Learning Collaborative Accomplishments, At a Glance

1. Learning Collaborative Accomplishments, At a Glance Full Scale Projects: 2011-2016

2. Pediatric Asthma Total Participating Clinics: 10 • Family Medicine Residency of Idaho •Pocatello Children’s Clinic • Primary Health Medical Group •Salter Medical Group - Nampa• St. Alphonsus - Boise • St. Luke’s Pulmonology • St. Luke’s Twin Falls Physician Center • St Lukes Treasure Valley Pediatrics – Eagle, Meridian, Boise. Total Participating Pediatricians: 18 Background: This quality improvement project addressed the need to improve asthma care for children in Idaho. Asthma is the most prevalent chronic illness seen by providers caring for children with an estimated prevalence of 7% among children in Idaho. It also is one of the most common pediatric diagnoses leading to acute care visits in Urgent Cares, Emergency Rooms and is a common cause of admission to the hospital. Asthma medications are also among the most commonly prescribed pediatric medications Fig.1 Fig.2 Fig.3 Project Aim: Process Measures Summary To improve the quality of care and outcomes for children with asthma. Core Measures 1 and 3 showed the most significant increase over the course of the project. Patients with asthma severity consistently documented nearly doubled, where asthma action plans more than tripled. Total Chart Audits: 915 Asthma Action Plan (AAP) Telephone Survey Results Fig.5 Clinics surveyed a total of 143 patients over the course of the learning collaborative to inquire about their AAP. On average, 84% remembered getting the AAP for their child, 73% of patients still had their AAP and 29% had used their AAP since their last visits. When asked about specifics of their AAP, 94% were able to answer medication questions if they were in the green zone of the AAP (using daily controller medication), and 90% answered correctly if their child was in the yellow zone of the AAP (additional prescribe medication). Balancing Measures Summary Project Objectives: Possible short-term cost increases were examined by using reports of monthly spirometry utilization and/or referral to specialist (Fig 5). Both measures decreased on average over the course of the project • To improve correct classification of a patients asthma • Identify patients who should be prescribed Inhaled Corticosteroids • Improve understanding of Stepwise Adjustment of Medications and basic concepts of using office spirometry • Identify which patients would benefit from allergy evaluation • Understand and develop patient specific asthma action plans Sustainability: Lessons Learned: • Increased care coordination and physician collaboration • Improved documentation of patient diagnosis and ability for families to improve self- management asthma symptoms with the Asthma Action Plan • AAP was a successful tool to understand and manage their asthma symptoms and for triage nurse to use during phone calls • Barriers reported were time - integrating the Asthma Action Plan into the EMR, follow-up, developing and explaining the AAP to patients/parents - as well as combining asthma care with other types of visits, and getting the project started, along with organizing information and options Clinic indicated they would continue to work on the core measures using various means to measure improvement , such as education and evaluation of barriers and progress at staff meetings, chart audits, and EMR reports. The Asthma Sustainability Survey indicated that 83% of respondents continued to classify the severity of their asthma patients and the same percentage planned to continue creating AAPs.

