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Learning Collaborative on Improving Quality and Access to Care in Maternal and Child Health

June 16, 2016

Westminster, CO

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Bright Futures at the State LevelReport from the South

Francis E. Rushton Jr. M.D. F.A.A.P.Medical Director; SC QTIP

Former Board Member, AAP

What I hope to convey:

• SC Children’s Health Insurance Program Reauthorization Act (CHIPRA) State demonstration grant experience• Importance of partnerships in improving pediatric care

quality• Service delivery transformation using quality

improvement (QI) technique•Optimizing Child health and development

• Tennessee Pediatric Healthcare Improvement Initiative (PHIIT) Learning collaborative focused on quality

•How these efforts overlap Bright Futures•Overlap provides an opportunity to merge Bright

Futures into statewide QI efforts

•How state policy supports such efforts

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born as a CHIPRA State Demonstration Project

• A partnership between SC Medicaid and the SC Chapter of the AAP with input from our Early Childhood Collaborative Systems at the health department, Family Connection, and USC’s Institute for Families in Society

• Built on a 25 year relationship between the public sector and the pediatric community

• Proactive leadership from the Commissioner of the health department and Medicaid

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SC Government Taking a Leadership Role in Partnership Development With Pediatricians

• 1990 Support of medical home by DHEC (SC Health Department) Commissioner Mike Jarrett

• 1992 Milk Partnerships

• 1992 On going dialogue with SC DHHS and DHEC

• 1994 Family Support Services

• 1994 First CATCH Meeting• Now working on 22nd CATCH meeting• Open Forum• CATCH• QI• National and local speakers• Public funding

• Multiple years AAP Family Connection participation in each others meetings

• Multiple years: Pediatric Advisory Council sponsored by DHEC, participation from Family Connection and Medicaid, broad based pediatrician participation

• 2000 Medical Home Grant• Family Connection• Title V• Medicaid• SC AAP

• 2005 ECCS Grant• Child Protective Services• Early Education and Child Care• Medical Home

• ABCD IV Grant• CHIPRA QI State Demonstration Grant

• 2010 CHIPRA State Demonstration Grant (QTIP)• Core Measures• Electronic Data Gathering• Learning Collaborative

• 2013 NIPN Partnership

• 2015 SC Medicaid funds QTIP

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Implementation: Government Needs Partnerships With State AAP CHAPTERS

•SC AAP was very helpful in engaging pediatricians

•SC AAP helps with academic oversight

•QTIPs learning collaborative sessions are linked to state chapter meetings (CATCH and annual) for information sharing.

•Funding from federal and state sources

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How IP Worked with Practices and Stakeholders

30 Pediatric Practices (Indirectly over 500 child health care providers)

Learning Collaborative

• Semi-annual sessions attended by QI team

• All 24 Original CHIPRA Core measures addressed over 4 yr

• Quality measures presented, expert speakers, PCMH and behavioral health concepts, information sharing, etc.

Site Visits

• QTIP team technical assistance site visits

• Peer reviewer participation

• Quality Improvement coaching

• Each practice identified a QI team lead: practitioner, nurse and office manager

• Several year commitment

Plan-Do-Study-Act cycles• Practices document quality

improvement work

Maintenance of Certification • Physicians can earn Part IV

MOC credit on QI work

Regular Contact• Monthly conference calls• Blog (where data and QI

minutes are also posted)

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2011

July 1, 2015 QTIP practicesmain and satellite offices

2011satellite

2015

2015satellite

States with CHIPRA QI Demonstration Grants:

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CHIPRA Core Measures useful topically(Bolded visits Bright Futures Related)

1. ADHD management

2. Development Screening including MCAT

3. Well Child Visit completion early

4. Well Child Visit completion middle

5. Well Child Visit completion Adol

6. Adol Vaccines (HPV)

7. Chlamydia Screening

8. Dental visits

9. Preventive dental visits

10. BMI

11. Mental Health follow up

12. Access

13. Family Centered care/ family experience

14. Central line infections

15. Childhood vaccine rates

16. Use of strep test for pharyngitis

17. C-Section rate

18. Less than 2,500 gm

19. Freq. of perinatal care

20. Onset of prenatal care

21. ER visitation rates

22. Asthma ER visitation rates

23. Asthma medication

24. Suicide evaluation in depressed patients

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Outcomes: Documentation of work on core measures

