Improving Mental Health Care in Pediatric Practice

1. Improving Mental Health Care in Pediatric Practice QI Basics: Introduction to Quality Improvement January 12, 2015 Childhood Mental Health QI MOC Learning Collaborative

2. Childhood Mental Health QI Collaborative: CME Learning Objectives • Participants will be able to: • Identify opportunities to implement clinical “best practices” in your practice setting. • Conduct PDSA cycles within a practice setting to measurably improve childhood mental health identification and management.

3. Today’s Presenters: Have no conflicts to disclose • All presenters have signed disclosure statements indicating: • No financial or business interest, arrangement or affiliation that could be perceived as a real or apparent conflict of interest in the subject (content) of their presentation. • No unapproved or investigational use of any drugs, commercial products or devices

4. CME Accreditation • ACCREDITATION: • This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of The George Washington University School of Medicine and Health Sciences and Children’s National. The George Washington University School of Medicine and Health Sciences is accredited by the ACCME to provide continuing medical education for physicians • PHYSICIAN CME CREDIT: • The George Washington University School of Medicine and Health Sciences designates this continuing medical education activity for a maximum of 30 AMA Physician Recognition Award Category 1 Credits™. • Participants will be required to certify attendance or participation on an hour-for-hour basis.

5. Are we ready to improve our care?

6. QI home for the region’s pediatricians • DC PICHQ • DC Partnership for Children’s Healthcare Quality (2005) • Based in Children’s National’s Goldberg Center for Community Pediatric Health • Part of evolving National Improvement Partnership Network (NIPN) (CHIPRA funded) • Key regional QI projects with measurable improved outcomes • DC EPSDT (2005-2009) • DC Immunizations (2007-2011) [MOC: ABP] • NCQA PCMH (2010-2011) • Childhood Obesity (2011-2012) [MOC: ABP] • Childhood Asthma (2012- current) [MOC: ABP & ABFM] • Childhood Mental Health 2014 [MOC: ABP & ABFM] • CNHN/DC PICHQ approved Part 4 QI MOC portfolio sponsor by the ABP

7. Web-based QI Learning & Participation • Permits regional multi-practice learning • Live web/audio conference or recorded • Internet access is required • If you joined us for our kick-off webinar and you are reading these slides- you can do it! • Support data entry and sharing of QI performance data & resources • Benchmark your practice performance vs group • CME credit for participation (hour for hour)

8. Patient & practice privacy • We do not request, report or share any patient-identified data. • We can complete & sign a Business Associate agreement if requested. • We do share practice data in blinded, de-identified fashion so you can compare (& improve) your practice performance to all other participating practices • We will invite high-performing practices to share tips & successes for key measures • We will invite practices to share PDSA cycle successes & failures- and invite comments from colleagues

9. ABP MOC Part 4: Quality Improvement • Now requiredfor Maintenance of Certification • Part 4:

10. ABP Maintenance of Certification:Performance in Practice (Part 4) Established QI Projects. Structured QI projects that involve physician teams collaborating across practice sites to implement strategies carefully designed to improve care. Experienced coaches guide these multi-practice improvement projects in clinical improvement.

11. What is a “learning collaborative”? • A learning collaborative is a model for conducting a targeted quality improvement project with a defined improvement aim, outcomes measures and timeframe.

12. Mental Health QI MOC Aim Statement (preliminary) • During our learning collaborative, participating pediatricians will improve their office identification and management of childhood behavioral health problems at annual well visits as measured by: • Increasing provider/practice readiness to perform annual mental health screenings for culturally diverse patients in their practice; • Increasing the percentage of annual well visits where an approved screening tool is administered (from baseline to 50%); • Increasing the percentage of records with mental health screening that have scored documentation of results (negative/positive) (from baseline to 50%); • Increasing the percentage of "positive" mental health screens which had an appropriate follow-up plan documented (i.e., addressed by provider and/or referred to care) (from baseline to 75%); • Increasing the percentage of time the administration of a screening tool is appropriately billed (from baseline to 75%). • Increasing the percentage of newly “positive” Mental Health Screens appropriately given an “–TS” modifier ( from Baseline to 75%) • These QI project measures & aims are based on benchmark practice chart audits. Note that target percentages may change via benchmarks determined over the course of the study.

