Helping Family Physicians Improve Developmental Screening Laura - - PowerPoint PPT Presentation

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Helping Family Physicians Improve Developmental Screening Laura - - PowerPoint PPT Presentation

Sep 05, 2022 389 likes •800 views

AUCD/CDC RTOI: Helping Family Physicians Improve Developmental Screening Laura McGuinn, MD Developmental-Behavioral Pediatrician Assistant Professor of Pediatrics Dee Kessler, BS Practice Enhancement Assistant University of OK Health

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AUCD/CDC RTOI:

Helping Family Physicians Improve Developmental Screening

Laura McGuinn, MD

Developmental-Behavioral Pediatrician Assistant Professor of Pediatrics

Dee Kessler, BS

Practice Enhancement Assistant

University of OK Health Sciences Center, Oklahoma City, OK

CDC NCBDDD Jan-30-2010

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Increase referrals to Early Intervention Enhance communication between PCPs and Early Intervention Improve developmental surveillance and screening by PCPs

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  • AAP Screening guidelines
  • Evidence re: current screening practices

BACKGROUND

  • Phase I-Needs Assessment
  • Phase II-In office QI intervention

METHODS

  • Needs Assessment responses

PHASE I RESULTS

  • Practice demographics
  • Preliminary chart audit data

PHASE II RESULTS

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SLIDE 4
  • AAP Screening guidelines
  • Evidence re: current screening practices

BACKGROUND

  • Phase I-Needs Assessment
  • Phase II-In office QI intervention

METHODS

  • Needs Assessment responses

PHASE I RESULTS

  • Practice demographics
  • Preliminary chart audit data

PHASE II RESULTS

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SLIDE 5

 AAP recommends

  • Developmental “surveillance”

at all well-child visits1

  • Developmental screening tool

9, 18, and 30 (or 24) months 1

  • Autism screening tool

18 and 24 months2

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SLIDE 6

Developmental (and Autism) Screening

9 months 18 months

(including ASD screen)

24 or 30 months

(including ASD screen) T O O L T O O L S T O O L S

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 Greater percentage of FPs:3,4

  • Believe autism cannot be diagnosed <18 months
  • Advocate wait-and-see approach
  • Do not know about EI or have misperceptions
  • Rely only on informal checklists rather than

structured tools

  • Are unaware of available validated parent-

completed screening instruments

 Problems are not entirely unique to FPs

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SLIDE 8

Cochrane-Effective Practice and Organisation of Care CME6 Mixed interactive & didactic CME6 Printed educational materials7 Audit and Feedback8 Educational outreach visits (detailing)9 Tailored interventions10 Pay-for-performance11

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Priority Facilitators Quality Improvement Change Process Capability Care Process Content Facilitators Barriers Barriers Barriers Facilitators = x x

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SLIDE 10
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SLIDE 12

Mental Health Care Hospitals/Long term Primary Care Offices Transportation Early Intervention Health Dept Public and Private Health Care Community Services

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SLIDE 13

Practice

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SLIDE 14
  • AAP Screening guidelines
  • Evidence re: current screening practices

BACKGROUND

  • Phase I-Needs Assessment
  • Phase II-In office QI intervention

METHODS

  • Needs Assessment responses

PHASE I RESULTS

  • Practice demographics
  • Preliminary chart audit data

PHASE II RESULTS

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SLIDE 15

Phase I (Dec ‘08 to Dec ’09) Phase II (Mar ‘09 to Nov ’10)

Summary Needs Assessment In-Office QI (quasi-experimental) Participants OK-PRN* members 12 FPs in a rural county** Recruitment ListserveAnnouncement/ Emails/Faxes/Calls Word of mouth thru other projects Strategies Online Questionnaire re: knowledge, beliefs, barriers, current practices

  • Academic detailing
  • Pre/Post Chart audit/feedback
  • Practice facilitation
  • Care coordination
  • HIT support
  • Local Learning Collaboratives

*OK-PRN-OK Physician Resource & Research Network (~230 FPs across state) **Original plan (see changes in later slides)

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SLIDE 16

 Purpose: Use results to

  • Tailor content of educational materials
  • Raise FPs’ awareness
  • Advertise in-office phase

 Methods

  • Developed & revised questionnaire re: FP’s

screening & referral to EI/ECE

  • Recruited from ~200 FP members of OK-PRN with

Listserve Announcements/Emails/Faxes/Calls

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SLIDE 17

Priority Change Process Capability Care Process Content Academic Detailing Audit/ Feedback Practice Facilitation Local Learning Collaboratives HIT Support

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 WHO:

  • University content experts (DB pediatrician & FP)

 WHEN/HOW:

  • Physician-to-physician recruitment call
  • Baseline visit to offices in person

 WHAT:

