Download Prevention First: Improving Well Child Exam Completion Rates in WV

Prevention First: Improving Well-Child Exam Completion
Rates in West Virginia
2016
Prevention First:
Improving WellChild Exam
Completion Rates
in West Virginia
A Provider’s Perspective
Dr. George Stablein
Cabin Creek Health Systems
[email protected]
The Importance of Well-Child
Care A Primary-Care Pediatrician's
Perspective
George Stablein, MD
Pediatrician and Clinical Coordinator School-Based
Health
Cabin Creek Health Systems
Barriers
• Transportation
• Finances
• Insurance (or lack thereof—still an issue although lessso)
• Parental/Guardian Work Schedule
Cabin Creek School-Based Health Centers
Riverside Health Center
Hoover Health Center
Clendenin Elementary
School
Indian Health Center
Pioneer Health Center
A TYPICAL WELL
CHILD VISIT
Snapshot of Some of the Services Offered
at Cabin Creek Health Systems

Screening for Health Risks and Physical Exams

Mental Health Assessment and Treatment

Health Education Programs

Lab tests, Rx, Allergy Injections, immunizations, wart
removal

Care for illnesses and minor injuries

Care for chronic conditions (i.e., asthma, diabetes,
various disabilities)

Including emotional health and coping with
chronic illness

Referrals and follow-up care

Administration of medication for minor health
problems as appropriate
Need dedicated
visits!
Nuts and Bolts
• Growth Charts
--Feeding
• Development
--Vision/Hearing
--Gross Motor
--Fine Motor
--Speech/language
--Schooling
•
•
•
Immunizations
General Review of Systems
Mental Health
Overall Health and Mental Health
"The Relationship of Adult Health Status to Childhood Abuse and Household
Dysfunction", published in the American Journal of Preventive Medicine in
1998, Volume 14, pages 245–258.
"The Relationship of Adult Health Status to
Childhood Abuse and Household Dysfunction",
published in the American Journal of Preventive
Medicine in 1998, Volume 14, pages 245–258.
220%
Resiliency and Mental Health
Support!
• Warm Handoff
• Medications
• Referrals
Feeding/Eating/BMI
Breastfeeding
When in doubt, observe breastfeeding in exam room
→ Lactation consultants (WIC and/or CAMC)
→ Nipple Shield
→ Lanolin
→ Supplemental Nursing System
→ Hand Expression
→ Vitamin D (400IU for baby or >2000IU for mother)
Thrush→ Treat baby’s mouth and mother’s nipples!
Formula/WIC
•
•
•
•
First two weeks of life→ 1-1.5ounces every 3-4 hours
2 weeks to 1-1.5 months→ 1.5-2 ounces every 3-4 hours
Up to 4 ounces (q4 hours) by 4 months of age
Up to 6 ounces (q6 hours) at 6 months
---------------------------------------------------------------• IF CONCERN FOR POOR GROWTH→ Make sure
mixing properly→ one scoop powder for 2 ounces water.
• If spitting up, make sure not overfeeding and make sure
slow-flow nipple
Common Feeding Errors
•
•
•
•
•
NO honey before age 1
NO cereal in bottle!
NO solids before 4 months!
NO juice
Can start PB and eggs at 6 months→
evolving research
Developmental Screening
Ages and Stages (ASQ-SE) (3rd revision)
→ Required by Medicaid at 9, 18, and 30 months.
→ Many more ages available, as needed when history
of developmental delay or concerns.
→ If meeting child for first time, tend toward
screening regardless of age under 56 months.
Developmental Screening, cont.
Ages and Stages (ASQ-SE) (3rd revision), cont.
5 categories of development.
• Gross Motor
• Fine Motor
• Personal-Social
• Problem Solving
• Communication
Followed by Yes/No questions with room for comments.
Scoring sheets available at the end of each questionnaire
M-CHAT
→ 11, 18, 20, 22
are the ONLY
ONES that should
be answered, “NO!!”
M-CHAT Score
● Total Score 0-2: No Follow-Up necessary. If child is younger than 24
mos, screen again at 24 mos (or after 3 mos has elapsed). Continue
developmental surveillance.
