The NMA Pediatric Section expressed deep concern about health and health care disparities for children of color.  The Section Task Force identified the following significant areas of priority toward which we will invest resources to develop Action Steps.  We expect to continue to promote quality health care for all children and to decrease, and then to eliminate, health care disparities for children of color.  Our rationale and Action Steps will place the Section at the crux of this national and global discussion and agenda.  While some of these areas overlap, they should be considered independently. 

Access to Quality Health Care Adolescent & Youth Care     
Children & Families Children with Special Health Care Needs
Community Collaboration Education
Environment Infant Mortality
Justice System Mental Health
Nutrition Parenting
Role of Pediatricians into the 21st Century
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Rationale for a Strategic Action Step within the Pediatric Section of the National Medical Association

            The overarching theme for the Pediatric Sections strategic Action Steps should be to define the Role of the Pediatrician into the 21st Century in improving the health status of children, and in decreasing health care disparities.  To this end, our determination and commitment to the health of children must be above reproach.  A prism where the agenda items intersect is a transparent understanding of the connected nature of health care solutions to the complexity of needs.  While advancements in medical technology in America promise the potential for superior health care for all, the health burden faced by children of color has not been relieved.  In fact, the gap is likely to increase across racial and ethnic lines if access to such advancing technology is not afforded children of color, equally.  As our nation grows in diversity, children of color who are either born in, or immigrate to, America are promised inferior, disparate health care as shown by numerous studies and reports.  The poor health care and health status for children of color is a major economic burden in our communities in particular and, therefore, our nation in general.  These disparities are threats to our future and our decency.

The NMA Pediatric Task Force proposes an action framework.  Section members propose to base these Action Steps on a developmental model that crosses all aspects of a child life.  This approach is essential in understanding the interplay of both protective and risk factors.  These factors can be best integrated and implemented in partnership with various community members, especially parents.

Pediatricians who predominantly practice in communities of color must actively engage families and leaders who can clarify concerns as well as provide guidance to addressing the local health crises.  We must include community-based participation in our prevention and intervention plans.  Our action items will help collate and formalize the health care needs so that our solutions will be focused and deliberate.

            We recommend that members the Pediatric Section of NMA consider developing work groups to take action and consolidate activities in the following areas; and, when appropriate, across areas of concern for children and families within our communities.  See the Proposed Strategic Action Prism schema as recommended by the Task Force members.  We established work groups to discuss and propose actions steps for consideration on the local, regional, national and global levels considering the list of topics provided at the 2005 Annual Pediatric Section Business Meeting of NMA.  We expect models of community health improvement, grounded in sound science and practicality for children and families to result from our proposed actions steps.  Work groups propose that the Pediatric Section utilize evidence-based medicine and develop talking points to help replicate any positive models in other communities for maximal impact of children health improvement.  In addition, the Task Force highly recommend that the proposed strategic actions steps for each domain be approached in a collaboration with other national organizations with similar agendas such as the American Academy of Pediatrics, American Association of Family Practice, American College of Obstetrics and Gynecology, National Association of African American Drug Policy Coalition, Joint Center for Health Policy Institute, Women Health, Maternal and Child Health Bureau, etc.  

A.   Access to Health Care (Insurance, Quality Care, Immunization, Workforce Diversity, Mental Health and Oral Health)

Rationale:  While America is proud of its most advanced health care system, many Americans—especially children in communities of color—do not enjoy the benefits of these advances.  Disproportionately and systematically, children of color are uninsured or underinsured, they live without adequate immunizations, without basic quality health care, and without equal access to specialty care when necessary.  In addition, as America grows in diversity, health professionals (including physicians, nurses, and dentists) have become less representative of the complex ethnic and racial mix of patients for whom they care.Action Steps

1. Identify prominent pediatricians in local areas interested in these issues

2. Invite them to the Pediatric Section of NMA

3. Presentations of Innovative Models of local community health improvement models as a priority for Annual Meetings and promote publications into in the NMA Journal

4. Continue to strengthen CME Programs Topics at regional and annual meetings of NMA

5. Host Networking Activities across community practitioners, medical students, residents and academicians at regional, national and international meetings

6. Work with high school and undergraduates in community of color to support their entry into the biomedical professions

7. Use national childhood immunization efforts as a model:

·         Encourage full participation of NMA members in the Vaccines for Children (VFC) Program to improve access to immunization services.  Promote the use of the VFC program among other providers.

·         Promote the use of assessment, feedback, incentives, and exchange of provider-based immunization coverage (AFIX) in practices of NMA members to improve quality of services.  Promote the use of AFIX among other providers.  (The CDC CASA software can be used to implement AFIX).

