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Volume 1: Table of Contents 

 

Volume 2

Volume 3

Volume 1: Improving Preventive Care in Your Office-Tools for Office Improvement

Downloadable files are available on the Training and Implementation Materials page.

 

 

 

SYSTEMS IMPLEMENTATION


 

 

Implementing Office Systems for Prevention and Development

 

All practices have “office systems” in which staff work together to accomplish a common purpose. Billing is an example of an office system common to most offices. As your office prepares to implement the Bright Futures framework, it may be helpful to think about each component as needing a system to support it. Ultimately, many system elements will serve multiple purposes (a prompting sheet can remind the health care team to inquire about special health care needs and prompt about the need for immunizations). Initially, however, it will be helpful to develop supports for each Bright Futures component and build on your system as you go. The following 4 steps describe how to develop a plan that will result in a comprehensive system to support prevention and development for young children in your office. (See page 7 for a high-level process flow outlining the steps involved in planning and implementing the Bright Futures components.)

  1. Form your improvement team.

    Select a team to work together to plan and test improvements in your office. Team members should be enthusiastic and willing to test new ideas.

  • Strive for broad representation. Include primary care providers (MD/NP/PA) and other nonmedical providers as well as support staff as part of your team. Broad representation will help you plan and test strategies from a variety of perspectives.

  • Select a team leader who can be the “voice” of your improvement efforts by facilitating communication with other health care professionals, office staff, and relevant community groups.

  • Elicit support from leadership.

    Encourage practice leaders to be involved in promoting new approaches to staff. Ask practice leaders to describe how the proposed changes will benefit patients, acknowledge that such changes may require extra time, and recognize staff efforts at improving care.

  • Prepare for the human side of change.

    Changes, even those that a practice agrees to make, can be difficult. People react differently to changes. Some staff may be resistant because the changes are unfamiliar. Some changes may create additional work until everyone is more accustomed to the new routines (eg, contacting the health department or filling out a new referral form). It is critical to communicate the benefits of new strategies and approaches clearly while also acknowledging that, at least initially, such changes often take added time.  

  • Establish team member goals and roles.

    When establishing a new team, it often is helpful to spend some time clarifying the team’s goal and the contributions needed from each team member. Be flexible—throughout your improvement efforts, team roles may shift or new roles may be required (eg, data collection). Although it sounds mundane, it can be helpful to decide early on which team member will be responsible for developing meeting agendas, scheduling, and communication.  

  • Use existing meetings and routines.

    Set regular meeting times to brainstorm, discuss ideas, and make decisions. Keep team meetings focused and short (“What did we learn from the latest round of testing and what is our next plan of action?”). Sharing updates and information does not always require a lengthy meeting. Rely on e-mail, written summaries, and huddles to stay up-to-date.

  • Communicate regularly about your efforts with the entire office.

    • Use existing meetings to offer training to staff about the new system and to update staff on your progress.

    • Share information about how changes will impact different jobs.

    • Describe how this change will affect patient care.

  • Celebrate success and learning.

    Recognize the efforts not only of the improvement team but also of the contributions of staff. Use staff meetings and office memos/e-mails to name individuals and their contributions to your efforts. Consider including letters of recognition and simple awards to celebrate. Periodically share insights and learning with the entire office at meetings and through written documents.

  • Use the Systems Implementation Worksheet on page 8 to develop your team’s plan. 

  1. Define the component in this volume.

    Your team will benefit from a clear definition for each component in this volume. A common definition can help clarify the boundaries of your efforts. Your definition need not be rigid. Rather, your definition is meant to provide direction and focus for your improvements. You may find, after implementing some systems and changes, that your definition needs to shift.

  • Conduct research on a new component. Refer to Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd Edition, and search the Internet for scientific and practical information on relevant tools and strategies. For example, a visit to the Web site www.dbpeds.org provides information on a range of tools and strategies for developmental screening. After reviewing and discussing this information within your practice, consider contacting experts in your community to provide a local perspective on the topic(s).

  • Discuss broad and narrow definitions to determine the right “fit.” Many of the components in this volume could be defined broadly or more narrowly. Your team will benefit from spending some time developing a definition and also identifying possible aspects of the component that are outside your current focus.


    Example: Community Resources can be defined broadly, such as establishing a link with most or all of the local resources that might be relevant for your patients. Conversely, focusing your community linkage efforts on 2 to 3 agencies may make more sense for your patient population because your patients’ needs are fairly homogeneous.


  • Identify patients in your practice for whom this component will be relevant. It may be helpful to focus primarily on one age (newborns) as you think about prompting systems for prevention, risk screening, and anticipatory guidance. Other important factors to consider when identifying your target population are cultural and language issues, staff skills and available tools, and patient expectations.


    Computer systems can often generate lists of patients based on age criteria or recent visit history. When considering which subgroup to target in your improvement work, be sure to have a system for identifying those patients.

  1. Test new ideas.

    Once you establish your team and its goals, test new ideas and tools to determine how best to incorporate the Bright Futures framework in your office. Evaluating new ideas through small, rapid tests of change can help provide insight into opportunities for improvement and identify barriers you might otherwise overlook.

  • Map office work flow. A work-flow diagram highlights opportunities to streamline or simplify a process. Use a work-flow diagram to document who gives a screening tool to the patient, who collects the completed tool, who files it in the chart, and when each step occurs. (See page 10 in Structured Developmental Screening for an example of a completed work-flow diagram.)

    • Ask a number of staff to review and edit the work-flow diagram so that it accurately reflects their understanding of the process.

    • Pay special attention to handoffs and patient experiences, and when materials and tools are needed in the process.

    • Brainstorm ideas for doing things differently.

  • Conduct small tests of new ideas before practice-wide implementation.

    • Try a new tool or strategy with a few families and review what you learn. For example, after developing or improving a link to one of your prioritized service providers, refer several families to the program and ask yourself, “Did these referrals occur more smoothly than in the past? What were the families’ experiences like? Do I need more information to improve the coordination?”

    • Repeat tests several times before deciding which new materials or strategies to implement. It is important that the team that is testing new strategies keeps track of its efforts to inform decisions about which strategies and approaches are successful in your practice.

    • Determine what data and feedback will help you track the progress and effectiveness of your test. To clarify what information will be most helpful, ask yourself, “How will we know that this change is an improvement?”

    • Plan to measure your tests with simple strategies such as brief, focused chart reviews.

    • Gather both quantitative and qualitative data to assess your efforts.

    • Use the PDSA Planning Worksheet on page 11 to guide your efforts.

For new strategies and tools you want to spread throughout your office,

  • Involve staff leaders and providers when changes to routines will affect support staff. The support and buy-in of supervisors is key to successful implementation and adoption of new approaches.

  • Check in regularly on how changes are affecting staff.

    Be open to feedback about difficulties staff face and encourage the sharing of new ideas. Use staff meetings and discussions to solicit input. Consider requesting anonymous input through a “suggestion box” or simple survey. Staff often appreciate being asked for their views, and their insights offer valuable information to strengthen the system.

  • Identify needed tools and supports.

    Look for new ideas by examining existing routines and tools used in your office. Some tools and approaches may not be widely used but may offer a starting place for building new routines. For example, some health care professionals may use a standard to assess development. Consider testing their tool with others in your office. 

You may need to locate new tools to prompt staff and providers or assist with documenting services. Many Web sites have helpful tools. Ask other physician offices what tools they use.

  • Define new or different roles and routines for each health care team member.

    • Consider holding staff question-and-answer sessions to clarify details about your new approach; keep it informal to allow people to share ideas and opinions freely.

    • Document instructions about roles and procedures for staff to refer to as needed.

    • Be specific about how new approaches will work. Consider sharing a work-flow diagram with staff that outlines each of the steps in the new process.

    • Offer staff training on difficult or new situations that may arise as a result of your new approaches (eg, domestic violence discussions and referrals).

    • Discuss new procedures with staff and be sure to include information on handoffs and clinic flow (“Who does what, when?”).

    • Be aware of legal implications of your new approach (eg, medical assistants are often limited in the scope of work they can undertake).

    • Offer training to increase cultural awareness and sensitivity among staff.

  • Identify resources and supports within the office and in the community.

    • Some situations are best addressed outside the office. Identify resources or referrals that will help meet patients’ needs most effectively.

    • Determine how to organize and display health education materials and resources relevant for the component. Depending on the component, you may need to identify new strategies for handling these resources or simply build on existing routines.

    • See Community Resources for more information about linking with your community.

  1. Solicit parent and staff feedback about the system.

    Seek input from patients, families, and staff on a regular basis about their experiences with your new approaches. Improvements should enhance your patients’ experiences and be manageable for staff.

  • Develop your plan for gathering data to assess the new system.

    • Determine what sources of data to use (eg, chart reviews, parent feedback). On which aspect of your new system do you need data?

    • Which patients will be best able to provide such input?

    • Which staff could you involve in providing feedback?

    • Assign responsibility for collecting data and summarizing results.

    • Establish a regular interval for collecting data. Some data may be best collected infrequently (annually or semiannually), while other data may be informative to collect more regularly (weekly or bimonthly).

    • Consider measuring visit length to ensure the new approach is not slowing you down.

    • Consider using the Bright Futures Status Grid (see page 13) to track the progress of your efforts at implementing Bright Futures components. It may be helpful to complete this tool multiple times.

  • Think simple and small—a few brief questions can yield important information.

    Try asking, “We have recently added several assessment questions in our patient interviews. Did you find these added questions helpful?” or, “Please tell us what parts of our intake process you find helpful and why.”  

  • Survey patients directly.

    Short surveys to gather patient feedback can provide helpful information. A brief survey can be administered to 15 to 30 patients after visits and summarized. (See sample survey on page 15.) Many patients will welcome the opportunity to offer their opinions.

  • Consider forming a Parent Committee.

    • Engaging a small group of parents to help assess changes and identify areas for improvement in your office can be an important step toward incorporating true patient-centered care.

    • Parent Committees need to reflect the racial and ethnic composition of your patient population. Attempt to recruit parents with varying interests.

    • Parents often do not know how to “work the system.” Involve local parent advocacy groups through churches, the mental health system, or juvenile justice systems.

  • Ask staff their opinion of new tools or approaches.

    • What do staff report about their experiences using the new approach?

    • Do they feel the tools and approaches improve communication with parents and patients?

    • Does using the new tools interrupt the office flow?

    • What are the benefits and costs to using this new approach?

    • Has staff received comments from patients or parents about the new tools or approaches?

    • What has surprised staff about using new tools and approaches?

  • Share your findings with the entire office.

    Summarize findings and disseminate throughout your practice. Summaries need not be lengthy—a simple bulleted list or graph is often effective. Share what you are learning through forums such as meetings, bulletin boards, practice newsletters, and e-mail. 

 

Process Flow: Planning and Implementing the Bright Futures Components

 

Suggested Tools 


Systems Implementation Worksheet

This worksheet walks you through the 4 steps to implementing Bright Futures components. In the following box, select the component on which you are working.

   

Bright Futures Components

  • Preventive Services Prompting System

  • Structured Developmental Screening

  • Eliciting Parental Strengths and Needs

  • Recall and Reminder System

  • Community Resources

  • Children With Special Health Care Needs

 

Consider advantages and barriers.

  • What advantages and barriers do you anticipate encountering during planning and implementation?

  • What strategies can you think of that will help address these barriers?

  Planning and Testing New Ideas 

 

1. Form improvement team.

  • Do you have a variety of perspectives represented?