3. 2 Year Old Immunizations Total Participating Clinics: 8 • St. Alphonsus Medical Group – Eagle/Boise • Lakeside Pediatrics • Saltzer Medical Group – Nampa/Meridian • Advanced Family Medicine • Kaniksu • Family Health Center Total Participating Providers: 19 • 11 pediatricians • 5 family physicians • 3 nurse practitioners Background: This quality improvement project addressed the need to improve immunization completion rates for children in Idaho. A CDC report in 2013 indicated Idaho had an average of 87% kindergarten vaccination rate including the MMR, DTAP/DT, and Varicella, which is about 10% below the national average. According to America’s Health Rankings, Idaho is listed at 24th in the nation for children aged 19 to 35 months receiving recommended doses of DTaP, polio, MMR, Hib, hepatitis B, varicella, and PCV vaccines. Fig.2 Fig.3 Fig.1 Fig.4 Project Aim: To improve the 2 year old immunization rate for children aged 22-26 months. *This measure included the second dose of HepA and audits were pulled only for children 22-26 month months (HepA can be given as early as 12 months and national statics examine age ranges from 18-36 months). If the second dose of HepA was excluded, clinic data results ranged from an as low as 15% at baseline to as high as 83% by the end of the project. This data was also measured at different intervals. Total Chart Audits: 2,652 Project Objectives: Balancing Measure – CoCASA Data Process Measures Summary Fig.5 • Understand best practices and incorporate at least 2 for immunizations • Understand best processes and incorporate at least 2 for immunizations • Understand the Idaho trends and parental beliefs in Immunization Refusal (incorporate use of V64 codes into clinical practice) The project measured the number of reminder/recalls, number of v64 codes used, and IRIS inquiries. As indicated, IRIS queries seemed to be the most frequent means to track and manage immunizations (Fig. 5) Lessons Learned: Sustainability: • Providers developed policies and processes for immunization delivery, status checks, and refusals • Improved comfort in conversations regarding immunization refusal and immunization education • Barriers included: increased time -- for running IRIS reports, checking immunization status at selected or all visit types, and time for conversation regarding immunization preferences and recommendations; some clinics reported no change in parent refusal for immunizations despite extra efforts Practices successfully developed sustainability plans that included improved processes and policies regarding immunizations. Of the six clinics who reported on their confidence in implementing their sustainability plans from 1(not confident) to 5(confident) , the mean score was 3.8. The most significant barrier to sustainability lay within family physicians to implement processes clinic-wide.

4. Preventing Childhood Obesity Learning Collaborative Total Participating Clinics: 18 • St. Luke’s Treasure Valley Pediatrics - Boise, Eagle, and Meridian • St. Alphonsus Medical Group - Boise and Caldwell• Family Medicine Residency of Idaho - Boise• St. Luke’s Pediatric Endocrinology • St. Mary’s/Clearwater Valley Hospital • Meridian Pediatrics •Pocatello Children’s Clinic • Saltzer Nampa •Shoshone Family Medical Center • St. Luke’s Jerome •St. Luke’s Wood River • Terry Reilly-Nampa Total Participating Providers: 74 • 39 pediatricians • 26 family physicians •4 nurse practitioners • 5 physician assistants Background: Based on the results of the 2011-2012 Idaho third grade BMI assessment and the 2011 Idaho Youth Risk Behavior Survey, there are an estimated 6,200 (29%) overweight or obese third grade students and 17,700 (23%) overweight or obese high school students (grades 9 through 12) in Idaho. Primary Care Providers were not routinely collecting and properly calculating a child’s BMI or BMI percentile in Idaho, nor were they including a diagnosis based on the national standard definitions surrounding obesity diagnoses for children, including patients at risk for obesity (BMI 85-94%) or obese (BMI > 95%) on the patient’s problem list. Referral Process Measures Across All PCP Clinics Fig.1 Fig.2 Fig.4 Fig.3 Project Aim: To ensure that children ­ages 2 -14 would have their BMI percentile measured and assessed during each Well-Child Check. To improve the use of educational tools and counseling on “5-2-1-0 Let’s Go!” messaging for patients and parents. Total Chart Audits: 4,713 Process Measures Summary The core measure indicated the use of only one of the four nationally recognized educational messages (5-2-1-0 Let’s Go!). However, all clinics recognized the value of each individual message and chose to adopt the use of the message in its entirety to ensure that even those children not at risk were given education tools for healthy eating and physical activity to support obesity prevention. Balancing Measures: Pre-Post Survey Results The balancing measures indicated clinics improved significantly in establishing a process and/or policy for treating obese and overweight patients including having a sustainability plan in place. Additionally, the perceived improvements in the assessment of BMI% accurately reflected the data results (as seen in Fig. 2). Project Objectives: • Improving knowledge and understanding of pediatric BMI percentile tools and their use in diagnosing obesity. • Improving knowledge and understanding of motivational interviewing and pediatric nutrition • Increasing awareness and utilization of community resources Lessons Learned: Sustainability: • Established efficient and effective processes for identifying and managing overweight and obese children • Statewide utilization of consistent educational messaging • Improved collaboration with registered dieticians and nutritionists and other community resources • Barriers related to limited community resources in rural areas, experience with conversational sensitivity related to weight and self-esteem with youth, and follow-up care proved difficult due to means and motivations for continued care (ass seen in Fig 4). Practices successfully developed sustainability plans. Prior to the LC 4% of clinics reporting having a plan in place, and by the end of the project that rose to 79%. Additionally, clinics expressed continued use of the 5-2-1-0 educational messaging tools since it was basic and applied to all children, regardless of assessed weight category.

