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Implementing Bright Futures into Practice: Lessons Learned from the Bright Futures Training Interven

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Title: Implementing Bright Futures into Practice: Lessons Learned from the Bright Futures Training Interven


1
Implementing Bright Futures into Practice
Lessons Learned from the Bright Futures Training
Intervention Project
Paula Duncan, MD, FAAP Ellen Buerk, MD, M.Ed
FAAPJuly 29, 2008
2
Disclosure Statements
  • Paula Duncan, MD I have the following financial
    relationships with the manufacturers of
    commercial products and/or provider of commercial
    services discussed in this CME activity Editor
    for Bright Futures Guidelines.
  • I do not intend to discuss an unapproved/investig
    ative use of a commercial product/device in my
    presentation.
  • Ellen Buerk, MD 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/investig
    ative use of a commercial product/device in my
    presentation.

3
What Are the Bright Futures Guidelines?
  • Comprehensive health supervision guidelines
  • Developed by multidisciplinary child health
    experts providers, researchers, parents, child
    advocates
  • Provide framework for well-child care from birth
    to age 21
  • Present single standard of care based on health
    promotion and disease prevention model
  • Include recommendations on routine health
    screening, and anticipatory guidance

4
3rd Edition Themes
  • Oral Health
  • Healthy Sexuality
  • Safety and Injury Prevention
  • Community Relationships and Resources
  • Child Development
  • Family Support
  • Mental Health and Emotional Well-Being
  • Nutritional Health
  • Physical Activity
  • Healthy Weight

5
2 ½ Year Visit
6
2 ½ Year Visit
7
2 ½ Year Visit
8
2 ½ Year Visit
9
2 ½ -year-old Anticipatory Guidance Examples
  • Family Routines
  • Consistency in parenting, daily schedule, fun
    family activities
  • Language Promotion and Communication
  • Interaction through song, play, and reading
  • Promoting Social Development
  • Play with other children, expect limited
    reciprocal play, imitation of others, offer
    limited choices
  • Preschool Considerations
  • Readiness for playgroups, play dates, early
    childhood educational programs
  • Safety
  • Water safety, car seat use, interacting with
    pets, fires and burns, outdoor safety

10
Bright Futures Training Intervention Pilot
Project
11
Training Intervention Project
  • Aim
  • To test the feasibility of implementing the
    Bright Futures systems framework for improving
    preventive care and developmental assessment
    for children age 0-5
  • Teams from 15 diverse practice settings
  • Adapted learning collaborative using quality
    improvement (QI) methods

12
  • The Bright Futures framework for preventive and
    developmental services is adapted from a systems
    model developed by The Center for Childrens
    Healthcare Improvement at the University of North
    Carolina at Chapel Hill (which is now the Center
    for Healthcare Quality at Cincinnati Childrens
    Hospital Medical Center).

13
Implementation Framework
  • Use of preventive services prompting system
  • Identification and consideration of children
    with special health care needs
  • Use of recall and reminder systems
  • Linking to community resources
  • Use of structured developmental assessment
  • Evaluation of parents needs and use of strength
    based approaches

14
Practice Profile
  • Type of Practices N15
  • Private Practice 29
  • Non-government hospital/clinic 29
  • Multi-specialty group practice 14
  • City/county/state government
    hospital/clinic 14
  • Medical school 7
  • Nonprofit community health center 7
  • Type of Practices N15
  • Urban inner city 43
  • Urban non-inner city 21
  • Suburban 7
  • Rural 29

Approximately 40 percent of the participating
practices had prior experience implementing
quality improvement methods
15
Comparison of Components at Baseline and
Follow-up
Baseline percents calculated from 171 charts
from 15 practices Follow-up percents calculated
from 305 charts from 8 practices
16
Preventive Services Prompting System
  • Reinforces practice guidelines
  • Facilitates communication across health care
    professionals
  • Ensures patients receive appropriate care

17
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18
Consideration of Children with Special Health
Care Needs
  • Routine way of identifying children with special
    health care needs (CSHCN)
  • Mechanism for asking and recording
  • Does your child have any special health care
    needs?
  • Develop standards of care for CSHCN

