Themed Breakout

HEALTHY - 27/30 Month Assessment

Introduction and overview

John O’DowdConsultant in Public Health Medicine (Child Health)NHS Greater Glasgow and Clyde

Themed breakout Day 1

Topic HEALTHY - 27/30 Month Assessment

Stretch aim to which topic relates To ensure that 85% of all children within each Community Planning Partnership have reached all of the expected developmental milestones at the time of the child’s 27-30 month, child health review, by end-2016

Sandra MacInnes, Programme Manager, Best Possible Start, University of West Scotland

Topic: Implementation of the 27-30 month Child Health Review across NHS Lanarkshire

Stretch Aim to which Topic relates:85% of all children within each CPP have reached all of the expected developmental milestones at the time of thechild’s 27-30 month child health review by end 2016

Presentation Outline

• Overview of NHS Lanarkshire Guidance• Emerging learning from Practice• Key Successes• Issues/Challenges• Future Actions

Best Possible Start Programme

A joint collaborative programme between NHS Lanarkshire and the University of the West of Scotland to implement a suite of national policy documents aimed at improving maternal, infant and child health outcomes in the early years to ensure Lanarkshire’s children have the best start in life.

Launched by Scottish Government 2011

PRE-CONCEPTION – 8 YEARS

Best Possible Start Policy Drivers

Overall Aim: “Strengthen contribution maternity

care makes to improving maternal and infant health

outcomes and reducing inequalities

Overall Aim: “To improve the capacity of Antenatal services to reach higher risk groups and identify and manage risks during pregnancy”

Overall Aim: “Improve the nutrition of

women of childbearing age, pregnant women, and young

children, particularly in disadvantaged areas’’

Overall Aim: “Strengthen Health for all

Children (2005) to ensure best quality care and support is delivered to children and

families in the vital early years”

Circulated to NHS Boards December 2012

Implementation by April 2013

NHS Lanarkshire Guidance

• Specialist Community Public Health Nurse - HV Lead• Named Person : GIRFEC Practice Model : SHANNARI

Wellbeing Framework• Clinic Venue : Home Outreach Model• Toolkit SGSII : Equipment Standards : Mary Sheridan! • Local Guidance Document : RAG ‘Request For Assistance’

Pathways• NHS Health Scotland Early Years Information Pathway• PHN Team additional capacity : Administrative Support

Specialist Community Public Health Nurse

‘Assessment is a complex task that requires a high level of professional knowledge and skill’.

(National Guidance Document ,2012) However, assessing and responding to different levels of

complexity requires substantial professional skills. It also means that assessment of very specific parameters such as language development can be seen as a lens through which to consider various issues such as parenting and the home learning environment, autism risk, and hearing.’

NHS Lanarkshire Guidance

• Specialist Community Public Health Nurse - HV Lead• Named Person : GIRFEC Practice Model : SHANNARI

Wellbeing Framework• Clinic Venue : Home Outreach Model• Toolkit SGSII : Equipment Standards : Mary Sheridan! • Local Guidance Document : RAG ‘Request For Assistance’

Pathways• NHS Health Scotland Early Years Information Pathway• PHN Team additional capacity : Administrative Support

SGS II Toolkit

SGS ll Toolkit

Examines 7 Developmental Skill areas

• Locomotor• Manipulative• Visual• Hearing and Language• Speech and Language• Interactive Social• Self-Care Social

Optional cognitive profile

NHS Lanarkshire Guidance

• Specialist Community Public Health Nurse - HV Lead• Named Person : GIRFEC Practice Model : SHANNARI

Wellbeing Framework• Clinic Venue : Home Outreach Model• Toolkit SGSII : Equipment Standards : Mary Sheridan! • Local Guidance Document : RAG ‘Request For Assistance’

Pathways• NHS Health Scotland Early Years Information Pathway• PHN Team additional capacity : Administrative Support

Physical developmentLanguage development (Speech and communication)

Personal and social developmentEmotional developmentCognitive development

Behavioural issuesNutritional status

Immunisation statusVision

HearingDental and oral health

Physical activity and play

0 20 40 60 80 100 120

Assessment of child development

Very Confident Confident Fairly Confident Not Confident

Preparatory Training Needs Analysis

Parents Evaluation of Developmental Status Questionnaire (PEDS).Parents Evaluation of Developmental Status: Developmental Milestones Questionnaire (PEDS:DM)

