The present study was developed because socially disadvantaged children in North Carolina suffer some of the worst health outcomes in the United States. Although improving access to care is the number one priority of the American Academy of Pediatrics and the Institute of Medicine, the combination of services which will best achieve this goal is unclear. We propose to develop and test the feasibility of combined home and office- based interventions to improve access to care and health outcomes of Medicaid-eligible infants in North Carolina. The pilot study will involve 120 Medicaid-eligible pregnant women, their babies and 4 pediatric and family practices in Guilford and Robeson Counties, North Carolina. Women will be randomly assigned to one of three groups: a coordinated home visitation/office intervention (HV/OI) group; an office intervention group (OI); and a usual care group. The home- visiting intervention will be coordinated with the local health department and with Medicaid. The intervention will be adapted from a structured curriculum, developed by Drs. David Olds and Harriett Kitzman, which focuses on parental education about psychosocial and environmental effects on the health and development of infants, the enhancement of social support and the linkage of families with needed community resources. The OI intervention will include three components: (1) implementation of a system which involves the entire office staff as a team to enhance the capacity of the practice to provide continuity of care and preventive care to disadvantaged patients; (2) instruction for office staff in the use of a simple prompting system to encourage performance of preventive measures (such as immunizations and screening) during acute care visits; (3) office- based training to help the physicians' office staff bill effectively for Medicaid patients. For families in the HV/OI group, the nurse will coordinate her activities with those of the practice. The proposed study will address the feasibility of the interventions, enrollment and randomization, and data collection. We will assess the feasibility of the project by determining if the home visitation program can be successfully implemented, if the practices will adopt and continue to use the office interventions, if study participation is acceptable to potentially eligible women, and if we can measure health outcomes with reliability and validity. If the feasibility study proves to be successful, we hope to be in a position to test the effectiveness of integrated office-based prevention and continuity of care and home visiting in a randomized trial.
