NASBHC National Collaboratives in Quality Improvement - Practice Management, Mental Health and Preventive Services Laura Brey, M.S. Holley Galland, M.D.

Objectives: Able to describe the development of quality standards for the model of school-based health centers and the similarities to standards in family medicine Able to discuss the process and tools used by the collaboratives to assist health centers progress toward the achievement of the standards Able to state the effect of the collaborative technical assistance and training programs on participating school-based health centers and how these programs might be used in family medicine

Bringing Health Care to Schools for Student Success!! Washington, DC or toll free

VISION WE ENVISION schools and communities working together to ensure that all children and adolescents have access to health care.

WE BELIEVE… schools are an excellent and time-proven place to provide health care. WE REPRESENT… those who support, receive and provide health care in schools and school-connected programs. WE ADVOCATE… for national and state policies, programs and funding that sustain, grow and integrate school-based health care into our nation’s health care and education systems.

WE PROVIDE… leadership, resources and technical assistance to enable school-based health centers to deliver high quality services, become financially stable, and play an active role in public policy. WE SUPPORT… the growth of state and regional school-based health care organizations and networks.

NASBHC Membership School-Based Health Centers and the interdisciplinary professionals who work in them Individuals and Organizations who support our advocacy mission

School Based Health Center National Definition Partnerships created by schools and community health organizations to provide on-site medical and mental health services that promote the health and educational success of school-aged children and adolescents One of the partners, usually a community health organization, becomes the sponsoring agency

The History of Standards for SBHCs Direction over time – Informal to more formal – Local to state to national 1980’s- no uniform standards, determined by funding and reporting requirements 1990’s - state standards developed, NASBHC Principles, CQI tool

Principles for School-Based Health Care set a national standard for the field provide guidelines by which to benchmark programs; define the essential elements of school-based health care; and provide a framework for accountability and continuous improvement NASBHC, 2000

Supports the School The school-based health center is built upon mutual respect and collaboration between the school and the health provider to promote the health and educational success of school-aged children. principles

Responds to the Community The school-based health center is developed and operates based on continual assessment of local assets and needs. principles

Focuses on the Student Services involve students as responsible participants in their health care, encourage the role of parents and other family members…, and are accessible, confidential, culturally sensitive, and developmentally appropriate. principles

Delivers Comprehensive Care An interdisciplinary team provides access to high quality comprehensive physical and mental health services emphasizing prevention and early intervention. principles

Advances Health Promotion Activities The school-based health center takes advantage of its location to advance effective health promotion activities to students and community. principles

Implements Effective Systems Administrative and clinical systems are designed to support effective delivery of services incorporating accountability mechanisms and performance improvement practices. principles

Provides Leadership in Adolescent and Child Health The school-based health center model provides unique opportunities to increase expertise in adolescent and child health and inform and influence policy and practice.

Trends in Services Provided by SBHCs (n=806) and (n= 1067) Dental care Dental Sealant Program Care for Infants of Students Dental Screenings Assess Psych Development Meds Admin’d in SBHC Anticipatory Guidance Lab Tests Nutrition Counseling Treatment of Chronic Illness Sports Physicals Comp Health Assessments Prescriptions for Meds Asthma Treatment Screenings (vis/hear/scoliosis) Immunizations Treatment of Acute Illness

Mental Health Services Provided by SBHCs (N=1004) Crisis Intervention Grief and Loss Therapy Psycho-education Assessment Screening Mental Health Diagnosis Brief Therapy Long Term Therapy Medication Management/Admin Case Management Skill-Building Referrals Substance Use Counseling Tobacco Use Counseling Conflict Resolution/Mediation Other

Trends in On-Site Reproductive Health Services Provided to Adolescents by SBHCs (n=547) and (n=819) Norplant insertions Prenatal care Emergency post-coital pills Depo-Provera injections Birth control pills Condoms HIV testing Papanicolaou (Pap) smear Follow-up of contraceptive users Gynecological examinations STD diagnosis and treatment Sexual orientation counseling HIV/AIDS counseling Counseling for birth control Pregnancy testing

