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Community Systems Change Through Learning Collaboratives: Multidisciplinary Partnerships for Healthy Child Development Jill Houbé, MD, MPhil Debra Lotstein,

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Presentation on theme: "Community Systems Change Through Learning Collaboratives: Multidisciplinary Partnerships for Healthy Child Development Jill Houbé, MD, MPhil Debra Lotstein,"— Presentation transcript:

1 Community Systems Change Through Learning Collaboratives: Multidisciplinary Partnerships for Healthy Child Development Jill Houbé, MD, MPhil Debra Lotstein, MD, MPH Early Developmental Screening and Intervention Initiative EDSI

2 Goal and Objectives Goals To discuss the principles and practical issues around multidisciplinary learning collaborative models to achieve health system change To review the experience of the EDSI Learning Collaborative To discuss potential applications in Canada. Objectives After participating in this activity, attendees will be able to : To describe the principles and practical applications of the learning collaborative approach to health system change and quality improvement; To identify the role of multidisciplinary partnerships for providing developmental health care services

3 Workshop Outline Introductions Background and scope Interprofessional collaboration Collaborative system change An example of a multidisciplinary learning collaborative in paediatric healthcare: Early Development Screening Initiative (EDSI) Learning collaboratives and health system change in Canada Discussion 3

4 4 What is interprofessional collaboration? Collective action toward a common goal, in a spirit of harmony and trust DAmour et al, (2005), Journal of Interprofessional Care, 19:2,

5 What is interprofessional collaboration? Five underlying concepts Sharing Partnership Interdependency Power Process 5

6 What is interprofessional collaboration? Multidisciplinary Interdisciplinary Transdisciplinary 6

7 Determinants of successful collaboration Interactional Organizational Systemic

8 8 What is Collaborative Learning? Learning is the social construction of knowledge Vygotsky Individuals with differing viewpoints, experiences, and levels of knowledge interact with one another Testing, reconciling, and forging a new, shared understanding Acquiring new knowledge and restructuring existing knowledge

9 Principles of Quality Improvement Performance is a system property Working harder in an unsupportive system will not change outcomes If you want improved performance, you have to seek a new system Improvement itself requires a system 9 Schecter and Margolis (2005), J Pediatr;147: ; Deming WE, The New Economics for Industry, Government, Education,Cambridge, Massachusetts, USA: The MIT Press; 2000; Berwick (1999), Managed Care Magazine

10 Promoting Optimal Child Development What are some challenges you are facing in: Eliciting parents concerns and addressing information needs? Helping parents enhance their childs development ? Identifying children at risk for developmental and behavioral problems? Linking families with needed community services?

11 The Gaps in Care Under-identification of developmental problems prior to school entry Lack of involvement of parents About half of parents are asked about concerns About half of these receive needed information Underserved families at high risk for poor care Poorer preventive care and elicitation of concerns Social norms about child development Limited time for ECE or PMDs to address concerns Glascoe FP, Dworkin PH. The role of parents in the detection of developmental and behavioral problems. Pediatrics 1995; 95 :829 –836; Glascoe FP, Dworkin PH. Obstacles to effective developmental surveillance: errors in clinical reasoning. J Dev Behav Pediatr 1993; 14 :344 – 349; Palfrey JS, Singer JD, Walker DK, Butler JA Early identification of children's special needs: a study in five metropolitan communities. J Pediatr. 1994; 111:

12 12 Multidisciplinary Collaboration: The EDSI experience Early Development Screening Initiative (EDSI) Implement reliable systems for providing effective preventive and developmental care to children less than 5 years of age. Create new systems of support through collaboration between physicians, nurses, ECE professionals, administrators, and parents. Funded by First Five, Los Angeles County

13 EDSI Aim: To create effective systems for early identification and promotion of optimal development Parents have the knowledge, confidence and supports to promote optimal development Health care and early care and education providers discuss and address development with parents effectively Providers understand and use pathways to family supports and services Relationships between providers and community agencies promote access to resources

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15 Partners in the EDSI Initiative Implementation partners Primary care practices Early care and education (ECE) Specialized programs (e.g., regional centers) Women, Infants and Children (WIC) Supplemental Food Program Steering Committee Representatives of implementation partners Opinion leaders, policy-makers, experts Affiliated programs and initiatives

16 EDSI Project Components 1.QI Learning Collaboratives 2.Population-based strategy - WIC sessions for parents 3.Policy change and spread

17 EDSI Project Components 1.QI Learning Collaboratives 2.Population-based strategy - WIC sessions for parents 3.Policy change and spread

