Population Health talk to Carnegie Fdn team 11.2013

Population and Community Health: A

Quality Improvement Approach

Robert Kahn, MD MPH

Anderson Center

General and Community Pediatrics

Nov 20, 2013

Overview of Community Health

Asthma

– health inequities, community partnerships,

community capacity

Infant prematurity

– total population, common metrics, user centered

design

Early child development

– Kindergarten readiness; alignment strategies –

model and narratives; community dashboard

Purpose

Lead, advocate and collaborate to measurably improve the health of

local children and reduce disparities in targeted populations

High Level MeasuresBy June 30 2015,

• Reduce the occurrence of unintentional pediatric injuries 30%

• Reduce infant mortality by 15%, 20 infant deaths per year

• Reduce the use of the ED and inpatient services by 20% in children with

asthma covered by Medicaid

• Reverse the trend of increasing childhood obesity in grades K-3

Goal and Initiatives

PopulationHamilton County: 190,000 children age birth -17yrs

Key Driver Diagram

AIM

KEY DRIVERS

SECONDARY DRIVERS

By 2015:

• Reduce the

occurrence of

unintentional

pediatric injuries 30%

• Reduce infant

mortality 15%

• Reduce the use of

the ED and inpatient

services by asthmatic

children 20%

• Reverse the trend of

increasing childhood

obesity

Shared vision, leadership, and

accountability to improve

outcomes, experience, and cost

Parents and communities

empowered to meet families’

health needs

Transparent measurement and

results sharing that drives

continuous learning

Drafted: June 2011

Lead, advocate &

collaborate to

measurably improve the

health of local children

and reduce disparities

in targeted populations.

GLOBAL AIM

Effective, efficient and reliably

linked services and supports for

families to ensure EVERY

child’s needs are met

Highly effective organizational

capacity aligned with existing

hospital, community assets

• Community listening, engagement, leadership, oversight

• Trust, relationship, and partnership building

• Mechanism for shared resource allocation

• Sense of urgency to act and learn

• CCHMC alignment with Board, TCHRF, Divisions, CTSA,

Community Relations, Community Benefits

• Strong functioning condition teams co-led w community

• Development of core teams for QI, measurement, community

engagement, administration, and academics

• Community leaders trainined in quality improvement

• Measure and share performance data monthly

• Reliable data systems and IT platform

• Involve families, community leaders on improvement teams

• Customized QI support to teams to optimize learning

• Best practices for knowledge sharing

• Evidence based inventory of key system components

• Highly reliable application of evidence based practice in all

system components

• High connectivity between services, supports for families

• Risk segmentation and shared population management

• Reduce social and physical barriers to optimal child health

• Enhanced parental self management and caregiving capacity

• Promoting collective efficacy of neighborhood s around health

• Shifting cultural norms to promote health and well being

• Parents, communities “owning” health data & results

What are we trying toaccomplish? AIM

How will we know that a changeis an improvement? MEASURES

What change can we make thatwill result in improvement? IDEAS

Model for Improvement

Act(Adopt, Adapt or

Abandon)

Plan

Study Do

Alignment

Capability

Capacity

Resources

Data comfort

Interfaces

Action LearningLangley et al. 1996

Asthma– health inequities

– community partnerships

– community capacity

0

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Asthma admission rate in Hamilton County, by n’hood(Per 1000 children, avg over 2010-2012)

CCHMC has 90+% of all asthma admissions in county

Quintile 1:• 18 admits among 29,000 kids• 0.6 per 1000• 17% of pop’n with 2% of admissions

Quintile 5: • 299 admits among 17,900 kids• 16.7 per 1000• 11% of pop’n with 35% of admissions

Prob

abili

ty o

f no

t bei

ng r

eadm

itted

0.5

0.6

0.7

0.8

0.9

1.0

Days from index admission

0 100 200 300 400 500 600 700 800

Race White Black

Readmission and racePe

rcen

t n

ot

yet

read

mit

ted

Days from index admission

African American

White

• 19% readmitted at 12 months• 23% of African American children• 11% of White children

365 Days

• Difficulty making ends meet

• Looking for work but being unable to find

• Financial difficult with rent or utilities

• Had to move in with others

• No home/car ownership

Beck

Who are the critical partners?

