Category: Clinical Care

3 Conversations You Might Need to Have With Your Teen About Their Weight

Posted on

mom and teen talkingTalking to your teenager about anything beyond what’s for dinner or their weekend plans might feel like pulling teeth. From one-word responses to disinterested tones, plenty of parents feel as though their teens aren’t exactly open books. When it comes to more serious topics, such as body image and weight conversations, it can be even more challenging.

Still, the topic of weight is likely to come up in one way or another. This is because weight and body image are significant parts of our society. While it’s important to avoid telling your teen to lose weight, there are times when you’ll need to respond to a situation that involves their weight or someone else’s.

Here are 3 situations in which you might need to have a conversation about weight — and how to navigate them.

1. Your teen asks about their weight.

If your teen asks about their weight directly, they’re placing trust in how you’ll respond. As a result, it’s important not to avoid their questions and to approach these conversations with honesty and facts.

Your teen might ask about their weight in a number of ways. For example, their health class might be discussing body mass index (BMI), leaving them with questions about theirs. They may even ask something like “Am I fat?” or “Am I too skinny?” You might tell them about BMI, including that it’s one way to measure their health alongside other things like listening to their heart and tracking their height. If their BMI is on the higher end, it means they have extra weight, which can make it so their body has to work harder.

Together, you can discuss ways to stay healthy by focusing on the importance of staying active, eating healthier foods, and limiting sweets. Remind them that staying healthy is also about how their body feels. Extra weight might make them feel tired or sluggish while eating healthy and staying active can help them feel more energetic.

2. Your teen is being bullied about their weight.

Weight is a common reason for teasing and bullying. If your teen is being teased for their weight, it’s important to take it seriously. Bullying can lead to depression, anxiety, loneliness, and lowered academic success, and it can lead to problems in adulthood.

Don’t immediately jump to conversations about how to lose weight if your teen tells you they’re being teased about their weight. Instead, tell them you’re glad they came to you, and ask them how they’re feeling about the situation. Be sure to actively listen while expressing support. Consider involving their school to create a game plan on how to address the bullying.

Remind your teen that their weight is not a reflection of who they are. Point out all of their positive qualities that aren’t related to looks, including if they are creative, kind, smart, or funny.

3. Your teen hears comments about weight from other adults.

Talking about people’s weight — even in a positive way — can make it seem acceptable to make judgments about people’s bodies. While you might be conscious of avoiding body talk around your teen, other adults might not. Whether an adult talks about their own body, your teen’s, or someone else’s, these comments can have a lasting impact.

Start by asking your teen how the comments made them feel, and listen to their responses. No matter what their reaction is, remind them that weight is a factor in someone’s health, but it doesn’t make a person who they are.

If your child expresses concerns about their weight, keep the focus on feeling healthy and how your family can prioritize healthy choices, like cooking meals together or going on bike rides. When your family takes on these habits together, your teen is more likely to stick with them long-term.

Keep the Weight Conversations Going

As with any important conversation with your teen, talking to them about weight won’t be a one-time situation. In fact, the more you foster open dialogue about weight and body image, the more opportunities you have to encourage a positive outlook on weight and health in general.

Remind your teen that they are more than the number on the scale and that talking with you and their pediatrician about how they feel is a better way to monitor their health. Together, you can help your teen have a positive relationship with weight now and into adulthood.

If you have questions about how to approach weight conversations with your teenager, reach out to your child’s pediatrician. They can provide talking points and resources and can make a referral to our Weight & Wellness Program if needed.

How to Master Potty Training in 8 Steps

Posted on

potty trainingThe day has finally come — your child has expressed interest in using the toilet for the first time. Take a deep breath as you begin buying potty training accessories, searching for tips and getting excited about the money you’ll be saving on diapers.

Potty training is a major milestone, and it’s easy to get excited. However, it’s also helpful to have a plan. It’s important to do everything in your power to make the process of potty training go smoothly for you and for your child.

Here are 8 steps to master potty training and say goodbye to diapers for good.

1. Wait until your child is ready to begin potty training.

Before doing anything, make sure your child is ready to start potty training. This depends on your child’s individual needs and development.

While the average age for potty training is 27 months, anywhere between 18 months and 3 years is considered on track.

Take note of all areas of development, including if they are ready:

  • Physiologically: Is their bladder and digestive system mature enough to make it to a toilet? Are their motor skills developed enough to manage their clothing and sit still on the potty?
  • Cognitively: Can they connect having to use the toilet with actually using it? Can they remember to do so? Can they avoid distraction long enough to complete the process?
  • Socially: Are they aware of how others use the toilet? Do they seem to want to imitate that behavior?
  • Verbally: Do they understand when you explain how a toilet works? Can they ask questions about using the toilet?
  • Emotionally: Are they working on their independence? Do they seem to want to use the toilet?

2. Talk with your child about using the potty.

Once you’ve determined your child is ready for potty training, start (or continue) having conversations about using the toilet. Talk about the process. Read books about using the toilet. Ask if they have questions, and answer them clearly.

Decide on the vocabulary you want to use, then stay consistent. While you can choose how to refer to a bowel movement or urine, always use proper names for body parts. This helps promote a more positive body image and sense of self as they grow and develop.

4. Gather your potty training gear.

Start finding your potty training accessories, such as:

  • A floor-level potty with a back. You may want to consider getting one with a flusher that makes noise to mimic the real thing.
  • Rewards, such as stickers, small treats, or small toys
  • A reminder watch
  • Color-changing stickers, which change color when they come into contact with urine

You may also want to create a potty training chart to help your child visually keep track of their progress.

5. Do some practice runs.

Encourage your child to try to use the potty at frequent intervals, including when they are showing signs such as:

  • Facial expressions
  • Noises, like grunting
  • Body language, like holding their genitals
  • Movement, like pacing

Also, have them use the toilet after naps, 20 minutes after meals, and after 2 hours.

6. Praise any success.

The goal of the practice runs is to eventually find success. Praise them for trying (“You’re trying so hard to go pee in the potty!”) and when they succeed (“Great job going pee in the potty!”). Be timely and consistent with rewards for using the toilet, whether you’re using a sticker chart, small toys, hugs, or a dance party to celebrate.

7. Ditch the diapers.

You can usually — for the most part — say goodbye to diapers after about ten successful potty trips with urine or a bowel movement.

