Community Systems Change Through Learning Collaboratives: Multidisciplinary Partnerships for Healthy Child Development Jill Houbé, MD, MPhil Debra Lotstein,

Community Systems Change Through Learning Collaboratives:

Multidisciplinary Partnerships for Healthy Child Development

Jill Houbé, MD, MPhilDebra Lotstein, MD, MPH

Early Developmental Screening and Intervention Initiative

EDSI

Goal and Objectives

• Goals To discuss the principles and practical issues around multidisciplinary

learning collaborative models to achieve health system change

To review the experience of the EDSI Learning Collaborative

To discuss potential applications in Canada.

• Objectives After participating in this activity, attendees will be able to : To describe the principles and practical applications of the learning

collaborative approach to health system change and quality improvement;

To identify the role of multidisciplinary partnerships for providing developmental health care services

Workshop Outline

• Introductions

• Background and scope Interprofessional collaboration Collaborative system change

• An example of a multidisciplinary learning collaborative in paediatric healthcare: Early Development Screening Initiative (EDSI)

• Learning collaboratives and health system change in Canada

• Discussion

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What is interprofessional collaboration?

“Collective action toward a common goal, in a spirit of harmony and trust”

D’Amour et al, (2005), Journal of Interprofessional Care, 19:2, 116 - 131

What is interprofessional collaboration?

Five underlying concepts

• Sharing

• Partnership

• Interdependency

• Power

• Process

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What is interprofessional collaboration?

• Multidisciplinary

• Interdisciplinary

• Transdisciplinary

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Determinants of successful collaboration

InteractionalInteractional

OrganizationalOrganizational

SystemicSystemic

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What is Collaborative Learning?

“Learning is the social construction of knowledge” Vygotsky

• Individuals with differing viewpoints, experiences, and levels of knowledge interact with one another

• Testing, reconciling, and forging a new, shared understanding

• Acquiring new knowledge and restructuring existing knowledge

Principles of Quality Improvement

• Performance is a system property

− Working harder in an unsupportive system will not change outcomes

− If you want improved performance, you have to seek a new system

• Improvement itself requires a system

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Schecter and Margolis (2005), J Pediatr;147:295-301; Deming WE, The New Economics for Industry, Government, Education ,Cambridge, Massachusetts, USA: The MIT Press; 2000; Berwick (1999), Managed Care Magazine

Promoting Optimal Child Development

• What are some challenges you are facing in: Eliciting parents’ concerns and addressing information

needs? Helping parents enhance their child’s development ? Identifying children at risk for developmental and

behavioral problems? Linking families with needed community services?

The Gaps in Care

• Under-identification of developmental problems prior to school entry

• Lack of involvement of parents

About half of parents are asked about concerns

About half of these receive needed information• Underserved families at high risk for poor care

Poorer preventive care and elicitation of concerns

Social norms about child development• Limited time for ECE or PMDs to address concerns

Glascoe FP, Dworkin PH. The role of parents in the detection of developmental and behavioral problems. Pediatrics 1995; 95 :829 –836; Glascoe FP, Dworkin PH. Obstacles to effective developmental surveillance: errors in clinical reasoning. J Dev Behav Pediatr 1993; 14 :344 –349; Palfrey JS, Singer JD, Walker DK, Butler JA Early identification of children's special needs: a study in five metropolitan communities. J Pediatr. 1994; 111:651-655

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Multidisciplinary Collaboration: The EDSI experience

• Early Development Screening Initiative (EDSI) Implement reliable systems for providing effective

preventive and developmental care to children less than 5 years of age.

Create new systems of support through collaboration between physicians, nurses, ECE professionals, administrators, and parents.

• Funded by First Five, Los Angeles County

EDSI Aim: To create effective systems for early identification and promotion of optimal development

• Parents have the knowledge, confidence and supports to promote

optimal development

• Health care and early care and education providers discuss and

address development with parents effectively

• Providers understand and use pathways to family supports and

services

• Relationships between providers and community agencies promote

access to resources

Partners in the EDSI Initiative

• Implementation partners Primary care practices Early care and education (ECE) Specialized programs (e.g., regional centers) Women, Infants and Children (WIC) Supplemental

Food Program• Steering Committee

Representatives of implementation partners Opinion leaders, policy-makers, experts

• Affiliated programs and initiatives

EDSI Project Components

1. QI Learning Collaboratives

2. Population-based strategy

- WIC sessions for parents

3. Policy change and spread

EDSI Project Components

1. QI Learning Collaboratives

2. Population-based strategy

- WIC sessions for parents

3. Policy change and spread

Barriers and Opportunities for Promoting Optimal Development

• Parent Knowledge about development Skills at managing behavior Views about clinicians and teachers as sources of

information about development/behavior• Teacher/Provider

Time Counseling resources and skills

• Early Childhood Center/Medical Practice Routine process for eliciting concerns Organized materials and resources to meet families’ needs Ability to link families with community resources

"Everyone wants change—they just don't want anything to be any different."

