prevention in the medical home lisa a. cosgrove, md, faap florida pediatric medical home...
TRANSCRIPT
Prevention in the Medical Home
Lisa A. Cosgrove, MD, FAAPFlorida Pediatric Medical Home Demonstration Project
Learning Session 2
April 27-28, 2012
Disclosure
I have no relevant financial relationships with the manufacturers of any commercial
products and/or provider of commercial services discussed in this CME activity. I
do not intend to discuss an unapproved/investigative use of a commercial product/device in their
presentation.
3
Objectives
Describe C4K goals around preventive care Share current AAP policy
recommendations Share examples of existing tools Explore implementation strategies
C4K Phase 2 Measures: Preventive Care
Review Charts of 24-month well-child visit: Appropriate risk assessments are performed at 95% of well-child visits
95% identified “at risk” have documentation in chart that risks were addressed at the visit 95% of patients have documentation of 1completed standardized
developmental screen at the 24 month health supervision visit (if you have a 30 month visit, there will be an “opt-out”).
90% of patients with a positive developmental screen have a follow-up plan in chart 95% of patients have documentation of a standardized autism-specific
screen at the 24 month health supervision visit. 90% of patients with a positive autism screen have a follow-up plan in chart
95% of patients have documentation in chart that BMI was plotted on the percentile curves according to age and sex at the 24 month visit.
90% of patients have documentation in the chart that the patient’s medical summary or comprehensive care plan was created or updated/maintained at the visit. (Continued from Phase 1, but now only looking at 2 year olds)
90% of patients have documentation in the chart that the patient’s current medical summary or comprehensive care plan was reviewed with the parent at the visit.
Explore use of Florida SHOTS immunization registry to begin looking at patients from a population level
Periodicity Schedule
Age Appropriate Risk Assessment
Standardization of preventive care
Increased reliability of thoroughness at each visit
Stratified approach based on patient’s risk
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Screening table – 2 year visit
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Risk assessment questions – 24 months
Body Mass Index Recommendations
BMI starting at the 2-year well visit on CDC growth chart
Documentation of %ile in well visit note Conditionality (if this, then…)
Specific counseling, labs, follow-up visit, etc.
Developmental Screening
Standardized developmental screening tools should be used when developmental surveillance identifies concerns and for all children at the 9, 18 and 30* month visitso *Note: Because the 30-month visit is not yet a part of the
preventive care system and is often not reimbursable by third-party payers at this time, developmental screening can be performed at 24 months of age. In addition, because the frequency of regular pediatric visits decreases after 24 months of age, a pediatrician who expects that his or her patients will have difficulty attending a 30-month visit should conduct screening during the 24-month visit.
o Note: if you use a 30 month visit, there will be an opt-out option on your chart reviews
o Use a QI model to integrate surveillance and screening into office procedures
Autism Screening
Standardized autism tools should be used when surveillance identifies risk and routinely on all children at the 18 and 24 month visit
Screening Follow-up
If screening is positive, recommendation for simultaneous referral to: Developmental evaluation Medical evaluation Early intervention services Audiologic evaluation (autism)
Communicate with referral source regarding outcome
Immunizations
Monthly Progress Report question asks about use of Florida SHOTS to manage your patient population.
Florida SHOTS (State Health Online Tracking System) is a free, statewide, centralized online immunization registry that helps health-care providers and schools keep track of immunization records. Helps with population management
Role of Medical Home
Screening and SurveillancePartnering with parents as experts on their childProviding information and resources for parentsNetworking with community resourcesFacilitate linkages for families with Part C, and
other diagnostic and treatment resourcesPopulation management (eg, use of
immunization registry, etc)**Parent partners can serve a vital role in
identifying community resources and linkages, providing support to families!
Tools for Implementation: Updated Change Package
The change package has been updated with several tools related to these new measures Modified Checklist for Autism in Toddlers (MCHAT) – for
16-48 months Developmental Screening Tools grid Bright Futures 24-month tools (these tools are available
for all ages on the periodicity schedule) Previsit Questionnaire Chart Documentation Form Parent Handouts
Immunization Resources
Implementation
How do we ask all these questions about risk?
How do we remember if we’ve asked the questions or completed age-appropriate screening/services/referral?
How do we incorporate patient designations? (CSHCN, Down Syndrome, hearing loss risk, etc.)
How will it work in your practice?
How do we ask all these questions?
Incorporate into well visit template (paper or EHR)
Use previsit questionnaire Provide screening tools to parent for
completion (ASQ, MCHAT)
Implementation Strategies
Chart Documentation Form Practitioner uses during visit to document activities Forms guide practitioner on what questions to
ask/issues to address based on child’s age and visit priorities
Forms include sections for each component of visit: History Surveillance Physical exam Screening Immunizations Anticipatory guidance
Implementation Strategies
Previsit questionnaire Paper, e-survey in health portal, kiosk, tablet,
staff-directed, physician-directed Literacy concerns Time concerns Author concerns (who is filling it out?,
confidentiality) EHR concerns (scanning, inputting data, data
retrieval)
Implementation Strategies
How do we remember if we’ve asked the questions or completed age-appropriate screening/services/referral?
Preventive Services Prompting Sheet
Practice management resource Facilitates communication across providers Helps to distribute work across team Allows anyone to quickly assess whether
up-to-date Identifies those in need of preventive
services Prompts team member to provide at any
visit
Preventive Services Prompting Sheet
Patient Designations
How do we incorporate patient designations? (CSHCN, Down Syndrome, hearing loss risk, etc.)
Enter into section on PVPS or integrate into EHR so defaults to appropriate growth chart and condition-specific periodicity
Implementation Strategies
How will it work in your practice?Questions to Consider:
What are the results you want? What do patients/parents want and deserve?
What processes and tools are currently used? How well are those working? What do you like/dislike? Who cares about this? Who can help make it work?
Clinicians? Back office staff? Front office staff? Parents? Payers? Community resources?
Implementation Strategies
Questions to Consider (continued): What tools are available to help? What are the pros and
cons of each? When and where should the tool be completed and by
whom? How can this best fit into the office flow? How and by whom will the tools be scored? How will parents be informed of the results? What happens when a child is found to be delayed? What resources are available to help?
Implementation Strategies
Questions to Consider (continued): Who will be responsible for each step in the process? When will you study your results? How will you know if the new process is working? How will you acknowledge/reward successs? Once the process is working, how will you assure
sustainability (and ongoing improvement)? Key staff member (or doc) leaves New employees Winter/RSV New tools become available Community resource change
Incorporating into EHR
When well visit scheduled, auto-prompts the correct age template
90/10 rule for defaults No click defaults PSPS becomes “to do” list or “not done”
list Screening questions can be built into
ROS but need scoring system
Incorporating into EHR
Conditionality very important, (if this, then ?) Standard, Routine or Alternate ordering
prompts Color codes can be tool to recognize
overdue service Query for reminder recalls Add specialized periodicity based on risk,
condition, insurance type
Incorporating into EHR
Itemization important for getting data back out of EHR for study, QI
Need to decide what level of detail gets a specific response (yes/no, drop down choice) vs. “text blob”
Acknowledgements
I would like to thank Bill Stratbucker, MD, FAAP and Chuck Norlin, MD, FAAP as well as the Bright Futures Preventive Services Improvement Project for use and modification of some slides