Improving Quality for ChildrenApproaches to Building State Capacity Charlie Homer, MD, CEO Child Health Services Research Meeting Academy Health, 2005.

Improving Quality for Children—Approaches to Building

State Capacity

Charlie Homer, MD, CEO

Child Health Services Research Meeting

Academy Health, 2005

Problem Statement

Quality chasm is widespread Quality chasm affects the care of children, youth and

families as it does adults Health care for children is:

Predominantly outpatientLocally delivered and organizedState regulatedSubstantially funded through state programsMajor state public health role (e.g., immunizations,

newborn screening)

Requirements for improvement

Will to improve Better Ideas Assistance with Execution

TrainingTools SupportBusiness Case

National improvement programs may have limited local impact

Cost Distance Credibility Practical assistance Variability in financial context

Numerous potential state based resources to support improvement

Professional society/medical association chapters Health Department

Immunization programsTitle V (Children and Youth with Special Health Care

Needs)

State universities Medicaid Agencies Combinations of the above

Children’s Quality Initiatives

State Approach NICHQ Initiated Improvement Program

Professional Society Partnership for Quality (ADHD)—AHRQ

Public Health: Immunization NJ, other

Public Health: Title V Medical Home Learning Collaborative

Combination Improvement Partnership (VCHIP, envision NM, etc.)

Aim: Medical Home Learning Collaborative

To improve care for children with special health care needs/youth by implementing the Medical Home concept

To foster substantial relationships between Title V programs and their state’s primary care community, enabling Title V to:Support improvement in practices andSpread improvement across their State

Why Title V: The Title V Mandate

OBRA 1989 Healthy People 2010

Objective 16.23 Six defining outcomes

The New Freedom Initiative

Six outcomes

Family participation at all levels A medical home for each child with special health

care needs Adequate coverage Screening Family-friendly community systems Transition services

Why focus on systems for children with special health care needs

The complexity of children’s lives The scope, scale and range of children’s special needs The inadequacy of baseline supports The gap between social needs and private resources

The central place of medical home

As a critical point of parent connection As hub of services As locus at which remaining 5 outcomes may be

addressed, operationalized, tested

The medical home from a Title V perspective

Where the action is for children and families Meeting place for powerful constituencies Public health at the molecular level

IHI Breakthrough Series™(12 month time frame)

Select Topic

(develop mission)

Planning Group

Develop Framework & Changes

Participants (10-100 teams)

Prework

LS 1

P

S

A D

P

S

A D

LS 3LS 2

Supports

Email (listserv) Phone Conferences

Visits Assessments

Monthly Team Reports

Dissemination

Holding the Gains

Publications

Congress

etc.

A D

P

SExpert Meeting

AP1 AP2 AP3

LS – Learning Session

AP – Action Period

Modifications to BTS Design

“Participants”=11 State Title V Programs, each of whom recruited3 Primary Care Practice Teams

Faculty=Clinical, Title V, and Parent Chair

Teams=Physician, Staff (Nurse/Care Coordinator), Parent

Topic=Medical Home, aka, Chronic Care Model for CYSHCN

Faculty and Staff

Faculty and Staff Faculty Leadership

Chair: Carl Cooley Co-Chairs: Debby Allen, Alan

Kohrt Director: Jeannie McAllister Improvement Advisor: Jane

Taylor

Staff Lisa Horvitz, Colleen

O’Rourke, Sandra Cragin

FacultyMaureen Mitchell,

Family VoicesBetty Pressler, Judy

Palfrey, Margaret McManus, Chris Stille, Richard Antonelli, Amy Gibson (AAP), Lois Kohrt

Participants- State Title V Agencies

Connecticut Colorado Florida Ohio Oklahoma

Louisiana Michigan New York Utah Virginia Wisconsin

+ North Carolina

Participants Teams-Practices

3 Teams from each State43% Community Based, Group Practice22% Community Hospital or Network Group Practice (e.g.,

Marshfield Clinic, Bassett Health)25% Academic Primary Care Sites9% Solo Practice

Team MembersPhysician, nurse/other office staff/care coordinator, parent

partner

Key Concepts

Medical Home/Care Model for Child Health Model for Improvement Model for Spread

Medical Home is

Accessible Family Centered Continuous Comprehensive Coordinated Compassionate Culturally Effective

