AMCHP 2005 ANNUAL CONFERENCE
DELIVERING RESULTS, IMPROVING PREGNANCY & BIRTH
February 19-23, 2005
JEAN SMITH: Well, I think that if you looked at what Carole had outlined in terms of the four different levels you're now to the micro in community and patient level. So that's where I'm going to go from, and I appreciate this opportunity to be here with this group of individuals because it's based on their work and the overall policy work and all of those things that allows us then to do some of these things at the grassroots level. And so what I'm going to be really describing is about this particular project that we call the Pediatric Developmental Surveillance Program, and that's our name for it in the health department. And you'll hear me refer to Wade County Human Services. In Wade County we've combined our public health Social Services and mental health so we're one big group. I used to say one big happy family when we first got united because it was really a joke we weren't all that happy at first. It's been about 10, 12 years we've been in this process and actually we're becoming a happy family with the usual type of family interactions one might anticipate. But we're indeed a happy family. When you hear me talk about Wade County Family Human Services, that's what I'm talking about my component in terms of being in the public health sector but not just in the medical clinic.
So at any rate, this project actually has a grant from our Wade County Smart Start and I'll explain about that as we go along. I wanted to mention, just sort of the themes that you may hopefully hear, if I present it correctly, is that the three themes that will be coming is that we're talking about shared goals and outcomes that we have obtained between public health and the private practicing primary care providers in our community in Wade County. We're also talking about a problem identification, and the one I'm going to be talking about is that of developmental surveillance. But you could make that applicable to other problems that you may see in your community, whatever your shared goals are in your community.
The other, and the third very important part of this, is that we have realized that one of the things that's very helpful, and again this is speaking to the micro level, is that ability to individualize and customize the kinds of processes, implementations and tools and just everything that we do to work with the individual practices so that we can even go down to the very, very fourth level and that is the direct patient community provider level. And so that's what we'll be talking about, that ability to individualize.
Wade County itself has a total population of around 720,000. Of those, about 62,000, a little over 62,000 are children that are zero to five. This particular project does focus because of the funding source on children zero to five. Although we certainly consult and do things with older children. It's primarily focused on this. We also have a very high Spanish‑speaking population. North Carolina had a jump in the last census in Wade County of over five percent of Spanish speaking patients in our child health clinic we have a public health clinic, we see probably, the estimates are 60 to 70% speak Spanish that come into our clinic now. So our clinic director just got back from a two‑week immersion coast in Costa Rica to improve her Spanish, and we're always looking for people that are bilingual to work with us, which sometimes comes as a surprise to people hearing that we're in Raleigh, North Carolina, but we speak a lot of Spanish there. And you're at a disadvantage if you don't.
The other thing that's important to realize is that as a part of this we also had some data that was useful from the Wade county public school system, and also from the Frank Porter Graham Institute that had done some studies in Wade County and looked at the fact that children, and this was a study done back in '99/2000, looking at data back then, was that about one in four of children in kindergarten in Wade County had some type of language skills deficiency, one in four that were entering school. And about a third of them, or over, between ‑‑ 3,000 out of about 10,000 kids entering school were exhibiting two or more developmental deficiencies that were going to interfere with their ability to become successful in school.
We knew we had some problems. We knew it wasn't obtained just by our public agencies, but it was public school data accumulated by the University of North Carolina the Frank Porter Graham Institute.
I also wanted to give you developmental history of our project. And there's lots of projects that had gone on in Wade County . Two that were seminal in actually bringing together this particular project I'm speaking of today. One was that there had been a North Carolina will speak about the second one first. That's the North Carolina Health Choice Enrollment Initiative. This was actually a definitive collaboration between the North Carolina Pediatric Society in Wade County . We had a couple of leaders in the pediatric community. And they came to the public health group and just said: Can you help us get some people to help enroll kids in North Carolina Health Choice. So this started a collaboration right away between one of the community physicians who represented the North Carolina Pediatric Society in Wade County as well as we also had collaborators with the Wade County Medical Society and public health to actually help enroll kids in the state health insurance program.