While switching to underwear will help your child continue to use the toilet, you can keep diapers around for naps and bedtimes. The goal is to master daytime potty training before nighttime. You can also use diapers for any travel outside the home as necessary.

8. Stay consistent and flexible.

Be consistent about your process, reminders, and praise so your child will know exactly what to expect.

At the same time, stay flexible. While accidents are inevitable, they will start to subside a few months after your child is considered mostly potty trained. If you run into roadblocks — such as your child suddenly refusing to use the toilet — take a step back and reset. Go back to diapers for a week, and restart when you’re both ready.

Support for Successful Potty Training

Potty training is one of many ways you can support your child as they gain independence and confidence. It isn’t easy, but you’re not alone in this process.

If you have questions about how to approach potty training or feel that you’ve hit a speed bump, talk to your child’s pediatrician.

Do you have questions about starting potty training with your child? Reach out to one of our pediatricians for support, resources, and more.

The Language of Children: Key Language Milestones and How You Can Encourage Them to Communicate

Posted on

alphabet language milestonesLong before your child utters their first word, they start communicating with you. From cries to squeals to cooing to even blowing raspberries, they’re experimenting with communication and, eventually, language. As you watch these language milestones unfold, it’s easy to get excited — but it’s also easy to become nervous. You might wonder if your child is achieving milestones at the right times, and you might look for ways to help nudge them along.

Here’s an overview of how much you should pay attention to these milestones, which ones to look out for, and how you can support your child’s language development.

How Important Are Children’s Language Milestones?

From how tall they are to what food they prefer to what makes them laugh, there are many things that make children unique. This includes how quickly and in what ways they begin to communicate.

Every child will develop language at their own pace.

Language development guides simply review when most children will meet each milestone. Your child may not meet each milestone at exactly the suggested time — and that’s okay.

In general, your child should achieve milestones by the top of the age ranges listed below. But if they are missing one skill, don’t worry. This doesn’t necessarily signal a problem.

If your child is missing many or most of the milestones, or you’re concerned about their language development, talk to their pediatrician. They can discuss how to determine if your child is on the right track or if they need some extra support.

Language Milestones to Look For in Your Child: Birth to 5 Years Old

Language development is complex — and it encompasses much more than spoken words. It involves hearing, reactions, gestures, and more. As you watch your child explore ways to communicate, look out for these key milestones starting from birth to 5 years old.

  • Birth to 3 Months

    • Reacts to loud sounds
    • Appears to recognize the voice of caregivers
    • Quiets or smiles when spoken to
    • During feeds, stops or starts sucking when they hear a sound
    • Makes pleasure sounds, like coos
    • Uses different cries for different needs
    • Smiles when they see a caregiver

  • 4 to 6 Months

    • Tracks sounds with their eyes
    • Appears to notice changes in the tone of your voice
    • Pays attention to music and toys that play sounds
    • Babbles in a way that seems like speech
    • Babbles when pleased or displeased
    • Makes gurgling noises while playing
    • Laughs

  • 7 Months to One Year

    • Looks in the direction of sounds
    • Listens when talked to
    • Understands commonly used words, like “cup” or “milk”
    • Responds to basic requests, like “come here”
    • Uses gestures like waving or holding up arms to be held
    • Mimics different speech sounds
    • Likes playing games like “pat-a-cake” and “peek-a-boo”
    • Babbles using short and long groups of sounds
    • Has one or two words by age one, such as “hi,” “mama,” or “dada”

  • 1 to 2 Years

    • Can identify a few parts of the body
    • Follows basic directions, like “roll the ball”
    • Enjoys stories, rhymes, and songs
    • Picks up new words on a regular basis
    • Uses basic questions, like “where doggy?”
    • Puts words together, like “more milk”
    • Can be understood by primary caregivers at least half of the time

  • 2 to 3 Years

    • Uses a word for nearly everything
    • Says two- or three-word phrases
    • Uses the names of objects to ask for them
    • Uses k, f, t, d, g, and n sounds
    • Can be understood by most family members and friends

  • 3 to 4 Years

    • Answer simple questions, like “who?” and “where?”
    • Talks about their day
    • Uses four-word sentences
    • Hears if you address them from a different room
    • Speaks without needing to repeat syllables or words

  • 4 to 5 Years

    • Answers basic questions about a short story you read together
    • Uses sentences with many details
    • Tells stories that remain on topic
    • Communicates with ease with other people
    • Understands most of what is said by others
    • Says most sounds correctly (with the exception of l, r, s, v, z, sh, ch, and th)
    • Uses words that rhyme
    • Names a few letters and numbers

How to Encourage Your Child’s Language Development

Supporting your child’s language development starts with simply communicating with them — even at a young age. In the early stages of development, you can support your child by:

  • Narrating what you’re doing
  • Reading books and singing songs together
  • Helping them mimic actions, such as clapping
  • Repeating sounds back to them
  • Acting pleased when your child speaks

As they get older, teach them new words. Talk about things like colors and shapes. Discuss objects around the house, while you’re out, and keep reading to them often. The world around them is full of ways to learn language in a real and meaningful way.

Although “baby talk” is okay on occasion, use correct grammar when you talk to your child. Ask them to repeat themselves if you don’t understand them, and encourage them to ask for help if they don’t understand a word.

If you’re concerned your child’s language isn’t where it should be, talk to their pediatrician. They can refer you to a specialist if necessary, such as a speech-language pathologist, who is trained in children’s language development.

Helping your child communicate is just one of the many responsibilities and honors you have as a parent. While it’s important to monitor their progress and support their development, remember that children are sponges. they’re always soaking up everything you do and say. By simply chatting about your day with them, you’re providing them with real-life and engaging practice in using language.

If you have concerns about your child’s language development, reach out to their pediatrician. They can help you determine the best way to support your child’s communication.

Nebraska Pediatric Clinical Trials Unit: How Children’s is Contributing to Pediatric Research [Podcast] – Part 1

Posted on

For many years, pediatric research has not been at the forefront of clinical trials. The Nebraska Pediatric Clinical Trials Unit (NPCTU) aims to fill the hole and provide much-needed research in the field of pediatric medicine.

At Children’s Nebraska, Russell “Rusty” McCulloh, MD, has made clinical trials for pediatric research his mission. He is the Director of the NPCTU, and the Division Chief for Pediatric Hospital Medicine at Children’s and the University of Nebraska Medical Center.

Dr. McCulloh explains more about NPCTU and a trial that Children’s is participating in — Pharmacology of Understudied Drugs in Children (POPS Study).

