1. Office Based Prevention of Child Abuse and Neglect: Lessons Learned from the Practicing Safety QuIIN Project Diane Abatemarco, PhD, MSW, CO-PI Ruth Gubernick, MPH, QI Advisor Steve Kairys, MD, MPH, FAAP, Co-PI

2. 2 Call Objectives At the end of this conference call, participants will be able to:  Identify which Practicing Safety (PS) tools were reported to be the most useful in each of the 3 bundles  Recall at least 2 qualitative themes uncovered by post in- depth interviews  Analyze the office supports and systems that enable successful adoption of interventions  List at least 2 lessons learned from the QuIIN PS project  Test 1 or more tools with your own practice team to improve assessment/screening and anticipatory guidance for 1 or more of the PS focused topics

3. 3 Practicing Safety: The Need  In 2006, an estimated 906,000 children were found to be victims of child abuse and neglect in the United States and Puerto Rico* 64.1% were victims of neglect 16.0% were physically abused Children under the age of 4 continue to have the highest rate of victimization Over one-quarter (30%) of the 906,000 victims were under the age of 4 Nearly 80% (79.4%) of perpetrators of child maltreatment were parents.  Pediatricians are in a unique position to address topics that can prevent child abuse and neglect Pediatricians can see a child a total of 13 times for well child visits before age 4 Literature documents the high value that parents place on the education and advice shared with them by their pediatrician *Source:U.S. Department of Health and Human Services, Administration on Children, Youth and Families. Child Maltreatment 2006. Washington, DC: U.S. Government Printing Office, 2008

4. 4 Practicing Safety Project Aims  Improve assessment/screening and anticipatory guidance by pediatric physicians and staff with parents/caregivers on topics of crying, maternal depression, toilet training, and discipline (to 100% by November 2009).  Test use of the Practicing Safety tools for education by pediatric physicians and staff with parents/caregivers on topics of crying, maternal depression, toilet training, and discipline.  Test the usefulness of the Practicing Safety tools and ease of use of the tools; and determine strategies for use of the tools.

5. 5 Practicing Safety Project Methods  Modified Learning Collaborative with 14 teams (lead physician plus 2 others from practice)  Model for Improvement; Plan, Do, Study, Act; small tests of change  Prework period (April 2009) Baseline chart review Pre-Inventory Survey  Learning Session 1(May 2009)  Action Period (June-November 2009) Monthly Chart Review/Chart Documentation Forms  10 charts of patients at the 2-month visit (infant and mother/caregiver bundles)  10 charts of patients at the 18-month visit (toddler bundle) Monthly Progress Reports Monthly Team Calls Review of Run Charts to guide improvements (posted to a Project Workspace Web site)  Follow-up (November 2009) Post-Inventory Survey Post Toolkit Evaluation Survey Post-Telephone Interviews

6. 6 Tuscaloosa, AL University Medical Center Dayton, OH Children’s Health Clinic Houston, TX Lyndon B. Johnson Pediatric Clinic Grand Rapids, MI Helen DeVos Children’s Hospital General Pediatrics Greenville, SC Center for Pediatric Medicine Brooklyn, NY Maimonides Infants and Children’s Hospital- Newkirk Family Health Center Flushing, NY Flushing Hospital Medical Center New Haven, CT Hospital of Saint Raphael Pediatric Primary Care Center West Reading, PA All About Children Pediatric Partners PC Longview, WA Child and Adolescent Clinic Bluefield, WV Dr Frazer’s Office Brewton, AL Lower Alabama Pediatrics Thank you to the 14 Practicing Safety Teams! Charlotte, NC CMC-Myers Park Pediatrics Midlothian, VA Pediatric & Adolescent Health Partners

7. 7 Practicing Safety Toolkit  3 Bundles Infant: coping with crying Mother/Caregiver: maternal depression, bonding/attachment Toddler: effective discipline, toilet training  Each bundle includes a practice guide as well as tools for each topic

8. 8 Infant Bundle Infant Bundle: Coping with Crying Practice Guide: includes care management plan, assessment/screening questions, anticipatory guidance. Green light:Assessment/ Screening Anticipatory Guidance -Example: How often does your baby cry and how do you handle it? -Provide anticipatory guidance -Welcome to the World of Parenting brochure -Guide for parents: Swaddling 101 -Crying poster Yellow light:Parent concerns-Example: Who can you call to help when you need a break? -Provide anticipatory guidance -Refer to family strengthening organization Red light:Possible safety concerns for infant Referral to Child Protective Services for evaluation and care management Introduce at 2 weeks to 4 weeks; Reinforce at 2 months **Tools are identified by purple font

