Prevention in the Medical Home

Lisa A. Cosgrove, MD, FAAPFlorida Pediatric Medical Home Demonstration Project

Learning Session 2

April 27-28, 2012

Disclosure

I have no relevant financial relationships with the manufacturers of any commercial

products and/or provider of commercial services discussed in this CME activity. I

do not intend to discuss an unapproved/investigative use of a commercial product/device in their

presentation.

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Objectives

Describe C4K goals around preventive care Share current AAP policy

recommendations Share examples of existing tools Explore implementation strategies

C4K Phase 2 Measures: Preventive Care

Review Charts of 24-month well-child visit: Appropriate risk assessments are performed at 95% of well-child visits

95% identified “at risk” have documentation in chart that risks were addressed at the visit 95% of patients have documentation of 1completed standardized

developmental screen at the 24 month health supervision visit (if you have a 30 month visit, there will be an “opt-out”).

90% of patients with a positive developmental screen have a follow-up plan in chart 95% of patients have documentation of a standardized autism-specific

screen at the 24 month health supervision visit. 90% of patients with a positive autism screen have a follow-up plan in chart

95% of patients have documentation in chart that BMI was plotted on the percentile curves according to age and sex at the 24 month visit.

90% of patients have documentation in the chart that the patient’s medical summary or comprehensive care plan was created or updated/maintained at the visit. (Continued from Phase 1, but now only looking at 2 year olds)

90% of patients have documentation in the chart that the patient’s current medical summary or comprehensive care plan was reviewed with the parent at the visit.

Explore use of Florida SHOTS immunization registry to begin looking at patients from a population level

Periodicity Schedule

Age Appropriate Risk Assessment

Standardization of preventive care

Increased reliability of thoroughness at each visit

Stratified approach based on patient’s risk

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Screening table – 2 year visit

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Risk assessment questions – 24 months

Body Mass Index Recommendations

BMI starting at the 2-year well visit on CDC growth chart

Documentation of %ile in well visit note Conditionality (if this, then…)

Specific counseling, labs, follow-up visit, etc.

Developmental Screening

Standardized developmental screening tools should be used when developmental surveillance identifies concerns and for all children at the 9, 18 and 30* month visitso *Note: Because the 30-month visit is not yet a part of the

preventive care system and is often not reimbursable by third-party payers at this time, developmental screening can be performed at 24 months of age. In addition, because the frequency of regular pediatric visits decreases after 24 months of age, a pediatrician who expects that his or her patients will have difficulty attending a 30-month visit should conduct screening during the 24-month visit.

o Note: if you use a 30 month visit, there will be an opt-out option on your chart reviews

o Use a QI model to integrate surveillance and screening into office procedures

Autism Screening

Standardized autism tools should be used when surveillance identifies risk and routinely on all children at the 18 and 24 month visit

Screening Follow-up

If screening is positive, recommendation for simultaneous referral to: Developmental evaluation Medical evaluation Early intervention services Audiologic evaluation (autism)

Communicate with referral source regarding outcome

Immunizations

Monthly Progress Report question asks about use of Florida SHOTS to manage your patient population.

Florida SHOTS (State Health Online Tracking System) is a free, statewide, centralized online immunization registry that helps health-care providers and schools keep track of immunization records. Helps with population management

Role of Medical Home

Screening and SurveillancePartnering with parents as experts on their childProviding information and resources for parentsNetworking with community resourcesFacilitate linkages for families with Part C, and

other diagnostic and treatment resourcesPopulation management (eg, use of

immunization registry, etc)**Parent partners can serve a vital role in

identifying community resources and linkages, providing support to families!

Tools for Implementation: Updated Change Package

The change package has been updated with several tools related to these new measures Modified Checklist for Autism in Toddlers (MCHAT) – for

16-48 months Developmental Screening Tools grid Bright Futures 24-month tools (these tools are available

for all ages on the periodicity schedule) Previsit Questionnaire Chart Documentation Form Parent Handouts

Immunization Resources

Implementation

How do we ask all these questions about risk?

How do we remember if we’ve asked the questions or completed age-appropriate screening/services/referral?

How do we incorporate patient designations? (CSHCN, Down Syndrome, hearing loss risk, etc.)

How will it work in your practice?

How do we ask all these questions?

Incorporate into well visit template (paper or EHR)

Use previsit questionnaire Provide screening tools to parent for

completion (ASQ, MCHAT)

Implementation Strategies

Chart Documentation Form Practitioner uses during visit to document activities Forms guide practitioner on what questions to

ask/issues to address based on child’s age and visit priorities

Forms include sections for each component of visit: History Surveillance Physical exam Screening Immunizations Anticipatory guidance

Implementation Strategies

Previsit questionnaire Paper, e-survey in health portal, kiosk, tablet,

staff-directed, physician-directed Literacy concerns Time concerns Author concerns (who is filling it out?,

confidentiality) EHR concerns (scanning, inputting data, data

retrieval)

Implementation Strategies

How do we remember if we’ve asked the questions or completed age-appropriate screening/services/referral?

Preventive Services Prompting Sheet

Practice management resource Facilitates communication across providers Helps to distribute work across team Allows anyone to quickly assess whether

up-to-date Identifies those in need of preventive

services Prompts team member to provide at any

visit

Preventive Services Prompting Sheet

Patient Designations

How do we incorporate patient designations? (CSHCN, Down Syndrome, hearing loss risk, etc.)

Enter into section on PVPS or integrate into EHR so defaults to appropriate growth chart and condition-specific periodicity

Implementation Strategies

How will it work in your practice?Questions to Consider:

What are the results you want? What do patients/parents want and deserve?

What processes and tools are currently used? How well are those working? What do you like/dislike? Who cares about this? Who can help make it work?

Clinicians? Back office staff? Front office staff? Parents? Payers? Community resources?

Implementation Strategies

Questions to Consider (continued): What tools are available to help? What are the pros and

cons of each? When and where should the tool be completed and by

whom? How can this best fit into the office flow? How and by whom will the tools be scored? How will parents be informed of the results? What happens when a child is found to be delayed? What resources are available to help?

Implementation Strategies

Questions to Consider (continued): Who will be responsible for each step in the process? When will you study your results? How will you know if the new process is working? How will you acknowledge/reward successs? Once the process is working, how will you assure

sustainability (and ongoing improvement)? Key staff member (or doc) leaves New employees Winter/RSV New tools become available Community resource change

Incorporating into EHR

When well visit scheduled, auto-prompts the correct age template

90/10 rule for defaults No click defaults PSPS becomes “to do” list or “not done”

list Screening questions can be built into

ROS but need scoring system

Incorporating into EHR

Conditionality very important, (if this, then ?) Standard, Routine or Alternate ordering

prompts Color codes can be tool to recognize

overdue service Query for reminder recalls Add specialized periodicity based on risk,

condition, insurance type

Incorporating into EHR

Itemization important for getting data back out of EHR for study, QI

Need to decide what level of detail gets a specific response (yes/no, drop down choice) vs. “text blob”

Acknowledgements

I would like to thank Bill Stratbucker, MD, FAAP and Chuck Norlin, MD, FAAP as well as the Bright Futures Preventive Services Improvement Project for use and modification of some slides