Home visits: A new screening tool for frailty? A retrospective exploratory study.

Disability in older adults has become a significant burden, both individually and socially, due to the rapidly aging population in Korea. It is important to manage both frailty and chronic diseases to delay disability. Frailty, which is considered to be a transition phase between healthy status and disability, is defined as a significant decline in functional reserves of multiple organ systems and the resultant extreme vulnerability to stressors, leading to a higher risk of adverse health-related outcomes. The frailty phenotype and frailty index are the most commonly used methods to diagnose frailty. Frailty is related to physical, psychological, cognitive, and social dysfunction, and is sometimes caused by chronic disease. Therefore, primary care providers are ideally situated to incorporate the concept of frailty into their practice, as they are champions in comprehensive care. Although the identification and treatment of frailty is not yet standard practice in primary care, primary care physicians must use the electronic frailty index to identify frailty in all the patients aged ≥65 years in the United Kingdom. In Canada, some insurance companies and governments are using a similar program, which is called the Community Actions and Resources Empowering Seniors model. The clinical practice guidelines of the International Conference of Frailty and Sarcopenia Research, as well as some additional references, will be introduced. Here, we review the current literature on how to diagnose and manage frailty in primary care.

In 2004, the American Academy of Pediatrics (AAP) Board of Directors formed the Task Force on Mental Health and charged it with developing strategies to improve the quality of child and adolescent mental health* services in primary care. The task force acknowledged early in its deliberations that enhancing the mental health care that pediatricians and other primary care clinicians† provide to children and adolescents will require systemic interventions at the national, state, and community levels to improve the financing of mental health care and access to mental health specialty resources. Systemic strategies toward achieving these improvements are the subject of other publications of the task force: “ Strategies for System Change in Children's Mental Health: A Chapter Action Kit ” (chapter action kit),1 “Improving Mental Health Services in Primary Care: Reducing Administrative and Financial Barriers to Access and Collaboration,”2 and “Enhancing Pediatric Mental Health Care: Strategies for Preparing a Community.”3 The task force also recognized that enhanced mental health practice will require competencies not currently achieved by many primary care clinicians; in the policy statement “The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care,”4 the task force collaborated with the AAP Committee on Psychosocial Aspects of Child and Family Health to outline these competencies and propose strategies for achieving them. This report offers strategies for preparing the primary care practice itself for provision of enhanced mental health care services. The task force proposes incrementally applying chronic care principles to the care of children with mental health and substance abuse problems as primary care clinicians apply them to the care of children with chronic medical conditions such as asthma. Most primary care clinicians will find that significant gaps exist between their current practice and the proposed ideal. The task force offers guidance in … Address correspondence to Jane Meschan Foy, MD, Department of Pediatrics, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157. E-mail: jmfoy{at}wfubmc.edu

Objectives:Little is known about the views of key stakeholders on frailty in Primary Care in Ireland. The aim of this study was to explore the views of Irish healthcare professionals and patients on frailty and its management in Primary Care.Methods:A qualitative descriptive design was used. Seventeen healthcare professionals and three patients were recruited using purposive sampling. Data were collected using semi-structured interviews which were analysed thematically.Results:Three themes were identified: (i) Perceptions of Frailty (ii) Current Management of Frailty and (iii) Comprehensive Geriatric Assessment in Primary Care. The results demonstrated variability in perspectives on frailty. Healthcare professionals described a fragmented service often delivering substandard care to frail older patients. The general consensus was that frailty management required an adequately resourced Primary Care service. Support for frailty screening and Comprehensive Geriatric Assessment was evident while the suitability of the current pathway for patients requiring assessment was questioned.Conclusion:This study highlights an absence of a shared and complete understanding of frailty among healthcare professionals and a fragmented model of care for community-dwelling frail older patients. Based on these findings, inter-professional training, investment in Primary Care, the development of a frailty pathway and an interface service is recommended.

