9 Old Indicators• Oral Health• Access• CAPHS/ Family Centered Care• ADHD management• Developmental Screening• ED department usage• Well Child Visit Completion rates to 15 months• Incorporating Behavioral Health into office

routines• NCQA PCMH Standards

New CHIPRA Indicators

• Annual number of asthma patients with more than 1 asthma related ER visit

• Late Term Premature Births– Percent of live births weighing less than 2,500 gm.– Frequency of ongoing prenatal care– C-Section Rate

2 SC CHIPRA Additional Indicators

• Mental Health• NCQA PCMH: Next Steps

– Looking for volunteers to meet once a month and begin work on PCMH. 2nd Thursdays for an hour

– Hope to develop some standard policies and methodology for documenting

– We have some limited additional funds for practices PCMH certified

Improving Outcomes: Late Term Prematures: At Discharge

• Discharge should not occur prior to 48 hours• Temperature of 97.7°-99.3° F• Weight loss <7% of birth weight• Normal vital signs for 12 hours prior to discharge• Risk assess for hyperbilirubinemia with follow-up

arranged• Car seat safety test passed• March of Dimes HBWW • 803 403 8522 Megan Bradham

Adamkin DH J Perinatol 2009; Ramachandrappa A & Jain L Pediatr Clin North Am 2009

Other Prenatal PDSA Cycle Suggestions

• Use of nursery discharge papers to trigger an immediate call to family to schedule follow-up

• Discussions about Late Term Prematurity as part of prenatal visit

• Documentation of bili at all nsy discharges• No d/c less than 48 hrs for late term

premature babies

Realistic Risk with Opportunity for Great Improvement

• An improvement in care of late preterm infants effects the greatest population of preterm infants

• Opportunities for partnering with in-patient QI programs

• Opportunity to show cost effectiveness– Average cost for treating 25 week infant: $202,000– Average cost for treating 35 week infant:$4,200However, population costs– $38.9 million dollars for 25 week infant– $41.1 million dollars for 35 week infant

Gilbert WM et al Obstet Gynecol 2003

Pediatrician/Neonatologist Role

• Promote obstetrical intervention to optimize pregnancy until term gestation

• Respect the morbidity and mortality risk of the late preterm infant population

• Intensive clinic follow-up for the first postnatal weeks

Asthma: GIP Report: Six Priority Messages

• Use inhaled corticosteroids• Use a written asthma action plan• Assess asthma severity

– Tools for assessing asthma severity

• Assess and monitor asthma control– Step wise care documented in the record including a

controller and a rescue agent

• Schedule periodic asthma visits• Control environmental exposures

Message #1: Use Inhaled Corticosteroids

• Inhaled corticosteroids are the most effective medications for persistent asthma

• Well tolerated– Small decrease in linear growth, but diminishes over time

• Superior to montelukast alone as preventive agent1,2

1Rachelefsky G. Pediatrics 2009;123:353-662Castro-Rodriguez JA, & Rodrigo GJ. Arch Dis Child 2009;95: 365-70.

Message #2: Use Written Asthma Action Plan

• All medications written in one place• Based on peak flow monitoring• Find out predicted based on height• Green Zone: 80% of predicted or >• Yellow Zone: 50-80% of predicted• Red Zone: 50% of predicted or less

Asthma Action Plan

Message #3: Assess Asthma Severity

• Classify all patients’ asthma based on measures of current impairment and future risk

• Impairment: Think Rule of 2s– Intermittent -- < 2 days/week of symptoms and less than

2 days/week of bronchodilators– Persistent– if at least ≥ 2 days/ week of symptoms and

bronchodilator use– Persistent asthma also includes activity limitations

• Risk: # exacerbations requiring oral steroids– 0-1/year = Intermittent asthma– ≥ 2/year = Persistent asthma

Message #4: Assess and Monitor Asthma Control

• Well Controlled (regardless of classification)– ≤ 2 days/week of symptoms– ≤ 1 nighttime awakening/month– ≤ 2 days/week of bronchodilator

• Not well controlled– > 2 days/week symptoms– ≥ 2 nighttime awakenings/month– > 2 days/ week of albuterol

• Very Poorly Controlled– Daily symptoms and multiple doses of albuterol/day

*No limit in activity indicates good control

Message #5: Schedule Follow-up Visits

• Schedule planned follow-up visits at periodic intervals to assess asthma control and modify treatment if needed– 1-6 months depending on control– 3 month interval if step down in therapy is

anticipated• Consider a patient reminder system for these

visits

Message #6: Control Environmental Exposures

• Review the environmental history of exposures• Develop a multi-pronged strategy to reduce exposure

to those triggers to which a patient is sensitive– HEPA air filters – Flu vaccine Is it documented in you– Documenting Smoking and smoking cessation advice

CHIPRA Indicator

• What percent of your patients with asthma was seen in the ER in the past year?

Asthma PDSA Cycle Topics• Define Asthmatic population

– Registry– ?Focus on your asthmatics who had a

hospitalization or ER visit this year• Control assessed?

– Tool?• Stepwise Care documented with

controller and rescue agent• Asthma Action Plan

– Share with schools?• Environmental Assessment

– Tool?– Plan?

• Adequate f/u visits– Q.2-6wks new pt. or poor control– Q.1-6 months when cont.– Q. 3 months for step down

• Flu Shot• Smoking Exposure

documented/addressed?– Motivational interviewing?– Drugs/1 800 Quit Now

• ER visits for asthmatics• Pt. Education/Project Breathe Easy?

Next Steps• Complete Next Steps Form and hand

in for possible QI projects• Schedule with Francis technical

assistance visit time• Turn in Mental Health Form to

Kristine.• Consider signing up for monthly work

on PCMH certification. Sign up with Kristine or Francis

• Use QTIP manual for PDSA cycles• Schedule next QI meeting• Complete evaluation• Hired thug outside door will slit your

throat if you have not done above before leaving

• Oral Health• Access• CAPHS/ Family Centered Care• ADHD management• Developmental Screening• ED department usage• Well Child Visit Completion rates to

15 months• Incorporating Behavioral Health into

office routines• NCQA PCMH Standards • Asthma• Pre Term Labor

• Thank You!