Yogi Berra

QI Learning Collaborative Format

• Adapted from the Breakthrough Series Method of the Institute for Healthcare Improvement*

• Each participating site sends a team

• Three “learning sessions” over 12 months, ongoing coaching

• Data collection and feedback

• Uses the Model for Improvement

• Defines common set of aims, measures and ideas for change for all participants

* www.ihi.org

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

Aim

EDSI Practice Goals

• >75% of parents report needs met: AGPE and child’s development

• >75% of parents read with child daily• >95% of parents have psychosocial screening• >20 Office System Inventory items in place• >95% of at risk children have documented follow-up plan• >75% of parents report receiving family centered care• >95% of children have documented developmental screening

• >75% of young children (birth to age 5) will have documentation of an age-appropriate structured developmental screening twice yearly.

• > 75% of young children (birth to age 5) will have documentation of a parent-teacher conference twice yearly.

• > 95% of at-risk children will have a follow-up plan documented in the child’s folder.

• > 95% of parents with young children (birth to age 5) report their information needs about their child’s development and behavior were met.

• > 75% of parents report reading or sharing books daily with their child.• > 95% of children will have a documented medical home provider’s

name and contact information in their folder, updated within the last six months

EDSI ECE Goals

Team Aim

The Clinica Monsenor Oscar A. Romero EDSI team is determined to improve preventive services and developmental screening and referral for children ages 0-5 years in our community.

We intend to develop practice-based systems to facilitate comprehensive preventive care and developmental screening and referral. We will test and implement strategies to integrate evidence-based screening tools and anticipatory guidance into the practice workflow, with an emphasis on parent reporting.

Team Aim (continued)

Our goals includes:

1. Greater than 75% of young children (birth to age 5) will have an age appropriate parent report based structured developmental screening at designated well-child visits.

2. Greater than 75% of young children (birth to age 5) will have documentation of a psychosocial screening in the previous 12 months.

Team Aim (continued)

3. Greater than 75% of young children (birth to age 5) identified as “at risk” will have a plan for follow up by the practice and/or referral to a community resource partner.

4. Greater than 90% of young children will have a documented provider endorsement of and referral to The Children's Institute School Readiness Program (an organization which will facilitate referral for Early Head Start, Head Start, Preschool, and other family support services)

Wilton Place ECC Team Aim

Implement reliable systems for effective preventive and developmental care and support for children 2 – 5.

We will achieve our aim by:Enhancing positive discussions with familiesBuilding relationships with community resources Building a continuous learning system for our centerGoals & Measures

75% of children will have documentation of an age - appropriate structured developmental screening

75% of teachers will have information from screening 95% of children will have contact information in their folder, updated

within the last six months

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

Measures

Example Data Feedback Reports

% of children with structured developmental screening within the

last 6 months

0%20%

40%60%

80%100%

R1

% of children with medical provider information up to date

0%

20%

40%

60%

80%

100%

R4

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

Ideas/Changes

Multiple Sources of Ideas for Change

• Tools from Healthy Development collaborative*• Literature review• Interviews/site visits with local high-performing early

childhood centers• Teams develop new ideas and share with each other

* A Practical Guide for Healthy Development http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=462115

Act Plan

Study Do

New Ideas are Tested and Implemented Using PDSA Cycles

Act Plan

Study Do

Use PDSA Cycles to Test and Implement Changes

Plan the details of the test and predict the outcome of the test

Act Plan

Study Do

Use PDSA Cycles to Test and Implement Changes

Plan the details of the test and predict the outcome of the test

Do: Conduct the test and collect data

Act Plan

Study Do

Use PDSA Cycles to Test and Implement Changes

Plan the details of the test and predict the outcome of the test

Do: Conduct the test and collect data

Study: Compare predictions to the test results

Act Plan

Study Do

Use PDSA Cycles to Test and Implement Changes

Plan the details of the test and predict the outcome of the test

Do: Conduct the test and collect data

Study: Compare predictions to the test results

Act: Take action based on the new knowledge

The Model Provides Structure for Repeated Tests

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The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003

Example:ECE First Plan-Do-Study-Act Cycle

Plan: Questions:Will a structured written form better assist for discussing developmental and behavioral observations of a

child?Will this form also be proactive to assist during parent – teacher conferences by answering their questions

and concerns? Predictions: Having a form to structure the discussion at the conferences will make it easier for teacher to focus the discussion and assure that important things are not left out. The form will make the conference more helpful in answering parents questions and concerns.DO:

Conference took 30 minutes. Family has 4 year old boy, bilingual, developing on track, without any behavioral or developmental concerns. Gave copy of form to parents and put copy in child’s folder.STUDY: Parent ask about Spanish translation of the parent survey. Need to re – word questions because they were not clear to parent. Parent likes being involved and was very open.ACT:

Team will revise the form; the teacher will test it out 2 more conferences over the next 2 weeks and report back to the team the following week.