This was done very effectively in North Carolina . I can't say that Wade County can take all the credit obviously, but obviously in our locale and other locales in North Carolina we did a fine job. I think we were one of the states, if I'm not mistaken, had one of the best enrollments in Rhode Island obviously as well. But we had the real good collaboration and real good success with that collaboration.
One of the nurses that actually helped me in sort of the thinking about this project was the one who was in charge of that North Carolina Health Choice initiative from the public health side. She was a public health nurse. She enjoyed going out and doing the actual work within practices disseminating information setting up liaisons getting families enrolled. The second project was the Healthy Start project. That's the one I was involved with. At this time the Smart Start initiatives in North Carolina were coming into effect. One things they asked for was a health component. So Wade County Smart Start said we need a health component, how do we get this on board? They said what we need to do was, since Smart Start is really child care initiative, we want to be able to make sure that children and child care are healthy. And so they said we'd like you, and they actually told us what they'd like us to do, which was come into the child care health centers and do essentially health screenings and developmental screenings.
After we started doing this for about a year or so, we realized that that really wasn't doing another physical exam on these children and finding out where their immunizations were, even though that was admirable that that was done. But what we needed of course was to be linking with the medical home. And this really was hard for me, because working in public health there at Wade County back when we first started this, I was quite surprised. We had people like our child service coordinators that were working with the kids. And I mentioned to them. I said you must be getting a lot of referrals from the private pediatricians for the work that you do and their comment to me was: We never get any.
How could that be? If they knew you were out there and you had this service to provide them I'm sure they would welcome you. This is true, it was said to me in a meeting: Pediatricians don't understand development.
I was like, oh my goodness we may not be very good at doing it but most of us feel like we understand development and that we should be able to provide developmental services for children with appropriate referrals.
So I realized that the job was going to be also convincing people that work with children in the public sector that in fact pediatricians had something to offer them as well. And so we started looking at this and realizing that one of the best things we could do would be to help actually the medical homes become much more efficient and competent at working in developmental surveillance.
Developmental surveillance is the topic that we chose in Wade County . And I'll describe that just right now. Why do we come to look at that? Well, there was a variety of things that were happening and coming together. There was a lot of information and studies coming out in the late '90s and in the 2000. So that in 2000 was actually the American Academy on Pediatrics, Committee on Children with Disabilities recommended the use of standardized screening tests in wellness. We take that committee standard and that's one that, the committee recommendations, that's one that we have copies of that we take into practices when we literally go into practices and talk to them about it.
So that was about 2000. And then we actually had the North Carolina Division of Public Health mandated some new screening guidelines. And so as a part of that, I mean we actually, they came out back in July of 2003 and Carole had spoken as of July 2004 the public health, the private practices could start to bill for developmental services; but in fact, coming from our women's and children health section, North Carolina Division of Public Health, it was mandated that screenings, appropriate screenings using specific tools that were validated would have to be required by the local public health departments as of July 2003.
Now, we were well ahead of the curve in Wade County with that because we had already, our project had already been starting at that time. So we were well ahead on that capacity. But we did see that as very useful in helping to push forward this idea was something that was important in the community.
The other thing that we found is that as we were looking around and working within our own public health, with the human services group, we had a set of 12 different outcomes that had been developed over years. And I'm sure that everybody's human services or health department probably has those sets of outcomes. And what we looked at was, in terms of looking ‑‑ we looked specifically at those outcomes and found that there were four of them that a project like we were talking about with working directly with the primary care providers would meet. And that was: One, that families would support their children successful development. Two, children would be ready for school. Three, children and youth will be successful in school. And, four, individuals and families and communities will have improved physical and behavioral health. So those were Wade County human services outcome goals. And we knew that those had been discussed at the community level by a variety of partners that had helped put those together.
