1. Improving Preventive Care in Your Practice Without Burden
Edward Curry, MD, FAAP
Judith Shaw, EdD, MPH, RN, FAAP
Session I2051 : 2016 NCE
10/23/2016

2. Agenda Introduction & Background
Big Winners for Implementation Cases 1 & 2
Maternal Depression
Autism Screening
Cases 3 & 4
Oral Health
Parental Strengths
Resources

3. Faculty Disclosure: Judith Shaw
In the past 12 months, I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation. I am one of the editors of the Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescent, 3rd Edition. I acknowledge that today’s activity is certified for CME credit and thus cannot be promotional. I will give a balanced presentation about well child care using the best available evidence to support my conclusions and recommendations.

4. Faculty Disclosure: Edward Curry
In the past 12 months, I do not have any Financial Disclosures I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

5. Changes in Practice Participants will be able to:
Plan to implement the Bright Futures/AAP Guidelines for children and adolescents
Use pediatrician-tested strategies and Bright Futures tools to improve the quality of preventive services delivered in their clinical setting 5

6. Bright Futures
…is a set of principles, strategies and tools that are theory - based, evidence - driven, and systems - oriented, that can be used to improve the health and well-being of all children through culturally appropriate interventions that address the current and emerging health promotion needs at the family, clinical practice, community, health system and policy levels. 6

7. Affordable Care Act: Section 2713
…requires all health plans to cover, with no cost-sharing
the services are outlined in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd Edition (Hagan J, Shaw JS, Duncan PM eds.)
“with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration,”

8. Periodicity Schedule
Available at:

9. Bright Futures
Bright Futures is the health promotion/disease prevention part of the medical home
At the heart of the medical home is the relationship between the clinician and the family or youth

10. Making the Most of the Guidelines
The Bright Futures Guidelines provide the background and all the details.
The question is:
How can you incorporate all that into a typical office visit?
Use the Guidelines along with other Bright Futures materials
Therapeutic relationship is still the key

11. Overview of Changes & Important Topics
Bright Futures Guidelines, 4th Edition (pending)
Part 1: Health Promotion Themes
12 chapters highlighting key health promotion themes
New themes in development: Social determinants of health; Media use, Children with Special Health Care Needs
Part 2: Health Supervision Visits
Rationale and evidence for screening recommendations
32 age-specific visits (including prenatal visit)
5 health supervision priorities for each visit
Designed to focus visit on most important issues for child that age
Includes: social determinants of health, health risks, developmental issues, positive reinforcement

12. Bright Futures Guidelines, 4th Edition
Child Healthy Development
Family Support
Mental Health and Emotional Well-Being
Nutritional Health
Physical Activity
Healthy Weight
Promoting Lifelong Health for Families and Communities
Oral Health
Healthy Sexuality
Safety and Injury Prevention
Community Relationships and Resources
Promoting the Healthy and Safe Use of Social Media
Children and Youth with Special Health Care Needs

13. Components of a Bright Futures Visit
History
Surveillance
Physical examination
Screening
Immunizations
Anticipatory guidance

14. Proposed Priorities in the 4th Edition
12 Month Visit Example
Social determinants of health (the economic and social conditions that shape the health of individuals and communities)
Establishing routines
Feeding and appetite changes
Establishing a dental home
Safety
Source: Healthy People 2020

15. Core Tools: Integrated Format
Previsit Questionnaires
Allows healthcare provider to gather pertinent information without using valuable time asking questions
Documentation Forms
Enables Provider to document all pertinent information and fulfill quality measures
Parent/Patient Handouts
Provides Parental Education all the Bright Future Priorities for the visit

16. Tool & Resource Kit
The Bright Futures Tool and Resource Kit also contains supplementary materials:
Additional Parent/Patient Handouts
Developmental, behavioral, and psychosocial screening and assessment tools
Practice management tools for preventive care
Information on community resources
All of Bright Futures developed materials are in the public domain
brightfutures.aap.org/materials-and-tools/tool-and-resource-kit/Pages/default.aspx

17. You and your team are the experts
Implementing Bright Futures into Daily Practice
How it gets done in your practice setting in partnership with your patients and parents
You and your team are the experts

18. Implementing Bright Futures into Daily Practice
Can it be done?
YES

19. Implementing Bright Futures
New Approaches
National AAP Preventive Services Implementation Project (Jan–Oct 2011)
Pediatricians, family physicians, nurse practitioners, physician assistants, nurses and office staff
Rural, urban and suburban practices and clinics, as well as community health centers and the Indian Health Service
Partner with Health Plan and Medicaid QI activities
For example: CHIPRA Demo Projects

