ABSTRACT
Well-Child visits (WCV) are an opportunity to maximize the health, development, and future well-being of
children. Scheduled but not attended (“no-showed”) visits can lead to negative health and economic
consequences for patients and families (delayed preventive care including screening and immunizations, and
avoidable ED visits and hospitalizations) and for the healthcare system (decreased efficiency and productivity,
lower quality measures, productivity, and revenue loss). Though adherence to the WCV schedule has
improved for the U.S. population over time, disparities persist. Children who are less adherent to the
recommended WCV schedule are more often to be identified as Black or African American, as Hispanic or
Latino, or are uninsured or publicly-insured. There is a need to identify high impact, cost-effective approaches
to engage families who have missed WCV, especially among minority and low-income populations.
Health systems increasingly utilize technology such as text messaging or personnel such as community health
workers (CHWs) to interact with patients or caregivers, and both approaches indicate positive effects. Indeed,
pilot work from this research team comparing text message follow-up only to usual care suggested that
sending text messages contributed to greater completion of a WCV within six weeks of no-show for some
families, but that there is a need to look at patterns over a full year to eliminate seasonal variation. CHWs are
most typically engaged following provider referral, hospitalization, or recurring ED utilization, and so there is a
need to explore deploying CHW resources in a more preventative manner through outreach following a missed
visit. No-shows may reflect barriers to care that include social drivers of health, which CHWs are well-
positioned to address, and through a relational approach CHWs may help promote ongoing engagement in
preventive care for families. Moreover, economic evaluation of technological and relational follow-up combined
with trial data about which strategy(ies) works for whom can help inform resource allocation.
The aims of this exploratory study are to: (1) demonstrate feasibility of merging a new referral protocol into
existing resources for CHW outreach following WCV no-show; (2) compare WCV attendance following no-
show between families who receive care-as-usual, text message (low-touch), and CHW outreach (high-touch)
interventions, using a year-long randomized controlled trial; and (3) define costs and cost-effectiveness of
using a low-touch or high-touch intervention to improve WCV attendance compared to care-as-usual. The
study will reach a demographically diverse, urban population, in English and Spanish.
Findings from the proposed study will help inform a future, larger scale trial that expands into rural areas and
other health system markets, tests tailored strategies for no-show follow-up, and incorporates advanced
economic simulation methods to consider implications of applying such strategies to even larger populations,
all with the long-term goal of reducing disparities in pediatric preventive care.
