Wendy Davis, MD, FAAP Senior Faculty, Vermont Child Health Improvement Program

1. Improvement Partnerships: State and Regional Collaboratives to Improve Children’s Healthcare DeliveryOctober 2, 2014 Warwick, Rhode Island Wendy Davis, MD, FAAP Senior Faculty, Vermont Child Health Improvement Program Associate Director, National Improvement Partnership Network Professor of Pediatrics, University of Vermont College of Medicine Barbara Frankowski, MD, MPH, FAAP Senior Faculty, Vermont Child Health Improvement Program and National Improvement Partnership Network Professor of Pediatrics, University of Vermont College of Medicine

2. What We Have Planned • Overview of the Vermont Child Health Improvement Program (VCHIP), Improvement Partnerships (IPs) and the National Improvement Partnership Network (NIPN) • Role of IPs in advancing children’s healthcare quality • Vermont Blueprint for (Child) Health • Vermont’s CHAMP Practice Network • Consider opportunities to collaborate & provide support as PCMH – Kids continues to evolve • Formalize membership in NIPN?

3. Missionto optimize the health of Vermont children by initiating and supporting measurement-based efforts to enhance private and public child health practice.In partnership with:Vermont Department of Health University of Vermont Department of Pediatrics, OB, FP & Psychiatry Vermont Chapter of the American Academy of Pediatrics Vermont Chapter of the American Academy of Family PhysiciansDepartment of Vermont Health Access (Medicaid) Vermont Agency of Human ServicesBanking, Insurance, Securities & Health Care Administration (BISHCA)Managed Care Organizations

4. How VCHIP Works with Sites of Care Measure (re-measure) provision of care and outcomes Feed results back to practices; compare across practices Practices share learning through collaborative meetings & conference calls Dramatically improved levels of performance Coach practices in setting improvement goals and implementing change Topic-specific improvement materials and tools

5. Practice Support • Learning Sessions • Baseline Chart Abstractions • Feedback presentations at practice sites • Collaborative phone calls • Monthly reports and data collection • Creation and modification of tools and forms

6. Month 2 Month 2 Month 3 Month 3 Month 1 Month 1 Month 5 Month 5 Month 6 Month 6 Month 4 Month 4 pre-work pre-work D D S A P P A S P D P A A S S A P D A D S P S D A Typical Learning Collaborative Identify team members Baseline practice assessment / patient registry Periodic practice assessment (small) Periodic practice assessment (small) Periodic practice assessment (small) Periodic practice assessment (small) Final practice assessment (big) Feedback Feedback Feedback Feedback Feedback Learning Session(s) Conference Call Conference Call Conference Call Conference Call Conference Call Site Visit Site Visit Site Visit Site Visit Wrap-up meeting

7. VCHIP Timeline • CHIPRA Quality Demonstration Grant • Adolescent Mental Health 2010-11 • National Improvement Partnership Network (NIPN) • Developmental and Autism Screening 2009 • Abusive Head Trauma Prevention in Primary Care • Bright Futures 2008 • VT Regional Perinatal Health Project • VT Integrated Family Health Care System 2005-7 • Blueprint Evaluation • Teen Safe Driving • Chronic Illness 2004 • Care of the Opiate Exposed Newborn • Child Development 2003 • Improvement Partnerships • Improving Prenatal Care • Child Mental Health • Vermont Hospital Preventive Services Initiative (VHPSI) 2002 • Youth in Foster Care • EQRO contract 2001 • Youth Health Improvement Initiative (YHII) 2000 • Vermont Preventive Services Initiative (VPSI) 1999 • VCHIP Executive Director Hired 1994-1998 • Formal presentation of VPSI to the AAP-VT Spring Meeting; VCHIP core funding obtained for preventive services work • Vermont Periodicity Schedule developed by Vermont Department of Health in collaboration with the AAP-VT and AAFP-VT Chapters

8. Active & Completed VCHIP Projects

9. No. of VT practices participating in at least one VCHIP project • 92% Pediatric Practices (36/39) • 40% Family Practices (42/106) • 27% OB Practices (7/26) • 39% Certified Nurse Midwife Practices (5/13) • 100% VT Hospitals (12/12)

10. Senior Advisory Group • Vermont Department of Health (MCH Director, EPSDT Director) • Agency of Human Services • AAP Chapter President • AAFP Chapter President • Parent • QI Expert (Vermont Oxford Network) • Chair, UVM Department of Pediatrics • UVM Faculty (College of Medicine; College of Nursing and Health Sciences)

12. Selected VCHIP Results Youth Health Improvement Initiative Improving Care for School-Aged Children with Asthma P<.001 Improving Prenatal Care in Vermont

14. Improvement Partnerships

15. Improvement Partnership …a durable, state or regional collaboration of public and private partners that uses measurement-based efforts and a systems approach to improve the quality of children’s health care

16. What are Improvement Partnerships? • State or regional quality improvement (QI) focused on maternal and child health and primary care practice • Bring partners together from across healthcare systems • Lead and coordinate QI projects in child-serving practices • Dedicated staff (e.g., QI coaches and measurement experts) • Housed within a university, children’s hospital, state government department/office,or local AAP chapter • Find resources to support child health improvement

