Implementing High Performing Well Child Care within a Large HMO Design Strategies CRISP D&I Training Workshop 2013 Implementing High Performing Well Child Care within a Large HMO Arne Beck, PhD Kaiser Permanente Colorado www.ucdenver.edu/implementation

Gaps in Well Child Care… Only 20% of children receive structured, validated, developmental assessments at the well child visit 50% of parents think their child’s developmental and behavioral issues were not adequately addressed

Pediatricians Aren’t Satisfied Either Pediatricians want to do a better job but have little time, resources, or training to deliver the prescribed services. They know that there is a need for change in the way well child care is delivered and who delivers it

High Performing Well Child Care Tailor content and frequency of WCC to needs of the family and vulnerability of the child e-visit, web-based assessment plus brief MD visit to increase the efficiency and effectiveness of WCC Co-visit with care coordinator for children with special health care needs Web based systems for pre-visit developmental and behavioral assessment by parents

Project Tasks Select practice sites within KPCO and complete social network mapping to identify opinion leaders and patterns of advice seeking focus groups and key stakeholder interviews Implement and evaluate 21st Century WCC within practice sites

Evaluation Measures Developmental and behavioral screening & referral rates Spread of model to three KPCO practices and DCHN using RE-AIM framework Results from focus groups and stakeholder interviews Patient and provider experience with HPWCC

Focus Groups Social Networkss From: Feldstein AC, Glasgow RE. A Practical, Robust Implementation and Sustainability Model (PRISM) for Integrating Research Findings into Practice. The Joint Commission Journal on Quality and Patient Safety. Apr 2008;34(4):228-43.

Social Network Mapping Pediatric clinic social network maps showing the most frequent patterns of communication / advice seeking network-centrality metrics of between-ness, power, reach to identify opinion leaders at each clinic Analyzed using the social network analysis program InFlow 3.0 Betweenness: The number of links within the network that include a given individual, indicating how much an individual has the potential to control information flows in the network. Power: A measure of informal power that uses the measures of betweenness and closeness (an indicator of access) to identify individuals who have quick access themselves but stand in the way of access for other individuals within the network. Individuals may use this power for positive or negative purposes. Network reach: The number of individuals who can be reached in a certain number of steps without being redundant. Individuals with high reach can facilitate dissemination efforts.

Social Network Mapping Survey All responses to the following statements/questions will be kept strictly confidential. Under no circumstances will anyone outside the study team be able to identify you with your responses. Social Network Mapping Survey Among people at your clinic, who do you look to for new ideas or better ways of doing things concerning pediatric care? 1. _________________________________________________ First name Last name Position:___________________________________________ I communicate with this person: 5 = daily or more 4 = weekly 3 = monthly 2 = quarterly 1 = yearly 2. _________________________________________________ 3. _________________________________________________ Familiarity with technology (circle one answer for each statement) I like using computers. Strongly Agree No Disagree Strongly Agree opinion disagree

Beck A, Bergman DA, Rahm AK, Dearing JW, Glasgow RE Beck A, Bergman DA, Rahm AK, Dearing JW, Glasgow RE. Using Implementation and Dissemination Concepts to Spread 21st Century Well Child Care at an HMO. The Permanente Journal, 2009; 13(3):10-18. A total of five opinion leaders were identified from this pediatric practice. Four opinion leaders were identified from group A on the basis of the metrics of betweenness and power: 021 (developmental specialist), 019 and 008 (both physicians), and 025 (medical assistant). One additional opinion leader was identified from group C, 028, a registered nurse serving as a pediatric chronic care coordinator.

Focus Group Results Choice of mode of completing pre-visit assessment Make WCC compatible with current appointment- scheduling procedures, including advanced access Flexibility - choice of clinician and visit type Member-centric: visits tailored to the needs of children and parents (e.g., longer visits for children with special health care needs) Account for clinicians’ time constraints both at the visit and in pre- and post-visit documentation

Lessons Learned Timing of implementation Engagement of key leaders Pay attention to single factors that can hinder dissemination www.ucdenver.edu/implementation

References PRISM (Feldstein & Glasgow) RE-AIM (Glasgow) http://www.re-aim.org Center for Health Education Dissemination and Implementation Research. http://www.research-practice.org/ Diffusion of Innovations (Rogers) Damschroder: consolidated framework for advancing implementation science. Implement Sci 2009;4:50. www.ucdenver.edu/implementation