The rapid growth in genetics knowledge with a subsequent impact on the health of the population has and will continue to increase the demand for NHS clinical genetics services. It has been proposed that general practitioners (GPs) could manage patients at low genetic risk. However, GPs do not have either the knowledge level or the confidence unless support is provided. A primary care genetic counsellor-led clinical genetics service could potentially support GPs in appropriate referral and as emerging NHS policy is planning to shift some specialist services from secondary to primary care settings, would seem a suitable setting for patients, who are not ill, but seek genetic information. This cluster-randomised trial was designed to evaluate the impact of two genetic counsellor-led primary care interventions: education to improve GP referral rates, and clinics to improve the patient pathway. GPs in 73 general practices (clusters) were randomised to receive a case scenario based seminar (intervention) or not (control), and their referred patients to receive a primary (intervention) or secondary (control) care clinic appointment. Outcome measures included GP referral and clinic attendance rates (primary), appropriate cancer and case scenario referral rates, GP referral attitude, clinic waiting times, patient satisfaction, patient and NHS clinic costs and referral case management (secondary). GP overall referral rate was not significantly higher and there was no indication of difference in clinic attendance rates, between groups. GPs from educated practices made significantly more referrals of patients at moderate and high genetic risk, of developing cancer (P=0·035, RRR 2×36, 95% confidence interval 1·07 to 5·24). To attend a primary care clinic appointment cost patients £3·28 less (P=0·000; £3·60 v. 6·62, 95% confidence interval -£4·76 to -£1·79) and 19 minutes less travel time (P=0·000, 95% confidence interval -30·70 to -7·90) than those who attended a clinic appointment in secondary care. More non-cancer than cancer appointments achieved the NHS 13-week clinic waiting time target (P=0·000, 81% v. 19%). 62% of all GP referrals, and 80% of all cancer referrals were entirely managed by genetic counsellors within the 18-week NHS referral to treatment pathway target. This trial has demonstrated that genetic counsellors can 1) provide GP education and improve access to clinical genetics services for individuals at increased cancer genetic risk and, 2) manage both the majority of all patients referred by their GP and those referred with a cancer diagnosis, irrespective of referrer, in a clinic closer to their home than the secondary care clinic and with less patient cost.

e15642 Background: Frailty is a measure of physiologic reserve and is associated with adverse perioperative outcomes in patients with cancer. Existing surgical frailty measures, such as the 11-factor and 5-factor modified frailty index, may not be routinely utilized due to time constraints. Electronic Frailty Index (EFI) serves as an efficient and automated alternative. There is limited data for the use of EFI in assessment of post-operative healthcare utilization in patients with non-metastatic colon cancer. Methods: We performed a retrospective cohort study using VA administrative files from 2016 -2020 and VA Central Cancer Registry. EFI was calculated based on the Veterans Affairs-FI (VA-FI), a validated 31-item cumulative deficit FI, to define three groups: robust (≤ 0.1), prefrail (0.1 - 0.2), and frail ( > 0.2). Cox proportional hazard analyses were conducted to evaluate survival. Logistic regression analyses were performed to examine healthcare utilization. All models were adjusted for age, gender, race, stage, and Charlson Comorbidity Index. Confidence intervals (CI) were calculated as 95%. Results: Among 2,861 patients (median age 70.7 ± 9.1 years) with stage I – III colon cancer who underwent surgery, 42.5% were robust, 36.6% were prefrail, and 20.8% were frail. The cohort was comprised of stage I (32.9%), stage II (34.9%), and stage III (32.2%) cases. Prefrail patients were at increased odds of emergency room (ER)/urgent care (UC) use at one year (adjusted odds ratio [aOR] 1.41, CI 1.09 – 1.83) compared to robust patients. Frail patients had an increased odds of ER/UC visits at 30 days (aOR 1.95, CI 1.19 - 3.20), 60 days (aOR 2.18, CI 1.42 - 3.34), and one year (aOR 2.79, CI 2.06 - 3.78). Increased risk of death was found in prefrail (adjusted hazard ratio [aHR] 1.34; CI 1.12 - 1.59) and frail (aHR 2.38; CI 1.97 - 2.86) patients when compared to robust patients. Conclusions: EFI was significantly associated with higher ER/UC utilization among frail patients with colon cancer who received curative intent surgery, independent of stage. Pre-frail and frail patients had worse survival outcomes compared to robust patients. Further work is needed to develop EFI as a risk-stratification tool in curative intent patients with colon cancer prior to surgery.

