A neighborhood-based approach to population health in the pediatric medical home.

Health care reform is increasingly focused on population health outcomes. Local strategies low-income neighborhoods could connect every newborn to a medical home and create a platform to link them with other health-promoting community resources. (1) To improve connections to the medical home for infants from one low-income neighborhood (2) To increase the number of families enrolled in a local home visiting program, and (3) To improve communication between medical staff and home visitors. The study was conducted in a neighborhood with 550 births per year and median household income of $27,000. Quality improvement methods were used to test: (1) newborn registry in the medical home, (2) proactive outreach by nursing staff, (3) standardized protocol for enrolling families in home visiting, and (4) coordination of care between medical home and home visitors. Outcomes were timeliness of well child care and enrollment in home visiting. Time series analyses compared patients from the intervention neighborhood with a demographically similar neighborhood. Mean age at newborn visit decreased from 14.4 to 10.1 days of age. Attendance at 2- and 4-month well child visits increased from 68 to 79% and 35 to 59 %, respectively. Rates did not improve for infants from the comparison neighborhood. Confirmed enrollment in home visiting increased. After spread to 2 more clinics, 43 % of infants in the neighborhood were reached. Neighborhood-based newborn registries, proactive nursing outreach, and collaboration with a home visiting agency aligned multiple clinics in a low-income neighborhood to improve access to health-promoting services.