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55

93

70

219

84

58

14

167

4 1 3

189

0

125

3

238

1

4231

58

07 3 0

169

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53

0

50

100

150

200

250

PDSA Jan 2011 - Dec 31, 2014 N= 1,545

Measure Category 2011 Rate 2012 Rate 2013 Rate p-value

Annual Dental Visits ADV - Rate - Total 71.4 72.3 72.2 0.0420*

Adolescent Well-Care Visits AWC - Reported Rate 50.7 54.9 60.9 0.0000***

Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents

Reported Rate - BMI Percentile - Total

1.2 1.9 12.7 0.0000***

Children and Adolescents' Access to Primary Care Practitioners

CAP - Rate - 7-11 Years 93.6 94.8 94.8 0.0045**

Children and Adolescents' Access to Primary Care Practitioners

CAP - Rate - 12-19 Years 95.8 96.3 97.3 0.0000***

Developmental Screening -screened by 12 months of age

DSC1 - Reported Rate 12.6 17.9 27.7 0.0000***

Developmental Screening -screened by 24 months of age

DSC2 - Reported Rate 9.4 16.3 31.8 0.0000***

Developmental Screening -screened by 36 months of age

DSC3 - Reported Rate 1.6 3.6 10.6 0.0000***

Total Eligible Who Received Preventive Dental Services

PDS - Reported Rate 57.3 59.6 58.8 0.0000***

Well-Child Visits in the First 15 Months of Life

W15 - Six or More visits Rate 41.9 41.8 53.0 0.0000***

Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life

W34 - Reported Rate 65.6 67.6 70.5 0.0000***

Outcomes: Improvements in Some Core CHIPRA Indicators 2011-2013

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Bright Futures Guidelines are:

• A set of guidelines on optimal preventive health care for children

• Required under the ACA

• Implemented by families, providers, public health and other community stakeholders

Work with states to make the Bright Futures approach the standard of care for infants, children, and adolescents

Help health care professionals deliver prevention-based, family-focused, and developmentally-oriented approach to care.

Foster partnerships between families, providers, and communities

Empower families with the skills and knowledge to be active participants in their children’s healthy development

Bright Futures

States and Communities

Health Care Professionals

Families

Bright Futures

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• Maternal Depression Screening and follow up

• Elicit and address family concerns

• Elicit and address family strengths

• Developmental Screening and follow up

• Autism Screening and follow up

• Age appropriate risk assessment and medical screening

• Weight, height (9 months) and BMI (24 months)

• Oral Health Risk Assessment

• Visit Specific Anticipatory Guidance (3 out of 5 suggested documented in chart)

• Elicit and discuss social determinants of health

Bright Futures Clinical Measures9 months and 24 months

Forces impacting practice in TN

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Lead to Learning Collaboratives as a

Response

Focused on the Spectrum of Pediatric Ambulatory Care

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Top 10 Proactive Vision for Pediatric Quality(Bold are Bright Futures related)

ACCESS: Family able to identify a Primary Care Provider. Is there a role for our partners to help us measure access?

SCHOOL READINESS: Be ready for school upon entry to kindergarten. What are the intermediate steps we can measure? Reach Out and Read? Positive Parenting Trainings? Referrals to other services?

DEVELOPMENTAL SCREENING: Screened for developmental delays*, screening for autism, screening for social-environmental factors impacting health, screening for strengths?

ORAL HEALTH: Linked to a dental home and receiving basic oral health services *

WELL CHILD CARE: Up to date in receiving quality pediatric well child care and immunizations, content appropriate to needs of our patients (breastfeeding, smoke exposure)*

OBESITY: Preventive guidance given, pt. screened, evaluated and if indicated treated for obesity*

MENTAL HEALTH: Screened for mental health conditions including substance abuse, domestic violence and family mental illness*

MENTAL HEALTH: Receive mental health services when indicated. Involved in preventive services when present

SPECIAL HEALTH CARE NEEDS: With Special Health Care Needs will have their care coordinated*

ASTHMA: Children with Asthma will be managed effectively and control maximized*

Outcomes: Proactive Pediatric Ambulatory Care Quality Vision

Important Role for Medicaid

• Recent Focus• Transition from federal CHIPRA grant to state funded QI initiative with core

funding (Similar to TN)• Enables us to work on issues that Medicaid and state’s pediatricians find

important, rather than issues with funding• SC Medicaid priorities: Asthma, Well Child Care completion rates, ADHD • TN focus: Asthma, behavioral health, smoke exposure, breast feeding

• 2016 Bright Futures work• Shift from well child visit completion rates to a QI effort focused on the

content of the visit• Partnering with AAP, Georgia, Virginia and New Jersey in this effort

• Next Steps for SC• Collecting data using the American Academy of Pediatrics QIDA system

based on our proactive vision of pediatric ambulatory care• Continuing to work on joint measures with early childhood partners• Continued learning sessions for 30 + practices• Continue our office visits, blog and phone contacts

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Key Takeaways for Other States

• Takeaway 1: Importance for Governor’s Office and Agency heads to nurture partnerships with key child health professional associations

• Takeaway 2: Opportunity to use Learning Collaboratives to improve quality across the breadth of child health care

• Takeaway 3: The need for a proactive vision of quality pediatric ambulatory care

• Takeaway 4: Bright Futures provides a rubric for this care• Takeaway 5: States can be proactive with leadership and

funding for core activities leading to broader incorporation of Bright Futures ideals in practice

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State Contacts / More Information

Francis E. Rushton Jr. M.D. F.A.A.P.Medical Director, SC QTIP (Quality through Technology and Innovation in Practice)QI Consultant TN PHIIT (Pediatric Health Improvement in TN)frushton@aap.net205 290 5557

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