To determine the influence of ethnicity, defined as foreign-born people, on consultation rates, admissions and prescriptions in out-patient care and primary health care. Prospective study of attenders at four different caregivers during seven consecutive weeks in 1988. Age-and sex-standardized relative risks and odds ratios with 95% confidence interval were calculated. A suburban area in Lund, a city located in the south of Sweden, with 28% foreign-born people. This population (N = 5085) made 1,348 consultations. Ethnic group and consultation rates of the local primary health care centre, the emergency department, hospital out-patient department, and private care, admissions to specialist care, prescriptions, and certified sick leave. Swedes made fewer age-and sex-standardized visits to the emergency department (RR = 0.69(0.48-0.99)) while the foreign-born people showed an opposite non-significant trend (RR = 1.37(0.95-1.99)). Latin Americans (RR = 1.60(1.02-2.51)) visited the local Primary Health Care centre in the residential area more than expected, while people born in Asia and Africa consulted the Primary Health Care centre less than expected (RR = 0.44(0.28-0.69)). There were no differences between Swedes and foreign-born people in being put on the sick-list, but foreign-born people were given significantly fewer prescriptions (RR = 0.07(0.03-0.19)) than Swedes. Foreign-born people, Latin Americans, and non-Swedish Scandinavians were referred significantly more often to hospital than other groups. There were important differences in consultations between Swedes and foreign-born people. It seems important to study these differences further to find out if they were due to morbidity or cultural differences in order to be able to meet the demands and needs of different ethnic groups.

<h3>Context:</h3> Home visits have become increasingly uncommon although evidence suggests they improve healthcare quality and reduce overall expenditures. <h3>Objective:</h3> This study identifies the number of physicians delivering home visits at patients’ end of life, describes characteristics of primary care physicians delivering end-of-life home visits, and explores associations with delivery. <h3>Study Design and Analysis:</h3> A retrospective cohort design with descriptive analysis of association between primary care physician characteristics and the propensity to deliver home visits to patients at the end of life. <h3>Setting or Dataset:</h3> Ontario, Canada using population-level health administrative data housed at ICES. <h3>Population Studied:</h3> Primary care physicians in Ontario, Canada between April 1, 2014-March 31, 2019, who were registered in the College of Physicians and Surgeons of Ontario database (CPSO) dataset on or after January 1, 1990 and as of March 31, 2016. <h3>Intervention/Instrument:</h3> Patients who were in their last year of life. <h3>Outcome Measures:</h3> Home visits delivered <h3>Results:</h3> A total of 9,884 physicians were identified, of which 2,568 (25.7%) delivered at least one end-of- life home visit. Physician characteristics showing increased odds ratio (OR) of home visit delivery were older age (OR 1.01 [95% Confidence Interval (CI): 1.00-1.02]) international training (OR 1.28 [95% CI:1.04-1.59]), previous home visit experience (OR 1.02 [95% CI: 1.01-1.02]), capitation models of remuneration; namely enhanced fee-for-service models (OR 1.5 [95%CI: 1.17-2.00]) and mainly capitation model (OR 1.4 [95% CI:1.11-1.79]), and population size of practice location with highest odds in small rural or remote areas (&lt;9,000 residents) (OR 1.38 [95%CI: 1.02-1.88]) and the largest metropolitan areas (OR 1.84 [95%CI: 1.46-2.57]). <h3>Conclusions:</h3> This research demonstrates primary care physicians’ characteristics influence home visit practice patterns. Furthermore, it highlights characteristics amenable to policy or system-level changes that could increase the provision of home visits. Increasing physician home services could greatly improve the dying experience of Canadians.

Characteristics of Family Physicians Delivering Home Visits: A Canadian Retrospective Cohort Study

