AMCHP 2006 ANNUAL CONFERENCE
EARLY CHILDHOOD: BUILDING THE FOUNDATION FOR LIFELONG HEALTH
March 4-8, 2006
PAULA DUNCAN: It’s a great privilege for me to be here today to talk about this with you. We’re going to go really deep. We’re going to go into the practice setting and I would love to talk about so many aspects of everything you’ve heard about, but actually my colleagues here Chris and Beth have covered it much better that I would. But I just want to say is what we’re trying to do is make sure that in a clinical setting or in a practice setting we can do this. So can this be implemented in a way that really makes sense to people and that’s really--we’ve done a little pilot project that I’d like to tell you about, but this is kind of the direction we’re going with the clinical piece of Bright Futures.
And what I have here today for you is this set of slides which will be on the Web. It’s a little bit long for the period of time that we have so I’m going to go fast through some of it but I wanted you to have the complete set in case you have to go take this and explain this to somebody where you live and work, then you’ll have the complete set and you can go back and look at it, even though I’m not going to go in depth on every slide today. I didn’t want to leave them out and then have an incomplete kind of approach. So we have a lot of people working on this. This is just the project team that worked on the implementation, but I just want to mostly acknowledge my Co-Chair Mary Margaret Gottesman, from NAPNAP who’s really been working with us a lot. And a couple of the people in the room including Betsy and Jane, thank you very much for working on this with us, folks.
So what I wanted to do is really be able to explain to somebody--could you walk out of here today and explain to somebody what it really means to practice in a way that’s consistent with Bright Futures? When you’re seeing patients as a child--we’re calling child health professionals, that means the pediatricians, the family physicians, the nurse practitioners, the physician assistants, public health nurses. When you’re seeing kids in a primary care kind of setting what’s it like? So here’s what we’ve got so far. If you’re really doing it right you’re soliciting parent’s concerns, kid’s concerns if it’s an older kid, and you’re really making sure you address those concerns. You’re doing the surveillance and screening that’s going to really make a difference for kids. You’re screening them for the things that they need, vision and hearing. You’re doing an assessment of strengths. What’s right with you is more powerful than what’s wrong with you, so let’s make sure we at least do identify strengths, give feedback to families about strengths. Then discuss certain visit priorities. That’s probably going to be the part that’s the most controversial in that--but you can’t do everything on that list, right? Average visit is 22 minutes, 18 minutes when you’re seeing patients in a busy clinical situation. You can’t do--well; you’re not doing everything that’s on the list, so how are you going to prioritize it? People are making those decisions already. Everybody that sees patients makes those decisions everyday.
We’re trying with this edition of Bright Futures we’re trying to make sure that we’ve given some thought to how to prioritize that. If there’s evidence that talking about car seats is really going to make a difference for child health outcomes, then obviously if there’s evidence there that’s one of the things that goes on the list. But there isn’t evidence for a lot of things. So how are we going to decide what things to recommend in a 20-minute visit to make sure that we’re doing the best we can? And then of course the real important thing, community linkages. So are you with me so far? Does that sound about right? That’s the way we’re kind of--so you would walk out the door and say yeah, this is what a Bright Futures practice, not practice, characteristics of a Bright Futures and has the right feel. Does it have the right feel? Because look at what’s at the top of the list. Solicitation of parent’s and child’s concerns. So the first part of the visit is that you’ve got to get that done somewhere in the visit, and if you don’t do it you haven’t done it right. You have to do the things that need to be done in terms of screening, surveillance, and if you identify something get kids up linked in with their community linkages, and we have to cover the things that are really important like back to sleep. Because back to sleep is going to make the difference for kids. So I just want to remind us about the logic behind Bright Futures. Then will be evidenced based recommendations, which are marked when we have them.
