2. Using Partnerships and Bright Futures to Improve the Delivery of EPSDT Services Jennifer May Paula Duncan Susan Castellano Judy Shaw

3. Agenda EPSDT and Bright Futures: the standard of care? MCH Programs and Bright Futures Primary care providers: state strategies to implement Bright Futures and improve EPSDT

4. EPSDT and Bright Futures: the standard of care? Susan Castellano Judy Shaw

5. The Federal EPSDT Program Created in 1967 during Johnson Administration –to discover, as early as possible, the ills that handicap our children and – to provide continuing follow up and treatment so that handicaps do not go neglected. For Medicaid enrolled children birth to age 21 Provides access to a broader range of services than may otherwise be covered by a states Medicaid program

6. The EPSDT Acronym Early: Identifying problems early, starting at birth Periodic: Checking children's health at periodic, age- appropriate intervals Screening: Doing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems Diagnosis: Performing diagnostic tests to follow up when a risk is identified, and Treatment: Treating the problems found.

7. The Two Parts of EPSDT Part 1: Access or Administrative Informing the family of the benefits of prevention and the health services and assistance available Providing assistance with finding a provider and scheduling an appointment Arranging for transportation and interpreters Following up on referrals and provide linkages to other agencies and services Sources: Center for Medicare and Medicaid Services, State Manual Part 5 EPSDT.

8. The Two Parts of EPSDT Part 2: Screenings and Services Assess the childs health needs through initial and periodic examinations and evaluation to assure that health problems found are diagnosed and treated early, before they become more complex and their treatment more costly. Provide for assessment and treatment of problems identified to correct or ameliorate the condition Sources: Center for Medicare and Medicaid Services, State Manual Part 5 EPSDT.

9. Federal EPSDT Requirements Periodicity Schedule must: (a)Meets reasonable standards of medical and dental practice determined by the agency after consultation with recognized medical and dental organizations involved in child health care; (b) Specify screening services applicable at each stage of the recipient's life…; (c) At the agency's option, provide for needed screening services … in addition to the otherwise applicable screening services (42 CFR 441.58) States required to achieve an 80% participation rate

10. Periodicity Schedule Flexibility States have the flexibility to chose their periodicity schedule: the frequency of recommended preventive health care visits Minnesotas schedule has 20 visits from birth to age 21 Informal survey in 2006: 39 states had more visits than Minnesota, 2 had less, 9 were the same Number of visits ranged from 15-30 from birth to age 21 2005 Deficit Reduction Act provided additional flexibility for benchmark benefit sets

11. Components of an EPSDT Visit Comprehensive health and developmental history, including mental and physical development Comprehensive physical examination Immunizations and laboratory tests, including blood lead Vision and hearing screening Dental screening and referral Health education and anticipatory guidance Diagnosis and treatment services as medically necessary

13. …is a set of principles, strategies and tools that are theory - based, evidence - driven, and systems - oriented, that can be used to improve the health and well-being of all children through culturally appropriate interventions that address the current and emerging health promotion needs at the family, clinical practice, community, health system and policy levels.

21. Bright Futures Linking it all together Tools, materials, strategies

22. Minnesota and Bright Futures Minnesota currently considering with how to update our Medicaid periodicity schedule based on Bright Futures recommendations Our Title V agency endorses and promotes Bright Futures for all children Issues: cost of additional visits, harder to achieve 80% participation rate

23. EPSDT and Bright Futures Comprehensive nature of EPSDT requirements lends itself to the Bright Futures recommendations Sometimes asked by pediatric providers regarding why Medicaid kids get more (comprehensive visit) Direct them to Bright futures; comprehensive care is recommended for all children

24. Small Group Discussion

25. MCH Programs and Bright Futures Paula Duncan

26. Health and wellbeing of children and families Access to health and dental care Disparities Performance Measures Public Health Priorities

27. Bright Futures and Title V Use Bright Futures as a guide to develop policies and programs to improve quality of childrens health care and health outcomes. Use Bright Futures as common standard for clinical care. Use materials to help parents and youth get prepared and make the most of every visit. Use the anticipatory guidance sections for education of community partners other child health professionals and parents directly.

28. Bright Futures and Title V Consider using Bright Futures themes in agency/community education activities. Use strength-based approaches and shared decision making strategies to engage with community partners and parents.

29. Documentation of great care New office systems approaches Ready for recertification and pay for performance Improved access to community resources Knowledge of latest best practice/materials Network of committed professionals/learn Potential For Public Health Clinics and Practices

30. Provide information about the content tools (how to order) or download Referral resources Public health data Provide training and support for office systems change (data from parents) Public Health a Key Partner

31. National Center for Cultural Competence Review of Bright Futures Literacy (lack of education) How do they prefer to receive information? (access to information) Language spoken at home Family structure, who lives in the home, and supports (lack of family resources, family disintegration) Sources of advice (media, marketing to children)

32. Parental expectations: childrearing beliefs, health beliefs Home environment (displacement, homelessness) Community environment (access to play, neighborhood safety) Establishing trust Do you see anyone else about the health of your child or family? National Center for Cultural Competence Review of Bright Futures

33. Small Group Discussion

34. Primary care providers: state strategies to implement Bright Futures and improve EPSDT Judy Shaw Susan Castellano Jennifer May