Topic Breakdown

0:26 — What is the Nebraska Pediatric Clinical Trials Unit?

7:00 — Types of medications being studied at Children’s trial

10:55 — Addressing ethical concerns with children and clinical trials

15:38 — How to get patients and families involved in the study

Transcript

CHN News: Hello, everyone. Welcome to the CHN podcast.

We are speaking with Dr. Rusty McCulloh, who is the Director of the Nebraska Pediatric Clinical Trials Unit, and the Division Chief for Pediatric Hospital Medicine at Children’s Nebraska and the University of  Nebraska Medical Center. Dr. McCulloh, thank you so much for here with us today.

Dr. McCulloh: Well, thank you so much for having me. It’s great to be here.

CHN News: In a nutshell, what is the Nebraska Pediatric Clinical Trials Unit?

Dr. McCulloh: The Nebraska Pediatric Clinical Trials Unit is a program funded by the National Institutes of Health whose objective is to extend clinical trials opportunities for children and their families in our region and to increase the ability of institutions in our region to develop conduct high-quality pediatric clinical research for the benefit of children and families in our community.

It is part of the Environmental Influences on Child Health Outcomes (ECHO) program that’s funded by the National Institutes of Health, whose overarching objective is to identify important and pragmatic ways to improve the healthy growth and development of children through better understanding of what influences the development of children in five general main areas.

These include: pediatric obesity; neurodevelopment (brain development and nervous system development); respiratory diseases and development; pre-, peri-, and post-natal exposure and outcomes — which includes anything from healthy pregnancies to safe deliveries to exposures that moms or infants can experience that impact their growth or development; and positive child health outcomes — which includes a variety of things ranging from the influence of technology on healthy brain development and behaviors to sleep hygiene.

CHN News: All of these things you’ve just mentioned are part of the ECHO program, correct?

Dr. McCulloh: That’s part of the ECHO program. Our piece of it — the Nebraska Pediatric Clinical Trials Unit — participates with 16 other states across the US in a clinical trials network called the IDeA States Pediatric Clinical Trials Network. The aim of this network is to identify and implement high-quality pediatric clinical trials to help ensure that the best treatments are available for children and their families from communities like ours and like the other states that are participating.

These states range all over the country. They are IDeA states — meaning that they participate in the Institutional Development Award program that the National Institutes of Health conducts.

These are states that don’t get as many federal dollars for research as their peer states. This way, we are supporting the development of high-quality researchers from within those states. So people who grow up in Nebraska have just as good a chance as folks who grow up in Illinois or Iowa or other non-IDeA states to pursue a career in scientific research and health sciences and health-related research.

These states include places like Alaska and Hawaii on the west coast to places like Vermont, New Hampshire, and South Carolina on the east coast, and then a bunch of states in the middle — including North Dakota, South Dakota, Nebraska, Kansas, Oklahoma. Lots of states — about ⅓ of the country — are participating in this network.

We’re focused on just a few clinical trials right now to help us get things started because we’ve only been around for the last 2 years or so. We’re building the car as we’re driving it, so to speak.

CHN News: And those 2 that you’re working on now are the POPS study and Vitamin D study?

Dr. McCulloh: Yes, and both of them are really great examples of clinical trials that are practical and can improve the lives of children and their families.

The POPS study — also called the Pharmacology of Understudied Drugs in Children study — focuses on improving our dosing of medicines that are commonly used in children. What I think is important to note is that 80% of all medicines that are used in children are used off-label, meaning that there’s not clear dosing guidance in the same way that there is for adults.

This means that what we’re providing in terms of the doses of medicines to children may not be the best fit for the treatment of the conditions. The analogy I give is: a newborn baby wears a certain size sock and an adult wears a certain size sock. No one would expect that the sock that fits a newborn baby would be the appropriate fit for an adult, so why would we expect that that adult sock should fit those children’s feet? And that’s the way that these medicines are: they’re the adult sock that we’re trying to put on that kid’s foot.

We participate with about 50 other sites across the country — and a few international sites. This project focuses on medicines that children are already taking — they’re not getting put on anything new — and we’re asking for a little blood sample to study the drug levels of the medicines they’re taking to see whether the dose they’re getting is the best dose for those medicines for them.

We don’t use any extra or experimental medicines. We’re looking at what we’re already doing and trying to improve that dosing.

The study had been going on long before we got involved — the last 10 years or so. And it’s helped change some of the labelings for certain medicines and it’s improved our understanding and our dosing for dozens of medicines over time: common things, like antibiotics, things like antiseizure medicines, blood pressure medicines — all sorts of things that kids get that if you give them the right fit, they’ll do much better.

CHN News: You mentioned blood pressure and seizure medications. There are so many different drugs and conditions that are being studied in the trial — are there any that are particularly being studied at Children’s right now?

Dr. McCulloh: There are a few that we’re looking at more closely at Children’s. A lot of the medicines that we’re focusing on have to do with safely putting a child to sleep for a procedure — so sedation medicines — particularly in young infants.

There are also some medicines where we’re looking at both the level of the medicine in the blood and also in the spinal fluid. For children who happen to be giving spinal fluid samples while on this medicine, we’re looking at those drugs as well. And those are typically antibiotics.

And the reason why that’s important is because — particularly for antibiotics — the level of the medicine in your blood, only a small fraction of that gets into your spinal fluid. So, having a better understanding of how much gets in there is really important to ensuring we give the right dose. Because that’s how we treat those severe bacterial infections that we require antibiotics: you give those antibiotics through the blood and then it gets filtered to the spinal fluid.

Ones that we’re looking at in the future are medicines used in children who undergo open-heart surgery — particularly babies who have to undergo open-heart surgery. As you can imagine, the research in that area is very slim because of how few of those babies at any one place in the country are experiencing those surgeries at any given time. So, we’ll be working on that as a focus. It’s good because the medicines that we use there — steroids — can help a lot with how children do after open-heart surgery.

We’re also looking at the use of steroids in premature infants as well. Those medicines often get used in the Neonatal Intensive Care Unit, so ensuring that we’re using the best doses there is really important to make sure these kids do as well as possible and benefit as much as possible from the medicines.

CHN News: Have you been able to use any of your research and results at Children’s so far?

Dr. McCulloh: Not yet. We just started work in this POPS study in the last 6 months or so and we’ve had a few folks enrolled. It takes time to have enough children enrolled in the study to have enough information to present out to change practices.

