Title: Implementing Bright Futures into Practice: Lessons Learned from the Bright Futures Training Interven
1Implementing 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
2Disclosure 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.
3What 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
43rd 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
52 ½ Year Visit
62 ½ Year Visit
72 ½ Year Visit
82 ½ Year Visit
92 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
10Bright Futures Training Intervention Pilot
Project
11Training 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).
13Implementation 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
14Practice 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
15Comparison 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
16Preventive Services Prompting System
- Reinforces practice guidelines
- Facilitates communication across health care
professionals - Ensures patients receive appropriate care
17(No Transcript)
18Consideration 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
19Use of Recall Reminder System
- Routine way of informing patients about the need
to return for services - System for communication with families
20Linking 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.
22Community 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
23EXAMPLE
24Community 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
25Use of Structured Developmental Assessment
- Tailor to families needs, risks, and concerns
- PEDS
- Ages and Stages
26Making 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
27Why 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
28Choosing 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
29Choosing 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?
30PDSA 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
31PDSA 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.
32PDSA - 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
33PDSA - 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.
34PDSA - 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.
35Problems 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
36If 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.
37What 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
38Coding
- 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
39Current 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.
40Keys 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
41Implementation 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
42Parents 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
43Use 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
44References
- 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
45Contact 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