AMCHP 2006 ANNUAL CONFERENCE
EARLY CHILDHOOD: BUILDING THE FOUNDATION FOR LIFELONG HEALTH
March 4-8, 2006
JOSEPH HAGAN: It is really always great fun to be able to talk about this project that so many of us in this room, so many people from the academy, and from all the wonderful groups that we work with, under the great leadership of (inaudible) Health Care Bureau.
It's always great to be able to talk about Bright Futures. I'm particularly excited to talk about Bright Futures in the context of developmental screenings, because as we try to conceptualize what would make Bright Futures work in practice, this was a piece of it. So let me talk a little bit about how we hope that's going to move forward.
So coming out early 2007, it's going out to external review in about a month or two and should be available in book form, and it will look just like that. This is the new Bright Futures in partnership with (inaudible) Health Bureau.
The academy took the leadership role in creating the Bright Futures Education Center, which has been charged with writing the guidelines. And to make the guidelines work in practice, such as with Paul's project, our project, to think about, as we're writing it, how it will be used? Don't think about, you know, putting out the book, but think about how the book is going to be part of practice.
We, with MCHP support, brought together wonderful expert panels from many disciplines. There are four co‑chairs, and we're from all over the place. Except it just so happens that three of us are from Vermont. But professionally, we're from all over the place.
Pediatricians, family physicians, remember that half the pediatric well‑child care is provided by family physicians. Pediatric and family nurse practitioners, specialists in mental health, oral health, nutrition, educators, families. A really wonderful group of, as we say, cast that we've been heard are having a wonderful time doing it.
So what is Bright Futures? I'm quoting my brother, who is also a pediatrician in Salem, Massachusetts ‑‑ you should never brag to a sibling ‑‑ when I got asked to be one of the co‑chairs, I was talking to Greg about something else and I told him that. And there was this dead pause, and he said, "Well, what is Bright Futures?" And I reminded him that these were these guidelines that we have when you're a resident. He said, "Oh, yeah. I know what that is."
But the point is, what is Bright Futures? But it has been in the past one of several competing sets of guidelines for how I should do primary care pediatrics. And there was a lot of ‑‑ there's support for those guidelines because they help establish standards of care. But there's also a lot of concern about, you know, are guidelines a cookbook? You know, are guidelines just ‑‑ you know, did they take away that person‑to‑person piece?
So we really fashioned what we believed Bright Futures was conceptually and what Bright Futures should be in a practice. Bright Futures is a set of principles and strategies and tools ‑‑ guidelines is too rigid ‑‑ that are theory driven. Theory based, rather. Evidence driven, when there is evidence. Systems oriented. They can be used to improve health and well‑being of all children through culturally appropriate interventions that address the current and emerging health promotion needs at the policy community health systems at family levels. That's been our mantra for the past five years and we're very proud of that.
Because we think that that will allow us the same focus in well‑child and well‑adolescent care, giving new formats and new techniques so the practitioners can implement this excellence in care. A new focus on the provision of community‑based well‑child care services in the primary care setting. Very apropos to what's been discussed today.
And certainly, if it is to work, it must be utilizable in practice. And we've tried to design a utility for practice that will cause people to say, "Well, yeah, I can do that," or better still, "Of course, I can do it that way," we hope.
So the third edition, as I said, will be coming out early '07. And within the guidelines, it will be set up with 10 health promotion themes. And then, unlike the previous book, embedded within this edition will be a providers' manual, if you will, thirty well‑child care visits, give or take, that help physicians walk through and nurse practitioners walk through what are the core components for the practice? For the family? For the patient? With it a Bright Futures tool kit which supports you in practice. It has the developmental screening tools in it. It has the community linkages in it, and the tool kit is going to be extremely exciting. They're going to come bubble wrapped in the same package when you get the book. It's cheaper if you buy them both. Okay?