The science of disease prevention, risk and disease detection, health promotion. If there are things there that are really important, as you can imagine, back to sleep being one. And here’s the third thing that we’re going to talk about today. If we decide that this is really--that everybody should have information about back to sleep, if everybody should have the certain kinds of screenings, then we need to make sure that everybody has them. So the third part of the science or logic behind Bright Futures is that we ought to make it really easy for practices to do the most important things for kids. So that’s where we’re going right now, we’re going deep with the practice. We decided to do birth to five first, and here’s what we got for you. We said in a Bright Futures clinical setting what can we measure? So as the public health person wouldn’t you like to know if the practices in your States are delivering care according to what we just said? How could you tell that? It’s a little bit tricky. You could talk to them, interview them, or you could try to get some data. So we’re trying to use these quality improvement mechanisms to help us get some data. So here’s what we got. All children, including those with special health care needs, receive preventative and developmental according to the Bright Futures Guide so when it comes out and it says you’re supposed to do this that you’re doing it. Parent’s informational needs are met, their strengths are identified, and their concerns are addressed. The families do receive information about community resources and help when they need it, and that they’re engaged as partners.
So that was the training intervention. Commonwealth is helping us with the funding. North Carolina--although Carole Lannon and Peter Margolis have now just in the process of moving to Cincinnati Children’s so this center will be out of Cincinnati Children’s in the future. Our aim was to test the feasibility in 15 diverse practice settings of implementing this Bright Futures. So we have--we developed the pilot test that we would develop an implementation curriculum and accompanying facilitator’s guide that all of you can use, and then disseminate the tool kit, curriculum, and facilitator’s guide. The new Bright Futures is going to have the guidebook, and it’s going to have a tool kit that goes along with it so that it’s really easy to implement. This tool kit is different. This tool kit is about how to get practices to change. How to help practices change. Guess what we found out is the most important thing about practice change? Is that the whole practice has to be involved; because we can’t change the amount of time we can spend on a visit. We have just make sure that we do it better, and if the whole practice is involved, the front office staff, the business office, the nurses, and the physicians and nurse practioners, things get done much faster, and that’s the methodology that we’ve used. Here’s these wonderful participating practices. Can you imagine doing this? Oh my goodness, they’re wonderful. So those are our heroes and heroines. The practice responsibility was that you had to select a team, collect some data from your charts to start off, come to our two workshops, and then collaborate with other teams. I just wanted you to see that we do have only 15 practices. We only have so much representativeness, but we’ve got a little bit there, which is great. Then what we did--we also had--we had a tool kit, the two one-day training workshops, bi-monthly conference calls, and then additional phone consultations and e-mail list.
Are many of you familiar with NICHQ/IHI, Institute for Healthcare Improvement kind of intervention? Does this look familiar to anybody? Okay, so the idea is that we looked at it, we said here’s what would happen to the practices, we tried it out. I’m not going to go through the details of this. We did a three and a half hour workshop on Sunday about the skill building session to understand this and I’d be happy to show you those slides if it would help you at all, but I just wanted you to see this picture so that when you see this again you say oh, that’s what Paula was talking about. That’s one of the ways that will help practices implement Bright Futures.
We had the initial workshop and over the period of a year we had the action periods, we collected feedback on the tool kit, measured change in the practices, and did the final workshop. We’re going to skip this for now. There’s that model for improvement, I just want you to see it. The characteristics of this approach are a couple. Your whole practice has to be involved. You have to measure something in the beginning. You don’t have to measure a lot of things, but a couple of things. You have to measure things at the end, so data for change not data for research, data for change in the practice. And the other idea is that usually when you’re going to do something you plan for a hundred years and then you do it, and you get every thing--this is a little bit backwards and you say what can I do by Tuesday with one nurse practitioner and one nurse trying something new like developmental screening next Tuesday with one patient we’ll see how it goes. So it’s really got a little bit different flavor to it.
