How Tennessee is implementing Bright Futures

Adaptation: Tennessee's Medicaid program has adopted the Bright Futures Guidelines as the standard of care in the state. The state's Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program follows the Bright Futures/American Academy of Pediatrics (AAP) Periodicity Schedule provided in the Guidelines. The state's sentiment on the importance of the Bright Futures Guidelines is evident through the enthusiasm of Michael Warren, MD, deputy commissioner of population health: "I think that if you think about moving the needle on maternal and child health issues, we always try to figure out how we move upstream and think more about prevention, rather than just focusing on treatment when disease occurs. I think Bright Futures really offers us a path for that, because it is so prevention focused."

The Tennessee Chapter of the AAP has developed an EPSDT manual that mirrors the Bright Futures/AAP Periodicity Schedule and outlines all the requirements for EPSDT in the state. The Tennessee Chapter encourages all practices to use the Bright Futures Guidelines as the standard of care for all children, including the Medicaid population. In addition, chapter representatives meet quarterly with Medicaid payers and frequently discuss the Bright Futures Guidelines and new recommendations or codes to ensure payers will cover appropriate services throughout Tennessee.

Partnerships: Established in 2012, the Tennessee Governor's Children's Cabinet is charged with coordinating and enhancing state efforts to provide resources and services to children in Tennessee. The Children's Cabinet comprises the Tennessee Department of Health (TDH), TennCare Bureau, Department of Children's Services, Department of Mental Health and Substance Abuse Services, Department of Education, and Department of Human Services. One of the Cabinet's first initiatives was kidcentral TN, which is a one-stop-shop Web site for families to obtain important state information and locate resources. The health section includes detailed information on screenings, well-child visits, immunizations, age-specific developmental milestones, and specialty care.

Training and Learning Collaboratives: The Tennessee Department of Health and the Tennessee Chapter of the AAP are committed to training providers throughout the state by offering multiple training programs that are based on or incorporate the Bright Futures Guidelines. Through a grant funded by the Tennessee Department of Education's Early Intervention Program, the Tennessee Chapter offers a free physician-led program, Screening Tools and Referral Training (START), in which physicians train other pediatric care providers on how to implement routine developmental and behavioral screenings using standardized screening tools. The training sessions cover referral procedures, office workflow, and proper coding for the screening tools. The program has been implemented in medical schools, nursing schools, residency programs, pediatric and family practices, and local health department clinics. Since its initiation in 2004, START has effectively trained participants at 495 pediatric practices and medical schools statewide.

The START program has partnered with TDH to train nurse supervisors in all local health departments across the state on the use of the Modified Checklist for Toddlers Revised with Follow-Up (MCHAT-RF). As a result of this training, 469 nurses have been trained to administer MCHAT-RF. The TDH continues to provide training as needed. MCHAT-RF is now implemented across the state in all TDH clinics. 

The Behaviorally Effective Healthcare In Pediatrics (BEHIP) project is another grant-funded initiative of the Tennessee Chapter that provides pediatric health care providers with tools and strategies to screen for, assess, and manage patients with emotional, behavioral, and substance abuse concerns. It also encompasses strategies for more efficient workflow (including information on coding), more effective care, and improved family and physician relationships. The training is facilitated by pediatricians and psychologists.

TDH has shown its commitment to training providers by working alongside local health department staff to train all home-visiting representatives and home-based care managers in developmental screening. Using the Bright Futures/AAP Periodicity Schedule as a road map, the trainings focus on common developmental screening tools by educating the representatives on how to use the tools, how to score them, and when and how to refer families to specialized treatment.

For the past 15 years, the Tennessee Chapter has had a grant from the TennCare Bureau to provide free training for EPSDT and coding for EPSDT and related services. The chapter offers training sessions both regionally and in individual practices to cover all the requirements for EPSDT based on the Bright Futures/AAP Periodicity Schedule. The chapter offers both in-person training sessions and online webinars.

TDH ensures that all new clinical staff members are introduced to the Bright Futures/AAP Periodicity Schedule, the EPSDT screening requirements, and the Bright Futures Tool and Resource Kit and requires all local health department facilities to perform EPSDT screenings. To facilitate implementation, TDH and the Title V MCH program provided each of the 95 local county health departments (approximately 120 facilities) with the Bright Futures Guidelines, 3rd Edition, and the Bright Futures Tool and Resource Kit for reference.

Implementation Activities: The Tennessee Chapter and TDH have implemented and incorporated the Bright Futures Guidelines through a variety of initiatives throughout the state.

Electronic Health Records. The state is moving toward adopting electronic health records (EHRs) in both local health department facilities and private practices. TDH is building a statewide EHR system based on the Bright Futures Guidelines and will adopt it within the next 2 years. The Tennessee Chapter offers age-specific chart documentation forms based on the Bright Futures Guidelines that include all recommended elements at each specific age. These documentation forms are used as a guide or template for elements to be included in preventive well-child visits and EHRs.

Quality Improvement Project. In 2014, the Tennessee Chapter was awarded a grant from the TennCare Bureau to continue and expand its work with the Pediatric Healthcare Improvement Initiative for Tennessee (PHiiT) program. PHiiT is a statewide quality improvement partnership to help practices implement quality improvements to measure their performance. Topic-specific programs to date include breastfeeding sustainment, asthma, human papillomavirus vaccination, and newborn tobacco exposure reduction. PHiiT also developed the Best Practice Provider Resource, which is a high-value metrics panel tracking tool to evaluate best practices in ambulatory pediatric practices. PHiiT will help pediatric practices collect the metrics, analyze the data, and make improvements in their clinics.

Dental Coverage. The Tennessee Chapter has worked with the dental provider under Medicaid to promote its dental fluoride varnish program. The chapter successfully encouraged the dental provider to increase its coverage through age 5 and to meet the recommendations in the Bright Futures/AAP Periodicity Schedule.


Tennessee AAP Chapter

For more information about maternal and child health activities in your state, visit the Health Resources and Services Administration's Web site to find local contact information for the Maternal and Child Health and Children With Special Health Care Needs representatives.