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Pediatr Qual Saf
Pediatr Qual Saf
PQS
Pediatric Quality & Safety
2472-0054
Lippincott Williams & Wilkins Hagerstown, MD

PQS-D-24-00069
00008
10.1097/pq9.0000000000000768
3
Multi-institutional collaborative and QI network research
Integrating Emotional Health Assessments into Pediatric Care: Initial Learnings from an MOC Part 4 Activity
Lannon Carole M. MD, MPH *†‡
Schuler Christine L. MD, MPH ‡§
Thomas LaCrecia RN, MSN, CPNP-AC/PC *
Gehring Emily MPH *
Mann Keith J. MD †
Leslie Laurel K. MD, MPH †
From the * James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
† American Board of Pediatrics, Chapel Hill, NC (CML as Senior Quality Advisor)
‡ Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
§ Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.
*Corresponding author. Address: Carole Lannon, MD, MPH, James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 27599, PH: 513-803-7120; Fax: 513-803-1610 Email: Carole.Lannon@cchmc.org
Sep-Oct 2024
18 9 2024
9 5 e76825 6 2024
23 8 2024
Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Introduction:

Living with a chronic condition often impacts the emotional health of children. Pediatricians frequently feel unprepared to address these concerns. The American Board of Pediatrics Roadmap Project aims to support these clinicians. We describe the results from the initial cohort of pediatricians who completed the American Board of Pediatrics Maintenance of Certification (MOC) Roadmap Part 4 activity.

Methods:

The Roadmap MOC activity uses a standardized improvement template with accompanying resources to guide participants. Physicians self-assess their ability to provide emotional health support by completing a Roadmap Readiness Checklist and creating a personal project relevant to their practice. They collect data at three time points: baseline, midpoint, and completion for two measures (the Readiness Checklist and a participant-selected measure). Physicians also reflect on their experience.

Results:

Of the initial cohort of 29 physicians, 22 submitted three sequential checklist assessments. Scores increased for “developing a family resource list” (by 90%), “confidence to address emotional health” (79%), “having a family crisis plan” (78%), and “staff awareness” (34%). Twenty-four physicians who measured whether clinical encounters addressed emotional health documented an increase from 21% to 77%. Physician feedback was positive, for example, “This project has had a profound impact on our care of children.”

Conclusions:

This initial cohort of participants improved on the Readiness Checklist and emotional health assessment. Both generalist and subspecialty pediatricians found the activity useful and relevant, suggesting that this MOC Part 4 activity is a feasible resource for supporting physicians in addressing emotional health.

American Board of Pediatrics FoundationCarole LannonDavid R Clare and Margaret C Clare FoundationCarole LannonOPEN-ACCESSTRUE
SDCT
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pmcINTRODUCTION

Navigating a chronic condition is emotionally challenging for children, adolescents, young adults (hereafter “children”), and their families. Chronic conditions are taxing for patients and families, coping is difficult, and the stresses of chronic conditions may have lasting, detrimental effects on child and family emotional health.1–5 Published studies have reported anxiety and depression in as many as one in five children with a variety of chronic health conditions and in their parents.6–11 Addressing emotional health is essential to care for all children and their families, including those with chronic conditions. Yet, pediatricians consistently report they lack training in recognizing and treating mental health problems.12–14 Only 20% of almost 4,000 graduating pediatric subspecialty fellows recently surveyed indicated that they felt competent to address patients’ mental health needs.13

As part of the American Board of Pediatrics (ABP) strategic priority on child mental health, the ABP Foundation has supported various projects.15 One of these efforts, the Roadmap Project, assists generalist and subspecialist pediatricians in supporting the emotional health of children with chronic conditions. The Roadmap Project was inspired by and co-designed with young adult patients and parents of children with chronic conditions.16 Roadmap aims to ensure that the emotional health of children with chronic conditions and their families is addressed as part of the care provided at routine health visits. (www.roadmapforemotionalhealth.org).

Through collaborative efforts of patients, families, clinicians, psychologists, and quality improvement (QI) experts, the project developed a toolkit with strategies and resources to support clinicians in addressing emotional health.17 The Roadmap framework and toolkit were next tested in a pilot learning collaborative of 11 teams from nine children’s hospitals using QI methods [eg, specifying the problem, developing the aim, identifying measures, using plan-do-study-act (PDSA) cycles]. Clinical teams from various pediatric subspecialties,18 in inpatient and outpatient settings and in training programs, applied the toolkit in their respective practices to test how to address patient and family emotional health needs better.