Functional and Clinical Outcomes

Resources and Policies

Community

Care Model for Child Health in a Medical Home

Health System

Health Care Organization (Medical Home)

Delivery

SystemDesign

Decision

Support

ClinicalInformatio

nSystems

Care Partnership

Support

Informed,ActivatedPatient/Family

Prepared,ProactivePractice Team

Family -centered

Coordinated and EquitableTimely & efficient

Evidence-based & safe

Supportive, Integrated Community

Prepared,ProactivePractice Team

CMHI

Model for Improvement

Act Plan

Study Do

What are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in an improvement?

Diffusion or Spread

“BETTERIDEAS”

Happens over time

COMMUNICATED

Thru a SOCIAL system

Adapted from Rogers, 1995

In a certain way

(C) 2003, Sarah W. Fraser

Measures

ED visits Hospitalization rates Family worry Front office satisfaction Medical Home Index Care Plans Practice Satisfaction

Medical Home Learning CollaborativeMHI Pre and Post Measures

4.85.27 5.13

4.69 4.46 4.424.79

3.42

2.73.23.53.45

3.983.67

1

2

3

4

5

6

7

8

OrgCap CCM CC CO DM QI Total

MHI-2003April MHI-2004Jan

CMHI

Results-Quantitative

Qualitative Results: Title V

Most valuable activities and insights:Conduct walk-throughs of practices—leading to

learning Connect teams to state resources Assist with care coordination Outreach to broad variety of audiencesPractices need help working with families

Positive impact on how to implement change and promote adoption of new models

Qualitative Results-Parents

Parents can be very effective in this process because they can counter assumptions health care providers make about the way things work"

"There are things I can do, like pre-register my child for appointments...my pediatric clinic and the hospital are willing to do [many things] to make things better for my family. I never would have known what to ask for, as a new parent, before the medical home training"

Qualitative Results-Practices The MHLC "helped the practice focus on

achievable steps to initiate a true medical home“

"the small changes have made a world of difference in our practice...

Specific changes (self-report)70% streamlining access64% have designated care coordinator63% working with community agencies60% partnering with families50% using some form of registry

Lessons Learned Feasible to address improvement using non-categorical

approach Parent involvement essential

Requires planning and support State/practice interaction feasible

Strengthened by broader coalition (funders, professional societies), greater training

Reform/improvement efforts require coordination Although CYSHCN broad category, efforts may remain in

silos It’s a great thing to do!

A SonnetWhen to NICHQ Learning Sessions we go,We summon up remembrance of tasks past.We sigh the lack of many a thing we know,But have hope to make Medical Home last. In the Northwoods our Wisconsin team met,

To have a group retreat and plan ahead--The practice teams’ commitment was set,And we shared Title V’s vision for spread.Then children and families noticed change;

care plans, identification and moreall became part of Wisconsin teams’ rangewith the Chronic Care Model as their core.

So, till the State Budget grants our evr’y wish,we will persevere—our defining niche.

The Job of Title V (Deborah Allen)

To the tune of “He’s Go the Whole World in His Hands ”

They got a coalition that won’t quit,

Got doctors, families, payers, to commit.

There’s not a single player, they omit,

Cause that’s the job of Title V.

TA to every practice, helps docs see,

How to engage kids’ parents, meaningfully.

Don’t want no tokenism, no siree,

That wouldn’t sit with Title V.

They’ve built a database that’s deep and wide.

They’ve listed every resource, in that guide.

They’ve found each scrap of info, that applied,

Cause that’s the job of Title V.

They’re gonna build a network, that’s a fact.

Where all the service systems, interact.

‘Til then they’ll have to plan, do, study, act,

Cause that’s the job of Title V.

MHLC II8 Additional States

DC, IL, ME, MD, MN, PA*, TX, WV, Expansion of State Teams

Include AAP/AAFP Chapter Representative Include Insurer (Medicaid) on Team Predominant Focus on Supporting Practices

Other Diffusion Several State Wide Collaboratives Change in Function and Activity National Center for

Medical Home