TABLE 4.

WCC Models

WCC Models
Model 1: Group Visit Model
This is a group WCC model with a health educator leading the group anticipatory guidance/health education session.
A small group of parent-child dyads (∼6) are scheduled for their age-specific well-child visit as a group. Each patient in the group visit needs the same age-specific well-child visit (eg, 4-mo visit). Parents arrive at the scheduled time, go to the conference room where the group session is held, and rotate through 2 stations for (1) measurements by an MA and (2) physical examination by the MD/NP.
While waiting for 1 of the 2 stations, parents complete a simple questionnaire on health history and anticipatory guidance as well as standardized screening tools for development, autism, and psychosocial screening, when indicated, on a touchscreen electronic tablet or kiosk in the group visit room. The data from this screening are automatically uploaded to the EHR, where red flags indicate areas of further need. For parents with Internet access, this can be completed via a Web-based application at home before the visit. The health educator gets a summary of the screening that notes any general areas of concern that can be addressed during the group anticipatory guidance session.
After each parent has rotated through each station, the health educator conducts the group session focusing on age-appropriate anticipatory guidance topics, encouraging group discussion and sharing. The MA reviews a summary of the screening forms, noting any red flags for areas of need. After the group session, the MA returns and administers immunizations to each child. Visits follow the usual AAP schedule: visits at 2 wk and at 2, 4, 6, 9, 12, 15, 18, 24, 30, and 36 mo.
Modifications
1. Parents may need additional care for urgent issues that arise during visits. Depending on the urgency of the issue, the parent may need an additional one-on-one visit with the MD/NP (eg, acute or chronic medical concerns) or social worker (eg, psychosocial concerns) directly after the group visit or at another scheduled time. An explicit, reliable, and monitored system to get these parents to the necessary provider should be in place. This system, often referred to as a “warm hand-off,” should include direct communication between providers about the parents’ needs and follow-up plan.
2. A clear plan is necessary for patients who miss the scheduled group visit or arrive too late to participate. One possible option is keeping an available slot for a well-visit on the day of the group visit.
Model 2: Station-to-Station Model
This is a one-on-one visit model. Parents complete standardized screening tools for development, autism, and psychosocial screening, when indicated, on a touchscreen kiosk in the waiting room or exam room. The data from this screening are automatically uploaded to the EHR, where red flags indicate areas of further need. For parents with Internet access, this can be completed via a Web-based application at home before the visit.
Patients are consecutively seen by 3 different providers in a single room. An MD/NP conducts the physical examination and addresses any red flags in the EHR from screening. The MA does the measurements, provides immunizations, and goes over follow-up instructions, referrals, etc (written by MD/NP), when health educator is unable to do so. The health educator provides individual anticipatory guidance. Visits follow the usual AAP schedule: visits at 2 wk and at 2, 4, 6, 9, 12, 15, 18, 24, 30, and 36 mo.
Patients are seen for 10 min by the MA, 10 min by the MD/NP, and 20 min by the health educator. The order of when each provider sees each patient is designed to accommodate late arrivals and parents who have not completed previsit screening materials into the schedule.
Modifications
1. The structure of the visit should be flexible so that patients can spend more or less time in each “station” depending on their needs. Children who have an acute care issue on the day of the visit may need extended time with the MD/NP. An experienced parent may not want the entire 20 min with the health educator. The visit structure should be tailored to meet the parent’s needs.
2. Patients can rotate through the stations in any order that the clinic deems feasible. However, at the end of the visit, there should be a wrap-up/summary of the visit and formulation of a plan that is conducted by the MD/NP. This could be done by always saving the MD time for the final station or by having the MD come back to the patient once all stations have been completed.
Model 3: Mixed One-on-One/Group Visit Model
This is a hybrid model, combining elements of a one-on-one visit with group sessions. The majority of anticipatory guidance is taken out of the individual MD/NP visit and provided through group classes. During individual visits, anticipatory guidance is brief and targeted, based on prescreening information. Group classes cover topics for multiple ages so that parents do not need to attend a group class for each well-child visit.
At individual visits, parents complete standardized screening tools for development, autism, and psychosocial screening, when indicated, on a touchscreen kiosk in the waiting room before their individual visit, or at home. The data from this screening are automatically uploaded to the EHR, where red flags indicate areas of further need. Patients are then seen consecutively by 2 providers in a single room. An MD/NP conducts the physical examination, addresses any red flags from screening, and provides brief but targeted anticipatory guidance on the basis of prescreening information. The MA performs measurements and provides immunizations.
Group classes are also provided for additional anticipatory guidance. Parents are encouraged to attend 2 classes when their child is age 0–11 mo, 2 classes when their child is 12–23 mo, and 1 class when their child is age 24–36 mo. Group classes are led by a health educator and are focused on age-appropriate anticipatory guidance topics for infants aged ∼2 wk (covers through 4-mo-old topics), 6 mo (covers 6- to 9-mo-old topics), 12 mo (covers 12- to 15-mo-old topics), 18 mo (covers 18- to 24-mo-old topics), and 30 mo (covers 30- to 36-mo-old topics). The individual visits follow the usual AAP schedule: visits at 2 wk and at 2, 4, 6, 9, 12, 15, 18, 24, 30, and 36 mo.
Modifications
The “warm hand-off” is used for patients with additional needs that arise during the group session (see model 1 changes).
Because these group classes are not meant to be “optional,” but are explicitly a part of the model for most parents, framing and marketing the classes will be critical as a way to encourage parent attendance.
Model 4: Technology-Based Model
This is a technology-based model with brief, targeted individual visits and additional health education and anticipatory guidance delivered by bidirectional e-mail, texts, health educator–moderated message boards, Web links, videos, and a well-child telephone help line.
Parents complete a simple questionnaire on health history and anticipatory guidance as well as standardized screening tools for development, autism, and psychosocial screening, when indicated, on a touchscreen kiosk in a semiprivate area of the clinic, or at home before the visit. The data from this screening are automatically uploaded to the EHR, where red flags indicate areas of further need as well as parent-requested anticipatory guidance topics. After completing the screening, parents have an opportunity to identify particular areas of need from an age-appropriate list, and print-out or e-mail information sheets on each topic to themselves. They can also indicate what topics they want discussed during the MD/NP visit. For parents with Internet access, this can be completed via a Web-based application at home before the visit.
Between visits, parents are encouraged to use the well-child telephone help line. A health educator is available at preestablished days/times by phone, e-mail, or text to answer questions that parents have on a range of anticipatory guidance–related topics.
During the one-on-one visit, the MA performs measurements and provides immunizations. The MD/NP conducts the physical examination and addresses any red flags or parent-requested topics that were identified through the screening. All general anticipatory guidance and health education messages are provided outside of this one-on-one visit through e-mails, texts, health educator–moderated message boards, Web-site links, and clinic-designed health education videos. Parents with additional questions can contact the well-child help line. Visits follow the usual AAP schedule: visits at 2 wk and at 2, 4, 6, 9, 12, 15, 18, 24, 30, and 36 mo.
Modifications: none

AAP, American Academy of Pediatricians; EHR, electronic health record; MA, medical assistant; MD, medical doctor; NP, nurse practitioner.