9. 9 Mother/Caregiver Bundle Mother/Caregiver Bundle: Maternal Depression/Bonding/Attachment Practice Guide: includes care management plan, assessment/screening questions, anticipatory guidance. Green light: Assessment/Screening Anticipatory Guidance -Edinburgh Postnatal Depression Scale (EPDS) -Example: Is the mom’s partner available for support? -Example: What do you enjoy doing with your baby? -Provide anticipatory guidance -Postpartum Depression Brochure -Refresh. Renew. Recharge Poster -Have you Read to Your Baby today button Yellow light: At risk for depression/<9* but have concerns/early signs Referral to support system, including PCP, OB, Behavioral health agency, home visiting program Red light: Depression/≥9* or ≥1 on Q#10*/potential risk to self and/or infant Referral to Child Protective Services and/or Behavioral Health agency *Refers to the EPDS Introduce at 2 weeks to 4 weeks; Reinforce at 2 and 3 months **Tools are identified by purple font

10. 10 Toddler Bundle: Discipline Practice Guide: includes care management plan, assessment/screening questions, anticipatory guidance. Green light:Assessment/ Screening Anticipatory Guidance -Example: What makes you lose it with your baby/child? How do you handle it? -How were you disciplined as a child? -Provide anticipatory guidance -Teaching Good Behavior-Tips on Discipline -Play is How Toddlers Learn -Reading. Routine. Relationships. Rewards poster Yellow light:Evidence help is needed/parental frustration/unrealis tic expectations -Example: How do you handle temper tantrums? -Provide anticipatory guidance -Temper Tantrum brochure -Refer to family strengthening organization Red light:Possible safety concerns for child Referral to Child Protective Services for evaluation and care management Introduce at 6 months; Reinforce at 12, 15, 18, 24, 36 months **Tools are identified by purple font

11. 11 Toddler Bundle: Toilet Training Practice Guide: includes care management plan, assessment/screening questions, anticipatory guidance. Green light:Assessment/ Screening Anticipatory Guidance -Example: Have you thouhgt about or started toilet training? How is it going? -Provide anticipatory guidance -AAP Toilet Training brochure Yellow light:Evidence help is needed/parental frustration/unrealis tic expectations -Provide anticipatory guidance -Potty Chart -Bedwetting Brochure -Refer to family strengthening organization Red light:Possible safety concerns for child Referral to Child Protective Services for evaluation and care management Introduce at 18 months; Reinforce at 2 and 3 years **Tools are identified by purple font

12. 12 Practicing Safety Results: Assessment/Screening and Anticipatory Guidance

13. 13 Infant

14. 14 Mother/Caregiver

15. 15 Toddler: Discipline

16. 16 Toddler: Toilet Training

17. 17 Practicing Safety Results: Usefulness of Tools

18. 18 Average Respondent Ratings of “Practicing Safety Tool Evaluation: Infant Bundle” Swaddling 101World of Parenting Coping with Crying Hug, Hold, Comfort, Cuddle Information/ Content Appropriate Information3.94.64.34.2 Adequately Comprehensive/ Thorough4.04.44.34.1 Aids in Patient Care3.94.54.34.2 Cultural Sensitivity Literacy Level is Appropriate3.53.94.54.4 Culturally Appropriate3.84.24.4 Free of Bias4.5 4.6 Usefulness Readability3.54.14.64.5 Relevant Information3.94.24.4 Purpose is Clear3.94.34.4 Effective3.94.24.3 Total (average)3.94.34.44.3 Key: 1 = Poor 5 = Excellent

19. 19 Average Respondent Ratings of “Practicing Safety Tool Evaluation: Mother/Caregiver Bundle” Post Partum DepressionRefresh, Renew, Recharge Edinburgh Postnatal ScaleRead to Baby Button Information/ Content Appropriate Information4.54.14.43.4 Adequately Comprehensive/ Thorough4.34.14.23.4 Aids in Patient Care4.54.14.53.4 Cultural Sensitivity Literacy Level is Appropriate3.74.23.64.3 Culturally Appropriate4.14.44.14.2 Free of Bias4.54.64.34.6 Usefulness Readability4.14.23.94.1 Relevant Information4.2 Purpose is Clear4.64.24.44.3 Effective4.1 4.43.9 Total (average)4.34.2 4.0 Key: 1 = Poor 5 = Excellent

