Systemwide Interventions to Reduce
Di
Disparities:
iti
Preventive and Developmental Care in
Community Systems
Moira Inkelas, PhD
UCLA School of Public Health
Peter Margolis, MD PhD
Robert Kahn, MD MPH
Cincinnati Children’s
Children s Hospital Medical Center
27 June 2010
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Overview
• Performance gaps
• Moving from practice to community systems
change
h
• Using population care management strategies
across community
it organizations
i ti
• Improvement methods and measurement
2
Improving
p
g Care for Young
g Children
• Childhood sets the scaffolding for lifelong health,
health
development, learning, and participation in civic
society
• Growing rates of behavioral and learning problems
• Only
O l 30
30-50%
50% off developmental
d
l
t l problems
bl
identified
id tifi d
before school entry
• Disparities
Di
iti in
i patient
ti t centered
t d medical
di l h
home ffor
children, by household income and race/ethnicity
How can we promote healthy development
development, prevent
problems, and identify concerns earlier?
3
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Developmental Screening, by State
Source: National Survey of Children’s Health (2007)
4
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Developmental Screening Rates for Publicly
Insured Children, by State
Source: National Survey of Children’s Health (2007)
5
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Daily Reading for Latino Children (1-5), by State
6
Challenges for Pediatricians in
P
Preventive
ti C
Care
• Demands of daily practice (numbers of patients,
scope of practice, many family needs)
• Increasing expectations for care
 Bright Futures
 Developmental and autism screening
• Effective communication with parents
• Resources
R
ffor d
developmental/behavioral
l
l/b h i l iissues
• Lack of EMR and other office systems that
organize care and help to stratify
f based on need
What Processes Do We Work On
• Use of structured screening tools
• Eliciting parent concerns
• Reliable
R li bl and
d effective
ff ti systems
t
ffor preventive
ti
services/ parent education
 Tailoring
T il i guidance
id
tto parents
t b
based
d on need
d
 Stratifying, tracking and follow-up of patients
b need
by
d and
d risk
i k
• Use community resources effectively
 Hand-offs and parent preparation
Improvement Methods Improve Rates of
Developmental Screening
100%
80%
60%
40%
20%
0%
Month 1
Month 6
Month 12
Month 15
For each month of the Collaborative, shows the average rate among practices
of structured developmental screening at 9-, 18- and 24 month visits
9
Moving From Practice Change to
C
Community
it Systems
S t
Change
Ch
• Despite e
excellent
cellent impro
improvements…
ements
 It is hard to sustain changes that are stymied by
limits in another part of the system
system.
• We can get much better results by bringing
multiple sectors together to work toward a system
• Need collaboration to make changes that keep the
larger system in balance
10
Every
y system
y
is perfectly
p
y designed
g
to
achieve exactly the results it gets
Therefore: New levels of p
performance can
only be achieved by re-design of existing
systems
Public Agencies with Recognition & Response Responsibilities/Activities, Los Angeles County
FEDERAL
STATE
IDEA Part B and Part C
Dept of
Developmental
Services
Office
of Child
Care
(CCPC)
STEP
Regional
Center
RC 3+ yrs
Early Start 0-3
Family
Resource Ctr
Westside NLARC
Harbor
Lanterman
East LA
SCLARC
San Gabriel/Pomona
Head Start/
Early HS
Dept of
Education
COUNTY
WITHIN
COUNTY
CCDBG
Local Ed
Area
(LEA)
Part B &
Part C
LAUSD
LACOE
Other LEAs
SCHIP
Managed
Risk
Medical
Insurance
Board
(MRMIB)
LACOE
L.A. Care
Blue Cross,
CHP, Care
1stt , Kaiser
Dept of
Ag
Medicaid
DHS
Medi-Cal
Managed
Care
Division
(MMCD)
DPH/CMS
Child
Health &
y
Disability
Prevention
(CHDP)
HealthNet
Dept of
Mental
Health
DPH
MCH
LAC
DMH
LAC
CHDP
Molina
Resource
& Referral
WIC
Medical groups and IPAs
PHFE
LA Biomed
NEVHC
Long Beach
Other WICs
Pathways
Connections
for Children
CCRC
Other R&Rs
Contracted
CBOs
Primary Care Clinicians, Early Care and Education Settings
Parents/Children
Includes only agencies with a general population focus (i.e. excludes CAPTA activities of DPSS, DCFS); excludes social services, local family support)
12
Assumptions:
p
Our Current Situation
• Improvements in individual service sectors will not be
enough to change outcomes
• Silos
Sil are a problem
bl
and
d cause excess work
k
• Children and families are served by clusters of service
providers so a network approach can work
providers,
• Organizations focus on providing excellent programs,
not on aligning their work toward shared ECD outcomes
• The existing “portfolio” of care and supports is not yet
balanced to achieve population impact
Using an Improvement Framework
f a Community
for
C
it System
S t
• Unites providers and sectors around common aims,
aims and a
common change process
• Focuses on improvements that are:
 aligned to have large impact
 achievable with current resources
 valued by those who would implement them
 reliable and robust when community resources expand or
contract
Collaboration is essential
14
Aim: A community system approach to optimize healthy development
Policy and organization
Leadership,
shared vision,
collaboration
Capacity and
capability for
support
Quality
improvement
supports
Performance
measurement
Incentives
and
motivation
Delivery of services/supports
Direct care delivery
(H lth promotion
(Health
ti
and
d
parenting education)
Hand-offs, flow and
connectivity
Population care
management
Parents
Expectations
for care
Experiences
with care
Family function
Preparation
for care
Outcomes
Positive parentchild interactions
Costs/value
Children’s
health/development
outcomes
What Could Each Group Do In a
B tt System?