  • When and how often will you meet?

  • Have you identified your team goals?

  • Have you discussed roles and responsibilities of team members?

  2. Define Bright Futures component.
  • Is there a subpopulation for which this component would be especially relevant?

  • What limitations does your office face regarding this component?

  3. Test new ideas.
  • What data will help you determine if this approach is worth adopting practice wide?

  • How will this approach affect office staff roles and routines?

  • What supports do you need to implement this new approach (tools, staff training)?

  • How can you spread this approach throughout the office?

  4. Solicit parent and seek feedback.
  • How can you seek input from patients about new tools and approaches?

  • What does staff think of new tools and approaches?

  Sample Systems Implementation Worksheet

This worksheet walks you through the 4 steps to implementing Bright Futures components. In the following box, select the component on which you are working.

 

Bright Futures Components

       Preventive Services Prompting System

      Structured Developmental Screening

      Eliciting Parental Strengths and Needs

      Recall and Reminder System

      Community Resources

      Children With Special Health Care Needs

 

Consider advantages and barriers.

  • What advantages and barriers do you anticipate encountering during planning and implementation?

  • What strategies can you think of that will help address these barriers?

Large numbers of patients do not keep appointments—task may be overwhelming. Staff
very busy and have limited time to devote to new tasks. Will focus efforts on
subpopulation initially and track amount of time needed to implement. May decrease number of missed appointments. 


Planning and Testing New Ideas 

 

1. Form improvement team.

  • Do you have a variety of perspectives represented?

  • When and how often will you meet?

  • Have you identified your team goals?

  • Have you discussed roles and responsibilities of team members?  

Team members: D. Smith (MD), S. Jones (nurse), L. Moore (receptionist), J. Brown
(office manager) will meet each week on Weds morning for 20 minutes (before first
patient arrives). Dr Smith will keep other providers informed of activities, Nurse Jones
will lead the meetings, and Mr Brown will record notes. Team will focus on testing recall and reminder strategies.

 

2. Define Bright Futures component.

  • Is there a subpopulation for which this component would be especially relevant?

  • What limitations does your office face regarding this component?

Team will focus on children due for 3-year checkup and adolescents needing new
immunizations and will not expand beyond these age groups until “kinks” are worked out.
Cannot cause overtime.

 

3. Test new ideas.

  • What data will help you determine if this approach is worth adopting practice wide?

  • How will this approach affect office staff roles and routines?

  • What supports do you need to implement this new approach (tools, staff training)?

  • How can you spread this approach throughout the office?

Team will track the number of patients in age group needing recall and how many
actually made appointments, the amount of time each team member spends on
implementing (testing) new recall strategies. Will likely need to generate reports and
need approval from information technology lead. Dr Smith will present results to provider
group at monthly meeting.

 

4. Solicit parent and seek feedback.

  • How can you seek input from patients about new tools and approaches?

  • What does staff think of new tools and approaches?

Receptionists will ask patients about receiving cards/calls about needed appointments
and record feedback. Mr Brown will solicit input from office staff regarding opinion of
new strategies and generate a report of cost of implementing steps.

 

 

Plan-Do-Study-Act Planning Worksheet  

 

Team Name: Cycle: Date:

PLAN:

 

Objective for this cycle: 

 

 

Questions:

 

 

 

Predictions:

 

 

 

Plan for change or test (Who, What, When, Where?):

 

 

 

 

Plan for collection of data (Who, What, When, Where?):

 

 

 

 

DO: Carry out the change or test. Collect data and begin analysis. Describe observations, problems encountered, and special circumstances.

 

 

 

 

 

STUDY: Complete analysis of data. Summarize what was learned.

 

 

 

 

 

ACT: Are we ready to make a change? Plan for the next cycle.

 

 

 

  

 

Sample Plan-Do-Study-Act Planning Worksheet 

 

Team Name: Main Street Pediatrics Cycle: PDSA #4 Date: March 2005

PLAN:

Test a recall and reminder system for 0- to 6-month-old pediatric patients. 

 

Objective for this cycle:

1. Determine size of patient population.

2. Determine strategy to test in next cycle.

 

Questions:

How large is our 0- to 6-month-old population? Do we need to target a smaller age range to keep task manageable?

How much time is involved in processing the data?

Who will contact the patients?

 

Predictions:

0- to 6-month-old population will be manageable for staff to implement system.

Appointment availability might be a problem if we identify large number of patients needing appointments.

Staff might find extra work overwhelming; we predict it will be temporary strain.  

 

Plan for change or test (Who, What, When, Where):

MIS team will generate report of 0- to 6-month-old patients (organized by birth date).

Office manager will review report and assign 3 receptionists to call patients who need to schedule appointments or who missed most recently scheduled appointment.

Receptionists will try to contact all families on list in 2 weeks.

 

Plan for collection of data (Who, What, When, Where?):

Elaine will gather data from MIS reports and receptionists.

Total # of patients in age group

# of patients identified who missed or need appointment

# of appointments scheduled of patients reminded

 

DO: Carry out the change or test. Collect data and begin analysis. Describe observations, problems encountered, and special circumstances.

  1. Two hundred seventy-one patients in this age group; MIS reported no problems generating reports.
  2. Reviewing reports was time consuming for Office Manager. New format discussed with MIS to expedite review by including date of last visit and visit type.
  3. Total number of patient families that need to be contacted is 45.
  4. Each receptionist contacted 15 patient families during 2-week period—time to make calls not a problem; a fair number of incorrect numbers (~6 per receptionist). Some parents commented call was helpful.

 

STUDY: Complete analysis of data. Summarize what was learned.

Approach was feasible, with changes to report from MIS. Need to confirm contact info at every visit. Ask patients about alternate numbers or mechanisms to contact them (for example, e-mail).

 

ACT: Are we ready to make a change? Plan for the next cycle.

Implement recall system at the beginning of next month with same age group.

Consider expanding to other ages (3 year olds, kindergartners, teens).

 

 

Bright Futures Status Grid 

 

For each of the 6 Bright Futures components, please indicate, with a check mark in the grid below, the extent to which your practice has worked on each component. Please check only one box for each component.

 

Categories of activity include the following:

AP: Already in Place (before this project began)

PT: Planning to Test

T: Testing

BI: Begun Implementation on a Pilot Basis

CI: Completed Pilot Implementation

 

For more information about these 5 stages, please refer to the Definitions sheet on the following page.

 

Bright Futures Components

AP

PT

T

BI

CI

Use of a Preventive Services Prompting Sheet 

 

Our practice uses a preventive services prompting sheet for each child younger than 5 years with at least one entry in the past 12 months.

 

 

 

 

 

Use of structured developmental assessment  

 

Our practice routinely documents the use of Parents’ Evaluation of Developmental Status or Ages and Stages Questionnaire to evaluate development at regular age intervals for each child younger than 5 years.

 

 

 

 

 

Evaluation of parental strengths and needs

 

Our practice routinely assesses and documents parental strengths and needs for each child younger than 5 years.

 

 

 

 

 

Development of recall and reminder system

 

Our practice has a system for recalling and reminding patients about missed and future appointments.

 

 

 

 

 

Development of linkages to community resources 

 

Our practice maintains a list of commonly used community resources that is easily accessible to everyone in our practice who needs it.

 

 

 

 

 

Identification of children with special health care needs

 

Our practice has a system for routinely identifying children younger than 5 years with special health care needs.

 

 

 

 

 

 

 

Definitions

 

Following are the definitions for 5 different activities to assess the status of each of the 6 Bright Futures Components for your practice.

  

Status

Symbol

Definition

Explanation

Already in Place

AP

Component was already in place prior to this project. For example, the practice has already implemented a recall and reminder system.
Planning to Test

PT

Planning to test involves any preparation that occurs prior to conducting a test of change. Collecting baseline data, meeting, brainstorming, and/or planning to change are not tests of change. These are examples of getting ready to test or planning to test.
Testing

T

A test of change involves complete Plan-Do-Study-Act (PDSA) cycles. The specific change idea is being used in the practice on a temporary basis. Testing involves all of the following steps:
  • Planning the change
  • Trying that change
  • Studying the results of the change
  • Acting logically on what was learned, including planning the next test(s), modifying the change and testing again, discarding the change, or moving to implement the change
Begun Implementation on a Pilot Basis

BI

Implementation is taking a successful change and making a permanent change to the way the entire pilot population or pilot practice does their work. Implementation begins when the entire pilot practice begins to adopt the successful change on a permanent basis.

 

If the tests of change culminated in 2 providers using a preventive services prompting sheet, implementation would involve taking that change and helping all 15 providers at the pilot practice adopt it.
Completed Pilot Implementation

CI

Implementation is complete when the entire pilot clinic has successfully adopted the change. It has become a permanent part of the pilot clinic's practice. Implementation may affect documentation, written policy, hiring, training, compensation, and aspects of the organization’s infrastructure often not heavily engaged in the testing phase.

 

By the time we implement a change, it is expected to be successful. Implementation also requires the use of the PDSA cycle.

 

Sample Parent Feedback Survey

 

Consider: 

  • Supporting privacy. Identify a location where parents can complete the survey without others looking on.

  • Offering an incentive for completing the survey (eg, a $5 to $10 gift card to a local pharmacy or bookstore).

 
 

Dear Parent,

 

Our office is testing out some new strategies to improve the care we provide to our patients. We have added several questions to our examinations about personal violence and bullying, family relationships, substance abuse, and depression. 

 

  1. How helpful do you think these questions are for you? (Please use the scale below, with 1 being not at all helpful, and 5 being extremely helpful.)
  2.  

    1

    2

    3

    4

    5

     

  3. Are there some questions we should not have asked? If so, which one(s) and why?
  4.  

     

     

     

  5. Can you think of any others we should ask? If so, please tell us what other questions you think we should add.
  6.  

     

     

     

  7. How should we discuss patients’ answers to the questionnaire and our recommendations?

 

 

 

Please feel free to write your comments below and turn your completed survey into the marked box at the checkout desk.

 

 

 

 

 

 

Original survey developed by Mousetrap Pediatrics, St Albans, VT. Adapted with permission.

 

 

PREVENTIVE SERVICES PROMPTING SYSTEMS


 

 

Bright Futures is a well-known resource to those working with children who are interested in the promotion of healthy lifestyles and prevention of disease. The major risks to children's health and development, particularly after infancy, are largely preventable. The leading cause of death for children older than 1 year is injury, including motor vehicle accidents, firearms, and drowning. Well-child care (or health supervision) provides a vehicle for health care professionals to promote healthy lifestyle choices, monitor children for physical and behavioral problems, and provide age-appropriate and individualized counseling (or anticipatory guidance). Health supervision is best viewed as a process that occurs over time and that is responsive to the emerging capabilities and challenges of the individual patient. The Bright Futures recommendations for the frequency of health supervision visits coincide with key developmental periods.

 

Preventive services prompting systems can support health care professionals in ensuring that all children receive needed health promotion and preventive care recommended by Bright Futures. The use of a preventive services prompting system has 3 purposes: (1) to enable any member of the health care team to quickly assess whether or not a patient is up-to-date on preventive services, (2) to assist in the identification of patients in need of preventive services, and (3) to prompt the health care team about recommended preventive services during a patient visit.

 

When coupled with clear roles and responsibilities, preventive services prompting systems can help distribute work across a health care team, often freeing up provider time and improving satisfaction of staff. Such a systems approach facilitates communication across providers, recognizing that children do not always see the same provider at every visit. A preventive services prompting system complements the provision of routine services at well-child visits. Finally, having a well-described preventive services prompting system can facilitate screening for preventive services at non–well-child care visits and help to reduce missed opportunities.

