Bright Futures Preventive Services Improvement Project Sixteenth Street Community Health Center Milwaukee, WI Our Team: Drs. Emilia Arana, Alisen Huske Francisco Enriquez, John Dunn

Our team plans as of January 2011 By October % of charts will have Parental Concerns elicited and addressed at each WCC visit. 95% of charts will have Parental Strengths discussed and documented. 95% CYSCHN will be identified as such, having the denomination of “Special Needs” in the problem list. 95% of 9mo WCC visits will have an ASQ completed. 95% of 2wk, 2mo, 6mo WCC visits will have Maternal PPD screen done. Improve the administration of our Oral Health Risk Assessment so that 95% of 9mo, 18mo, and 24mo have it done. Improve the administration of our 18mo and 24mo ASQ and MCHAT so that 95% of WCC's designated as “18mo” or “2y” WCC have it done, regardless of their actual age at the WCC (i.e. 30mo “late” 2y WCC will get an MCHAT and a 30mo ASQ to do). Implement a pre-visit questionnaire at the 9mo and 24mo WCC visits. Update quarterly our list of Dental Providers, classified according to HMOs. Have a one sheet hand-out for each WCC visit - age appropriate anticipatory guidance. Have an organized, current list of community resources for parents. Use Intergy-EHR system to track referrals, lab orders and imaging.

Our team now… how close to our Aim? 9 month old visits Baseline Data September data -Parental concerns elicited:80%90% (100% in August) -Parental concerns addressed:85% 100% -Risk assessment done:50%90% (100% in August) -Risks addressed: 50% 100% -Weight for Length: 100% 100% -Developmental screen: 0% 70% (100% in July) -Follow-up for positive screen: % In June (Data gaps on graph) -3 BF anticipatory guidance used: 90% 100% -Parental strengths assessed: 0% 50% (80% in August) -Oral Health Risk Assessment done: 45%90% (100% in August) -Maternal Depression Screening: 0%90%

Our team now… how close to our Aim? 24 month old visits Baseline Data September data -Parental concerns elicited:85%75% (90% in July) -Parental concerns addressed:85% 100% -Risk assessment done: 100% 100% -Risks addressed: 100% 100% -BMI: 100% 100% -Developmental screen: 85% 100% -Follow-up for positive screen: 100% 100% -Autism Screen:85% 100% -Autism Screen follow-up:85% 90% in April (Data gaps on graph) -3 BF anticipatory guidance used: 100%100% -Parental strengths assessed: 0% 35% (40% in August) -Oral Health Risk Assessment done: 95%100%

PDSA cycle Maternal Depression  Plan the change: Implement PPD Screening at 2wks, 2mo, 6mo visits. Screening tool: EPDS (Edinburgh).  Do the plan: Modified EHR template, adding PHQ-2 and EPDS. Inform Pediatric and Behavioral Health Providers. Create handout on PPD and list of community resources for PPD.  Study the results. We found more PPD than expected. Poor access to BH provider. Excellent access to SW services/counseling.  Act on the new knowledge: If screen positive, Pediatrician refers mother to FP or CPM identified as prenatal care provider. Task provider, scan Edinburgh in mother’s chart.

PDSA cycle Pre-visit Questionnaires  Plan the change: Implement Pre-visit Q at the 9mo and 24 mo WCC  Do the plan: Modify versions of the Bright Futures Pre-Visit Q. Translate it in Spanish. Pilot use by 5 Pediatricians  Study the results. Tool is useful in guiding what anticipatory guidance to provide. Parent misunderstands some sections. Little time for parents filling it out along with other screening tools.  Act on the new knowledge: Modify the initial version. Ask parents feedback. Pilot test for 2 weeks. Final versions to be available in our Patient Portal

Changes we made that resulted in improvement  Use of Pre-visit Questionnaires at 9mo and 24 mo visits  Identify Patients with Special Health Care needs.  Addressing and documenting parental concerns (HPI, EHR-template modified)  Maternal Depression Screening Implementation of use in Pediatrics, Family Practice, Women’s Health Departments. Social Services involved. Coordination of care of mothers with PPD: Pediatrician can now refer to prenatal care provider (FP or CPM)  Earlier use of ASQ tool, starting at 9 months age and broader use of the ASQ and MCHAT at the 18mo and 24mo WCC’s.  Discuss, reinforce Parental Strengths, documented in WCC e-note.  Use of EHR to track lab tests, imaging tests and referrals to specialists.  Regularly updated list of Dental Providers, organized according to each HMO.

Challenges and Barriers  Lack of time to invest in this project. Very busy providers.  Low literacy level of our patients/families  Poor access to Mental Health Services.  Poor access to Dental Home.  Parents do not have enough time to complete/answer forms. They arrive late or just in time to appointments.  Lack of non-medical staff available to help with this project (e.g. update list of community resources for parents).

What did we accomplish  The single change we are most proud of is Coordination of services between departments FP, Midwifes, Social workers, Perinatal case managers to serve patients with PPD.  Our greatest innovation was…we began screening for maternal depression systematically at pediatric WCC’s.

What are we doing next  Pre visit Questionnaires, 12mo and 36mo visits. Adapt them to our population needs and language use.  Actively involve families in evaluating and modifying screening tools.  Obtain feedback, more so on the experience of the CYSHC families.  Dental Home. Document Dental Provider. Communication Pediatric-Dental provider.  Request and document parent’s if available. Quantify our patient’s computer/web access.  Start working with out IT team in order to include pre-visit questionnaires, ASQs and M-CHAT in the patient portal. Our team is wondering if next we should...  Prepare Pre visit questionnaires for every WCC visit, and make it available in in Patient Portal  Social Workers to help organize a list of community resources, make it available in our Intranet and on the patient portal.  Training/Practice session for providers to become more familiar and use more often the HEALTH tab (Our Preventive Services Prompting System)  Anticipatory guidance at every WCC visit: Prepare a one sheet hand-out based on the Bright Futures recommendations, modified to fit our population needs and language.