CHIPRA QUALITY DEMONSTRATION GRANT:

Kristine Hobbs, LMSWNASHP Presentation, 

Seattle, Washington, October 10, 2013

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“High Hopes!” And Other Things My Grandmamma Said Over Coffee

South Carolina’s CHIPRA Focus for Medicaid 

and CHIP Children CHIPRA  Core Measures: 

Category A – Experiment with, and evaluate the use of, new measures for quality in children’s health care

EHRs/HIT:Category B – Promote the use of Health Information Technology (HIT) for the delivery of care for children

Medical Home/Behavioral Health: Category C – Evaluate provider‐based models which improve the delivery of children’s health care services

QUALITY

through

TECHNOLOGY

and

INNOVATION

in

PEDIATRICS 

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People Involved…Grant Staff Grant Contractors

Planning and Steering Committee

Full‐time Staff:Grant DirectorMental Health Integration CoordinatorQuality Improvement Specialist – hired 7/13Part‐time Staff:Medical Director

State Agencies:USC – Institute for Families in SocietyAdvocacy Groups:Family ConnectionFederation of FamiliesOthers:Truven Health AnalyticsCare EvolutionSC AAP

Grant PartnersGrant StaffSC DMHSC DHECSC Primary Care AssociationSelect Health of SCPalmetto Health Hospital System

In Addition, we have anExpert Panel to help plan our Learning Collaborative Sessions

And of course, none of this would be possible without our pediatric practices…

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South Carolina’s 18 Pediatric Practices

Demographics…• Business Models:

– FQHCs, RHCs, Academic Practices, privately owned, or hospital owned

• Sizes:– From 1 doc to 18 docs; some have NPs

• EMR systems:– 11 different EMR systems; 2 still using 

paper charts• Medicaid Populations:

– Range from 50 to 98%• Communities:

– Rural, suburban, and urban (for SC)• Desire for integration:

– Attitudes ranged from “I don’t do mental health.”…. “I have to do mental health”

• Grant interests– May have been more interested in 

other parts of grant rather than integration or vice versa

• All members of SCAAP

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Responsibilities

Practices• Attending semi‐annual  Learning 

Collaborative/CATCH meetings• Implementing a practice based quality 

improvement team• Working  toward NCQA – PCMH 

certification • Adopting and using an Electronic 

Medical Record to exchange data over the SC Health Information Exchange(SCHIEX) system

• Participating with Academic Detailing• Participating with Evaluation activities• Integrating mental health services• QI activities using PDSA Cycles

QTIP Staff and Partners• Conduct  the Learning Collaborative  Sessions 

– To introduce quality measures– To help in obtaining NCQA certification– To introduce Mental Health Concepts

• Provide Technical Assistance – QI activities– HIT adoption– Quality Reporting– To support Part IV Maintenance of 

Certification ABP credit – Reinforce Mental Health Concepts

• Provide Academic Detailing information• Conduct Evaluation Activities• Assist with Mental Health Integration• Quality Reports with data extracted from 

their EMRs

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SC’s CHIPRA Grant Final Operational PlanMental Health Integration Activities

Pursue Family InvolvementIdentify within practices • current mental health integration • conduct environmental scan of mental health services

Identify mental health screening toolsIntegration of MH models w/in practices • Incorporate developmental and mental health screenings into practice models • Provide assistance with integration• Work with community supports, other state agencies Training in Primary Care Behavioral Health (PCBH)• Research options for training• Identify options for training• Initiate training/certificate program in PCBH providers

NCQA ‐ PCMH• Provide assistance with NCQA tasks and additional QI measuresReview family involvement • Assess degree of family involvement• Incorporate recommendations made by Planning and Steering Committee

and QTIP practicesRefine integrated mental health practice model • Incorporation of prevention strategies and screening such as maternal depression, 

substance abuse, and community connectedness to address prevention services.• Incorporation of treatment services with QTIP practices

Grant activities Jan 2011 to present.

Grant activities going forward…

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Family Involvement Mental Health Integration Screening Certification PCBHI NCQA

Practice Interven

tions

‐ALL

Family care concept toolkit; Parent Partners; presentations from groups at LC; QTIP monthly call re: Patient and Family Advisory Councils; Facilitate meetings between family groups and practices ;AAP MHPRI family questions; CAHPS surveys; Distributed Federation of Families referral packets and MHW posters

Surveyed practices; Practices choose 3 top priorities; Practices completed AAP MHPRI 2x – results and options for next steps were presented to practices; 2 AAP MH Toolkits per practice; Collated lists of MCO BH providers; Meetings with practices and providers to discuss services, referral process, feedback loops, integration; Resources shared  ‐MH fact sheets, clinical protocols; Academic detailing on ADHD and antipsychotic; Learning collaborative sessions; Site visits

TeenScreen.org Resources shared; 3 practices piloted CHADIS; MHI – shared  resources for clinical decision making around screening; Billing and coding recommendations; Screening protocol recommended; 32% of PDSA cycles Jan 13‐June 13 were related to MH screening; Medicaid bulletin published 2013; Anecdotal stories; Post‐partum screening

