First STEPS 2014: ( Strengthening Together Early Preventive Services) Improving Developmental and Autism Screening:

1. First STEPS 2014: (Strengthening Together Early Preventive Services)Improving Developmental and Autism Screening: Kick Off & Orientation Call Amy Belisle, MD Director of Child Health Quality Improvement Sue Butts-Dion First STEPS Program Manager, QI Specialist Maine Quality Counts February 13, 2014 and Repeated March 13, 2014

2. Agenda • Welcome Teams and Roll Call • Review First STEPS Year 5 Aim and Logistics • Expectations for Teams and for MOC • QI Teamspace • Q & A

3. Maine Child Health Improvement Partnership (ME CHIP) MissionTo optimize the health of Maine children by initiating and supporting measurement-based efforts to enhance child health care by fostering public/private partnership. Vision All practices providing health care to children will have the skills, support, and opportunities for collaborative learning needed to deliver high quality health care.

4. Aim for First STEPS 2014 • Raise Screening Rates: Improve Developmental and Autism Screening Rates • Work Together: Work collaboratively with other primary care practices and community partners to learn from each other and to improve systems and to test changes (using the Model for Improvement and Plan-Do-Study-Act Cycles as a frame) • Welcome Parent-Partners: Enhance how we are including the voice of the parent partners in our improvement work. • Optimize Existing Work: Build on the work of the Patient Centered Medical Home, Health Homes, healthcare organizations, and community organizations.

5. Participating Practices • Non-MOC • Aroostook Pediatrics • Bethel Family Center • Blue Hill Memorial • Bridgton Pediatrics • D.F. Russell Medical Center • EMMC Family Medicine • Eleanor Widener Dixon Community Center • Elmwood Family Practice • Foden Road Pediatrics • Healthreach Community Center • Lincoln Medical Partners • Lovejoy Health Center • Mayo Psychiatry • Mayo Regional Hospital • Mid Coast Pediatrics • MMP Family Medicine • MMP Pediatrics • Yarmouth Pediatrics • York County Community Corp • MOC • CMMC Family Medicine Residency, Lewiston • Ellsworth Family Practice, Ellsworth • Elmwood Family Practice, Waterville • Fore River Family Medicine, Portland • IntermedFoden Road, South Portland • Intermed Marginal Way, Portland • Intermed Yarmouth, Yarmouth • Martin’s Point Healthcare-Brunswick Pediatrics, Brunswick • Waterville Pediatrics, Waterville

6. First STEPS andCommunity Partners • MaineCare • Muskie School of Public Service, USM • Maine Developmental Disabilities Council • Maine Autism Society • Maine Parent Federation • Maine CDC • Child Development Services • Office of Child and Family Services • Maine Children’s Alliance • Maine Children’s Growth Council • Head Start • Families and Parent Partners • State Agencies Interdepartmental Early Learning and Development Team (SAIEL) • Developmental Systems Integration (DSI) Project

7. Why is this important? • Developmental delays and conditions affect 10% of children • 1/88 kids with autism* *(March 30, 2012, MMWR, Prevalence of Autism Spectrum Disorders — Autism and Developmental Disabilities Monitoring Network, 14 Sites, United States, 2008)

8. Periodicity Schedule for Developmental Screening and Metrics • The American Academy of Pediatrics (AAP) recommends the following: • Developmental Surveillance: at every well-child care visit (Bright Futures) • Children receive general developmental screening with a standardized tool at ages 9, 18, and 24 or 30 months. • Children receive screening for autism at 18 and 24 or 30 months. • Children's Health Insurance Program Reauthorization Act (CHIPRA)/Maine Health Homes metric is a documented developmental screening by ages 1, 2, and 3 years. AMCHP January 25, 2014

9. Our Challenge MaineCare claims documented rates for developmental screening is 1-6% for children ages 1, 2, and 3. Source: MaineCare claims data, 2011 Source: Improving Health Outcomes for Children (IHOC) Summary of Pediatric Quality Measures for Children Enrolled in MaineCare FFY 2009-FFY 2012, Muskie School of Public Service, University of Southern Maine, April 2013, p. 25.

10. 2014 work focused on creating a circle of strength around kids to promote healthy development. Assess Surveillance S S Ev Screening Evaluation Evaluation Assess Assess Screening Screening Surveillance Assess Surveillance

11. Requirements for Provider Champions Desiring MOC • Submit MOC sign up forms and BAA (data agreement) to QC for Kids • The First STEPS Practice Teams will: • lead office practice improvement by identifying goals and processes for improvement, removing barriers and providing resources • attend 1 Regional Training (must include provider champion) • submit data monthly—PDSA and Process data • meet as a team on a monthly basis for quality improvement discussion • participate in monthly phone calls to share improvements made and to receive coaching • In collaboration with the practice team, the practice’s physician champion will complete a pre and post practice profile describing the practice structure and changes in office systems.

