Adaptation: The North Dakota Department of Health and Department of Human Services worked together to integrate Bright Futures into their statewide Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, Health Tracks. Through this collaboration, providers throughout the state use the Bright Futures Guidelines and Bright Futures/American Academy of Pediatrics (AAP) Periodicity Schedule to meet Health Tracks requirements for every child. By making this joint decision to use Bright Futures' best practice model, the state is better able to provide more comprehensive health and developmental screenings to all children throughout the state.
Through the North Dakota Well-Child Check Collaborative, the North Dakota Department of Health has worked closely with Blue Cross Blue Shield of North Dakota, Blue Alliance to partner with health care facilities throughout the state to improve well-child visit rates. The team working on this initiative adapted and marketed Bright Futures materials to increase the screening rate significantly. Within approximately 1 year, team members raised the well-child visit rate more than 5% in both the 0- to 15-month-old population and the 3- to 6-year-old population. They focused on these specific age ranges to support children during the periods when most immunizations are delivered to children and beyond. To make this significant impact, the team made Bright Futures more user friendly and established a template for all providers. To increase material use by providers, they created a template that allowed each provider to add its own branding and encouraged providers to share resources widely with families. The goal of the public awareness campaign was to ensure that all families and providers understood that the well-child visits are about more than just staying up to date on immunizations. Using Bright Futures materials helped all audiences understand that the well-child visit is an opportunity to conduct screening and monitor growth and development over time.
Implementation: The North Dakota Department of Health has focused primarily on raising the well-child visit rates throughout the state. Several efforts have made a significant difference in reaching this goal, but close partnerships with providers has been a critical component of success.
The North Dakota Department of Health has worked closely with multidisciplinary clinics to make sure they are following the Bright Futures Guidelines and appropriately integrating Health Tracks screenings into their practice or referring patients to providers who perform Health Tracks screenings. Using medical home recognition and pediatric medical home system improvement contracts, North Dakota has worked with providers to reach NCQA Patient-Centered Medical Home Recognition. A critical piece of this work focuses on ensuring providers conduct regular well-child visits and offer required immunizations following the Bright Futures Guidelines and Bright Futures/AAP Periodicity Schedule, as also followed by Health Tracks. Regular training opportunities have increased provider awareness of the importance of complete well-child visits that meet EPSDT requirements. As providers have identified ways that Bright Futures supports their practice, rates of well-child visits have risen. Providers who may not have completed a few of the components of Health Tracks (for example, lead screening) have learned that completing these additional components will allow them to receive payment from North Dakota Medicaid. In addition, providers who complete Health Tracks requirements experience less frustration when referring a child to specialists for necessary medical services through EPSDT.
Finally, partnerships have been critical in improving family knowledge about Health Tracks and Bright Futures. North Dakota focuses on providing family-led information, education, consultation, and support programs to raise patient awareness and health literacy. The North Dakota Department of Health has provided outreach materials to families from the Bright Futures toolkits. These easy-to-understand and usable materials offer accurate and consistent information from both the AAP and Bright Futures. After organizing several different packets on topics like nutrition and child development, the Department of Health compiled these packets into a comprehensive resource and disseminated it to providers and families throughout the state. When families attend well-child visits, providers are able to share high-quality, accurate information about various child health topics.
Quality Improvement: One challenge of this adaptation has been maintaining consistent, reliable record-keeping systems within local departments of health and within other medical homes. Before the transition was made to use Bright Futures as the Health Tracks requirement, providers used a wide range of record-keeping systems that varied in the types of information collected and the ways this information was recorded. Many health administrators and health care providers found that their existing systems were incompatible with the Bright Futures forms. In some settings, providers used paper forms and entered information into a system later, resulting in record-keeping inconsistencies and inefficiencies in time. Working with the Health Tracks Quality Improvement group, a team of administrators brainstormed solutions to support EPSDT implementation and improve screening rates across the state. These efforts have helped providers become consistent with the Health Tracks requirements. Although some local health departments are still using paper forms, the information they are gathering is much more consistent with information collected by other departments across the state and some are scanning these forms into electronic medical record systems to simplify the process.
As members of the Health Tracks Quality Improvement group focus on improving screening rates throughout North Dakota, they are also strategizing next steps. One area of focus may include ensuring that health providers implement Health Tracks in culturally and linguistically appropriate ways. A new Health Equity/Maternal Child Health Partnership Coordinator in the North Dakota Department of Health will serve as a resource, and officials in neighboring states have begun to participate in conversations throughout the Department about health equity in all areas of health services. Another area of focus is the importance of referral and follow-up. The team recognizes that collaborative relationships are essential to successful implementation, yet these relationships have not been established in all areas of the state. Often when local health departments make referrals, they request feedback from referring providers or organizations (such as early intervention or special education services).
Unfortunately, communication is often one way—the original provider may receive little information about the families' next steps or results from referral agencies. Currently, the group is exploring the possibility of using the Health Information Exchange Network to support referral and follow-up. The team will continue to strategize ways to streamline and improve collaboration and communication.