13. QI “learning collaborative” basics • Practice teams meet regularly to implement and measure small improvement pilots in their practice • Practice-based QI is augmented by periodic web-based “learning sessions” (CME accredited) and monthly conference calls-where colleagues share solutions and best practices. • Each practice is required to regularly collect and report a small amount quality data for the practice and each participating pediatrician • Your practice improvement will be benchmarked against all practices participating in the QI learning Collaborative

14. QI Learning Collaborative model • Do QI as practice team- get individual MOC & CME credit • 6 month “virtual” project (January– June 2015(July optional) • Web-based learning conferences (live or recorded) • Baseline and monthly chart audits to measure mental health screening& improvement • Monthly practice team meetings to look at data & implement mini-improvements • Monthly team leader project calls with other practices to share data & tips • Hands-on QI coaching in your practice & by phone

15. To receive ABP MOC credit… • Pediatricians & practices must demonstrate active participation in: • Kick-off & web-based learning sessions • Baseline and monthly pediatrician/practice chart audits • Three (3) practice mini-improvement cycles • Brief monthly practice team meetings to review your practice QI data & progress • Monthly QI project conference call with QI team & participating practices • CNHN QI practice coaching office visit (as needed) • CNHN will make your required ABP MOC QI as user-friendly as possible

16. Quality Improvement in Primary Care Practice The MOC Version…

17. How does a Learning Collaborative work? • Pediatric practices participate with other practices to improve the quality of care they deliver. • Key components: • Initial objective assessment of current practice (chart audits) • Participation in kick-off Learning Session to hear the evidence & “best practices” and learn how to implement process improvement in your practice • Ongoing follow-up and technical assistance, including periodic assessments (chart audits to assess whether improvement is happening), conference calls (to get questions answered and learn from other practices) • An end-of-collaborative assessment to measure your improvements, allow comparisons with other practices, and guide your next efforts • A formal or informal wrap-up session to help you organize your thoughts and to provide advice on maintaining the improvements in the future

18. Act Plan Study Do “Model for Improvement” What are we trying to accomplish? Aim How will we know thata change is an improvement? Measures What change can we make that will result in improvement? Ideas Act Plan Study Do From: Associates in Process Improvement

19. Implement and measure test of change in your practice to improve mental health care • Plan a Change • Identify opportunity • What is the problem • Suggest the causes • Design the change • Three PDSA cycles over 9 months • Act • Did your change make a positive or negative change? • If positive Standardize within your practice • Monitor your change over time • What will you work on next? PDSA • Do • On a small scale implement change • Where you can control setting • Study • Collect data • Analyze data

20. A P S D D S P A A P S D A P S D Repeated Use of the PDSA Cycle:Small scale pilots  spread success practice-wide Changes That Result in Improvement DATA Implementation of Change Wide-Scale Tests of Change Follow-up Tests Hunches Theories Ideas Very Small Scale Test

21. Remember: Keep it simple! • PLAN and DO a change (for the next 5-10 patients, for one week) and then STUDY (measure) what works/doesn’t, then adjust and ACT (try again) until successful. • Then implement more broadly in practice and measure (again) • Participating practices will design and measure simple PDSA cycles (and share results)- move incrementally toward overall goal(s)

22. PDSA Cycle Example Using your Practice Readiness Inventory survey to implement your first PDSA Cycle

24. MH Practice Readiness Inventory • Four page self-assessment of extent to which practice supports MH assessment and intervention • Complete as a team • 3 point Likert scale of how well you practice • Complete to the best of your ability- this is just a baseline measure • Select priority area and stage incremental practice improvements

25. Practice Areas • Community resources • Health care financing • Support for children and families • Clinical information systems / delivery system redesign • Decision support for clinicians

26. Implement & measure tests of change in your practice to improve mental health care • After benchmarking practice data (Practice Readiness survey/chart audit), each practice will be required to develop PDSA pilots • Moves practice closer to shared goal- improving mental health care in practice • Measure results of PDSA • Limited monthly chart audit to measure success/impact • Review results and make adjustments to improve • ABP: document three PDSA cycles over 9 months • You will likely do more…

27. Example: After completing the Practice Readiness Inventory, it is identified that providers and clinic team recognize they have no structured practice routine for implementing MH screening tools PLAN: Introduce MH screening and screening tools at practice team meeting. Identify pilot workflow in well child visit for completing and scoring MH screening tools. Practice proposed that medical/nursing assistants would introduce screener and pre-score. DO: For next two weeks, pilot workflow with select group of patients (eg all 3 year old well child exams). STUDY: After two weeks, review charts to see how well pilot workflow was implemented. MA’s/NA’s report that families did not have enough time to complete, collect and score screen during VS. ACT: Practice team decides to pilot having front desk staff distribute screens after check-in while families are waiting for VS. Pilot for two weeks then re-asses and make further PDSA adjustments.

28. Example: After completing the Practice Readiness Inventory, it is identified that: providers and practice team are not aware of community resources… PLAN: Identify the online resource guide available via learning collaborative. Introduce resource guide at staff meeting and instruct team members on its use for referring positive screens. DO: Practice implements using resource guide to facilitate referrals for positive screens. After two weeks, review 10 referrals. STUDY: Practice staff reports that searching online for community MH resources very difficult in busy practice- not always able to access. ACT: Practice nurses agree to review online resource and develop practice worksheet of top/common referral resources to facilitate quicker referrals. Online resources available asback-up. Will pilot for new PDSA cycle x 2 weeks then re-adjust.