20. National AAP Preventive Services Implementation Project (PreSIP)
(Jan – Oct 2011) 20

21. Chart Audit Measurement
9 and 24 Month Visits
Eliciting & addressing parental concerns
Age appropriate risk assessments
Oral health risk assessment
Developmental screening/follow-up (9 & 24 m)
Autism specific screening/follow-up (24 m)
Maternal depression screening (2 m)
Evaluation of parental strengths
Weight for length or BMI
Addressing 3 Bright Futures priorities in AG

22. PreSIP Data

23. Office-Based Systems Components
Utilize a preventive services prompting system
Utilize a recall/reminder system (to address immunizations and well child visits)
Utilize a system to track referrals (paper-based or electronic)
Utilize a system to identify children with special health care needs
Link families to appropriate community resources
Utilize a strength-based approach and shared decision-making strategy

24. Practice-Level System Changes

25. Bright Futures Preventive Services
PreSIP Data
Bright Futures Preventive Services

26. What were the Big Winners?
Previsit Questionnaires
Which involved follow-up
Which involved links to community or in-office systems
Documentation forms/Prompting systems
Handouts
Partnership with Parents
Recall and Reminder System

27. Preventive Services Implementation State Spread Project (PreSIPS2)
Pediatric Practices
Approx. 10 per Chapter + residency program
Chapter Leadership Teams
Lead Physician, Project Mgr./QI Coach, State MCH rep, Family rep
AAP National Leadership Team & Staff
AAP Chapter Participants: Georgia, New Jersey, South Carolina and Virginia 27

28. Questionnaires
Paper
Electronic
At the visit in the waiting or exam room
At home (via )
Make appointment time 15 minutes earlier
Practice support and nursing staff in charge of how this happens:
Have a staff session to reinforce importance and contribution
Train how to distribute
Develop a scoring system
Develop a system to alert practitioner to know “when ready to proceed”
Help parents/youth with literacy or language differences
Have all tools and supplies ready
Shift some responsibilities from the clinician to non-clinician staff where appropriate

29. What can you get from a Bright Futures Previsit Questionnaire?
Questionnaires cont.
What can you get from a Bright Futures Previsit Questionnaire?
Maternal depression screening
Medical risk screening
TB, Lead, Anemia, STIs, Cholesterol
Vision and Hearing
If possible, practice staff can perform or set up
“Parental/youth concerns and questions” for this visit
Oral health risk assessment
Dental home/fluoride H2O
Developmental surveillance for young children
Strength/developmental surveillance for school aged children & adolescents

30. Setting the agenda PRIORITIES Family support
Child development and behavior
Language promotion/hearing
Toilet training readiness
Safety

31. Medical Screening

32. Developmental Surveillance

33. Questionnaires cont.
Which Bright Futures standardized screenings could be done with additional questionnaires?
Developmental screening
Autism specific screening
Maternal depression screening
Excerpt from 2 month previsit questionnaire

34. What’s Left?
Further history including identification of parental strengths
Additional visit questionnaire with questions in each of the five visit priority areas
BMI
Physical exam
Answering questions, addressing concerns and anticipatory guidance about five priority topics
If a change needs to be considered, use a shared decision-making approach
Immunizations

35. Final Questionnaire Tips from Practices
Include tools in the EHR
Include pass/fail categories for MCHAT in EHR
Include secondary screens for use if screen is positive
Staple screening tools to Previsit Questionnaires so the entire previsit packet is provided to parents

36. Case Studies 1 & 2

37. Mia Case Study 1: Maternal Depression :
28-year-old married mother of two
College educated
Currently a high school math teacher, but considering staying at home
On 3 month parental leave
Husband is computer consultant and travels once a week for job
She is well-liked at school and has friends from school and book club
With her first child she had a relatively easy adjustment and has a good child care situation

38. Case Study 1: Maternal Depression cont.
Embarrassed that she is having so much trouble
Mia is at home and feels like she should be able to do this
IF WE DO SCREENING
WHAT SCREENING TOOL

39. Maternal Depression: PHQ-2
Maternal Depression Questionnaire
Maternal Depression: PHQ-2
Information from: Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2:validity of a two-item depression screener. Med Care. 2003;41: Available at:

40. Maternal Depression Questionnaire
Maternal Depression: PHQ-9
Available at:

41. Jason Case Study 2: Autism
24-month-old who is only speaking 2 to 3 words. Most of his speech is jibberish. He also has prolonged temper tantrums lasting 15 to 20 minutes
Mother brought her concerns to her previous pediatrician at 18 months. She was told boy’s usually talk later and temper tantrums are normal

