Improving Quality for Children—Approaches to Building State Capacity

1. Improving Quality for Children—Approaches to Building State Capacity Charlie Homer, MD, CEO Child Health Services Research Meeting Academy Health, 2005

2. Problem Statement • Quality chasm is widespread • Quality chasm affects the care of children, youth and families as it does adults • Health care for children is: • Predominantly outpatient • Locally delivered and organized • State regulated • Substantially funded through state programs • Major state public health role (e.g., immunizations, newborn screening)

3. Requirements for improvement • Will to improve • Better Ideas • Assistance with Execution • Training • Tools • Support • Business Case

4. National improvement programs may have limited local impact • Cost • Distance • Credibility • Practical assistance • Variability in financial context

5. Numerous potential state based resources to support improvement • Professional society/medical association chapters • Health Department • Immunization programs • Title V (Children and Youth with Special Health Care Needs) • State universities • Medicaid Agencies • Combinations of the above

6. Children’s Quality Initiatives

7. Aim: Medical Home Learning Collaborative • To improve care for children with special health care needs/youth by implementing the Medical Home concept • To foster substantial relationships between Title V programs and their state’s primary care community, enabling Title V to: • Support improvement in practices and • Spread improvement across their State

8. Why Title V: The Title V Mandate • OBRA 1989 • Healthy People 2010 • Objective 16.23 • Six defining outcomes • The New Freedom Initiative

9. Six outcomes • Family participation at all levels • A medical home for each child with special health care needs • Adequate coverage • Screening • Family-friendly community systems • Transition services

10. Why focus on systems for children with special health care needs • The complexity of children’s lives • The scope, scale and range of children’s special needs • The inadequacy of baseline supports • The gap between social needs and private resources

11. The central place of medical home • As a critical point of parent connection • As hub of services • As locus at which remaining 5 outcomes may be addressed, operationalized, tested

12. The medical home from a Title V perspective • Where the action is for children and families • Meeting place for powerful constituencies • Public health at the molecular level

13. IHI Breakthrough Series™(12 month time frame) Participants (10-100 teams) Select Topic (develop mission) Prework Dissemination Holding the Gains Publications Congress etc. P P Develop Framework & Changes P A D A D A D Expert Meeting S S S LS 2 LS 1 LS 3 Planning Group AP1 AP2 AP3 Supports Email (listserv) Phone Conferences Visits Assessments Monthly Team Reports LS – Learning Session AP – Action Period

14. Modifications to BTS Design • “Participants”= • 11 State Title V Programs, each of whom recruited • 3 Primary Care Practice Teams • Faculty= • Clinical, Title V, and Parent Chair • Teams= • Physician, Staff (Nurse/Care Coordinator), Parent • Topic= • Medical Home, aka, Chronic Care Model for CYSHCN

15. Faculty and Staff

16. Faculty Leadership Chair: Carl Cooley Co-Chairs: Debby Allen, Alan Kohrt Director: Jeannie McAllister Improvement Advisor: Jane Taylor Staff Lisa Horvitz, Colleen O’Rourke, Sandra Cragin Faculty Maureen Mitchell, Family Voices Betty Pressler, Judy Palfrey, Margaret McManus, Chris Stille, Richard Antonelli, Amy Gibson (AAP), Lois Kohrt Faculty and Staff

17. Connecticut Colorado Florida Ohio Oklahoma Louisiana Michigan New York Utah Virginia Wisconsin Participants- State Title V Agencies + North Carolina

18. Participants Teams-Practices • 3 Teams from each State • 43% Community Based, Group Practice • 22% Community Hospital or Network Group Practice (e.g., Marshfield Clinic, Bassett Health) • 25% Academic Primary Care Sites • 9% Solo Practice • Team Members • Physician, nurse/other office staff/care coordinator, parent partner

19. Key Concepts • Medical Home/Care Model for Child Health • Model for Improvement • Model for Spread

20. Medical Home is • Accessible • Family Centered • Continuous • Comprehensive • Coordinated • Compassionate • Culturally Effective

