ABCD III Project in Oklahoma“Connecting the Docs”

Sue RobertsonOklahoma Health Care AuthorityNASHP Annual Meeting

Connecting the Docs: Improving Care Coordination and Delivery of Developmental Screening and

Referral Services in Oklahoma

• Initiative aimed at advancing systemic improvements focused on improving outcomes for young children with and at risk for developmental delays

• Builds on existing infrastructure to establish new and strengthen existing linkages among entities serving children and families

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State Readiness

• SoonerCare patient-centered medical home• Oklahoma State Department of Education

SoonerStart/Early Intervention program • “Fax-back” form, piloted by OK-Kids partners, aimed

at facilitating information between PCP offices and SoonerStart

• Developmental Screening Initiative (DSI)• Quality Improvement Initiatives - Practice Facilitation • Oklahoma Family Network (OFN)

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Outline

Overview of State StrategyPilot Level Strategies/Activities

◦Practice Level◦Community Level◦Web Portal/Care Coordination Tool

Systems Level ActivitiesEvaluation and MeasurementLessons Learned & Implications…

◦Looking to the Future

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Overview of State Strategy

• Partners• Team Framework

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ABCD III Project“Connecting the DOCS”

Strategy: Creation and deployment of a web portal to connect PCPs to Early Intervention and community partners. Participating PCPs send referrals to Community Teams via the web portal and receive referral outcomes back through the portal

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ABCD III Project“Connecting the DOCS”

A partnership between: • Oklahoma State Medicaid • Part C Early Intervention• Child Guidance• Developmental Pediatrics• Family Medicine• Family and Care Coordination Support• Primary Care Practices (Medical Home)

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Acronym Name Program

OHCA OK Health Care Authority

State Medicaid/SCHIP (SoonerCare)

SoonerCare Choice Medicaid/SCHIP Medical Home

OUHSC University of OK Health Sciences Center

Dept of Pediatrics Section on Developmental Behavioral Pediatrics (Implementation & Evaluation Support)

Dept of Family and Preventive Medicine(Web Portal/Technical support)

EI SoonerStart IDEA Part C Early Intervention

OSDH/CG Oklahoma State Dept. of Health

Child Guidance Program

OFN Oklahoma Family Network

Family-to-Family health information network

CC Sooner SUCCESS Care Coordination Program

PEAs Practice Enhancement Assistants

OUHSC Research assistants who work longitudinally with practices in each of the counties to facilitate change

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Local Core Teams Mirror State Core Team

STATE TEAM LOCAL TEAMS (x 4)

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Pilot Level Strategies & Activities

• Practice Level • Community Level• Development of Web Portal (Care

Coordination Tool)

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Pilot Activities

Practice facilitation/supportTechnology to improve ease of referral and feedback

(web portal)Sharing of successes and/or ‘non-successes’ between

practices and among community partners (PDSA Cycles)

Support development of productive communication and response patterns among partners at state and community levels

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Practice Activities: Strategy Summary

Multifaceted “Facilitated Change” strategy:1. Performance measurement and feedback using

pediatric quality indicators2. Academic detailing with discussions of evidence-

based and local exemplary practices3. Practice facilitation using “Practice Enhancement

Assistants” (“PEAs”)4. HIT support

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Integration into PCP Practices: PEAs

• Recruitment• Perform “academic detailing” • Bring practices to whatever state of readiness

needed to implement or continue screening• Introduce community teams• Demonstrate web-based portal • Ongoing problem solving using PDSA cycles

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OKLAHOMA’S LINKAGE PROCESS

Send New Referral

For SoonerCareChoice patients, the demographic information is pre-populated; address/phone number can be updated as needed.

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Closing the Loop

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Community Level Activities: Initial Phase

Relationship/Team Building◦Getting partners together in monthly meeting◦Developing rapport, communication, and trust◦ Introducing ABCD project to partners◦Teaching web portal/HIT support◦ Introducing teams to PCP practices

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Community Level Activities: Ongoing Phase

Community teams now function independently Meet monthlyTroubleshoot referral communication, feedback

process, information needs (PDSA cycles)Develop “Referral Resource Tool” for PCPs and

families TA provided by PEAs, as needed

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Systems Level Activities

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Improving State Systems and Policies

Data sharing and security of the web portal◦HIPAA/FERPA issues◦Security Certificate◦ Integrating OFN/family professionals

Eliminating duplications between PCPs & EI◦ASQ by PCP or outside agency can be used for EI’s

evaluation process◦Clarification of FERPA – Consent obtained by PCP is

sufficient for EI. If PCP does not obtain consent, EI can obtain consent

Medical Home PoliciesHealth Access Networks (HANs)Maintenance of Certification (MOC 4)

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Evaluation & Measurement

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Oklahoma’s Common Measure

# of children receiving EI services whose PCP knows of the services

__________________________________________# of children receiving EI Services

Use of web portal to electronically collect referral and feedback data

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Web Portal Initial Evaluation*

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Referral Status Number Percent

Total Received 161 100%

Pending 5 3%

Processing 23 14%

Responded 52 32%

Completed 78 48%

Withdrawn 3 2%

*Rollout began March 2011. Data pulled August 30,2011.

Lessons Learned & Implications…Looking to the Future

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Positive Outcomes

Streamlines routine visits Provides focus to the visit when concerns are present More accurate and more timely identification of children

with developmental delays Enhances parental education about appropriate

developmental expectations

Facilitates communication between providers and early childhood programs and resources

Facilitates communication between families and providers

Better lifelong outcomes for children Step toward becoming Tier 3 Medical Home

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Challenges

Communication across programs and subsystems◦Multiple systems to coordinate◦Multiple processes for referral◦Multiple levels of decision making

Data and Information Sharing◦Diverse and unconnected data systems

Community Team Challenges◦Discussion about what constitutes a closed referral◦Discussion about responsibility during referral loop process

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Looking to the Future……

• ABCD III project will reap lessons regarding how to facilitate the medical home becoming more competent in appropriate referral and follow up interactions with community based services and resources

• Potential to adapt or expand the basic processes of Connecting the Docs to many other identified needs that necessitate follow up outside the traditional health care system (practice facilitation, community teams/partners, portal technology, etc.)

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