Home visiting programs provide graduate medical training an ideal form of experiential and immersion learning to fulfill ACGME educational competencies. Bringing the health provider to the home bridges the gap in understanding the patient's/family's strengths and priorities and improves trust, which is linked to better health outcomes. The growing cultural diversity of the U.S. population, continued health disparities, and rise in importance of behavioral modification to address chronic disease amplifies the importance of strengthening the patient/family-physician relationship. The dearth of structured home visiting programs described in the literature underscores the need to identify best practices to incorporate home visitation into graduate medical education. The Health Begins at Home (HBH) Pediatric Resident Newborn Home Visiting Program was designed and implemented in 2008 by the Johns Hopkins Pediatric Residency Program. The aims of HBH are to: 1) Increase resident awareness of family, environmental, cultural, religious, and socioeconomic factors that affect their patients; 2) Change resident knowledge, attitudes, and behaviors regarding the patients, families, and communities they serve; and 3) To increase family trust in a pediatric resident primary care provider after a newborn home visit to at-risk, low-income families. Residents serving as primary care providers of newborn infants participated in HBH, an educational home visit intervention consisting of an hour educational module on home visiting and social determinants of health, a home visit to a newborn who is their longitudinal primary care patient, and a debriefing session to share lessons learned with other residents. Post-HBH residents demonstrated a significant positive change (all p < 0.05) in: adequacy of medical knowledge, understanding of home and community, excitement about home visits, and less concern about personal safety in the community. These changes were sustained through the end of residency which was 14-22 months post-intervention. Sixty-two percent reported a change in how they treated patients and 94% indicated home visits should be part of the permanent curriculum. Post-HBH mothers who were >90% African-American, publically insured and from a traditionally low trust-in-physician community reported higher trust-in-physician (p<0.01) compared to a control group and particularly increased trust-in-physician advice, judgment, and truth-telling (all p<0.01). Mother's also reported enhanced family involvement in decisions, high quality care, and increased likelihood of bringing their child to visits. All families "enjoyed the home visit" and 97% reported the physician learned important things that would not have been learned through clinic-only visits. Conducting the HBH intervention, resulted in sustained improvement in residents' understanding of the community and the home environment of their patients. Residents overwhelmingly thought home visits provide a uniquely important educational experience and should be part of the permanent curriculum. Mother's report that the home visits increased their trust-in-physician and increased the quality of care their children received. To improve resident knowledge of the family, home, community and social determinants of health, training programs should incorporate structured home visiting programs, like the HBH, into curricula.
KeywordsCurriculum, Health Equity Research, Community Health, Pediatric Resident, Home Visit, Newborns
Megan M. Tschudy, MD, MPH, Johns Hopkins School of Medicine
Janet R. Serwint, MD, Johns Hopkins School of Medicine
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