Communities Coordinating for Healthy Development

1. Communities Coordinating for Healthy Development Training for Districts

2. Coordinating Communities for Healthy Development The goal of the CCHD project is to create and institutionalize a feedback communication loop between clinical providers and early intervention and preschool special education providers to benefit children with developmental delays or socio/emotional or behavioral health concerns.

3. Training Topics • Before you begin • Goals & Tools • How to start • Model for implementing change • Guiding the team through the process • Completing and Spreading the Work • Modifications

4. Before you Begin 1. Review the materials in the toolkit, especially the roles and responsibilities, and how to work with clinics. 2. Recruit someone who also works within the early intervention/ preschool education system to work with you.

5. Goals & Tools

6. How to Start Identify team members to recruit Reach out through established relationships Share materials Begin meeting

7. Identifying Team Members • Clinic Staff • Look for a champion, someone who will support the project at their clinic, and recruit onto the team • Start by identifying clinics serving children in your area, and reaching out to inform them about the project and inviting them to join the team • Local public health or agencies doing childhood screening • Parents • Other agencies involved in referral process • Who are you currently sending referrals to? • Other providers of early childhood services such as Head Start, ECFE • Clinicians providing medical services to your patients – OT, PT, Mental Health

8. After you’ve identified potential team members… Contact them, talk about the goals of the project, see if they’re interested in meeting to discuss it or have ideas of other people who should be included. Be open to varying length of commitment – this project may lead to long term connections, but at the same time some team members may only be able to be involved as long as it takes to implement the feedback cycle. Share materials and resources. Invite them to a launch meeting.

9. Suggestions for Launch Meeting • Introductions and roles in current referral and service system in the community • Discussion of goals for CCHD team and CCHD process • Review of materials to learn (other trainings or toolkit) • Set up next steps (start meeting regularly, using change model, etc.)

10. Model for Improvement The team can work together to create a system for implementing the CCHD changes, or you can use the Model For Improvement. The model leads the team through testing out small changes toward big goals, in a Plan-Do-Study-Act process. More information on the Model is found in the CCHD toolkit.

11. Guiding the Team through the Process • Meet regularly • Identify a way to know when your team has completed the project • At the beginning, learn how the current system works, to identify where to approach changes • Work through modifying the tools to be useful to all the team members • Ask the early intervention/ preschool special education providers to start sending referral feedback forms • Track the responses through clinic EMR • Report back to team on progress • Address issues and barriers • Add team members when needed or available

12. Creating a Workflow as a Team Creating a work flow diagram may help your CCHD team examine all the aspects of the referral feedback loop and be able to identify areas where changes are needed. Here are examples of a few work flows that CCHD teams created in the past.

13. Child visits clinic, completes a screening tool with a score that triggers a referral District receives referral, assigns to staff for evaluation Evaluators contact family and set up meeting Family refuses evaluation or is unable to be contacted, referral is closed HMG determines appropriate district, sends them the referral Clinic sends referral to the Help Me Grow state online system Early Intervention/ Preschool Special Education Referral Report Workflow District sends this information back to the clinic Family accepts, service plan is created, student begins to receive services Student is determined to be ineligible for services, is given alternative resources, possibly signed up for Follow Along Program Clinic sends referral directly to early intervention office at school district Family refuses services, referral is closed Student comes in for evaluation, consent to send results back to clinic is requested. Student is determined to be eligible for services District Workflow Referral Report Opportunity

14. Family arrives for visit and either gives check in staff the completed questionnaire or completes one in the lobby Nurse or other clinic staff score the questionnaire and give results to the child’s practitioner Practitioner determines if a referral is needed, notifies the family and asks clinic staff to make the referral Prior to office visit, clinic administrative staff send screening questionnaire to family Referral is made to Help Me Grow (state referral system) Sample Internal Referral FeedbackWorkflow for Screening at Clinic Help Me Grow funnels referral to appropriate school district for early intervention or preschool special education evaluation Early intervention or preschool special education program staff send referral report form back to clinic via fax Family consent to report back to clinic is obtained Practitioner reviews report, highlights any issues, and gives it to care coordinator Care coordinator reviews report to identify any follow up needs to act on and gives it to support staff Administrative staff receive report by fax, give to practitioner Support staff files in medical record Clinics will vary in which staff will perform which of these functions. As part of the CCHD project, it will be important to identify these staff and engage them in the improvement process.

15. Early Childhood Screening • Screens children for concerns • Screening forms are sent to the clinic, along with consent forms Clinic/Community Workflow for Early Intervention and Preschool Special Education Referrals • Developmental Screening Coordinator (DSC) (part of clinic staff) • Enters reports and consent forms into medical records • Sends electronic update messages to providers • Responds to information requests from community partners (when consent is provided) Follow Along Program Tracks children with potential concerns Sends both a monthly list of enrollees and abnormal screening reports to clinic • School District Early Intervention or Preschool Special Education Staff • Receives referrals from DSC and conducts evaluations with children • When an evaluation is completed, and the child is a clinic patient who has consented to share information, sends a report back to the DSC • Clinic: Primary Care Provider • Reviews reports received from DSC • Conducts screenings with patients • Sends recommendations to DSC to follow up or call family

16. Completing and Spreading the Work • Complete when you’ve met your team goals. • Celebrate! • Tell others about your work, to encourage spreading the CCHD project to other communities, clinics, and families.

17. Modifications: Enhancements to the project that might attract clinics • Health Care Homes/ Medical Home Model: completing the CCHD project can help your clinic prepare for HCH certification in MN. Contact information for HCH is found on the CCHD website. • MOC 4 Project: The first round of CCHD projects applied for and received MOC 4 certification from the Academy of Physicians. Data run charts used in that process are available in the toolkit.

18. Technical Assistance Available The CCHD website has sample referral communication forms, examples of work flow diagrams, and links to many resources to support the project. You can also email CCHD.Info@state.mn.us . www.dhs.state.mn.us/cchd

19. Resources • Developmental Screening Overview: http://www.health.state.mn.us/divs/fh/mch/devscrn/ • Developmental Screening Tools: http://www.health.state.mn.us/divs/fh/mch/devscrn/instruments.html • Online Developmental Screening Training Module: http://www.health.state.mn.us/divs/fh/mch/webcourse/devscrn/index.cfm • Institute for Healthcare Improvement’s Model for Improvement: http://www.ihi.org/knowledge/Pages/HowtoImprove/default.aspx • Information for Parents and overview of MN’s online referral system: • www.mnparentsknow.org . Follow the button in the top right hand corner to Help Me Grown, the online referral page. • Online trainings for practitioners, with CME Credits: www.edopc.net, go to training page and look for “Coordinating Care Between Early Intervention and the Primary Care Practices” • Helpful Toolboxes for Clinicians www.nashp.org

20. Communities Coordinating for Healthy Development Funded by a grant from The Commonwealth Fund and supported by the National Academy for State Health Policy Created in cooperation with the Minnesota Department of Education and the Minnesota Department of Health. www.dhs.state.mn.us/cchd