Offered opportunity to participate in University of Massachusetts Certificate Program in Primary Care Behavioral Health

MHI Staff ‐job

 tasks

Continued contact with family advocacy groups; Suggestions of family friendly practice methods; Making contacts

Assist practices with identified priorities; Network and coordinate with state initiatives related to integration; Presentations to state level treatment/clinical staff for state agencies; 

Research screening tools, protocols; and community resources to meet identified needs; worked to identify billing and coding needs resulting in Medicaid changes and bulletin

Research training options; Recruit practice staff; Evaluate interest and benefit; Process payments

Led activity to  crosswalkNCQA standards with AAPMHPRI components

Practice Initiatives

Bulletin Boards; Latino Health fair; NAMI using office space

Choose who/how often they want community visits; Integration methods/model; Took clinical guidelines book and personalized it with community resources and family handouts bases on practice needs; Dunbar ADHD Fellowship

Implementing screening at own pace; Choose which risks to screen for

8 staff – representing  4 practices have attended the training; 4 staff representing another 3 practices are attending training this fall

Challenges

Funding; Different resource structures across the state

coding for mental health services; prior authorization; rate cuts; lack of needed providers and services; 18 different practices located in 11 of 17 state DMH catchments; reorganizations within state Medicaid system ‐MCO carve in bureaucratic hassles with credentialing and employing behavioral health counselors

TeenScreen.org closed; MCO carve in; Lack of detailed baseline data; Billing and coding took 13 months; Children with MH issues need multiple visits ; Changes in office processes; Tracking screens, referrals , follow up

Training is web‐based so everyone gets same thing; Not community focuses; Our practices are spread out so don’t get benefit of taking training together

This was too great to have sandwiched into this part of grant – hired another staff to support QI and NCQA work.

SC’s Grant Activities Related to Category C

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CHIPRA/QTIP Behavioral Health Integration Activities(LC, SV, State Level)Learning Collaborative

CHIPRA “Topics”LC activities/ Presentations

related to BHI QTIP Official Site Visits Site Visits and Community Visits

Other interventions

State Level Activities

Jan-

11 ED visits; WCC first 15 months; Dev. screening first 3 yrs.; ADHD

ADHD evidenced based protocol

Visits with Grant’s Medical Director; Short questionnaire – ultimate success? Dismal failure? Realistic? Contributors to success? Challenges? Current services? Needs from MHI staff?

Academic detailing around ADHD medications

New Governor New Director of DHHS Operating over budget Rate cuts for physicians

Jul-1

1 Access to PCP; Preventative dental; CAHPS

MHI staff presented info collected on site visits – ideas for next steps – practices choose top 3 priorities to work on

LIPS providers; DMH school based services & ER telepsychiatry; web-based resources for top priorities; 1 pager for DHHS prior authorization process; MH fact sheets; ACE study brief; referral info for Fed of Families

Jan-

12 Low birth weight; cesarean rates; prenatal care; Asthma

Each practice completed the AAP’s MHPRI inventory (MNOP – Dr. Seuss)

Review of each practices AAP’s MHPRI with suggestions for next steps

Jan ‘11 – July ‘12 13 community meetings with practice staff present; 52 SV/TA visits

Academic detailing around Asthma medications

Birth outcomes initiative BH carve into MCO’s

Jul-1

2 Obesity; Hemoglobin testing & control; NCQA-PCMH

Winnie the Pooh Motivational Interviewing

Review of 1st interview, priorities chosen; AAP MHPRI areas for change; clinical resources – such as www.palforkids.org – primary care principles for child mental health review of motivational interviewing techniques

July – Dec ’12 8 community meetings with practice staff present;: 17 SV/TA visits

On-going obesity task force SC recognizes obesity as disease state Codes open

Jan-

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Follow up after hospitalization for Mental Illness; Psychosocial screening; Suicide risk

AAP MHPRI completed 2nd time; Level of Integration Matrix completed for state evaluators Presentations on AAP MH competencies, AAP Toolkit, conducting screens, office processes, QTIP screening protocol, Medicaid billing and coding

Review of Learning Collaborative activities; discussions of successes and challenges related to implementing screening, billing, and patient/staff interactions BH MCO provider lists

Jan- June ’13 10 community meetings with practice staff present; 21 SV/TA visits

Academic detailing of anti-psychotic medications Conference call –MCO BH provider lists

Codes change for psychiatrist and some behavioral health

Jul-1

3

Adolescent well care; Timeliness of prenatal care; Adolescent immunizations ;Chlamydia screening

Butterflies Strengths based Anxiety dx and Mgmt.