5. Adolescent Depression Screening Total Participating Clinics: 18 • St. Luke’s Treasure Valley Pediatrics - Meridian, Eagle, Boise • St. Alphonsus Medical Group - Caldwell• Family Medicine Residency of Idaho – Boise • Meridian Pediatrics •Pocatello Children’s Clinic • St. Luke’s Developmental Pediatrics •St. Luke’s Jerome • St. Luke’s Wood River • Primary Health Medical Group • Lost River Medical Center • Mackay Medical Clinic • Caribou Medical Clinic • Grace Clinic • Browne Family Practice • Teton Valley Medical Center• Primary Care Pediatrics (Utah) Total Participating Providers: 62 • 45 pediatricians • 11 family physicians • 5 nurse practitioners • 1 physician assistants Background: This quality improvement project addressed the gap between the goal of screening all adolescents for depression and the reality that most primary care providers wait for patients and families to bring up the issue. A recent report by the Surgeon General estimates that while 11% of adolescents have been diagnosed with a mental health disorder, double that amount remain undiagnosed, preventing them access to treatment and resources.. Additionally, a survey of key stakeholders in November 2011 identified pediatric mental health as a priority, second only to improving immunization rates Referral Process Measures Across All PCP Clinics Fig.1 Fig.2 Fig.3 Fig.4 Project Aim: To increase early detection and initiation of treatment for adolescent depression through the introduction of a process of universal depression screening (PHQ-9/PHQ-9M) for children ages 12-17 years of age. To increase provider knowledge of appropriate treatment strategies and referral. Process Measures Summary Physicians tripled their utilization of a validated screening tool (Patient Health Questionnaire PHQ-9 or PHQ-9M) for depression and improved their documentation of those screening results. Screening for substance abuse also increased from 48% to 59%. Total Chart Audits: 3,233 Pre-Post Survey Results The balancing measures indicated perceived improvements made in screening for depression, discussion about access to firearms if patient reports suicide ideation, care plans, and educational material utilization. The following graphs depict “Yes” responses from the pre and post surveys. Project Objectives: • Improve knowledge and understanding of depression and substance abuse screening tools, how to use them, interpretation and limitations • Improve knowledge and understanding of best practices and processes for addressing adolescents at risk for depression • Increase awareness and utilization of community resources related to adolescent depression Lessons Learned: Sustainability: • Providers developed stronger relationships with child and adolescent psychiatrists. • Improved ability to treat and manage depression, including prescribing anti-depressant medication, as well as when and how to refer • Balancing measures indicated that Idaho Medicaid participants had an increase in the number of SSRI and other antidepressant claims and patients, while the number of atypical antipsychotic claims and patients declined. • Barriers included: increased time -- for screening patients and for following up with positive screens – and navigating the depression screening process into clinic workflow and electronic medical record systems Practices successfully developed workflows and processes to continue to improve their practice. Some clinics planned to continue to run EMR reports and conduct internal chart audits to continue monitoring their progress, others developed a registry for their moderate to severe patients for population management, and many clinics expanded their mental health resource list to continue to provide additional support for their patients.

