and patients with dry food at clinic visits. They also covered transportation costs and baby supplies by partnering with local organizations such as Bayview Children’s Medical Practice, Maryland Food Bank, Share Baby, and Roundtrip Transportation Services.
The intervention process:
- Provided food, supplies, and transportation during each eligible patient visit
- Called patients who overlapped with outreach lists to reach SSI patients separately
- Messaged patients for measles vaccination reminders
- 66 patients aged 12 months to 3 years who were missing measles vaccines received their measles vaccine
Meharry Department of Pediatrics is located in Nashville, TN; the department works to address low immunization rates amongst children in the communities they serve. Low immunization rates have been attributed to COVID-19 clinic closures, slow tornado recovery, and limited incentive to get vaccinated due to school closures.
Meharry launched a two-fold initiative that consisted of the “No Baby Wet Behind Incentive” and a patient-centered smart phone app.
Meharry partnered with Nashville Diaper Connection to provide 50 diapers/pull-ups to families for each of the 10 routine Early Periodic Screening, Diagnosis, and Treatment (EPSDT) sessions completed. Patients could receive upwards of 500 diapers if they were compliant with routine care.
The intervention process:
- Distributed free diapers to families who completed EPSDT sessions
- Implemented a smartphone app to deliver physician messaging and provide immunizations and appointment reminders
- 13% increase in immunization rates
- 100% of families “loved” the free diapers incentive
KidsCARE: A Collaboration between MARC Head Start and Swope Health Services
Mid-America Regional Council Head Start (MARC HS) and Swope Health Services (Swope) collaborated under their shared commitment to support children’s health and school readiness via preventive and early intervention services. KidsCARE focuses on addressing health disparities by removing barriers to quality medical, behavioral, and dental health care for children. KidsCARE is dedicated to remaining a scalable and sustainable public health initiative.
KidsCARE is a family-centered approach designed to increase well-child visits and immunizations through a streamlined scheduling and reminder process, access to well-child visits and immunization services using a variety of methods and coordinated support services between MARC HS program staff and Swope. KidsCARE launched the “Come on Now!” Platform, an innovative software platform designed to promote two-way communication between providers and families.
The intervention included:
- Support with scheduling and appointment reminders
- Helped to establish cohesiveness between health and early learning programs to better support children and families
- 197 wellness care exams completed
- 308 dental exams completed
- “Come on Now!” Platform launched
Well Care and Immunization Novel Solutions/Improving Immunizations and Well Care Through School Health Roving Vaccine Clinics and a Primary Care Texting Initiative
Nationwide Children’s Hospital (Nationwide Children’s) is based in Columbus, Ohio. The hospital’s school health program serves over 3,000 unique patients, ages 3 to 20, via its 14 school-based health centers and two mobile units. Nationwide Children’s team operates under the “Whole Child Model” which includes primary care offices in schools, wheelchair clinics, COVID-19 support, as well as many other meaningful initiatives.
The goal was to implement roving vaccine clinics and a primary care texting initiative to improve immunization rates in their community.
Nationwide Children's implemented Roving Vaccine Clinics with simple logistical set-up and deployed to in-need locations which enabled growth potential by adding the COVID-19 vaccine to the service.
The roving vaccine clinics used flexible locations such as:
- Schools vestibule/parking lots
- Apartment complexes
- 25 Roving Vaccine Clinics (new service) completed
- 1,645 patients served for routine immunizations (excluding COVID-19 vaccine)
- 10% increase in overall patients served for vaccines and well-child checks compared to 2019-2020
Bringing Children Back to the Office: The Use of Technology and Child-care Programs to Promote Healthy Children
Neighborhood Health is dedicated to advancing health equity by providing high quality care regardless of a patient’s ability to pay. For the last 24 years, Neighborhood Health has been providing communities in Northern Virginia with accessible, comprehensive, and patient-centered primary care.
Neighborhood Health’s intervention was an integrated technology and child-care program implemented in collaboration with the organization’s two largest pediatric clinics. The two pediatric clinics serve a low-income and racially diverse patient population.
Neighborhood Health aimed to bring children back to the office using technology and child-care programs to promote healthy children.
The intervention process:
- Implemented a mass texting campaign
- Helped community partners access Direct Appointment Scheduling
- Provided transportation (free Lyft rides to and from appointments)
- Distributed a $20 VISA gift card incentive for a completed well-child check
- 9% increase of patients up to date on well-child checks
Northeast Valley Health Corporation Well-Child and Vaccination Program
Northeast Valley Health Corporation (NEVHC) is based in San Fernando, CA. NEVHC is committed to providing quality primary health care to medically underserved residents in Los Angeles County. Like most of the country, Los Angeles County saw a sharp decline in well-child exam (WCE) and immunization rates because of the COVID-19 pandemic.
NEVHC aimed to improve WCE rates for the food insecure. Patients who had screened positive for food insecurity within the past 24 months were sent a text message inviting them to food distribution events hosted by the CalFresh Healthy Living (CalFresh) team.
The process scheduled patients who are due for WCEs. Patients received live phone calls inviting them to the food distribution event. At the same time, they were reminded to schedule a WCE.
The CalFresh food distribution team physically handed printed copies of the appointments to patients when they attended the produce distribution event.
- 81.3% average improvement rate from 1/21 - 10/21 in attendance at WCE and vaccine uptake
The Design, Development, and Deployment of a Mobile-based Child Vaccination Program for Underserved Communities in Illinois Using Novel Digital Analytics, Artificial Intelligence Constructs, and Mobile-based Engagement Systems
Based in Illinois, OSF HealthCare is committed to making health care safer, more accessible, and more affordable. OSF HealthCare’s Innovation Design Lab’s work focuses on human-centered design and creating technology and tools for vulnerable populations.