13. First STEPS 2014 Webinars, 2nd Thurs 12-1 pm

14. Practice Team Preparation Checklist • Review the orientation packet • Save the important dates on your calendar (Regional Training Sessions, monthly calls/webinars, data reporting deadlines) • Complete and submit Office Systems Survey by February 28, 2014 • Submit baseline data measures to the online collection tool by March 15, 2014. (MOC)

15. Meet as a Team • Complete an office system survey to help your office identify opportunities for improvement. • Emailed to practices following this call • Discuss and write a rough draft of your team’s improvement aim and targets for improving developmental and autism screening.

16. Office Systems Assessment Components • Developmental Surveillance practices • Developmental and Autism Screening practices • Referral and Follow up practices • Informing and engaging parents and care givers • Working with community partners • Quality Improvement practices • Billing and coding practices

17. What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement Act Plan Study Do Method for Change API’s Deming’s PDSA cycle

18. Year 5: High Level Aim & Goals 2014 First STEPS Aim Statement: To improve the rate of developmental and autism screening for children ages 0 to 3 by 50% from March 2014 to September 2014 using chart review data. Goals • 75% of children will have a documented developmental screening using a validated tool (ASQ or PEDS) at the 9 mo, 18, and the 24/30 mo well child visits • 75% of children will have a documented autism screening (MCHAT R or MCHAT F) at 18 and 24/30 mo. • 75% of children identified with a concern of developmental delay will have a documented follow-up plan (observation, recheck in office, or referral) • 75% of all visits with developmental and autism screening will be billed and coded correctly.

19. Your Aim Statement • The (name of your team/practice): • intends to accomplish (This is a general over arching statement describing what you intend to accomplish during the time you work on this process – it answers the first question of the Model for Improvement. The process is identified in the statement, any specific or segmented area is mentioned and words like improve, reduce, and increase are often utilized) • by (time frame, i.e. month/year in which you intend to accomplish improvement) • for (what group are you doing this for – who is the customer) • because (the rational and reasons to work on this improvement project) • Our goals include: (your measures – it answers the second question of the Model for Improvement. Here they are stated as numeric goals) “Soon is not a time, some is not a number, hope is not a plan.” -Donald Berwick, MD, Former CEO, Institute for Healthcare Improvement

20. Example Aim & Goals • By September 30, 2014, our practice will improve our autism screening rates for children at the 18 or 24/30 month appointments from 45% having completed to 90% having them completed. • By September 30, 2014, 100% of Developmental and Autism Screening results will be reviewed with family/care givers. • By September 30, 2014, 100% of Developmental Screening results with a referral or follow up indicated will have a documented action plan in their charts (currently at 65%). • The goals should be directed by your baseline data. Your practice, for example, may be at 100% for the Autism Screening measures and choose to focus the improvement work on Developmental Screening. We will, however, still expect practices to report all of the process measures for both Development Screening and Autism Screening each month.

21. Optional Quality Improvement Science Webinars with QI Coach • April 23rd noon • June 4th noon • July 23rd noon • Introduction to the Model for Improvement and the Science of Improvement • Assessing Processes and Establishing Aims • Measurement for Improvement • Holding the Gains

22. Quality Improvement Coaching If you currently work with your system’s or PHO’s Quality Improvement (QI) Coach on other initiatives, alert them to your involvement in this collaborative. If you are an independent practice, we will work with your practice to identify a coaching resource.

23. Data Submission • Submission Dates • March 15 (Baseline), April 15, May 15, June 15, July 15, and August 15 • Randomly select 20 charts from ages 9 mo- 30 months for children seen in your practice for WELL CHILD VISITS for the month that you are doing the chart review. For sampling purposes, please select approximately 5-7 charts per month from the 9 and 18 month categories and 10 from the 24/30 month category. • Enter chart data into your QI Team Space each month. (Note: You can use the paper chart review tool if helpful.) • Collecting data at three levels: • Level 1: Total number of children general developmental and/or autism screening AND results documented in chart. • Level 2: Of those in “a)”, number with a referral or follow-up indicated. • Level 3: Of those in “b)”, number with documented follow-up plan in chart.