·         Identify effective outreach strategies for educating the community on the Vaccine For Children (VFC), State Children Health Insurance Program (SCHIP) and Medicaid programs to improve access   

B. Parenting (Economic Insecurity, Foster Care)

      Rationale:  As children develop physically, cognitively, emotionally and spiritually, parents must be knowledgeable about community resources to optimize each child’s ability to develop into productive citizens in our society.  Pediatricians can be an invaluable resource to guide and support parents in their childrearing skills and secure safe and stimulating environments for children to thrive.  Related to access, children in poverty are especially removed from routine, scheduled health care.  Even if Pediatric Periodicity Schedule is accepted by physicians, health plans and parents; far too many low-income families often do not participate in health care maintenance.  Care is often episodic and acute, leaving chronic conditions, such as asthma, out of control until the next crisis.  Parents may not be aware of the role they play in their children’s health, therefore specific communication and education to families regarding health care, language rights, culturally competent care can be conveyed by pediatricians.  Parents alone do not have the necessary tools to counteract society’s influence on children (violence, sexual behavior, nutrition).Action Steps

1.      Establish “Parenting” as in agenda item/goal for sectional meetings

2.      Establish Sectional Level Task Force to address identified goals/actions

3.      Research/Develop “Community Resource Guides” for use by pediatricians to facilitate parental navigation of systems and utilization of resources (the guide would, of course, be tailored to each community/ hence the need sectional involvement)

4.      Establish grassroots community coalitions (that include pediatricians) focused on creating early intervention programs throughout the community for children from pregnancy through age three years.

5.      Create CME programs that focus on Early Intervention Parenting Programs

6.      Investigate/Learn more about Dr. T. Barry Brazelton’s “TouchPoints” program as a model to possibly replicate throughout our communities.

C.   Infant Mortality (late prenatal care, low birth weight, SIDS) (i.e. back to sleep media campaign not reaching parents).

Rationale: The infant mortality rate has precipitously dropped over the past 40 years in all ethnic groups except African Americans and American Indians. In 2000 an African American infant was more likely to die with a rate of 14.1 deaths per 1,000 lives births as compared to our counterpart, the white population which is 6.9 deaths per 1000 live births. The leading causes of death are congenital anomalies, pre-term/low birth weight, Sudden Infant Death Syndrome (SIDS), pregnancy complications and respiratory distress syndrome. The reasons for some of the above causes are late or no prenatal care, poor quality of care access, decrease access to high-risk OB programs, lack of health insurance, multigenerational stressors, lack of health literacy, poor communication to pregnant women of color, and inability to receive early, high quality prenatal care.

Action Steps

1. Pediatric section members of NMA to partner with local public health departments an/or CDC/ATSDR, American College of Obstetrics and Gynecology, Maternal and Child Health Bureau, policymakers, community agencies as, local churches, drug rehab centers, high schools, boys and girls clubs, etc. to concentrate on modifying behavior and lifestyle changes i.e. smoking and use of drugs, improved nutrition and exercise and seeking preventive and early medical assistance for care.

2. Utilized home health nurses as liaisons in the community for the hard to reach population.

3. Provide a media campaign such as brochures and/or national radio and television media to alert the African American population to health risk that they personally can improve to provide healthy outcomes of pregnancies.

4. Establish a network with Historically Black Colleges and Universities (HBCU’s), high schools, churches to advocate for back to sleep program as well as early prenatal care, good nutrition, etc.

5. Consider multi-center research project looking at stressors and relationship to preterm delivery or unique programs that are working in communities to improve access to prenatal care.

D. Education (ADHD, Autism, Common Learning Disabilities, Dyslexia)

            Rationale:  Families without solid grounding in education for several generations, and schools without resources to capture children early and direct them to health care services, contribute to disparities in the care and outcomes children endure in our medical system.  Children are often not screened early for common learning disabilities, ADHD, and Autism.  Referrals to regional developmental centers or developmental pediatricians’ involvement early are critical to these children’s success in school and later life.  Often, children of color have difficulty gaining access to such specialists and go undetected in many systems, childcare, public/private school, health care settings, etc.  Action Steps

1. Hold a scientific symposium that summarizes current knowledge of the etiology of ADHD, Autism, and learning disabilities to identify primary, secondary, and tertiary preventive strategies.

2. Identify the best, evidenced-based strategies for early detection, treatment and education (secondary prevention) of children with ADHD, Autism, and learning disabilities.  Primary care and developmental pediatricians should have a major role in delivery of primary and secondary preventive strategies in children with behavioral and learning disabilities. 

