November 2020

In Memoriam: Calvin CJ Sia, MD, FAAP

The American Academy of Pediatrics remembers the Grandfather of Medical Home, Cal Sia, MD, FAAP.
Dr. Sia, instrumental in the development of the family-centered medical home and Emergency Medical Services for Children Program, died August 19, 2020, in Honolulu at the age of 93. It was Dr. Sia who said, “Every child and youth deserves a medical home." His advocacy spanned a range of pediatric areas, including children with disabilities, emergency services for children, child abuse prevention and early periodic screening, diagnosis, and treatment standards.
Throughout his career, he received numerous honors, including the Barbara Starfield Primary Care Leadership Award from the Patient-Centered Primary Care Collaborative (2015), Clifford G. Grulee Award (2001), Job Lewis Smith Award in Community Pediatrics (2001), AMA Benjamin Rush Award (1998), the first Emergency Medical Service for Children National Heroes Lifetime Achievement Award (1998) and the AMA/AAP Abraham Jacobi Award (1992). In 2005, the AAP Council on Community Pediatrics established the Calvin C.J. Sia Community Pediatrics Medical Home Leadership and Advocacy Award. He was a member of the Council on Community Pediatrics, Section on International Child Health, and Section on Emergency Medicine within the AAP.
For more information on medical home and family-centered care, visit the National Resource Center for Patient/Family-Centered Medical Home.

Implementation Resources from the National Resource Center for Patient/Family-Centered Medical Home

Social Determinants of Health: Action Learning Collaborative
The Action Learning Collaborative (ALC) was an 8-month quality improvement project developed by the National Resource Center for Patient/Family-Centered Medical Home to highlight collaborations between state agencies and clinical practices. The goal of the ALC was for teams to work collaboratively to advance patient/family-centered medical home by strengthening state partnerships, increasing screenings for social determinants of health (SDoH), increasing referrals and linkages to local and community resources after positive screenings for SDoH are identified, identifying protective factors for social/emotional health in partnership with families, and increasing access to a patient/family-centered medical home. Participating teams collectively achieved the project objectives,
including: increase in the number of patients screened for SDoH by 52%, and increase in referrals to community resources for positive SDoH screens by 57%. Tools and resources developed for the ALC include an interactive Change Package which lists countless resources to support SDoH implementation at the clinical, community, and state level. Each resource listed in the Excel page is hyperlinked and free to access or download. During the action period of the project, faculty presented on various topics related to SDoH screening, referral, and follow up. Virtual presentations are available to download.
Advancing Systems of Services for CYSHCN Network
The American Academy of Pediatrics is joined by Catalyst Center (Boston University) and Got Transition (The National Alliance to Advance Adolescent Health) to form a national network of technical assistance resource centers, Advancing Systems of Services for Children and Youth with Special Health Care Needs (CYSHCN) Network (Network). In collaboration with the Maternal and Child Health Bureau these technical assistant centers develop
shared goals and activities to address three main areas to improve outcomes for CYSHCN and their families: health care financing, transitions, and patient/family-centered medical home. In response to the COVID-19 pandemic, the Network has brought together CYSHCN program directors to discuss various topics related to the COVID-19 response for CYSHCN and their families including Emergency Preparedness, Title V/Medicaid Partnership, Racial Equity, School Reopening, and Behavioral Health. Resources and notes from these discussions are now available.
Educational Webinar Series
The National Resource Center for Patient/Family-Centered Medical Home, in partnership with Bright Futures National Center and the Screening Technical Assistance and Resource (STAR) Center, implemented an educational webinar series titled Making Connections: The Critical Role of Family-Centered Care in Addressing Social Determinants of Health for Children and Youth with Special Health Care Needs (CYSHCN). The goal of this 2-part webinar series was to provide state Title V Maternal and Child Health (MCH)/CYSHCN programs, pediatricians, families, and others with information about the impact of social determinants of health (SDoH) on CYSHCN and their families as well as implementation strategies for state programs. The series discussed the role of these groups and state systems in addressing SDoH for CYSHCN by using components of the medical home model. The first webinar in this series provided relevant background information about how CYSHCN are impacted by SDoH, including a review of current data. The second webinar featured 2 state Title V MCH/CYSHCN programs that discussed how their states are addressing SDoH for CYSHCN.
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Additional Implementation Resources

Seize the Moment to Increase your Epilepsy Awareness!
Collaborate, find support, and learn with colleagues - The National Coordinating Center for Epilepsy is launching a quality improvement (QI) collaborative, AAP Epilepsy Management ECHO. The ECHO (Extension for Community Healthcare Outcomes) model^TM is a telementoring program designed to create communities of learners by bringing together health care providers and experts in topical areas using didactic and case‐based presentations, fostering an “all learn, all teach” approach. The AAP Epilepsy Management ECHO will build a bi-directional virtual knowledge network whereby participants from the primary pediatric practices will learn from experts and each other, gaining access to evidence-based and capacity-building resources to improve the access to quality care for children and youth with epilepsy. Using the American Academy of Neurology (AAN) measure set for epilepsy as the framework, the ECHO program aims to use established QI methodology to improve:
The AAP project team is seeking up to 20 primary pediatric practices to participate in this 9-month QI collaborative starting December 2020. The ECHO sessions are conducted monthly for 1 hour combining both a brief lecture presentation and de-identified, in-depth practice-based cases in the format of PDSA cycles for discussion, problem-solving and guidance.

