Improving Quality for
Children—Approaches to
Building State Capacity
Charlie Homer, MD, CEO
Child Health Services Research Meeting
Academy Health, 2005
Problem Statement
 Quality chasm is widespread
 Quality chasm affects the care of children, youth and
families as it does adults
 Health care for children is:
 Predominantly outpatient
 Locally delivered and organized
 State regulated
 Substantially funded through state programs
 Major state public health role (e.g., immunizations,
newborn screening)
Requirements for improvement
 Will to improve
 Better Ideas
 Assistance with Execution
 Training
 Tools
 Support
 Business Case
National improvement programs may have
limited local impact

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
Cost
Distance
Credibility
Practical assistance
Variability in financial context
Numerous potential state based resources
to support improvement
 Professional society/medical association chapters
 Health Department
 Immunization programs
 Title V (Children and Youth with Special Health Care
Needs)
 State universities
 Medicaid Agencies
 Combinations of the above
Children’s Quality Initiatives
State Approach
NICHQ Initiated
Improvement Program
Professional Society
Partnership for Quality
(ADHD)—AHRQ
Public Health: Immunization
NJ, other
Public Health: Title V
Medical Home Learning
Collaborative
Combination
Improvement Partnership
(VCHIP, envision NM, etc.)
Aim: Medical Home Learning Collaborative
 To improve care for children with special health care
needs/youth by implementing the Medical Home
concept
 To foster substantial relationships between Title V
programs and their state’s primary care community,
enabling Title V to:
 Support improvement in practices and
 Spread improvement across their State
Why Title V: The Title V Mandate
 OBRA 1989
 Healthy People 2010
 Objective 16.23
 Six defining outcomes
 The New Freedom Initiative
Six outcomes
 Family participation at all levels
 A medical home for each child with special health
care needs
 Adequate coverage
 Screening
 Family-friendly community systems
 Transition services
Why focus on systems for children with
special health care needs
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The complexity of children’s lives
The scope, scale and range of children’s special needs
The inadequacy of baseline supports
The gap between social needs and private resources
The central place of medical home
 As a critical point of parent connection
 As hub of services
 As locus at which remaining 5 outcomes may be
addressed, operationalized, tested
The medical home from a Title V
perspective
 Where the action is for children and families
 Meeting place for powerful constituencies
 Public health at the molecular level
IHI Breakthrough Series™
(12 month time frame)
Participants (10-100 teams)
Select
Topic
(develop
mission)
Expert
Meeting
Prework
Develop
Framework
& Changes
Planning
Group
Dissemination
P
A
P
D
A
S
P
D
S
LS 2
LS 1
A
AP1
AP2
D
S
LS 3
AP3
AP – Action Period
Publications
Congress
etc.
Supports
LS – Learning Session
Holding the
Gains
Email (listserv)
Visits
Phone Conferences
Assessments
Monthly Team Reports
Modifications to BTS Design
 “Participants”=
 11 State Title V Programs, each of whom recruited
 3 Primary Care Practice Teams
 Faculty=
 Clinical, Title V, and Parent Chair
 Teams=
 Physician, Staff (Nurse/Care Coordinator), Parent
 Topic=
 Medical Home, aka, Chronic Care Model for CYSHCN
Faculty and Staff
Faculty and Staff
 Faculty Leadership
 Chair: Carl Cooley
 Co-Chairs: Debby Allen, Alan
Kohrt
 Director: Jeannie McAllister
 Improvement Advisor: Jane
Taylor
 Staff
 Lisa Horvitz, Colleen
O’Rourke, Sandra Cragin
 Faculty
 Maureen Mitchell,
Family Voices
 Betty Pressler, Judy
Palfrey, Margaret
McManus, Chris Stille,
Richard Antonelli, Amy
Gibson (AAP), Lois
Kohrt
Participants- State Title V Agencies





Connecticut
Colorado
Florida
Ohio
Oklahoma
+ North Carolina


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Louisiana
Michigan
New York
Utah
Virginia
Wisconsin
Participants Teams-Practices
 3 Teams from each State
 43% Community Based, Group Practice
 22% Community Hospital or Network Group Practice (e.g.,
Marshfield Clinic, Bassett Health)
 25% Academic Primary Care Sites
 9% Solo Practice
 Team Members
 Physician, nurse/other office staff/care coordinator, parent
partner
Key Concepts
 Medical Home/Care Model for Child Health
 Model for Improvement
 Model for Spread
Medical Home is

