Bright Futures Preventive Services Improvement Project Sixteenth Street Community Health Center

1. Bright Futures Preventive Services Improvement Project Sixteenth Street Community Health Center Milwaukee, WI Our Team: Drs. Emilia Arana, Alisen Huske Francisco Enriquez, John Dunn

2. Our team plans as of January 2011 By October 2011... • 95% of charts will have Parental Concerns elicited and addressed at each WCC visit. • 95% of charts will have Parental Strengths discussed and documented. • 95% CYSCHN will be identified as such, having the denomination of “Special Needs” in the problem list. • 95% of 9mo WCC visits will have an ASQ completed. • 95% of 2wk, 2mo, 6mo WCC visits will have Maternal PPD screen done. • Improve the administration of our Oral Health Risk Assessment so that 95% of 9mo, 18mo, and 24mo have it done. • Improve the administration of our 18mo and 24mo ASQ and MCHAT so that 95% of WCC's designated as “18mo” or “2y” WCC have it done, regardless of their actual age at the WCC (i.e. 30mo “late” 2y WCC will get an MCHAT and a 30mo ASQ to do). • Implement a pre-visit questionnaire at the 9mo and 24mo WCC visits. • Update quarterly our list of Dental Providers, classified according to HMOs. • Have a one sheet hand-out for each WCC visit - age appropriate anticipatory guidance. • Have an organized, current list of community resources for parents. • Use Intergy-EHR system to track referrals, lab orders and imaging.

3. Our team now… how close to our Aim? • 9 month old visits • Baseline Data September data • Parental concerns elicited: 80% 90% (100% in August) • Parental concerns addressed: 85% 100% • Risk assessment done: 50% 90% (100% in August) • Risks addressed: 50% 100% • Weight for Length: 100% 100% • Developmental screen: 0% 70% (100% in July) • Follow-up for positive screen: ----100%In June(Data gaps on graph) • 3 BF anticipatory guidance used: 90% 100% • Parental strengths assessed: 0% 50% (80% in August) • Oral Health Risk Assessment done: 45% 90% (100% in August) • Maternal Depression Screening: 0% 90%

4. Our team now… how close to our Aim? • 24 month old visits • Baseline Data September data • Parental concerns elicited: 85% 75% (90% in July) • Parental concerns addressed: 85% 100% • Risk assessment done: 100% 100% • Risks addressed: 100% 100% • BMI: 100% 100% • Developmental screen: 85% 100% • Follow-up for positive screen: 100% 100% • Autism Screen: 85% 100% • Autism Screen follow-up: 85% 90% in April (Data gaps on graph) • 3 BF anticipatory guidance used: 100% 100% • Parental strengths assessed: 0% 35% (40% in August) • Oral Health Risk Assessment done: 95% 100%

5. PDSA cycle Maternal Depression • Plan the change: Implement PPD Screening at 2wks, 2mo, 6mo visits. Screening tool: EPDS (Edinburgh). • Do the plan: Modified EHR template, adding PHQ-2 and EPDS. Inform Pediatric and Behavioral Health Providers. Create handout on PPD and list of community resources for PPD. • Study the results. We found more PPD than expected. Poor access to BH provider. Excellent access to SW services/counseling. • Act on the new knowledge: If screen positive, Pediatrician refers mother to FP or CPM identified as prenatal care provider. Task provider, scan Edinburgh in mother’s chart.

6. PDSA cycle Pre-visit Questionnaires • Plan the change: Implement Pre-visit Q at the 9mo and 24 mo WCC • Do the plan: Modify versions of the Bright Futures Pre-Visit Q. Translate it in Spanish. Pilot use by 5 Pediatricians • Study the results. Tool is useful in guiding what anticipatory guidance to provide. Parent misunderstands some sections. Little time for parents filling it out along with other screening tools. • Act on the new knowledge: Modify the initial version. Ask parents feedback. Pilot test for 2 weeks. • Final versions to be available in our Patient Portal

7. Changes we made that resulted in improvement • Use of Pre-visit Questionnaires at 9mo and 24 mo visits • Identify Patients with Special Health Care needs. • Addressing and documenting parental concerns (HPI, EHR-template modified) • Maternal Depression Screening Implementation of use in Pediatrics, Family Practice, Women’s Health Departments. Social Services involved. Coordination of care of mothers with PPD: Pediatrician can now refer to prenatal care provider (FP or CPM) • Earlier use of ASQ tool, starting at 9 months age and broader use of the ASQ and MCHAT at the 18mo and 24mo WCC’s. • Discuss, reinforce Parental Strengths, documented in WCC e-note. • Use of EHR to track lab tests, imaging tests and referrals to specialists. • Regularly updated list of Dental Providers, organized according to each HMO.

8. Challenges and Barriers • Lack of time to invest in this project. Very busy providers. • Low literacy level of our patients/families • Poor access to Mental Health Services. • Poor access to Dental Home. • Parents do not have enough time to complete/answer forms. They arrive late or just in time to appointments. • Lack of non-medical staff available to help with this project (e.g. update list of community resources for parents).

9. What did we accomplish • The single change we are most proud of is Coordination of services between departments FP, Midwifes, Social workers, Perinatal case managers to serve patients with PPD. • Our greatest innovation was…we began screening for maternal depression systematically at pediatric WCC’s.

10. What are we doing next • Pre visit Questionnaires, 12mo and 36mo visits. Adapt them to our population needs and language use. • Actively involve families in evaluating and modifying screening tools. • Obtain feedback, more so on the experience of the CYSHC families. • Dental Home. Document Dental Provider. Communication Pediatric-Dental provider. • Request and document parent’s e-mail if available. Quantify our patient’s computer/web access. • Start working with out IT team in order to include pre-visit questionnaires, ASQs and M-CHAT in the patient portal. • Our team is wondering if next we should . . . • Prepare Pre visit questionnaires for every WCC visit, and make it available in in Patient Portal • Social Workers to help organize a list of community resources, make it available in our Intranet and on the patient portal. • Training/Practice session for providers to become more familiar and use more often the HEALTH tab (Our Preventive Services Prompting System) • Anticipatory guidance at every WCC visit: Prepare a one sheet hand-out based on the Bright Futures recommendations, modified to fit our population needs and language.