42. Jason Case Study 2: Autism cont. M-CHAT-R Screening
Bright Future Guidelines
Autism screening at 18 and 24 months

43. M-CHAT-R Screening (excerpt)
Case Study 2: Autism cont.
M-CHAT-R Screening (excerpt)
For more information on autism screening tools, go to: mchatscreen.com/

44. Establishing a Workflow!!!

45. Workflow Needs to be Job Specific, not Person Specific
Workflow Previsit Questionnaire
Workflow Needs to be Job Specific, not Person Specific
Starts with Initial Entry Point to Medical Office
Receptionist Provides Age Appropriate Previsit Questionnaire
Pre-formatted Age Specific Packet (18 Month Packet)
18 Month Previsit Questionnaire
CHAT or MCHAT Questionnaire
Parent would Complete Questionnaire in Waiting Area
Medical Assistant on Rooming Child would Make Sure Questionnaire is Completed
MA attaches Questionnaire to Chart or Enter the Results into the EHR
Physician Would Review either Paper Copy or EHR
Would Document Intervention in Chart
Completion of Visit Medical Assistant would Provide Appropriate Parent Handout

46. Workflow: Autism Screening
Physician reviews both Questionnaire and confirms red flag results
If child fails two items, physician initiates referral
Referral tracking is referred to staff member to follow-up
Regional Center Referral
Referral to Developmental Pediatrician

47. Follow-up of Red Flag Results
Workflow Screening Questionnaire
Follow-up of Red Flag Results
Maternal Depression Screening
If PHQ-2 Done, then Need to Do PHQ-9
If Positive, then:
Low Risk Referral to Community Resources
Moderate Risk Social Worker or MFT
Emergency Mental Health Evaluation
Autism Screening
Administer M-CHAT-R
If Positive, Set Follow-up Process

48. Questionnaires How do I address a positive screening response?
Maternal depression
Referral to OB/nurse midwife, primary care or mental health professional (set up ahead of time)
Co-located/employed mental health practitioner in the practice
Referral to a mental health professional
Adolescent mental health issues
More practitioner education and experience
Telephone, telemedicine and support systems
Developmental screening
Have a developmental behavioral specialist come to practice once a month to see kids with positive screens

49. Community Linkage Tips from the Practices
Systems measure
Do you have someone in your office or clinic who is in charge of liaisons with community organizations and updates to accessible list of community resources for parents?
Hire a care coordinator, or use current staff with skills in this area
Use community liaisons in the practice to handle referrals, communicate with specialists, and coordinate services/resources for families
Consider hosting “mixers” with potential referral sources in the community to establish relationships
If you have set it up, everything related to a difficult situation goes better

50. Billing and Coding for Questionnaires
Billing & Coding
Billing and Coding for Questionnaires
When standardized developmental screening tools are administer, scored, and interpreted as part of preventive service visit each screening can be individually coded
Appropriate CPT code: 96110

51. Case Studies 3 & 4

52. Case Study 3: Oral Health
Fernando
Fernando is a 9-month-old baby who comes in with Maria, his mother, and grandmother for his checkup
Maria has no concerns, but does wonder if he should be feeding himself
His parents both work
They work opposite shifts so that one often can be there with the baby
They have arranged to always have all day Sunday together as a family
His grandmother often has him for dinner and breakfast to cover the overlap times and takes special care to prepare his food and feed him
He eats table food, some baby food at mealtime and breast milk 4x a day
She has utilized the WIC supplements for breast feeding moms

53. Case Study 3: Oral Health cont.
Maria enjoys his happy disposition and his calling out when she comes home from work
She is also pleased that he is growing so well on her breast milk and can feed himself the bottle.
On his oral health risk assessment…
Maria and her mother have many dental caries and have been unable to access dental care
Fernando takes bottles in his crib at least twice a day

54. Strengths Strengthening Families Framework
Social Connections/Source of Support
Ability to Access Services in Times of Need
Knowledge of Child Development
Resiliency – Enjoys about Her Baby
Child’s Social & Emotional Competence

55. Anticipatory Guidance Priorities
9 Month Visit
Family adaptations
Infant independence
Feeding routine
Safety

56. Case Study 4: Patient/Parental Strengths
Samantha
21-year-old mother with an 18-month-old daughter
They have just begun living in a homeless shelter
Refusing to put her daughter in child care so she can’t get a job
Doesn’t have a place to live and doesn’t want to live with her mom anymore no matter what 56

