An Evaluation of CenteringParenting: A Group Well-Child Care Model in an Urban Federally Qualified Community Health Center

Abstract

Objectives:

For CenteringParenting—an integrated, group participatory approach to maternal and child health—this study aimed to explore maternal participants' experiences and children's clinical metrics compared with those receiving traditional well-care visits in the same community health center.

Design:

A mixed-methods approach evaluated the impact of the CenteringParenting program on infant outcomes and maternal and staff experiences.

Settings/Location:

This study was conducted at Neighborhood Family Practice (NFP), an urban federally qualified community health center on the west side of Cleveland, Ohio. NFP is an accredited Centering Health care Institute site for both CenteringPregnancy and CenteringParenting.

Subjects:

Consecutive participants from the CenteringParenting program at NFP were included with age-matched controls.

Outcome measures:

Quantitative outcome measures included the number of well-child visits attended, immunization and lead screening rates, as well as breastfeeding initiation and duration. Semistructured interviews assessed maternal, provider, and program staff satisfaction with the program.

Results:

Children participating in CenteringParenting as compared with traditional individual care were demographically similar. Well-child care visits in the first 15 months of life were higher in the CenteringParenting Group (9.19 vs. 5.28, p < 0.001), which also exhibited a trend toward higher rates of completing noninfluenza immunizations. There was no difference in lead screening, with high percentages of completion in both groups. Interviews discovered strong maternal, clinician, and staff satisfaction with the program. Mothers noted the unique benefits of learning from and building relationships with each other.

Conclusions:

This study in a community health center indicates that innovative group care models, such as CenteringParenting, hold promise for delivering value-added elements of social interaction between parents and health care staff, in addition to increasing the number of visits attended by parents and children in the first 15 months of life. Future study is needed to further elucidate maternal, population health, and cost benefits.

Introduction

Well-child care has been a cornerstone of primary care practice for decades, providing an opportunity for parents and guardians to ensure the health and well-being of children from birth through adolescence.¹ Most well-child visits occur in the traditional individual office visit model; however, prior studies have documented limitations in this model related to time and the inability of clinicians to cover all recommended preventive care and anticipatory guidance.^2
–4

To address the limitations associated with individual well-care visits, a promising group well-child care model was developed by the Centering Health care Institute. This model, which builds on the success of the CenteringPregnancy group care model, is known as CenteringParenting. CenteringParenting has been implemented in diverse practices serving pediatric patients; however, to date, literature evaluating it has been limited.^5
–7

CenteringParenting group well-child visits are generally 90–120 min in duration with a combination of health care staff and clinicians.^4,8,9 Group well-child care is unique, in that the parents play a pivotal role in supporting their children's growth and development. During group visits, parents may participate in their child's assessment and meet with the health care provider.^7,10 The remainder of the time is spent in group discussion guided by the parents and their needs with a curriculum used flexibly.⁷

The CenteringParenting model builds on these elements of 120-min group well-child visits at 1, 2, 4, 6, 9, 12, 15, 18, and 24 months of age. During the course of this evaluation, group visits concluded at 15 months of age with a return to traditional care at the 18-month visit, however based upon current recommendations, future CenteringParenting cohorts will extend to 24 months of age at this study site. At each visit, parents perform standard well-child measurements on their children in the group setting, including head circumference, weight, and length. Parents also track their child's growth and developmental milestones in a Centering handbook. Each parent–child dyad has individual time in the group setting with the clinician to discuss concerns and for physical examination; however, most issues are brought to the group for discussion. Immunizations and testing, such as lead and hemoglobin when indicated, are provided in the shared setting at the end of the group visit.

Because of the promise of group parenting visits and the early stage of scientific knowledge of the CenteringParenting approach, a pilot study was conducted, which aimed to explore maternal participants' experiences with CenteringParenting, identify clinical outcomes of children participating in CenteringParenting compared with those receiving traditional well-care visits in the same community health center, and explore organizational stakeholders' experiences with the program.