The prevalence of hearing loss increases with age. Untreated hearing loss is associated with poorer communication abilities and negative health consequences, such as increased risk of dementia, increased odds of falling, and depression. Nonetheless, evidence is insufficient to support the benefits of universal hearing screening in asymptomatic older adults. The primary goal of the present study was to compare three hearing screening protocols that differed in their level of support by the primary care (PC) clinic and provider. The protocols varied in setting (in-clinic versus at-home screening) and in primary care provider (PCP) encouragement for hearing screening (yes versus no). We conducted a multisite, pragmatic clinical trial. A total of 660 adults aged 65 to 75 years; 64.1% female; 35.3% African American/Black completed the trial. Three hearing screening protocols were studied, with 220 patients enrolled in each protocol. All protocols included written educational materials about hearing loss and instructions on how to complete the self-administered telephone-based hearing screening but varied in the level of support provided in the clinic setting and by the provider. The protocols were as follows: (1) no provider encouragement to complete the hearing screening at home, (2) provider encouragement to complete the hearing screening at home, and (3) provider encouragement and clinical support to complete the hearing screening after the provider visit while in the clinic. Our primary outcome was the percentage of patients who completed the hearing screening within 60 days of a routine PC visit. Secondary outcomes following patient access of hearing healthcare were also considered and consisted of the percentage of patients who completed and failed the screening and who (1) scheduled, and (2) completed a diagnostic evaluation. For patients who completed the diagnostic evaluation, we also examined the percentage of those who received a hearing loss intervention plan by a hearing healthcare provider. All patients who had provider encouragement and support to complete the screening in the clinic completed the screening (100%) versus 26.8% with encouragement to complete the screening at home. For patients who were offered hearing screening at home, completion rates were similar regardless of provider encouragement (26.8% with encouragement versus 22.7% without encouragement); adjusted odds ratio of 1.25 (95% confidence interval 0.80-1.94). Regarding the secondary outcomes, roughly half (38.9-57.1% depending on group) of all patients who failed the hearing screening scheduled and completed a formal diagnostic evaluation. The percentage of patients who completed a diagnostic evaluation and received a hearing loss intervention plan was 35.0% to 50.0% depending on the group. Rates of a hearing loss intervention plan by audiologists ranged from 28.6% to 47.5% and were higher compared with those by otolaryngology providers, which ranged from 15.0% to 20.8% among the groups. The results of the pragmatic clinical trial showed that offering provider encouragement and screening facilities in the PC clinic led to a significantly higher rate of adherence with hearing screening associated with a single encounter. However, provider encouragement did not improve the significantly lower rate of adherence with home-based hearing screening.

370 Correlation Between the Electronic Frailty Index and Hospitalization Mortality in Older Adults Infected with SARS-CoV-2

Home visit is a modality of health care that is expanding in Brazil and in the world. Public and private services have invested in the implementation of this type of assistance. It happens due to its potential to transform the model of care, highlighting the work quality of the primary health care teams. To analyze house call rates in primary care in the Brazilian public healthcare system according to professional categories and health macro-regions in the state of Minas Gerais, southeast region of Brazil. An ecological study that used as the information source the production data from the Primary Care Information System (2010 to 2015). House call rates (per 3000 inhabitants) by primary care professionals constituted the response variable. The independent variables were professional categories and the 13 health macro-regions of the state. The data were analyzed using the Mann-Whitney test. A total of 26,932,463 house calls were performed in the period, but the number of visits in 2015 was significantly lower compared to 2010. Significantly higher house call rates were found for some professional categories (mid-level professionals and nurses) and significant differences were found among the macro-regions (P < 0.05). The profile of house calls by primary care professionals revealed the constant presence of this care modality, but the distribution of these visits is uneven among the different professional categories and macro-regions of the state.

Medical claims are widely used in workforce estimation and health services research but identifying primary care (PC) clinicians is challenging. Existing methods relying on specialty or activity-based metrics are imprecise and hard to duplicate. We seek to develop a simple, accurate decision tree classifier using claims data, trained on survey responses from family physicians (FPs). And to use this classifier to estimate the PC workforce in Virginia. We linked 2016-2023 Virginia All-Payer Claims Database (APCD) data with responses from American Board of Family Medicine surveys to infer whether FPs provided PC. Using claims-derived features, we trained a decision tree to classify clinicians providing PC. We developed an enhanced version of the tree, adding exclusion criteria, and applied both classifiers to the entire APCD, including other PC clinician types. Virginia clinicians. Estimated classifier accuracy by clinician type and workforce estimates with bootstrapping used to estimate 95% confidence intervals. The base decision tree correctly classified 93% of the training sample using three clinician-level features: percent of claims with diagnosis category of Z00, percent with place of service 19-23 or 31-32, and percent of patients having multiple visits with the clinician. We estimate the enhanced tree achieved at least 89% accuracy for every clinician type. We found that from 2016 to 2023, the percentage of Virginia PC clinicians who were nurse practitioners (NPs) grew from 17 to 32%, with NPs passing FPs as the most common PC clinician type. This decision tree approach overcomes shortcomings of existing methods and offers a straightforward, scalable, interpretable tool for classifying PC clinicians, with applications in workforce planning and health services research.