E.      Nutrition (Anemia, Overweight, Obesity, Diabetes)

      Rationale:  Parents appropriate knowledge on infant and toddler feeding habits may prevent iron deficiency anemia and minimize the cognitive deficit that children experience if this condition goes untreated.  This educational need rest squarely within families.  Pediatricians can play an active, vital role of translating evidence-based science to guide parents in age-appropriate nutritional choices for children.  But elders, experienced family, and extended family members support parents and provide them with valuable resources when raising infants.  Inviting them to participate in the nutrition education of parents on behalf of their children is important.  However, since many times, communication of recommended pediatric feedings may not coincide with family and community practices, pediatricians must participate in culturally and economically sensitive education to arrive at practical solutions.  In addition, the growing problem of childhood obesity, which begins in early childhood, is a most serious problem for children of color.  Obese toddlers will likely grow into obese children who will likely grow into obese adolescents and ultimately become obese adults.  The epidemic of obesity, pre-diabetes, and diabetes in adolescents is a major problem for all American children.Action Steps

1. Promote Breastfeeding (birth--12 months):  Encourage and/or emphasize benefitsIdentify and provide options to the working mom in an effort for continuation of breastfeedingIdentify best venue of delivery/support, barriers to promotion/delivery, benefits, etc.        

2. Cows milk-induced iron deficiency anemia (>1 year): 

a.   Increase awareness, identification and prevention

3. Obesity prevention (toddlers): 

a.   Explore positive incentives eating factors, creating healthy eating environment/active lifestyle across generations for families.

b.   Consumption of a variety of foods and being mindful of ethnic-driven food selections and preparations. 

c.   Identification of barriers to eating healthy/healthy activities

4. Obesity- Intervention/Treatment (childhood/teens/young adults): 

a.   Identify barriers to weight reduction/control.  Identify best venue for treatment, delivery/support---long-term--

b.   Encourage long-term healthy lifestyle and identification of eating disorders

F. Adolescent & Youth Care (HIV/AIDS, Risky Behaviors, etc.)

            Rationale:  The multiple issues of adolescence and addressing the challenges of providing quality adolescent health care are a convincing cause for the Pediatric Section of the NMA to join forces with like organizations such as the Academy of Pediatrics, Society of Adolescent Medicine and others.  Often, parents do not understand the need for preventive and maintenance adolescent health care, pediatricians are not comfortable managing teenagers and their health, based on common teen behaviors, and teenagers don’t typically want to see a physician unless there is a positive established relationship.  However, suicide, homicide, STDs affects communities of color in ways that are preventable if high-quality adolescent medicine is made available.  Mental health and attention to risky behaviors such as using tobacco or illicit drugs, participation in gang activities, driving under the influence of alcohol, etc., may not be addressed early enough for adolescents.  The importance of communicating the value of Well Adolescent Care has not penetrated enough families and physicians who could collaborate to care for teenagers in schools, social settings, etc.Action StepsIdentify prominent pediatricians interested in these problems of adolescent patients and invite them to join in association with the Pediatric Section of the NMA.Present for review and refinement the Pediatric Section Strategic Action Steps for Adolescent & Youth Care (HIV/AIDS, Risky Behaviors, etc.)Using the National Immunization Project as template, re-educate pediatricians as well as parents to the tenants of preventive well child care which extends beyond immunizations and pre-school readiness.  Emphasis upon educating and mentoring parents on the benefits of continuance of age-appropriate preventive means for managing challenges of various temptations presented during the adolescent years is critical to the success of the project.  Using evidence-based best practice in adolescent health care medicine will be beneficial in the development of a project curriculum.Creative methods for augmentation of practice staff for both assessment and educational support of anticipated increased workload such as referrals, extra visits, after hour clinics, peer counseling, etc.may include such activities as joint sessions shared among 2 or 3 pediatric practices.Pediatricians are encouraged to become more involved and establish a relationship with their local school, beyond that related to physical examinations for athletic activities, through offering services for lectures to parents or staff on adolescent behavior, preventive health, nutrition, etc.Pediatricians are encouraged to become more knowledgeable about the policies and quality of services provided by referral agencies that may be in conflict with accepted medical practice.Pediatricians are encouraged to become more engaged with advocating for adolescents whose families find themselves in homeless or shelter situations to be allowed to reside in the same environment as their younger siblings and parents and not be separated from the family unit.  