Ages and Stages Questionnaire 3 (ASQ 3)Schedule of Growing Skills 11 (SOG S11)

Ages and Stages Questionnaire 3 - Social and Emotional (ASQ3: SE)Modified Checklist for Autism in Toddlers (M-CHAT)

Sure Start Language Measure (SSLM)Strengths and Difficulties Questionnaire (SDQ)

Eyberg Child Behaviour Inventory (ECBI)Home Observation for Measurement of the Environment: Infant/Toddler Version (HOME: I/T)

0 20 40 60 80 100 120

Developmental toolkits recommended

Very Confident Confident Fairly Confident Not Confident

Preparatory Training Needs Analysis

Tiered Training Programme

• Large Group awareness raising 211 SCPHN’s: Introduction to the Review/Process/Toolkit

• Master class SGSII : Training the Trainer approach (GL Assessment)

• Locality/Team Practice Development roll out programme

• Evaluation positive

Testing the process......

PDSA Cycle

DoAct Plan

Study Do

PLAN

STUDY

ACT

Sets goals based on patient/service needs

Implement

Analyse what happened

Make sure improvement is permanent

PLAN D S A

Test the time required to complete an assessment clinic and associated documentation in preparation for the implementation of 27-30 month child health review

Public Health Nurse unable to complete all areas within the timeframePHN’s confidence of using SGSII toolkit would improveParents/carers may require time spent on anticipatory guidance to support parenting roleOnward request for assistance or PHN follow up may be required

Parents would have increased understanding of importance of CHSP and be more inclined to attend

What did you predict?

Objective of first test

What’s the plan?Recruit 2 volunteer Public Health Nurses - 1 North CHP, 1 South CHPProvide staff training on the SGSII toolkit /CHSP Form/Wellbeing formEnsure availability of suitable rooms and equipmentArrange 2 clinics inviting 5 CORE children each within the age groupCall the parent/carer to offer an appointment and explanation of the assessmentInitial appointment time allocated 1 hour per childCreate a data capture form to support clinical activity and timing evidence

PLAN D S A

What measures do you plan to use to assess the success of this test?

Time spent for each child in minutes on the following activities:

• SGS assessment and SGS forms completion including parent feedback• Completion of CHSP form including height and weight• Provision of anticipatory guidance and gathering wellbeing information• Completion of wellbeing documentation• RFA documentation

How many children required further support:

• Signposting• Follow up by PHN or by support staff within team• RFA to another agency or discipline

P DO S A

• Public Health Nurses were trained in the use of SGSII toolkit and associated documentation by Community Paediatrician and Best Possible Start PHN

• Both clinics were coordinated by the PHN’s : booking rooms, equipment standard and contacting clients for the clinic - each inviting 5 children for 1 hour appointments

• Both clinics went ahead as planned

• A total of 8 children attended – 4 for each PHN with 2 cancellations

• All 8 children received a SOGS II assessment and parents were provided with feedback/discussion of child’s progress

• All 8 CHSP forms were completed.

• PHN’s completed their recording forms to reflect time taken

• Reflective meeting was held to provide PHN’s with the opportunity to feed back qualitative information

What actually happened?

P D STUDY A

• 4 of the 8 accompanying adults required a greater degree of anticipatory guidance – mainly toileting/behaviour strategies

• 1 issue required extra support and a follow up home visit was arranged – this had implications for future clinical time

• 1 child required a RFA to SALT – this took longer again as it created additional documentation

• Neither PHN was able to complete the wellbeing with any of the clients in the time frame

• PHN’s reported their confidence in the use of the tool increased by the end of the clinic and they found they could complete the SGS II assessment slightly quicker

• Both found the new lay out CHSP form difficult to complete in the time but did persevere (a copy was unavailable for parents at this time)

What were the results of the test, and how did they compare to the prediction?