 

One tool that can assist in the implementation of a preventive services prompting system is a preventive services prompting sheet (PSPS). (See pages 7 and 8 for sample tools.) Use of a PSPS will result in a 10% to 30% increase in the proportion of children who are up-to-date on preventive services. 

 

Bibliography

Bordley WC, Margolis P, Stuart J, Lannon C, Keyes L. Improving preventive service delivery through office systems. Pediatrics. 2001;108:1-8. Available at:

http://pediatrics.aappublications.org/cgi/content/abstract/108/3/e41. Accessed Dec-ember 18, 2008

 

Schor, E. Rethinking well-child care. Pediatrics. 2004;114:210-216. Available at:

www.pediatrics.org/cgi/content/full/114/1/210. Accessed December 18, 2008.

 

1Prislin MD, Vandenbark, MS, Clarkson QD. The impact of a health screening preventive services prompting sheet on the performance and documentation of health screening procedures. Fam Med. 1986;18:290-292

 

 

Implementing a Preventive Services Prompting System

 

To implement an office-wide preventive services prompting system, practice-wide
guidelines are needed. By starting with the Bright Futures: Guidelines for Health
Supervision of Infants, Children, and Adolescents, 3rd Edition,
your office will be
able to prioritize preventive services for your patient population.

  1. Form your improvement team.

  • Identify the group within your practice that will prioritize your practice guidelines.

    This will include some or all of the providers in your practice. It may be helpful to keep this group small.

  • Discuss how to handle differences of opinion regarding importance and timing of services.

    Recall the purpose of this activity—to develop an agreed-upon practice guideline on which to base your preventive services prompting system. Strive for agreement on a minimum set of services required for all your patients. Individual providers can always do more.

  • Strive to reach consensus about periodicity of visits among the clinical staff in your office.

    Your office could link visits to typical transitional times in children’s lives, such as entering kindergarten.

  • Partner with school nurses and school-based health centers to determine your office priorities for your patients.

    These individuals and agencies are important sources of information about the children in your community.

  • See pages 1 and 2 in Systems Implementation for additional ideas.

  1. Define the Toolkit component.

  • Obtain the most current immunization schedule and screening recommendations.

    • Review Appendix C in Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd Edition.

    • Consider the state Department of Public Health as another resource.

    • Consider revising an existing prompting sheet.

  • Consolidate opinions regarding the importance of services and recommended timing.

    • Limit circular discussions by agreeing in advance about your goals.

    • Attempt to summarize areas of disagreement and use data and scientific literature to inform your final decisions.

  • Prioritize which services to emphasize.

    • Use the Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd Edition, coupled with information about your patient population to decide which services to emphasize.

    • Consider placing greater emphasis on those problems for which the burden of illness in your patient population is substantial and where there is stronger evidence that interventions in a clinical setting make a difference.

  • Consider expanding the entries on your PSPS.

    • Include prompts beyond clinical preventive care. Such prompts can help support the health care team in being sensitive and aware of issues that can have implications for providing high quality care.

    • It is important to use culturally sensitive approaches to the following:

      Psychosocial prompts such as discipline, maternal depression, home visitors, or other counseling and coordination services
      Prompts regarding literacy, special health care needs, language barriers, and translator needs
  • Adapt existing chart tools, use the samples in this volume, or develop a new one. Use a sign-off system that allows staff to review the final product prior to printing.

  • See pages 2 and 3 in Systems Implementation for additional ideas.

  1. Test new ideas.

    Your team can conduct small tests to check your new system, determine how to integrate the tools into practice flow, and identify further refinements needed before expanding to the entire office. Include health care professionals and staff in this process.

  • When mapping your office flow, include steps for reviewing the PSPS, prompting, and documenting services given to the patient.

  • Build reminders and prompts into new routines whenever and wherever possible.

    It is particularly easy to forget new steps when the day is busy. Be sure to get input from staff performing new routines about what types of prompts might be helpful (sticky notes, signs, stickers, materials, etc).

  • Test seemingly minor details.

    • Where in the chart should a new PSPS be placed?

    • How to document information on the PSPS.

    • This often requires repeated experimentation.

  • If your office has an electronic record, determine how to have the system prompt providers about needed services at every visit.

  • Establish roles and responsibilities to support implementation.

    • Who needs to screen the PSPS tool?

    • When should screening occur?

    • Who will document information on the PSPS?

    • What documentation is needed (a date, a test result, etc)?

    • Who will ensure PSPS tools are in the charts?

    • How will you exchange information with day cares and community agencies?

For new strategies and tools to spread office wide,  

  • Write instructions for staff on new tools and approaches.

    For example, describe who needs to review a new prompting tool and when that review should occur during the patient visit.

  • Standardize the wording of questions or prompts.

    For example, posting a set of assessment questions in the examination rooms for all providers to use is one way to standardize language.

  • Communicate with staff about your new preventive services prompting system.

    • Use your existing meeting structure for training staff about the new system.

    • Share information about how changes will impact different jobs.

    • Describe how this change will impact patient care.

  • See pages 3 through 5 of Systems Implementation for additional ideas.

  1. Solicit parent and staff feedback about the system.

  • Ask parents their opinion of the visit.

    • Ask patients about what your office could do to support them with appointments and keeping track of services. For example, parents often appreciate a prompting sheet that captures data for camp and school physicals.

    • Ask about the best way of communicating with parents and note that information in their chart.

    • Rather than asking parents their opinion directly, consider using simple written surveys. (See page 15 of Systems Implementation for a sample survey.) Surveys do not need to be highly formal, but it is important to consider where and when parents will complete them and to share how the data will be compiled and used with parents prior to completing the survey.

    • Be mindful of language and cultural issues when soliciting patient feedback.

  • Ask staff their opinions of the new approach.

    • Ask about both benefits and barriers to the new approach.

    • How do tools help or hinder the routines?

    • Can staff identify unexpected benefits of using this approach?

  • See pages 5 and 6 of Systems Implementation for additional ideas.

 

Common Barriers to Using Preventive Services Prompting Systems

 

Barrier

Solution

Backfilling in charts

Choose an age and start using the PSPS with those patients.

Disagreement among physicians

Agree to disagree and try the PSPS on a few patients.

Medical record policy of institution

Consider policies ahead of time and plan for processing through system.

Lack of clarity about who is doing what

Create a process flowchart for using the PSPS and review in a team meeting.

Duplication of immunization records

Some duplication is unavoidable, but your team can plan how to minimize duplication by determining various purposes for the PSPS.

 

Suggested Tools 


See the following sheets.

 

Bright Futures Preventive Services Prompting Sheet

 

 

 

Tips for Adapting the Bright Futures Preventive Services Prompting Sheet

 

 

STRUCTURED DEVELOPMENTAL SCREENING


 

 

Bright Futures believes that families and health care professionals have much to learn from one another, individually and collectively. The use of evidence-based, parent-centered structured developmental screening is a useful approach not only for screening children for developmental delays, but also for providing an opportunity for families to ask questions and discuss developmental concerns without adding significant time to the office visit. National experts have found that systematically eliciting parental concern about development is an important manner for identifying children with developmental problems. In addition, most parents wish that more behavioral and developmental issues were addressed during the clinic visit.

 

Expert opinion and research evidence supports developmental surveillance as optimal clinical practice for monitoring children’s development. The effectiveness of developmental surveillance is enhanced by incorporating valid measures of parents’ appraisals and descriptions (parent questionnaires) and objective measures of children’s development using professionally administered tools. In the context of an overwhelming array of recommended clinical topics to address during each encounter, structured developmental screening tools can help to quickly identify issues and concerns for discussion and follow-up, and help prioritize the content of health maintenance visits to meet children and families’ needs.  

 

Considerations regarding screening and assessing for development

  • About 16% of children have disabilities, including speech and language delays, intellectual disabilities, learning disabilities, and emotional/behavioral problems.

  • Only 50% of children with disabilities are detected prior to school entrance.

  • Under-detection eliminates the possibility of Early Intervention.

  • There is no point in waiting to screen until the problem is observable.

  • Do not ignore screening results—there is no value to “wait and see.”

  • Informal checklists have no validated criteria for referral.

  • The American Academy of Pediatrics (AAP) Committee on Children with Disabilities recommends the use of standardized screening tests.

 

Several strategies that are available to support office-based structured developmental screenings are (1) History/Interview, (2) Direct Elicitation and Observation, and (3) Parent Questionnaires. Please see pages 8 and 9 in this section for examples of specific tools that correspond to these categories. Parent-completed questionnaires (such as the Parents’ Evaluation of Developmental Status and the Ages and Stage Questionnaire) are tools that standardize the assessment task and promote partnering with parents, and can be flexibly administered in most settings. Distinct from parent-completed questionnaires are professionally administered tools, such as the Denver II and the Bayley, which can be used to strengthen observations of children’s development, and used as a second stage screen to confirm the diagnosis and develop the intervention plan.

 

Following are the key advantages to using structured developmental screenings routinely: (1) they help health care professionals identify children who need referral for diagnostic assessment and families needing psychosocial referral and (2) they engage families in identifying concerns.

 

A possible schedule for administering developmental screening can be found on page 10

 

Bibliography

Brown B, Weitzman M, Bzostek S, et al. Early Child Development in Social Context: A Chartbook, The Commonwealth Fund. 2004;Pub 778. Available at: http://www.commonwealthfund.org/usr_doc/ChildDevChartbk.pdf. Accessed December 18, 2008 

 

Council on Children with Disabilities; Section on Developmental Behavioral Pediatrics; Bright Futures Steering Committee; Medical Home Initiatives for Children with Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics. 2006;118:405-420: Erratum in: Pediatrics. 2006;118:1808-1809

 

Dworkin PH. 2003 C. Anderson Aldrich Award Lecture: Enhancing developmental services in child health supervision—An idea whose time has truly arrived. Pediatrics. 2004;114:827-831. Available at: http://pediatrics.aappublications.org/cgi/content/full/114/3/827. Accessed December 18, 2008

 

Earls M, Hay S. Setting the stage for success: integrating developmental and behavioral screening and surveillance in primary care into primary care practice. Pediatrics. 2006;118:e183-e188

 

Glascoe FP, Dworkin PH. The role of parents in the detection of developmental and behavioral problems. Pediatrics. 1995;95:829-836

 

Regalado M, Halfon N. Primary care services: promoting optimal child development from birth to three years. Arch Pediatr Adoles Med. 2001;155:1311-1322. Available at: http://archpedi.ama-assn.org/cgi/content/full/155/12/1311. Accessed December 18, 2008

 

Squires J, Nickel RE, Eisert D. Early detection of developmental problems: strategies for monitoring young children in the practice setting. J Dev Behav Pediatr. 1996;17:420-427

 

Triggs EG, Perrin EC. Listening carefully. Improving communication about behavior and development. Recognizing parental concerns. Clin Pediatr. 1989;28:185-192 

 

National Center on Birth Defects and Developmental Disabilities. The Child Development and Public Health page. Available at: http://www.cdc.gov/ncbddd/child/development.htm. Accessed December 18, 2008 

 

National Center on Birth Defects and Developmental Disabilities. The Pediatric Developmental Screening Flow Chart page. Available at: http://www.cdc.gov/ncbddd/child/screen_provider.htm#chart. Accessed September 29, 2005 

 

 

Implementing a System for Structured Developmental Screening

 

Careful preparation and planning will increase the likelihood that you will successfully implement and sustain new systems for using structured developmental screenings in your practice.  

