Maine Child Health Improvement Partnership (ME CHIP) Advisory Group Friday, April 8, 2015, 1-2 pm ME CHIP and the First STEPS Learning Initiative is part of the Maine Improving Health Outcomes for Children demonstration grant awarded by the Centers for Medicare and Medicaid Services to MaineCare in partnership with the Maine Center for Disease Control and Prevention, the Muskie School of Public Service at the University of Southern Maine, Vermont’s Medicaid Program, and the University of Vermont. Maine Quality Counts Webinar/Phone Webinar: Audio: , Access Code: #

Maine Child Health Improvement Partnership (ME CHIP) Mission To optimize the health of Maine children by initiating and supporting measurement- based efforts to enhance child health care by fostering public/private partnerships. Vision All practices providing health care to children will have the skills, support, and opportunities for collaborative learning needed to deliver high quality health care. ME CHIP is part of the National Improvement Partnership Network (NIPN)

ME CHIP Agenda 1:00Welcome and review of February minutes, follow-up on ECCS Grant application (Amy Belisle, MD); Welcome to our new QC Child Health Project Manager- Angie Bellefleur and QC Consultant- Dr. Gita Rao 1:05Discuss Help Me Grow Model and the work of the 4 planning groups with DSI Project (Sue Mackey Andrews, Gita Rao, MD) 1:40Update on child health metrics for PTE 1:50Discuss Youth in Transition Workgroup that QC is facilitating for the Office of Children and Family Services (Gita, Amy) 1:55Other Updates: Caring for ME 2:00Adjourn

Prevention (Age 0-5) Lead/Anemia Screening Oral Health of Young Children Adolescent Medicine Teen Depression Screening Social Determinants of Health Adverse Childhood Events Care Coordination Transitions Drug Affected Infants Structure/Process Metrics Chronic Care Asthma ADHD ME CHIP Priority Areas:

5

Maine Child Health Improvement Partnership (ME CHIP) Mission To optimize the health of Maine children by initiating and supporting measurement- based efforts to enhance child health care by fostering public/private partnerships. Vision All practices providing health care to children will have the skills, support, and opportunities for collaborative learning needed to deliver high quality health care. ME CHIP is part of the National Improvement Partnership Network (NIPN) 6

Background on Developmental Screening Work CDS worked to improve developmental screening across state- statewide task force assembled Maine involved in initial ABCD work The Developmental Disabilities Council led a developmental screening pilot in Maine with 5 sites and the CDC Maternal Child Health Director did many grand rounds between on developmental screening DHHS’ Children with Special Health Needs (CSHN) program applied for and was awarded a three-year State Autism Implementation Grant (AIG) of approximately $300,000 annually, funded under the federal Combating Autism Act Initiative with 2 sites in Bangor and Portland

Previous Child Health Outreach Efforts ME/VT awarded CHIPRA grant to improve child health care quality Maine Children’s Growth Council HAT Screening Report CHIPRA demonstration project: Improving Health Outcomes for Children (IHOC) and Maine Quality Counts for Kids did 12 practice pilot called “First STEPS” on developmental and autism screening -CDS, Home Visiting, and Public Health work to improve screening Work at practice level led to call for more coordination across systems with head start, child care, public health nursing, primary care, early childhood education - work came together with IHOC partners and CDC in partnership with DSI-SAIEL group 8

Past and Present Child Health Outreach Efforts Fall Claims based rates on MaineCare Utilization Review (UR reports) Jan Health Homes/PCMH practices required to implement developmental screening First STEPS/DSI/SIM/PCMH/Health Homes trained 100 primary care practices trained and 9 did full MOC project DSI project led Developmental Screening Community Initiative in Waterville, Bangor, MidCoast DSI is exploring the Help Me Grow Model Portland looking at DSCI model for work with community partners, MaineHealth and United Way March ECCS Grant submitted; awards by Aug 1,

Resources Developed Updated MaineCare billing codes for oral health and preventive screening MaineCare made available AAP Bright Futures Toolkit, 3 rd ed. and AAP Autism Toolkit to Maine providers Universal sharing/consent form CDS online referral and CDS consent form to share info about referral List of resources around Early Intervention “Why is Developmental Screening Is Important” handout Understanding Developmental Screening Tips for families Example of a practice workflows First STEPS Periodicity Chart and Poster Developmental Milestones Brochures and Magnets from CDC’s “Learn the Signs, Act Early” First STEPS and DSI work- start to look at cultural implications of screening- webinar 10

11 Change in Care for Maine Kids and Families: Other Reports Show Statewide Improvements in MaineCare Developmental Screening Source: MaineCare administrative paid claims data as reported in: IHOC Summary of Pediatric Quality Measures for Children Enrolled in MaineCare FFY , Muskie School of Public Service, University of Southern Maine, publication pending.