• Home health care

• Pharmacies

• Cincinnati Public Schools

• Cincinnati Health Department

• Legal Aid Society

• Community health workers

Missed days of day care or school (n=774)

19.5%

25.1%

23.5%

12.4%

8.9%

3.1%

4.8%

2.7%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

Does not attend/work 0 1 to 3 4 to 6 7 to 10 11 to 15 16 to 30 30+

Difficulty connecting to provider

Get frustrated with appointment system

Don’t get the results they need

Conflict between what school nurse says regarding urgency of appointment

and what scheduling gives them. Parents feel “in the middle”

Limited contact between school nurse & provider re: urgency of appt

No established process for communication between school nurse & providers

Caution: If your

last answer is

something you

cannot control, go

back up to previous

answer

Root Cause

Why ?

Why ?

Why ?

Why ?

Rapid Cycle Improvement Collaborative (RCIC)

Why ?

Process Name: Breathing Room – CPS Health TeamF

AIL

UR

E M

OD

ES

INT

ER

VE

NT

ION

SC

UR

RE

NT

PR

OC

ES

S

Research re:

current Asthma

Action Plans.

Parent Inquiry

re:recent medical

visits (using #

from PS);

Ramp:student

interviews for #

Connection to

Medical Home

No health

history

Parents mis-

understand

diagnosis

Old or

incorrect

diagnosis

Students

absent or

difficult to

locate

Questionable

skill level of

screeners

School admin

push-back

Physical

space

limitations

Fitness

levels

Illness

Unable to

reach parent

Discrepanci

es between

child &

parent ACT

staffing

Lack of

monitoring

process

Info not in

PowerSchool

No ongoing

care

No

emergency

meds/EAPs

Sustainability

issues

Student

identified with

Asthma

ACT obtained

Care

Coordination

Identify

Medical HomeACT score

<20

Unable to

reach

parents

No health hx

Transience

of students

No show

policies

No

transportation

Difficulty

getting appts

Insurance

issues

Limited

provider

availability

Staffing

caseload

HIPAA

Parent

doesn’t

consider

priority

Contact

identified

providers to

establish

expedited

appt process

Ramp:

contact all

named

providers

Comprehensive

process to

assure appt

scheduled &

completed at

established

medical home

Student

asthma

education

Parent

asthma

education

Asthma data

validation

ACT

screening

training for

nsg students

Mass ACT

screenings

using CCHMC

protocol

ACT score

education

ACT score

validation &

respiratory

assessment

Breathing Room:

% of students with poorly controlled asthma who completed medical

home visit (March 6--June 5, 2013)

PDSA #1

verification of medical home

with parent/AAP

PDSA#2

develop expedited

appointment

process

PDSA#3

schedule appts

utilizing expedited

process

PDSA #4

Modify expedited process

PDSA#5

visit medical home site

PDSA #6

persistant phone contact w/family &

provider

0

5

10

15

20

25

30

35

40

45

50

55

60

65

70

75

80

85

90

95

100

01/3

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n=

36)

02/0

6/1

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02/1

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02/2

0/1

3 (

n=

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02/2

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n=

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6/1

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03/1

3/1

3 (

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03/2

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n=

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03/2

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n=

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n=

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05/0

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n=

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05/1

5/1

3 (

n=

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05/2

2/1

3 (

n=

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05/2

9/1

3 (

n=

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06/0

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n=

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weekly count of students with ACT score <20

% o

f s

tud

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ith

AC

T <

20

wit

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om

ple

ted

me

dic

al

ho

me

vis

its

cumulative percentages median Goal (60)

Rapid Cycle Improvement Collaborative (RCIC)

Cincinnati Asthma Admissions and

Neighborhood Asthma Hotspots

Legal Aid Housing Cases Mapped

Against Neighborhood Asthma Hotspots

James M. Anderson Center for

Health Systems Excellence

Handoffs from pediatrics to legal aid

0%

20%

40%

60%

80%

100%

Perc

ent

of handoffs s

uccessfu

l

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13

Rate 83% 100% 100% 94% 94% 98% 100% 100% 100% 100% 100% 100%

# of Referrals 64 57 49 71 67 46 73 57 43 53 81 60



CCHMC-Health Department Referrals

Network of care for children with

chronic illness

Figure. Collaborations between agencies serving children with complex chronic

conditions. Acad Ped 2012

schools

pharmacy

community

health worker

Focus on the System

“Every system is perfectly

designed to get the results it gets.”