The common questions are why should we measure? Please what I don’t need to do is measure anything because it’ll make me crazy and it’ll make the practice crazy. But it turns out that all of us, I don’t know about you but we go to the CME and everybody gets a binder and you walk home and the binder goes on the shelf, it’s really hard to get a new thing going in a practice when people are seeing 60 kids and really worried about if anybody has meningitis. I mean it’s just a difficult thing to implement in the office. Measurement--even measuring things on 10 charts, five charts has been shown to help. So that’s why I measure. Don’t we have to spend more time planning something like this? No, this is--this one really starts out a little bit differently. And here’s the most common thing. This seems a little complicated. This is the practice talking to Paula. Can’t we just get X to work a little harder? No, this intervention is not about one person working harder. It’s really about many people working differently together with a measurement goal and they can see where they’re going. That’s kind of the theme of this. So here’s what we came up with.
To do Bright Futures what could we measure that could show us we were really implementing those concepts that I just talked about? One thing is use of a preventative services summary sheet. Does anybody know what that is? How many of you know what that is? I didn’t know what this was before. Many people have this in their clinical charts already and you have a copy--do you have a copy with their handout? Could you hold it up? This is just an example of ones that the practices--there’s different ones that the practices work out, but you put this little puppy in the chart and every time you see a kid you see what’s shaded, what things you have to do at each visit. And you check off, or the nurse checks--the physician, the nurse, the nurse practitioner checks off did I do it? And you really keep it rolling that way. And this one tool has been the most effective thing in terms of changing practice. Because when people see this they love it. It’s easy, or easier than some other things, and they can use it and they can keep track of things.
One of the practices that we worked with found three--they implemented it and they got much better about their lead screenings. They found three lead poisoned kids over the period of the year just by--they say, this is not me saying it, just by using this form and making sure they did the screening on everybody that needed it. So you get the idea. This is one way to get that first thing done. Am I delivering care according to the Bright Futures Guidelines? The second is the use of a destructured developmental assessment, and the idea in this particular project we used PEDS and Ages and Stages, and the reason was because they’re validated, they’re simple, and also because to us they had a lot of flavor of Bright Futures you’re asking parents what they think. And I’m just going to tell you a tiny bit that the practices that worked on this and other practices that have been implementing this, I’m not saying that it’s the only way to do developmental screening, but I’m just saying the ones that have done this parents really liked it in a lot of settings, and the nurses and physicians in the practice felt that they really were making some strides by using it. A structured assessment of parental strengths and needs. All it meant was did you get asking the parents about their needs and what they wanted to get accomplished? Recall and reminder systems have been shown to actually improve the care delivered because it’s a communication tool and you get things--make sure the kids get back for their appointments or their follow-ups.
Development of linkage to community resources. And identification of children with special healthcare needs. All that means is that every kid that gets in your practice you know which kids have special healthcare needs. Because one of the things we’re really trying to do with Bright Futures is make sure that all those kids get their health promotion and prevention needs met. That they do not get only their needs met in terms of their special needs, but their needs as children and as families. That we make sure we get all of that done in a really timely way and we keep track that we’re doing it. So that was it. These are the things we measured with these practices over a period of a year. They had a year to work on things. They did their own--they did little chart audits of--and there’s the preventative services prompting sheet that people used. And here’s what happened. So we started and every month they would send us their reports on a few charts when they looked in their charts did they use the preventative services practice sheet and it went way up over the period of the year. This is the thing that many practices I think--10 out of the 15 practices decided to do this. They thought this was a need and they implemented the preventative services prompting sheet. This is the way that we report the data. So you can see that there was--the H’s mean that some practices were at 100 percent when they reported the data, and we put that the Academy we would put this together with North Carolina. There’s some practices that started out zero for a while, not using the preventative prompting sheet, and then they came up. The reason that you do the highs and lows is just because practices that are in this kind of work then say oh, there are people at 100 so I guess there is a way to get to 100, and so it’s a very encouraging thing.