The Bright Futures pocket guide is tremendously popular. Oh, our consumer's awake. The Bright Futures pocket guide is very popular in teaching both medical students and residents. We will also have a systems change curriculum, not unlike the one that Paul just described for implementation for the developmental surveillance and screening project, and a tool kit to implement and help with that implementation.
So what's the relevance to today? What's the relevance to today's topic and to this (inaudible) gathering of leaders? Well, developmental surveillance, as Paul said, has traditionally been the method to identify children's delays and problems in the setting where I work.
What's the result of that? As we heard a few minutes ago, only about 30 percent of kids are detected ‑‑ who should be detected are detected. That means that early intervention opportunities are lost or at least missed and delayed. And the community linkages to statement of health's maternal child health services school and community‑based services are also delayed. That's a problem.
Developmental screening, of course, is now the recognized standard. What will that bring us? Well, we know that will give us known sensitivity and specificity to the tool. Hopefully, a higher case find rate, and likely an earlier referral. And I'm referencing what Dr. Lipkin just referenced in that upcoming statement, which I think he's optimistic if he thinks it will be in May, but sometime soon.
What's the relevance? Well, we know that developmental screening is not now widely utilized. How can we change that? Well, the promise of Bright Futures, I think, is part of that. There's enhanced opportunities in the way we structured this providers manual and ‑‑ for developmental surveillance and screening. Standardized visits should improve the concept of surveillance. My surveillance ought to be similar to your surveillance.
We've asked our experts to help prioritize, what are the important things? What are the most important priorities for this child at this visit, at this age and stage of development? You know, not to make it a cookbook and not stay, "It's got to be this way," but to help interested practitioners who want to do it right, be able to focus on what's key for this family and this child at this visit.
And that leads to a defined content that helps us drive an improved standard of care. Developmental screening is going to be embedded in well‑child preventative services. But as you know, it's not being done now.
What are we hearing? Well, we're hearing people say, "How will this really improve my practice? How can this make practice easier? Why should I change? Why should I adopt it? But don't tell me to do too much." This is the key thing we hear. You know, it's the wine, okay? You know, you still got pediatricians, you know, and for dinner, they bring the wine list. There's three choices, white, red and don't tell me to do too much in developmental screening.
You know, because people say they don't have enough time to do well‑child care. And what they really mean is they want to do it well, and they don't know how to do it in a compressed fashion. That's with time constraints and financial constraints and feel that they've done it competently and feel good at the end of the day that they have done it well. That's been one of the driving forces for how we've tried to design this. So we can help people feel like it's being done properly, and that they are doing their work well.
We have conceptualized then what is ‑‑ what we've called the Bright Futures system of care. You might break it down to things that I might do as a practitioner. The Bright Futures guidelines, the Bright Futures content tool kit, tell us what I should do. Um, the change tool kit intervention project will tell people how to do it. How to make those changes. How to improve their practice, because we believe that every visit could be described or should be described, ultimately, as a Bright Futures visit. An age specific, well‑child health supervision visit that uses techniques described in the guidelines that experts, such as the ones at this the table have helped us develop, that encourage community and practice specific modifications, and that are designed to allow practitioners to improve that desired standard of care.
That visit includes solicitation of parental and child concerns, of course. That visit includes always surveillance and frequently screening for developmental and other areas. That visit certainly includes an assessment of family strengths. What are their assets? What can they bring to the table? What do they bring to the table? And a discussion of certain visit priorities for improved health of children, adolescents and family function over time. The priorities that our expert panels have helped us derive as important for that child at that age.
So if the third edition, as we said, the guidelines have been developed by expert panels. They have the themes and the manual. The tool kit has been put together by the Bright Futures Pediatric Implementation Project. I want to talk about the tool kit with a little bit of depth just for a second and point out one of the things that will make the visits work is the tool kit.
In tool kit will be a description of each of the, give or take, 30 visits. For a visit to be efficient and effective, it seems that most practitioners will use a questionnaire. It seems that each practitioner needs to document what they did last time, so they don't repeat it next time. So we've include these aspects in the ‑‑ what are you flashing me, five or two? Five, cool. I'll take two ‑‑ it seems that most practitioners ‑‑ see, now I can talk a little slower because ‑‑
UNKNOWN SPEAKER: (Inaudible).