35. Vermont Child Health Improvement Program …one model VERMONT CHILD HEALTH IMPROVEMENT PROGRAM

36. Mission to optimize the health of Vermont children by initiating and supporting measurement-based efforts to enhance private and public child health practice. In partnership with: Vermont Department of Health University of Vermont Department of Pediatrics, OB, FP & Psychiatry Vermont Chapter of the American Academy of Pediatrics Vermont Chapter of the American Academy of Family Physicians Office of Vermont Health Access (Medicaid) Vermont Agency of Human Services Banking, Insurance, Securities & Health Care Administration (BISHCA) Managed Care Organizations

37. 1994-1998 1999 2000 Vermont Preventive Services Initiative (VPSI) 2001 VCHIP Timeline 2002 Vermont Hospital Preventive Services Initiative (VHPSI) 2003 2004 2005 Vermont Periodicity Schedule developed by Vermont Department of Health in collaboration with the AAP-VT and AAFP-VT Chapters Formal presentation of VPSI to the AAP-VT Spring Meeting; VCHIP core funding obtained for preventive services work VCHIP Executive Director Hired Improving Prenatal Care Youth Health Improvement Initiative (YHII) EQRO contract Child Development Youth in Foster Care Improvement Partnerships Care of the Opiate Exposed Newborn Child Mental Health

38. Number of VT practices participating in at least one VCHIP project 85% Pediatric Practices (33/39) 23% Family Practices (24/106) 27% OB Practices (7/26) 39% Certified Nurse Midwife Practices (5/13) 100% VT Hospitals (12/12)

39. Improvement Partnership …a durable, regional collaboration of public and private partners that uses measurement-based efforts and a systems approach to improve the quality of childrens health care.

40. are customized according to the characteristics of each state or region IPs are developing in different ways with a variety of partners. Some are housed at academic medical centers, state of local health departments or state chapters of the American Academy of Pediatrics Improvement Partnerships

42. MN Title V/Title XIX Collaboration –Intro to EPSDT –Lead screening –Developmental and Mental Health screening –Hearing screening –Vision screening –Oral Health screening To educate private and public health providers, Medicaid agency has a contract with Title V to: Provide trainings on EPSDT screenings including vision and hearing Develop on-line training modules for providers to learn components on their own time, including:

43. Collaboration (cont.) Developed Your Growing Child Brochures age-appropriate fact sheets with anticipatory guidance information which providers give to parents Created age-specific screening templates to assist providers in documenting EPSDT components provided at visits County Title V agencies conduct the informing and outreach activities of the EPSDT program

44. The Minnesota Child Health Improvement Partnership

45. Why MN Established an Improvement Partnership Growing interest from providers in quality improvement activities, some larger clinic systems creating their own Not a strong state AAP Chapter, no learning activities Occasional cost-saving projects from a health plan quality improvement consortium, focused on adults No existing structure focused on quality improvement for children

46. Spring 2007 - An Opportunity Minnesota Chapter of the American Academy of Pediatrics (MN- AAP) application for funding from Commonwealth Fund for a technical assistance grant provide by VCHIP to develop a permanent entity in the state Leadership Partners: –Minnesota Department of Human Services –Minnesota Department of Health

47. Healthy Development through Primary Care Project Goal: increase the use of standardized developmental, mental health and maternal depression screening tools into pediatric primary care clinic visits 9 practice teams from around the state, each team includes at least: a pediatric primary care provider, nurse and third individual determined by the team 1 ½ - 2 year project, learning collaborative kick-off mtg. November 9, 2007 and a second learning collaborative session on January 15, 2009

48. Project Activities Choosing screening tools Clinic workflow Scoring Documentation Billing Referrals Integration into electronic medical record system Measuring change

49. Project Activities for Participating Teams Participate in learning collaborative session Meet as a team twice a month Participate in a monthly telephone conference with other teams and project staff Collect family surveys to measure satisfaction Gather data from medical records to measure screening rate

50. Preliminary Findings Screening Rates Developmental screening rate Increased from 55% at baseline to 89% Mental health screening rate Increased from 3% at baseline to 11%

51. Preliminary Findings

52. Next Steps Spread change from 9 practices statewide Retreat last month to determine priorities and how to pick next project Continue to strategize on funding opportunities (may ultimately define above bullet point!) Continue to expand membership to include other disciplines (AAFP, NAPNAP), parent representatives, etc.

53. Questions?

54. Contact Information Susan Castellano, Manager Maternal and Child Health Assurance Minnesota Department of Human Services (651) 431-2612 Susan.Castellano@state.mn.us

55. Contact Information Jennifer May National Academy for State Health Policy 10 Free Street, 2nd Floor Portland, ME 04101 207.874.6524 jmay@nashp.org

56. Contact Information Judith S. Shaw EdD, MPH, RN Research Associate Professor of Pediatrics Executive Director, Vermont Child Health Improvement Program University of Vermont College of Medicine phone: (802) 656-8319 judith.shaw@uvm.edu

57. Contact Information Paula Duncan, MD Youth Health Director, VCHIP Professor of Pediatrics, University of Vermont College of Medicine 802-656-9622 Paula.Duncan@uvm.edu