18 Barriers and Opportunities for Promoting Optimal Development Parent Knowledge about development Skills at managing behavior Views about clinicians and teachers as sources of information about development/behavior Teacher/Provider Time Counseling resources and skills Early Childhood Center/Medical Practice Routine process for eliciting concerns Organized materials and resources to meet families needs Ability to link families with community resources

19 " Everyone wants changethey just don't want anything to be any different." Yogi Berra

20 QI Learning Collaborative Format Adapted from the Breakthrough Series Method of the Institute for Healthcare Improvement* Each participating site sends a team Three learning sessions over 12 months, ongoing coaching Data collection and feedback Uses the Model for Improvement Defines common set of aims, measures and ideas for change for all participants *

21 What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement ActPlan StudyDo

22 What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement ActPlan StudyDo Aim

23 EDSI Practice Goals >75% of parents report needs met: AGPE and childs development >75% of parents read with child daily >95% of parents have psychosocial screening >20 Office System Inventory items in place >95% of at risk children have documented follow-up plan >75% of parents report receiving family centered care >95% of children have documented developmental screening

24 >75% of young children (birth to age 5) will have documentation of an age-appropriate structured developmental screening twice yearly. > 75% of young children (birth to age 5) will have documentation of a parent-teacher conference twice yearly. > 95% of at-risk children will have a follow-up plan documented in the childs folder. > 95% of parents with young children (birth to age 5) report their information needs about their childs development and behavior were met. > 75% of parents report reading or sharing books daily with their child. > 95% of children will have a documented medical home providers name and contact information in their folder, updated within the last six months EDSI ECE Goals

25 Team Aim The Clinica Monsenor Oscar A. Romero EDSI team is determined to improve preventive services and developmental screening and referral for children ages 0-5 years in our community. We intend to develop practice-based systems to facilitate comprehensive preventive care and developmental screening and referral. We will test and implement strategies to integrate evidence-based screening tools and anticipatory guidance into the practice workflow, with an emphasis on parent reporting.

26 Team Aim (continued) Our goals includes: 1.Greater than 75% of young children (birth to age 5) will have an age appropriate parent report based structured developmental screening at designated well-child visits. 2.Greater than 75% of young children (birth to age 5) will have documentation of a psychosocial screening in the previous 12 months.

27 Team Aim (continued) 3.Greater than 75% of young children (birth to age 5) identified as at risk will have a plan for follow up by the practice and/or referral to a community resource partner. 4.Greater than 90% of young children will have a documented provider endorsement of and referral to The Children's Institute School Readiness Program (an organization which will facilitate referral for Early Head Start, Head Start, Preschool, and other family support services)

28 Wilton Place ECC Team Aim Implement reliable systems for effective preventive and developmental care and support for children 2 – 5. We will achieve our aim by: Enhancing positive discussions with families Building relationships with community resources Building a continuous learning system for our center Goals & Measures 75% of children will have documentation of an age - appropriate structured developmental screening 75% of teachers will have information from screening 95% of children will have contact information in their folder, updated within the last six months

29 What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement ActPlan StudyDo Measures

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31 Example Data Feedback Reports

32 What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement ActPlan StudyDo Ideas/Changes

33 Multiple Sources of Ideas for Change Tools from Healthy Development collaborative* Literature review Interviews/site visits with local high-performing early childhood centers Teams develop new ideas and share with each other * A Practical Guide for Healthy Development

34 ActPlan StudyDo New Ideas are Tested and Implemented Using PDSA Cycles

35 ActPlan StudyDo Use PDSA Cycles to Test and Implement Changes Plan the details of the test and predict the outcome of the test

36 ActPlan StudyDo Use PDSA Cycles to Test and Implement Changes Plan the details of the test and predict the outcome of the test Do: Conduct the test and collect data

37 ActPlan StudyDo Use PDSA Cycles to Test and Implement Changes Plan the details of the test and predict the outcome of the test Do: Conduct the test and collect data Study: Compare predictions to the test results

38 ActPlan StudyDo Use PDSA Cycles to Test and Implement Changes Plan the details of the test and predict the outcome of the test Do: Conduct the test and collect data Study: Compare predictions to the test results Act: Take action based on the new knowledge

39 The Model Provides Structure for Repeated Tests 39 The Breakthrough Series: IHIs Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003

40 Example: ECE First Plan-Do-Study-Act Cycle Plan: Questions: Will a structured written form better assist for discussing developmental and behavioral observations of a child? Will this form also be proactive to assist during parent – teacher conferences by answering their questions and concerns? Predictions: Having a form to structure the discussion at the conferences will make it easier for teacher to focus the discussion and assure that important things are not left out. The form will make the conference more helpful in answering parents questions and concerns. DO: Conference took 30 minutes. Family has 4 year old boy, bilingual, developing on track, without any behavioral or developmental concerns. Gave copy of form to parents and put copy in childs folder. STUDY: Parent ask about Spanish translation of the parent survey. Need to re – word questions because they were not clear to parent. Parent likes being involved and was very open. ACT: Team will revise the form; the teacher will test it out 2 more conferences over the next 2 weeks and report back to the team the following week.

