STRATEGIC DIRECTIONS: Key Informant Interviews with EPSDT Directors

1. STRATEGIC DIRECTIONS:Key Informant Interviews with EPSDT Directors Peggy McManus MCH Policy Research Center July 12-13, 2005

2. STRATEGIC DIRECTIONS STANDARDS & POLICIES • Session Objectives: • Examine state EPSDT policies for hearing screening & follow-up • Compare with JCIH, AAP guidelines, & Healthy People 2010 objectives • Consider strategies for updating state EPSDT policies on hearing

3. Interview Findings: Current Picture and Strategies • EPSDT standards primarily based on AAP preventive care guidelines, with some variations • EPSDT standards on hearing focus almost exclusively on screening, not referral & follow-up • Unclear the extent to which EPSDT standards reflect JCIH guidelines

4. Standards & Policies: Interviews • States have organized mechanisms for regularly updating EPSDT, with input from other state agencies & key stakeholder groups • New standards & policies disseminated through provider manuals, bulletins, & newsletters • Effective ways of implementing new standards -- work closely with state AAP chapters

5. Standards & Policies: Interviews • Less involvement with AAFP, though states interested in more • Hospital involvement critical • State universal newborn hearing screening laws – key in facilitating adoption of standards • Attention needed to address outreach, screening, & follow-up of failed screens.

6. Strategic Directions Information & Education • Session Objectives: • Share ideas about effective educational strategies for working with PCPs, families, hospitals, MCOs, and local health departments (LHDs) • Examine potential opportunities for informing & involving key stakeholders

7. Information & Education: Interviews Primary Care Physicians: • No magic bullets or single approaches • Very little done so far on follow-up • Important to have good, actionable data about how PCPs perform • Evidence-based data also important • Newsletters that profile promising practices useful

8. Information & Education: Interviews PCPs continued: • Ongoing training of residents helps • CME necessary, but not sufficient • More needed to target PCPs in rural areas, with small numbers of children in practice

9. Information & Education: Interviews Families: -- Work with existing family networks -- More education is needed on follow-up, esp. with families whose children have complex health care needs -- Follow-up telephone calls & face-to-face meetings work best

10. Information & Education: Interviews • Use of popular media helpful • Critical to have a “why” piece – explaining why both screening & follow-up are necessary • Informing families about standard of care is important and can positively influence parent demand for services

11. Information & Education: Interviews • Hospitals • State EHDI efforts, esp. involving on-site work, critical in implementing universal newborn hearing screening • Funding hearing aid loaner program important • Need to target small, rural hospitals and move beyond screening • Perinatal conferences important • Also, having short educational videos about hearing screening for use by hospitals important

12. Information & Education: Interviews • Local Health Departments • EPSDT outreach workers have critical role to play, but few have focused on hearing • Important to link with home visiting, case management, disease mgmt., & other initiatives involving LHDs • Regular training opportunities for LHDs, with CME important

13. Information & Education: Interviews • Hard-to-reach groups • EPSDT outreach workers have critical role to play • Home visiting & case mgmt. programs reach high-risk groups, though hearing follow-up seldom addressed • More attn. to cultural competence to reduce families’ delays in seeking follow-up • Translation & transportation are critical

14. Information & Education: Interviews • Overarching Comments • Comprehensive strategy needed, promoted through various channels (e.g., immunization) • Have a simple, consistent message – 1/3/6 • Involve key groups at outset • Address shortage of audiologists, incl. causes – education & training, reimbursement, other • Streamline & integrate hearing follow-up services with CM, EI, WIC, 1-800 #, EPSDT outreach, etc

15. Strategic Directions: Quality & Financial Incentives • Session Objectives • Review potential opportunities for incorporating national benchmarks from Healthy People 2010 • Examine Medicaid reimbursement levels for hearing services • Consider alternative performance incentive strategies

16. Quality Incentives: Interviews • Few EPSDT programs use or are aware of Healthy People 2010 hearing objectives • Most Medicaid quality standards from NCQA (HEDIS), AAP • Use of quality indicators (e.g., 1/3/6) could be an effective strategy • Important to have actionable data for use by providers • Comparative state data also helpful

17. Quality Incentives: Interviews • NICHQ’s model of collaborating with practices, conducting chart reviews, identifying improvement strategies, & providing feedback (eg, lead, immuniz) • Need to make sure hearing screening & follow-up is incorporated into EPSDT evaluations. Records could be tagged for follow-up

18. Quality Incentives: Interviews • Consider a GPRA project (e.g., immunization) • CMS could set a standard (e.g., dental care) • Maintain close link with public health • Issue certificates of excellence to providers scoring 95% of higher • Acknowledge the good work of providers “They’re not doing this work for the financial rewards, but for the benefits to children.”

19. Reimbursement Incentives: Interviews • “Ha, ha, ha. Stand in line.” • State Medicaid and public health funding is already stretched to its limits • Important to piggyback with existing EPSDT administrative outreach efforts • Through Medicaid’s administrative match, possibly some potential for funding follow-up activities

20. Reimbursement Incentives: Interviews • To claim administrative match requires financial support from other state agencies – good luck! • To justify payment changes, evidence of cost savings needed • Professional organizations & provider groups need to advocate for rate increases showing costs not being met and access adversely affected

21. Reimbursement Incentives: Interviews • Also, comparative state fee data useful – no one wants to be lowest (see handouts) • See examples from dental care. Also, incentives used successfully with EPSDT visit rates, immunizations, & lead screening • Examine hospital payment mechanisms to assess where to place incentive • Consider outside foundation & community funds

22. Strategic Directions: Monitoring & Tracking • Session Objectives • Examine existing state data sources and data-sharing arrangements to link with • Consider ways to improve accuracy & quality of reportable data on hearing screening & follow-up

23. Monitoring & Tracking: Interviews • Accurate data depends on accurate provider coding. Providers/office staff may need training on appropriate coding. • When hearing services bundled into a single code or folded into DRG payments, difficult to rely on claims data • Tracking hearing is much more complicated than lead screening

24. Monitoring & Tracking: Interviews • Potential data sources: vital records, EPSDT, EHDI tracking system, early intervention, care management, hospital databases, administrative claims, case management systems, registries • Data-sharing agreements most helpful • Publish program success

25. Strategic Directions:Collaboration • Session Objectives • Identify new & existing opportunities to effectively promote collaboration among key stakeholders • Share information about promising strategies • Consider roles & responsibilities for state EHDI programs to play with Medicaid & participating MCOs and other providers

26. Collaboration: Interviews • Already a great deal of collaboration between Medicaid and EHDI programs, mostly around newborn screening • Meetings at least quarterly help, involving Medicaid & other key stakeholders • Written interagency agreements useful in promoting accountability

27. Collaboration: Interviews • Examples: MD – a portion of EHDI coordinator’s time/salary is dedicated to working with Medicaid. • IL: “Think Tank Day” on newborn hearing projects for coming year; developed education, referral, & follow-up document; grand rounds training with AAP; newborn screening advisory group; now working on parent website

28. Collaboration: Interviews • Linking with other screening programs, such as electronic birth certificates, immunizations, or newborn metabolic screening, may have potential but not yet done for most part • State Early Childhood Comprehensive Systems (SECCS) grants important vehicles to link with in many states. Other initiatives – Healthy Babies/Healthy Kids& Families, Commonwealth’s ABCD program, & Early Education and Care