Better
S t ?
• Family/parent
 Appreciate how children develop, take note of their own child’s
development, have skills to share observations or concerns
with
i h professionals
f
i
l
• Early care and education
 Have skills and confidence to discuss development and
learning with parents, promote enriching parent-child activities
through parent education, tailor activities to children’s needs
• Medical practices
 Discuss development and learning with parents, promote
enriching parent
parent-child
child activities,
activities connect parents with
appropriate preventive and intervention supports
• Community agencies
 Provide parent education and support, reliable hand-offs and
information flow
16
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Population Care Management: How
Can We Have the Greatest Impact?
Goal: 100% of
children reach
their full
potential
Loss: The
potential that
children are losing,
for which we have
effective, feasible
interventions
Hypothetical
H
h i l
distribution of risk in a
population of young
children
% of
population
potential lost by
children in the
lowest decile
% of
population
potential lost by
children in the
middle 50%
% of
population
potential lost by
children in the
upper 40%
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Improvement Goals Target Different Risk Groups
Goal: 100% of
children reach
their full
potential
Prevention and
promotion
Specialized
response
Secondary
prevention and
risk reduction
Development
p
is influenced byy direct experiences
p
with the family,
y, community,
y,
and providers of services/supports. What improvements will lead to
providing the right care to the right children at the right time?
Designing Care to Achieve the Triple Aim in
Community Systems: Outcomes, Experiences
and Value
• Define and standardize care for each risk category
• Reliable performance in the care/supports that affect
outcomes
• Innovation in design ideas and strategies that can go to
scale
• Process improvements methods targeting systems, not
individuals
• Regular measurement
Population Care Management for
Child
Children
with
ith Medium
M di
Risk
Ri k
EDSI
Earlyy Developmental
p
Screening
g and
Intervention Initiative
• The most learning can take place in this group
 Care for them is least defined, most unpredictable
and inconsistent
• This category of children can yield the most
improvement
p
and functionalityy
• Large enough group to work with
• Small enough
g g
group
p to handle in p
planning
g and trying
y g
to standardize care/supports
Standardizing Care: How
O
Organizations
i ti
C
Can W
Work
k Diff
Differently
tl
EDSI
Earlyy Developmental
p
Screening
g and
Intervention Initiative
• Use common definitions and classifications of risk
• Assess and respond to a common set of needs for
services/supports
• Safe hand-offs (referral checklists, preparing parents for the
referral)
• Standardize information flow
• Regular feedback to referring providers
• Share information about available resources
Risk Stratification for Diabetes
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Source: UNC
Stratification for Developmental Risk
Examples
p
of Changes
g
• WIC program: Add a session that builds parent skills for talking
to doctors and teachers, into WIC’s mandated parent education
(build parent confidence to talk about development)
• School districts, Regional Centers, mental health: Develop a
“parent contact form” so doctors/ECEs can coach parents on
what to tell the referral agency
agency, and parents can report back to
the doctor/ECE what they were told (connect children with
needed services/supports in a timely way)
• Family resource center: Develop parent-to-parent training on
activation and self-management, focusing on moderate
family/developmental risk (enhance positive home behaviors
and increase parent social support)
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Developmental progress at school entry
Developmental progress ages 1‐4 years
Care processes & experiences for children 0‐
5
% of children 0‐5 who are reached by h db
network improvements
3rd grade grade
reading proficiency
Stressors in families with children 0‐5
Outcomes: Developmental Progress by
Thi d Grade
Third
G d
• Green bars show the % of children who are “very
very proficient”
proficient or
“proficient” in third grade reading
y and for children
 Shows rates for all children in the community,
whose parents have less than high school education
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Shows 2009 data for the 12 LAUSD schools in the Magnolia Community Initiative area
26
Care Processes and Experiences with Care
Are parents being asked if they have any concerns about
the child
child’ss development
development, learning or behavior?
•
•
•
•
Green line is the target goal set by the community
Green triangles show rates for parents surveyed in offices of local
doctors working to improve in a Learning Collaborative
Blue diamonds show rates for parents surveyed in local ECE
settings working to improve in a Learning Collaborative
Yellow squares show rates for parents in a community sample
((surveyed
y at WIC centers))
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27
Measuring Reach of Improvement Efforts
to the Population of Children
C
in the Area
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28
Reaching
g All Young
g Children
Reaching
g children
through early care and
education settings
Reaching
children through
primary care
practices
I P i
In Pacoima: 9,000 children 0‐5 yrs
9 000 hild
05
In WIC (98% of those <185% FPL): 6,000 children 0‐5 yrs
(
) ,
y
Participating primary care practice #1
C
Participating primary care practice #2
ECE #1
ECE #2
ECE #3
ECE #3
ECE #4
ECE #5
Summary
y of Our Goals
EDSI
Earlyy Developmental
p
Screening
g and
Intervention Initiative
• Develop prototypes of community systems that
achieve better population outcomes, using
improvement
p
science
• Offer support so that practices can achieve greater
efficiency and satisfaction with preventive care
• Find sustainable and scalable strategies for getting
better results
• Build a cohort of champions who have gotten results
• Increase understanding of what it will take to achieve
and sustain better practice
30
Acknowledgements
g
• UCLA Center for Healthier Children,
Children Families and
Communities
• UCLA School of Public Health
• Cincinnati Children’s Hospital Medical Center, Center
for Health Care Qualityy
• First 5 LA
31