I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in their presentation. Age Appropriate Risk Assessment Bill Stratbucker, MD, MS, FAAP Preventive Services Improvement Project September 2011

2 Objectives  Familiarize yourself with the benefits of Age Appropriate Risk Assessments  Share examples of risk assessment tools  Explore implementation strategies

Periodicity Schedule

Benefits of the Risk Assessment  Standardization of preventive care  Increased reliability of thoroughness at each visit  Stratified approach based on patient’s risk 4

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 6

Age-specific tools  9-month well child risk assessment  24-month well child risk assessment

8 Screening table – 9 month visit

Risk assessment questions – 9 months

Screening table – 2 year visit 10

Risk assessment questions – 24 months

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

Visit Priorities – 18 months 14

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)

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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?

Preventive Services Prompting Sheet

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

Preventive Services Prompting Sheet

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”

Periodicity Schedule