Materials and Methods

Setting

This study was conducted at Neighborhood Family Practice (NFP), an urban federally qualified community health center located on the west side of Cleveland, Ohio. In 2018, NFP served 18,931 patients through 71,165 patient visits with a scope of services, including medical, behavioral health, midwifery, and dental. NFP is an accredited Centering Health care Institute site for both CenteringPregnancy and CenteringParenting.¹¹ Through the CenteringPregnancy group care model, NFP served 431 pregnant women between 2011 and 2017 with clinical maternity care outcomes proving to be better than the Healthy People 2020 (HP2020) goals with a low birth weight rate of 5.6% (HP2020 goal <7.8%), a 3.7% preterm birth rate (HP2020 goal <9.4%), and 88% initiation of breastfeeding (HP2020 goal 81.9%).¹² Given these early recognized clinical benefits of CenteringPregnancy at NFP, a CenteringParenting program was initiated in 2015 and has served 54 mother–baby dyads through November 2018.

NFP employs a full-time patient advocate who is also a trained CenteringPregnancy and Parenting facilitator. This staff member manages the program, including recruitment, and cofacilitates all sessions with a clinician. During this study, both parents were invited to attend all sessions in both programs and fathers frequently attended, although none volunteered for participation in this study. The attendance of families at CenteringParenting sessions during the evaluation period ranged from 2 to 8. Higher attendance was observed on visits where vaccinations were provided. All participants were provided with a CenteringParenting handbook at the first visit and subsequent visits followed the curriculum outlined in the handbook. Additional topics were also included as needed based upon parental questions or concerns and to standardize to other clinical needs in the population, such as mandated lead screening. The lead author in this study is a CenteringParenting facilitator and clinician at NFP; however, the other authors had no direct role in implementing this program.

Mixed-methods approach

A mixed-methods approach employing quantitative and qualitative methods was chosen to analyze a diverse array of data. The study protocol was approved by the Case Western Reserve University Institutional Review Board. A convergent parallel (or concurrent triangulation) strategy was implemented in which both quantitative and qualitative data collection methods were simultaneously conducted. Qualitative data were collected through semistructured interviews and a comments section at the end of a parent survey, while quantitative data collection included chart review and parental surveys.

Parents of all children who completed the CenteringParenting program with participation in ∼50% of visits for each cohort at the time of study initiation were invited to participate. All mothers of children in the study group received care in CenteringPregnancy at NFP. Control subjects were also randomly selected from infants whose mothers received prenatal care through CenteringPregnancy at NFP born in the same time frame as CenteringParenting study participants to provide a comparison between children whose mothers received the same type of prenatal care.

Semistructured interviews were conducted by purposively selected NFP staff members who worked with the CenteringParenting program. Interviews were conducted with key stakeholders, including administrative staff, clinical providers (physicians and nurse practitioners), and CenteringParenting program staff (Centering-trained patient advocate and group facilitator). To provide an observer perspective within the organization, one provider with experience in caring for children apart from the program was also interviewed. Ten interviews were conducted in a semistructured manner, and written notes were taken. Note accuracy was confirmed with participants either through direct readback at the time of the interview or through review of written notes. Themes were extracted after review of interview notes. Notes were initially analyzed in groups based on staff role to assess for themes within departments. Thematic analysis was then conducted across all interviews to identify broad themes organizationally.

Mothers who participated in CenteringParenting were invited to focus groups; however despite verbal commitments, only one mother arrived at each session, thus these interactions were converted to semistructured interviews. These mothers were provided with $15 USD gift cards for participation. No other study participants received incentives. These data were analyzed in conjunction with qualitative comments obtained on maternal surveys as described below.

The electronic health record of the child of each participating mother was reviewed for the following outcomes: number of well-child visits with a physician or nurse practitioner, completion of recommended vaccinations according to Centers for Disease Control and Prevention recommendations, and completion of lead screening at 12 months of age per Ohio law for children covered by Medicaid.¹³ These measures were chosen as modified Healthcare Effectiveness Data and Information Set measures, which are accepted measures of health care quality and frequently cited population health care metrics.¹⁴

Influenza vaccination rates were assessed separate from other vaccination completion because guidelines require two vaccines ∼28 days apart during the first flu season children are vaccinated. Rotavirus vaccine requirements changed during the study period, thus completion was defined as two vaccinations of either valency.