BackgroundThailand’s hospitals may adopt different supervision approaches to improve tuberculosis (TB) treatment adherence.ObjectiveThe aim of this study was to compare out-of-pocket (OOP) expenditures, indirect costs, and health-related quality of life (HRQoL) among TB patients who received pharmaceutical care (pharmacist-led patient education and telephone consultation), home visit, and self-administered therapy (SAT) in Thailand.MethodsWe conducted a prospective study to collect OOP expenditures, indirect costs, and HRQoL from a subsample of 104 adult pulmonary TB patients who started treatment between January and May 2014 in three hospitals. The three sources of data included patient interviews, patient medical records, and the hospital billing database. Patients were followed from January 2014 to March 2015. Relevant OOP expenditures collected during the interviews included (1) healthcare costs and other medications costs (e.g. vitamins, antibiotics, anti-cough) occurring in private healthcare units; and (2) costs of transportation, food, and accommodation. Productivity loss was measured using the self-reported amount of time a patient was unable to work due to TB, travel time to and from the hospital, time spent at the hospital (waiting time, consultation time, and hospitalizations), and time spent accompanying family members on outpatient visits or during hospitalizations. Cost differences among treatment strategies were adjusted for baseline characteristics by generalized linear models (GLMs). All costs were converted to international dollars (I$).ResultsA total of 256 eligible patients who started pulmonary TB treatment during the specified period were approached, with 104 patients being included in the analysis (29, 38, and 37 patients receiving pharmaceutical care, home visit, and SAT, respectively). Mean OOP expenditures per patient receiving pharmaceutical care, home visit, and SAT were I$907.56 [confidence interval (CI) I$603.80–I$1269.41], I$148.47 (CI I$109.49–I$194.89), and I$95.35 (CI I$69.11–I$129.63), respectively. The GLM indicated statistically significantly lower OOP expenditures for patients receiving either home visit or SAT (ratio of mean costs 0.247, CI 0.142–0.427; and 0.318, CI 0.187–0.540, respectively) than those receiving pharmaceutical care. Patient’s indirect costs for receiving pharmaceutical care, home visit, and SAT were I$1925.68 (CI I$922.06–I$3284.94), I$2393.66 (CI I$1435.01–I$3501.98), and I$833.33 (CI I$453.87–I$1263.45), respectively. The GLM found no statistically significant differences in indirect costs for the home visit and SAT groups (ratio of mean costs 1.904, CI 0.754–4.802; and 0.792, CI 0.289–2.175, respectively) when pharmaceutical care was set as the reference. Mean utility scores [EuroQol five-dimensional three-level (EQ-5D-3L)] at baseline and treatment end were 0.679 and 0.830, 0.713 and 0.905, and 0.708 and 0.913 for patients receiving pharmaceutical care, home visit, and SAT, respectively.ConclusionPharmaceutical care patients experienced the highest OOP expenditures, compared with home visit and SAT patients. Home-visit patients reached the highest indirect costs and utility score improvements. A large-scale prospective study is required in order to strengthen evidence to support policy making regarding the most efficient use of limited resources for the management of TB.Electronic supplementary materialThe online version of this article (doi:10.1007/s41669-017-0057-9) contains supplementary material, which is available to authorized users.