Continuous Quality Improvement Tool (CQI- Tool ) Purpose Evaluation of quality in SBHCs Site-specific goal setting provement1.htm provement1.htm

Description of CQI Tool Sentinel Conditions by Age Clinical Resources Markers of Outcomes Evaluation Measures (1-5) Glossary with web links for reference

Sentinel Conditions by Age Group ElementaryMiddle SchoolHigh School Hx/PE Asthma Immunizations Injuries ADHD/Child Abuse Poor School Performance Hx/PE Pregnancy Smoking Parent Child Conflict ADHD/Depression Poor School Performance Hx/PE Drug/ETOH STDs Violence ADHD/Depression Poor School Performance

National Assembly’s Clinical Network Mental Health Intervention Asthma Financing Practice Management Improvement Parent Engagement Health Education Obesity/ Cardio Health Getting Started and SBHC Expansion Web-based resources Web conference presentations Continuing education programs Quality improvement collaboratives STDs/HIV Prevention Benchmarking Evaluation and Quality Measures

NASBHC’s Quality Improvement Collaborative Model Experienced in using QI Collaboratives since 2001 resulting in systems change Adaptation of –Institute for Healthcare Improvement’s (IHI) quality improvement model –HRSA’s Bureau of Primary Care Health Disparities Collaboratives

NASBHC’s SBHC Quality Improvement Collaboratives Preventive Services Improvement, (risk assessments, physical exams and STDs/HIV prevention): 3 cycles Mental Health Education and Training, (mental health screening, interventions, and documentation): 1 cycle Practice Management Improvement (coding, chart documentation, clinic operations): 1 cycle Adolescent STD/HIV Avoidance Project (STD/HIV Prevention activities): started January 2005: first cycle in progress

Quality Improvement Collaboratives California Colorado Connecticut Florida Illinois Louisiana Maine Maryland Massachusetts Michigan New Jersey New Mexico New York North Carolina Washington West Virginia Over 5 years, NASBHC has implemented quality improvement collaboratives with 99 SBHCs from 16 states. As a result, NASBHC possibly influences the care of over 150,000 children and adolescents annually who are served by these sites.

NASBHC’s Adaptation of the Collaborative Model Volunteer SBHCs are selected through a competitive process Applications submitted as clusters or individual SBHCs Collaborative leaders are selected from each state and/or school-based health center Change is measured at baseline, intermediate, and final increments

NASBHC’s Adaptation of the Collaborative Model (continued) Sites in a collaborative measure the same targets using the same forms. However, each SBHC selects their own measurable objective Participants from previous years participate in training of trainers and serve as faculty for next year Progress reports submitted every other month. No face to face meetings other than learning sessions

Standardized Components for NASBHC’s Collaboratives Progress Reports (see forms) Workplans (see forms) Storyboards Learning Sessions Chart Reviews Conference Calls Individual Site Consultation Training of Trainers Incentives

Preventive Services Improvement Initiative 3 Cycles National Assembly on School-Based Health Care

PSII Objectives Documented improvement in the following areas for students receiving care at the SBHCs:  Annual risk assessment  Physical examination every two years  Appropriate assessment and treatment for students at risk for STD/HIV  Documented risk reduction for STDs/HIV

Charts Indicating Risk Assessment by Audit Audit (N=440) Baseline AuditFinal Audit Percent

Charts Indicating Biennial Physical Exam by Audit (N=440) Baseline AuditFinal Audit Audit Percent

Students At Risk For STI Who Were Tested, Treated and Counseled (N=380) Chart Audit Yes% Baseline 76 Final 89

Documented STD/HIV Risk Reduction (N=380) Chart AuditYes% Baseline 37 Final 63

Cycle Cycle

PMI Objectives  Increase SBHC team’s knowledge and understanding of practice management and practice management improvement  Complete a situational analysis of the SBHC practice environment.  Internal and external practice environments  SCORE Model  Internal and External S.W.O.T. analyses

PMI Objectives  Utilize SBHC situational analysis and recommendations to establish a mission statement for the SBHC  Develop a SBHC practice improvement plan/strategy with short and long term objectives that support the SBHC mission

PMI Objectives  Code and document SBHC evaluation/ management office visits and preventive health visits appropriately.  Code and document SBHC mental health visits appropriately.  Use ICD 9 codes and other CPT codes appropriately to maximize SBHC reimbursement and to correctly report the services done in SBHCs.

