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STRATEGIC DIRECTIONS: Key Informant Interviews with EPSDT Directors. Peggy McManus MCH Policy Research Center July 12-13, 2005. STRATEGIC DIRECTIONS STANDARDS & POLICIES. Session Objectives: Examine state EPSDT policies for hearing screening & follow-up

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STRATEGIC DIRECTIONS:Key Informant Interviews with EPSDT Directors

Peggy McManus

MCH Policy Research Center

July 12-13, 2005


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STRATEGIC DIRECTIONS STANDARDS & POLICIES

  • Session Objectives:

    • Examine state EPSDT policies for hearing screening & follow-up

    • Compare with JCIH, AAP guidelines, & Healthy People 2010 objectives

    • Consider strategies for updating state EPSDT policies on hearing


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Interview Findings: Current Picture and Strategies

  • EPSDT standards primarily based on AAP preventive care guidelines, with some variations

  • EPSDT standards on hearing focus almost exclusively on screening, not referral & follow-up

  • Unclear the extent to which EPSDT standards reflect JCIH guidelines


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Standards & Policies: Interviews

  • States have organized mechanisms for regularly updating EPSDT, with input from other state agencies & key stakeholder groups

  • New standards & policies disseminated through provider manuals, bulletins, & newsletters

  • Effective ways of implementing new standards -- work closely with state AAP chapters


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Standards & Policies: Interviews

  • Less involvement with AAFP, though states interested in more

  • Hospital involvement critical

  • State universal newborn hearing screening laws – key in facilitating adoption of standards

  • Attention needed to address outreach, screening, & follow-up of failed screens.


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Strategic Directions Information & Education

  • Session Objectives:

    • Share ideas about effective educational strategies for working with PCPs, families, hospitals, MCOs, and local health departments (LHDs)

    • Examine potential opportunities for informing & involving key stakeholders


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Information & Education: Interviews

Primary Care Physicians:

  • No magic bullets or single approaches

  • Very little done so far on follow-up

  • Important to have good, actionable data about how PCPs perform

  • Evidence-based data also important

  • Newsletters that profile promising practices useful


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Information & Education: Interviews

PCPs continued:

  • Ongoing training of residents helps

  • CME necessary, but not sufficient

  • More needed to target PCPs in rural areas, with small numbers of children in practice


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Information & Education: Interviews

Families:

-- Work with existing family networks

-- More education is needed on follow-up, esp. with families whose children have complex health care needs

-- Follow-up telephone calls & face-to-face meetings work best


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Information & Education: Interviews

  • Use of popular media helpful

  • Critical to have a “why” piece – explaining why both screening & follow-up are necessary

  • Informing families about standard of care is important and can positively influence parent demand for services


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Information & Education: Interviews

  • Hospitals

    • State EHDI efforts, esp. involving on-site work, critical in implementing universal newborn hearing screening

    • Funding hearing aid loaner program important

    • Need to target small, rural hospitals and move beyond screening

    • Perinatal conferences important

    • Also, having short educational videos about hearing screening for use by hospitals important


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Information & Education: Interviews

  • Local Health Departments

    • EPSDT outreach workers have critical role to play, but few have focused on hearing

    • Important to link with home visiting, case management, disease mgmt., & other initiatives involving LHDs

    • Regular training opportunities for LHDs, with CME important


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Information & Education: Interviews

  • Hard-to-reach groups

    • EPSDT outreach workers have critical role to play

    • Home visiting & case mgmt. programs reach high-risk groups, though hearing follow-up seldom addressed

    • More attn. to cultural competence to reduce families’ delays in seeking follow-up

    • Translation & transportation are critical


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Information & Education: Interviews

  • Overarching Comments

    • Comprehensive strategy needed, promoted through various channels (e.g., immunization)

    • Have a simple, consistent message – 1/3/6

    • Involve key groups at outset

    • Address shortage of audiologists, incl. causes – education & training, reimbursement, other

    • Streamline & integrate hearing follow-up services with CM, EI, WIC, 1-800 #, EPSDT outreach, etc


