Communities Coordinating for
Healthy Development:
Minnesota’s ABCD III Initiative
National Academy for State Health Policy
Annual Conference
October 5, 2011
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Project Overview
• Purpose of the project
– To improve linkages between primary care
providers, medical specialists, and other child and
family service providers in the community to
support the healthy development of Minnesota’s
children ages birth to 3 years
– Build upon previous initiatives (ABCD II and ABCD
Screening Academy)
– Focus is on referral, care coordination and building
a system within the community
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Project Structure
• 4 pilot community teams including: a clinic
and early intervention, plus public health,
Head Start, and others
• Clinic has a designated care coordinator
• Clinic conduct universal developmental and
mental health screening
• Early Intervention program willing to work
with clinic staff to improve referrals
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CCHD Participating Communities
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Team Project Participation
• Attend annual in-person learning collaboratives
• Participate in monthly technical assistance
phone calls and/or webinars
• Hold regular, local team meetings (monthly)
• Use Model for Improvement PDSA cycles for QI
• Participate in project evaluation activities
(monthly data submission, annual surveys)
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Technical Assistance to Teams
• Attend team meetings
• Assist with quality improvement process
• Help teams figure out how to collect the evaluation
data at their site
• Provide sample forms and materials from other sites
or states
• Assist in setting up and using the Access database for
tracking
• Topical webinars over the lunch hour
• Annual learning collaboratives
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Technical Assistance Webinars
• October 2010 - Screening and Referral
• November 2010 - Help Me Grow and Care Coordination
• February 2011 – Implementing screening tools and a referral
system (Park Nicollet Clinic System)
• March 2011 – Data gathering and tracking for HMG (Wilder
Research)
• April 2011 – Coding and Billing
• May 2011 – ABCD III Baseline Data
• Upcoming – Help Me Grow/IEIC restructure and how to
engage and involve parent partners
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Community Based Activities
• Community teams meeting regularly
• Clinic consent forms in use
• Teams using referral/feedback forms between
HMG and clinic
• Written protocols for clinic flow and
clinic/early intervention communication
• Clinics using Access database or other tracking
system to support care coordination
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Health Care Home Helps
• Parallel activities to HCH requirements and
measures:
– Access data base meets all HCH referral tracking
requirements
– Care coordinator role similarly defined
– Expectations regarding follow-up
– A clinic improvement team in place w/parents
• Most participating clinics viewed ABCD III as
step toward preparing for Health Care Home
certification
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Systems Based Activities
• Joint Human Services and Education Dept. trainings to
enhance billing for early intervention services
• Continued work on consent forms w/Dept. of Ed
• Enhancing early intervention statewide on-line referral
to give providers local contact info for follow-up
• Refining data base
• MOC4 application
• Developing standardized referral and feedback forms
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St. Luke’s Clinic Referral Process
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St. Luke’s Clinic Referral Process
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St. Luke’s Clinic Referral Process
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Evaluation & Measurement
• Frequency: baseline and each subsequent year
of the grant for most measures
• Five surveys:
– Parent
– Provider
– Help Me Grow/Early Intervention staff
– Clinic administrators
– Care Coordinators
• Clinic tracking data, monthly reports
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Provider Referrals
Strongly Agree
Somewhat agree
Somewhat disagree
0
2
4
6
8
10
12
Understanding of developmental referral options
Understanding of mental health referral options
Comfortable referring to HMG
Kinds of services children receive @ HMG
Comfortable referring to medical specialists
Comfortable referring to community services
Confident most appropriate referral made
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Parent Survey
• Majority of parents said they completed a
questionnaire of child’s development (63%) and
mental health (56%) some time in the last year
• Less than ½ of those whose provider noted a
concern were referred to HMG
• Parents reported referrals most often to
specialists (18%), followed by community
services (10%), Early Intervention (7%)
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Parent Survey
• Providers discussed next steps with ½ of those
receiving mental health screening and 62%
receiving developmental screening
• 12% of families indicated they were receiving
care coordination from their clinic
• 7% said that they need someone to
coordinate their child’s care
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Early Intervention Referrals since January, 2010
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What We’ve Learned
• Office flow very individualized, everyone has to invent
their own wheel, would be hard to role out en masse
• Written protocol an important step
• State agency restructure of EI changed local contacts
• Clinics in the midst of other projects (EMR) struggled
• Helps for clinic and EI staff to meet each other
• Some EI programs discouraging “too many” referrals –
2 way communication helps build trust on both sides
• Previous clinic experience with QI important, or teach
it to them
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Contacts
• Glenace Edwall: 651.431.2326
glenace.edwall@state.mn.us
• Susan Castellano: 651.431.2612
susan.castellano@state.mn.us
• Meredith Martinez: 651.431.2623
meredith.martinez@state.mn.us
• Ruth Danielzuk: 651.431.2061
ruth.danielzuk@state.mn.us
• Catherine Wright: 651.431.2336
catherine.wright@state.mn.us
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