  1. Form improvement team.

  • Identify areas of agreement and disagreement.

    You may find a range of opinions and approaches to screening among your clinical staff. You may find that staff welcome a chance to discuss this issue and to standardize an approach.

  • Elicit support from practice leadership.

    Practice leadership support is important when introducing new tools and strategies. Be prepared with the evidence that supports the use of structured developmental screening.

  • Determine what approaches are used currently in your office.

    There may be a range of strategies and tools used by health care professionals in your office. It may be helpful to create a list so you can gather information on each strategy or tool.

  • Conduct relevant research.

    Engage the clinical staff in discussions early to identify their questions and concerns about various tools and strategies. 

  • See pages 1 and 2 in Systems Implementation for additional ideas.

  1. Define structured developmental screening for your office.

  • Select target age group.

    Ages at which you could distribute the structured developmental screening tool are 9, 18, and 30 (or 24 months if not doing a 30-month visit) months. At other visits, consider asking a consistent question, such as, “Do you have any concerns about your child’s behavior, development, or learning?” 

  • Select a structured developmental screening instrument.

    • Determine the interval for patients to receive the structured developmental
      screening. Structured developmental screening tools can be administered at
      different ages. Bright Futures: Guidelines for Health Supervision of Infants,
      Children, and Adolescents, 3rdEdition,
      and the AAP statement on
      developmental surveillance and screening recommend developmental
      surveillance at each visit and structured screening at the 9-, 18-, and
      30-month visit (or 24 months if not doing a 30-month visit).

    • Consider targeting a sub-sample of your practice population based on patient characteristics associated with increased risks. For example, you might decide to conduct a structured developmental screening of all families with children aged 18 to 30 months because this is an ideal age to assess a child’s development.

    • Some tools are protected by copyright and must be ordered from the publisher. Other tools are in the public domain and can be reproduced free of charge.

    • The advantages of parent-completed questionnaires include the following: (1) ease and flexibility of administration, (2) they do not require the child’s cooperation, (3) and they sample a broad range of skills and issues.

  • Determine how to identify patients who will need structured developmental screening.

    If you determine that not all patients will be assessed (at least initially), develop a plan for identifying the patients who are supposed to be assessed (eg, flagging charts, incorporating a reminder system into patient appointments).

  • Determine which topics you will address during the visit and which topics are suitable for follow-up or referral to outside resources.

    • For those topics that can be addressed effectively through a clinic-based encounter, provide counseling, use patient education materials, recommend appropriate resources (eg, book, video), and schedule a follow-up appointment as needed.

    • For those topics that are not likely to be addressed effectively through a clinic-based encounter, make a referral to a community resource. (See Community Resources.)

    • Consider language barriers.

  • See pages 2 and 3 in Systems Implementation for additional ideas.

  1. Test new ideas.

Your team is now ready to generate new ideas to test for your office.

  • Complete a workflow diagram to illustrate how new screening tools will be implemented. (See sample on page 10.)

    • Distribute the work among several staff members. For instance, a receptionist can be in charge of making sure parents complete the assessment, while a nursing assistant, nurse, or developmental specialist can score the assessment and highlight areas for the health care professional to follow up.

    • Determine where completed structured developmental screenings will be stored and how information from the assessments will be incorporated into future care. If you plan to compile data from a sample of assessments to inform office improvements, determine who will tally and present the data.

    • Determine when the parent will receive the structured developmental screening. There are several options for distributing structured developmental screening tools to parents.

      The structured developmental screening tool is mailed to families prior to the appointment. Doing so allows the parent more time to complete the information. This option also allows input from day care providers or others close to the child and provides parents with more time to complete the screening tools. However, parents can forget the tools and it is important to establish a procedure for when this happens.
      The parent completes the tool during office visit prior to appointment. Some parents may not read well. In this situation, it can be helpful to use a simple form and offer parents the opportunity to get assistance when completing the tool. Ask parents, “Would you like to complete this on your own or have someone go through it with you?”
      Administer the parent questionnaire over the phone prior to the visit.
  • Determine how to introduce structured developmental screening to parents. Consider explaining to parents that the assessment is very important because it helps the physician understand their children’s development better. Let parents know whom they can ask for help if they need assistance understanding the structured developmental screening. Remind them that all the information gathered is confidential.

  • Determine how to use the information from the tool.

    Information derived from the structured developmental screening will serve as one source of information to prioritize topics for the visit. Combine the parents’ concerns you obtain from the structured developmental screening with your practice’s established guidelines that incorporate authoritative and risk factors (eg, poverty, single parent) and the impression formed from the clinical interview to determine the priorities for each visit.  

  • Establish roles and responsibilities.

    Teamwork is critical to the successful implementation of structured developmental screening tools. It is helpful to have one person who is responsible for overseeing the effort, but, most likely, multiple people will be involved in ensuring that the new tools are routinely used.

    • Assign staff to monitor inventory, place forms in appropriate locations, file completed forms in charts, etc.

    • Identify someone in your practice to lead and coordinate efforts to incorporate structured developmental screening tools into your practice, such as monitoring the inventory of tools.

For new strategies and tools that you want to spread throughout your office,

  • Consider what new resources or referrals your practice may need.

  • Gather data about the most common concerns of your patients to decide which referrals and community resources are the most likely to be needed and used by your patients.

  • Communicate with staff about the new system for using structured developmental screenings.

  • Seeking ideas and input from staff will help you develop the right system for incorporating structured developmental screening tools into your practice.

    • Inform staff that tools and resources are now available.

    • Share information about how using these tools will improve patient care.

    • Describe how materials will be organized so that staff can easily access materials and information as needed.

  • Train health care professionals and staff.

    • Consider holding informal training sessions for all staff to present the rationale for using new tools. Include scientific evidence that supports their use. Provide opportunities for questions and review the new tools and how they will be used.

    • Discuss new roles or responsibilities for staff or health care professionals.

    • Plan sessions on how to talk about sensitive topics or how to handle difficult situations that may arise after using the new tools (eg, maternal depression, violence).

    • Emphasize with staff the importance of being aware of literacy issues and cultural barriers when administering forms.

  • See pages 3 through 5 in Systems Implementation for additional ideas.

  1. Solicit parent and staff feedback about the system.

  • Ask parents their opinion of new tools or approaches.

    • Do parents find the new approach helpful?

    • Are there particular tools or processes that are especially helpful to parents?

    • Do they have questions about why you are doing things differently?

    • Keep track of whether language, literacy, and cultural norms are an issue for parents receiving forms.

  • Ask staff members their opinion of the new approach, including the tools.

    • What are staff members reporting about their experiences using the new approach?

    • Do they feel the tools are uncovering important issues or information?

    • Does using the new tools interrupt the office flow?

    • What are the benefits and costs to using this new approach?

    • Have they received comments from patients about the new tools and approaches?

  • Gather system data to assess your strategy.

    • Consider reviewing structured developmental screening forms at the end of 2 weeks to identify services your families most frequently need.

    • Review your charts to see if structured developmental screenings are happening more frequently than before you used the tools.

  • See pages 5 and 6 in Systems Implementation for additional ideas.

 

Screening Tools Overview

 

Types of developmental screening tools include the Parent Questionnaire, History/Interview, Direct Elicitation, and Observation. In the 2008 Pediatrics in Review article, Selecting Developmental Surveillance and Screening Tools, a list of possible developmental screening tools is provided and discussed. A chart of these tools is listed below. The 2006 AAP policy statement also contains a list of screening tools. Note: A complete list of tools, ordering information, and a discussion of the pitfalls of screening can be found at www.dbpeds.org.

 

General Information Concerning Screening Instruments (instruments are listed in alphabetical order within categories)

 

 

 

 

Suggested Tools

 

Guilford Child Health Practice Workflow Model (Sample)

 

 

Reprinted with permission (source): “Developmental & Behavioral Surveillance. The Longitudinal Relationship with Children and Families” developed by Marian Earls, MD. 

 

ELICITING PARENTAL STRENGTHS AND NEEDS


 

 

The Bright Futures: Guidelines for Health Supervision of Infants, Children, and
Adolescents, 3rd Edition,
is based on the belief that effective health supervision involves an
ongoing partnership between health care professionals and families. The success of Bright Futures health supervision depends on creating and nurturing a true partnership through which children and adolescents, families, and health care professionals all work together to establish both short- and long-term goals. Working in partnership with the family, health care professionals can be remarkably effective in promoting health. By eliciting parental strengths and needs, the health care professional is creating opportunities for thoughtful dialogue between families and health care professionals.

 

Bright Futures views health as contextual (ie, the child is viewed within the context of the family and community). Most families want to learn how to help their children reach full potential. Eliciting parental strengths and needs promotes this learning and affirms and strengthens the role of the family as primary partner in health promotion. Since families most often are responsible for implementing next steps and recommendations, it is important that health care professionals listen to and learn from their perspectives.

 

Systematically eliciting parent and family strengths and needs can

  • Improve communication between parents and health care professionals by increasing the likelihood that concerns will be addressed during the visit. When parents note that their concerns are considered important by the health care professional, their satisfaction with the quality of care improves.

  • Help build rapport with parents by demonstrating respect and creating a partnership between the health care professional and parent that is focused on identifying and meeting the child’s and family’s needs. A strong relationship between health care professional and family can serve as an important foundation from which to address specific problems should they arise later.

  • Build parental confidence by eliciting concerns and honoring their importance.

  • Allow health care professionals to prioritize needs and issues for discussion and follow-up and facilitate early detection of potential problems.

  • Identify needed referrals or community resources that will enhance a family’s ability to maximize their child’s development.

  • Offer opportunities for parents to share triumphs and challenges of child rearing. Health care professionals can use this information to help parents devise strategies to address issues in the future.

  • Support patient-centered approaches to care.

 

Bibliography

Bethell C, Peck C, Abrams M, Halfon N, Sareen H, Collins KS. Partnering with parents to promote healthy development of young children enrolled in Medicaid in three states. The Commonwealth Fund. 2002;Pub 570

 

Duncan PM, Garcia AC, Frankowski BL, et al. Inspiring healthy adolescent choices: a rationale for and guide to strength promotion in primary care. J Adolesc Health. 2007;41:5195-520

 

Glascoe FP, Dworkin PH. The role of parents in the detection of developmental and behavioral problems. Pediatrics. 1995;95:829-836

 

 

Implementing a System for Eliciting Parental Strengths and Needs

  1. Form your improvement team.

    Select a team to work together to plan and test improvements in the area of eliciting parental strengths and needs in your office. Team members should be enthusiastic and willing to test new ideas.

  • Discuss the challenges your team anticipates facing in implementing approaches to elicit parental strengths and needs.

  • Consider involving parents in your team—their insights are likely to be especially helpful.

  • See pages 1 and 2 in Systems Implementation for additional ideas.

  1. Define parental strengths and needs for your office.

    It may be easier to focus on a particular group of patients as you adopt new strategies for eliciting parental concerns. It often is easier to start with a small, focused population, such as newborns or preschool-aged children, when testing new approaches. After your system is in place, your office can expand the focus to address other ages.

  • Discuss the challenge of balancing recommended anticipatory guidance and preventive services with addressing family strengths and needs with your office staff.

  • Different approaches may lend themselves to different ages.

    Several strategies and tools exist to elicit parental concerns during office visits effectively. When children are younger, much of the visit is focused on obtaining information from parents so strategies for adults, such as motivational interviewing, can be effective.