 Early detection and connection to services leads to the best outcomes for children with developmental or behavioral challenges  Identifying and linking all vulnerable children to community-based supports as early as possible is essential to optimal child development Problem Statement  Families, child health providers, and other professionals often have difficulty recognizing when children show early signs of developmental delays or behavioral health issues HOWEVER… EXPERTS AGREE  Even when needs are identified, accessing programs designed to address those needs can be confusing and time-consuming

4 Assumptions of Help Me Grow 1.Children with developmental/behavioral problems are eluding early detection 2.Many initiatives exist that provide services to young children and their families 3.Child health providers, early care education professionals, and others who work with children face challenges in connecting vulnerable children with needed services 4.Children and their families benefit from Help Me Grow, a coordinated, statewide system of early detection and intervention for vulnerable children

All states have comprehensive Help Me Grow systems so that… Families Knowledge of and access to services Support in learning about child development Support in making connections Child Health Care, Early Care & Education, Human Service Providers Identify at-risk children Partner with families to promote healthy development Public officials and other key stakeholders Understand gaps in supports and services Know how to ensure system capacity to meet needs Click to edit Master title style Help Me Grow Vision

The Help Me Grow System 15 Organizing Entity Plan for Statewide Expansion Continuous Quality Improvement Structural Requirements Child health care provider outreach to support early detection and intervention 2 1 Centralized telephone access point for connecting children and their families to services and care coordination Community outreach to promote use of HMG and facilitate networking for families and service providers 3 Data collection to understand all aspects of the HMG system, including gaps in and barriers to services 4 Core Components

There are no wrong doors Sponsored by the Florida Developmental Disabilities Council, Inc. and The Florida Department of Education, Office of Early Learning

17 Help Me Grow in 7 Steps 4 Provider or family contact Help Me Grow 6 Family connected to resources 7 Information loops back to provider from HMG 2 Provider solicits family concerns Identify behavioral and/or developmental concern 3 HMG Care Coordinator provides resources 5 1 Well-child visits (Surveillance & Screening)

Sponsored by the Florida Developmental Disabilities Council, Inc. and The Florida Department of Education, Office of Early Learning Barriers to Surveillance & Screening… …and How Help Me Grow Eases Them Lack of system for linkage to community-based referral resource Help Me Grow is a FREE service that links children to community-based resources No time to learn the range of resources available Help Me Grow maintains a comprehensive, up-to-date resource directory Unfamiliarity with screening tools Help Me Grow can provide trainings on screening tools HMG streamlines the referral process Insufficient time Concerns about cost HMG is a FREE service for all

Maine Community Meeting: The Help Me Grow System  using developmental surveillance at every visit How HMG Provider Outreach Works HMG staff conduct outreach to child health providers on…  using a valid, reliable developmental screening tool at 9, 18, and 24 months (American Academy of Pediatrics 2006 recommendation)  connecting children to services using Help Me Grow, a free, confidential resource that will save you time

Maine Community Meeting: The Help Me Grow System Care Coordinators link families with children to appropriate services and supports. CARE COORDINATORS PROVIDE  assessment of needs and referrals to services  education on development, behavior management, programs  ongoing developmental monitoring & developmental screening  advocacy and follow up Connecting Families to Services

Maine Community Meeting: The Help Me Grow System Why do Community & Family Outreach? A community presence encourages support for and participation in the Help Me Grow system. Regularly meeting with service providers helps build the HMG resource directory and keep it up-to-date.  Networking meetings for regional service providers  Trainings & events for community, parents and child health providers  Partnerships with family- friendly organizations Examples of Community & Family Outreach

The Community Outreach Liaison  Facilitates Community Networking Meetings  Maintains listserv  Is an expert on programs, services, and initiatives in regions—a “living resource directory”  Provides trainings for parents, child health providers, early care and education professionals, and the community  Supports telephone care coordinators  Identifies gaps and barriers

Maine Community Meeting: The Help Me Grow System Tools for Data Collection & Analysis Results Based Accountability All performance indicators can fit into any of the following categories… How much did Help Me Grow do? How well is Help Me Grow doing? Is anyone better off as a result of using Help Me Grow? (Friedman, 2005) Data Collection is in the following four areas: 1.Help Me Grow demographics 2.Nature of presenting issues 3.Referrals by Help Me Grow to service/programs 4.Help Me Grow outcomes * Definitions and Categories provided by Help Me Grow National HMG Common Indicators