After these efforts, the Roadmap team developed and launched an ABP Part 4 Maintenance of Certification (MOC) activity. Board-certified pediatricians must participate in QI activities, also called MOC Part 4, as part of continuing certification.19 This MOC activity used a specific component of the Roadmap toolkit, the Readiness Checklist, which assesses physician and practice readiness to address emotional health. Here, we describe the findings from the initial cohort completing the MOC Part 4 activity on emotional health.

METHODS

The Roadmap MOC Improvement Activity

The Roadmap Project MOC Part 4 activity guides physicians who independently choose to participate through a structured QI project. As with all ABP-approved MOC Part 4 activities, physicians must identify a measurable gap in practice, specify an aim, initiate and test at least one change strategy, and use data to measure change over time. This activity begins with the problem statement, as depicted in Table 1.

Table 1. MOC Part 4 Activity Template

Template Component	Content	
Problem statement	Many children and adolescents living with chronic conditions and their families navigate extremely challenging and sometimes traumatic issues that often negatively impact their emotional health. Some of these negative effects include stress, anxiety, depression, and altered coping mechanisms	
Sample aim statement	By x date, increase by 50% from baseline the number of visits for children with a chronic condition with documentation that emotional health was assessed or discussed with a patient with a chronic condition or their parent
	
Example measure	Measure Name: Documentation of assessing or documenting child emotional health
Numerator: Number of visits with documentation that emotional health was assessed or discussed (eg, documentation of a verbal discussion, use of a formal depression or anxiety screening tool)
Denominator: Number of child visits for a chronic pediatric condition
Data Source: Medical record
Unit of Measurement: Rate of documentation
Type of Measure: Process	

Physicians are then introduced to the Roadmap Project’s four key drivers: (1) raising awareness; (2) identifying resources and making them available; (3) developing knowledge, skills, and confidence; and (4) building surveillance and assessment into routine clinical processes, as outlined in the key driver diagram (Fig. 1). A graphic, which can be shared with office staff (Fig. 2), visually highlights the four key drivers. The MOC activity emphasizes the importance of two key drivers: identifying resources and developing knowledge, skills, and confidence to address emotional health. Next, physicians self-assess their ability to provide emotional health support to children and families by completing a baseline Roadmap Readiness Checklist (Supplemental Material, Supplemental Digital Content 1, http://links.lww.com/PQ9/A600). They repeat the checklist at several points, allowing them to assess their progress over time. The checklist contains five questions about (1) awareness of emotional health issues in patients with chronic conditions and their families, (2) availability of relevant resources for patients and families, (3 and 4) the availability of crisis plans for both patients and families, respectively, and (5) clinician confidence in addressing emotional health.20 Physicians score their current status for each checklist item on a three-point scale (0 = not currently in use, 1 = developing or testing, and 2 = part of my practice setting). At baseline, physicians reflect on their initial score and how their practice supports emotional health. They also commit to an aim that addresses their identified practice gaps.

Fig. 1. Roadmap Project key driver diagram.

Fig. 2. Roadmap key driver graphic summary.

To establish a foundation for their improvement work, the MOC activity prompts participating physicians to consider how emotional health affects physical health in their unique patient population, create or update a list of resources for emotional health, and develop a crisis plan for patients and family members. They also review relevant Roadmap resources that provide helpful strategies21,22; these include, for example: (1) how to begin conversations about emotional health (an 8-minute video developed by a pediatric psychologist),23 (2) how to develop a list of referral resources,24 and (3) how to equitably address the emotional health needs of those living with a chronic condition who are diverse and marginalized (a 12-minute video developed by a pediatric psychologist).25

Based on each physician’s reflections on the results of the Readiness Checklist and review of the Roadmap resources, physicians create projects relevant to their practice. Physicians specify an aim and the time they hope to accomplish it. Aims can be related to any aspect of the Roadmap Project outlined in Figure 1. Participants receive sample aim statements in the MOC activity template (example in Table 1).

After baseline data collection (see Data Collection section), physicians select a change strategy to test that aligns with their identified aim(s). Physicians choose at least one additional measure to track (eg, the proportion of visits with documentation that emotional health was addressed, or the proportion of parents reporting they were connected with peer-to-peer support). Next, physicians collect data on ten patient interactions as a baseline assessment. Several examples of measures are provided in the MOC Part 4 activity. One measure example matching the sample aim is displayed in Table 1.