G.      Justice System (Mental Illness)

            Rationale:  With the deterioration of public education, the disintegration of the traditional family, and the paucity of community mental health services and inpatient facilities, the juvenile justice system will interface with even more of our young men and women.  Until the aforementioned societal forces are improved, increasing numbers of our youth will be managed within the juvenile criminal justice system.  Fortunately, most, if not all, of the juvenile detention and jail facilities must comply with the standards set up by the “National Commission on correctional Health Care.”  The comprehensive and progressive standards include: governance and administration; managing a safe and healthy environment; personnel training; health care services and support; juvenile care and treatment; health promotion and disease prevention; special needs and services; health records and medical/legal issues.  As much as 68% of the admissions to juvenile detention facilities carry a mental health diagnosis; ranging from attention deficit disorder, drug abuse, schizophrenia, bipolar disorders, antisocial personality disorder and often mental retardation.  Children enter the American justice system early and may even remain there through adulthood.  Especially vulnerable to this are children with mental health conditions, in out-of-home placement, foster children, and homeless children.  Routine health, inclusive of mental and dental care, is important in early detection and treatment of common conditions.  Maintenance care is also critical for these children.  Adults charged with caring for these children’s health should be very mindful of the mental health needs for these children early in their life cycle.



Action Steps

1. Network with key stakeholders to ensure that at least adequate standards of medical care are in place.

2. Adhere to the guidelines, with appropriate resources, dedicated staff and leadership are secured while juvenile are detained. 

3. Advocate for the support of our communities with appropriate funding and a comprehensive follow through system of educational, psychological and social underpinnings that will redirect our youth energies into more constructive areas.  This will include dealing with their families, or lack of, homelessness and the communities in which our children reside.

4. We need to elevate the awareness and urgency to federal, state and local organizations (social, philanthropic and political) who might embrace partnering with the Pediatric Section of NMA in order to enhance awareness of the need to have a dedicated, comprehensive, and seamless approach to the reduction of juvenile crime. 

5. Act within a consortium with key stakeholders in establishing interconnected programs dedicated to assisting youth breaking the cycle of crime, poverty and marginalized employment which leads to detention and incarceration.  The consortium member who should join Pediatric Section of NMA to truly address rehabilitation are American Academy of Child and Adolescent Psychiatrists; American Academy of Pediatrics; American Academy of Psychiatry and The Law; American Health Information Management; American Nurses Association; American Psychological Association; National Association of County and Health Officials; American Public Health Association; Society of Adolescent Medicine; National Teacher’s Association, etc. 

6. Conduct a summit with local, state and federal groups who have responsibility in these programs to establish an agenda, expectations, time-lines and measurements for the mandated changes in the juvenile justice system.  

H.      Environment (Asthma, Violence, Tobacco, Lead, etc.)

      Rationale:  The environment—physical toxins, social habits, social and physical dangers—along with poor access to quality of health care render children much sicker when/if they enter the medical care system.  Pediatricians may be aware of how environmental factors impact health, but might lack the resources to direct prevention and treatment with traditional health care models.  Children who have experienced violence—whether a victim or a witness—become a health burden to themselves and society.  Toxins in the house and in the community also affect children’s ability to live healthful lives.  Pediatricians are charged with negotiating not only individual patients but whole communities in creating healthy and safe environments for populations of children. 

Action Steps

1.      Create user friendly educational materials on potential harmful environmental toxins for children, parents, schools and communities to cover the typical environments that children are exposed to:  home, playgrounds, parks, schools, etc.  Set up incentives for avoiding environmental toxins.

2.      Create an environment with the NMA and local pediatric and medical society to strongly promote smoke-free environments.

3.      The NMA should create a resource program to train pediatricians and other health care professionals in violence prevention.  Should work to promote and enhance where possible handgun regulatory legislation.  Work with state and local juvenile justice systems to emphasize lessening childhood violence.

4.      Create a liaison with federal, state and local media campaigns for continued emphasis on coverage of media violence.

5.      Create liaison with all organizations that work for violence in the pediatrics age range.

6.      Advocate for an environment that support safe and affordable housing for all low-income families.   

I.     Children with Special Health Care Needs (prematurity, sickle cell, inborn errors, congenital heart disease, birth defects, chronic care…)
This committee suggests that the NMA become much more visible in the community. The NMA should be at the forefront in providing resources and educational information for children with special health care needs, as well as other health care issues.  As pediatricians, many of us have patients with special health care needs, such as children with cerebral palsy, congenital anomalies, sickle cell and the like, but are unaware of the spectrum of resources available to our patients and their families. Often families see a variety of specialists without any particular coordination of care. Subspecialty care is scarce in some communities for children with special health care needs. Pediatricians struggle to get these children into subspecialist’s offices and Centers of Excellence when medically necessary.  Education and collaboration within the Pediatrics Section of the NMA does not contain enough input from the various subspecialities and must be addressed for children in communities of color.

