Age Appropriate Risk Assessment Bill Stratbucker, MD, MS, FAAP Preventive Services Improvement Project September 2011
Objectives • Familiarize yourself with the benefits of Age Appropriate Risk Assessments • Share examples of risk assessment tools • Explore implementation strategies
Benefits of the Risk Assessment • Standardization of preventive care • Increased reliability of thoroughness at each visit • Stratified approach based on patient’s risk
PreSIP goal • “100% of pratices have a documented system in chart to assess preventive services and risk screenings”
Risk Assessment Tools • Age-specific tools • Condition-specific tools • Previsit Questionnaire • Preventive Services Prompting Sheet
Age-specific tools • 9-month well child risk assessment • 24-month well child risk assessment
Condition-specific tools • Examples • Eliciting Parental Concerns • BMI and weight-for-length • Oral Health • Developmental • Autism • Parental Depression • Eliciting Parental Strengths
Eliciting Parent Concerns • Drives the visit discussion and, sometimes, decision making • Highest priority • Asked by questionnaire, staff, physician • Asked within specific risk assessments • Vision • Hearing
Weight-for-length and BMI • Plot weight-for-length under 2 on WHO growth chart • BMI starting at the 2-year well visit on CDC growth chart • Documentation of %ile in well visit note • Conditionality (if this, then…) • Specific counseling, labs, follow-up visit, etc.
Depression screening • Who do you screen? • Mother, father, guardian, grandparent • When do you screen? • Which visit(s), timing within visit • How do you screen? • Which tool, back-up tool? • When do you refer? • Diagnostic evaluation? Treat?
Implementation • How do we ask all these questions about risk? • How do we remember if we’ve asked the questions or completed age-appropriate screening/services/referral? • How do we incorporate patient designations? (CSHCN, Down Syndrome, hearing loss risk, etc.)
How do we ask all these questions? • Incorporate into well visit template (paper or EHR) • Use previsit questionnaire • Provide screening tools to parent for completion (ASQ, MCHAT)
Implementation Strategies • Previsit questionnaire • Paper, e-survey in health portal, kiosk, tablet, staff-directed, physician-directed • Literacy concerns • Time concerns • Author concerns (who is filling it out?, confidentiality) • EHR concerns (scanning, inputting data, data retrieval)
Implementation Strategies • How do we remember if we’ve asked the questions or completed age-appropriate screening/services/referral?
PSPS • Practice management resource • Facilitates communication across providers • Helps to distribute work across team • Allows anyone to quickly assess whether up-to-date • Identifies those in need of preventive services • Prompts team member to provide at any visit
Patient Designations • How do we incorporate patient designations? (CSHCN, Down Syndrome, hearing loss risk, etc.) • Enter into section on PVPS or integrate into EHR so defaults to appropriate growth chart and condition-specific periodicity
Incorporating into EHR • When well visit scheduled, auto-prompts the correct age template • 90/10 rule for defaults • No click defaults • PSPS becomes “to do” list or “not done” list • Screening questions can be built into ROS but need scoring system
Incorporating into EHR • Conditionality very important, (if this, then ?) • Standard, Routine or Alternate ordering prompts • Color codes can be tool to recognize overdue service • Query for reminder recalls • Add specialized periodicity based on risk, condition, insurance type
Incorporating into EHR • Itemization important for getting data back out of EHR for study, QI • Need to decide what level of detail gets a specific response (yes/no, drop down choice) vs. “text blob”