ABCD III Project in Oklahoma “Connecting the Docs”
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Transcript of ABCD III Project in Oklahoma “Connecting the Docs”
ABCD III Project in Oklahoma“Connecting the Docs”
Sue RobertsonOklahoma Health Care AuthorityNASHP Annual Meeting
Connecting the Docs: Improving Care Coordination and Delivery of Developmental Screening and
Referral Services in Oklahoma
• Initiative aimed at advancing systemic improvements focused on improving outcomes for young children with and at risk for developmental delays
• Builds on existing infrastructure to establish new and strengthen existing linkages among entities serving children and families
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State Readiness
• SoonerCare patient-centered medical home• Oklahoma State Department of Education
SoonerStart/Early Intervention program • “Fax-back” form, piloted by OK-Kids partners, aimed
at facilitating information between PCP offices and SoonerStart
• Developmental Screening Initiative (DSI)• Quality Improvement Initiatives - Practice Facilitation • Oklahoma Family Network (OFN)
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Outline
Overview of State StrategyPilot Level Strategies/Activities
◦Practice Level◦Community Level◦Web Portal/Care Coordination Tool
Systems Level ActivitiesEvaluation and MeasurementLessons Learned & Implications…
◦Looking to the Future
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Overview of State Strategy
• Partners• Team Framework
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ABCD III Project“Connecting the DOCS”
Strategy: Creation and deployment of a web portal to connect PCPs to Early Intervention and community partners. Participating PCPs send referrals to Community Teams via the web portal and receive referral outcomes back through the portal
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ABCD III Project“Connecting the DOCS”
A partnership between: • Oklahoma State Medicaid • Part C Early Intervention• Child Guidance• Developmental Pediatrics• Family Medicine• Family and Care Coordination Support• Primary Care Practices (Medical Home)
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Acronym Name Program
OHCA OK Health Care Authority
State Medicaid/SCHIP (SoonerCare)
SoonerCare Choice Medicaid/SCHIP Medical Home
OUHSC University of OK Health Sciences Center
Dept of Pediatrics Section on Developmental Behavioral Pediatrics (Implementation & Evaluation Support)
Dept of Family and Preventive Medicine(Web Portal/Technical support)
EI SoonerStart IDEA Part C Early Intervention
OSDH/CG Oklahoma State Dept. of Health
Child Guidance Program
OFN Oklahoma Family Network
Family-to-Family health information network
CC Sooner SUCCESS Care Coordination Program
PEAs Practice Enhancement Assistants
OUHSC Research assistants who work longitudinally with practices in each of the counties to facilitate change
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Local Core Teams Mirror State Core Team
STATE TEAM LOCAL TEAMS (x 4)
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Pilot Level Strategies & Activities
• Practice Level • Community Level• Development of Web Portal (Care
Coordination Tool)
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Pilot Activities
Practice facilitation/supportTechnology to improve ease of referral and feedback
(web portal)Sharing of successes and/or ‘non-successes’ between
practices and among community partners (PDSA Cycles)
Support development of productive communication and response patterns among partners at state and community levels
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Practice Activities: Strategy Summary
Multifaceted “Facilitated Change” strategy:1. Performance measurement and feedback using
pediatric quality indicators2. Academic detailing with discussions of evidence-
based and local exemplary practices3. Practice facilitation using “Practice Enhancement
Assistants” (“PEAs”)4. HIT support
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Integration into PCP Practices: PEAs
• Recruitment• Perform “academic detailing” • Bring practices to whatever state of readiness
needed to implement or continue screening• Introduce community teams• Demonstrate web-based portal • Ongoing problem solving using PDSA cycles
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OKLAHOMA’S LINKAGE PROCESS
Send New Referral
For SoonerCareChoice patients, the demographic information is pre-populated; address/phone number can be updated as needed.
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Closing the Loop
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Community Level Activities: Initial Phase
Relationship/Team Building◦Getting partners together in monthly meeting◦Developing rapport, communication, and trust◦ Introducing ABCD project to partners◦Teaching web portal/HIT support◦ Introducing teams to PCP practices
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Community Level Activities: Ongoing Phase
Community teams now function independently Meet monthlyTroubleshoot referral communication, feedback
process, information needs (PDSA cycles)Develop “Referral Resource Tool” for PCPs and
families TA provided by PEAs, as needed
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Systems Level Activities
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Improving State Systems and Policies
Data sharing and security of the web portal◦HIPAA/FERPA issues◦Security Certificate◦ Integrating OFN/family professionals
Eliminating duplications between PCPs & EI◦ASQ by PCP or outside agency can be used for EI’s
evaluation process◦Clarification of FERPA – Consent obtained by PCP is
sufficient for EI. If PCP does not obtain consent, EI can obtain consent
Medical Home PoliciesHealth Access Networks (HANs)Maintenance of Certification (MOC 4)
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Evaluation & Measurement
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Oklahoma’s Common Measure
# of children receiving EI services whose PCP knows of the services
__________________________________________# of children receiving EI Services
Use of web portal to electronically collect referral and feedback data
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Web Portal Initial Evaluation*
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Referral Status Number Percent
Total Received 161 100%
Pending 5 3%
Processing 23 14%
Responded 52 32%
Completed 78 48%
Withdrawn 3 2%
*Rollout began March 2011. Data pulled August 30,2011.
Lessons Learned & Implications…Looking to the Future
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Positive Outcomes
Streamlines routine visits Provides focus to the visit when concerns are present More accurate and more timely identification of children
with developmental delays Enhances parental education about appropriate
developmental expectations
Facilitates communication between providers and early childhood programs and resources
Facilitates communication between families and providers
Better lifelong outcomes for children Step toward becoming Tier 3 Medical Home
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Challenges
Communication across programs and subsystems◦Multiple systems to coordinate◦Multiple processes for referral◦Multiple levels of decision making
Data and Information Sharing◦Diverse and unconnected data systems
Community Team Challenges◦Discussion about what constitutes a closed referral◦Discussion about responsibility during referral loop process
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Looking to the Future……
• ABCD III project will reap lessons regarding how to facilitate the medical home becoming more competent in appropriate referral and follow up interactions with community based services and resources
• Potential to adapt or expand the basic processes of Connecting the Docs to many other identified needs that necessitate follow up outside the traditional health care system (practice facilitation, community teams/partners, portal technology, etc.)
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