  • Gather information on a range of approaches.

    There are varieties of strategies that practice staff and providers can use to elicit parental concerns. Several simple tools are included in this section of Volume 1. The Parents’ Evaluation of Developmental Status is a tool designed to help identify developmental issues as well as to elicit parental needs effectively.

    Other approaches to consider are HEEADSSS (for adolescents), Motivational Interviewing, GIMB (Generosity, Independence, Mastery, Belonging), and The Helping Skill, among others. Identify strategies that your office can test out with several patients before adopting throughout the office.

  • Determine topics you will address during the visit and topics for which you will refer to outside resources.

    For those topics that can be addressed effectively through a clinic-based encounter (eg, toilet training), provide counseling, use patient education materials, recommend appropriate resources (eg, book, video), and schedule a follow-up appointment as needed. Topics such as domestic violence or substance abuse may require outside referrals and/or a series of follow-up appointments.

  • Consider what new resources or referrals your practice may need.

    Identify new community resources or referrals for issues that are best handled outside the office. Gathering data about the most common concerns of your patients may help you decide which referrals and community resources are the most likely to be needed and used by your patients. (See Community Resources.)

  • See pages 2 and 3 in Systems Implementation for additional ideas.

  1. Test new ideas.

    Your team can conduct small tests to check your new system, to determine how to integrate the tools into practice flow, and to identify further refinements needed before expanding to the entire office. Include health care professionals and staff in this process.

  • Map the office flow.

    Develop a flow chart that includes steps for administering tools and integrating them into the office routine. The office flow chart often will help clarify roles and responsibilities of team members.

  • Use prompts and reminders.

    Build reminders and prompts into new routines whenever and wherever possible. It is particularly easy to forget new steps when the day is busy. Be sure to get input from staff performing new routines about what types of prompts might be helpful (sticky notes, signs, stickers, materials, etc).

  • Be thorough when testing new strategies.

    Do not forget to check seemingly minor details, such as where in the chart a screening tool should be placed or how to document information gathered from the patient. This may require some planning and experimentation.

For new strategies and tools you want to spread throughout your office,

  • Check in regularly on how changes are affecting staff.

  • Communicate with staff about new system.

    Seeking ideas and input from staff will help you develop the right approach or approaches for systematically eliciting parental concerns.

    • Inform staff members that tools and resources are now available so they can use them with patients.

    • Share information about how using these tools and approaches will improve patient care.

    • Describe how materials will be organized so that staff can easily access materials and information as needed.

  • Train health care professionals and staff.

    • Consider holding informal training sessions for all staff to present the rationale for using new tools. Include scientific evidence that supports their use. Provide opportunities for questions and review the new tools and how they will be used.

    • Discuss new roles or responsibilities for staff or health care professionals.

    • Staff might welcome a session on how to talk about sensitive topics or how to handle difficult situations that may arise as a result of using the new tools (eg, maternal depression, violence).

    • It can be important to raise awareness among care team staff about how cultural issues such as beliefs and values can affect a patient’s openness. It may be helpful to discuss staff experiences with those issues and develop strategies for addressing them.

  • See pages 3 through 5 in Systems Implementation for additional ideas.

  1. Solicit parent and staff feedback about the system.

  • Ask parents their opinion of new tools or approaches.

    • Do parents find the new approach helpful?

    • Are there particular tools or processes that are especially helpful to parents?

    • Do they have questions about why you are doing things differently?

    • Keep track of whether language, literacy, and cultural norms are creating barriers for your patients in sharing strengths and needs.

  • Ask staff their opinion of the new approach, including the tools.

    • What do staff report about their experiences using the new approach?

    • Do they feel the tools are uncovering important issues and information?

    • Does using the new tools interrupt the office flow?

    • What are the benefits and costs to using this new approach?

    • Has staff received comments from patients about the new tools and approaches?

  • Gather system data to assess your strategy.

    • Review charts to track documentation of assessment of strengths and needs.

    • Formally survey parents to gather feedback at the practice level.

    • Determine if the new approach lengthens visit time.

    • Summarize findings and disseminate them throughout your practice.

  • See pages 5 and 6 in Systems Implementation for additional ideas.

 

Suggested Tools

See the following pages.

 

Understanding Your Needs for Today’s Visit

 

Dear Parent,

 

Our practice is always looking for opportunities to improve our care for your child and your family. To help us learn about your needs as a parent and those of your child, please take a moment to answer the following questions:

 

I. Special Health Care Needs

Does your child have any special health care needs (including chronic medical problems, such as asthma, learning or behavior problems, or other health problems, for which he or she receives special services, such as counseling, therapy, or frequent medical tests)?

Yes    ❑ No

 

II. At today’s visit, I would like to

 

1. Better understand my child’s development and what to expect next.

Yes    ❑ No

 

2. Discuss any concerns I have about my child. ❑ Yes    ❑ No

a. Sleep

b. Discipline

c. Feeding

d. Other 

 

3. Discuss and build on my strengths as a parent. ❑ Yes    ❑ No

 

4. Share values or traditions that are important to my family and me. ❑ Yes    ❑ No

 

5. Take home print resources about things with which I need help. ❑ Yes    ❑ No

 

6. Learn about community resources that may be helpful to my family and me.

Yes    ❑ No

 

III. Please list any other specific questions or concerns you would like to

discuss today.

_______________________________________________________________

 

_______________________________________________________________

 

_______________________________________________________________

  

Thank You!

 

 

 

Practice Name: ____________________ MR Number: ________________________

 

Patient Name: _____________________ Today’s Date: _______________________

 

 

Pre-visit Checklist

Our practice wants your input! We have created this form to help focus your visit on those topics you find most important. Please check the items you would like to address today as well as those items that you feel you do well as a parent.

 

 

Things I

do well

as a parent

Things I would like to discuss today

Feeding my child

Understanding what to expect next from my child

Managing my child’s behavior

Helping my child sleep

Creating a safe environment for my child

Using resources in the community to help my child

Supporting my child’s speech and language development

Helping my child fit into our family; get along with others

Helping my family handle stress

Helping my child learn through play and be physically active

Managing my child’s moods

Managing my child’s special health care needs

 

The 40 Developmental AssetsTM for Early Childhood (Ages 0-5)

 

Prototype Early Childhood Assets Framework

 

External Categories and Assets

Support

Family Support – Primary caregivers, at least one of whom is a member of the child’s immediate family, consistently and predictably provide high levels of love, physical care, attention, and nurturing in a way responsive to the child’s individuality.

Positive Family Communication – Primary caregivers communicate positively, openly and respectfully, expressing themselves in a language and style appropriate to children’s age, developmental level, and individuality.

Other Adult Relationships – With the support of their family, children experience interactions and relationships with non-familial adults, including caregivers, relatives, older people, and community figures. These interactions are characterized by investment, enrichment, consistency, and caring.

Caring Neighbors – Young children know neighbors that extend both the child’s network of relationships and sense of safety and protection.

Caring Alternative Care and School Climate – Alternative caregivers and teachers, whether within or outside of the home, are nurturing and accepting, and provide stability and security.

Parent Involvement in Early Care & Education – Parents, teachers, and caregivers communicate with each other in order to attain a consistent and understanding approach to young children. Parents play various roles in the childcare and educational setting.

 

Empowerment

Community Cherishes and Values Young Children – Communities are responsive to issues relevant to the wellbeing of young children, offering an array of activities and quality resources, including those that promote physical health, appropriate to their developmental characteristics and needs.

Young Children Receive and Are Seen as Resources – Communities show their caring and investment in young children’s futures through community system building and by providing families what they need to function as a “child rearing system” and alternative caregivers and child care programs with adequate financial subsidy.

Young Children are Able to Make a Contribution – Young children are provided opportunities to offer assistance and help with simple chores that bring pleasure and order to their environment, and enable them to feel valued.

Young Children Feel and Are Safe – Adults, including parents, caregivers, and neighbors are able to reassure young children that their safety and well-being are a high priority, and that they are protected. The community provides physical safety, opportunity for physical development, and access to adequate health care.

 

Boundaries and Expectations

Family Boundaries The family makes reasonable, developmentally appropriate guidelines for acceptable behavior by young children in ways that are understandable and attainable by young children.

Alternative Care or Out-of-Home Boundaries – Alternative care and early education programs use positive ways of implicitly and explicitly teaching young children acceptable behavior; they avoid inappropriate and punitive methods that confuse, shame and isolate.

Neighborhood Boundaries – Neighbors encourage positive and acceptable behavior in young children in a supportive, non-threatening way.

Adult Role Models – Adults serve as role models by showing the same kind of self-regulation, empathy, acceptance of others and engagement with learning that they would expect and value in young children.

Positive Peer Relationships – Young children’s peers offer inclusion and acceptance, opportunity for having fun in constructive play, and opportunity for developing and practicing pro-social skills.

Positive Expectations – Adults expect young children to behave appropriately, undertake challenging tasks with their assistance, and to do well at an activity within the child’s capacity to perform by giving encouragement; and avoid negative labeling if the child does not succeed.

 

Constructive Use of Time

Play and Creative Activities – Young children have daily opportunities to play with a variety of developmentally appropriate materials both structured and unstructured, that allow self-expression, physical activity, and interaction with others.

Out of Home and Community Programs – Young children are exposed to developmentally appropriate, out of home programs staffed with competent adults that offer a variety of well maintained, suitable materials. Children are periodically taken to community settings such as parks, museums, and theatres that offer stimulating experiences.

Religious Experiences – Young children participate in age appropriate spiritual activities that reflect the family’s faith and beliefs such as the role of faith in building feelings of security, optimism, and caring for others; and that address their own emerging interest in religious issues.

Time at Home – Young children spend a major portion of their time at home where they receive individual attention from primary caregivers, participate in family activities, play with a variety of materials, interact with non-family visitors of all ages, and view TV minimally.

 

Internal Assets and Categories

Engagement in Learning

Motivation to Mastery – Young children respond to novelty and new experiences with interest, curiosity and energy reflective of physical wellbeing, leading to successful and pleasurable experiences.

Active Participation in Learning Experiences – Young children are engaged and invested in developmentally appropriate materials and experiences.

Bonding to Alternative Care Programs – Young children feel positive about their ongoing attendance in and out-of-home care and educational programs, and after an initial period of adjustment, attend willingly.

Home-School Connection – Young children experience security, connection and consistency between home and school or other out-of-home program as a result of mutual concern by adults at each site, and through sharing information about concerns, interests, and activities.

Early Literacy – Young children increasingly show interest in print material and representational symbols (pictures, letters, numbers) as a result of being involved in language rich activities particularly being read to frequently and being exposed to print materials.

 

Positive Values

Caring – Young children begin showing empathy, understanding and awareness of others’ feelings, and make comforting and accepting gestures to peers and others in distress.

Equality and Social Justice – Young children show concern for people who are at a disadvantage or who are excluded from activities because they are different.

Integrity – Young children express their world views in various ways, which include asking questions, making comments, and enacting play episodes. They are also increasingly able to stand up for their own sense of justice.

Honesty – Young children come to understand the pro-social value of honesty and are truthful to the extent their construction of and perception of reality permits it.

Responsibility – Young children can carry out or follow through on simple tasks that help or benefit others.

 

Social Competencies

Interpersonal Skills – Young children have “friendship skills.” They can play harmoniously with their peers through cooperation, give and take of ideas, increasing ability to share, and by showing interest in and awareness of the feelings of others.

