Communities Coordinating for Healthy

DevelopmentTraining for Districts

Coordinating Communities for Healthy Development

The goal of the CCHD project is to create and institutionalize a feedback communication loop between clinical providers and early intervention and preschool special education providers to benefit children with developmental delays or socio/emotional or behavioral health concerns.

Training Topics

• Before you begin• Goals & Tools• How to start • Model for implementing change• Guiding the team through the process• Completing and Spreading the Work• Modifications

Before you Begin

1. Review the materials in the toolkit, especially the roles and responsibilities, and how to work with clinics.

2. Recruit someone who also works within the early intervention/ preschool education system to work with you.

Goals & ToolsGoal Tool

Build Relationships with Primary Care Clinics that work with children in your area

Team

Implement a Work Flow for Communication between Clinic and District

Sample Work FlowTeam members

Simplify Communication Process While Following Consent Rules

Sample Referral Response FormsTeam Members

Track Referrals and Communication to Monitor Progress

Electronic Medical Records DatabaseTeam Members

How to Start

1.Identify team members to recruit

2.Reach out through established

relationships

3.Share materials

4.Begin meeting

Identifying Team Members• Clinic Staff

– Look for a champion, someone who will support the project at their clinic, and recruit onto the team

– Start by identifying clinics serving children in your area, and reaching out to inform them about the project and inviting them to join the team

• Local public health or agencies doing childhood screening• Parents• Other agencies involved in referral process

– Who are you currently sending referrals to?• Other providers of early childhood services such as Head Start,

ECFE• Clinicians providing medical services to your patients – OT, PT,

Mental Health

After you’ve identified potential team members…

1. Contact them, talk about the goals of the project, see if

they’re interested in meeting to discuss it or have ideas of

other people who should be included.

2. Be open to varying length of commitment – this project

may lead to long term connections, but at the same time

some team members may only be able to be involved as

long as it takes to implement the feedback cycle.

3. Share materials and resources.

4. Invite them to a launch meeting.

Suggestions for Launch Meeting

• Introductions and roles in current referral and service system in the community

• Discussion of goals for CCHD team and CCHD process

• Review of materials to learn (other trainings or toolkit)

• Set up next steps (start meeting regularly, using change model, etc.)

Model for Improvement

The team can work together to create a system for implementing the CCHD changes, or you can use the Model For Improvement. The model leads the team through testing out small changes toward big goals, in a Plan-Do-Study-Act process.More information on the Model is found in the CCHD toolkit.

Guiding the Team through the Process• Meet regularly• Identify a way to know when your team has

completed the project• At the beginning, learn how the current system

works, to identify where to approach changes• Work through modifying the tools to be useful to all

the team members• Ask the early intervention/ preschool special

education providers to start sending referral feedback forms

• Track the responses through clinic EMR• Report back to team on progress• Address issues and barriers• Add team members when needed or available

Creating a Workflow as a Team

Creating a work flow diagram may help your CCHD team examine all the aspects of the referral feedback loop and be able to identify areas where changes are needed. Here are examples of a few work flows that CCHD teams created in the past.

Early Intervention/ Preschool Special Education Referral Report Workflow

Clinic sends referral directly to early

intervention office at school district

Clinic sends referral to the Help Me Grow

state online system

HMG determines appropriate district,

sends them the referral

District receives referral, assigns to staff for evaluation

Evaluators contact

family and set up

meeting

Family refuses evaluation or is

unable to be contacted, referral is

closed

Student is determined to be

eligible for services

Student comes in for evaluation, consent to

send results back to clinic is requested.

Family accepts, service plan is

created, student

begins to receive services

Family refuses services, referral is

closed

Student is determined to be ineligible for services, is

given alternative resources, possibly signed up for Follow Along Program

Child visits clinic, completes a

screening tool with a score that triggers a referral

District sends this information back to

the clinic

District WorkflowReferral Report Opportunity

Sample Internal Referral FeedbackWorkflow for Screening at Clinic

Nurse or other clinic staff score the questionnaire and give results to the child’s practitioner

Family arrives for visit and either gives check in staff the completed questionnaire or completes one in the lobby

Prior to office visit, clinic administrative staff send screening questionnaire to family

Practitioner determines if a referral is needed, notifies the family and asks clinic staff to make the referral

Referral is made to Help Me Grow (state referral system)

Help Me Grow funnels referral to appropriate school district for early intervention or preschool special education evaluation

Family consent to report back to clinic is obtained

Early intervention or preschool special education program staff send referral report form back to clinic via fax

Administrative staff receive report by fax, give to practitioner

Practitioner reviews report, highlights any issues, and gives it to care coordinator

Support staff files in medical record

Care coordinator reviews report to identify any follow up needs to act on and gives it to support staff

Clinics will vary in which staff will perform which of these functions. As part of the CCHD project, it will be important to identify these staff and engage them in the improvement process.

Clinic/Community Workflow for Early Intervention and Preschool Special Education Referrals

Follow Along Program•Tracks children with potential concerns•Sends both a monthly list of enrollees and abnormal screening reports to clinic

Developmental Screening Coordinator (DSC) (part of clinic staff)•Enters reports and consent forms into medical records•Sends electronic update messages to providers•Responds to information requests from community partners (when consent is provided)

Clinic: Primary Care Provider•Reviews reports received from DSC•Conducts screenings with patients•Sends recommendations to DSC to follow up or call family

Early Childhood Screening•Screens children for concerns•Screening forms are sent to the clinic, along with consent forms

School District Early Intervention or Preschool Special Education Staff•Receives referrals from DSC and conducts evaluations with children•When an evaluation is completed, and the child is a clinic patient who has consented to share information, sends a report back to the DSC

Completing and Spreading the Work

• Complete when you’ve met your team goals.

• Celebrate!• Tell others about your

work, to encourage spreading the CCHD project to other communities, clinics, and families.

Modifications: Enhancements to the project that might attract clinics

• Health Care Homes/ Medical Home Model: completing the CCHD project can help your clinic prepare for HCH certification in MN. Contact information for HCH is found on the CCHD website.

• MOC 4 Project: The first round of CCHD projects applied for and received MOC 4 certification from the Academy of Physicians. Data run charts used in that process are available in the toolkit.

Technical Assistance Available

The CCHD website has sample referral communication forms, examples of work flow diagrams, and links to many resources to support the project.

You can also email CCHD.Info@state.mn.us .

www.dhs.state.mn.us/cchd

Resources• Developmental Screening Overview:

http://www.health.state.mn.us/divs/fh/mch/devscrn/• Developmental Screening Tools:

http://www.health.state.mn.us/divs/fh/mch/devscrn/instruments.html• Online Developmental Screening Training Module:http://www.health.state.mn.us/divs/fh/mch/webcourse/devscrn/index.cfm• Institute for Healthcare Improvement’s Model for Improvement:

http://www.ihi.org/knowledge/Pages/HowtoImprove/default.aspx• Information for Parents and overview of MN’s online referral system:• www.mnparentsknow.org . Follow the button in the top right hand corner to Help

Me Grown, the online referral page.• Online trainings for practitioners, with CME Credits: www.edopc.net, go to training

page and look for “Coordinating Care Between Early Intervention and the Primary Care Practices”

• Helpful Toolboxes for Clinicians www.nashp.org

Communities Coordinating for Healthy Development

Funded by a grant from The Commonwealth Fund and supported by the National Academy for State Health Policy

Created in cooperation with the Minnesota Department of Education and the Minnesota Department of Health.

www.dhs.state.mn.us/cchd