But we do have results that have gone into the larger study that will be used for future research publications that will help change guidance on dosing.

I think it’s important to note that one of the reasons that our network even exists is that most pediatric clinical trials don’t successfully enroll all of the children necessary to complete the clinical trial.

And not as many clinical trials get started in the first place for children because they’re more expensive to run, there are lots of differences in how children respond to medicines based on their age, and — unlike adults — there’s a much smaller market for those medicines. So, drug companies often don’t have as much of a financial interest to support that sort of research.

This is why 8 out of 10 drugs have not been studied robustly or fully in pediatric populations. So we have to go back and try to fix that.

CHN News: Are there more ethical concerns about doing clinical trials involving children?

Dr. McCulloh: they’re a bit different. For children under the age of 7 and those who don’t have decision-making capacity, their parents are essentially making the decision on their behalf whether or not to participate in that clinical trial.

And what goes into that decision-making is different for parents than if that parent was the research subject themselves. There’s a lot more interest in the benefit or how uncomfortable the study is going to be. Some parents have a lot of concern regarding comfort in participating in a clinical trial — more than they would potentially if they were participating or making the decision for themselves to participate.

When children are older and have some decision-making capacity, but are not yet adults, their perceptions of the study get taken into account as well.

So, it’s a different sort of consent process. Although what other researchers have found in surveying children and families is that there’s a strong desire to participate in clinical trials among children and families — particularly families with children who have chronic medical conditions — because it helps them better understand their own medical condition, and because it feels like they’re contributing toward a greater good. And that in and of itself can be therapeutic and provide benefit to the individual, even if the study they are participating in may not benefit them directly.

CHN News: You also mentioned that dosing changes by age. Do you follow these kids that you’re working with as they get older or do you take a one-time sample?

Dr. McCulloh: That’s a great question. The way that this study works is that, rather than try to follow the same child over many years, they recruit different age groups of children — about 25 kids for each of the age groups — and those age groups include young infants in the first few months of life, infants who are born premature, and then by clusters of years.

There are also special populations focused on children with obesity because obesity has an impact on where medicines go throughout your body. And also, [we have a special grouping for] children who are on a heart-lung machine — because those medicines often may stick to the plastic of the tubing — and these are some of the sickest patients.

So, making sure we get the right dosing for the sickest patients is super important for them as well. Not that it’s not important for everybody, but in this group, in particular, the risk of not getting the right dose may have a larger impact because of how sick they are.

CHN News: If they have multiple conditions or are on multiple types of medications, can they be in this trial or does it have to be someone who’s really just on one medication?

Dr. McCulloh: They can be on multiple medicines. They can even be on multiple medicines that are being focused on in the study as well. We obtain samples — with their permission — for each of the drugs of interest that they are on. There’s not a limitation from that standpoint. The only limitation is: are you on a medicine of interest already — because we don’t want to put you on any medicines — and are you in a right age category or medical condition category to participate in the study.

The study is pretty straightforward. For many of the children we see, they already have IV access, so we can get the blood without having to do a poke. For other children, we can do it with as small amount of blood as possible — like a finger poke, not having to put a needle in the vein.

CHN News: When you are working with kids who are on multiple medications, do you also get good information on drug interactions?

Dr. McCulloh: We do. It’s not a primary focus of the study, but we do get a lot of information about how those drugs may interact when they’re given at the same time. And that’s information that can be shared with people who are focused on improving on dosing or learning more about drug-drug interactions as they are developing new medicines.

CHN News: You’d mentioned some of the upcoming tests you’ll be doing at Children’s. Is there anything else on the horizon for this study?

Dr. McCulloh: The really good news is that the National Institutes of Health said this program has been so successful that they’re renewing it for another 8 years. We anticipate participating in this study for many years to come.

We also have the ability to propose new drugs of interest through the network with our participating researchers. There is always the opportunity for patients and families to make their voice heard and say, “These are medicines that are important to us and our community.”

We would love to hear more of that because I think the more input from the community on research a) the better people understand the process and b) the more trust there is in the process. It should be this cycle where we try to answer important questions based on what the community tells us is important — at least in part — and that we share what we find back to the community, so they understand what happened and what we learned.

The last piece is that for folks who are interested in learning more about the study, we do have it listed on the Nebraska Pediatric Clinical Trials Unit website, which has a lot of patient and family information. And folks can also express their interest if they sign up for the Nebraska Pediatric Participant Registry.

CHN News: And is this also where providers should go if they think they have a patient who might be interested in this?

Dr. McCulloh: Yes. I will say that we’re conducting the study right now at Children’s Nebraska and the clinics that are connected, and at the University of Nebraska Medical Center’s main campus — because there’s a bit of a time limit on when the blood sample has to be put in the freezer, so that we make sure we get accurate drug levels from that blood sample.

But absolutely, if folks are interested and they aren’t on those campuses, they can feel free to reach out if they’ve got some interest in learning more about the study.

CHN News: Can providers who are not a part of Children’s refer patients to Children’s for this study?

Dr. McCulloh: They can. That’s absolutely something we would be happy to talk about. We can obtain consent from a child and their family and obtain the blood sample here at Children’s with the help of our research coordinators.

CHN News: Dr. McCulloh, thank you so much for your time today, and for telling us more about the Nebraska Pediatric Clinical Trials Unit and the POPS Study.

Dr. McCulloh: Thanks for having me.

If you are interested in learning more about the Nebraska Pediatric Clinical Trials Unit, email Dr. McCulloh at [email protected].

 

Project ECHO: Behavioral Health [Podcast]

Posted on

Dr. Jennifer McWilliams, Division Chief for Psychiatry in the Department of Behavioral Health at Children’s Nebraska in Omaha, provides details on Project ECHO Behavioral Health.

project echo logo

Topic Breakdown

2:25 — Project ECHO offers resources to primary care providers to address pediatric mental health provider shortage in Nebraska

4:32 — Project ECHO will look at common issues, such as depression, anxiety, and ADHD

8:15 — Why it’s crucial for providers to address common mental health issues in children early on

9:02 — Screening for mental health concerns in primary care settings

Transcript

CHN News: Hello, everyone. Welcome to the CHN podcast. We are speaking with Dr. Jennifer McWilliams, who is the Division Chief for Psychiatry in the Department of Behavioral Health at Children’s Nebraska in Omaha, Nebraska.