Please be mindful of these important dates:
If interested, click here to apply by November 23, 2020. For more information, visit the AAP Project ECHO website.
New Bright Futures Implementation Tip Sheets
The Tips to Link Your Practice to Community Resources clinical implementation tip sheet has been updated. Visit the Clinical Practice page on the Bright Futures website to view the complete collection of tip sheets, including 2 new tip sheets listed below. These handy tip sheets offer practical advice to help you integrate the Bright Futures approach, tools, and resources into your daily practice.

Promoting Oral Health
Promoting Healthy Weight

Bright Futures Parent and Patient Education
Find easy-to-access, web-based educational handouts for parents, caregivers, and patients related to each well-child visit from birth through age 21. The anticipatory guidance is consistent with the Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th Edition. This guidance is organized by age and stage: Infancy, Early Childhood, Middle Childhood, and Adolescence (available in both English and Spanish). The Parent and Patient Educational Handouts are now available.
NEW! Resources from the AAP Early Hearing Detection and Intervention Program
The Early Hearing Detection and Intervention (EHDI)/Bright Futures Implementation Tip Sheet provide checklists and screening algorithms for the birth to 6-month period to ensure that screening, surveillance, referral, and intervention can occur at appropriate times for optimal development. Use the EHDI Literature Review Table to find articles focused on the role of the primary care pediatrician in addressing EHDI within the medical home model, a focus on EHDI systems of care, as well as articles focused on advancing health equity. This literature review table outlines recent data, and seminal literature pertaining to EHDI, specifically for the field of pediatrics.

Partners and National Initiatives

Technical Assistance Available from the AAP Distant Care Project
As part of the “Supporting Providers and Families to Access Telehealth and Distant Care Services for Pediatric Care" project, the American Academy of Pediatrics (AAP) is offering free technical assistance to pediatric health professionals on the following topics:
Technical assistance services may include connection to tools and resources and subject matter experts. Email distantcare@aap.org if you have a technical assistance request(s). Please note, the AAP does not endorse or support the use of any specific telehealth technology and does not provide technical assistance on the use of any one specific telehealth technology.

We want to hear from you! The Maternal Child Health Bureau (MCHB) is seeking public input on A Blueprint for Change: Guiding Principles for Advancing the System of Services for Children and Youth with Special Health Care Needs (CYSHCN) and Families (Blueprint).
In the fall of 2019, MCHB began working with a small group of CYSHCN experts and families to reexamine systems of care for CYSHCN and to identify priorities and opportunities that can advance those systems and improve outcomes. The result is a draft Blueprint that can inform programs and policy at the community, state, and federal levels.

MCHB invites you to review the draft Blueprint and provide input on how this work can be operationalized at the community, state, and federal levels in four key areas:
Please submit comments via email to CYSHCN@hrsa.gov and reference "CYSHCN Blueprint RFI" in the subject line. Deadline to respond is Monday, November 30, 2020 by 11:59 p.m. Eastern Time.

Please note that: Responses to this Request for Information (RFI) may be made publicly available; do not include any proprietary or confidential information. HRSA/MCHB will not respond to any individual comments, except to clarify written responses. HRSA also will not respond to questions about potential policy issues related to this RFI.
Six Core Elements of Health Care Transition™ and Revamped Got Transition Website
Got Transition®, the federally funded national resource center on health care transition (HCT), has developed new and improved tools, resources, and a revamped website for clinicians, youth/young adults, and parents/ caregivers to assist youth and young adults (with and without special health care needs) as they move from a pediatric to an adult-centered model of health care.

After extensive review and input from clinicians, youth/ young adults, and family HCT experts, Got Transition has updated the Six Core Elements of Health Care Transition™ 3.0, which define the basic components of HCT support and are intended for use by pediatric, family medicine, med-peds, and internal medicine practices. The three packages are aligned with the 2018 AAP/AAFP/ACP Clinical Report on Health Care Transition and are available for these scenarios:
As part of these updated materials, Got Transition has revised its measurement tools for each package. The Six Core Elements 3.0 materials are all available in Spanish, and customizable sample tools from each package are available in English and Spanish.

To help practices transform their HCT processes, Got Transition has also developed new practical step-by-step Implementation Guides dedicated to each core element. Got Transition recommends a quality improvement (QI) approach to incrementally incorporate the tools as a standard part of care, and these guides offer real world examples from practices utilizing the Six Core Elements. Got Transition offers background information on how to use the Implementation Guides, as well as a Quality Improvement Primer for those unfamiliar with the QI processes. Guides and information are available at www.GotTransition.org/Implementation.