Help Me Grow Demographics 31,022 children Number of Children Caregivers: Mothers Providers: Healthcare Mental Health care Early Intervention Who contacted HMG? Data from 12 States

Top 5 Presenting Issues/Concerns Top 5 in order: 1.Communication Issues 2.Behavioral Issues 3.Developmental Concerns 4.Developmental Information & Resources 5.Educational Needs & Resources

Outcomes, Impact & Effectiveness Cost Benefits of “De-medicalizing” Childhood Developmental and Behavioral Concerns Help Me Grow Promotes Optimal Child Development by Enhancing Protective Factors Policy briefs available at

Maine Community Meeting: The Help Me Grow System Maine Stakeholder Findings after Sept 2015 HMG Site Visit Through the course of the site visit, the National Center Team also learned that:  Maine’s early childhood system is rich with caring and dedicated people who are making a meaningful difference across the state.  The DSI leadership team is highly efficient and respected among early childhood programs and services across the state.  Maine has an active and wide-spread United Way system.  ME CHIP is a successful partnership with complementary goals to HMG

Maine Help Me Grow Community Meeting Survey Results It is clear to me why Maine is exploring the Help Me Grow system. Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree 66.6%29.6%3.70%0% Should Maine implement the Help Me Grow system? YesNoI don’t know 70.4%0%29.6% If “yes,” how strongly do you support Maine moving forward with implementing the Help Me Grow system? Strongly favor Somewhat favor Neither favor nor oppose Somewhat opposeStrongly oppose 78.9%21.1%0% This table of percentages is from a total of 27 survey responses.

Maine Community Meeting: The Help Me Grow System Three Structural Requirements An organizing entity  QC is well positioned to initially fill the role of organizing entity. They are highly organized, well networked throughout the state, and have common goals with HMG. Strategy for expanding statewide over time  A plan for statewide expansion and sustainability will need to be developed. Implementation of a continuous quality improvement plan  A continuous quality improvement plan will need to be developed. Data collection and analysis will be the foundation of the quality improvement plan.

Next Steps 4 Workgroups will meet until June based on core components Amy and Angie will attend HMG National Meeting on May th and meet regional partners to learn how they implemented work Recommendations will be made to State Leaders at DSI Meeting on Wed., July 20 th from at Cross Building Final Report will be presented to DSI Steering Group in August for Review Final Report on planning will be completed by September 30,

Child Health Care Provider Work Group Tasks This group analyzes how Help Me Grow child health provider outreach would fit into the community and establishes important relationships in that community. Tasks include: Research and meet with organizations that already provide outreach and/or can serve as entities to manage Help Me Grow provider outreach efforts Establish a relationship with the local chapter of the American Academy of Pediatrics and/or the Academy of Family Physicians Identify potential physician as a Help Me Grow champion if not already secured Make recommendations to the Leadership Team for provider outreach efforts 31

Maine Health Management Coalition | 11 Bowdoin Mill Island, Suite 260 | Topsham, ME | (207) | | Pathways to Excellence (PTE) Pediatric Measures Updates ME CHIP Friday, April 8, 2016

Maine Health Management Coalition | 11 Bowdoin Mill Island, Suite 260 | Topsham, ME | (207) | | PTE Pediatric Measures: Recommended Changes to Asthma and Immunization The following changes to the PTE Pediatric Asthma and Immunization Measures have been endorsed by the PTE Clinicians Steering Committee (at their February 24, 2016 meeting). The Maine Health Management Coalition (MHMC) Board of Directors must know approve these changes (scheduled to be reviewed at April 28 th Meeting). If approved by the Board, these changes will take place beginning in Q4 of 2016 (beginning with the October 2016 GetBetterMaine.org website update). The changes detailed in the following slides were developed and reviewed by a multi- stakeholder workgroup that reported back to the PTE Clinicians Steering Committee.

Maine Health Management Coalition | 11 Bowdoin Mill Island, Suite 260 | Topsham, ME | (207) | | PTE Pediatric Measures: Recommended Changes to Asthma and Immunization Adding “Low” and adjusting minimum patient panel required for full population submittal. The workgroup recommended adding “Low” for those practices that submit to the MHMC’s PTE Program but do not meet the minimum criteria for obtaining a “Good” rating. Currently, practices in this situation appear on GetBetterMaine.org as “Did Not Report.” The workgroup recommended that for both measures the minimum patients required for submittal be 25 for full population reporting, and that the numbers of patients required currently listed in the program technical specifications for chart review remain the same (40 for immunization; 30 for asthma).