So that’s the first thing. Did you do a preventative services prompting sheet? The second one was did you do structured developmental assessment? And this one we were really excited when we got to the August there, you can see that we were on a trend upward, but by the end of the project we had a little bit of a drop off there. And what it really turned out is that people when they first reported that they were doing a structured validated developmental screening, guess what they were doing? They checked off yes I’m doing that. They were doing a sort of Denver. I don’t know how many of you--when I was in practice one of the things that I had was questions from the Denver. I took five questions from this and we put them all on a sheet and we asked the questions. And the problem is that that isn’t validated for especially the sort of Denver that I was using, because it’s a couple of questions, it’s not all the questions and we weren’t using really a structured developmental screen. So what happened is that as they got into this project with us and realized what was going on, some of them realized they weren’t using it and so that--I think that if we kept to these data going we would something increasing there. But this also shows it’s not easy to implement structured developmental screening in a year project.
Here’s the structured assessment of parental strengths and needs. That also kind of stayed low, but it came up a little bit and I can tell you more about that at another time, what we think happened there. This is another one that I think 12 of the 16 practices chose to do. Identification of children with special healthcare needs right out of the gate. They really liked this one. They thought I can’t believe I never thought to do this before because it’s so wonderful for them to have either on a computer or somewhere a list of the kids that have special health needs. This was a question that just got asked of everybody as they came in and then when they did the chart audits they went and said did we ask everybody? Did we identify all the kids? And they did, so this--a lot of this you can see and I bet you’re sitting there thinking this isn’t that complicated Paula. That’s right, it better be easy or we won’t do it, right? Use of a recall and reminder system, which turns out to be a routine way of informing parents. And systems for communication and we definitely showed an increase in the number of practices that are using that. And then linking to community resources. This was also a composite score which I could go over with you sometime about whether the practice really was able to link to the--get families linked to the community resources that they needed.
So what have we learned that you can use? Oh yeah, and we have, can you just say that Jane. Just hold it up.
JANE: You also in your hand out have the community resources assessment, which is a snapshot of one of the tools that are in your system tools.
PAULA DUNCAN: So what the practice did was use this to see what community resources they knew about, whether they wanted to link to them more, or how their linkage went. We just gave you those examples, the preventative services prompting sheet and the community resource, as things that will be in the tool kit, but we just wanted you to see what kind of supports we’re thinking of using, and that you might want to think about using with practices where you’re trying to help them improve, help them adopt Bright Futures.
So what have we learned that you can use? Here’s a very short list that Peter Margolis from North Carolina and I came up with at the end of the Healthy Development Collaborative, and we said--this is the short list of everything I just said. If you’re going to and help a practice, or work with a group of practices, ask them to look at how they’re doing, do a few chart audits, pick a focus area, engage the whole team, agree on the approach, try something by Tuesday, measure, see how you’re doing going along, keep it simple, simple, simple. Everybody that tried to get too complicated and fancy out of the gate and didn’t start with just one thing, started with all six, then they got back and started with one thing. Link with community resources. Know your resources. And that’s another place where public health can be so helpful. Because if you have a little extra time in a health supervision visit, and you’ve covered everything in the priorities, what would be the next most important thing to do? To address things that are really important in your community. How are you going to know what’s really important in your community? Link with public health and they’ll tell you what’s going on. Partner with parents and use strength-based approaches.
So I think--what time is it? Do we have enough time? Do you want me to go through these? Okay, I’m just going to run through these slides. Being an MCH Director and thinking about this project, I was thinking from when I was an MCH Director what would I have wanted to hear about here? So I just wanted to remind you that I think this little intervention with the 15 practices as we go forward this could be one of the ways, and I just want to say one of the ways, that we implement Bright Futures. Because we can say your practice is--you’re doing a great job now, but if you really want to be doing Bright Futures and doing it the best possible--in collaboration with the medical home and being a great medical home, here’s what you could do, you could measure these six things. This is birth to five, and we could help you improve on these things. I have a wind at the back philosophy. I think that we--in Vermont I need to be the wind at the back of the practices. They are really working hard, and in many cases doing fabulous work, great relationships with families and doing what families need. And what my job is then is to run around behind the scenes and try to get them all the resources and materials and things that they need to keep doing that and to improve. So I think that one thing that if they do that, if they really do improve the care that they deliver in a measurable way, then they would contribute to improved performance measures of things that we as MCH people have to report on. We’d have measurable implementation of the guidelines. Can you imagine if you could say 70 percent of the practices in my State practice according to Bright Futures and somebody says to you, “And how do you know?” And you say, “Because these are the measures that we use, that we’ve worked on them with.” Another one is that this can help with needs assessment and planning, because you have this information from practices. And also it really gives you nice synergy with other partners work. The AAP Chapters, the AFP Chapters, and the NAPNAP groups. So when I was thinking about it I was thinking it would really help me on my immunization performance measure and on my infant mortality performance measure if everybody was talking about back to sleep and I could document that.