● Total Score 3-6: M-CHAT/F is important to evaluate risk. If child
continues to score 3 or higher, refer immediately for clinical evaluation
and to determine eligibility for early intervention services. Please note,
if Follow-Up score is 2 monitor carefully, since child may need referral.
● Total Score 7-23: At risk for ASD or other developmental delays.
→ IMMEDIATE developmental referral
What To Do If The Screen is
Abnormal
Birth to Three!!
• They come to child
• FREE!!
• Multidisciplinary Team Evaluation and then, follow up if at least
25% delay (score of 35 or less in ASQ categories)
• IMPORTANT: Meetings/therapy do not have to be at patient’s
house→ can be neutral location (even at health center), as needed
(when mom says, “I don’t want strangers in my home!”).
• Refer ASAP
What if Too Old for Birth To
Three?
• Refer to individual therapy (e.g. Speech/language, PT,
OT)
• ALL KIDS WITH DELAYS, REGARDLESS OF
AGE, can be referred to Dr. Beth Emrick,
Developmental/Behavioral Pediatrician in Charleston
• Long wait list → educate parents to please be patient
Could it be Autism?
Refer for Applied Behavioral Analysis (ABA) and to
Autism Center, if possible
→ Huntington Autism Center
→ Cincinnati Children's
→ Pittsburgh
Birth to Three will do some of the developmental work up
until 3 yo
Immunizations
• Can get report from previous PCP or school nurse or
WVSIIS (need login for this)
• Vaccines are public domain and do not require
consent/release to be obtained.
• Does not need to be a well child visit to give shots!!
Vaccine Contraindications
(Myths and Facts)
“My kid is sick. I can come back for shots.”
→ ACTUAL contraindications to vaccines
→ Otherwise healthy kids who are wheezing
→ Immunocompromised child or pregnant women (Only for
live vaccines (MMR and Varicella and Flumist)
→Kids who are around immunocompromised people
(pregnant or otherwise) CAN received live vaccines.
→ Receipt of steroids (oral or IV) in past 6 weeks.
Teenagers….
• Reproductive Health/Risk-Taking Behaviors
• CT/GC
• Grade A Evidence → every 6 months at age 15-25
• ACEs
• Update social history!
• Alcohol
• Tobacco
• Drug use
• “Do you smoke weed” → marijuana perceived as “not a drug”
Barriers
• Transportation
• School-Based Health—Already in the schools (for summer, anyway)
• Medicaid Transportation--MTM
• Finances
• School-Based Health—Do not collect over insurance reimbursement
• Insurance (or lack thereof—still an issue although less-so)
• School-Based Health—See regardless of ability to pay
• Parental/Guardian Work Schedule
• School-Based Health—Seen without parent/guardian present
• Evening hours
Prevention First:
Improving WellChild Exam
Completion Rates
in West Virginia
A Payor’s Perspective
Sharon Carte
WV Children’s Health Insurance Program
[email protected]
2016 West Virginia
Immunization Summit
June 21, 2016
Charleston Civic Center
Sharon L. Carte, MHS
Executive Director
WV Children’s Health Insurance Program
CHIP – A Commitment to
Prevention and Well Child Visits
• Alignment with Bright Futures Guidelines
• Measuring of CHIP WCV Exam Rates since 2003
• Developmental standardized screening as part of
WCV
• Promoting full screening and completion in
partnership with OMCHF and DOE for KidsFirst
• Promoting Prevention and Well Child exams to
our members and increasing public
understanding
CHIP Well Child Visit Exam Rates:
Birth to 19*
01
4
Co N
u
En n t m
i
ro nu be
lle o r o
d us f
Ch ly
2
ild
H 01
re
4
av
n
in Nu
g m
W b
el er
lV
%
is
it
Y
ea
r
20
14
%
Y
ea
r
20
%
1
3
P
ri
or
Y
ea
r
20
1
2
2
A
ge
G
ro
up
Measure Steward: NCQA/HEDIS: The number of children ages birth to 19 years enrolled for calendar year 2014 who had one or
more well-child visits with a PCP as defined by CPT Codes: 99382, 99383, 99392, and 99393