Self-Regulation – Young children increasingly can identify the emotions they are feeling, are able to regulate their emotions in conflictual and stressful situations, and can focus their attention when needed on a matter at hand.

Planning & Problem Solving – Young children can intentionally plan for the immediate future, make a choice among several options, and attempt to solve problems or surmount frustrations.

Cultural Awareness & Sensitivity – Young children show positive and accepting attitudes toward people who are racially, physically, culturally or ethnically different from themselves.

Resistance Skills – Young children have an increasingly accurate sense of danger appropriate to their expanding sense of self and environmental knowledge, seek protective help from trusted adults and resist pressure from peers to participate in unacceptable behavior.

Conflict Resolution –Young children are increasingly able to mediate harmonious responses to conflicts by being helped to see the other person's perspective and learning how to compromise in a mutually respectful way.

 

Positive Identity

Personal Power –Young children have a sense of being able to make something happen that matters to them and to others.

Positive Self-Esteem –Young children have a growing sense that they are valued and that their presence and activities gain positive responses from others.

Positive View of Personal Future –Young children feel a sense of optimism—that life is exciting and enjoyable, and that they have a positive place within it.

Sense of Purpose –Young children look forward to appropriate milestones that will energize and confirm their growth such as upcoming birthdays, holidays, kindergarten and school entrance.

 

 

 

RECALL AND REMINDER SYSTEMS


 

 

Recall and reminder systems involve reviewing each patient’s preventive service needs at regular intervals to ensure that nothing has been missed and to identify patients who have not come in at appropriate intervals. Practices that implement recall and reminder systems increase their immunization rates by 10% to 20%.1

 

Developing a recall and reminder system can seem overwhelming, yet the work is actually much easier than it seems at first glance. By breaking the tasks into small pieces, effective recall and reminder systems can be accomplished in a large practice in as little as 1 to 2 hours per month. Recall and reminder systems may lead to increased practice revenues, enable the practices to use community outreach sources, and provide an excellent means of identifying inactive patients.

 

Recall and reminder systems need to reflect the unique characteristics of the practice’s office system, staff, and patient population. There are many options for practices interested in recall and reminder systems. Some systems involve targeting patients who are behind on services (the most effective approach), while other systems focus on sending reminders to an entire age group (a less effective approach). It may help to start with individual components of a system and gradually work toward more sophisticated systems.

 

Bibliography

Daley MF, Barrow J, Pearson K, et al. Identification and recall of children with chronic medical conditions for influenza vaccination. Pediatrics. 2004;113:e26-33. Available at: http://pediatrics.aappublications.org/cgi/reprint/113/1/e26. Accessed December 18, 2008

 

Tierney CD, Yusuf H, McMahon SR, et al. Adoption of reminder and recall messages for immunizations by pediatricians and public health clinics. Pediatrics. 2003;112:1076-1082. Available at: http://pediatrics.aappublications.org/cgi/reprint/112/5/1076 . Accessed December 18, 2008

 

1 Szilagyi PG, Schaffer S, Shone L, et al. Reducing geographic, racial and ethnic disparities in childhood immunization rates by using reminder/recall interventions in urban primary care practices. Pediatrics. 2002;110:1-10

 

 

Implementing a Recall and Reminder System

  1. Form your improvement team.

  • Select a team to work together to plan and test improvement ideas.

  • Team members might include staff from the front office, business office, and medical records, as well as clinical staff.

  • See pages 1 and 2 in Systems Implementation for additional ideas.

  1. Define a recall and reminder system for your office.

  • Determine what services will be the focus of your recall and reminder system.

    • What services are the most important for you to track?

    • Can you use something as a proxy to track a range of services (ie, immunization status for other preventive services)?

    • Do you currently have outreach or recall systems in place on which you can build?

    • Decide if using computers or other technology will work in your office. If not, you can build a system that does not rely on the computer.

  • Estimate the workload.

    Data indicate that about two-thirds of patients will be up-to-date on preventive services, while approximately one-third of patients will be behind on some service. In a busy practice with 60 newborns per month, action is likely to be needed for approximately 20 patients per month.

  • Identify patients to include in your recall and reminder system.

    The simplest approach to a recall and reminder system is to review the charts of children of particular age(s) monthly. It is helpful to estimate the number of patients who would likely be included in your population (eg, how many children are born in a typical month in your practice).

  • Refine the criteria by which a child will be considered eligible for tracking.

    You could target a particular age group (eg, all 20-month-olds in your practice) or focus on a particular service (eg, immunizations) to narrow your focus for the recall and reminder system. It is helpful to start with a small, focused group and then expand once you feel your system is working well. Possible criteria may include

    • Age—focusing efforts on 20-month-old children provides an opportunity to recall patients and bring them up-to-date by age 24 months

    • Missed most recent recommended well-child care visit—use 18-month visit as a proxy for being delinquent, assuming children seen for well-child care visits will receive needed services

    • Delinquent on immunizations

    • Delinquent on preventive services

  • Use computer systems when possible.

    Most offices have a computer system for billing and appointments. It is less common for an office to have a computer system that stores visit data. Nonetheless, most computer systems can be of use when undertaking recall and reminder efforts (some systems have built-in features).

     

    Call your computer vendor directly to determine if you can use your computer system to help you with recall and reminder tasks. Following are some questions you may want to ask your computer vendor or your information technology staff.

    • Does the computer system have a built-in tracking system? Is it possible to purchase a tracking system as an add-on?

    • Can the system generate a list of all children born in a given month (eg, all children born in December 1999)?

    • Does the computer store data on specific services such as immunizations or tuberculosis skin test (PPD skin test)?

    • Does the system contain information on diagnosis or type of visit?

    • Can the system be programmed to link date of birth with receipt (or no receipt) of individual services (eg, all children born in August 2003 who have received all appropriate DaPT immunizations)?

  • See pages 2 and 3 in Systems Implementation for additional ideas.

  1. Test new ideas.

    It is important to balance staff availability and the desire to implement a recall and reminder system. Starting with a narrow focus will help.

  • Determine which staff will be involved.

    The office manager or business manager can often be of assistance when trying to generate patient lists. Ask for his or her help early in your planning process.

    • Who will generate the list of children of a particular age?

    • Who will screen the charts?

    • Who will send reminder postcards or make phone calls?

    • Who is responsible for follow-up tracking?

  • Establish a relationship with local agencies to coordinate efforts.

    On those occasions when recall efforts are unsuccessful, having an established relationship with local outreach efforts (such as health department programs and the Special Supplemental Nutrition Program for Women, Infants, and Children) can provide helpful information, such as if the child has moved or up-to-date contact information, as well as assistance in conducting outreach activities.

    • Many state and local health departments have programs that track and follow up on children who are delinquent on immunizations or who have missed preventive health care visits.

    • Practice staff can call the health department to determine how best to collaborate.

    • Be sure to identify a specific contact at the health department.

    • Develop a written agreement describing how you will work together.

  • Track the results of your tests.

    It might be helpful to see how many patients keep appointments to determine whether your new ideas are helpful before expanding to other ages. It may be helpful to track how much time staff is taking to implement the recall and reminder strategies. A system that requires too much time will not be sustained.

  • See pages 3 through 5 in Systems Implementation for additional ideas.

  1. Solicit parent and staff feedback about the system.

  • Ask parents if reminder calls are helpful.

    • Consider your patient population. Perhaps many of your parents do not have reliable phone numbers or your contact information is not up-to-date.

    • Consider ways of involving parents in recall and reminder systems. Patients could complete address or contact information on a card while waiting to check out.

    • Ask parents to describe how other organizations or offices remind them of upcoming appointments or needed services. Ask what they like or dislike about these approaches.

  • See pages 5 and 6 in Systems Implementation for additional ideas.

 

Strategies for Recall and Reminder Systems

 

Following are several approaches to designing a recall and reminder system.

 

Missing Required Health Maintenance (RHM) visit(s) used as proxy for being delinquent

  • Each month, the computer system produces a list of patients aged 19 months who missed a RHM visit, and prints an address label for each child.

  • Patients on the list are sent a reminder about the need for an appointment.

  • The list of patients who were sent a postcard is filed in a “tickler box” or computer database. One month later, the list is reviewed to determine if the patients have scheduled a RHM since the reminder was sent. Patients who did not make an RHM are the “no-response group.”

  • The list of no-response patients receive appropriate follow-up (such as a second postcard or phone call) from your office, health department, or school.

Individual chart screening to identify patients needing tracking

  • The same steps as above are followed, except that the added step of screening patient charts is added prior to contacting patients with reminders. This approach requires more staff time, but narrows the task of reminding patients about needed appointments or services.

All children of a particular age receive reminder

  • The computer system produces a list of patients who are in a specified age group (eg, 15 months) and prints an address label for each patient.

  • Postcard reminders are sent to all patients on the list, stating that your practice generally sees patients in this age group annually. The postcard can emphasize the importance of preventive health care.

  • Two months later, the follow-up tracking is initiated. The list of patients who were sent a postcard reminder is reviewed to determine if they have been seen for a RHM or if they have scheduled one.

  • The no-response patients are sent another reminder or called to request that they contact the office to make an appointment.

 

COMMUNITY RESOURCES


 

 

Taking full advantage of the resources in your community may enable you to provide a wider range of services to your patients. Many communities have agencies and organizations that can extend the reach of the primary care provider by supporting extended counseling, offering extensive follow-up for patients who are more complex, and providing targeted services for routine patients. A practice is most effective when it identifies the needs and strengths of the individual child and family, works within its own limitations, and maximizes community supports to address the wide range of issues patients face.

 

Following are several key changes that practices can undertake to more effectively link with their community:

  • Identifying an individual or team who is responsible for coordinating with the community

  • Identifying the most frequent community referrals for patients in your practice

  • Determining the resources in the community that offer services and support that will meet the needs of your infancy and early childhood population

  • Identifying specific people at agencies that can provide your practice with information and support referred patients

  • Creating a list of relevant community resources and agencies and making it available to patients and staff

  • Developing simple systems to track patient care among agencies and the practice (eg, non-carbon referral forms, school nurse contact information, obtaining eligibility criteria from agencies, and uniform “release of information” forms)

  • Gathering information from these community resources

  • Documenting the use of community services in patients’ charts

  • Ensuring a mechanism for continuously or periodically updating information about community resources

 

Start Small

Creating effective partnerships with your community is an ongoing, evolving process. It can be daunting to identify all the community resources that your practice might want to refer patients to and to set up systems to support coordination with those resources. Lack of time, knowledge and staff resources are among the challenges that may limit practices’ use of community resources to their full potential. To avoid having the task seem insurmountable, narrow your focus initially to one or 2 services your patients need most frequently and one or 2 strategies for linking to those agencies. Learn as much as you can about community resources for those topics and then develop good systems for working with the organizations that provide relevant services. What you learn by fully developing one or 2 links at a time will translate into knowledge that your practice can use in the future.

 

 

Implementing a Community Resources System

 

Careful preparation and planning will increase the likelihood you will successfully plan, implement, and monitor a new or enhanced system for linking with your local community. Your community may have systems that are outside what is suggested here. Because so much variability exists among communities, it is not feasible to inventory all the possible strategies your practice might eventually employ to become more connected to your community.

  1. Form your improvement team.

  • Involve families as you plan your community resources system. Involving families in your planning about linking with the community will help ensure that your efforts reflect families' needs and experiences. Parents’ perspectives of community services will provide you with information you will not likely get from the agencies or programs themselves. Understanding parents’ perspectives of services will enable you to make more informed referrals.