P D S ACT

• Conclusion to recommend 1 hour appointments for all children

• Clinic destination was recommended as a suitable venue for most children

• Training for all staff on the use of the SGS II toolkit and accompanying

documentation was commenced using the learning from the test

• Wellbeing documentation/analysis best completed out with the assessment process

• Where there was a cancellation/FTA, this created an hour long gap – this could be

used by practitioners to complete other clinical documentation/work if able to do so

Based on what you learned, what did we do next?

Data Support TriggersEmerging ‘Failed to attend’ Reports • PDSA Action Response• Public Poster/personalised appointment letter • Telephone contact to parent prior to 2nd FTA

appointment• PDSA Access tests (day/time)• PDSA Base Tests (location)• Monitoring Improvements

Local Poster

% Clinic Attendance Data (NHSL)

June 55%

July 62%

August 67%*

*Locality range 67-78% August

Emerging ‘Meaningful Review’ Reports• PDSA Action Response• Recall of 231 national forms from Child Health

Department• Minor misunderstanding/coding : issues with

National CHS Form• Proactive return of forms to staff via senior nursing

professional structures/practice development to apply ‘teach back’ technique

Data Support Triggers

June 77%

July 78%

August 73%

September 82%*

% ‘Meaningful Review’ Data (NHSL)

*Locality range 80- 92% Sept

Key Successes• Implemented June 2013!• Quality and GIRFEC based approach to Implementation

consistent with national guidance• Identification of children requiring additional support• Public Health Nurse ‘buy in’ – universal approach as an

essential contemporary practice model • Use of SGSII as a popular toolkit within practice• Parental involvement and ownership of the review - a

developing public confidence in the local child health service?• Quality of information transfer opportunity to early years

establishments

Issues /Challenges

• Increase in workload for SCPHN staff • Administrative support inconsistent• 30 month implementation – timescale of ‘breach’ definition• Emerging ‘reviews’ within system and workload implications• CHS National Form – user group action?• Cultures and Language • Scanning National Form/SGSII into electronic record• Pre - review communication to SCPHN : access to GP summary

records• GP participation/role in preventative child health programme

Future Actions

• Addressing our issues/challenges!• Electronic version of SGSII/Mobile MiDIS test• Staff user group to review progress and coordinate

improvements • Children on SNS – ‘wellbeing review’ standard• Service Impacts• Process of data transfer to Early Years establishments • Test 15-18 month review : North/South Lanarkshire• Research : local and national

Monthly reportsMonthly summary and locality level reports are in development

Sina Currie

Clinical Team LeaderEarly Years, Children and Families Community Nursing ServiceNHS Ayrshire & Arran

Overview of NHS Ayrshire & Arran Guidance

• 27 month assessment introduced April 2013•Universal Home Visit by Health Visitor•Parental Involvement : ASQ & ASQ ( SE)• Holistic GIRFEC Practice Model assessment•Pathway development to meet stretch aim

Review of Emerging Learning from Practice

• Staff focus group identified

What are we doing well?• Child focused approach• Strength based working• Parents as Partners• Standardised approach to professional practice• Supportive of GIRFEC and Named Person role• Improving access to services through the

development of pathways

What can we improve on?

• Completion of ASQ’s prior to assessment in some areas

• Language barriers• Increase parental knowledge of assessment

process• Administration processes

How are we going to carry out these improvements and future actions?

• Small tests of change to identified areas• Staff working group and action plan• Parent focus group• Develop leaflet/promotional materials• Continue to involve our partners

Key successes to date

Devlin’s Story..........

Questions?........

Contacts• sandra.macinnes@lanarkshire.scot.nhs.uk• scott.purdie@lanarkshire.scot.nhs.uk• liz.kearney@lanarkshire.scot.nhs.uk• fiona.gray2@lanarkshire.scot.nhs.uk• margaret.clark@lanarkshire.scot.nhs.uk

Table Discussion

Who are the individuals and/or teams currently working on this area?

Are they currently using Quality Improvement methods/tests of change to guide their learning?

What evidence based practice is being used?

What learning can be shared between CPP areas?

Feedback

One/ two “headline”per table

Alsh(Ground Floor)

National Partners

Boisdale (Ground Floor)

Falkirk

East Dunbartonshire

West Dunbartonshire

Stirling

Dochart(First Floor)

East Ayrshire

West Ayrshire

North Ayrshire

South Ayrshire

Carron(First Floor)

Glasgow