Physicians are required to perform at least two PDSA cycles.26 Following each PDSA cycle, they are prompted to sample ten clinical encounters or patient reports (depending on their selected measure) and track this information on a run chart to follow their progress. The Readiness Checklist is also completed at two additional time points during the Roadmap MOC Part 4 activity, with each sampling of patients. Physicians thus track two process measures: the Readiness Checklist and one or more participant-selected measure(s). Data collection for these measures occurs at a minimum of three time points: baseline, midpoint, and at completion.

Upon completing the Roadmap MOC Part 4 activity, all physicians are asked to reflect on why they selected this MOC Part 4 activity, the changes made, the results, and associated learnings. Specifically, they consider how this MOC Part 4 activity changed how they practiced pediatrics, the types of skills or knowledge they gained through participating in this work, and how those learnings might influence a future project.

Data are submitted to the ABP using an Excel template integrated within the Roadmap Part MOC Part 4 activity.

Data Collection

The Roadmap MOC Part 4 activity launched in April 2022. The ABP compiled data for those completing the module by the end of December 2022, recognizing that completing and documenting the improvement efforts typically takes several months. For this evaluation, we assessed participants who completed the Readiness Checklist and the clinical encounter evaluation measure at all three time points.

Data Analysis

Twenty-nine physicians completed at least two PDSA cycles and submitted data on each measure to receive MOC 4 credit for the Roadmap activity in 2022: (1) Readiness Checklist data and (2) data on a self-selected measure. Any physicians who reported 100% performance on their baseline measure were excluded from analyses as they could not demonstrate improvements (n = 3). Thus, the 2022 cohort included 26 physicians (24% male, 43% pediatric subspecialists, and 57% primary care physicians). Twenty-two had complete Readiness Checklist data, and 24 physicians elected to track the percent of sampled visits where emotional health was addressed and/or assessed as a second measure. These groups were included in analyses.

The Roadmap project team analyzed data entered by physicians into the ABP’s MOC Part 4 interface; no ABP staff were involved in analyses to avoid any potential or perceived conflict of interest. Individual Readiness Checklist scores were collated, and descriptive statistics calculated. Entries without data for all three time points were excluded from the analysis. The average across participants for each component of the Readiness Checklist over time was graphed. Additionally, percent improvement scores between the multiple time points were calculated for each Readiness Checklist component, specifically overall improvement (baseline to conclusion), baseline to midpoint, and midpoint to conclusion.

Similarly, data associated with the participant-selected measure (assessment of emotional health) were collated and aggregated to calculate an overall average for each time point concerning the number of PDSA cycles completed (physicians could do more than two). Entries without data for at least three time points were excluded from the analysis. Graphs were populated based on the number of PDSA cycles completed, and differences in percentages and the degree of change from final to baseline were calculated.

The institutional review board of Cincinnati Children’s Hospital Medical Center reviewed the study protocol and determined that it did not constitute human subjects research.

RESULTS

Physician Responses: Why Did You Choose This QI Project?

Physicians reported various reasons at baseline for selecting the Roadmap MOC part 4 project. Overall, participants highlighted the general importance of emotional health. Select quotes are displayed below.

I feel that improving our support system for the emotional needs of patients is imperative to improving overall health. We are often the home base for many of these pediatric patients, and they rely on us to take care of all their needs, not just physical.

I recognize the importance of addressing family stressors and mental health as well as improving their resilience factors in order for the health of their children to achieve better health and mental health outcomes.

I work primarily with a medically complex population and have heard from a lot of parents about the stressors they feel, but haven’t had a good framework to use to respond/help.

I think as pediatric subspecialists, we tend to concentrate on the physical well-being of the child and leave the emotional challenges to the general pediatrician. However, we understand the disease complexity and the possible clinical course of the disease and may be better at managing the fears of the unknown.

Readiness Checklist

Scores (possible range 0–3) increased for each checklist component (Fig. 3). The component with the greatest increase was “resource list,” which increased by 90% from an average score of 0.95 to 1.82 at project completion. The average provider confidence score also showed substantial improvement, increasing by 79% from 1.09 to 1.95. The category with the lowest average score at baseline was having a “crisis plan for families”; the score increased by 78% from a baseline of 0.82 to 1.45 after the project. The highest average baseline score was for “staff awareness”; this score increased 34% from 1.45 at baseline to 1.95 after the project.

Fig. 3. Change in Readiness Checklist scores over time by category (scores were 0 = not currently in use, 1 = developing or testing, and 2 = part of my practice setting).

