Bright Futures Preventive Services Improvement Project

Sixteenth Street Community Health Center

Milwaukee, WI

Our Team: Drs. Emilia Arana, Alisen Huske

Francisco Enriquez, John Dunn

Our team plans as of January 2011

By October 2011...

95% of charts will have Parental Concerns elicited and addressed at each WCC visit.

95% of charts will have Parental Strengths discussed and documented. 95% CYSCHN will be identified as such, having the denomination of “Special

Needs” in the problem list. 95% of 9mo WCC visits will have an ASQ completed. 95% of 2wk, 2mo, 6mo WCC visits will have Maternal PPD screen done. Improve the administration of our Oral Health Risk Assessment so that 95% of

9mo, 18mo, and 24mo have it done. Improve the administration of our 18mo and 24mo ASQ and MCHAT so that 95%

of WCC's designated as “18mo” or “2y” WCC have it done, regardless of their actual age at the WCC (i.e. 30mo “late” 2y WCC will get an MCHAT and a 30mo ASQ to do).

Implement a pre-visit questionnaire at the 9mo and 24mo WCC visits. Update quarterly our list of Dental Providers, classified according to HMOs. Have a one sheet hand-out for each WCC visit - age appropriate anticipatory

guidance. Have an organized, current list of community resources for parents. Use Intergy-EHR system to track referrals, lab orders and imaging.

Our team now… how close to our Aim?

9 month old visits

Baseline Data September data- Parental concerns elicited: 80% 90% (100% in August)

- Parental concerns addressed: 85% 100%- Risk assessment done: 50% 90% (100% in August)

- Risks addressed: 50% 100%- Weight for Length: 100% 100%- Developmental screen: 0% 70% (100% in July)

- Follow-up for positive screen: ---- 100% In June (Data gaps on graph)

- 3 BF anticipatory guidance used: 90% 100%- Parental strengths assessed: 0% 50% (80% in August)

- Oral Health Risk Assessment done: 45% 90% (100% in August)

- Maternal Depression Screening: 0% 90%

Our team now… how close to our Aim?

24 month old visits

Baseline Data September data- Parental concerns elicited: 85% 75% (90% in July)

- Parental concerns addressed: 85% 100%- Risk assessment done: 100% 100% - Risks addressed: 100% 100%- BMI: 100% 100%- Developmental screen: 85% 100%- Follow-up for positive screen: 100% 100%- Autism Screen: 85% 100%- Autism Screen follow-up: 85% 90% in April (Data gaps on graph)

- 3 BF anticipatory guidance used: 100% 100%- Parental strengths assessed: 0% 35% (40% in August)

- Oral Health Risk Assessment done: 95% 100%

PDSA cycle Maternal DepressionPlan the change: Implement PPD Screening at 2wks, 2mo, 6mo visits. Screening tool: EPDS (Edinburgh). Do the plan: Modified EHR template, adding PHQ-2 and EPDS. Inform Pediatric and Behavioral Health Providers. Create handout on PPD and list of community resources for PPD.Study the results. We found more PPD than expected. Poor access to BH provider. Excellent access to SW services/counseling.Act on the new knowledge: If screen positive, Pediatrician refers mother to FP or CPM identified as prenatal care provider. Task provider, scan Edinburgh in mother’s chart.

PDSA cycle Pre-visit Questionnaires

Plan the change: Implement Pre-visit Q at the 9mo and 24 mo WCCDo the plan: Modify versions of the Bright Futures Pre-Visit Q. Translate it in Spanish. Pilot use by 5 PediatriciansStudy the results. Tool is useful in guiding what anticipatory guidance to provide. Parent misunderstands some sections. Little time for parents filling it out along with other screening tools.Act on the new knowledge: Modify the initial version. Ask parents feedback. Pilot test for 2 weeks.

Final versions to be available in our Patient Portal

Changes we made that resulted in improvement

Use of Pre-visit Questionnaires at 9mo and 24 mo visits Identify Patients with Special Health Care needs. Addressing and documenting parental concerns (HPI, EHR-template

modified) Maternal Depression Screening Implementation of use in Pediatrics,

Family Practice, Women’s Health Departments. Social Services involved. Coordination of care of mothers with PPD: Pediatrician can now refer to prenatal care provider (FP or CPM)

Earlier use of ASQ tool, starting at 9 months age and broader use of the ASQ and MCHAT at the 18mo and 24mo WCC’s.

Discuss, reinforce Parental Strengths, documented in WCC e-note. Use of EHR to track lab tests, imaging tests and referrals to specialists. Regularly updated list of Dental Providers, organized according to each

HMO.

Challenges and BarriersLack of time to invest in this project. Very busy

providers.Low literacy level of our patients/familiesPoor access to Mental Health Services.Poor access to Dental Home.Parents do not have enough time to

complete/answer forms. They arrive late or just in time to appointments.

Lack of non-medical staff available to help with this project (e.g. update list of community resources for parents).

What did we accomplish

The single change we are most proud of is Coordination of services between departments FP,

Midwifes, Social workers, Perinatal case managers to serve patients with PPD.

Our greatest innovation was…we began screening for maternal depression systematically at pediatric WCC’s.

What are we doing next Pre visit Questionnaires, 12mo and 36mo visits. Adapt them to our population needs

and language use. Actively involve families in evaluating and modifying screening tools. Obtain feedback, more so on the experience of the CYSHC families. Dental Home. Document Dental Provider. Communication Pediatric-Dental provider. Request and document parent’s e-mail if available. Quantify our patient’s

computer/web access. Start working with out IT team in order to include pre-visit questionnaires, ASQs and

M-CHAT in the patient portal.

Our team is wondering if next we should . . . Prepare Pre visit questionnaires for every WCC visit, and make it available in in

Patient Portal Social Workers to help organize a list of community resources, make it available in

our Intranet and on the patient portal. Training/Practice session for providers to become more familiar and use more often

the HEALTH tab (Our Preventive Services Prompting System) Anticipatory guidance at every WCC visit: Prepare a one sheet hand-out based on

the Bright Futures recommendations, modified to fit our population needs and language.