Well Child
Less Than Or Equal To 15 Months
Third Year Of Life
Fourth Year Of Life
Fifth Year Of Life
Sixth Year Of Life
Total
Adolescents
12 To 19 Years of Age
Total
*Unaudited CHIP administrative data
15
268
264
308
297
15
199
204
232
198
100.0
74.3
77.3
75.3
66.7
95.5
77.1
79.0
74.6
62.9
100.0
81.1
82.3
82.4
64.0
1,152
848
73.6%
73.2%
77.4%
3,235
1,437
44.4
43.2
36.0
4,387
2,285
52.1%
49.0%
36.0%
Increasing WCV Completion Rates:
Ideas & Tools
For PC Practices & CHC’s
• Workflow Analysis of WCV process
• Quality Improvement Projects (improve teen
WCV and adolescent immunizations)
• Check for billing barriers (WCV is electronic,
but manual when modified)
• Turning partial visits into WCVs
Increasing WCV Completion Rates:
Ideas & Tools
For Patients and Parents
• Reminder systems: phone calls, texts,
Facebook
• Partnering with schools to catch stragglers in
school settings; special monthly evening
clinics
• Information brochures, new patient education
Developing a Partnership Strategy:
What works for your community?
Schools
Practices
Payers &
MCOs
Prevention First:
Improving WellChild Exam
Completion Rates
in West Virginia
A Public Health Perspective
Patty McGrew
WVDHHR Adolescent Health Initiative
[email protected]
WVDHHR/OMCFH
ADOLESCENT HEALTH
INITIATIVE
Patty McGrew, Director Adolescent Health Initiative
June 2016
Adolescent Health Initiative
• FORMAL WORK BEGAN IN 1988
• THE ADOLESCENT HEALTH INITIATIVE (AHI) MAINTAINS A
COMPREHENSIVE AND HOLISTIC VIEW OF AN ADOLESCENT'S
HEALTH AND WELL-BEING. THE AHI LOOKS BEYOND INDIVIDUAL
RISK BEHAVIORS TO FOCUS ON THE OVERLAP BETWEEN
BEHAVIORS, THEIR UNDERLYING COMMON CAUSES, AND
SUCCESSFUL INTERVENTIONS.
• THE TITLE V MATERNAL AND CHILD HEALTH BLOCK GRANT
FUNDS A DEDICATED NETWORK OF 8 REGIONAL ADOLESCENT
HEALTH COORDINATORS TO ENGAGE INDIVIDUALS,
ORGANIZATIONS, INSTITUTIONS AND THE COMMUNITY ATLARGE TO ADDRESS NEGATIVE IMPACTS AND CREATE A
SUPPORTIVE ENVIRONMENT IN WHICH ADOLESCENTS CAN
ACHIEVE THEIR FULL POTENTIAL
49
50
Adolescent Well-Visits are a Priority
•
ADOLESCENCE IS MARKED BY COMPLEX PHYSICAL, COGNITIVE, SOCIAL,
AND EMOTIONAL DEVELOPMENT, WHICH CAN BE STRESSFUL FOR
FAMILIES AND ADOLESCENTS
•
PHYSICAL, SOCIAL AND EMOTIONAL CHANGES DURING ADOLESCENCE
INCREASE THE NEED FOR CONTINUOUS, COMPREHENSIVE PREVENTIVE
SERVICES
•
ADOLESCENTS WHO CAN EASILY ACCESS PREVENTIVE HEALTH SERVICES
ARE MORE LIKELY TO BE HEALTHY AND ABLE TO REACH MILESTONES
SUCH AS HIGH SCHOOL GRADUATION AND ENTRY INTO THE WORK
FORCE, HIGHER EDUCATION OR MILITARY SERVICE
•
DURING ADOLESCENCE, THE FOUNDATION FOR LIFESTYLE AND
BEHAVIORS THAT PERSIST INTO ADULTHOOD IS LAID
51
Adolescent Well Visit Surveys
• TWO SURVEY TOOLS WERE DEVELOPED
• Youth
• Parents
• SURVEYS WERE DESIGNED TO BE USED ON SURVEY MONKEY
• Multiple Choice
• “Other”
• SIMPLE AND EASY, WITH A COMPLETION TIME OF UNDER A
MINUTE
• YOUTH “TEST” GROUPS FOR FEEDBACK
52
Adolescent Well Visit Surveys
• YOUTH AND PARENTS WERE SURVEYED STATEWIDE
• Forum/focus group discussions---most in conjunction with
other meetings or events, some stand alone
• Handed out at health fairs, community events, meetings,
etc.
• Links distributed via social media and email
• LOTS OF RESPONSES!!
• 1420 Youth
• 704 Parents
53
Youth Survey
54
Parent Survey
55
Q2: Your (your child’s) Age
YOUTH:
PARENTS:
56
Q3: Your (your child’s ) Race
YOUTH:
PARENT:
57
Q4: Do you have medical coverage (insurance, Medicaid, CHIP, etc.) ?
YOUTH:
PARENT:
58
Q5: Do you (your child) have a regular family doctor or pediatrician?
• BOTH YOUTH AND PARENTS OVERWHELMINGLY SAY THEY DO
HAVE A REGULAR FAMILY DOCTOR:
• Youth
86%
• Parents
90%
• OF THOSE WHO RESPONDED NO:
• Youth chose “I haven’t found a doctor that’s convenient for
me” most often (31%)
• Parents chose “I haven’t found a doctor that I’m