Action Steps:

1. The Pediatric Section of the NMA will partner with subspecialists and other professionals who play instrumental roles in working with children with special health care needs, e.g. High Risk and developmental pediatricians, social workers, physical therapists, occupational therapists.  The partnership will provide a vehicle by which members of the Pediatric Section have access to educational material, practical advice, and resources for their patients.  A half day session of the NMA Convention will consist of a mini symposium on children with special health care needs—experts from a variety of backgrounds, including medical, social work, and developmental, and will help members of the Section identify and partner with available community resources to be the best advocates for their patients.

2. The Pediatric Section of the NMA will provide local seminars, workshops, and other educational/advocacy programs to the community.  The section will partner with churches and other organizations that directly deal with these families.

3. The Pediatric Section of the NMA will establish a referral list of local, regional, and/or national advocacy centers for parents of children with special health care needs.  These centers will direct parents to resources they need to provide the best possible care for their children.

4. The Pediatric Section of the NMA will actively recruit and invite subspecialists into the Section.  These subspecialists will help to revitalize the Section and will be a resource for general pediatricians who care for children with special health care needs.

5. The Pediatric Section will mentor and include area pre-medical and medical students in community efforts as part of long-term recruitment.   

J. Role of Pediatrician in 21st Century

Rationale:  The approach to pediatrics is evolving. Pediatrics is different now as compared with even just a decade or two ago.  The emphasis is more and more on outpatient care (due to Hib and Prevnar vaccines, Ceftriaxone, decreased age for hospital admission for ROS, asthma controller medications) rather than inpatient care.  Prevention is an even bigger part of our routine well child visits.  Capitation dictates comprehensive, rather than episodic, care.  So, a comprehensive exam and management is monetarily rewarded more than frequent episodes of acute care.  A non-traditional approach in solo and small group, as well as large and academic groups will be necessary to provide quality care while considering market constraints.  Managed care, pay-for-performance physician incentives, patient incentives from health plans, chronic care models (i.e. asthma management), and an approach to populations of patients is already here.  The resources in offices that impact care in underserved areas—often acute/urgent episodic care, where preventive services (immunizations, developmental screening, asthma control) are postponed—must keep up with the changing reimbursement for care.  Both quality and cost-effectiveness is our goal.  They are both possible and urgent.  Comprehensive approaches to care for pediatricians includes interacting with schools, media, parents and extended families, and policy makers to insure children are considered from various positions of our health care system.  Resources now exist, and will be strengthened, within health care insurance plans to collaborate with data and outreach to patients/families rather than episode of care for acute illness.  Of course, uninsured children must be considered as well.  The pediatrician, as advocates for children of color, on all levels from local to global health improvement, is necessary to lessen the burden of disparate health status.

Action StepsExplore interactive technology advancement in Continuous Medical Education (CME).Collaborative care should be emphasized in addition to system-based practice and practice-based learning and improvement are critical focus to be highlighted in CME.Patient-driven quality care and patient satisfaction need to a focus with purchasers of care being recognized as health care consumers.Consideration should be given to complete CME credits in courses be structured to be awarded only when application of educational objectives can be demonstrated in pediatricians’ practicesExplore the assignment of Ombudspersons for community health centers, public health agencies and pediatricians’ practices for technology linkages to optimize quality of care.Retraining pediatricians in the Pediatric Section of NMA should stress Active Learning and could be incorporated with the Emergency Preparedness and Response Curricula being developed in NMA.Incorporate continuous medical education regarding HEDIS, pay-for-performance, quality metrics as they related to physician contracts and reimbursement.Establish tools in assessing Quality of Care in Practices such as “AFIX” should be consideredEducation Blocks or Sections in NMA should require that all presenters include a 2-3 minutes reflection on how information being shared in their specific area of medicine will evolve into the 21st Century Practice of Pediatricians.  

The Task Force Members of the Pediatric Section of NMA are committed to seeing several of these designated areas addressed in an incremental fashion to impact children who are burdened with health disparities.  We recognize that resources to address these issues at the local, regional, state, national and global levels must be incorporated into our action plans.  We welcome all experts and citizens to join us in taking on this challenge over the next five to ten years to reduce the gap in health status for all children.  We present these Action Steps to the Executive Committee and to the membership of the Pediatric Section of NMA for their consideration and actions.