The Innovation Design Lab team has developed a mobile vaccination program that provides free recommended vaccinations to medically underserved children in central Illinois.
OSF Healthcare deployed a solution to identify at-risk and vulnerable communities in both urban and rural Illinois. As part of this project, a regional map with zip-code level coloration representing the predicted under-immunization rates at various selectable time intervals was created.
Other key features of the intervention included:
- Deployment of a mobile Care-A-Van system
- Development of informational materials directed towards school-aged children and their parents
- Communication with community leaders to identify optimal dissemination locations and methods
- 82 vaccinations given at mobile clinics
- 201 well-child visits implemented
ZIPping Up Well-Child Care: A Mobile Solution to Equitable Access Peninsula Community Health Services
Peninsula Health Services (PCHS) is a Federally Qualified Health Center (FQHC) located in downtown Bremerton, WA.
Regardless of insurance status or one’s ability to pay, PCHS is committed to delivering comprehensive health care services to all patients.
PCHS used a mobile clinic for targeted pediatric care in zip codes where the clinic had higher numbers of patients who had not completed their well-child visit, sports physical, and/or adolescent well-visit checks.
Medicaid partners supplied well-child visit care gap reports and local schools promoted the mobile events.
- 77 doses of vaccine given
- 205 well-child visits implemented
WOW - Improving Access and Utilization of Well-Child Visits
PRIDE Community Services was founded in response to high unemployment in local coalfields. Their mission is to make a positive impact on the lives of those in need by bringing together educational, financial, and human resources that support self-sufficiency.
PRIDE Community Services deployed Well-Child On Wheels (WOW), a mobile care unit with events to coordinate physicals of children in need. To give additional families an opportunity to participate in the program and receive the additional incentive, the WOW program continued to offer the incentive for completed physicals, even after the WOW events were completed. This enabled WOW to collect additional completed physicals.
WOW events were held in collaboration with community partners including:
- Local healthcare providers
- Town police
- Fire departments
- Other organizations in Logan County, WV
By combining physicals with fun and engaging activities for children, WOW greatly increased the total number of completed children’s physicals.
- 93 well-child visits given
- 47% increase between 2020 and 2021 in completed physicals
Bundle Up Your Shots - Early Intervention and Collaboration
Vista Community Clinic (VCC) is committed to creating a caring experience while making sure children have everything they need to grow up healthy. Located in Vista, California, VCC is part of the larger Vista Community Health Clinic Network.
Team Pediatrics at VCC aimed to encourage patients and their parents to come in for a comprehensive well-child visit and receive routine immunizations.
The intervention process:
- Expanded access to Saturday and evening clinics
- Bundled vaccines at pre-teen visits, including early initiation of the HPV vaccine among pre-teens
- Integrated with other departments within the clinic including dentistry and optometry specialties
- 3,847 adolescent vaccines given (Tdap, MCV4, and HPV) from January - October 2021
- 13,764 well-child visits in all age groups (0-17 years) from January - October 2021
ULPS Frayser Community Clinics
UT Le Bonheur Pediatric Specialists (ULPS) is the region's only multispecialty pediatric practice solely focused on children's health care. ULPS is a partnership between The University of Tennessee Health Science Center (UTHSC) and Le Bonheur Children’s Hospital. ULPS General Pediatrics Clinic provides high quality patient care, education, research and advocacy.
ULPS General Pediatrics Clinic held seven community clinics at Impact Baptist Church in the North Memphis Frayser community. By partnering with a local church and community support organizations, the collaborative intervention provided an accessible space for clinics to be held in local community centers.
The community clinics aimed to close gaps in care for patients by conducting at least one hundred well-visits over the course of the project.
- 146 patients were scheduled for well visits and immunizations at 7 clinics
- 116 patients showed up for their appointment
- 115 well visits were performed
- 80 immunizations were given
Promoting Child Health to Children Receiving Foster Care Services
The University of Texas Health Science Center at San Antonio (UT Health San Antonio) is a leading academic health center with a mission to make lives better through excellence in advanced academics, life-saving research, and comprehensive clinical care. Their pediatric division is one of only two Foster Care Centers of Excellence in South Texas designated by Superior Health.
UT Health San Antonio began offering clinic services, mobile unit services, and telehealth services “after hours” to accommodate patients. Along with these, UT Health:
- Met with the Chief Medical Director of the Children’s Health Insurance Program (CHIP) and Medicaid to discuss the health needs of foster children
- Appeared on local news four times to promote back-to-school vaccinations
- Co-chaired a QI project with a Nursing Doctoral Student to improve patient portal access
- Sent vaccination and well-visit appointment reminders by text to patients with activated patient portals
Clinic Services at the Children’s Shelter:
- Adjusted hours according to the frequency of need
- Conducted pre-screening via telehealth to accommodate school and work
- Provided Home visits
Mobile Unit Services:
- Provided COVID-19 vaccinations for qualifying adolescents and foster families
- Provided Child and Adolescent Needs and Strengths (CANS) assessments
- Conducted pre-screening to reduce wait time in clinics
- Followed up on care and care coordination
- Provided mental health services
- 46 vaccinations completed after hours since 8/21
- 78 health fair vaccinations
- 78 high school (Youth @ Risk) vaccinations
- 28 well-child visits through outreach events
- 51 vaccines given through outreach events