Paula Duncan, MD, FAAP Ellen Buerk, MD, M.Ed FAAP July 29, 2008

1. Implementing Bright Futures into Practice: Lessons Learned from the Bright Futures Training Intervention Project Paula Duncan, MD, FAAP Ellen Buerk, MD, M.Ed FAAPJuly 29, 2008

2. Disclosure Statements Paula Duncan, MD: I have the following financial relationships with the manufacturers of commercial products and/or provider of commercial services discussed in this CME activity: Editor for Bright Futures Guidelines. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation. Ellen Buerk, MD : 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 my presentation.

3. What Are the Bright Futures Guidelines? Comprehensive health supervision guidelines: • Developed by multidisciplinary child health experts —providers, researchers, parents, child advocates • Provide framework for well-child care from birth to age 21 • Present single standard of care based on health promotion and disease prevention model • Includerecommendations on routine health screening, and anticipatory guidance

4. 3rd Edition Themes • Oral Health • Healthy Sexuality • Safety and Injury Prevention • Community Relationships and Resources • Child Development • Family Support • Mental Health and Emotional Well-Being • Nutritional Health • Physical Activity • Healthy Weight

5. 2 ½ Year Visit

6. 2 ½ Year Visit

7. 2 ½ Year Visit

8. 2 ½ Year Visit

9. 2 ½ -year-old Anticipatory Guidance Examples • Family Routines • Consistency in parenting, daily schedule, fun family activities • Language Promotion and Communication • Interaction through song, play, and reading • Promoting Social Development • Play with other children, expect limited reciprocal play, imitation of others, offer limited choices • Preschool Considerations • Readiness for playgroups, play dates, early childhood educational programs • Safety • Water safety, car seat use, interacting with pets, fires and burns, outdoor safety

10. Bright Futures Training Intervention Pilot Project

11. Training Intervention Project • Aim: • To test the feasibility of implementing the Bright Futures systems framework for improving preventive care and developmental assessment for children age 0-5 • Teams from 15 diverse practice settings • Adapted learning collaborative using quality improvement (QI) methods

12. The Bright Futures framework for preventive and developmental services is adapted from a systems model developed by The Center for Children’s Healthcare Improvement at the University of North Carolina at Chapel Hill (which is now the Center for Healthcare Quality at Cincinnati Children’s Hospital Medical Center).

13. Implementation Framework • Use of preventive services prompting system • Identification and consideration of children with special health care needs • Use of recall and reminder systems • Linking to community resources • Use of structured developmental assessment • Evaluation of parents’ needs and use of strength based approaches

14. Practice Profile • Type of Practices: N=15* • Private Practice 29% • Non-government hospital/clinic 29% • Multi-specialty group practice 14% • City/county/state government hospital/clinic 14% • Medical school 7% • Nonprofit community health center 7% • Type of Practices: N=15* • Urban – inner city 43% • Urban – non-inner city 21% • Suburban 7% • Rural 29% *Approximately 40 percent of the participating practices had prior experience implementing quality improvement methods

15. Comparison of Components at Baseline and Follow-up *Baseline percents calculated from 171 charts from 15 practices **Follow-up percents calculated from 305 charts from 8 practices

16. Preventive Services Prompting System • Reinforces practice guidelines • Facilitates communication across health care professionals • Ensures patients receive appropriate care

18. Consideration of Children with Special Health Care Needs • Routine way of identifying children with special health care needs (CSHCN) • Mechanism for asking and recording: • Does your child have any special health care needs? • Develop standards of care for CSHCN

19. Use of Recall Reminder System • Routine way of informing patients about the need to return for services • System for communication with families

20. Linking to Community Resources • Educational and referral information about local services and programs • Link with resources appropriate for patient population

21. Hagan JF, Shaw JS, Duncan PM, eds. 2008. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition. Elk Grove Village, IL: American Academy of Pediatrics.

22. Community Resources • Does your practice have a satisfactory link? • Priority to develop link • Need information about organization or referral process? • Leadership or participant role in community improvement activities

23. EXAMPLE

24. Community Linkage Strategies • Organized approach to links to community that works for youth and parents • Practice community meetings • In practice – responsible person • Single referral form • Single exchange of info form using HIPAA standards • Registry - in office of referrals and follow-up • Report back from referral specialist • System for information exchange with SBHC • Consider co-location for services your families find hardest to access e.g. WIC, dental hygienist, mental health counselor, nutrition, social worker • Help Me Grow

25. Use of Structured Developmental Assessment • Tailor to families’ needs, risks, and concerns • PEDS • Ages and Stages

26. Making Structured Developmental Assessment a Reality Oxford Pediatrics and Adolescents Rural private practice in college town • 4 physicians 2 nurse practitioners and support staff • 3 offices 25 percent Medicaid managed care • Electronic medical records • Using a structured developmental assessment since 2004

27. Why use a structured developmental assessment? • Recommended by AAP • Is it too much to do in a 20 minute Health visit? • Identify problems at an earlier age • Validate parent concerns or provide reassurance • Standardized way for all providers in the group to assess development

28. Choosing a Screening Tool • Parent Questionnaire • Ages and Stages Developmental Questionnaire ( ASQ) • Parents Evaluation of Developmental Status (PEDS) • Child Development Inventory (CDI) • Pediatric Symptom Checklist (PSC) • Direct Elicitation • Bailey Infant Neurodevelopmental Screener BINS) • Brigance • Denver II

29. Choosing a screening Tool • How much time to use the tool and score test • Given at home vs. office • Cost of tool • One time fee or ongoing fees • Can copies by made • What ages are screened • How sensitive/specific is each tool • How does the tool fit in with the office flow?

