ABCD III Project in Oklahoma “Connecting the Docs”

1. ABCD III Project in Oklahoma“Connecting the Docs” Sue Robertson Oklahoma Health Care Authority NASHP Annual Meeting

2. Initiative aimed at advancing systemic improvements focused on improving outcomes for young children with and at risk for developmental delays • Builds on existing infrastructure to establish new and strengthen existing linkages among entities serving children and families Connecting the Docs: Improving Care Coordination and Delivery of Developmental Screening and Referral Services in Oklahoma Robertson

3. SoonerCare patient-centered medical home • Oklahoma State Department of Education SoonerStart/Early Intervention program • “Fax-back” form, piloted by OK-Kids partners, aimed at facilitating information between PCP offices and SoonerStart • Developmental Screening Initiative (DSI) • Quality Improvement Initiatives - Practice Facilitation • Oklahoma Family Network (OFN) State Readiness Robertson

4. Outline • Overview of State Strategy • Pilot Level Strategies/Activities • Practice Level • Community Level • Web Portal/Care Coordination Tool • Systems Level Activities • Evaluation and Measurement • Lessons Learned & Implications… • Looking to the Future Robertson

5. Overview of State Strategy Partners Team Framework Robertson

6. Strategy: Creation and deployment of a web portal to connect PCPs to Early Intervention and community partners. Participating PCPs send referrals to Community Teams via the web portal and receive referral outcomes back through the portal ABCD III Project“Connecting the DOCS” Robertson

7. A partnership between: • Oklahoma State Medicaid • Part C Early Intervention • Child Guidance • Developmental Pediatrics • Family Medicine • Family and Care Coordination Support • Primary Care Practices (Medical Home) ABCD III Project“Connecting the DOCS” Robertson

8. Robertson

9. STATE TEAM LOCAL TEAMS (x 4) Local Core Teams Mirror State Core Team Robertson

10. Pilot Level Strategies & Activities Practice Level Community Level Development of Web Portal (Care Coordination Tool) Robertson

11. Practice facilitation/support • Technology to improve ease of referral and feedback (web portal) • Sharing of successes and/or ‘non-successes’ between practices and among community partners (PDSA Cycles) • Support development of productive communication and response patterns among partners at state and community levels Pilot Activities Robertson

12. Practice Activities: Strategy Summary Multifaceted “Facilitated Change” strategy: Performance measurement and feedback using pediatric quality indicators Academic detailing with discussions of evidence-based and local exemplary practices Practice facilitation using “Practice Enhancement Assistants” (“PEAs”) HIT support Robertson

13. Integration into PCP Practices: PEAs • Recruitment • Perform “academic detailing” • Bring practices to whatever state of readiness needed to implement or continue screening • Introduce community teams • Demonstrate web-based portal • Ongoing problem solving using PDSA cycles Robertson

14. OKLAHOMA’S LINKAGE PROCESS Oklahoma's Linkage Process Robertson

15. Send New Referral For SoonerCareChoice patients, the demographic information is pre-populated; address/phone number can be updated as needed. Robertson

16. Robertson

17. Closing the Loop Robertson

18. Relationship/Team Building • Getting partners together in monthly meeting • Developing rapport, communication, and trust • Introducing ABCD project to partners • Teaching web portal/HIT support • Introducing teams to PCP practices Community Level Activities: Initial Phase Robertson

19. Community teams now function independently • Meet monthly • Troubleshoot referral communication, feedback process, information needs (PDSA cycles) • Develop “Referral Resource Tool” for PCPs and families • TA provided by PEAs, as needed Community Level Activities: Ongoing Phase Robertson

20. Systems Level Activities Robertson

21. Improving State Systems and Policies • Data sharing and security of the web portal • HIPAA/FERPA issues • Security Certificate • Integrating OFN/family professionals • Eliminating duplications between PCPs &EI • ASQ by PCP or outside agency can be used for EI’s evaluation process • Clarification of FERPA – Consent obtained by PCP is sufficient for EI. If PCP does not obtain consent, EI can obtain consent • Medical Home Policies • Health Access Networks (HANs) • Maintenance of Certification (MOC 4) Robertson

22. Evaluation & Measurement Robertson

23. Oklahoma’s Common Measure # of children receiving EI services whose PCP knows of the services __________________________________________ # of children receiving EI Services Use of web portal to electronically collect referral and feedback data Robertson

24. Web Portal Initial Evaluation* *Rollout began March 2011. Data pulled August 30,2011. Robertson

25. Lessons Learned & Implications…Looking to the Future Robertson

26. Streamlines routine visits • Provides focus to the visit when concerns are present • More accurate and more timely identification of children with developmental delays • Enhances parental education about appropriate developmental expectations • Facilitates communication between providers and early childhood programs and resources • Facilitates communication between families and providers • Better lifelong outcomes for children • Step toward becoming Tier 3 Medical Home Positive Outcomes Robertson

27. Challenges • Communication across programs and subsystems • Multiple systems to coordinate • Multiple processes for referral • Multiple levels of decision making • Data and Information Sharing • Diverse and unconnected data systems • Community Team Challenges • Discussion about what constitutes a closed referral • Discussion about responsibility during referral loop process Robertson

28. ABCD III project will reap lessons regarding how to facilitate the medical home becoming more competent in appropriate referral and follow up interactions with community based services and resources • Potential to adapt or expand the basic processes of Connecting the Docs to many other identified needs that necessitate follow up outside the traditional health care system (practice facilitation, community teams/partners, portal technology, etc.) Looking to the Future…… Robertson