The second quantitative measure was a survey sent to all maternal participants of CenteringParenting at NFP. The survey was sent through the electronic health record patient communication portal (EPIC MyChart) to those with an active account (n = 44). One reminder message was sent to encourage participation. Five surveys were completed. The survey included questions related to maternal experience with CenteringParenting, program impact on breastfeeding practices, confidence in caring for their child, and access to health care services. Participants were also asked to report what they most valued about the program.

Statistical analysis comparing CenteringParenting and control group patients used t tests for continuous variables and Fisher's exact tests for comparisons of rates.

Results

Perspectives from the semistructured interviews

A high degree of congruence of perspective was seen across CenteringParenting staff, clinical providers, and administration, with patient experience seen as a key factor in determining program value. Maternal social support, a feeling of community, and an opportunity for relationship building between mothers and office staff were cited as critical elements of the program's utility. Clinical metrics, such as immunization rates, were noted as important variables for continued organizational commitment to this model of care.

Clinical providers noted that the program is parent centered, while offering unique clinician benefits and an enjoyable way to observe and interact with parents and children not possible in traditional office visits. One clinician commented, “You get to see what's important to the parents, what questions they're addressing when it's up to them to lead.”

Administrators spoke of the desired outcome of improved maternal mental health and parental confidence in caring for their child, as well as the need to address barriers and challenges associated with the program such as recruitment and dedicated provider time away from traditional clinical productivity. CenteringParenting program staff identified the program as a better care experience, including the unique opportunity for mothers to build relationships with each other.

“You're letting the group down by not being there…the value becomes the group, and what they're learning and sharing, and not as much about the one on one interaction with the doctor.”

—Administrator interviewee

“Provides women and families opportunity to build social capital with each other.”

—Clinical Provider interviewee

“Sense of community is really beneficial especially for moms who lack resources and interactions with other moms.”

—Program Staff interviewee

“…I like the community aspect the best. The idea of it takes a community to raise a child takes place here. Especially since I don't have one elsewhere…”

—CenteringParenting mother

In open-ended survey responses and interviews, CenteringParenting mothers described the newness of the motherhood experience and the opportunity to learn about caring for their infants and themselves through this program. Further, interviewees stated that they left their first CenteringParenting group feeling “excited.” Mothers stated, “I couldn't wait to keep coming, I wish it lasted longer and I wish my child didn't age out after 1 year, I would have liked to see it last the first 2 years.” One participant noted that the group provided resource and networking opportunities between mothers. “Being with people I felt comfortable to talk to without feeling awkward or judged” was also highlighted as an important benefit. Both parental interviewees identified distractions inherent in the group dynamic as a difficulty.

Quantitative clinical results

Table 1 details the demographic information for the two groups. There were no statistically significant differences in median age, race, ethnicity, or percentage participating in Medicaid. Table 2 details the results of the analysis for the three clinical outcomes. On average, infants in CenteringParenting participated in 3.91 more (p < 0.001) well-child visits in a 15-month period compared with control participants who experienced traditional well-child care. Immunization completion without flu was higher among the Centering group, with a trend toward statistical significance (p = 0.056); but with influenza, the difference between the two groups was not statistically significant. Lead screening was also not significantly different, with both groups being nearly equal with high percentages of completion of ∼75%.

Table 1.

Participant Demographics

Participant characteristic	Centering (n = 32)	Noncentering (n = 25)	p
Mean maternal age	26.8	25.6	0.435
Race
White	27	18	0.332
Other^a	5	7
Ethnicity
Hispanic	13	7	0.406
Non-Hispanic	19	18
Medicaid (%)	78.1%	88%	0.487

Analysis did not allow for further division due to small sample sizes.

Table 2.