29. Project Management The Basics

30. Optional Project Timeline: Track 1 (New Sites) April Team Leader Call: Thurs 4/9 May Team Leader Call: Thurs 5/14 June Team Leader Call: Thus 6/11 Summer Team Leader Call: TBD March Team Leader Call: Thurs 3/12 Feb Team Leader Call: Thurs 2/12 Learning Session #1: DATE Learning Session #5: DATE Learning Session #2: DATE Learning Session #3: DATE Learning Session #4: DATE Kick-Off Part 1 DATE Kick-Off Part 2 (Archived) Practice Team Meeting Practice Team Meeting Practice Team Meeting Practice Team Meeting Practice Team Meeting Practice Team Meeting Practice Team Meeting March Chart Audits (15) Summer Chart Audits (15) Baseline Chart Audits (30) Feb Chart Audits (15) May Chart Audits (15) April Chart Audits (15) June Chart Audits (15) Pre-Provider Survey Mid-QI Balancing Survey Post Provider & Balancing Survey AAP Practice Readiness Inventory PDSA Cycle Progress Report 1 (Jan-Feb) PDSA Cycle Progress Report 2 (March-April)) PDSA Cycle Progress Report 3 (May-June) AAP Practice Readiness Inventory

31. * Kick-off learning sessions required, though QI 101 may be skipped if participated in previous project; Must watch 4 sessions total for MOC

32. How To Earn MOC/CME Credit • As a Practice Team • As a Provider

34. How to earn Credit as a Provider

35. MOC & CME credit • We are approved for 25 MOC part 4 points • We will submit our ABFM MOC part 4 application for within the next few weeks. • We are additionally approved for up to 25 hours of CME credit by GWUMC CME office • Approved activities • Monthly chart audits( up to 1 hr each) • Monthly practice team meetings (up to 1 hr each) • Monthly conference calls (up to 1 hreach) • Learning session webinars (1 hr each)

36. Project Measures

37. Approved Mental Health Screening Tools

38. Ages and Stages Questionnaire: Social-Emotional (ASQ-SE)

39. Strengths and Difficulties Questionnaire (SDQ)

40. Parent Health Questionnaire ( PHQ-9)

41. Edinburgh Postnatal Depression Scale

42. A Positive Mental Heath Screen Using the -TS modifier

43. DC Medicaid updates billing manual codes for EPSDT services • Updates codes to track and pay for required EPSDT services • Released 10/1/14- effective 1/1/15 • Full info on DC Health Check website: www.dchealthcheck.net • Key findings: • Mental Health Screening: 96110 (V79.3) • V20.2 well child examination • V79.3 screening for developmental handicaps in early childhood • New –TS modifier to track POSITIVE findings on EPSDT screens • Append –TS modifier to (+) CPT screening codes to help track if children receive subsequent services

44. Mental Health Screening & -TS modifier • DC DHCF updated billing manual for providers & payers • Added description for billing for developmental and behavioral health screening (96110) • Also added unique modifier (-TS) to append to all positive screens to facilitate identification and tracking of (+) EPSDT screens for subsequent care/claims

45. TS Modifier- Background: As of July 1, 2013, DC Medicaid Managed Care Organizations are required to ensure annual mental health screenings by the beneficiaries' Primary Care Provider, using an approved screening tool. As of January 1st, 2015 the following tools are approved for use with the –TS Modifier: • Edinburgh Postnatal Depression Scale (EPDS; for postpartum women) • Ages and Stages Questionnaires: Social-Emotional (ASQ:SE; for children 3 to 66 months) • Strengths and Difficulties Questionnaire (SDQ; for youths 2 to 21 years) • Patient Health Questionnaire-9 (PHQ-9; for individuals 18 to 21 years) • Use the TS Modifier when the screening score is positive(“abnormal,” “high,” “clinical,” and “clinically elevated.” )

46. The table below lists guidelines for the DBH-approved tools, though providers are encouraged to use the TS Modifier with any mental health tool in which a 96110 code is used (e.g., Vanderbilt). Use the TS Modifier in these cases even if further assessment indicates that the family has minimal concerns or there is minimal impairment.

47. TS Modifier- Cutoffs • The TS Modifier can also be used in situations in which the screening score indicated in the table does not fall in the clinical range (i.e., score falls in the normal or borderline range) • However, If the provider determines through discussion with the family, clinical observation, etc., that a need related to the child’s mental health is present. • If a screener is initially scored as positive but further clarification with the family indicates confusion about questions, it is best to obtain updated responses from the family and re-score the tool. If, at that point, the score is not positive, then do not use the TS modifier.

48. QI Team Space QI Data Management Website

49. Benefits of using QI TeamSpace QI TeamSpace • Access practice materials & national guidelines • Watch recorded webinars • Complete and submit data reports/forms: • Chart audit • Monthly meetings • PDSA cycles • Automated process for: • Data entry • Data validation • Report generation and publishing • Increased efficiency • Reduced errors

50. Patient & Practice Privacy