17. What do Improvement Partnerships do? • At the practice/clinician level • Coach clinicians and practice teams in measuring and improving care • Develop, test, and share tools, measures, and strategies • Connect clinicians with academic and systems experts • Support practices/clinicians in meeting regulatory and certification requirements (e.g., PCMH, MOC, CME)

18. What do Improvement Partnerships do? • At the State and System levels • Provide access to clinical practices; engage clinicians in public health aims • Serve as a convener and “honest broker” for interested organizations and entities; engage reluctant stakeholders • Spread successful approaches statewide • Inform policy

19. WA ME ND MN VT MT OR ID NH NY WI SD MI MA RI WY CT PA OH NB NV UT DE IL MD CO CA KS VA MO KY NC TN AZ OK AR NM SC GA AL MS LA TX FL AK HI 0 100 Miles 0 500 Miles 0 0 100 Km 500 Km Est. 2005 Est. 1999 Est. 2011 Est. 2007 Est. 2010 Est. 2013 Est. 2011 Est. 2005 Est. 2005 Est. 2007 Est. 2008 IA Est. 1999 Joined NIPN 2012 NJ Est. 2011 IN Est. 2007 Est. 2011 Est. 2012 WV Est. 2003 Est. 2007 DC Est. 2005 Est. 2013 Est. 2005 Est. 2007 Est. 2004 IP Pre-IP* Inactive IP† *in process of becoming an IP †IP not currently participating in NIPN activities

20. Improvement Partnership Development . K KIDS O TheOKlahoma Key to Improving Developmental-Behavioral Services

21. Why are States Developing Improvement Partnerships? • Investing in improving the healthcare (and health) of children • Recognizing, embracing, and supporting local expertise – “all improvement is local” • Sharing knowledge, innovations, and successes throughout the state, and across states, to optimize the impact on child health delivery and outcomes

22. Where are they located? • AAP Chapter • Arizona, Iowa*, Minnesota, Oregon, Rhode Island, West Virginia • Medicaid • Connecticut, Michigan • Department of Health • New York, Ohio, Washington • Academic Institution • Indiana, Iowa*, New Mexico, Oklahoma, Oregon, Utah, Vermont • Children’s Hospital • District of Columbia • Quality Improvement Organization • Maine *Iowa’s IP is a partnership between the Iowa chapter of the AAP and the University of Iowa

23. Funding Sources as reported by NIPN States over the past 2 years Key: A check mark “” indicates one grant by type. 23

24. Examples of What IPs DO! 11

25. Current QI Projects by Topic *Note that some of the QI projects fall into more than one topic ME Data self-reported for 12 states as of 5/2012 within last 2 years AZ IN IA NM ID UT NY B ME IN AZ AZ NM OR IA AZ UT OR VT NY B IA UT ID NM OR IN DC NYB NYB ME UT NM NM VT VT VT VT VT VT VT UT VT

26. Selected Improvement Partnership Programs’ ABP-Approved MOC Projects • DC Partnership to Improve Children’s Healthcare Quality (DC PICHQ) • Improving Early Childhood Immunization Rates • Obesity Quality Improvement Initiative • Envision New Mexico: The Initiative for Child Healthcare Quality   • New Mexico Asthma Care Improvement Module  • Developmental Screening Initiative   • Pediatric Overweight Quality Improvement Initiative • Oregon Pediatric Society  • Oregon Screening Tools and Referral Training (Oregon START) • Utah Pediatric Partnership to Improve Healthcare Quality (UPIQ)  • Early Autism Detection and Referral in the Medical Home  • Prevention, Recognition and Treatment of Childhood Obesity • Vermont Child Health Improvement Program (VCHIP)  • Promoting Healthier Weight in Pediatrics  • Youth Health Improvement Initiative

27. NIPN

30. Lessons Learned • Primary care practices need skills, structure, and facilitation to improve the care they provide to children • IPs impact care as no single agency can • IPs convene disparate stakeholders to align priorities and find solutions for common problems • The IP approach may not be applicable to all states • IPs bring expertise and experience to state policy discussions • NIPN provides a forum for sharing and learning across IPs Shaw JS, Norlin C, Gillespie RJ, Weissman M, McGrath J. The National Improvement Partnership Network: State-Based Partnerships That Improve Primary Care Quality. Academic Pediatrics. 2013 (in press).