Clinical Outcome Comparisons

Outcome	Centering (n = 32)	Noncentering (n = 25)	p
Well-child visits (mean)	9.19	5.28	<0.001
Immunization complete (not including influenza), n (%)
Complete	28 (87.5)	16 (64)	0.056
Not complete	4 (12.5)	9 (36)
Immunization complete (including influenza), n (%)
Complete	15 (46.9)	7 (28)	0.178
Not complete	17 (53.1)	18 (72)
Lead screening
Complete	24 (75)	19 (76)	1.00
Not complete	8 (25)	6 (24)

Parent survey results

Parent survey respondents as noted in Table 3 (n = 5) revealed significant overall satisfaction, which was supported by the following accompanying quote: “As first-time parents, CenteringParenting gave us the confidence, knowledge, and resources to raise our baby from Day 1. Our Centering classes were incredibly helpful for us to get timely information from our doctor and share stories with other parents in our birth cohort. We absolutely loved our CenteringParenting classes and would whole-heartedly recommend it to other parents considering the program. Thanks for offering such a valuable program! We are eternally grateful!”

Table 3.

Demographics of Survey Respondents

Mean maternal age (n = 4)	30.75 years
Race/ethnicity (n = 5)	White/Caucasian (4), “Human” (1)
Number of children (n = 5)	1 (4), 2 (1)
Birth order of child who was/is in CenteringParenting (n = 4)	1st (3), 2nd (1)
Health care insurance (n = 5)	CareSource [Medicaid] (2), Buckeye [Medicaid], UMR [Commercial], Blue Cross Blue Shield [Commercial]

UMR, United Medical Resources.

Additional electronic survey results showed that 60% (n = 3) of respondents breastfed for >6 months (40% for 12 months), with all breastfed infants (n = 3) being exclusively breastfed during the first 6 months of life. The majority of respondents (60%, n = 3) reported meeting with other parents during the session as the most useful part of CenteringParenting, while one respondent noted education during the group session and another playtime between the babies as most important. About 60% of respondents also indicated the second most important element was time with the provider and 40% identified having more time for the visit as their second most important component. One hundred percent of respondents were likely or very likely to join a future CenteringParenting group, and all respondents reported being very likely to recommend CenteringParenting to other parents.

Discussion

CenteringParenting participants consistently reported a positive experience of care in the program through the 1st year of life and articulated many benefits of participation that are not possible in traditional care. For example, the following key program elements were highlighted by participants, including interaction with other mothers, as well as comprehensive education and discussion during extended time (120 min) with a clinician. Additionally, mothers highlighted the value of obtaining resources, such as those listed in Table 4, during CenteringParenting sessions. These results are similar to those found by Mittal who reported on a CenteringParenting pilot where mothers identified that they most appreciated the support of other mothers and the opportunity to develop closer relationships with their providers.¹⁵ Resident physicians in that study noted that the women are empowered by teaching each other and were “supported in their own context by their peers from the community.”¹⁵

Table 4.

Examples of Services or Resources Accessed Through CenteringParenting

1. “I have been provided a thermometer when I did not have one and they also gave me a sleep sack for my baby because blankets while baby is sleeping is not recommended.”

2. “Farmers market coins”

3. “My baby loved the group play with other babies near her own age, I enjoyed talking with other mothers and discussing being a new parent and exchanging advice. I also remember things being offered to help new moms, pack n plays etc. We also loved that they gave us free board books when we visited.”

These results also indicate that those participating in CenteringParenting received more well-child visits than those participating in traditional care. These findings are similar to a study by Johnson et al.¹⁶ that reported families who received care in CenteringParenting received a total of 12 contact hours with public health clinics, compared with 3 h in a typical care model over the 1st year of life. That study also reported improved immunization rates (100% vs. 95% at 4 months, and 100% vs. 50% at 12 months, with nonoverlapping 95% confidence intervals determining significance due to small sample sizes) for CenteringParenting infants.¹⁶ In addition, breastfeeding rates at 6 months were higher at 81%, compared with 59% for the province, though exclusive breastfeeding in the control group was higher than that in the Centering group at 4 months (60% compared with 36%, though not statistically significantly different).¹⁶

Interview data, including representative quotes above, indicate the statistically significant increase in well-child visits as compared with traditional care may be related to social interaction between mothers within the group, providing a value not possible in traditional individual visits. These findings were further corroborated by survey data, indicating that participants viewed interactions with other mothers as one of the most important program elements.