I won’t go into the parent feedback today, but I have another idea about that. So the potential--here’s the sales pitch for the practices. This is our best thinking about why you would want to participate in this kind of a project. Probably a project maybe a little less intensive than this, but this is why. Because you’d be documenting the great care that you’re delivering and we would be helping you with that. That you’d learn this new office systems approach. This office systems approach has been tested with ADHD, improving ADHD care, improving asthma care, improving lots of care. We’re just taking it and applying it to preventative services and Bright Futures. But it would show you how your whole office can work together. You’d be ready for recertification. In 2008, the pediatricians and family medicine physicians are going to have recertify with--the part four of their recertification is going to be they have to demonstrate quality in their practice. If you--and of course, doesn’t it seem perfect to have Bright Futures be one of the things that they could use to recertify if they had put this data together? Pay for performance. If somebody in your State is going to be paying for performance, your practices would already have all these things demonstrated, more than HEDIS measures, because remember the HEDIS measures only three things that really apply particularly well. So we’re deepening that with having more measures and that would be really helpful. Improve access to community resources. This is one of the things we could probably really do in public health.
The practices, just as we heard at the luncheon, sometimes people don’t like to ask about things if they don’t know what they’re supposed to do with it after that. So if we really linked up the community resources from the public health side and whatever system you want to use. Help Me Grow in Connecticut obviously we’re trying to--we’re thinking about if we could ever implement that in Vermont it would be such a dream to be able to have parents call up and get the resources they need and have somebody that really knows what’s going on. But manuals or however you would do the resources. Knowledge that the practice would also get the knowledge of the latest, best practice and materials, all the Bright Futures materials and they’d know that they were practicing in a way that’s really consistent with best practice. And then they’d also be part--I think that’s it’s fun for people to be in a network of committed professionals, nurses, other office staff, physicians, where they’re really working on something together and I think that it really could--I think it contributes to satisfaction with your practice.
In another little project that we’re working on that’s very similar to this, I’m not going to tell you the data from it today Healthy Development, but I’d be happy to share another time with you. One of the things we asked was how satisfied are you, nurses and physicians, with the developmental services that you deliver in your practice? And the numbers went up dramatically from the beginning of the project to the end of the project. They were proud of what they were doing. We did a little balancing measure too. How much time does it take from the time the child walks in the office til the child leaves the office before you started these little improvement activities, because if it’s taking an hour and a half longer obviously nobody’s going to want to do it. And there was no statistically significant difference before and after. So that’s another small number of practices. All this is fledgling work, but I think that it’s still taking what we’ve learned from the quality improvement world and saying how can we really make Bright Futures sing? How can we make sure that parent’s needs and concerns are addressed, that we’re partnering with parents? So we’re taking some things from this data based world of improvement and saying we can do this. We can make Bright Futures more data based without losing it’s really true heart and soul; at least that’s what I hope we’re doing. So I’m anxious to have you work with us on this. There’s Ed’s beautiful thing and these are the ideas then. Improve developmental services delivered anywhere you do direct services and WIC. Identify and keep up to date community resources, population health needs and get that message out to people. Support the collection of practice or clinic level patient data, and views. Provide information about the content tools and training, which Beth already talked about that that’s one of the things that public health really did a lot of with Bright Futures before. And then getting reimbursement. So there we go.