Got Transition has also revamped its website to offer an interactive experience to clinicians, youth/young adults, parent/caregivers, and researchers/policymakers. The revamped site includes new toolkits, online quizzes, one-pagers, Six Core Elements samples, and other HCT-related resources and information.

Patient-Centered Primary Care Collaborative (PCC): Online Congressional Briefing
The PCC is a national stakeholder organization focused on improving primary care through increased implementation of the patient-centered medical home. On October 7, 2020, the American Academy of Family Physicians, the American Academy of Pediatrics, and the American College of Physicians (all Executive Members of the PCC) held an online congressional briefing titled Primary Care in Crisis: How Congress Can Support Patients and Practices During and After COVID-19. The briefing included frontline primary care physicians speaking about their experiences and challenges in meeting their patients' needs during the COVID-19 pandemic, a patient's perspective on the importance of primary care to their family's health, and how Congress can support primary care in 2020 and beyond. View the recording of the briefing here.

Patient Centered Outcomes Research Institute (PCORI) Virtual Annual Meeting
This national research institute awards projects working to develop tools and techniques for improving patient-centered care and decision-making and serves a national leader in advancing patient-centeredness throughout the clinical research enterprise and comparative clinical effectiveness research. Their 6th annual meeting was held on September 16-17, 2020 to address several topics of critical importance for health and healthcare including: health and healthcare disparities and inequities, maternal health, child and adolescent health, disabilities, and telehealth. Recordings of the entire program are available on demand.
The Healthy Tomorrows Partnership for Children Program
The Healthy Tomorrows Partnership for Children Program is a collaboration between AAP and the Maternal Child Health Bureau (MCHB). MCHB provides funding to support innovative, community-based initiatives that focus on improving the health status of infants, children, adolescents, and families in rural and other underserved communities by increasing their access to preventive care and services. The story below highlights one grantee’s innovative project to reduce obesity and strengthen self-efficacy among adolescents.

The B'N Fit Power Program in the Bronx: A Story of Youth Empowerment

Where can we find models for overcoming the conditions that lead to obesity in adolescents? How do we address health disparities among adolescents in low-income minority communities? And then how can we adapt and innovate during the pandemic? Your team might find inspiration from the B'N Fit POWER program in New York City's Bronx neighborhood. B'N Fit stands for Bronx Nutrition and Fitness Initiative for Teens.

Dr. Jessica Rieder leads this initiative that was created 15 years ago by the Division of Adolescent Medicine at Children's Hospital at Montefiore and the Mosholu Montefiore Community Center (MMCC). Dr. Rieder explains, “This program has been able to evolve, thanks to MCHB funding. One of the critical things we have learned from our kids is that we have to make this program available not just to teens with severe weight issues, but to a wider group of teens so that we destigmatize obesity as well as integrate healthy eating and lifestyle into the overall culture."

B'N Fit POWER's mission is to teach teens how to adopt healthy lifelong nutritional and physical activities. They do this using a hybrid approach. The program integrates holistic evaluation and treatment plans (medical, nutritional, and psychosocial) at a School-Based Health Center with nutrition and physical activity education in an afterschool program setting. The project decreased the rate of weight gain and changed behaviors in adolescents.

As the program continues to evolve through 2020 MCHB funding, the next steps will integrate 7 Target Behavior messages central to the project's mission into all clinical encounters and the school and afterschool environment to promote a culture of health and wellness. The 7 Target behaviors include: 1) eating three meals daily, 2) eating at least 3 servings of vegetables daily, 3) eating 2-3 servings of fruits daily, 4) drinking at least 8 cups of water a day and limiting sugary drinks to no more than one cup a day, 5) getting at least an hour of physical activity daily, 6) sleeping at least 8 hours a night, and 7) limiting fast food and processed snack food to no more than once a week. Target behavior promotion will be incorporated into electronic medical record documentation. Promotional messages will be channeled via posters and wellness-promoting events at the school. The program will also incorporate a service-learning internship that supports adopting those targeted behaviors.

When the pandemic hit, the leadership team transformed its in-person programs to virtual events. These included collaborations between DJ Dance parties (co-hosted by Hot 97, a local radio station), MMCC, J Train, a fitness and wellness business, and a national non-profit organization Wellness in the Schools, and they—struck a chord with the youth participants. “It was brilliant," says Dr. Rieder. “The DJ shared our messages, encouraging kids to dance, move, and eat nutritious snacks. And the kids really soaked it up. Just by offering the party, we modeled the behaviors and provided an opportunity to adopt them. There were even prizes for best dance moves." The 55 kids at the first dance party in June fueled our enthusiasm to host monthly DJ Dance parties throughout the summer.

“Over the years, we have had over 1000 participants and my favorite moments have been when youth tell me how their confidence has blossomed as a result of participating in B'N Fit POWER. They will tell me that they feel more energetic and confident, their mood has improved, they joined a club, sport or dance program, or they have made new friends," notes Dr. Rieder. To learn more about Healthy Tomorrows Partnership for Children Program and how it might support your local initiative, please email MCHB program officers Madhavi Reddy or Kelly Dawson. To learn more about B'N Fit, visit their
website.