  • Present guidelines, payers' policies, exemplar practices
  • Introduce Practice Enhancement Assistant (“PEA”)
  • Sign business associate agreements
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 WHO: PEA  WHEN: Baseline and 9 months  HOW:

  • PEA (or office staff member) pulls charts
  • PEA audits charts (~1-1 ½ days), deidentifies data
  • Project staff compiles data; feeds back to office

 WHY:

  • QI is not incentivized-extra data collection unrealistic
  • Offices often lack QI skills
  • Personalizes need for change
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SLIDE 20

 WHO: PEA  WHEN: Ongoing (# visits varies widely between practices)  HOW:

  • PEA schedules with office staff
  • PEA builds “back door access” relationships to

▪ Understand office microsystem (barriers and facilitators to change) ▪ Be credible to use motivational interviewing /adult learning theory- based techniques to foster change

 WHY:

  • Objective observer can identify resistance to change areas
  • Translating change skills to office gradually = sustainability
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SLIDE 21

 WHO: Community Care Coordinator (in another project)  WHEN: Ongoing (# of visits varies between practices)  HOW:

  • Coordinator is shared between practices
  • Like PEAs, initial task is trust/relationship building

 WHY:

  • Medical homes tasked with this but lack the resources
  • Daunting task for offices to keep up with ever-

changing community resources

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SLIDE 22

 WHO: PI and PEA  HOW:

  • Helping implement IT resources (e.g. EHR-, web-, or

palm-pilot-versions of DB screening tools, etc.)

  • Building OK mirror site www.medhomeportal.org
  • Creating 2-way communication process (fax-back

referral form and “Doc2Doc”)12

  • Giving access to OK-PRN’s list-serve discussions
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SLIDE 23

 WHO: Families from each practice  WHEN/WHERE:

  • Ongoing (# of visits will vary between practices)
  • Small group (5) in each office, county-wide meeting

 HOW:

  • County Coordinator and PEA will assist practices to

form groups, run meetings

 WHY:

  • Novel to most of the practices, parent-perspective
  • ften eye-opening

* not started

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SLIDE 24

 Project staff (PI and PEA) organized monthly

to every-other monthly meetings for all participating practitioners to

  • Meet each other
  • Learn process strategies from each other
  • Determine priorities for shared resources
  • Collaboratively design in office QI priorities
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SLIDE 25
  • AAP Screening guidelines
  • Evidence re: current screening practices

BACKGROUND

  • Phase I-Needs Assessment
  • Phase II-In office QI intervention

METHODS

  • Needs Assessment results

PHASE I RESULTS

  • Practice demographics
  • Preliminary chart audit data

PHASE II RESULTS

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SLIDE 26

N or % Response Rate (96/161) 59.6% Total OK-PRN Listserve Members 161 Total responses 96 FPs who do not see children under 3 44/96 Questionnaires with large amount of missing data 2/96 Questionnaires analyzed 50

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Gender N % Female 37 73.1 Male 13 26.9 Age (yrs) N % 31 – 40 13 25.8 41 – 50 9 18.0 51 – 60 20 39.3 61 – 70 7 14.2 71 – 90 1 2.7 Specialty N % FP 42 81.8 IM 3 6.7 Peds 3 6.7 Med-Peds 2 4.8 Degree N % APRN 2 4.6 DO 4 8.5 MD 42 81.5 PA 1 2.7 Other * 1 2.7 Setting N % Academic 14 28 Clinic 36 72 Location N % Suburban 19 37 Urban 17 34 Rural 14 29 *MBA, MPH, PhD, MS/MA

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SLIDE 28

94.2 36.5 17.3 13.4 9.6 1.9

Strategies Used to Screen

History/Physical Informal checklist Ages & Stages Other (Denver, PEDS, etc.) MCHAT MCHAT f/u ?

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SLIDE 29

Agree or Strongly Agree N % PCPs receive sufficient training to ID kids 0-5 with:

  • Developmental delay

19 36.5

  • Autism

12 23.1 PCPs should be expected to ID kids 0-5 with:

  • Developmental delay

37 71.2

  • Autism

36 69.3 Early ID is important as earlier intervention = better outcomes

  • Developmental delay

37 71.1

  • Autism

34 65.3 Strategies I now use allow me to recognize __ as early as possible

  • Developmental delay

22 42.3

  • Autism

11 21.1

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10 20 30 40 50 60 70 80 90 Parent responses unreliable No tools feasible for PCPs Frustrate parents Insurance doesn't reimburse use Too much staff time Using them increases visit length

Percent who Agree or Strongly Agree that factor is a barrier to use of standardized screening tool

Percent

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10 20 30 40 50 60 70 80 Yes No Not Sure Routinely refer to SoonerStart EI Routinely refer to Child Guidance

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5 10 15 Program not medically modeled Child must have DX first Program too expensive for pts Not available in our area Referring makes families leave practice Families have had bad experiences Wait list too long Do not receive feedback when I refer pts SoonerStart EI Child Guidance