We are talking to her about Project ECHO Behavioral Health, which goes from all of 2018 to the spring of 2019. Thanks so much for being here.

Dr. Jennifer McWilliams: Thank you for having me.

CHN News: In a nutshell, can you describe Project ECHO generally, and then a little more specifically about the Behavioral Health ECHO?

Dr. McWilliams: Absolutely. ECHO is a really exciting program that’s spread throughout the country, where specialists engage with primary care providers through a series of talks and case studies to help support primary care providers with feeling more comfortable with a specific specialty area.

So, as an example, what we’re going to be doing in behavioral health is a series of 11 lectures — or 11 sessions, rather — which are going to be comprised of a 15- to 20-minute lecture where an expert in a topic from Children’s will be discussing that area — whether it be depression, anxiety, etc.

The next 20 minutes of the session will be a case study where people will be able to present cases — real patients that they’re dealing with — so that the group as a whole can talk through those concerns and what they’re experiencing, and how to handle them.

And then, finally, we end each session with a question and answer time period where people can ask other questions that may have come up.

The goal overall is that as the 11-session series goes on, the primary care providers will not only begin to feel more comfortable in treating pediatric patients with mental health concerns, but they’ll also develop a network of colleagues with whom they can share their experiences and bounce ideas off of.

We’re really trying to build a community of learning as much as providing direct knowledge.

CHN News: Why is this so important for primary care providers, especially pediatricians in Nebraska?

Dr. McWilliams: One of the biggest challenges that we’re facing in Nebraska — and even in the Omaha area — is that there simply aren’t enough pediatric mental health providers. Similarly, looking at psychiatrists, there are only a handful of us in the state of Nebraska. And while we all are dedicated to seeing patients and love our work, we recognize that it’s really hard for patients to get in and see us in a timely manner.

As a result, a lot of primary care providers are left in the trenches having to manage these kids on a day-to-day basis. Many times, they end up feeling overwhelmed, undereducated, unsupported — and this is an opportunity for us to try to help build up that foundation, so that they can feel more comfortable with treating the kids that they end up seeing on a day-to-day basis.

CHN News: Is this something that has been going on for a while in Nebraska — this shortage of child psychiatrists and behavioral health specialists?

Dr. McWilliams: Unfortunately, it’s a chronic problem that’s going on across the country, not even in just Nebraska. The areas of the country that have the highest per-capita population of child mentalists and psychiatrists are still woefully underserved.

But in Nebraska, it’s particularly profound because of some of our geographic issues. Almost all of the child mentalists and psychiatrists live and work primarily in Omaha and Lincoln, leaving the vast majority of the state with virtually no access to pediatric mental health care or pediatric care — unless the patient is willing to drive to Omaha.

CHN News: So, these sessions are particularly useful for pediatricians in rural areas?

Dr. McWilliams: Absolutely. We’re offering it to pediatricians across the state, including the Omaha area, but my goal is that we’ll be able to reach out to our colleagues who are practicing in rural parts of the state.

CHN News: What are some of the topics that you’re going to be covering?

Dr. McWilliams: We’re looking really at a lot of the bread-and-butter disorders that affect kids, realizing that primary care providers are never going to want to be in the position — nor would we want them to be in the position — to treat some of the more significant, chronic mental health concerns like schizophrenia and bipolar disorder, etc.

So, we’re focusing on depression, anxiety, ADHD. We’re going to have a session touching on autism, a session on disruptive behavior disorders. We’re also going to be looking at some more processed-based things: How to do a suicide risk assessment, how to screen for mental health concerns in the primary care setting, looking at the effects of adverse childhood experiences.

CHN News: Are these sessions eligible for CME credit?

Dr. McWilliams: Yes. We have gotten each of the sessions approved for CME credit through Children’s Nebraska. CME will be offered for each session individually. And in addition, providers who participate in a certain number of the sessions will be able to participate in a maintenance of certification project, which will give them credit towards board certification and recertification.

CHN News: Since this is very beneficial for rural providers, are they going to have to come into Omaha to do this, or is this through teleconferencing — how does it work, exactly?

Dr. McWilliams: That’s what makes ECHO so cool. We recognize that it’d be impossible to get everybody to come and even spend a day with us. The way the sessions are structured is that we use web-based technology — Zoom technology. So, it’s all on people’s local desktops or some groups, if there’s more than one provider in a setting that want to sit down together in a conference room and project the screen, all they have to do is be able to log into the web.

And then, for better or worse, they’ll be able to see us as we give our presentations and we go through the case reviews. They’ll be able to participate and work with us through the video conference call — all from the comfort of their office or their home.

We’ve tried to set the sessions up so that they’re consistently going to be on Thursdays from noon until 1:15, with the hope that over the lunch hour we’ll hopefully be least restrictive for people — and we’ll do that every few weeks.

CHN News: Can people listen in afterward if they aren’t able to attend?

Dr. McWilliams: Yes, we’re going to be recording all of the sessions and then posting them on our website so that eventually we’ll have the full series up there for people to review. Currently, we have the sessions from the ECHO series that we did on pediatric obesity on the web as well.

So, long-term, our goal is to have an archive of different topics that people can refer back to.

CHN News: Which of these topics are you most excited about? Which topic do you think is going to be the most surprising for people who are participating?

Dr. McWilliams: That’s hard, but obviously I’m a child psychiatrist and mentalist, so I love it all. I think really focusing on depression and anxiety — I think those two sets of topics are going to be the most profound. I think there’s a lot of misperceptions among providers that it’s risky and dangerous to treat kids with those disorders.

In reality, the sooner kids can get treatment for depression and anxiety, the sooner they respond, the better their long-term outcomes. And the treatment options that we have are very safe and very effective. So I’m really hoping, personally, that we can hit home what a huge population health problem depression and anxiety are for children and adolescents — and how important it is that we all work together to treat these kids as early and as effectively as possible.

CHN News: How do you anticipate participation in these sessions will impact patient care?

Dr. McWilliams: One of the topics that we’re going to be talking about is screening in primary care settings. We’re going to be specifically looking at the PHQ-9, which is a depression screening tool that a lot of primary care providers are already aware of, if not completely comfortable with.

Our goal — and we’re actually folding this into the maintenance of certification piece and project — is that as people get more comfortable with using the PHQ-9 and screening more patients in their clinics, that they will recognize some of the more subtle, subclinical cases where depression is either just starting to develop or where the kids are doing a good job of masking those symptoms. So that we’ll be able to identify kids earlier and more effectively, so that we can start getting them the treatment they need.