Assessment of Emotional Health

Data were analyzed from the 24 physicians who chose to track the percent of visits where emotional health was addressed and/or assessed and who completed at least two PDSA cycles. A few physicians completed more than two PDSA cycles, as displayed in Figure 4. For those completing two PDSA cycles, the percentage of sampled visits where emotional health was addressed/assessed increased from 21% to 77%. Generally, physicians who completed more PDSA cycles reached higher percentages of visits with emotional health addressed/assessed; among those completing at least five PDSA cycles, the percentage of visits where emotional health was addressed/assessed increased from 13% to 90%.

Fig. 4. Graphs documenting the aggregate percent of visits where emotional/behavioral health was assessed according to the number of PDSA cycles completed.

Physician Reflections upon Activity Completion

Upon project completion, physicians also provided reflections. Select comments are displayed in Table 2, grouped by the relevant key driver. These physicians’ comments reflect their documented improvements. For example, one developed a dedicated medical record section to document emotional health assessment; another used the resource template to assemble a list of local and regional resources to support children and families’ emotional health. Only one comment indicated some difficulty completing the project. One participant wrote that for a “computer challenge[d]” physician, data entry was difficult and led to frustration, but that despite this challenge, they made some “very worthwhile changes to how I address the emotional needs of my chronically ill patients and their families.”

Table 2. Physician Comments Pertaining to the Four Roadmap Key Drivers

Driver	Comments	
Raise awareness	This project has had a profound impact on our practice of medicine… Projects like these, bring emotional health to the forefront and in many ways may be first steps of battling the huge existing problems (of addressing pediatric mental health).
It has made me more aware and attuned to the importance of screening patients with chronic conditions for their emotional health status.
We learned that families with young children with chronic illness experience significant social and emotional stressors and we were not identifying these as often as we should.	
Identify resources and make them available	I’ve been surprised by the needs patients and their families have and have been forced to make sure to have resources available to meet their needs - it’s hard to ask a question like “how are you really doing?” and “what can I do to help?” if you don’t have a plan in place to follow through on what they want/need.
We have been able to put together a folder of essential resources for chronic services that is locally and regionally available. When I began my impression was that services for disabled patients and perhaps clinics for weight management would be the most important part of our new folder. The unfortunate reality of our current social situation brought to light the importance of depression/counselling services, crisis intervention, after school programs, communication with schools regarding services for patients that required IEPs greatly emphasized the importance of emotional support services.
Through conducting this QI project, I became more aware of the resources available for my patients in different parts of the region. I also learned about <our state> Child Psychiatry Access Network.
I created a list for resources for parents, such as support groups and providers. Although our program does not have the capacity to do crisis management for family members, I learned the process in which to refer our families in case of emergency.	
Develop skills and build confidence	One of the main skills I gained from this QI project was approaching my patients and families with open ended questioning regarding their mental health like asking, “how are you doing and how is your family doing?”
I have become more proficient and comfortable having BH [behavioral health] discussions with children and their families.
I definitely realized that if you only ask the family once, they will quickly answer “fine.” This changed the way I ask, the attention I give and follow-up questions to ensure families feel I truly want to know. I now make sure to discuss after we finish the typical patient care, papers down and eye contact.
Asking patients and parents about emotional health is something that requires establishing a rapport and a safe place for the patients and parents to trust the provider. I have also learned to be bold in these encounters, as most people will not divulge information without being asked. These are nuanced skills that I’m grateful for.	
Build surveillance	This project has had a profound impact on our care of children with type 1 diabetes. The EHR driven workflow we developed and implemented has been successful in identifying children at risk for depression getting them the behavioral health support they need.
I was surprised at how little I documented talking about mental health of my patients and their families in the context of chronic health conditions, and because of that, it is not clear if any steps were taken to address the burdens the patient or family was dealing with.
With this project a dedicated section of the health records is now available to document assessment of mental health of my patients as it relates to chronic health conditions. Also, any referrals to mental health providers are documented as well.	

DISCUSSION

This initial cohort of physicians participating in the Roadmap MOC Part 4 activity showed improvement in both Readiness Checklist scores (indicating improvement in processes to address emotional health), and in the percentage of sampled visits during which emotional health was addressed. The few physicians who completed more PDSA cycles had more substantial improvements in assessing emotional health in their practices. All the physicians completing the Roadmap MOC Part 4 activity reported that improving emotional health was worthwhile and that the project yielded improvements in a reasonable amount of time. Their reflections indicated that participation in this MOC Part 4 activity positively affected their emotional health and practice awareness. It was also encouraging that general pediatricians and subspecialists found the activity relevant and useful.