DR. HAGAN: I wasted half, jeez. It seems that most practitioners want to know what they did last time so that they can move on next time and not ‑‑ because it's different from child to child and family to family. There needs to be a prompt sheet. You know, what gets done at what age? There needs to be screening tools. There need to be tools that drive and disciplinary guidance that service in that function. The tool kit has been developed by the Bright Futures Pediatric Implementation Project, ably leaded by Paula Duncan, my wonderful colleague. It accompanies the third edition, bubble wrapped. You know, buy them together. It will enhance the implementation of Bright Futures, we believe, because these are tools for practice.
And it allows us to construct what I will close with in discussing the Bright Futures visit. Well, the visit starts with a questionnaire. The questionnaire helps you obtain appropriate history at that visit. The questionnaire is specific for each of the 30 visits. It's different from visit to visit. It helps you identify anticipatory guidance needs that one family has that another one might not and vice versa. It helps certainly identify the family's agenda for that visit. It helps us to discern family strengths.
It's modeled, in many ways, after Art Elsinore, Missy Fleming's AMA GAPS program trigger questionnaire. And the trigger questionnaire is like ours, was evidence based, when evidence is available. And there's not a tremendous amount of evidence for one way versus the other in health supervision activities. But where it is there, we certainly must use it.
It includes screening questions for common things that are of low impact, but high frequency and uncommon things that are of high impact but low frequency, which ‑‑ both of which are important with the clinical encounter. It's important to talk about the rare things that are serious and the common things that are less serious. And again, it will assess strengths.
So the Bright Futures visit, we hope, defines a newer and more family‑driven and enhanced content for the well‑care of infants, children and adolescents in American primary care practices. That has been our goal. We'll see how we do in St. Louis.
So what's happening in the states? Well, let's talk first about ‑‑ good heavens. We're in Virginia. Okay. Who knows the Virginia state bird?
UNKNOWN SPEAKER: Cardinal.
DR. HAGAN: Very good. You win the Bright Futures pen and ‑‑
UNKNOWN SPEAKER: Thank you.
DR. HAGAN: You're welcome. You're welcome. All right. So who knows ‑‑ who knows the State of Virginia's, you know, guidelines for well‑child care? You know, it's Bright Futures. Virginia has designed and printed Bright Futures health records. They've included the health record in a new parents' kit from the governor. They've trained child care providers, thousands of them, about the guidelines and the Bright Futures nutrition packet. And they've compiled training for Bright Futures practice guide and mental health for foster care workers and mental health counselors. A wonderful book by the way, The Bright Futures of Mental Health, The Bright Futures in Practice Mental Health Book, I would highly recommend to you. So it's working in the states.
Let's go to the other side of the country, to Washington. Now, I, too, I'm a native Marylander. Brookmere County. So I consider myself a Washingtonian. Okay? Now those people over there, are they Washingtonians too? What do they call themselves?
UNKNOWN SPEAKER: I would rather not go there.
DR. HAGAN: Actually, I did go there to a wonderful meeting last fall, and they're great people. Among other things, they're extraordinarily proud of their wines. So if you go to a meeting, you know, it's a nice place, they're very proud of them and they usually share them.
All right. In Washington, Head start, Early Head Start, EC, EAP, all use training materials and Bright Futures technical assistance in their youth and foster care program, their children special health care needs, use of family support materials, which have been brought together between Bright Futures and Family Voices, their school nurse, mental health and child care consultant training issues Bright Futures, and Youth Watch Academic Programs in dentistry nursing and public health all include Bright Futures, Volume II in their curriculum.
So thank you for this opportunity to present a project we're very excited about, and I hope you will be excited about. We hope the people in your community will say, "Yeah, this is the way to do it". Because it is, I think an effective way to embed surveillance and make screening a part of primary care practice. Thank you.