CHN News: Do you know of any other programs in the country that have done something like this that have been successful?

Dr. McWilliams: ECHO is a nationwide program. It started out in New Mexico, I believe with adult gastroenterology. There have been ECHO projects that have been done across the US and there are a number that have been looking at behavioral health, but I’m not aware of any others that are specifically focusing on pediatric mental health.

But, the more the merrier. I think we need to get this out everywhere across the country.

CHN News: Is this program only open to primary care providers or is it open to anyone who is involved in care of children?

Dr. McWilliams: Right now our target audience is primary care providers — so pediatricians, family practice doctors, advanced nurse practitioners, physician assistants, and all of the staff that work with those folks.

CHN News: How can people get more information or sign up to participate in Project ECHO?

Dr. McWilliams: People can go to Children’s Nebraska website for Omaha and they’ll see a link to the ECHO program. The registration is linked in there. It’s free, it’s easy, and if anybody has any questions, they’re more than welcome to the Behavioral Health Department here at Children’s: 402-955-3900 and ask to speak either to myself or my partner in crime, Dr. Vance. We’d be happy to help guide people on how to get registered and participate as well.

CHN News: Dr. McWilliams, thank you so much for being here with us today.

Dr. McWilliams: Thanks for having me. I really enjoyed it!

CHN News: You have been listening to the Children’s Health Network podcast. That was Dr. Jennifer McWillams from the Children’s Nebraska in Omaha, Nebraska.

Improving Outcomes And Lowering Costs For Asthma

Posted on

Asthma affects nearly 26 million Americans, according to the American Lung Association. More than 7 million children have asthma. It’s the third leading cause of hospitalization among children and results in millions of lost school days every year.

While there’s no cure, managing the condition is possible so children can lead a productive, normal and healthy life.

A roundtable was convened in March 2015 by the Brookings and Asthma and Allergy Foundation of America (AAFA), which published a report on the opportunities that exist for improving outcomes and lowering costs by better addressing the social determinants of asthma. Innovations around coordinated asthma care are happening nationwide. The report notes that the most successful community-based asthma programs:

  • Target the highest risk patients
  • Provide education and home-environment assessment
  • Coordinate community, public health, and social services
  • Plan for sustainability

Electronic Health Records: 7 Ways To Hook The Right Patient Data In The Digital Ocean [Slideshow]

Posted on

When electronic health records (EHRs) started mushrooming on the landscape in the early 2000s, they were met by significant resistance.1 That wasn’t a surprise. Poor usability, expense, and time-consuming training made an unappealing package for physicians.

Now, it’s almost impossible to find a healthcare facility that doesn’t use EHRs. Almost 90% of office-based physicians, and 96% of hospitals, use some sort of EHR system.2,3

While they’ve improved over the years, they still present some challenges. EHRs hold a vast amount of patient data, which has the potential to improve public health. But with so much information, and with the complexity of EHR systems, extracting the most meaningful data can be overwhelming.

As a physician, how can you make EHRs more helpful tools to your practice? Here are 7 recommendations.

1 Health Affairs (March 2004)
2 Health IT (December 2016)
3 Modern Healthcare (May 31, 2016)

How Mobile Technology Can Drive Care Management [Podcast]

Posted on

In today’s technology-dominated world, social media and the internet are playing an increasingly larger role in healthcare. But what does this mean for physician practices and care management?

Brad Brabec, M.D., Chairman of Children’s Health Network and President of Complete Children’s Health, an independent physician practice, shares his thoughts on the relationship between the internet and healthcare for both providers and patients.

Topic Breakdown

1:06—Dr. Brabec on social media and what’s next for Children’s Health Network
1:50—The role of physicians in an internet-dominated world
7:00—Challenges physicians face with electronic medical records
7:45—Managing your online reputation as a healthcare provider

Takeaways

  • The spread of misinformation online is a challenge physicians must confront head-on by engaging patients in conversations and involving them in the medical decision-making process.
  • Maintaining electronic medical records can be challenging for practices as certain systems become obsolete — but the benefits of electronic access for patients are numerous, especially if a child has complex medical needs.
  • Technology can help streamline pre-appointment information gathering, which gives providers more time to help patients in-office.
  • Online reputation management is important for providers — but not something that medical schools necessarily prepare new physicians for.

Transcript

CHN News: Hello, everyone. Welcome to the CHN podcast. We are speaking with Dr. Brad Brabec.

Dr. Brabec, can you give us an introduction to who you are and what you do?

Brad Brabec, M.D.: Absolutely. I’m a general pediatrician in a private practice, here in Lincoln, Nebraska. The practice is called Complete Children’s Health, which I first founded coming on 22 years ago, back in 1995, after having been in private practice for six years in Seattle, and having trained out there at a children’s hospital and medical center.

With regards to this practice, we have taken it from one office location to, currently, four office locations. We have plans to expand to a fifth office location in the next couple of years here in Lincoln, Nebraska.

The Evolving Role Of Physicians In A Digital World

CHN News: Our topic for this podcast is how mobile technology can drive care management. How are you seeing your patients and families use mobile apps, social media to be patients or to be healthcare consumers?

Dr. Brabec: We’re obviously seeing that more and more nowadays. Families come in and say, “Well, I was on the internet and …” Or “What about this, Dr. Brabec? I read this on the internet …” Or, unfortunately, the things that steer patients in the wrong directions — in our opinion — sometimes with their medical decision-making, such as choosing to not vaccinate their child.

It is something that we have to constantly learn to deal with. Probably the most important piece of information I could give anybody is just to make sure you develop as close of a working, medical professional relationship that you can with your families.

And also guide them in their decision-making and care. All too often, I’ll hear families say, “This doctor I went to for my care as an adult basically gave me some choices and options and left it up to me.” I try to help guide the patient’s decisions, ultimately, in terms of what they decide to do with their child.

Now, mind, you, the discussion regarding the choice to not vaccinate, I give my strong beliefs. But, ultimately, families have to make a choice and decision about what they’re going to feel most comfortable with in regards to their child. I respect that, but I also let them know that we firmly believe in the need to vaccinate, as an example.

But I think when it comes to that knowledge out there, having that relationship with your patient families is most important. Discussing in a congenial manner the information that they’ve found on the internet can help them make the best choice they can for the healthcare they’re going to receive.