19
Use of Recall Reminder System
  • Routine way of informing patients about the need
    to return for services
  • System for communication with families

20
Linking to Community Resources
  • Educational and referral information about local
    services and programs
  • Link with resources appropriate for patient
    population

21
?Hagan JF, Shaw JS, Duncan PM, eds. 2008. Bright
Futures Guidelines for Health Supervision of
Infants, Children, and Adolescents, Third
Edition. Elk Grove Village, IL American Academy
of Pediatrics.
22
Community Resources
  • Does your practice have a satisfactory link?
  • Priority to develop link
  • Need information about organization or referral
    process?
  • Leadership or participant role in
  • community improvement activities

23
EXAMPLE
24
Community Linkage Strategies
  • Organized approach to links to community that
    works for youth and parents
  • Practice community meetings
  • In practice responsible person
  • Single referral form
  • Single exchange of info form using HIPAA
    standards
  • Registry - in office of referrals and follow-up
  • Report back from referral specialist
  • System for information exchange with SBHC
  • Consider co-location for services your families
    find hardest to access e.g. WIC, dental
    hygienist, mental health counselor, nutrition,
    social worker
  • Help Me Grow

25
Use of Structured Developmental Assessment
  • Tailor to families needs, risks, and concerns
  • PEDS
  • Ages and Stages

26
Making Structured Developmental Assessment a
Reality
  • Oxford Pediatrics and Adolescents
  • Rural private practice in college town
  • 4 physicians 2 nurse practitioners and support
    staff
  • 3 offices 25 percent Medicaid managed care
  • Electronic medical records
  • Using a structured developmental assessment since
    2004

27
Why use a structured developmental assessment?
  • Recommended by AAP
  • Is it too much to do in a 20 minute Health
    visit?
  • Identify problems at an earlier age
  • Validate parent concerns or provide
    reassurance
  • Standardized way for all providers in the group
    to assess development

28
Choosing a Screening Tool
  • Parent Questionnaire
  • Ages and Stages Developmental Questionnaire
    ( ASQ)
  • Parents Evaluation of Developmental Status (PEDS)
  • Child Development Inventory (CDI)
  • Pediatric Symptom Checklist (PSC)
  • Direct Elicitation
  • Bailey Infant Neurodevelopmental Screener
    BINS)
  • Brigance
  • Denver II

29
Choosing a screening Tool
  • How much time to use the tool and score test
  • Given at home vs. office
  • Cost of tool
  • One time fee or ongoing fees
  • Can copies by made
  • What ages are screened
  • How sensitive/specific is each tool
  • How does the tool fit in with the office flow?

30
PDSA Cycle - Plan
  • Objective Use screening tool for well visits
    under age 5
  • Which visits will be used
  • When will the parents fill it out?
  • Who will score the test and when? Where will
    the results be kept in chart or EMR How will
    patients and providers feel about using the tool
  • Prediction - Parent will enjoy doing the
    activities and providers will do a better job
    assessing development

31
PDSA Plan
  • Plan for change
  • In our practice 2 providers used the tool
    first
  • A front desk staff member mailed
    questionnaire 2 weeks in advance
  • Parents did activities with child at home
  • Plan for Data collection
  • Monthly chart review
  • Amount of time for visits before and after
    ASQ was instituted.

32
PDSA - Do
  • ASQ was mailed out 2 weeks before appointments
  • Parents gave form to Medical Assistant (M.A.)
    when called back for appointment
  • M.A. scored while preparing patient for well
    visit
  • Provider reviewed ASQ results with parent during
    visit, made referrals as needed

33
PDSA - Act
  • Continue plan
  • Involve all the other providers in the office
  • Expand to well visits 9 months, 18 months, 2
    years, 30 months and 4 years.

34
PDSA - Study
  • Well accepted by parents
  • Providers felt tool was valuable
  • Children with problems previously unidentified
    were identified observed or referred
  • Use of tool did not prolong visit time unless
    parent filled out tool in office.