41 Physicians Office PDSA Developing Office Systems Question: Is it helpful to use a case manager to endorse the provider s referral to an early education program? Are our parents able to access early education programs through the Children s Institute? Plan for Test: Dr. Prestwich and Dr. Willard will ask the 3 different parents 0-5year old children if the child is enrolled in an early education program. If not, they will refer the parent to The Children s Institute. Dr. Prestwich and Dr. Willard will have the same discussion with 3 other parents, but they will then refer them on to Alba or Yvonne for reinforcement of the referral. Do/Study: 6 parents were referred and all of them expressed intent to keep an appointment. After 3 weeks we found that 1 (mother of 15 month old, referral by MD without Case Manager assist) kept appointment. She was frustrated that Early Head Start has a waiting list. The other 5 had not yet called, but indicated they plan to. Act: We confirmed that there are long wait lists for kids 0-2 years, but immediate access to early education programs for 3-5 year olds in our area. May need case manager to assure follow-up after the visit. Will continue to follow the 5 parents; test with 5 more.

42 Multiple PDSA Cycle Ramps A P S D A P S D A P S D D S P A Testing and Adaptation A P S D A P S D A P S D D S P A A P S D A P S D A P S D D S P A A P S D A P S D A P S D D S P A Develop office systems Work as a team Use structured screening tools Discuss parent concerns Partnerships with community resources Continuous learning system

43 Lessons Learned (so far…) Challenges Teams used to top-down approach to change Working effectively as a team Data collection is something extra (not able to get from existing processes) Strengths Sharing and learning across disciplines Professional development for staff Staff validation and engagement in the big picture

44 EDSI Project Components 1.QI Learning Collaboratives 2.Population-based strategy - WIC sessions for parents 3.Policy change and spread

45 WIC Sessions for Parents Women Infants and Children program pre-natal to years old nutritional and educational services provided by trained peers Curriculum developed to teach parents skills for talking with clinicians Themes: Parents are the best observers of their childs development; expectations for their childs doctor

46 EDSI Project Components 1.QI Learning Collaboratives 2.Population-based strategy - WIC sessions for parents 3.Policy change and spread

47 Policy Change and Spread Clarify specific policy issues for an improved system E.g. shared vision, respective roles, expectations and guidelines, workforce and training, reimbursement Convene several policy summits including County and State policymakers

48 What the best and wisest parent wants for her own child, that must be what the community wants for all its children. John Dewey

49 Planning for Change in Your System using a Learning Collaborative Approach What is your general aim for improvement? Who should be involved? What are some incentives for encouraging their participation? Who might help support such an effort? What are some potential facilitators of collaboration (e.g. data sources, aligned incentives, etc) What are some potential barriers to collaboration?

50 50 Multidisciplinary learning collaboratives: A Model for Quality Improvement in Canada? Potential barriers Boundaries between subspecialty and primary care systems Limited communication between systems of care Limited data collection and sharing between systems of care Potential promoters Publicly funded health insurance Population-level data collection Potential benefits Improvement in healthy child development outcomes Improvement in adult health and well-being

51 Percentage of Students Vulnerable Emotional Maturity scale of the EDI (Based on Provincial cutoffs), Wave 1

52 52 Acknowledgements Sunny Hill Foundation British Columbia Child and Family Research Institute Hillel Goelman and Clyde Hertzman Consortium for Health, Intervention, Learning and Development Human Early Learning Partnership BC Healthy Child Development Alliance Neonatal Follow-Up Program Dana Brynelsen and Infant Development Program Contact:

53 53 EDSI Team UCLA Center for Healthier Children, Families, and Communities Center for Health Care Quality, Cincinnati Children's Hospital Medical Center RAND Corporation Public Health Foundation Enterprises (PHFE) WIC LA BioMed WIC California State University, Los Angeles Childrens Hospital Los Angeles Cedars-Sinai Medical Center


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