comfortable with” most often (27%)
59
Q6: Do you (your child) have a yearly well-visit (annual check-up)
with your doctor?
• MOST RESPONDED YES:
• 74% of Youth
• 84% of Parents
• OF THOSE WHO RESPONDED NO:
• Top 3 reasons for parents: I don’t think it’s important for my
child to see a doctor when he or she isn’t sick (40%); I can’t
afford it (16%); and Office hours aren’t convenient (15%)
• Top 3 reasons for youth: I don’t think it’s important to see
the doctor when I’m not sick (58%); I can’t afford it (16%);
and I feel awkward going to a doctor for little kids (14.2%)
60
Q7: I would be more likely to get a check-up every year if: (check all
that apply)
61
Q7: My child would be more likely to get a check-up every year if:
(check all that apply)
62
More Education is Needed
• Several parents expressed confusion about what a well-visit
was and how or if it differs from a sports physical
• “I thought I took my child for a well visit, but I learned
today that’s not what it was”
• Lots of questions about insurance coverage
• Youth don’t know if they have insurance or not
• Parents think well-visits aren’t covered
63
More Education is Needed
• Youth felt like it just wasn’t important enough to make time for
• “Why bother? I have things to do”
• “How about a health event for well check-ups and have famous
people there like dirt bike riders or musicians”
• Parents felt like there should be more education about the
importance of well child exams
• “I do not like fighting with my 17 year old to go. Maybe kids
that age should be educated on why it’s important”
• “Parents aren’t as invested in their child’s life. Lack of education
and knowledge”
64
Increase SBHC Utilization and Access
• PARENTS: SCHOOL-BASED HEALTH CENTERS!!!
• “We need health clinics at every school”
• “We love school-based health clinics!”
• “I am grateful to my health center so I don’t have to take my
daughter for her well check ups”
• “I did not realize school based health centers offered wellchild check-ups until the Adolescent Health Coordinator
told me so”
• BOTH PARENTS AND YOUTH: TIME AND CONVENIENCE
• Waiting room times are too long
• Too far to travel, lack of (good?) doctors in their area
• Loss of time from work and school
• “After hours appointments/clinics would be helpful”
65
Promote Teen-Friendly Services
• YOUTH: WAITING ROOMS ARE LAME!!!
• Wi-Fi
• SNACKS!
• More comfortable chairs
• Video Games, tablets, “Nook books”
• Better TV shows
• Teen focused magazines
• Puzzles, games, coloring books, art supplies
• Separate areas from the babies and little kids
• Brighter colors
66
Promote Teen-Friendly Services
• “The clinic should be less depressing. They need colors and
smiling faces. They should have free snacks and a kid room
with games”
• “If there were tablets that have games and we can download
them and not be bored while waiting on exam”
• “I would like the doctor a lot better if the office had Wi-Fi and
less little kids shows or the waiting room had a TV on
programs for teens---and the center had a more friendly
environment---if the chairs were more comfortable maybe
have bean bag chairs”
67
Promote Teen-Friendly Services
• “A clinic that has more variety rather than directly towards
little kids or adults. A bit more teen friendly in both
atmosphere in the waiting room and the staff”
• “Doctors could make it at least somewhat decent of a time”
• “In the clinical area/waiting room can they at least play some
music, do not let it just be quiet and awkward and everybody
staring at each other”
68
Promote Teen-Friendly Services
• BOTH PARENTS AND YOUTH EXPRESSED A LACK OF TRUST,
LACK OF COMFORT AND CONFIDENTIALITY CONCERNS
• “We don’t want parents around for personal reasons”
• “Makes me uncomfortable”