What we learned then from starting to work with practices with other issues. For example, immunizations has been another, a history in the development of this project. There's been real strong relationship in Wade County with private practices in terms of improving immunization rates. So that about five years ago we were able to reach 85 to 90% of kids under two getting their immunizations, having them up‑to‑date. And that was a real private and public health sector partnership.
Assessing and monitoring the children's developmental status we found was a priority for the primary care practices and we found the practices were welcoming assistance if we found we could integrate it into their practices.
Two models that we've used. One is called Academic Detailing. I don't know if any of you have heard of it. We literally will go into the office and bring tools and freebies and samples. We bring samples of the tools we think they should use. It's paid for by our grant. We use a process planning approach, and that's just in a handout. I'm not going to go through the details of that. But we use a process planning approach which is similar to what the process that Carole had talked about.
What's our staff? Our staff is pretty simplistically this: And we are planning to add some more. But I can tell you just a little bit about how we got started again. How did we sell the idea? This was the important part. How did we assign it? We assigned by aligning again with our public health goals and objectives. We shared with our Wade County human services leadership how the program would address these specific goals and didn't they really really want to support us as we applied to try and get some funding to just try and pilot this project. And they said yes, that they felt it really did meet their goals.
We identified that funding through Smart Start, depending on your local group, you may find that getting outside funding or finding funding within the health department itself, which is where I'm really trying to go now is to sustain the program, is probably what's best. And then we had to educate the practice is and start them getting to start to know what's going on with this. What we found we were able to use grand rounds to do presentations about the work that had been done on developmental surveillance, talking about research that was done. Like Neurons to Neighborhoods. American of pediatrics committee recommendations and literally presenting that and asking the practices: Think about it what are you doing? Are you meeting the standards of care? After we present, then they'd start calling us and say when can you come to our practice and how do we do that? Well, what we actually did. The grant pays for us to actually put developmental specialists in primary care offices for approximately a half to one day a week. And when we first started we went into a practice that we had had good relationships, talk about going on the positives, we went to a practice where we knew we had good relationships with the North Carolina health choice project, and so they said, sure, come on in we're happy to let you come on in.
We went in, started working with them. They were sort of our guinea pigs, if you will and we started learning from them how did they make things work? How did they incorporate new practices into their practice? So we had developed then after about a year of working with this we found there's implementation training, mentoring, consultation, surveillance and support and continuing quality improvement different phases we worked with. Generally many of the practices the implementation training is about six months. Mentoring consultation, we stepped back, we go about every other week. Surveillance and support means that we make periodic phone calls. They have our number. They can call us.
And all of these have incorporated in them the ability to identify people that are leaders and will be able to do this project in their practice. But it's flexible. For example, we go in with the sets of tools that we have found that have been valid. And that the literature would say are sensitive and specific for primary care developmental surveillance. We give them that as a menu. Samples they can use. Starter kits we call them. We also give them secondary screening tools and the opportunity to teach somebody in their practice how to do secondary screening tools, if they want to.
So we actually do that with them then we step back and mentor them and visit them periodically. They decide for themselves, besides what's required by the EPSTD screens for those particular visits at the six months, the 12 to 18 months, the two‑year and then the three, four and five. So there's about five that are North Carolina EPSTD says we have to do the developmental assessment at. They decide if they want to do it more times than that. Some of our practices say we're only going to what EPSTD says we have to do. But many of our practices say they want to do more than that. We'll do it more times in our practice. But we step back and we actually then help them and do surveillance and support. Now, in terms of continuing quality improvement, one of the things we will do is we actually will go back, and this is a new component that we've added, but we go back and layer and see about a year or so afterwards we go back into the practices and developmental specialists just has a checklist of things she's looking for.
Are they using developmental surveillance tools? If so, where are they kept? Who knows where they are. Are they actually getting into the charts? We do chart audits and look at the charts. And we actually then will have a list of different specific criteria. And much like you would go into a restaurant and look at some specific criteria, that's what we're doing in the practices. And we will then give them a developmental certificate of, A, if they meet over 90% of what we've been asking them to do. And that is, we don't give them a B or Cs, but we do give them, the As, and those that do not meet the criteria that we are looking for, then we ask them if we can come back in, if they'd like us to come back in and offer some more consultation. So what makes it work? Clearly that we identify the problem. And within Wade County , it was a joint effort that everybody thought it was a problem that we weren't identifying children with developmental needs before they hit kindergarten.