Paul Batalden

25



Prematurity

• total population

• value of common metrics

• user centered design

All births Preterm births* %

National 11.5

Hamilton County 10,782 1460 13.5

Avondale 206 36 17.5

East, Lower Price Hill 356 64 18.0

Preterm birth in Hamilton County





Local area preterm birth rates: Developing interventions to cool ‘hotspots’



• In 2011 in these 3 zip codes 15 infants died

• Annually ~100 infants born <37 weeks gestation (17.8%)

• In Avondale alone, 5 infants at <30 weeks GA

Two smaller communities:Smaller learning system then test scale

Target Communities

Total Population

Women 15-44 yr

Annual Births 2009-2012

Annual Preterm

Births 2009-2012

Good Sam Births

UH

Births

Avondale 12,466 3,219 206 36 83 82

Price Hill 16,415 3,750 356 64 143 167

Totals 28,881 6,969 562 100 226 249



Measurement

Improve maternal and infant health with a focus on prematurity and early infant ED usage

• Percent of all pregnancies identified each month

• Earlier gestational age at entry to prenatal care

• Earlier gestational age at first prenatal home visit

• Day of life for first newborn visit to health care



Portfolio of Measures and Projects

• Percent of all new pregnancies identified each month– Identify and link all prenatal care providers serving a region

– Begin collecting geographic identifiers for all patients

• Gestational age at entry to prenatal care– Same day access for pregnancy test and 1st PN visit

– Community engagement – ethnography, community organizing

• Gestational age at first prenatal home visit– Increase % of all eligible that are enrolled

– Improved engagement and referral strategies

• Day of life for first newborn visit to health care– Electronic health record registry based on zip codes

– Test welcome call scripts, resource offerings



Partnerships to reduce prematurity

Prenatal1University HospitalPrenatal2 Pediatrics1

Prenatal3 Pediatrics2

Prenatal4 Good Samaritan

Hospital

Pediatrics3

Prenatal5

Prenatal6

Home visiting

Housing, partner violence, legal assistance, food assistance, mental health svcs



Handoffs from birth hospital to clinic

14.4

10.1

0

10

20

30

40

50

60

70

80

90

09

/27

/10

10/1

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5/1

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103/1

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3/2

4/1

10

4/1

5/1

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4/2

2/1

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4/2

8/1

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5/1

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5/1

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6/0

1/1

10

6/1

7/1

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7/1

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7/1

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11

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112/2

/2011

12

/19

/20

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01

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1/2

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02

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23

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23

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6/2

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04/1

8/1

24

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/201

25/3

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25

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25/2

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6/7

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6/2

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06

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7/9

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7/1

7/2

01

27

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/201

207/2

7/1

20

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1/1

20

8/1

0/1

20

8/2

1/1

20

8/2

9/1

20

9/0

2/1

20

9/2

5/1

21

0/0

5/1

21

0/0

8/1

2

Ag

e in

Da

ys

Date of Birth

Age in Days Average Age in Days Control Limits

RN welcome calls begin

C. Brown



Handoffs from pediatrics to home visiting

ECS Grand Rounds,

Talking points rolled out

Newborn Coordinators

Started

0

5

10

15

20

25

30

04

/01

/12

05

/01

/12

06

/01

/12

07

/01

/12

08

/01

/12

09

/01

/12

10

/01

/12

11

/01

/12

12

/01

/12

01

/01

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02

/01

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03

/01

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04

/01

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05

/01

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06

/01

/13

07

/01

/13

08

/01

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Mo

nth

ly N

um

ber

of

Refe

rrals

Monthly Number of Referrals Median

C. Brown



Early Child Development

• population of kindergarteners

• alignment strategies

• community dashboard

Birth to kindergarten readiness

Transforming Early Childhood Community Systems (TECCS)

• Goal: improve developmental and physical health outcomes for children 0-5 years with focus kindergarten readiness

• Collaboration of all committed disciplines:

– physicians, early childhood education providers, social service agencies, home visiting agencies, public, parochial schools

• Clear shared objectives, improvement science methods

• Partners - United Way, Kellogg Foundation, UCLA

• Begin in East, Lower Price Hill – but focus on spreadable strategies

40

Kindergarten Readiness Assessment – Neighborhood Profile

Who is in - Child Denominators“EVERY CHILD” (not „every child we serve‟)