6. Diagnosis and Management of ADHD Total Participating Clinics: 10 • St. Luke’s Treasure Valley Pediatrics - Boise, Eagle, and Meridian • St. Alphonsus Medical Group - Boise and Kuna • Family Medicine Residency of Idaho – Boise • St. Luke’s Physician Center – Twin Falls • Meridian Pediatrics •Shoshone Family Medical Center • Primary Care Pediatrics – Logan, UT. Total Participating Providers: 38 • 32 pediatricians • 2 family physicians •2 nurse practitioners • 2 physician assistants Background: ADHD is one of the most common chronic childhood disorders and often persists into adulthood. In Idaho, the prevalence of parent reported AHDD diagnosed by a health care professional was 8.4% in 20011, up from 6.4% in 2003 (Key Findings: Trends in the Parent-Reporting of Health Care Provider-Diagnosis and Medication Treatment for ADHD: United States, 2003-2011). The comorbidity rate of ADHD with other disorders varies between the different diagnoses, but is prevalent enough to warrant direct attention. Referral Process Measures Across All PCP Clinics Fig.1 Project Aim: To ensure that all children ages 4-18 years with suspected or diagnosed ADHD are systematically and accurately diagnosed, including assessment for comorbidity, and receive optimum treatment and management for their ADHD. TotalChartAudits: 1457 Process Measures Summary Project Objectives: Clinics made significant progress in the core measures. The largest percentage increase related to adding ADHD patients to a patient registry. • Understand the current state of the diagnosis and management of ADHD • Accurately diagnose ADHD in children and adolescents, ages 4 to 18 • Identify and screen for conditions comorbid to ADHD • Learn to assess functional impairment • Become familiar with resources for parents • Learn to optimize pharmacologic treatment of ADHD • Learn behavioral management strategies for treating ADHD • Understand and be able to apply the principles and practices of quality improvement Balancing Measures: Pre-Post Survey Results The balancing measures indicated clinics improved significantly in multiple areas, including knowledge of clinic policies related to ADHD patients, creating sustainable plans, tracking ADHD patients and offering educational material to patients and their families. Lessons Learned: Sustainability: • Substantial improvement was made in the utilization of a standardized screening tool (Vanderbilt) for initial and follow-up visits to ensure consistency of care. • Providers increased their disbursement of educational material to established patients and their families • practices successfully developed patient registries • Barriers included : communication between providers for standardized processes, utilization of registries as a population management tool, and difficulty scheduling follow-up appointments within the AAP’s recommendations. • Each practice successfully developed a sustainability plan and providers shared their experiences with other participants. • Prior to the LC, 41% of physicians reported having a plan in place, and by the end of the project that increased to 96%. • Additionally, 100% of physicians participating for MOC reported that they can envision their practice sustaining the process changes implemented during this project.

7. Adolescent Immunizations Total Participating Clinics: 15• St. Alphonsus Medical Group – Boise • St. Luke’s Payette Lakes• Saltzer Medical Group Pedatrics– Nampa/Meridian • St. Luke’s Family Health East• St. Luke’s TVP Boise/Eagle/Meridian • St. Luke’s Family Medicine (Greenhurst) •Terry Reilly Nampa •St. Luke’s Ada Medical Assoc. •St. Luke’s Physician Center Twin Falls (Addison and Pole Line) •St. Luke’s Capital City Family Medicine •Shoshone Family Medicine •Meridian Pediatrics •Primary Care Pediatrics (Logan, Utah) Total Participating Providers: 56 • 33 pediatricians • 17 family physicians •6 ACPs Project Aim: To increase the vaccination coverage for Tdap, MenACWY, and HPV 3-dose series for adolescents 11-17 years of age in Idaho. This was accomplished by focusing on assessing and documenting the immunization status of these adolescents, reducing the number of missed opportunities, and by scheduling appropriate follow up appointments related to the HPV 3-dose series. Fig.1 Fig.2 Fig.3 Project Objectives: • Increase assessment and documentation of immunization status among adolescents 11-17 years old. • Decrease rate of missed opportunities among adolescents 11 -17 years old. • Improve the rate of subsequent dose appointments scheduled for the HPV vaccine 3-dose series • Increase provider awareness and utilization of community and national immunization resources. • Improve immunization rates among adolescents 11-17 years old in Idaho. Total Charts Audited: 3,293 Lessons Learned: Sustainability: • Providers experienced an increased focus on immunizations including: pre-visit planning, better utilization of the EMR, proactive measures related to the HPV vaccine, and a more streamlined method for scheduling follow up appointments. Improved comfort in conversations regarding immunization refusal and immunization education • One common barrier among clinics were consistently screening at sick visits. They were often a challenge because of the short amount of time that the provider team had to prepare for the visit and screen the patient immunization records from multiple sources. Practices successfully developed sustainability plans that included improved processes and policies regarding immunizations. Clinics developed systems for scheduling HPV follow-up appointments, assessing and documenting within a designated area within the EMR, and teams committed to meeting regularly to discuss immunization processes. Each team submitted a sustainability plan and chart audit to ensure measures were being met. 100% of participants agreed that this LC improved their quality of care.