The other one was understanding the program. So that this was an opportunity for us to really have the pediatricians tell us that they understood what the problem was. And let me give you a couple brief examples. One was that one practice that we went into, it was a family practice, we don't exclusively go into pediatric practices, although we have targeted them because that's where a lot of the kids are. But one of them was a family practice. And as sort of our process, we usually meet with the key leader of the practice to discuss whether or not they want to do this project in their practice. Usually it's over lunch. And so the nurse, coordinator and myself met for lunch. The primary care provider, family practitioner was there with his nurse practitioner.
And so the four of us chatted. He said: You know, what are you talking about? We showed him some of the tools. We showed him what we'd like to do. He said, great, talk to the nurse practitioner when you want to come in and we'll get started.
Our developmental specialist went out within the week. Maybe it was two weeks, because I think she couldn't go the first week, but it was within two weeks. This particular practice already had the tools and was using them. They already had place for them. They already had exactly who was going to take care of them. They were doing it. And she was what am I going to do here? I said you have to encourage them about knowing the referral resources, because each practice as we found might have different referral resources and we were gaining information from them as well as help them streamline their referral patterns so we could help them know where to go within the community of Wade County . And we update, we have a program that helps us update our community resources.
So that particular practice understood what the problem was, and they were ready to go. Another practice that just recently we were invited to come, after grand rounds I said we only need you to come out and talk to us because we're not sure ‑‑ actually I'm trying to remember. It's not we weren't sure we're doing the right thing. It was we want you to talk to us individually is the way it was framed. We went out, the particular physician, this was a solo practice, felt like he was doing a good job. And that there was no problem. And we said: Do you want us to come back? Can we make an appointment to come back? Well, I'll let you know. I'll call you.
We haven't heard yet from him. That's a smaller practice, so we're not as worried about getting back into that right away. But we certainly will want to.
The other one is of course identifying leadership.
So with a problem identification it's the whole practice staff. Not just the one person. But after that initial lunch meeting then we go back in, we have it go to a staff meeting or one of the provider meetings, and we provide more in depth information. And then they say yes this is a problem, we want your help. Your technical assistance to work on this.
The specifics of knowing what the program will do. So we say we just need a place for them to sort of hang out, and they aren't going to change anything that you say they can't change. They're only going to work with you to help you find what's easiest for your practice to develop these tools and use them.
We've also learned to find out what the expectations are. Some of the practices have just expected that it's a referral resource that they're going to just refer all the cases to the developmental specialist and not incorporate that into their own practice. We remind them through that six months that we're going to be backing off. And of course identifying the leader is very, very important, having a champion for the plan itself and having a commitment to help implement and maintain the plan.
We have found that all of our practices have been very, very supportive to the point that we don't have the outcome data as much as we have the implementation data. And certainly in terms of discussing with the providers and asking them what they think about it is that essentially 100 percent of the primary care staff have reported an increase in knowledge of the developmental surveillance process. 97% of the primary care staff, and this isn't just the providers but the whole staff in those practices we look at the nurses, we looked at the case managers, those kinds of individuals. They have those kinds of individuals. Some of our practices are huge. Some are smaller. But 97 percent felt they were applying new knowledge and skills in the use of developmental surveillance process.
Overall we're in 30 practices now in Wade County . There's about 60 some odd practices that take care of children in Wade County . We've been targeting those with a high Medicaid population. We also have been targeting those that after a couple of years of being in the system we may hear from child service coordinators or others about: You know are you in so and so's practice. Well, no, not yet. Should we be. They'll say we would really like to see you go and recruit that practice. So over the years we've started this project back in '99. And so over the years we've been recruiting more and more.
I think I'm going to end there so we can have questions.