M+F M+F

All ages 0 to 5 Births

Hamilton County 802,374 58,104 11,373

East/Lower Price 16,415 1,745 339

East Price Hill 15,340 1,594 305

Lower Price Hill 1,075 151 34

41

PRICE HILL IMPROVEMENT COLLABORATIVE

Key Driver Diagram

AIM

KEY DRIVERS

INTERVENTIONS

Goals: (by 12/31/2013)

Outcome Measures:

•<30% of children score

”vulnerable” on one or more

EDI domains at kindergarten

•>3 percentage point increase

in children who score 19 or

above on the K-RAL

•<15% of children score as

moderate risk on the 36 mo

ASQ

•<20% of children score as at

risk on the ASQ:SE at 36 mo

•>10% annual increase in the

percentage of families read to

children daily

Leadership that builds shared purpose to

improve outcomes

Parents empowered to meet their

child's, family’s and community’s needs • Expanded, tailored parents services designed to build

parental capacity to meet needs of their families

• Promote and strengthen early literacy programs

• Improve capacity by better matching child need and existing

programs

• Expanded, tailored, office and home-based services focused on

development and health (e.g., ECE, medical, HV,, WIC, agency)

• Increase efficiency

• Enable new and better ways for parents to promote health

development

• Elicit parent concerns about learning development and behavior

• Provide parent education tailored to increase knowledge, self

confidence, and health promoting behavior

•Standardize referral and feedback process with mutually

understood eligibility criteria

•Enhanced communication to manage support for children at risk

Reliable linkages between services and

supports for children and families

Drafted: Sept 19, 2011

Revised: May 6, 2011

Improve early childhood

physical

health, language, cognitiv

e, and social and

emotional development for

all children 0-5 in East and

Lower Price Hill

GLOBAL AIM

Effective and efficient services and

supports for families with young children

Transparent measurement and data

sharing to drive continuous learning and

application of QI

• Measure and share performance data monthly to promote

learning

• Involve families on improvement teams

• Provide customized QI support to teams

• Develop data collection system to monitor progress

• Peer-to-peer communication facilitated by technology to share

knowledge and best practices

• Align all participants around a compelling vision

• Build leadership knowledge, skills, and commitment

• Assume responsibility to drive outcomes

• Advocate for policy or community systems change

System of care meets the needs of every

child in East and Lower Price Hill

• Tailor care to needs and risks using stratification (e.g

low, medium, high)

• Define and develop core services and supports based on risks

and need (e.g., content/frequency/follow-up)

• Utilize a shared population registry across services/supports

• Optimize preventive and chronic care

(prevention, asthma, injury, obesity)

Positives• GED/college aspirations

• Literacy interests (supermarket coupons)

• Pride: Staying “because I grew up here”

• Strong matriarchy

• Volunteerism – safety, community action teams

• Existing parent groups – supported by nurse visitors, Santa Maria, Life Point

• Periods of unemployment

• Limited mental health services, dental care or regular adult HC

• Safety/security issues

• Perceived racism

• Social isolation

• Lack of afterschool opportunities

• Possible lack of knowledge re Rec ctr, Boys and Girl Club opportunities

• Self-reliance/trust issues – caregiver needing to be a ‘rock’

• Homeless stretch

Shared Mental Model: In depth parent interviews, Why are you here?

Why are YOU here?

PPC 110 babies/yr Price Hill HC ~160 babies/yrHopple 80 babies/yr

Getting to the whole denominator EVERY baby born into Lower and East Price Hill…

• To ensure each gets to his/her newborn visit, and connects long term to a medical home

• Aligning clinics that see ~65% of babies born in the area

• Redesigning medical roles to reach out to new parents

47

Improvementproject began

Calls toparent

Schedulefrom exam room

Same dayeval

Clinic-widetesting

Coordinatespeech/audio

scheduling

Referralcoordinator

started

Glitchin referral

report fixed

Staffretrained

Epicchanges

live

0

10

20

30

40

50

60

70

80

90

10005/3

1/1

2 (

n=

09)

06/0

7/1

2 (

n=

08)

06/1

4/1

2 (

n=

05)

06/2

1/1

2 (

n=

08)

06/2

8/1

2 (

n=

11)

07/0

5/1

2 (

n=

05)