These findings are particularly important because addressing emotional health is an essential part of care for all children, including those with chronic conditions and their families. This ABP MOC Part 4 activity supported physicians in integrating how to address the emotional health needs of patients and families into their practice and provided tools and strategies to do so effectively. Addressing emotional health may be a task that some providers shy away from, fearing they might be unable to meet patient and family needs or may be “opening a can of worms” that they are not equipped to address.21 The improvements and positive feedback noted here indicate that physicians can successfully address emotional health and find it extremely valuable for their patients and families.

This MOC Part 4 activity may have been successful and well-received for various reasons. First, the framework and strategies used to develop this activity were tested in diverse clinical and geographic settings before the development of the MOC activity. Materials were also reviewed by young adult patients, parents, and mental health professionals. This vetting likely enhanced the relevance and quality of materials included in this activity. It ensured these materials were feasible to use in varied clinical practice settings and patient populations with various chronic medical conditions. Also, the increase in pediatric mental health needs heightened by the COVID-19 pandemic likely raised awareness of the importance of addressing mental health in children and families.27–29

In the past, pediatricians have expressed dissatisfaction with the MOC Part 4 improvement activity templates.30 Specifically, concerns have included the excessive time required to complete a project, the lack of relevance to the clinical practice of some MOC Part 4 activities, and the fact that the changes failed to affect their practice.30 The results presented here indicate that these concerns were not substantial issues for physicians participating in the Roadmap MOC Part 4 activity. Using a deliberate, stakeholder-engaged development process, and testing the framework and tools for the Roadmap improvement template in diverse settings with various clinical teams, may have addressed many of the concerns noted by previous users of the other ABP improvement activities. Participants also chose to undertake this specific MOC activity, which may indicate a particular interest in or dedication to emotional health.

The results reported here have potential limitations. The initial cohort was small; not all those who began the activity completed it, and all participants chose to participate individually, which may have biased results and reflections on the experience. The MOC part 4 work was self-limited (occurring at most over 8 months), and participants were not required to demonstrate improvement to receive MOC credit. Consequently, relatively few data points were collected, and sustainability data were unavailable. However, responses in the reflections section strongly suggest that the clinician and practice changes have become part of clinical care for patients with chronic conditions and their families; for example, prompts in the EHR, development of resource lists, and comments regarding the value of addressing emotional health. Success in integrating change into routine care is not surprising. Rogers’ Diffusion of Innovation suggests that feasible and practical measures to make a change are more likely to lead to uptake.31 The ABP’s MOC activities do not require documenting balancing measures. Positive reflections suggest that clinicians and the families did not experience adverse effects. However, future work could include patient experience and balancing measures to obtain a more thorough impression of this effort.

CONCLUSIONS

The measures tracked and the reflections shared in the online Roadmap MOC Part 4 activity indicate that this improvement module had a powerful impact on both generalist and subspecialist physicians’ perspectives, confidence in addressing emotional health, and documented clinical practice change. Testing the framework and tools for the ABP improvement template in diverse settings with various clinical teams may be useful in addressing many of the concerns noted by previous users of the ABP improvement activities. The Roadmap MOC Part 4 activity can be a useful and feasible means of addressing the emotional health of children with chronic conditions and their families for general pediatricians and pediatric subspecialists.

ACKNOWLEDGMENTS

The authors gratefully acknowledge Laura E. Peterson, BSN, SM, who served as the QI Specialist during the pilot collaborative and helped to synthesize learnings and develop the framework for the Roadmap MOC Part 4 activity, and Amy Roberts, Project Manager, Continuing Certification, ABP who compiled the data of the physicians completing the Roadmap MOC Part 4 activity.

Supplementary Material

Supplemental digital content is available for this article. Clickable URL citations appear in the text.

Disclosure: Drs. Leslie and Mann are employed by the American Board of Pediatrics. The Roadmap Project is supported by grants from The American Board of Pediatrics Foundation and the David R. Clare and Margaret C. Clare Foundation. The funding organizations had no role in this work.

Presented at the Association of Pediatric Program Directors Spring Meeting in April 2024 and the Pediatric Academic Societies Annual Meeting in May 2024.

To cite: Lannon C, Schuler CL, Thomas L, Gehring E, Mann KJ, Leslie LK. Integrating Emotional Health Assessments into Pediatric Care: Initial Learnings from an MOC Part 4 Activity. Pediatr Qual Saf 2024;9:e768.
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