31. NIPN Resource List Annual Operations Training October 2nd – 4th Washington, DC ListServ Need Advice? Have Tips To Share? Correspond with IP’s and others working on Child and Maternal Health Improvement. Send an e-mail to LISTSERV@LIST.UVM.EDU SharePoint Contact Information Engaging Parents IRB MOCs QI Publications Working with Practices IP Operations Measures EHR Adoption Adolescent Depression Past QI Coaching and All-Sites Calls Previous Operations & National Meetings List of IPs and IP Contact Information A How-to Guide Establishing a Child Health Improvement Partnership NIPN Website www.nipn.org QI Coaching Support Technical Assistance Monthly All-Sites Webinars

33. Building a Foundation For The Future • Advanced Primary Care Practices (PCMHs) • Community Health Teams • Multi-Insurer Payment Reforms • Health Information Infrastructure • Central Clinical Registry • Health Information Exchange • Evaluation & Reporting • Learning Health System

34. Evaluation • NCQA Scoring • Patient Experience Survey (PCMH CAHPS) • Central Clinical Registry • All-payer Claims Database

37. Pediatrics

38. Pediatric Practices NCQA Scored as of 4/1/13 * NCQA score/level if available (otherwise, VCHIP estimated score/level was used) Pediatric: Round 1 only, Adult/FM: Round 1 and 2

39. Pediatric Practices

40. Quality Measures • What measures are available? • What data are available?

43. Who has the data?

44. Vermont Child Health Measures Database • 1. Create a global chartbook of child health measures in VT that can serve as a rapid resource and guide users toward more in-depth material • 2. Inform changes for existing data collection (e.g., to bring measures into line with each other for comparison) • 3. Inform who is best at collecting what data (e.g., to prevent unnecessary duplication, to direct users toward the best data for a given query) • 4. Inform the creation of new data collection (e.g., to identify gaps in current measurement, to provide resources for implementing concurrent measurement) • 5. Guide data validation (e.g., to easily identify multiple data sources for a given measure that could be cross-walked) • 6. Ultimately present extant data in such a form as to more easily inform changes in child health

45. Data and Measures • Measures • CHIPRA • HEDIS • MU • CAHPS • Medical Home • PCMH • Medical Home Index (MHI) • Data • CHAMP • EHR (DocSite, FAHC)\ • NSCH • NSCSHCN • OBNet • SNAP • VDH Epi • VDH Immunization • VFACTS/CIS EMR • VHCURES (all payer claims) • Vital Stats • VRPHP • WIC • YRBS

46. CHAMP: Child Health Advances Measured in Practice September 17, 2014

47. What is CHAMP? • Child Health Advances Measured in Practice • A longitudinal approach to improving health outcomes for VT children, youth, and families • A network of primary care practices engaging in collaborative improvement activities over time to • Partnership: VCHIP, VT Dept of Health, AAP, AAFP • Builds on national and state legislation to improve health care delivery for children and families. • Grounded in Bright Futures

48. CHAMPModel Annual Learning Session Rapid Cycle MOC-Based QI Projects D P Training on Topic-Specific Content & QI Methods Guidelines, Tools, & Resources Data Collection Feedback Reports Networking with Colleagues Content-Driven Conference Calls A S Team Meetings Longitudinal Data Collection & Reporting

49. Northeastern Vermont Border Pediatrics, Derby Line Danville Health Center, Danville Dr. David Toll, St. Johnsbury Hardwick Health Center, Hardwick Newport Pediatric & Adolescent Medicine St. Johnsbury Pediatrics, St. Johnsbury Northwestern Vermont Burlington Primary Care, Burlington Colchester Family Practice, Colchester Community Health Center, Burlington Essex Pediatrics, Essex Franklin County Pediatrics, St. Albans Hagan, Rinehart & Connolly Pediatricians, Burlington Hinesburg Family Practice, Hinesburg Milton Family Practice, Milton Mousetrap Pediatrics, Enosburg Mousetrap Pediatrics, St. Albans Rebecca Collman, MD, Colchester Richmond Pediatrics, Richmond Shelburne Pediatrics, Shelburne South Burlington Family Practice Timberlane Pediatrics, Burlington Timberlane Pediatrics, South Burlington University Pediatrics, Williston and Burlington St. Albans St. Johnsbury Essex Burlington Danville Barre Central Vermont Associates in Pediatrics, Berlin Barre Pediatrics, Barre Berlin Family Health, Berlin Little Rivers Health Care, Bradford Little Rivers Health Care, Wells River Newbury Health Clinic, Newbury Middlebury Pediatric & Adolescent Medicine Mt. AscutneyHospital & Health Center, Windsor Rainbow Pediatrics, Middlebury South Royalton Health Center, South Royalton The Health Center, Plainfield White River Family Practice, White River Junction Wells River Middlebury Bradford South Royalton Rutland Londonderry Bennington CHAMP Participating Practices 2014 Derby Line Newport Enosburg Falls Milton Hardwick Colchester Richmond Hinesburg Plainfield Berlin Newbury White River Junction Windsor Southern Vermont Bennington Family Practice, Bennington Green Mountain Pediatrics, Bennington Hogenkamp & Hogenkamp, Rutland Just So Pediatrics, Brattleboro Mountain Valley Medical Clinic, Londonderry Northshire Medical Center, Manchester Center Springfield Pediatrics, Springfield Springfield Manchester Center Brattleboro

50. Why Longitudinal Data Collection? • Mechanism to identify “gaps” in care • Practices can assess & track their progress • The “sustainability” question • Health surveillance • Spark new QI project foci