Using Key Informant Interviews to Identify Areas of Improvement to Assess and Manage Kindergarten Readiness

Background: NC Integrated Care for Kids (NC InCK, ncinck.org) is an innovative child-centered local service delivery and payment model across five North Carolina counties to improve the health and well-being of children insured by Medicaid or the Child Health Insurance Program (CHIP). A priority performance measure in the NC InCK model is kindergarten readiness, which reflects a meaningful cross-sector measure of child well-being. Kindergarten readiness will be measured in schools, and NC InCK aims to increase rates of kindergarten readiness.

Methods: To guide the development of NC InCK kindergarten readiness interventions, we conducted key informant interviews with pediatricians (N=10) in eight unique pediatrics practices. A semi-structured interview guide was developed and piloted. Interviews explored how kindergarten readiness is currently assessed in primary care, issues affecting equitable access to the assessment and promotion of kindergarten readiness, and potential office-based interventions to improve kindergarten readiness. Interviews were audio-recorded and transcribed. Thematic analysis identified key themes, subthemes, and illustrative quotes using Dedoose qualitative analysis application.

Results: When describing kindergarten readiness assessments, respondents described challenges posed by current screening tools (process limited to developmental and physical assessments; need for a brief office-based tool); timing (occurring later than ideal to improve readiness), and personnel bandwidth (assessments generally completed by pediatricians who are eager to involve nonphysician staff). Respondents described multiple intersecting challenges to equitable kindergarten readiness assessment and promotion, including language access, cultural sensitivity, and funding and policy issues (e.g., families with decreased access to pre-K services). Respondents also identified multiple opportunities for kindergarten readiness improvement through primary care including: increased staff training and involvement; office-based approaches (systematic outreach, literacy programs); and stronger linkages and engagement with multiple community-based organizations that promote kindergarten readiness (Pre-K programs, Head Start).

Conclusion: Practicing pediatricians identified numerous challenges to screening for and addressing kindergarten readiness in primary care. Initiatives such as NC InCK can leverage clinical and community resources to further improve both the assessment and management of kindergarten readiness in young children. Improving kindergarten readiness in partnership with health systems will require changes and support for office practices (e.g., staffing) and improved information sharing between clinical practices and community agencies. Information obtained through these interviews is being used to guide the development of a kindergarten readiness promotion bundle, which will be part of the pediatric alternative payment model (APM) structure that will be implemented within Medicaid Managed Care by NC InCK.