BackgroundFrailty is a state of increased vulnerability from physical, social, and cognitive factors resulting in greater risk of negative health-related outcomes and increased healthcare expenditure. A 36-factor electronic frailty index (eFI) developed in the United Kingdom calculates frailty scores using electronic medical record data. There is currently no standardization of frailty screening in Canadian primary care. In order to implement the eFI in a Canadian context, adaptation of the tool is necessary because frailty is represented by different clinical terminologies in the UK and Canada. In considering the promise of implementing an eFI in British Columbia, Canada, we first looked at the content validation of the 36-factor eFI. Our research question was: Does the eFI represent frailty from the perspectives of primary care clinicians and older adults in British Columbia?MethodsA modified Delphi using three rounds of questionnaires with a panel of 23 experts (five family physicians, five nurse practitioners, five nurses, four allied health professionals, four older adults) reviewed and provided feedback on the 36-factor eFI. These professional groups were chosen because they closely work as interprofessional teams within primary care settings with older adults. Older adults provide real life context and experiences. Questionnaires involved rating the importance of each frailty factor on a 0–10 scale and providing rationale for ratings. Panelists were also given the opportunity to suggest additional factors that ought to be included in the screening tool. Suggested factors were similarly rated in two Delphi rounds.ResultsThirty-three of the 36 eFI factors achieved consensus (> 80% of panelists provided a rating of ≥ 8). Factors that did not achieve consensus were hypertension, thyroid disorder and peptic ulcer. These factors were perceived as easily treatable or manageable and/or not considered reflective of frailty on their own. Additional factors suggested by panelists that achieved consensus included: cancer, challenges to healthcare access, chronic pain, communication challenges, fecal incontinence, food insecurity, liver failure/cirrhosis, mental health challenges, medication noncompliance, poverty/financial difficulties, race/ethnic disparity, sedentary/low activity levels, and substance use/misuse. There was a 100% retention rate in each of the three Delphi rounds.Conclusions and next stepsThree key findings emerged from this study: the conceptualization of frailty varied across participants, identification of frailty in community/primary care remains challenging, and social determinants of health affect clinicians’ assessments and perceptions of frailty status. This study will inform the next phase of a broader mixed-method sequential study to build a frailty screening tool that could ultimately become a standard of practice for frailty screening in Canadian primary care. Early detection of frailty can help tailor decision making, frame discussions about goals of care, prevent advancement on the frailty trajectory, and ultimately decrease health expenditures, leading to improved patient and system level outcomes.

Major changes in medical care challenge health care professionals to discover new ways to address health needs in primary care and prevention (Berkman, 1996). Replacing fragmented systems with coordinated networks of care is one of the greatest challenges. Ensuring that underserved and vulnerable populations have access to comprehensive care is another. Both call for the development of creative partnerships among traditional health care providers, social services professionals, and members of the community. Building and participating in partnerships will require retooling for many professionals. MODELS THAT WORK Recognizing the urgent need for partnerships, the Human Resources and Services Administration's (HRSA, 1996) Bureau of Primary Health Care in the U.S. Department of Health and Human Services is leading a partnership of 36 national foundations, associations, and nonprofit organizations in a Models That Work campaign. The campaign seeks to increase access to primary and preventive health care for underserved and vulnerable populations by encouraging communities to establish comprehensive primary health care programs that are creative, responsive to the community, and transferable to other communities. The following six examples are partnerships that communities have developed to achieve these objectives in a variety of settings. First, the partnerships involve community members in the design and delivery of services. The Cure/Heart, Body and Soul program in Baltimore uses trained neighborhood health workers to carry out prevention efforts in urban African American communities. Workers complement traditional systems of primary care by providing preventive screening, health education, referral, follow-up, advocacy, and community organization. Similarly, the Camp Health Aide Program in Michigan enlists migrant farmworkers to provide culturally appropriate health education, advocacy, outreach, referral, and follow-up services. The Community Health Advisor program in Mississippi uses trained natural helpers who live and work in rural communities to provide health information and advice; organize self-help action projects; and connect neighbors, families, and friends to needed services. This program has reduced infant mortality in one county by 16 percent. Second, the partnerships identify people at risk for health problems during crisis events. In a poverty-stricken neighborhood of St. Paul, Minnesota, HouseCalls identifies families at risk of homelessness through referrals from housing inspectors, outreach workers, and traditional service providers. A staff social worker and the family develop a crisis intervention plan to identify housing priorities as well as health needs related to inadequate prenatal care, delayed immunizations, and overdue well-child checks. Home visits, transportation, and other support services are provided to facilitate access to housing and health services. The Adolescent Community Services project in Binghamton, New York, provides reproductive health services, health education, counseling, and transitional housing supports to pregnant, parenting, and high-risk adolescents and their families. Intervention during this crisis-prone stage of life reduces teenage pregnancy rates, lowers foster care placements, and increases high school completion rates. Third, the partnerships reach out to people by providing coordinated health services in accessible community sites or in the homes of families. For example, Enloe Hospital in Chico, California, offers a wide array of health and social services at a community center for migrant farmworkers and their families. This approach decreases pediatric visits to emergency rooms by increasing access to primary and preventive care. In the Arkansas Delta Community Integrated Service System, a family care coordination team uses a home-visiting model to improve access to services, pregnancy outcomes, and infant health in rural areas. …