Reasons not referring to Early Intervention/Child Guidance

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SLIDE 33
  • AAP Screening guidelines
  • Evidence re: current screening practices

BACKGROUND

  • Phase I-Needs Assessment
  • Phase II-In office QI intervention

METHODS

  • Needs Assessment responses

PHASE I RESULTS

  • Practice demographics
  • Preliminary chart audit data

PHASE II RESULTS

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SLIDE 34

Garfield Logan Canadian Oklahoma Grady Jackson Murray Tulsa Seminole

Practice Locations Relative to P0pulation Centers*

Main Population Centers Oklahoma County (1 FP group) Tulsa County (none)

Practice Locations Relative to P0pulation Centers

Original Rural County Canadian County

(2 solo FPs, 1 FP group, 1 NP grp)

Additional Rural Counties Garfield (1 solo FP, 1 Pedi group) Logan (1 Med-Peds group) Grady (3 FPs) Murray (1 FP group) Jackson (1 Pedi group)

Garfield Logan Oklahoma Canadian Tulsa Grady Jackson Murray

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SLIDE 35

Type County Specialty Recruited Pre-Data Post/Int-Data Rural Canadian FM Dec ‘08 Dec ‘08 Aug ’09 (post) Canadian FM March ‘09 June ‘09 Garfield Peds April ‘09 June ‘09 Jan ’10 (int) Logan Med-Peds May ‘09 Aug ‘09 Urban Oklahoma FM Aug ‘09 N/A Type County Specialty Recruited Pre-Data Progress Rural Garfield FM March ‘09 Sep ‘09 Canadian FM (NPs) May ‘09 Delayed Murray FM Nov ‘09 Feb ‘10 planned Jackson Peds Dec ‘09 Jan ‘10 partial Jackson Peds (NP) Dec ‘09 Jan ‘10 partial Grady FM Dec ‘09 Jan ‘10 partial Data Collection Proceeding Data Collection Beginning

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SLIDE 36

 All but one practice at baseline was adherent

with AAP screening guidelines

 Preliminary post results from 2 practices

point towards intervention increasing use of standardized tools according to AAP guidelines

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SLIDE 37

 2 year project – Oct 2008 through Nov 2010  Involves 12 practices  Lessons learned:

  • Recruiting only family medicine in single county

has been challenging

  • Plan longer period for recruitment (EHR, flu

season, employee turnover, etc.)

  • May need >2 people to accomplish scope of work
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SLIDE 38

1.

  • AAP. Identifying Infants and Young Children With Developmental Disorders in the

Medical Home: An Algorithm for Developmental Surveillance and Screening.

  • Pediatrics. 2006;118:405–420.

2.

AAP Identification & Evaluation of Children With Autism Spectrum Disorders.

  • Pediatrics. 2007; 120(5).

3.

Kilker K. The Learn the Signs, Act Early Campaign Presentation. AUCD Region VI Act Early Summit. Albuquerque, NM; March 13-14, 2008.

4.

Sices L. Developmental Screening in Primary Care: The Effectiveness of Current Practice and Recommendations for Improvement. December 2007. The Commonwealth Fund. Available at: http://www.commonwealthfund.org/usr_doc/1082_Sices_developmental_screening _primary_care.pdf?section=4039.

5.

Solberg LI. Improving Medical Practice: A Conceptual Framework. Ann Family Med. 2007; 5(3):251-6.

6.

Forsetlund L, Bjørndal A, Rashidian A, Jamtvedt G, O'Brien MA, Wolf F, Davis D, Odgaard-Jensen J, Oxman AD. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD003030.

7.

Farmer AP, Légaré F, Turcot L, Grimshaw J, Harvey E, McGowan JL, Wolf F. Printed educational materials: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD004398.

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8.

Jamtvedt G, Young JM, Kristoffersen DT, O'Brien MA, Oxman AD. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD000259.

9.

O'Brien MA, Rogers S, Jamtvedt G, Oxman AD, Odgaard-Jensen J, Kristoffersen DT, Forsetlund L, Bainbridge D, Freemantle N, Davis D, Haynes RB, Harvey E. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD000409.

10.

Cheater F, Baker R, Gillies C, Hearnshaw H, Flottorp S, Robertson N, Shaw EJ, Oxman AD. Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD005470.

11.

GiuffridaA, GosdenT, Forland F, Kristiansen I, Sergison M, Leese B, Pedersen L, Sutton M. Target payments in primary care: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 1999, Issue 4. Art. No.: CD000531.

12.

Akbari A, Mayhew A, Al-Alawi MA, Grimshaw J, Winkens R, Glidewell E, Pritchard C, Thomas R, Fraser C. Interventions to improve outpatient referrals from primary care to secondary care. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD005471.

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SLIDE 40

QUESTIONS?