Prevention in the Medical Home

1. Prevention in the Medical Home Lisa A. Cosgrove, MD, FAAP Florida Pediatric Medical Home Demonstration Project Learning Session 2 April 27-28, 2012

2. 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.

3. Objectives Describe C4K goals around preventive care Share current AAP policy recommendations Share examples of existing tools Explore implementation strategies

4. 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

5. Periodicity Schedule

6. Age Appropriate Risk Assessment Standardization of preventive care Increased reliability of thoroughness at each visit Stratified approach based on patient’s risk

7. Screening table – 2 year visit

8. Risk assessment questions – 24 months

9. 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.

11. 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 visits • *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. • Note: if you use a 30 month visit, there will be an opt-out option on your chart reviews • Use a QI model to integrate surveillance and screening into office procedures

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

13. 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

14. 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

15. Role of Medical Home • Screening and Surveillance • Partnering with parents as experts on their child • Providing information and resources for parents • Networking with community resources • Facilitate linkages for families with Part C, and other diagnostic and treatment resources • Population management (eg, use of immunization registry, etc) **Parent partners can serve a vital role in identifying community resources and linkages, providing support to families!

16. 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

17. 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?

18. 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)

19. 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

21. 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)

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

24. 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

25. Preventive Services Prompting Sheet

26. 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

27. 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?

28. 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?

29. 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

30. 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

31. 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

32. 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”

33. 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