using partnerships and bright futures to improve the delivery of epsdt services jennifer may paula...
TRANSCRIPT
Using Partnerships and Bright Futures to Improve the Delivery
of EPSDT Services
Jennifer MayPaula Duncan
Susan CastellanoJudy Shaw
Agenda
• EPSDT and Bright Futures: the standard of care?• MCH Programs and Bright Futures• Primary care providers: state strategies to
implement Bright Futures and improve EPSDT
EPSDT and Bright Futures: the standard of care?
Susan Castellano
Judy Shaw
The Federal EPSDT Program• Created in 1967 during Johnson Administration
– “to discover, as early as possible, the ills that handicap our children” and
– to provide “continuing follow up and treatment so that handicaps do not go neglected.”
• For Medicaid enrolled children birth to age 21
• Provides access to a broader range of services than may otherwise be covered by a state’s Medicaid program
The EPSDT Acronym• Early: Identifying problems early, starting at birth• Periodic: Checking children's health at periodic, age-
appropriate intervals• Screening: Doing physical, mental, developmental,
dental, hearing, vision, and other screening tests to detect potential problems
• Diagnosis: Performing diagnostic tests to follow up when a risk is identified, and
• Treatment: Treating the problems found.
The Two Parts of EPSDT Part 1: Access or Administrative
• Informing the family of the benefits of prevention
and the health services and assistance available
• Providing assistance with finding a provider and
scheduling an appointment
• Arranging for transportation and interpreters
• Following up on referrals and provide linkages to
other agencies and services
Sources: Center for Medicare and Medicaid Services, State Manual Part 5 EPSDT.
The Two Parts of EPSDT Part 2: Screenings and Services
• Assess the child’s health needs through initial and periodic examinations and evaluation to assure that health problems found are diagnosed and treated early, before they become more complex and their treatment more costly.
• Provide for assessment and treatment of problems identified to correct or ameliorate the condition
Sources: Center for Medicare and Medicaid Services, State Manual Part 5 EPSDT.
Federal EPSDT RequirementsPeriodicity Schedule must: (a) Meets reasonable standards of medical and dental
practice determined by the agency after consultation with recognized medical and dental organizations involved in child health care;
(b) Specify screening services applicable at each stage of the recipient's life…;
(c) At the agency's option, provide for needed screening services … in addition to the otherwise applicable screening services (42 CFR 441.58)
States required to achieve an 80% participation rate
Periodicity Schedule Flexibility• States have the flexibility to chose their periodicity
schedule: the frequency of recommended preventive health care visits
• Minnesota’s schedule has 20 visits from birth to age 21• Informal survey in 2006: 39 states had more visits than
Minnesota, 2 had less, 9 were the same• Number of visits ranged from 15-30 from birth to age 21• 2005 Deficit Reduction Act provided additional flexibility
for benchmark benefit sets
Components of an EPSDT Visit• Comprehensive health and developmental history,
including mental and physical development• Comprehensive physical examination• Immunizations and laboratory tests, including blood lead • Vision and hearing screening• Dental screening and referral• Health education and anticipatory guidance• Diagnosis and treatment services as medically necessary
…is a set of principles, strategies and tools that are theory - based, evidence - driven, and systems - oriented, that can be used to improve the health and well-being of all children through culturally appropriate interventions that address the current and emerging health promotion needs at the family, clinical practice, community, health system and policy levels.
Bright FuturesLinking it all together
Tools, materials, strategies
Minnesota and Bright Futures• Minnesota currently considering with how to
update our Medicaid periodicity schedule based on Bright Futures recommendations
• Our Title V agency endorses and promotes Bright Futures for all children
• Issues: cost of additional visits, harder to achieve 80% participation rate
EPSDT and Bright Futures• Comprehensive nature of EPSDT requirements
lends itself to the Bright Futures recommendations• Sometimes asked by pediatric providers regarding
why Medicaid kids get “more” (comprehensive visit)
• Direct them to Bright futures; comprehensive care is recommended for all children
Small Group Discussion
MCH Programs and Bright Futures
Paula Duncan
•Health and wellbeing of children and families
•Access to health and dental care
•Disparities
•Performance Measures
Public Health Priorities
Bright Futures and Title V
• Use Bright Futures as a guide to develop policies and programs to improve quality of children’s health care and health outcomes.
• Use Bright Futures as common standard for clinical care.
• Use materials to help parents and youth get prepared and make the most of every visit.
• Use the anticipatory guidance sections for education of community partners other child health professionals and parents directly.
Bright Futures and Title V
• Consider using Bright Futures themes in agency/community education activities.
• Use strength-based approaches and shared decision making strategies to engage with community partners and parents.
• Documentation of great care
• New office systems approaches
• Ready for recertification and pay for performance
• Improved access to community resources
• Knowledge of latest best practice/materials
• Network of committed professionals/learn
Potential For Public Health Clinics and Practices
• Provide information about the content tools (how to order) or download
• Referral resources
• Public health data
• Provide training and support for office systems change (data from parents)
Public Health a Key Partner
National Center for Cultural Competence Review of Bright Futures
• Literacy (lack of education)• How do they prefer to receive information? (access to
information)• Language spoken at home• Family structure, who lives in the home, and supports
(lack of family resources, family disintegration)• Sources of advice (media, marketing to children)
• Parental expectations: childrearing beliefs, health beliefs
• Home environment (displacement, homelessness)• Community environment (access to play,
neighborhood safety)• Establishing trust• Do you see anyone else about the health of your child
or family?
National Center for Cultural Competence Review of Bright Futures
Small Group Discussion
Primary care providers: state strategies to implement Bright Futures and improve EPSDT
Judy Shaw
Susan Castellano
Jennifer May
Vermont Child Health Improvement Program
…one model
VERMONT CHILD HEALTH IMPROVEMENT PROGRAM
VERMONT CHILD HEALTH IMPROVEMENT PROGRAM
Mission to optimize the health of Vermont children
by initiating and supporting measurement-based efforts to enhance private and public child health practice.