PMI Objectives Utilize NASBHC’s CQI Tool to assess and improve the delivery of comprehensive risk assessments, biennial physical exams, and another sentinel condition) Implement a multifaceted approach for measuring the SBHC’s productivity across core components

PMI Results All 13 sites: Completed Strengths, Weaknesses, Opportunities, and Threats (S.W.O.T.) Analysis of their SBHC; Developed a practice improvement plan/strategy with short and long term objectives to support the SBHC mission; Demonstrated improvement in SCORE Model ratings on all 5 domains (facilities, business operations, human resources, care management, and practice compliance) from pre to post site visits

PMI Results Demonstrated improvement from pre to post chart reviews /coding compliance audits in appropriate documentation and coding of evaluation and management visits, preventive health visits, and mental health visits. Incorporated CQI tool sentinel conditions, chart audit criteria, and resources into the care management and practice compliance activities

PMI SCORE Model Ratings Cycle 1 (pre and post)

PMI SCORE Model Ratings Cycle 2 (pre and post)

Mental Health Education and Training Initiative Two Cycles

MHET Mission Increase knowledge and implementation of mental health –screening, –diagnosis, –referral, –coding, and –evidence-based short-term mental health interventions among SBHC primary care and mental health providers.

Mental Health Program Evaluation Template (MH-PET) – (Year 2) * Significant change from LS 1 to LS 4, p<.001

SBHC Mental Health Screening and Assessment ( 1 = Very Poor, 4 = Very Good) * Significant change from LS 1 to LS 4, p<.05

Chart Audits: RISK ASSESSMENTS (N = 30 charts per site)*

Chart Audits: SCREENING (N = 30 charts per site)*

Chart Audits: POSITIVE IDENTIFICATION OF SYMPTOMS IN CHARTS WITH A SCREENING (N = 30 charts per site)*

Chart Audits: If Positive ID, is there documentation of follow-up mental health assessment? (N = 30 charts per site)*

SBHC Mental Health Diagnostic Assessment * Significant change from LS 1 to LS 4, p<.001

SBHC Mental Health Referral Process ( 1 = Very Poor, 4 = Very Good) * Significant change from LS 1 to LS 4, p<.05

Chart Audits: If Positive ID, is there documentation of follow-up mental health referral? (N = 30 charts per site)*

SBHC Use of Diagnostic and Procedural Codes ( 1 = Very Poor, 4 = Very Good)

How frequently to you document codes? ( 1 = Never, 4 = Very Frequently) * Significant change from LS 1 to LS 4, p<.05

Chart Audits: MENTAL HEALTH CODING IN CHARTS (N = 30 charts per site)*

Chart Audits: IF CODE IS NOT IN CHART, IS IT ELSEWHERE (E.G., ENCOUNTER FORM, LOG, ETC.)? (N = 30 charts per site)*

Mental Health-Primary Care Integration ( 1 = Very Poor, 4 = Very Good) * Significant change from LS 1 to LS 4, p<.05

SBHC Use of Evidence-based MH Practice ( 1 = Very Poor, 4 = Very Good) * Significant change from LS 1 to LS 4, p<.05

Chart Audits: ASSESSMENT OF PROTECTIVE FACTORS (N = 30 charts per site)*

Knowledge of Core Skills * Significant change from LS 1 to LS 4, p<.001

Chart Audits: USE OF CORE SKILLS WHEN SYMPTOMS HAVE BEEN IDENTIFIED (N = 30 charts per site)*

Trainings in evidence-based interventions All SBHCs selected and received training in an evidence-based, manualized intervention during Learning Session IV. Selected manuals: –Cognitive Behavioral Intervention for Trauma in Schools (CBITS) –FRIENDS for Children, FRIENDS for Youth –Defiant Teens –Skillstreaming