21. Health System Community Health Care Organization (Medical Home) Resources and Policies ClinicalInformationSystems Care Partnership Support DeliverySystem Design Decision Support Timely & efficient Family -centered Evidence-based & safe Coordinated and Equitable CMHI Functional and Clinical Outcomes Care Model for Child Health in a Medical Home Supportive, Integrated Community Informed, Activated Patient/Family Prepared, Proactive Practice Team Prepared, Proactive Practice Team

22. What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in an improvement? Act Plan Study Do Model for Improvement

23. Diffusion or Spread “BETTER IDEAS” COMMUNICATED In a certain way Happens over time (C) 2003, Sarah W. Fraser Thru a SOCIAL system Adapted from Rogers, 1995

24. Measures • ED visits • Hospitalization rates • Family worry • Front office satisfaction • Medical Home Index • Care Plans • Practice Satisfaction

25. CMHI Medical Home Learning CollaborativeMHI Pre and Post Measures

26. Results-Quantitative

27. Qualitative Results: Title V • Most valuable activities and insights: • Conduct walk-throughs of practices—leading to learning • Connect teams to state resources • Assist with care coordination • Outreach to broad variety of audiences • Practices need help working with families • Positive impact on how to implement change and promote adoption of new models

28. Qualitative Results-Parents • Parents can be very effective in this process because they can counter assumptions health care providers make about the way things work" • "There are things I can do, like pre-register my child for appointments...my pediatric clinic and the hospital are willing to do [many things] to make things better for my family. I never would have known what to ask for, as a new parent, before the medical home training"

29. Qualitative Results-Practices • The MHLC "helped the practice focus on achievable steps to initiate a true medical home“ • "the small changes have made a world of difference in our practice... • Specific changes (self-report) • 70% streamlining access • 64% have designated care coordinator • 63% working with community agencies • 60% partnering with families • 50% using some form of registry

30. Lessons Learned • Feasible to address improvement using non-categorical approach • Parent involvement essential • Requires planning and support • State/practice interaction feasible • Strengthened by broader coalition (funders, professional societies), greater training • Reform/improvement efforts require coordination • Although CYSHCN broad category, efforts may remain in silos • It’s a great thing to do!

31. A Sonnet When to NICHQ Learning Sessions we go, We summon up remembrance of tasks past. We sigh the lack of many a thing we know, But have hope to make Medical Home last. In the Northwoods our Wisconsin team met, To have a group retreat and plan ahead-- The practice teams’ commitment was set, And we shared Title V’s vision for spread. Then children and families noticed change; care plans, identification and more all became part of Wisconsin teams’ range with the Chronic Care Model as their core. So, till the State Budget grants our evr’y wish, we will persevere—our defining niche.

32. The Job of Title V (Deborah Allen) To the tune of “He’s Go the Whole World in His Hands ”

33. They got a coalition that won’t quit, Got doctors, families, payers, to commit. There’s not a single player, they omit, Cause that’s the job of Title V.

34. TA to every practice, helps docs see, How to engage kids’ parents, meaningfully. Don’t want no tokenism, no siree, That wouldn’t sit with Title V.

35. They’ve built a database that’s deep and wide. They’ve listed every resource, in that guide. They’ve found each scrap of info, that applied, Cause that’s the job of Title V.

36. They’re gonna build a network, that’s a fact. Where all the service systems, interact. ‘Til then they’ll have to plan, do, study, act, Cause that’s the job of Title V.

37. MHLC II • 8 Additional States • DC, IL, ME, MD, MN, PA*, TX, WV, • Expansion of State Teams • Include AAP/AAFP Chapter Representative • Include Insurer (Medicaid) on Team • Predominant Focus on Supporting Practices • Other Diffusion • Several State Wide Collaboratives • Change in Function and Activity National Center for Medical Home