    • Find out what families say about their experience of care. Ask, “What programs or services have you found helpful? What should we tell families whom we refer to this agency?”

  • Clarify your team’s goals. Discuss the challenges the team anticipates and some of the possible benefits to your practice.

  • Seek ideas and input from your staff.

    • Ask staff to share their experiences in coordinating with community agencies.

    • Build on existing relationships with community agencies and programs.

    • Ask staff for input on team goals.

  • See pages 1 and 2 in Systems Implementation for additional ideas.

  1. Define community resources for your office.

    Systems to link with community resources can range from very simple to more complex. It often is easier to start with a narrow focus and build on that system as you go, rather than starting efforts without a clear focus.

  • Determine the needs of your patient population. When developing a system for improving coordination with community resources, start by identifying the areas most needed by your patient population. This will provide a focus to your efforts. You can expand your systems as you identify new needs.

    • What resources do your patients need most frequently or urgently?

    • For example, how many of your patients use tobacco, alcohol, or other drugs?

    • Consider reaching out to day cares and public clinics.

  • Identify local agencies and groups in your community.

    • If your office is in a fairly large community (more than 50,000 residents), it is likely that a local agency has developed a resource list (such as a community hospital). Start by determining whether such a resource list exists and how to make it available in your office.

    • The Community Resources Assessment tools on pages 7 through 9 may be helpful in focusing your efforts.

  • See pages 2 and 3 in Systems Implementation for additional ideas.

  1. Test new ideas.

  • Evaluate strategies for your practice to link with the community. What strategy or strategies make the most sense for your practice? After you have a clearer picture of your patient population’s needs, your office capacity, and community resources, you will be better able to prioritize what strategies to pursue. Several questions to help you get the biggest benefit from your efforts include the following:

    • What are the systems your practice already has in place for supporting patients who need community services?

    • What systems do you have in place for communicating with community services?

    • Do you have established contacts in the community already?

    • How can you build on the success of existing connections and partnerships?

  • Assign responsibility for coordinating community resources. Identify someone in your practice to oversee and coordinate your efforts. Consider creating a team to undertake this responsibility (2 or 3 hours per month focused on this activity will produce measurable improvements). Some questions to consider are

    • What, specifically, is expected of this person or team?

    • Are there teams or individuals within your office who could assist with creating links with the community (eg, nurse who coordinates with the local health department)?

    • Where and how will contact information about community agencies be organized?

    • What space is available for displaying information about community services?

    • How often will you update information? How can this task be shared among staff (eg, rotate calling 6 agencies monthly)?

    • Is there a way for community resources to contact and communicate with your office? Is there a contact person?

  • Create a list of contacts and eligibility information for staff and patients. It will be helpful to decide how to organize and display printed materials from community agencies. Consider integrating these materials with standard patient education handouts and information.

  • Assign staff to participate in existing coalitions or community meetings. This could be a rotating responsibility. The key is to have a practice representative present at meetings so that your office is informed about community activities. Being present in person also promotes relationship building and enhances communication. Participation also provides an opportunity for the practice to represent your office needs.

  • See pages 3 through 5 in Systems Implementation for additional ideas.

  1. Solicit parent and staff feedback about the system.

  • Provide different opportunities for parents to provide input. Several suggestions for gathering parent input include the following:

    • Set up a comments section in your community resources area where parents can submit feedback about different services or agencies with which they are familiar. Create a simple form for families to complete. Post the feedback for others to review. (Review the comments before they are posted publicly.)

    • Consider asking parents to be available to speak with other parents from the practice. This could be done at an informational session organized in your office or, if the parent is willing, you could provide contact information (eg, e-mail address).

    • During routine well-child visits, periodically ask 5 to 10 families about their experiences with community services. What would they recommend you tell other parents about this agency or service?

    • Include questions on parent surveys to elicit information about community programs.

  • Track how often you link with community agencies. Keeping track of how many referrals you make could be informative. Follow up with agencies to determine how to improve your coordination and communication as well as patient compliance with referral.

  • See pages 5 and 6 in Systems Implementation for additional ideas.

 

Strategies for Linking to Community Resources

 

Linking with your community resources often requires multiple strategies. The following suggestions are divided into those strategies that are internal to your office and those that are more externally focused. Limit your efforts initially by selecting one of the strategies listed. Choose an approach that builds on existing routines or expertise within your office.

  1. Office-based Strategies

Create a “Community Resources” area in your practice for patients.

Select an area in your office that will be dedicated to information about community programs and resources in your practice.

 

Include materials, such as

  • List of local community agencies contact information

  • Information about financial assistance for services

  • Pamphlets and brochures from local community programs and service providers

  • Marketing collateral (magnets, business cards, posters) from local agencies

  • Parenting education information

  • Feedback forms for parent input about community resources and topics of interest

Other features that might be helpful in your Community Resources area are

  • Telephone parents can use to call agencies

  • A private area to place a call

  • Pen, paper, maps, public transit schedules

  • Computer terminal with online access

Identify tools to support improvements staff in linking to the community.

Creating new links with your community often introduces new forms and responsibilities into your practice. Suggestions to streamline staff efforts include

  • Stock standard referrals forms for local community agencies.

  • Orient staff to referral forms from local agencies.

  • Assign a staff person to be a “referral specialist” who is responsible for completing and processing forms and following up on referrals.

  • Determine how to exchange forms with local agencies. For example, should your office e-mail or fax referral information, or give it to the patient?

  • Determine where to store completed copies of referral forms (eg, in patient chart).

Consider co-locating agency staff at your practice.

  • Offer space to both medical and nonmedical staff.

  • Identify or hire an in-house community referral specialist to handle coordination of referrals and to act as a practice-patient community resource.

  • Encourage Medicaid, the State Children’s Health Insurance Program, The Special Supplemental Nutrition Program for Women, Infants, and Children, or other services to enroll patients in your office.

  1. Community-based Strategies

Participate in centrally coordinated community services efforts.

Centralized systems for identifying and referring families typically use a standard community-wide eligibility screening mechanism. Such efforts are usually coordinated by the public health department. Steps to becoming involved may include the following:

  • Identify the agency or group responsible for “central triage” in the community.

  • Evaluate the pros and cons of participating in the system for your practice.

  • Participate in training to use the system. (Staff from the lead agency may come to your practice and provide training to your health care professionals and staff.)

  • Understand criteria and language for referral and enrollment to various services.

  • Maintain an ongoing relationship with the system coordinator.

  • Evaluate regularly the costs and benefits of participating in the system.

Capitalize on existing coalitions and coordinated efforts.

In some communities, a central agency or organization (eg, United Way) may have published a resource guide that provides some or all of the information your practice needs to connect to local resources. There also may be an organized group of providers or agencies that has developed mechanisms where information about services can be shared. If a coordinated effort is organized, some of the questions you may want to answer include the following:

  • Is there a network of providers collaborating and coordinating needed services?

  • Are there regular meetings someone from your practice can attend to learn more about services being coordinated? Could you obtain meeting summaries if you cannot send a practice representative?

  • Is there a newsletter, Web site, or e-mail list you can access to remain informed about the full range of community resources and services?

  • Are there information materials (brochures or pamphlets) about community resources and services for families that your practice can provide to patients?

  • What referral systems exist? How do they work?

  • Is there a community resources guide? How can your practice become listed in it? How can you get copies? How can you get updated versions?

Consider assigning health care professionals/staff to see patients at a satellite or community clinic where other service providers are practicing.

 

 

Suggested Tools

 

Community Resources Assessment

 

The purpose of the Bright Futures Community Resources Check Sheet on page 8 is to structure an approach to identifying community resources that may enhance your practice’s ability to serve your patients. The tool will allow you to evaluate which organizations you would like to develop or improve links with as well as to prioritize which links are most important to establish immediately. The tool is organized around specific categories of services. Under each category are examples of resources in your community that might provide these services.

 

Your practice can take 2 approaches in developing a community resources inventory. One approach is to use this assessment to create an exhaustive list of all community resources in the area that might be useful for your practice and prioritize based on your knowledge of the patient population. The other approach is to assess the community resources that are needed by your practice by making a list, over the next 2 weeks, of all community resources to which you refer patients or from which you need more information. You could then prioritize this list by working on setting up those links first. Consult page 9 of this section for a more complete list of services for which your practice might want links.

 

To evaluate whether your practice’s link with a particular organization is satisfactory, ask yourself, “Do we know what programs and services are offered through this organization?” “Do we know how to refer our patients?” “Do we know how to find out the status of our referrals?”

 

 

Bright Futures Community Resources Check Sheet

 

Services and Potential

Community Resources

Satisfactory Link in

This Area?

Priority to Develop This Link

Made Information About Organization or Referral

Health

 

 

 

Title V Services for Children and Youth with Special Health Care Needs

Yes      No

High     Low

Yes      No

State Children’s Health Insurance Program

Yes      No

High     Low

Yes      No

Local Child and Family Health Plus Providers

Yes      No

High     Low

Yes      No

Medical specialty care

Yes      No

High     Low

Yes      No

Public health nursing

Yes      No

High     Low

Yes      No

Medical assistance programs

Yes      No

High     Low

Yes      No

Home care

Yes      No

High     Low

Yes      No

Respite care

Yes      No

High     Low

Yes      No

Mental health resources

Yes      No

High     Low

Yes      No

Substance abuse treatment

Yes      No

High     Low

Yes      No

Environmental health units

Yes      No

High     Low

Yes      No

Health literacy resources

Yes      No

High     Low

Yes      No

Physical activity resources

Yes      No

High     Low

Yes      No

Development

 

 

 

Head Start and Early Head Start

Yes      No

High     Low

Yes      No

Early intervention programs

Yes      No

High     Low

Yes      No

Early education and child care programs

Yes      No

High     Low

Yes      No

School-based or school-linked programs

Yes      No

High     Low

Yes      No

Recreation programs

Yes      No

High     Low

Yes      No

Playgroups

Yes      No

High     Low

Yes      No

Family Support

 

 

 

United States Department of Agriculture (USDA) Women, Infants, and Children (WIC) nutrition program

Yes      No

High     Low

Yes      No

Social service agencies and child protection services

Yes      No

High     Low

Yes      No

Parenting programs/support groups

Yes      No

High     Low

Yes      No

Faith-based organizations

Yes      No

High     Low

Yes      No

Home visiting services

Yes      No

High     Low

Yes      No

Domestic violence resources

Yes      No

High     Low

Yes      No

Bereavement and related supports (due to child death)

Yes      No

High     Low

Yes      No

Food banks

Yes      No

High     Low

Yes      No

Child care resource and referral agencies

Yes      No

High     Low

Yes      No

Child care health consultants

Yes      No

High     Low

Yes      No

Parents Helping Parents organizations for children with special health care needs

Yes      No

High     Low

Yes      No

Adult Assistance

 

 

 

Adult education and literacy resources

Yes      No

High     Low

Yes      No

Job training resources

Yes      No

High     Low

Yes      No

Adult education for English language instruction

Yes      No

High     Low

Yes      No

Legal Aid

Yes      No

High     Low

Yes      No

Immigration services

Yes      No

High     Low

Yes      No

Racial- and ethnic-specific support and community development organizations

Yes      No

High     Low

Yes      No

Volunteering opportunities

Yes      No

High     Low

Yes      No

 

 

Community Resources List

 

American Red Cross

Behavior evaluation and treatment

Car seats

Child abuse and neglect prevention and treatment

Child care resource and referral (financial assistance with child care)

Child services coordination or case management

Child support enforcement

Civic, community-service groups (Ruritan, Elks, etc)

Community-based social service agencies

Community colleges

Department of Mental Health

Department of Public Health

Department of Social Services

Developmental delay assessment and early intervention programs

Domestic violence hotlines and safe houses

Early childhood development programs

Faith-based organizations (mosques, synagogues, churches, etc)

Fire prevention services (such as free smoke detectors)

Food banks

Food kitchens

Health insurance (Medicaid, State Children’s Health Insurance Program)

Hearing or auditory referrals

Home visiting programs

Housing authority

Housing services, shelters

Issue-specific family support groups (Children and Adults with Attention-Deficit/Hyperactivity Disorder [CHADD], 12-step programs, Parents Without Partners)

Job training and placement

Legal Aid

Licensed counselors and social workers

Neighborhood associations

Parenting training and education

Poison prevention services (lead poisoning detection)

Smoking cessation services

Speech evaluation

Substance abuse treatment programs

Temporary Aid to Needy Families

United Way

United States Department of Agriculture (USDA) Women, Infants, and Children (WIC) nutrition program

Work First programs

 

CHILDREN WITH SPECIAL HEALTH CARE NEEDS


 

 

Establishing a clear and planned approach to managing and caring for children with special health care needs (CSHCN) can offer many advantages to a practice. There is a range of definitions to the label CSHCN; therefore, the first step is to clarify for your practice how you collectively understand this term and discuss the degree to which your practice wants to build a specific system to support CSHCN. Much of the system for caring for CSHCN builds on other systems described in this volume, namely community resources and preventive services prompting systems.