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Strategic Directions: Quality & Financial Incentives

  • Session Objectives

    • Review potential opportunities for incorporating national benchmarks from Healthy People 2010

    • Examine Medicaid reimbursement levels for hearing services

    • Consider alternative performance incentive strategies


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Quality Incentives: Interviews

  • Few EPSDT programs use or are aware of Healthy People 2010 hearing objectives

  • Most Medicaid quality standards from NCQA (HEDIS), AAP

  • Use of quality indicators (e.g., 1/3/6) could be an effective strategy

  • Important to have actionable data for use by providers

  • Comparative state data also helpful


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Quality Incentives: Interviews

  • NICHQ’s model of collaborating with practices, conducting chart reviews, identifying improvement strategies, & providing feedback (eg, lead, immuniz)

  • Need to make sure hearing screening & follow-up is incorporated into EPSDT evaluations. Records could be tagged for follow-up


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Quality Incentives: Interviews

  • Consider a GPRA project (e.g., immunization)

  • CMS could set a standard (e.g., dental care)

  • Maintain close link with public health

  • Issue certificates of excellence to providers scoring 95% of higher

  • Acknowledge the good work of providers “They’re not doing this work for the financial rewards, but for the benefits to children.”


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Reimbursement Incentives: Interviews

  • “Ha, ha, ha. Stand in line.”

  • State Medicaid and public health funding is already stretched to its limits

  • Important to piggyback with existing EPSDT administrative outreach efforts

  • Through Medicaid’s administrative match, possibly some potential for funding follow-up activities


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Reimbursement Incentives: Interviews

  • To claim administrative match requires financial support from other state agencies – good luck!

  • To justify payment changes, evidence of cost savings needed

  • Professional organizations & provider groups need to advocate for rate increases showing costs not being met and access adversely affected


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Reimbursement Incentives: Interviews

  • Also, comparative state fee data useful – no one wants to be lowest (see handouts)

  • See examples from dental care. Also, incentives used successfully with EPSDT visit rates, immunizations, & lead screening

  • Examine hospital payment mechanisms to assess where to place incentive

  • Consider outside foundation & community funds


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Strategic Directions: Monitoring & Tracking

  • Session Objectives

    • Examine existing state data sources and data-sharing arrangements to link with

    • Consider ways to improve accuracy & quality of reportable data on hearing screening & follow-up


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Monitoring & Tracking: Interviews

  • Accurate data depends on accurate provider coding. Providers/office staff may need training on appropriate coding.

  • When hearing services bundled into a single code or folded into DRG payments, difficult to rely on claims data

  • Tracking hearing is much more complicated than lead screening


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Monitoring & Tracking: Interviews

  • Potential data sources: vital records, EPSDT, EHDI tracking system, early intervention, care management, hospital databases, administrative claims, case management systems, registries

  • Data-sharing agreements most helpful

  • Publish program success


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Strategic Directions:Collaboration

  • Session Objectives

    • Identify new & existing opportunities to effectively promote collaboration among key stakeholders

    • Share information about promising strategies

    • Consider roles & responsibilities for state EHDI programs to play with Medicaid & participating MCOs and other providers


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Collaboration: Interviews

  • Already a great deal of collaboration between Medicaid and EHDI programs, mostly around newborn screening

  • Meetings at least quarterly help, involving Medicaid & other key stakeholders

  • Written interagency agreements useful in promoting accountability


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Collaboration: Interviews

  • Examples: MD – a portion of EHDI coordinator’s time/salary is dedicated to working with Medicaid.

  • IL: “Think Tank Day” on newborn hearing projects for coming year; developed education, referral, & follow-up document; grand rounds training with AAP; newborn screening advisory group; now working on parent website


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Collaboration: Interviews

  • Linking with other screening programs, such as electronic birth certificates, immunizations, or newborn metabolic screening, may have potential but not yet done for most part

  • State Early Childhood Comprehensive Systems (SECCS) grants important vehicles to link with in many states. Other initiatives – Healthy Babies/Healthy Kids& Families, Commonwealth’s ABCD program, & Early Education and Care