07/1

2/1

2 (

n=

09)

07/1

9/1

2 (

n=

09)

07/2

6/1

2 (

n=

07)

08/0

2/1

2 (

n=

07)

08/0

9/1

2 (

n=

03)

08/1

6/1

2 (

n=

06)

08/2

3/1

2 (

n=

05)

08/3

0/1

2 (

n=

16)

09/0

6/1

2 (

n=

07)

09/1

3/1

2 (

n=

11)

09/2

0/1

2 (

n=

16)

09/2

7/1

2 (

n=

09)

10/0

4/1

2 (

n=

11)

10/1

1/1

2 (

n=

08)

10/1

8/1

2 (

n=

14)

10/2

5/1

2 (

n=

07)

11/0

1/1

2 (

n=

13)

11/0

8/1

2 (

n=

13)

11/1

5/1

2 (

n=

15)

11/2

2/1

2 (

n=

06)

11/2

9/1

2 (

n=

05)

12/0

6/1

2 (

n=

10)

12/1

3/1

2 (

n=

09)

12/2

0/1

2 (

n=

03)

12/2

7/1

2 (

n=

01)

01/0

3/1

3 (

n=

16)

01/1

0/1

3 (

n=

14)

01/1

7/1

3 (

n=

13)

01/2

4/1

3 (

n=

10)

01/3

1/1

3 (

n=

09)

02/0

7/1

3 (

n=

12)

02/1

4/1

3 (

n=

06)

02/2

1/1

3 (

n=

05)

02/2

8/1

3 (

n=

06)

03/0

6/1

3 (

n=

11)

03/1

3/1

3 (

n=

07)

03/2

0/1

3 (

n=

10)

03/2

7/1

3 (

n=

10)

04/0

2/1

3 (

n=

06)

04/0

9/1

3 (

n=

10)

04/1

6/1

3 (

n=

06)

04/2

3/1

3 (

n=

12)

04/3

0/1

3 (

n=

12)

05/0

7/1

3 (

n=

12)

05/1

4/1

3 (

n=

09)

05/2

1/1

3 (

n=

04)

05/2

8/1

3 (

n=

05)

06/0

3/1

3 (

n=

17)

06/1

0/1

3 (

n=

14)

06/1

7/1

3 (

n=

12)

06/2

4/1

3 (

n=

17)

07/0

1/1

3 (

n=

06)

07/0

8/1

3 (

n=

12)

07/1

5/1

3 (

n=

05)

07/2

2/1

3 (

n=

07)

07/2

9/1

3 (

n=

14)

08/0

5/1

3 (

n=

10)

08/1

2/1

3 (

n=

17)

08/1

9/1

3 (

n=

11)

08/2

6/1

3 (

n=

04)

09/0

2/1

3 (

n=

13)

09/0

9/1

3 (

n=

10)

09/1

6/1

3 (

n=

08)

09/2

3/1

3 (

n=

10)

09/3

0/1

3 (

n=

07)

10/0

7/1

3 (

n=

09)

10/1

4/1

3 (

n=

18)

10/2

1/1

3 (

n=

15)

10/2

8/1

3 (

n=

06)

11/0

4/1

3 (

n=

09)

11/1

1/1

3 (

n=

06)

11/1

8/1

3 (

n=

11)

11/2

5/1

3 (

n=

15)

12/0

1/1

3 (

n=

07)

12/0

8/1

3 (

n=

10)

12/1

5/1

3 (

n=

11)

12/2

2/1

3 (

n=

06)

Pe

rce

nt A

tte

nd

ing

Week that 60 Day Referral Window Ends

Percentage of PPC Patients 0-3 Years Old Referred to CCHMC Audiology or Speech Therapy Who Attend an Initial Appointment

within 60 Days

Weekly Percent Attending Median Goals = Window not yet closed, data point can still

C. Brown

Place based literacy: Program inventory

48





Overview of Community Health

Asthma

– QI for health inequities, community

partnerships, community QI capacity

Infant prematurity

– QI for the total population, common metrics, user

centered design

Early child development

– QI for population of kindergarteners; trajectories

and overlap; alignment strategies –model and

narratives; community dashboard

Population Health talk to Carnegie Fdn team 11.2013

Health & Medicine

Transcript of Population Health talk to Carnegie Fdn team 11.2013