There are many apps and websites out there. As a provider, I think you just have to be ready and develop a style for how you’re going to address that when it comes to you.

The Dangers And Benefits Of Technology In Healthcare

CHN News: There are some ways that your practice is using technology to understand patients better. You probably have an electronic records system. Tell me how you guys are using technology to understand your patient population and make care management decisions.

Dr. Brabec: The rudimentary Facebook we have is up and going. And I think, again, the key with that is making sure you have people who know how to use Facebook and deal with the comments as they come in from patients. I think a good, knowledgeable user who can manage that is most important as well.

After 22 years at this practice here in Lincoln, we’re actually getting ready to go to new electronic medical records. This has always been a stressful thing for physicians in terms of trying to find the ideal electronic medical records system to use in your office.

Sometimes the product that you thought was going to be around forever has been bought by a large company that is going to be shelving the product and driving practices to their product. We decided against that and spent close to 10 months looking for a new product that we’re getting ready to evolve toward that as well.

What we want to do here in our practice — and again, this has to do with the amount of time patients have to spend getting off of work to come into the office — is to drive more of the information gathering process that we all experience to before the office visit.

Things like giving your insurance card, filling out a two- or three-page form that updates demographic information, filling out a form about the child’s check-up that day — we’re hoping to drive a lot of that data gathering pre-office visit through our website or other mobile devices.

This will allow us to streamline the process and spend more time when they come into the office educating them and talking to them about their medical problems, rather than most of the visit being about collecting the data.

So for us, what’s going to be key is using the website and various apps that interact with our electronic medical record system to provide that information gathering ahead of time, so we can improve on the patient experience and the care they receive when they come in the office.

Likewise, we also have to — through federal mandates and initiatives — allow our patients access to their medical records, which will be done through the website or apps that link in with the electronic medical records.

This allows them more portability with their medical information, so that whether they’re in Lincoln or whether they’re in Orlando, Florida, if their child gets sick and has medically complex needs and medications, they are able to easily pull that information up and extend that information to other healthcare providers who may otherwise not be familiar with that child’s care.

Then, they can provide the best quality medical care, even though they’re not the child’s regular provider.

CHN News: You may have already answered this question about the greatest dangers and benefits surrounding technology and medical care. It sounds like the danger can be the misinformation that can be spread when it’s not vetted by your actual pediatrician.

Dr. Brabec: Yeah, the misinformation is huge. We all know about that because we’ve all used the internet to search for information and resources. So, first of all, misinformation is a big concern.

But another big concern is social media management of your reputation online. That’s another huge, huge issue and concern that probably drives some practices and physicians away from wanting to be involved with social media and utilizing it for their practices or themselves individually.

There are so many resources out there — Healthgrades.com is one example — where all it takes is for one negative comment to pop up and that can mean a lot for your reputation.
And it may be a situation where you provided adequate medical care but yet for some reason somebody was dissatisfied with the care or the outcome. That’s a huge concern that we’re going to have to learn to manage more and more as time goes on as well.

Transparency is something that’s being put out there more and more by everybody —including the federal government — and I don’t think there’s anything wrong with transparency. It’s just you have to be prepared to manage that.

But, when it comes to medical school, none of us were prepared for that. For those of us who have been in practice for several years now, things have evolved. These are aspects of medical education that need to occur through time.

And then when it gets to residency, more education about the business of medicine and what it means for you if you’re in private practice or working for a larger hospital system. And again, social media management is something that is going to have to be implemented within our medical education system as well.

CHN News: Absolutely. Well, we look forward to getting tweets from you soon.

Dr. Brabec: We’ll start working on that, maybe, next week.

CHN News: You’ve been listening to the Children’s Health Network podcast. That was Dr. Brad Brabec, President of Complete Children’s Health in Omaha, NE, and Chairman of Children’s Health Network.

Thanks so much for listening.

This podcast was brought to you by Children’s Health Network.

Patient Experience 10.0: What Can Physicians Learn From The Hottest Companies? [Podcast]

Posted on

Top notch. World class. Gold standard. Such expressions are often used to describe a positive customer experience with good outcomes. But what does that experience actually look like, and how can we apply that to patients in healthcare?

Brad Brabec, M.D., Chairman of Children’s Health Network and President of Complete Children’s Health, an independent physician practice, offers some insights.

Topic Breakdown

1:37 — Dr. Brabec on how the service in his favorite restaurant inspired him on running a healthcare practice

3:40 — Be respectful of your patient’s time

4:56 — Avoid redundancy

5:30 — Provide the value perceived by your patients

Takeaways

  • Running a healthcare practice is no different from running a restaurant in terms of providing a good customer experience. Fostering a culture of working as a team is important.
  • To provide the ultimate patient experience, be attentive to their needs, respectful of their time, and aim to reduce redundancy in information gathering.
  • 99% of the referrals are word of mouth. Quality care and positive experience bring more business to your practice.

Transcript

CHN News: Hello, everyone. Welcome to the CHN podcast. We are speaking with Dr. Brad Brabec. Dr. Brabec, can you give us an introduction to who you are and what you do?

Brad Brabec, M.D.: Absolutely. I’m a general pediatrician in a private practice, here in Lincoln, Nebraska. The practice is called Complete Children’s Health that I first founded coming on 22 years ago, back in 1995, after having been in private practice for six years in Seattle, and having trained out there at a children’s hospital and medical center.

With regards to this practice, we have taken it from one office location into, currently, four office locations. We have plans to expand to a fifth office location in the next couple of years here in Lincoln, Nebraska, as well.

CHN News: Talking about patient experience, as you know that’s sort of a huge distinguishing factor for many companies. You know, everybody watches movies, for example. But for some reason, there’s something about Netflix that took over and now there’s no more Blockbuster. And it’s not that it’s so much that there are so many different movies. It’s the experiences are different. And we started to see a lot of that translate into healthcare, just focusing more on the actual patient experience. Before we talk about the healthcare part of it though, can you think of a company you really admire because of the experience they give their customers?

Dr. Brabec: Well, you know I love food, so one of them that comes to my mind immediately was, when we moved from Seattle, Washington to the Midwest, particularly Lincoln, Nebraska, we saw a distinct difference in the level of customer service you received in a restaurant. Any by that, people who constantly fill up your water, people who take dirty plates right away, people who took your order right away. All of those things. Yeah, one of our favorite restaurants here in Lincoln, Nebraska, called Lazol’s, provided an incredible level of service, customer service that we even found to be in paralleled some of the finer restaurants in Seattle, Washington. And what did they, [it’s] what makes you want to come here eating there, doesn’t it? So, what did they put forth that created that experience or fostered that culture?