24. First STEPS 2014 Measures • % documented use and results of a developmental screening tool (PEDS or ASQ-3) at 9, 18 and 24/30 months. • % documented that the screening results were reviewed and discussed with the family. • % Documented use and results of an autism-specific screening tool at 18 and 24/30 mo of age (MCHAT R or F) • % of children identified with a concern of developmental delay (referred on PEDS/ASQ-3 or MCHAT R/F) that have a documented follow-up plan (observation, recheck in office, or referral • Total number of referrals to Child Developmental Services (CDS) and Developmental Pediatricians each month under age 5 • % of charts where billing was done with correct modifiers for developmental screening and autism screening

25. Example General Developmental Screening Example: • Level 1: Of 20 charts, total of 12 had screening results documented in chart. (Num=12 and Den=20 for 60%) • Level 2: Of 12 with documented screen and results, 3 w/ referral or f/u indicated. (Num=3 and Den=12 for 30%) • Level 3: Of the 3 with referral or f/u indicated, 2 had a documented follow-up plan in chart. (Num=2 and Den=3 for 77%) Autism Screening Example: • Level 1: Of 20 charts, 9 were eligible for autism screening (18 or 24/30 month visit). Of 9, total of 4 had screening results documented in chart. (Num=4 and Den=9 for 53%) • Level 2: Of 4 with documented screen and results, 4 w/ referral or f/u indicated. (Num=4 and Den=4 for 100%) • Level 3: Of the 4 with referral or f/u indicated, 2 had a documented follow-up plan in chart. (Num=2 and Den=4 for 50%)

26. Summary Notes • Still opportunity for practices to participate for MOC—would need to get paperwork submitted ASAP • If you are participating for MOC and have not submitted your paperwork, please do so! • Another orientation call on March 13th for any teams member wanting to attend. • See you at the Regional Meeting! • Those participating for MOC (and anyone interested in the on-line QI Team Space) please remain on the line for additional training.

27. Take a deep breath…technical support available AFTER this call and throughout the project

28. QI Team Space: System Requirements • Tested and supported web browsers: • Mozilla Firefox 17.0 or greater • Google Chrome • Apple Safari 5.1.4 or greater • Microsoft Internet Explorer 9.0 or greater. • Microsoft Internet Explorer 8.0 (on Windows 7 or greater) is partially supported through June 30, 2014, but may not be supported after this date. • Note: Windows XP users must use the most recent version of Google Chrome or Mozilla Firefox. Microsoft Internet Explorer on Windows XP is NOT supported by TeamSpace.

39. THIS DATA IS TEST DATA—NOT ACTUAL DATA FROM A PRACTICE. FOR DEMONSTRATION PURPOSES ONLY!!

40. THIS DATA IS TEST DATA—NOT ACTUAL DATA FROM A PRACTICE. FOR DEMONSTRATION PURPOSES ONLY!!

41. THIS DATA IS TEST DATA—NOT ACTUAL DATA FROM A PRACTICE. FOR DEMONSTRATION PURPOSES ONLY!!

42. Tips from Practices • Initial entry might take 2-5 minutes/chart until you get used to it • Sue Butts-Dion will set up individual meetings as needed to train and work with practices • Don’t wait until the last minute to enter all 20 charts • You know you need 20 charts total (@5-7 each for 9 mo. and 18 mo. and @6-10 for 24/30 mo.) • Plan to pull 5 each week and spend 30+ minutes entering • Then, submit on the due date of the 15th of the month starting with baseline on March 15th

46. Getting Started • Need your signed MOC paperwork and BAA (Data Sharing Agreement) returned to Maine Quality Counts to activate your QI Teamspace • Set up your system requirements (See “Getting Started” document sent out prior to call.)

47. Questions & Reactions

48. Contact Information • Amy Belisle, MD, Director of Child Health Quality Improvement, Maine Quality Counts, abelisle@mainequalitycounts.org/ 207-847-3582 • Sue Butts-Dion, First STEPS Project Manager, 207-283-1560, sbutts@maine.rr.com • Debra Gilbert, Administrative Coordinator, Maine Quality Counts • dgilbert@mainequalitycounts.org, 207.620.8526 ext. 1017 • Nan Simpson, MSW, DSI Project Manager, nsimpson@mainequalitycounts.org, 207-441-3722 • Sue Mackey Andrews, Consultant to QC for Kids on DSI Project, sdmandrews@aol.com, 207-564-8245 • Kyra Chamberlain, BS, RN, IHOC Project Manager, Maine, 207-228-8085, kchamberlain@usm.maine.edu • Kim Fox, MPA, Research Associate, Muskie School of Public Service, kfox@usm.maine.edu • Joanie Klayman, LCSW, IHOC Project Director, Maine and Vermont, jklayman@usm.maine.edu, 207-780-4202