Maine Health Management Coalition | 11 Bowdoin Mill Island, Suite 260 | Topsham, ME | (207) | | PTE Pediatric Measures: Recommended Changes to Immunization Adding language to GetBetterMaine.org regarding immunization opt-outs The workgroup recommended (during meetings in June and July of 2015) adding language to GetBetterMaine.org regarding the immunization measure to educate consumers who are looking at this measure that parents are able to opt out of immunizing their children, and that this could, potentially, influence a practice’s rating. Currently, in the rating structure, there is no direct consideration of patents who choose to opt out of recommended immunizations for their children.

Maine Health Management Coalition | 11 Bowdoin Mill Island, Suite 260 | Topsham, ME | (207) | | PTE Pediatric Measures: Recommended Changes to Immunization Adding language to GetBetterMaine.org regarding immunization opt-outs (continued) After considerable discussion, the group decided that by putting this, there should also be some information about the importance of immunizing children as it relates to overall health. The group then decided that this would be too cumbersome, and decided to nix the suggestion for adding any sort of language around opt outs in general.

Maine Health Management Coalition | 11 Bowdoin Mill Island, Suite 260 | Topsham, ME | (207) | | PTE Pediatric Measures: Recommended Changes to Asthma Spirometry measure considerations Though no recommended changes were made by the workgroup to the current measure technical specification regarding documentation of spirometry, the workgroup did feel it was important to ask for clinical feedback on the measure requirement of the documentation of spirometry (due to discussions around this requirement in previous clinical reviews of the PTE Pediatric Asthma measure). Those attending the workgroup meetings cited the National Heart, Lung, and Blood Institute (NHLBI) guidelines that are every 1 to 2 years for lung function testing using spirometry.

Maine Health Management Coalition | 11 Bowdoin Mill Island, Suite 260 | Topsham, ME | (207) | | PTE Pediatric Measures: Recommended Changes to Asthma Spirometry measure considerations (continued) Clinical feedback on this did bring concerns of resources, as well as the possible option of using peak flow for lung function testing. The workgroup, after reviewing this feedback, decided to stay with the requirement of documentation of spirometry (for the lung function measure within the PTE Pediatric Asthma measure, the requirement is documentation of spirometry completed at least once in the last 24 months). The group did discuss staffing and resource concerns. There were many in the workgroup who felt that spirometry is the NHLBI guideline, and therefore should be what is included in the measure.

Maine Health Management Coalition | 11 Bowdoin Mill Island, Suite 260 | Topsham, ME | (207) | | PTE Pediatric Measures: Recommended Changes to Asthma Spirometry measure considerations (continued) No one disagreed, but folks were concerned that the point structure might not be achievable/fair for those practices that are not able to do spirometry for their patients Some workgroup members noted that even if a practice documents no recording of spirometry in a 24 month period, it is still possible for that practice to receive a “Best” in the current point structure, assuming they are performing well on the other individual measures within the asthma composite.

Maine Health Management Coalition | 11 Bowdoin Mill Island, Suite 260 | Topsham, ME | (207) | | PTE Pediatric Measures: Recommended Changes to Asthma Spirometry measure considerations (continued) The workgroup decided to consider changing the point structure for this. One suggestion was to say that if a practice reaches a certain percentage of documentation of spirometry for their patients, they get all of the points (e.g., if the practice percentage is 70% or higher, they get all the points available for that section, and anything less than 70% gives them that percentage of the full points available—if a practice rate was 65%, they would get 65% of the 13.5 points available). Using the practice rate multiplied by the available points for each measure within the measure set is how the other measures are scored.

Maine Health Management Coalition | 11 Bowdoin Mill Island, Suite 260 | Topsham, ME | (207) | | PTE Pediatric Measures: Recommended Changes to Asthma Spirometry measure considerations (continued) Some workgroup members made available CDC rates of intermittent versus persistent asthma Generally, the rates demonstrate about 1/3 intermittent and 2/3 persistent (rates vary by state) Ask of the PTE Clinicians Committee: Should the scoring be adjusted so that if a practice reaches a rate of 70% or higher of documenting spirometry for asthma patients at least once in the past 24 months the practice receives the full points for this measure? Results from PTE Clinicians Steering Committee Meeting on February 24, 2016: The Steering Committee endorsed keeping the spirometry measure calculation as is—not adopting full credit at a certain percentage rate.

