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1 Learning Collaborative on Improving Quality and Access to Care in Maternal and Child Health June 16, 2016 Westminster, CO 1 Bright Futures at the State Level Report 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 2

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  • 1

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

    June 16, 2016

    Westminster, CO

    1

    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

    2

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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

    4

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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:

  • 5

    9

    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

    11

    55

    93

    70

    219

    84

    58

    14

    167

    4 1 3

    189

    0

    125

    3

    238

    1

    4231

    58

    07 3 0

    169

    2

    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)[email protected] 290 5557

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    mailto:[email protected]