20. 20 Average Respondent Ratings of “Practicing Safety Tool Evaluation: Toddler Bundle” Toilet Training Potty Chart Bed- Wetting Teaching Good Behavior Temper Tantrum Playing is Learning Reading, Routine, etc. Information/ Content Appropriate Information4.74.64.24.84.94.74.5 Adequately Comprehen-sive/ Thorough4.64.34.24.7 4.64.5 Aids in Patient Care4.74.54.14.74.84.54.4 Cultural Sensitivity Literacy Level Appropriate4.14.64.3 4.24.44.3 Culturally Appropriate4.44.54.44.54.6 4.3 Free of Bias4.7 4.64.8 4.74.5 Usefulness Readability4.54.74.14.6 4.5 Relevant Information4.74.54.14.74.8 4.4 Purpose is Clear4.8 4.34.8 4.6 Effective4.54.64.04.64.74.64.2 Total (average)4.6 4.24.64.74.64.4 Key: 1 = Poor 5 = Excellent

21. 21 Practicing Safety Results: Office Systems Inventory

22. 22

23. 23

24. 24 Average Time spent at 2- and 18-month well child visits from pre to post intervention Pre-test Average (n=13 practices) Post-test Average (n=13 practices) Change in minutes (average) On average, how much time is spent at a 2-month well child visit (in minutes) 19.2 minutes20.6 minutes+1.4 minutes On average, how much time is spent at a 18-month well child visit (in minutes) 21.7 minutes22.3 minutes+0.6 minutes

25. 25 Practicing Safety Results: Qualitative Themes

26. 26 Qualitative Themes  Consistent use of PS toolkit  Systemization of risk  Changes to chart documentation  Community resource linkages  Initiation of meetings  Improved medical education  Implementation of QI methodology  Increased awareness  Challenges  Unanticipated positive outcomes

27. 27 Practicing Safety Lessons Learned  Practices need guidance in order to incorporate practice- based protocols that address child abuse and neglect prevention as part of well-child care  Pediatricians, once supported and mentored, are excited to offer families more concrete and systematic guidance in these areas  Practicing Safety can inform more successful implementation of enhanced care and assists practices in establishing a medical home  Parents are receptive to guidance on these topics and believe these issues are of significant concern  Practicing Safety provided an opportunity for enhanced clinical education for physicians, nurses, residents, etc

28. 28 Practicing Safety Lessons Learned (con’t.)  Practices tailored tools to fit their patient population. Some practices incorporated tools for more than the project prescribed well-child visit based on age. Some practices collapsed the suggested “green” and “yellow” assessment questions and anticipatory guidance and used both levels routinely as primary prevention topics at well-visits for all of their families with children in the targeted age ranges  Some practices found a need for multi-lingual, low literacy and more graphic materials for parents  Just participating in PS raised awareness of child abuse and neglect issues for all roles in the pediatric office  Chart documentation is key to determining improvements in care

29. 29 Practicing Safety Lessons Learned (con’t.)  It is important to have an engaged practice champion to succeed & leadership support, teams enhance practice change  Some practices found it challenging to promote the bigger picture of their work to the rest of the practice physicians and staff – the importance of testing and measuring prior to full-on implementation  Administrative and clinical priorities compete with making change (H1N1, EMR implementation, staff turnover)  Coding and reimbursement remain a challenge  The project motivated practices to link with community.  Lastly, practices would like more info on diffusion.

30. 30 Any PS Teams on the Call? Share your experiences and lessons learned! What is your proudest accomplishment? What lesson do you find important for others interested in making change?

31. 31 Additional Resources  Practicing Safety QuIIN Web Page: http://www.aap.org/qualityimprovement/quiin/ PracticingSafety.html http://www.aap.org/qualityimprovement/quiin/ PracticingSafety.html  Project Staff Jill Healy, QuIIN Project Manager jhealy@aap.orgjhealy@aap.org Tammy Hurley, Manager, Child Abuse and Neglect Prevention Activities thurley@aap.org thurley@aap.org

32. 32 Thank you! Questions