Improving Quality for ChildrenApproaches to Building State Capacity Charlie Homer, MD, CEO Child...
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Transcript of Improving Quality for ChildrenApproaches to Building State Capacity Charlie Homer, MD, CEO Child...
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