• “If I wasn't afraid to see my weight”
• “The doctor is a very scary place I have been afraid of the
doctor since I was little-maybe better kinder attitudes
would help”
• “I feel like in a small community you have confidentiality
issues, things can’t be unheard and even though it’s against
the law to discuss health records, providers and more likely
their staff discuss with their friends about what goes on in
the doctor’s office”
69
In Summary
PROVIDE EDUCATION ON THE IMPORTANCE OF ADOLESCENT WELL
VISITS, INSURANCE COVERAGE AND AVAILABLE INCENTIVES
• Utilize social media to encourage youth to develop educational
campaigns, public service announcements, etc
• Capitalize on school and community based events to provide
education
• Educate about well-visits while promoting other adolescent health
priorities
UTILIZE PARTNERSHIPS WITH KEY COMMUNITY STAKEHOLDERS
• Pediatric Advisory Board
• HealthCheck
• WVDE--Regional School Wellness
• The West Virginia Well-Child Initiative
• School-Based Health Assembly
• HMOs and insurers
70
In Summary
LEVERAGE MISSED OPPORTUNITIES TO INCREASE ADOLESCENT WELLCARE VISITS
 Encourage parents and providers to incorporate well-care into other
required routine visits such as sports physicals.
 Increase utilization of school-based health services
 Utilize “out-of-the-box” strategies for increasing access
ENCOURAGE TEEN-CENTERED CARE
• Identify and promote providers meeting “teen friendly” criteria;
• Provide education and/or trainings to providers to become more
accessible to youth;
• Create and provide youth friendly materials such as posters,
brochures, etc;
71
Questions? Comments?
PATTY MCGREW, DIRECTOR
ADOLESCENT HEALTH INITIATIVE
OFFICE OF MATERNAL, CHILD AND FAMILY HEALTH
WV BUREAU FOR PUBLIC HEALTH
WV DEPT OF HEALTH & HUMAN RESOURCES
350 CAPITOL STREET , ROOM 427
CHARLESTON, WV 25301-3714
1-800-642-9704 OR 1-800-642-8522
[email protected]
HTTPS://WWW.FACEBOOK.COM/TAGWV/
72
Prevention First:
Improving WellChild Exam
Completion Rates
in West Virginia
A Population Health
Perspective
Kelli Caseman
WV School-Based Health Assembly
[email protected]
Prevention First
What’s the “big deal” about well-child exams?
• Surveillance and screenings- Well-Child Exams are incredibly important for preventing
and screening for illness, disease and developmental delays. They are also a great opportunity for parents to
raise questions and concerns that they may have regarding your child’s development, behavior and wellbeing.
• Affordable Care Act- No co-pays for families- some insurers are providing incentives
(gift certificates, etc.)
• Required for school entry, now 2nd grade entry- with 7
th
grade and 12th
grade requirements coming in future years
•
“Synchronicity” between public and private sectors to
increase rates in our state
Prevention First
What’s the “big deal” about collaborating to increase well-child exams?
• Improve children’s health
• Change generational attitudes and behaviors toward accessing preventive health
care
• Improve data collection- i.e. what we know about the health of West Virginia’s kids
• Improve our referral networks for specialty health care and community services
• Improve our ability to work collectively to connect primary care and public
/community health
•
Improve population health of all kids ages 0 – 21, regardless of where they
live in WV, or socioeconomic status
Prevention First
What is the role of the West Virginia Well-Child Initiative?
Prevention First
WV Well-Child Initiative 2016 Workplan
• Priority Area: Access
• Priority Area: Communications & Data Collection
• Priority Area: Education
• Priority Area: Quality & Standardization
Prevention First
Ways to get involved
• Social Media
• Email list
• Conference calls
• Quarterly Meetings
Questions?
2016