Maine Health Management Coalition | 11 Bowdoin Mill Island, Suite 260 | Topsham, ME | (207) | | PTE Pediatric Measures: Recommended Changes to Asthma Tobacco Exposure versus Tobacco Treatment/Cessation The workgroup recommended (during meetings in June and July of 2015) including tobacco cessation advice/treatment as a condition of counting a patient within the numerator for this specific measure. The current requirement is only documentation of tobacco exposure for the patient, not tobacco cessation advice/treatment.

Maine Health Management Coalition | 11 Bowdoin Mill Island, Suite 260 | Topsham, ME | (207) | | PTE Pediatric Measures: Recommended Changes to Asthma Tobacco Exposure versus Tobacco Treatment/Cessation (Continued) After considerable discussion, the workgroup recommended not changing this measure. The reason behind this was the difficulty in capturing this data accurately, and truly defining what cessation advice/treatment means (is it a conversation, handing a patient/family a pamphlet on tobacco use, directing the patient/family to the state tobacco quit helpline, etc.). Folks liked the idea of connecting patients/families to the helpline, but there were worries that this would be difficult for some systems to document (though some currently can). So, this is tabled for now and will be looked at in the future.

UPDATE ON YOUTH IN TRANSITION WORK GROUP

UPDATE ON CARING FOR ME

Caring for ME Introduction: The current opioid and heroin epidemic in Maine presents an enormous public health challenge and requires creative, collaborative, and innovative approaches. With 272 Mainers dying and 1013 babies affected by this epidemic in 2015 and thousands of Mainers actively suffering from addiction, this issues calls for immediate and collective action. Maine is a strong and resilient state and can successfully address this epidemic by bringing together our clinicians and communities, building on our unique strengths, and committing our shared leadership and compassion to protect the health and well-being of people in our state. Caring for ME - Be Part of the Solution! Recognizing the need for creative and bold solutions, Maine Quality Counts (QC) is launching “Caring for ME”, a collaborative effort that aims to bring together a wide set of partners to promote shared messages, educational resources, and practical tools for health care providers. The goals of Caring for ME are: to support prevention efforts maintain a compassionate and trauma-informed approach to chronic pain management improve the safety of opioid prescribing appropriately diagnose addiction when it exists and improve access to effective treatments for patients with substance use disorder Tools & Resources for Health Care Providers*

Next Steps If ME CHIP members are interested in joining the HMG workgroups- please let Amy or Angie know. Next meetings are April 15 th and 29 th Developmental screening materials will be sent out to PCMH/Health practices end of April. Please let us know if you have resources to include MAAP meeting is at the next month- register soon! (See next slide) We will be changing to ZOOM videoconference this summer- will need to update calendar info.

Annual MAAP Meeting Saturday, April 30 Opening Keynote: Behavior Management/ADHD in Medical Practices Morning Plenary Talk: Medical Obesity Luncheon Keynote: "CBT Plus: Making Evidence Based Psychotherapy Accessible to Youth and Families in Maine" Afternoon Keynote: Adolescent Opioid Addiction: Awareness, Understanding & How to Respond Afternoon Plenary Talk: Early Literacy & Brain Development and Raising Readers Success Sunday, May 1 Setting the Stage: Depression and Anxiety among Youth in Maine Opening Keynote : 'Opportunities For the Prevention of Depression in Families' Closing Keynote: Self-Injurious Behavior

Upcoming Dates Future ME CHIP Meeting Dates (2 nd Friday, alternating in person and by phone) We are changing to zoom technology this summer! Friday, June 10, 2016, 12-2 in person, QC Friday, August 12, 2016, 1-2 by phone Friday, October 14, 2016, 12-2 in person, QC ME CHIP subgroup on ACES/Tools/Learning Collaborative: next meeting if April 27 th from 2-3:30 at MaineHealth in Portland and by phone

ME CHIP Contact Information Amy Belisle, MD, Director of Child Health Quality Improvement, Maine Quality Counts, / , 1002 Sue Butts-Dion, First STEPS Program Manager, Quality Specialist, Maine Quality Counts, / Deb Gilbert, QC for Kids Administrative Coordinator, / x 1017 Angie Bellefleur, QC Child Health Program Manager, Gita Rao, MD, QC Consultant, Sue Mackey Andrews, QC Consultant,