30. PDSA Cycle - Plan • Objective – Use screening tool for well visits under age 5 • Which visits will be used • When will the parents fill it out? • Who will score the test and when? Where will the results be kept in chart or EMR How will patients and providers feel about using the tool • Prediction - Parent will enjoy doing the activities and providers will do a better job assessing development

31. PDSA Plan • Plan for change • In our practice 2 providers used the tool first • A front desk staff member mailed questionnaire 2 weeks in advance • Parents did activities with child at home • Plan for Data collection • Monthly chart review • Amount of time for visits before and after ASQ was instituted.

32. PDSA - Do • ASQ was mailed out 2 weeks before appointments • Parents gave form to Medical Assistant (M.A.) when called back for appointment • M.A. scored while preparing patient for well visit • Provider reviewed ASQ results with parent during visit, made referrals as needed

33. PDSA - Act • Continue plan • Involve all the other providers in the office • Expand to well visits 9 months, 18 months, 2 years, 30 months and 4 years.

34. PDSA - Study • Well accepted by parents • Providers felt tool was valuable • Children with problems previously unidentified were identified observed or referred • Use of tool did not prolong visit time unless parent filled out tool in office.

35. Problems and Solutions • Parents forgot to bring back questionnaire • Mail it in later or fill out another • Questionnaire was not received in mail • Box of toys in office for kids to try activities • Parents filled it out at home , but don’t want to be charged for ASQ. Want the activities that go with form. • Give them a verbal heads up that we think it is important and we will be doing it at the next exam Provider does a verbal dev. assessment

36. If a delay is found on the assessment • Verify that the delay exists • Sometimes the child didn’t try the activity • Was the child in a good mood? • For some ages the ASQ is for a month beyond the visit. It states it can be used 1 month before. This happens with the 9 month visit and the 15 month visit. The ASQ is for 10 months and 16 months. The child may look like there is a delay but if you talk about what child is doing it is appropriate for the age.

37. What to do if there is not a delay but the parents are concerned • Acknowledge parental concerns • Remember the sensitivity of the tool • Repeat the developmental screen soon or use another tool • Consider need for referral

38. Coding • 96110 - developmental screening with report • Most insurance and some Medicaid Managed Care pay this code. • Parental complaints about charge • sent letter to parents in advance about questionnaire

39. Current Practice • ASQ at 9 months, 15 months, 24 months and 4 years • MCHAT at 18 months and 30 months • We decided not to do an ASQ and MCHAT on the same day generating 2 charges. • ASQ – has an initial charge of about $250 , can be copied and pays for itself within the first month of use • ASQ has general activities for each age and if there is a delay has specific suggestions to correct delay.

40. Keys to Success • Ask for ideas from everyone the change will affect • Make certain all staff are aware of the changes, how they will be implemented and who is responsible for which tasks and what benefits are • Be willing to change plans if it is not working • Tell everyone when it is working and share patient feedback

41. Implementation Framework • Use of preventive services prompting system • Identification and consideration of children with special health care needs • Use of recall and reminder systems • Linking to community resources • Use of structured developmental assessment • Evaluation of parents’ needs and use of strength based approaches

42. Parents Concerns and Strength based approaches • What would you like to discuss today • Do you have any concerns about your child’s growth development, behavior or learning? • We are interested in answering your questions Please check off the boxes of things you would most like to discuss today

43. Use of Strength-based Approaches Identify strengths Give feedback using a framework Use shared decision-making strategies Get feedback from parents and youth about office practice P.M. Duncan et al., Inspiring Healthy Adolescent Choices: A Rationale for and Guide to Strength Promotion in Primary Care; Journal of Adolescent Health, 41 (2007), 525-535

44. References • Lannon CM, Flower K, Duncan P, Strazza Moore K, Stuart J, and Bassewitz J. The Bright Futures Training Intervention Project: Implementing systems to support preventive and developmental services in practice. Pediatrics. 2008;122: e163-e171. • www.dbpeds.org • Bright Futures Systems Toolkit, 2004 • The ASQ User’s Guide, second edition 1999 • Hagan JF, Shaw JS, Duncan PM, eds. 2008. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition. Elk Grove Village, IL: American Academy of Pediatrics. • Recommendations for Preventive Pediatric Health Care. American Academy of Pediatrics. Pediatrics. 120:6 (1367). 2007

45. Contact Information QuIIN Phone: 847 434 4260 E-mail:quiin@aap.org New Web site:http://quiin.aap.org Staff Contacts: Jill Healy, MS: Program Manager Keri Thiessen, MEd, Senior Program Manager Bright Futures Phone: 847 434 4223 E-mail:brightfutures@aap.org New Web site:www.brightfutures.aap.org Staff Contacts Jane Bassewitz, MA; Manager, Bright Futures Education Center Amy Pirretti, MS; Manager, Materials Development and Promotion