57. Case Study 4: Strengths cont.
Samantha
Filled out all the forms
Found out that her concerns were
Boyfriend's mother had a child with autism
Risk factors identified:
Grandmother smokes in the house

58. Doesn’t want to live with grandmother who smokes
Case Study 4: Strengths cont.
Worried about additional shots because boyfriend’s mother had a child with autism
Doesn’t want to live with grandmother who smokes

59. Search for Strengths Risks need to be identified BUT:
Strengths are an essential part of health
Look for Resiliency and Strengths: ask about strengths at every encounter!
Promoting strengths will enhance interactions with parents
Search for strengths
Connection
Competence/ Mastery
Independent decision-making
Generosity
Copyright University of Vermont

60. Identified Parental Strengths
Case Study 4: Strengths cont.
Identified Parental Strengths
Has a partner who has been with her and Samantha for 6 months – lives with his parents
Wants to have her daughter grow up always feeling safe and smoke-free
Helps out at the shelter with reading – went to the library to get the books
Finished her GED, works as a waitress, never interacted with an agency before

61. Anticipatory Guidance Priorities
18 Month Visit
Family support
Child development & behavior
Language promotion/hearing
Toilet training readiness
Safety

62. Tips on Strengths from the Practices
If you see a parent doing something great, point it out
Provide positive feedback during the visit
Instead of telling the parent they “should” do something, offer that they “could” do something
Share your own experiences as a parent (if applicable)
Ask the parents about their role as a parent, how they differ from their own parents, what they like to do with their child
Take an interest in the parents
Recognize the strength of extended family and offer strategies to assist

63. Pediatric Preventive Coding Resource
Bright Futures and Preventive Medicine Coding Fact Sheet This resource contains comprehensive listings of codes that may not be used by your practice on a regular basis. We recommend that you identify the codes most relevant to your practice and include those on your encounter form/billing sheet.

64. Education in Quality Improvement for Pediatric Practice (EQIPP)
EQIPP Bright Futures, an online learning program, weaves improvement principles and concepts with pediatric-specific clinical content to improve health outcomes. It is designed to identify and continuously close gaps in practice using practical tools.
EQIPP Bright Futures courses are currently undergoing revision. It is expected to re-launch within 6 – 12 months.
EQIPP participants simultaneously earn CME credit and meet MOC Program Part 4: Performance in Practice requirements. EQIPP is now a member benefit.

65. brightfutures.aap.org/
Web Site Resources
brightfutures.aap.org/

66. Resources: Parent/Family
healthychildren.org
General information related to child health and/or more specific guidance on parenting issues
Information on AAP policies, guidelines, publications, and other child health resources
Tips & tools
Brightfutures.aap.org
Patient/Parent handouts in the Bright Futures Tool & Resource kit
Family Resources Web page
Virginia Department of Health educational videos
brightfutures.aap.org/
Healthy Child Care America
Promotes cognitive, social and physical development of children in early education and child care
Supports the needs of health professionals interested in promoting healthy and safe early education and child care programs
Resource library (for health care and early education & child care professionals)
Bright Futures Family Pocket Guide
Developed by the National Family Voices Project IMPACT with input from the Bright Futures National Center
Easy-to-use book designed to help families support health and wellness for their children at every age (in English and Spanish)

67. Changes in Practice: Recap
Participants will be able to:
Plan to implement the Bright Futures/AAP Guidelines for children and adolescents
Use pediatrician-tested strategies and Bright Futures tools to improve the quality of preventive services delivered in their clinical setting
Previsit questionnaires
Documentation forms
Handouts
Office systems changes
Strength-based approach 67

68. Questions & Answers

69. References
American Academy of Pediatrics. Bright Futures Tool and Resource Kit [CD-ROM]. Duncan PM, Shaw JS, Gottesman MM, Swanson J, Hagan JF, Pirretti AE, eds. Elk Grove Village, IL: American Academy of Pediatrics; 2010.
Duncan P, Pirretti A, Earls MF, Stratbucker W, Healy JA, Shaw JS, Kairys S. Improving delivery of Bright Futures preventive services at the 9- and 24-month well child visit. Pediatrics
Hagan JF, Shaw JS, Duncan PM, eds: 2008, Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents. Third Edition. Elk Grove Village, IL: American Academy of Pediatrics.

70. Contact Information
American Academy of Pediatrics Bright Futures National Center
Jane Bassewitz, MA
Manager, Bright Futures National Center
Kathy Janies
Manager, Bright Futures Implementation
Web site brightfutures.aap.org