And that’s what’s important, culture. They all work together as a team. So, whether you are actually waiting the table and taking the order, or you are that person who was assigned that table but you are walking by another table you are not assigned to, for instance. One of the several key initiatives to be working efficiently and providing excellent experience was that you never come back to this kitchen without a dirty plate in your hand. So, even though I just took the order over here, I walk by that table, they are on my way back and even though it’s not my table, I pick up the dirty dish that I see right away.

So anyway, providing that ultimate level of service and customer care, and to this day, that restaurant is what I put in front of my staff and say what do you think about the Lazlo’s experience, and what we need to provide here in terms of the customer services and experience for our families? Because it’s really no different. One of the first things we should say is “How can I help you?” And being able to follow through with how can I help you by giving them a solution once they started to tell you about what their needs are. I never want to hear, for instance, somebody schedule and say “You know I’m sorry. All of our appointments are filled up for the day. If your child needs to be seen today, you have take him somewhere else.” You just don’t want to do that. You just absolutely don’t want to do that.

You find a way to help the patient for the day with the child who has ear infection rather than make them wait until tomorrow and saying all the appointments are filled for the day and you have to take them to the urgent care center. So customer experience, all too often, there just hasn’t enough attention paid to that obviously in terms of providing the ultimate customer service and experience. Time is of the essence for them just like it for anybody else, so being respectful of their time more than anything is very very important, number one.

Number two, also trying to avoid redundancy in the care we deliver or in information gather. I alluded to that early on about the forms you constantly having filled out and filled out again, we need to get better reducing redundancy in the healthcare because we see that happening. Why do I just got to tell them that doctor about that, now I have to tell you again about this. So, trying to reduce the redundancy there and trying to deliver again good quality healthcare, being able to spend more time talking and educating on the reason and the problem why you came to the office today as well.

I tell my nurses, when you go to call the family back and you see there’s a mom with a toddler and also happens to have a little baby and a carrier. Help the mom. Offer to take the carrier. Take the diaper bag. Take the toddler by the hand and help guide them back as well. Get patients back to the exam room right away rather than having them sit out and hustling and bustling waiting room with others. Children who are sick and their child isn’t sick.

There’s a lot of different aspects to customer service and experience. And basically when you look at the AAA. What’s the value, what’s the value of the medicine I’m receiving today? Everybody defines value differently and we have to cognize that, of that varying definition of value for everybody and try to serve the perception of what value is to all of our families in the way they perceive that.

CHN News: And that’s great for the patient. Like you said you know what gives them a good experience, they feel valued. How does that help the practice to focus on the patient experience?

Dr. Brabec: Now they again too, Lincoln again there’s a time when you know our growth here and practice continue to be good as well, but our local hospital systems both of them have continued to employ their own physicians and open up their own practices. Other pediatric practices have continued to add pediatricians to their practices as well. So, we are competing more and more in particular for the commercial paying patients and for the Medicaid patients as well. So, you want to provide again AAA medicine. You want to be able to provide good service and good quality care. And I founded this practice here when we started to look at how people got referred to the practice. Literally 99% of referrals were word of mouth. It’s not putting an ad in the paper that’s getting patients to come to our practice. It’s word-of-mouth referral. So, you know a good experience will be told through for others. A bad experience will be told to others.

CHN News: That’s right. That’s absolutely right.

Dr. Brabec: So, provide a good experience and care that you put forth in your practice and the customer service that you are giving as well.

CHN News: You’ve been listening to the Children’s Health Network podcast. That was Dr. Brad Brabec, President of Complete Children’s Health in Omaha, Nebraska, and Chairman of Children’s Health Network.

Value-based Care: 3 Ways To Leverage It To Benefit Your Practice

Posted on

Value-based care has been a breakthrough idea for payers. But to many physicians, it might seem like the vampire that just won’t die.

Yes, it’s designed to lower costs in the long run, a goal most of us can support. But there’s always a fear that it might not align with optimum patient care … and can put a significant burden on your practice.

Still, value-based care seems to be creeping into more contracts as payers, particularly the government, work to get costs under control. So, the question arises: Are there ways to leverage it for the good of your practice? Here are 3 strategies to consider.

1. Amp Up Your Patient Satisfaction Rates

The shift toward value-based care has put a stronger emphasis on patient satisfaction rates. In that capacity, you’ve always been ready to deliver excellent medical care. But maybe you could look at some extra details that are part of the care experience at your office.

For example, you might see opportunities to:

  • Improve your scheduling system
  • Make your billing statements easier to understand
  • Increase your number of follow-up calls and appointment reminders

You also might consider providing financial counseling to patients, or referrals to payment assistance programs, if you’re not already doing so.

Value-adds like these can boost patient satisfaction rates and improve health outcomes in the process.

2. Launch Quality Improvement Projects

It’s an old formula: Prevention saves money. If your reimbursements will be tied to your patients’ long-term health, maybe it’s time to take a look at some new quality initiatives in your practice.

value-based care

Your quality improvement projects can provide valuable data to payers in the value-based care arena and tie into parallel projects, such as complying with HEDIS quality measures.

3. Make A Stronger Impact On Population Health

It’s no secret that payers have taken a stronger interest in population health management as they move toward value-based care. This gives physicians an opportunity to look more broadly at their patient populations — for example, children with chronic conditions like asthma or diabetes.

To “move the needle” toward better health for these patients, the Health Information and Management Systems Society (HIMSS) suggests three keys to a successful population health management program2:

  • Data analytics
  • Technology adoption
  • The inclusion of the patient as a partner

In particular, consider new technology that provides real-time data and predictive analytics. These tools can drive clinical decisions that better support your patient populations, HIMSS notes. Contact a health information technology consultant to discuss how to implement tools like these with your EMR and workflow.

When your at-risk patient populations start to show better numbers — fewer hospitalizations, more days without asthma attacks, lower blood sugar — you’ll not only create grateful parents. You might also make value-based care contracts easier to manage over time.

Share this article with a colleague who is implementing value-based care contracts into his practice.

1 AAP News (March 9, 2017)
2 HIMSS News (June 20, 2016)

Give Feedback

X

Search the Children's Nebraska Website

Looking for a provider?