Going on now…. July – present

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SC QTIP Recommended Routine Screening Protocol – Introduced Jan 2013Babies and Preschoolers Elementary School Adolescents

Developmental Screening ALL:ASQ‐3 or PEDSMCHAT

All:PSC – parent report

All:PSC‐Y 11+

Psychosocial/EnvironmentalRisk Factors ‐ ALLEdinburgh Post‐Partum depression screen for momsSEEK‐PSQ

If indicated:SCARED – 8+Vanderbilt

If indicated or desired:Modified PHQ‐9CRAFFTSCAREDVanderbilt 

Practice Report of Routine Screens  (n=18) ‐ July 2013

Screening ToolPeds or ASQ MCHAT Edinburgh PSC PSC‐Y CRAFFT

# of practices reporting routine use of this screen 13 13 14 4 8 2Prior to QTIP, were you using this scale in this way? 10 8 10 2 7 2

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Community Resource Meetings and Technical Assistance VisitsCommunity Meetings without a practice present 7/2012 – 8/ 2013 = 27Community Meetings with a practice present Grant life = 37TA visits with practice Grant Life = 90

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Words of Wisdom from Mrs. Ursula – My Grandmamma

• Who “their people” are is important.

• “                 AND                    are NOT the same.”• “Smells like bread and butter, honey.”• “Don’t get too big for your britches.”• “When visiting someone in the hospital, limit your visit to 20 minutes.”

• “Fair to Middlin’”

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Who “their people” are is important.• PEDIATRICIANS are ‘their people’

– American Academy of Pediatrics – Our Medical Director, Dr. Francis Rushton– We shared other practice’s successes– We used our QTIP Pediatricians to ‘push’ our QTIP Agenda

• Discover what motivates them…– competition, money, other tangibles

• QTIP awards, handouts, booklets, resources, AAP toolkits• Their COMMUNITY IS ‘their people’

– Community make up, practice make up, needs and resources of those served

• KIDS are ‘their people’– With our grant, practices haven’t differed what they do for Medicaid kids from kids with other insurances

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“              AND             aren’t the same.”

• Pediatricians aren’t the same• Pediatric offices aren’t the same• Let them tell you what they 

want to accomplish• Help them find options • Affirm their Communities 

– Acknowledge their challenges– Help them discover their resources

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“Don’t bite off more than you can chew.”

• Let the practice’s set their own priorities– “Start where the client is” – with the goal of moving each practice toward integration

• Remember there is already a lot going on with our practices

• Help them connection the grant activities to what they are already doing – we created crosswalks of NCQA, AAP MHPRI, HEDIS, MOC‐IV, Meaningful Use, and others

• Top down or bottom up? Yes.

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“Smells like bread and butter, honey.”

• Frame mental health in the context of physical health – ACE study; numbers of kids with mental health challenges, pediatrics article about # of visits with mental, physical, emotional basis; white coat effect; HELP; Common Factors, 

• Pay them for what they do  – dental varnish – huge uptake small financial incentive 

• Dr. Martha Edwards, “You have made mental health mainstream.”

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“Don’t get too big for your britches”

• “Don’t go in there and tell them what to do.” FCM• Introduce yourself and your biases • Education matters 

– pick a few key facts and stick with them

• Remember, you don’t know what you don’t know– legislative, billing, administrative structures

• Hire or make friends with people who know what you need to know

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“When visiting someone in the hospital, limit your visit to 20 minutes.”

• Pediatric offices work in 10‐15 minute increments; you need to also– Quick sound bites; short emails; just the facts ma’am

• Mental health visits take longer – our practices are learning to work over multiple visits to meet the needs

• Find your early adopters and make headway with them – share with others…

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“Fair to Middlin’”

• Challenge ‐ we did not do good baseline data from the beginning

• Did ask them about ultimate success, failure, realistic, challenges, current services, and how I can help…

• We can describe what we did; can’t necessarily say how it has changed in quantitative terms – anecdotal and qualitative data

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CHIPRA/QTIP Behavioral Health Integration ActivitiesLearning

CollaborativeCHIPRA “Topics”

LC activities/ Presentations related to BHI

QTIP Official Site Visits

Site Visits and Community Visits

Other interventions

State Level Activities

Jan 2

014 Pharyngitis; otitis

media; central blood line infections

Early interventionand home visiting

July

2014

Childhood immunization; Well child visits 3,4,5, 6 yrs.; Dental treatment services

Jan 2

015

Recap and Review…

What’s Left…SC’s CHIPRA Grant Final Operational Plan

Mental Health Integration ActivitiesReview family involvement • Assess degree of family involvement• Incorporate recommendations made by Planning and Steering Committee

and QTIP practicesRefine integrated mental health practice model • Incorporation of prevention strategies and screening such as maternal 

depression, substance abuse, and community connectedness to address prevention services.

• Incorporation of treatment services with QTIP practices

Grant activities going forward…

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References

• http://www.milbank.org/uploads/documents/10430EvolvingCare/10430EvolvingCare.html

• http://pediatrics.aappublications.org/content/125/Supplement_3.toc

• http://www.scaa.org/chronicle/2012/07/06/differing‐perspectives‐common‐goals‐demystifying‐specialty‐coffee/

• http://kulakiko.com/Quotes/ByAuthor?author=James%20F.%20Byrnes

• http://weheartit.com/from/www.quertime.com

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