Physicians’ Office PDSA Developing Office Systems

Question: Is it helpful to use a case manager to endorse the provider’s referral to an early education program? Are our parents able to access early education programs through the Children’s Institute?

Plan for Test:• Dr. Prestwich and Dr. Willard will ask the 3 different parents 0-

5year old children if the child is enrolled in an early education program. If not, they will refer the parent to The Children’s Institute.

• Dr. Prestwich and Dr. Willard will have the same discussion with 3 other parents, but they will then refer them on to Alba or Yvonne for reinforcement of the referral.

Do/Study: 6 parents were referred and all of them expressed intent to keep an appointment. After 3 weeks we found that 1 (mother of 15 month old, referral by MD without Case Manager assist) kept appointment. She was frustrated that Early Head Start has a waiting list. The other 5 had not yet called, but indicated they plan to.

Act: We confirmed that there are long wait lists for kids 0-2 years, but immediate access to early education programs for 3-5 year olds in our area. May need case manager to assure follow-up after the visit. Will continue to follow the 5 parents; test with 5 more.

Multiple PDSA Cycle Ramps

A P

S D

A PS D

A P

S D

D S

P A

Testin

g and A

dapta

tion

A P

S D

A PS D

A P

S D

D S

P A

A P

S D

A PS D

A P

S D

D S

P A

A P

S D

A PS D

A P

S D

D S

P A

Develop office systems

Work as a team

Use structured screening

tools

Discuss parent

concerns

Partnershipswith

communityresources

Continuous learning

system

Lessons Learned (so far…)

• Challenges Teams used to top-down approach to change Working effectively as a team Data collection is something “extra” (not able to get

from existing processes)

• Strengths Sharing and learning across disciplines Professional development for staff Staff validation and engagement in the “big picture”

EDSI Project Components

1. QI Learning Collaboratives

2. Population-based strategy

- WIC sessions for parents

3. Policy change and spread

WIC Sessions for Parents

Women Infants and Children program pre-natal to

years old nutritional and educational services

provided by trained peers

Curriculum developed to teach parents’ skills for

talking with clinicians

Themes: Parents are the best observers of their

child’s development; expectations for their child’s

doctor

EDSI Project Components

1. QI Learning Collaboratives

2. Population-based strategy

- WIC sessions for parents

3. Policy change and spread

Policy Change and Spread

Clarify specific policy issues for an improved system • E.g. shared vision, respective roles,

expectations and guidelines, workforce and training, reimbursement

Convene several policy summits including County and State policymakers

“What the best and wisest parent wants for her own child, that must be what the community wants for all its children.”

John Dewey

Planning for Change in Your System using a Learning Collaborative Approach

• What is your general aim for improvement?

• Who should be involved?

• What are some incentives for encouraging their participation?

• Who might help support such an effort?

• What are some potential facilitators of collaboration (e.g. data sources, aligned incentives, etc)

• What are some potential barriers to collaboration?

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Multidisciplinary learning collaboratives: A Model for Quality Improvement in Canada?

• Potential barriers Boundaries between subspecialty and primary care systems Limited communication between systems of care Limited data collection and sharing between systems of care

• Potential promoters Publicly funded health insurance Population-level data collection

• Potential benefits Improvement in healthy child development outcomes Improvement in adult health and well-being

Percentage of Students Vulnerable Emotional Maturity scale of the EDI (Based on Provincial cutoffs), Wave 1

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Acknowledgements

• Sunny Hill Foundation

• British Columbia Child and Family Research Institute

• Hillel Goelman and Clyde HertzmanConsortium for Health, Intervention, Learning and DevelopmentHuman Early Learning Partnership

• BC Healthy Child Development Alliance

• Neonatal Follow-Up Program

• Dana Brynelsen and Infant Development Program

Contact: [email protected]

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EDSI Team

• UCLA Center for Healthier Children, Families, and Communities

• Center for Health Care Quality, Cincinnati Children's Hospital Medical Center

• RAND Corporation• Public Health Foundation Enterprises (PHFE) WIC• LA BioMed WIC• California State University, Los Angeles• Childrens Hospital Los Angeles• Cedars-Sinai Medical Center