 

There are a number of tools and techniques that will improve care for a CSHCN population and that can be tested and adapted to meet practice preferences and capacity. A simple strategy is to ask the parent one question: “Does your child have any special health care needs that I should know about?” This simple question can elicit important information regarding the parent’s concerns and perceptions regarding his or her child’s health. The provider can then ask follow-up questions to determine if the child needs to be referred to a specialist and/or other community resources. The sample preventive services prompting sheet (PSPS) (See the Preventive Services Prompting Systems section in this volume.) includes a prompt for the provider to ask this question and document it in the chart.

 

There are different levels of caring for children with special health care needs.

  1. Identification of CSHCN and basic management of patient’s health care

    1. Establish a practice-wide definition of CSHCN.

    2. Assess the burden in your patient population and method of identification.

    3. Develop standards for supporting families of CSHCN.

    4. Identify appropriate resources in your community.

    5. Establish partnership with a case manager (consider insurance status).

    6. Facilitate internal office communication regarding status of the patient.

    7. Facilitate 2-way communication among primary care providers, specialist(s), and others providing services to the patient.

    8. Seek input from families on how things are going (eg, does the child have non–school-related activities, does the child have social activities, do the parents get support from a parent network or group?).

  1. More complex development of medical home for CSHCN

    1. Refer to more detailed, in-depth American Academy of Pediatrics materials.

    2. American Academy of Pediatrics Policy Statement: The Medical Home.

 

Bibliography

American Academy of Pediatrics, Committee on Children with Disabilities. Care coordination: integrating health and related systems of care for children with special health care needs. Pediatrics. 1999;4:978-981. Available at: www.pediatrics.org/cgi/content/full/104/4/978. Accessed December 18, 2008.

 

 

Implementing a System for Children With Special Health Care Needs

  1. Form improvement team.

  • Identify the group within your practice that works on your new system. This group may include clinicians in your practice and one or more administrative staff. It will be helpful to keep this group small.

  • Consider how to include input from service providers not located in your office who may care for your children with special health care needs.

  • See pages 1 and 2 in Systems Implementation for additional ideas.

  1. Define special health care needs for your office.

    Your practice will need to discuss the definition of CSHCN. You could decide to define it broadly (children with any chronic condition) or narrowly (only children with multiple specialists involved in their care). Such a definition will help focus your efforts at meeting the needs of a special population of patients within your office. This is a critical step in this section.

  • Select strategies for identifying children with special health care needs.

    • Consider multiple medications as a proxy—flag charts of children taking medications and create a registry or list of these patients.

    • Compile a list of the 10 to 20 most complex children in your practice and flag those charts so they can be identified easily. Be certain to explain to parents why there is a flag on the chart.

    • Use frequent emergency department visits, medication refills, or the need for extended visits as a way of identifying patients with special needs. You may be able to use the computer to create this list by using the billing system and designated codes.

    • Request a list from your Title V Agency, rate complexity, and mark these patients’ charts. Use Title V list to compare to current list (if applicable).

    • Consider including in your definition a focus on psychosocial needs, such as social functioning, parent support, and advocacy.

  • See pages 2 and 3 in Systems Implementation for additional ideas.

  1. Test new ideas.

  • Consider a simple prompting system. Remind health care professionals to ask about special health care needs by adding prompts to a PSPS. The PSPS can capture

    • Identified special health care needs

    • General health concerns for these patients

    • The involvement of other service providers (eg, case managers)

  • Establish your role as primary care provider with the family.

    • Discuss roles of various health care team members with the family, including who to contact and when. Emphasize the importance of open, frequent communication among those involved in providing services to the family. Discuss the role of the primary care provider in the context of other services the family is receiving.

    • Create a care plan and emergency care plan for the child that can be shared with day care providers, teachers, specialists, emergency department personnel, etc. Triplicate forms can be helpful for these types of shared care plans.

  • Select strategies for caring for CSHCN.

    • Develop a strength list with parent input in addition to a problem list. Rely on the strength list when planning care and working with parents about caring for their children.

    • Plan ahead for the additional time these patients may need during visits. Using chart flags or computer prompts to trigger extended appointments can be a helpful strategy.

    • Enlist the parents’ help in developing care plans and emergency plans. Parents of children with special health care needs are often well-informed about their children’s condition(s) and often know what works for their children during a crisis.

    • Find out from parents what questions or challenges patients and parents face in coordinating care. Try to use this information as a guide for focusing your efforts.

    • Plan for other aspects of caring for patients with special needs (eg, wheelchair, oxygen, or infection control, such as with patients with cystic fibrosis).

    • Consider offering an option at checkout to schedule longer visits when needed.

  • Support communication with other providers involved in patient’s care.

    • Test a simple fax-back form to facilitate timely exchange of information.

    • Create a list of all providers supporting the family, such as medical specialists or therapists and document information prominently in chart.

    • Document and confirm insurance information at each visit.

    • Reach out to agencies that may provide services to CSHCN. Establish a contact person and gather information regarding the types of services and eligibility.

    • Use of e-mail for team members is a very efficient way to communicate. For adolescents, this is true not just for those with medical diagnoses like cancer and diabetes, but also for those with mental health problems like major depressive disorder.

  • See pages 3 through 5 in Systems Implementation for additional ideas.

  1. Solicit patient and staff feedback about the system.

  • Ask parents their opinion of new tools and approaches.

    • How do parents feel about being asked about special needs?

    • Are there particular aspects of this new approach that parents find particularly helpful? Uncomfortable?

    • What are parents’ ideas for strengthening support of CSHCN?

  • Consider forming a parent group from whom you receive regular feedback. This is especially important as new services and systems are being implemented. Parents can support each other, and your office can learn firsthand about the challenges parents face and learn about creative strategies and resources to share throughout your office.

    • Parents can benefit from sharing concerns and strategies with other parents. Your office can learn firsthand about needed supports and resources from this group.

  • Consider identifying a care coordinator in your office.

  • See pages 5 and 6 in Systems Implementation for additional ideas.

 

Suggested Tools

 

Sample Parent Survey

The Fond du Lac Regional Clinic is in the process of making some exciting changes to better serve your family! In the spirit of improving health care for children with special health care needs, we would like to know what would make your life easier. Please rank the following statements according to their importance to you (5 = highest importance, 1 = lowest importance). Thank you so much for your help!

  

5

4

3

2

1

 

I would like help finding specialty doctors and/or scheduling specialty appointments for my child.

 

5

4

3

2

1

 

I would like help finding health insurance for my child.

 

5

4

3

2

1

 

I would like help finding information about my child’s medical condition.

 

5

4

3

2

1

 

I would like help communicating with my child’s school/Early Intervention services about my child’s health condition.

 

5

4

3

2

1

 

I would like help finding special equipment for my child.

 

5

4

3

2

1

 

I would like help finding appropriate transportation services for my child.

 

5

4

3

2

1

 

I would like help finding information about Social Security Income for my child.

 

5

4

3

2

1

 

I would like help communicating with doctors or therapists about my child.

 

5

4

3

2

1

 

I would like help finding out about other community services that may benefit my family.

 

5

4

3

2

1

 

I would like help finding better housing and/or food subsidies for my family.

 

 

Is there anything else that you need help with that could ease the stress on your family?

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

 

Thank you for your time!

 

Developed by Fond du Lac Regional Clinic (Fond du Lac, WI) for the NICHQ Medical Home Learning Collaborative. 

 

VOLUME 1: IMPROVING PREVENTIVE CARE IN YOUR OFFICE: TOOLS FOR OFFICE IMPROVEMENT


 

Send your Feedback Form to

American Academy of Pediatrics

Bright Futures

141 Northwest Point Blvd

Elk Grove Village, IL 60007-1098

E-mail: brightfutures@aap.org

Fax: 847-434-8000

Name __________________________
Title __________________________
Organization __________________________
Address __________________________
City __________________________
State ___________ Zip____________
Phone __________________________
Fax __________________________
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Tool Reviewed

Section

Systems Implementation Worksheet

1 Systems Implementation

Sample Systems Implementation Worksheet

1 Systems Implementation

PDSA Planning Worksheet

1 Systems Implementation

Sample PDSA Planning Worksheet

1 Systems Implementation

Bright Futures Status Grid

1 Systems Implementation

Definitions

1 Systems Implementation

Sample Parent Feedback Survey

1 Systems Implementation

Preventive Services Prompting Sheet

2 Preventive Services Prompting Systems

Tips for Adapting the Preventive Services Prompting Sheet

2 Preventive Services Prompting Systems

Guilford Child Health Practice Workflow Model (Sample)

3 Structured Developmental Screening

Understanding Your Needs for Today’s Visit

4 Eliciting Parental Strengths and Needs

Pre-visit Checklist

4 Eliciting Parental Strengths and Needs

The 40 Developmental Assets™ for Early Childhood (ages 0 to 5)

4 Eliciting Parental Strengths and Needs

40 Developmental Assets® for Early Childhood (ages 3 to 5)

4 Eliciting Parental Strengths and Needs

Community Resources Check Sheet

6 Community Resources

Community Resources List

6 Community Resources

Parent Survey

7 Children With Special Health Care Needs

The Children with Special Health Care Needs (CSHCN) Screener©

7 Children With Special Health Care Needs

 

(5 = Excellent and 1 = Poor)

1. Utility/Helpfulness 5   4   3   2   1 3. Appearance 5   4   3   2   1
2. Ease of Use 5   4   3   2   1 4. Overall Rating 5   4   3   2   1

 

  1. Advantages ______________________________________________________ ________________________________________________________________ ________________________________________________________________
  2. Challenges ______________________________________________________ ________________________________________________________________ ________________________________________________________________
  3. Special Considerations/Suggestions _________________________________ ________________________________________________________________ ________________________________________________________________

 

 

Go to:

Volume 2

Volume 3

Training & Implementation Materials home page (includes links to download volumes)

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