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
Accessible
Family Centered
Continuous
Comprehensive
Coordinated
Compassionate
Culturally Effective
Care Model for Child Health in a Medical Home
Health System
Community
Resources
and
Policies
Health Care Organization (Medical Home)
Care
Partnership
Support
Supportive,
Integrated
Community
Family centered
Delivery
System
Design
Decision
Support
Informed,
Activated
Patient/Family
Timely &
efficient
Evidence-based &
safe
Clinical
Information
Systems
Prepared,
Prepared,
Proactive
Proactive
Practice
PracticeTeam
Team
Coordinated and Equitable
Functional and Clinical Outcomes
Model for Improvement
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in an
improvement?
Act
Plan
Study
Do
Diffusion or Spread
COMMUNICATED
“BETTER
IDEAS”
In a certain way
Happens
over time
Thru a SOCIAL system
Adapted from Rogers, 1995
(C) 2003, Sarah W. Fraser
Measures
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ED visits
Hospitalization rates
Family worry
Front office satisfaction
Medical Home Index
Care Plans
Practice Satisfaction
Medical Home Learning Collaborative
MHI Pre and Post Measures
8
7
6
4.8
5
4
5.27
3.98
3.45
5.13
3.67
4.69
3.5
3
4.46
4.42
4.79
3.42
3.2
2.7
2
1
OrgCap
CCM
CC
CO
MHI-2003April
DM
MHI-2004Jan
QI
Total
Results-Quantitative
Qualitative Results: Title V
 Most valuable activities and insights:
 Conduct walk-throughs of practices—leading to
learning
 Connect teams to state resources
 Assist with care coordination
 Outreach to broad variety of audiences
 Practices need help working with families
 Positive impact on how to implement change
and promote adoption of new models
Qualitative Results-Parents
 Parents can be very effective in this process
because they can counter assumptions health
care providers make about the way things
work"
 "There are things I can do, like pre-register
my child for appointments...my pediatric
clinic and the hospital are willing to do
[many things] to make things better for my
family. I never would have known what to ask
for, as a new parent, before the medical
home training"
Qualitative Results-Practices
 The MHLC "helped the practice focus on
achievable steps to initiate a true medical
home“
 "the small changes have made a world of
difference in our practice...
 Specific changes (self-report)
 70%
 64%
 63%
 60%
 50%
streamlining access
have designated care coordinator
working with community agencies
partnering with families
using some form of registry
Lessons Learned
 Feasible to address improvement using non-categorical
approach
 Parent involvement essential
 Requires planning and support
 State/practice interaction feasible
 Strengthened by broader coalition (funders, professional
societies), greater training
 Reform/improvement efforts require coordination
 Although CYSHCN broad category, efforts may remain
in silos
 It’s a great thing to do!
A Sonnet
When to NICHQ Learning Sessions we go,
We summon up remembrance of tasks past.
We sigh the lack of many a thing we know,
But have hope to make Medical Home last.
In the Northwoods our Wisconsin team met,
To have a group retreat and plan ahead-The practice teams’ commitment was set,
And we shared Title V’s vision for spread.
Then children and families noticed change;
care plans, identification and more
all became part of Wisconsin teams’ range
with the Chronic Care Model as their core.
So, till the State Budget grants our evr’y wish,
we will persevere—our defining niche.
The Job of Title V
(Deborah Allen)
To the tune of “He’s Go the Whole World in
His Hands ”
They got a coalition that won’t quit,
Got doctors, families, payers, to commit.
There’s not a single player, they omit,
Cause that’s the job of Title V.
TA to every practice, helps docs see,
How to engage kids’ parents, meaningfully.
Don’t want no tokenism, no siree,
That wouldn’t sit with Title V.
They’ve built a database that’s deep and wide.
They’ve listed every resource, in that guide.
They’ve found each scrap of info, that applied,
Cause that’s the job of Title V.
They’re gonna build a network, that’s a fact.
Where all the service systems, interact.
‘Til then they’ll have to plan, do, study, act,
Cause that’s the job of Title V.
MHLC II
8 Additional States
 DC, IL, ME, MD, MN, PA*, TX, WV,
Expansion of State Teams
 Include AAP/AAFP Chapter Representative
 Include Insurer (Medicaid) on Team
 Predominant Focus on Supporting Practices
Other Diffusion
 Several State Wide Collaboratives
 Change in Function and Activity National Center for
Medical Home