In partnership with: Vermont Department of Health
University of Vermont Department of Pediatrics, OB, FP & Psychiatry Vermont Chapter of the American Academy of Pediatrics
Vermont Chapter of the American Academy of Family PhysiciansOffice of Vermont Health Access (Medicaid)
Vermont Agency of Human ServicesBanking, Insurance, Securities & Health Care Administration (BISHCA)
Managed Care Organizations
1994-1998
1999
2000 Vermont Preventive Services Initiative (VPSI)
2001
VERMONT CHILD HEALTH IMPROVEMENT PROGRAMVERMONT CHILD HEALTH IMPROVEMENT PROGRAM
VCHIP Timeline
2002
Vermont Hospital Preventive Services Initiative (VHPSI)
2003
2004
2005
Vermont Periodicity Schedule developed by Vermont Department of Health in collaboration with the AAP-VT and AAFP-VT Chapters
Formal presentation of VPSI to the AAP-VT Spring Meeting; VCHIP core funding obtained for preventive services work
VCHIP Executive Director Hired
Improving Prenatal Care
Youth Health Improvement Initiative (YHII)
EQRO contract
Child Development
Youth in Foster Care
Improvement Partnerships
Care of the Opiate Exposed Newborn
Child Mental Health
Number of VT practices participating in at least one VCHIP project
• 85% Pediatric Practices (33/39)• 23% Family Practices (24/106)• 27% OB Practices (7/26)• 39% Certified Nurse Midwife Practices
(5/13)• 100% VT Hospitals (12/12)
Improvement Partnership
…a durable, regional collaboration of public and private partners that uses measurement-based efforts and a systems approach to improve the quality of children’s health care.
Phase I sites:ARIZONA
NEW YORKRHODE ISLAND WASHINGTON
WASHINGTON D.C.
Phase II sites:OHIO
MICHIGANMINNESOTAOKLAHOMA
WEST VIRGINIA
Washington DC
Existing sites:VERMONT
NEW MEXICOUTAH
• are customized according to the characteristics of each state or region
• IP’s are developing in different ways with a variety of partners.
• Some are housed at academic medical centers, state of local health departments or state chapters of the American Academy of Pediatrics
Improvement Partnerships
MN Title V/Title XIX Collaboration
– Intro to EPSDT– Lead screening– Developmental and Mental
Health screening
– Hearing screening– Vision screening– Oral Health screening
• To educate private and public health providers, Medicaid agency has a contract with Title V to:
• Provide trainings on EPSDT screenings including vision and hearing
• Develop on-line training modules for providers to learn components on their own time, including:
Collaboration (cont.)• Developed “Your Growing Child Brochures”
age-appropriate fact sheets with anticipatory guidance information which providers give to parents
• Created age-specific screening templates to assist providers in documenting EPSDT components provided at visits
• County Title V agencies conduct the informing and outreach activities of the EPSDT program
The Minnesota Child Health Improvement Partnership
Why MN Established an Improvement Partnership
• Growing interest from providers in quality improvement activities, some larger clinic systems creating their own
• Not a strong state AAP Chapter, no learning activities• Occasional cost-saving projects from a health plan
quality improvement consortium, focused on adults• No existing structure focused on quality improvement
for children
Spring 2007 - An Opportunity
• Minnesota Chapter of the American Academy of Pediatrics (MN- AAP) application for funding from Commonwealth Fund for a technical assistance grant provide by VCHIP to develop a permanent entity in the state
• Leadership Partners: – Minnesota Department of Human Services – Minnesota Department of Health
Healthy Development through Primary Care Project
• Goal: increase the use of standardized developmental, mental health and maternal depression screening tools into pediatric primary care clinic visits
• 9 practice teams from around the state, each team includes at least: a pediatric primary care provider, nurse and third individual determined by the team
• 1 ½ - 2 year project, learning collaborative kick-off mtg. November 9, 2007 and a second learning collaborative session on January 15, 2009
Project Activities• Choosing screening
tools• Clinic workflow• Scoring• Documentation• Billing
• Referrals• Integration into
electronic medical record system
• Measuring change
Project Activities for Participating Teams
• Participate in learning collaborative session• Meet as a team twice a month• Participate in a monthly telephone conference with
other teams and project staff• Collect family surveys to measure satisfaction• Gather data from medical records to measure
screening rate
Preliminary Findings
Screening Rates• Developmental screening rate
Increased from 55% at baseline to 89%
• Mental health screening rateIncreased from 3% at baseline to 11%
Preliminary Findings
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Either Developmental Mental Health
Type of Screening Found
Pe
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Baseline Time 2
Next Steps• Spread change from 9 practices statewide• Retreat last month to determine priorities and
how to pick next project• Continue to strategize on funding opportunities
(may ultimately define above bullet point!)• Continue to expand membership to include other
disciplines (AAFP, NAPNAP), parent representatives, etc.
Questions?
Contact Information
Susan Castellano, Manager
Maternal and Child Health Assurance
Minnesota Department of Human Services
(651) 431-2612
Contact Information
Jennifer MayNational Academy for State Health Policy10 Free Street, 2nd FloorPortland, ME [email protected]
Contact Information
Judith S. Shaw EdD, MPH, RN
Research Associate Professor of Pediatrics
Executive Director, Vermont Child Health Improvement Program
University of Vermont College of Medicine
phone: (802) 656-8319
Contact Information
Paula Duncan, MD
Youth Health Director, VCHIP
Professor of Pediatrics, University of Vermont College of Medicine
802-656-9622