This study also highlights the opportunity to strengthen ambulatory and preventive population health outcomes, such as exclusive breastfeeding initiation and duration and increased number of well-child visits in the first 15 months of life. Future study of CenteringParenting programs should include larger samples and emergency department utilization data, control comparisons of breastfeeding initiation and duration within the same clinical practice to determine if the effect is related to strong organizational lactation support or a function of the CenteringParenting program, additional immunization data, adherence to safe sleep practices, parental smoking status, and linkage to prenatal data from the CenteringPregnancy program. Strengthening evidence around population health metrics in this model will provide guidance for other practices regarding implementing innovations in group care models. Furthermore, a study including risk factors for infant mortality may provide evidence for expanding group models to reach populations with inequities in infant mortality related to modifiable risk factors, such as parental smoking, safe sleep practices, and breastfeeding.

This study also highlighted multiple organizational benefits of the program, including clinical provider and program staff satisfaction with the model, which has the potential to reduce clinician burnout, which remains a dilemma across multiple health care institutions.^17,18 Maternal satisfaction with the model and increased access to care through CenteringParenting are also important organizational considerations for care model innovations that were found in this study. Furthermore, social determinants of health remain challenging to address in traditional models of care, but were highlighted as being more readily addressed during CenteringParenting in this study. At NFP, parents have access to portable cribs to enhance safe sleep practices, other baby items such as thermometers, new books through Reach Out and Read, and incentives to facilitate healthy eating such as produce prescriptions and farmer's market coins. All of these resources are available to all NFP patients except for produce prescriptions and farmer's market coins, which are specifically available to families in CenteringPregnancy and Parenting. Additional studies should include an evaluation of resource assessments and provisions that address social determinants to determine if they are more readily utilized through CenteringParenting as compared with traditional care.

Fewer women participated in CenteringParenting as compared with CenteringPregnancy at the same community health center. Future study needs to identify reasons for limited enrollment to consider program improvement and feasibility in other settings. Additional future evaluation measures should also include indicators of maternal health. These were not included in this study due to time and resource limitations, but will enhance understanding of CenteringParenting impacts on the heath of mothers as well.

Cost data were not analyzed in this study, but future studies should include a cost-effectiveness analysis. Program start-up costs were covered by grant funds; however, program sustainability must be considered with regard to the impact on clinical revenue in the context of the value-added elements of the program. The group well-child care model has been studied elsewhere and found to be cost-neutral with the proper ratio of participants.⁹

The limitations of this study include a small sample size and narrow time frame. While the data are promising, generalizability to other settings is limited. Future studies of CenteringParenting programs longitudinally and with additional study elements, including parental surveys of a control group, will provide helpful insights on the scalability and sustainability of this promising innovation in group well-child care. Additional study may also provide an opportunity to link this type of model to broader population health outcomes, such as infant mortality, particularly when considering high rates of exclusive breastfeeding.

Conclusions

Well-child care is an important vehicle to facilitate periodic preventive health care and anticipatory guidance. This study in a community health center indicates that innovative group care models, such as CenteringParenting, hold promise for delivering value-added elements of social interaction between parents and health care staff, in addition to increasing the number of visits attended by parents and children in the first 15 months of life. Future study is needed to further elucidate population health and cost benefits to this program, particularly with an extension to 24 months of age.

Footnotes

Acknowledgments

The authors thank the leadership, staff, and patients of Neighborhood Family Practice for their support of this study. They also thank Robin Gotler for his support in preparation of this article.

Author Disclosure Statement

No competing financial interests exist.

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