35
Problems and Solutions
  • Parents forgot to bring back questionnaire
  • Mail it in later or fill out another
  • Questionnaire was not received in mail
  • Box of toys in office for kids to try
    activities
  • Parents filled it out at home , but dont want to
    be charged for ASQ. Want the activities that go
    with form.
  • Give them a verbal heads up that we think it is
    important and we will be doing it at the next
    exam Provider does a verbal dev. assessment

36
If a delay is found on the assessment
  • Verify that the delay exists
  • Sometimes the child didnt try the activity
  • Was the child in a good mood?
  • For some ages the ASQ is for a month beyond the
    visit. It states it can be used 1 month before.
    This happens with the 9 month visit and the 15
    month visit. The ASQ is for 10 months and 16
    months. The child may look like there is a delay
    but if you talk about what child is doing it is
    appropriate for the age.

37
What to do if there is not a delay but the
parents are concerned
  • Acknowledge parental concerns
  • Remember the sensitivity of the tool
  • Repeat the developmental screen soon or use
    another tool
  • Consider need for referral

38
Coding
  • 96110 - developmental screening with report
  • Most insurance and some Medicaid Managed Care pay
    this code.
  • Parental complaints about charge
  • sent letter to parents in advance about
    questionnaire

39
Current Practice
  • ASQ at 9 months, 15 months, 24 months and 4
    years
  • MCHAT at 18 months and 30 months
  • We decided not to do an ASQ and MCHAT on the
    same day generating 2 charges.
  • ASQ has an initial charge of about 250 , can
    be copied and pays for itself within the first
    month of use
  • ASQ has general activities for each age and if
    there is a delay has specific suggestions to
    correct delay.

40
Keys to Success
  • Ask for ideas from everyone the change will
    affect
  • Make certain all staff are aware of the changes,
    how they will be implemented and who is
    responsible for which tasks and what benefits are
  • Be willing to change plans if it is not working
  • Tell everyone when it is working and share
    patient feedback

41
Implementation Framework
  • Use of preventive services prompting system
  • Identification and consideration of children
    with special health care needs
  • Use of recall and reminder systems
  • Linking to community resources
  • Use of structured developmental assessment
  • Evaluation of parents needs and use of strength
    based approaches

42
Parents Concerns and Strength based approaches
  • What would you like to discuss today
  • Do you have any concerns about your childs
    growth development, behavior or learning?
  • We are interested in answering your questions
    Please check off the boxes of things you would
    most like to discuss today

43
Use of Strength-based Approaches
  • Identify strengths
  • Give feedback using a framework
  • Use shared decision-making strategies
  • Get feedback from parents and youth about office
    practice
  • P.M. Duncan et al., Inspiring Healthy
    Adolescent Choices A Rationale for and Guide to
    Strength Promotion in Primary Care Journal of
    Adolescent Health, 41 (2007), 525-535

44
References
  • Lannon CM, Flower K, Duncan P, Strazza Moore K,
    Stuart J, and Bassewitz J. The Bright Futures
    Training Intervention Project Implementing
    systems to support preventive and developmental
    services in practice. Pediatrics. 2008122
    e163-e171.
  • www.dbpeds.org
  • Bright Futures Systems Toolkit, 2004
  • The ASQ Users Guide, second edition 1999
  • Hagan JF, Shaw JS, Duncan PM, eds. 2008. Bright
    Futures Guidelines for Health Supervision of
    Infants, Children, and Adolescents, Third
    Edition. Elk Grove Village, IL American Academy
    of Pediatrics.
  • Recommendations for Preventive Pediatric Health
    Care. American Academy of Pediatrics. Pediatrics.
    1206 (1367). 2007

45
Contact Information
  • QuIIN
  • Phone 847 434 4260
  • E-mail quiin_at_aap.org
  • New Web site http//quiin.aap.org
  • Staff Contacts
  • Jill Healy, MS Program Manager
  • Keri Thiessen, MEd, Senior Program Manager
  • Bright Futures
  • Phone 847 434 4223
  • E-mail brightfutures_at_aap.org
  • New Web site www.brightfutures.aap.org
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