Tracking and Improving Preventive Services Quality for Young Children Application of The Promoting H

1
Tracking and Improving Preventive Services
Quality for Young ChildrenApplication of The
Promoting Healthy Development Survey

• Christina Bethell, PhD, MBA, MPH
• Colleen Peck, MS
• Debra Read, MPH
• FACCT--The Foundation for Accountability

2
Short Description of The Promoting Healthy
Development Survey (PHDS)
Parent survey focusing on care for children age
4-48 months of age Developed in 1998-1999 under
the rubric of the Child and Adolescent Health
Measurement Initiative (CAHMI), a national
initiative coordinated by FACCT Supported by The
Commonwealth Fund
3
Short Description of The Promoting Healthy
Development Survey (PHDS)
Based on national guidelines (AAP, Bright
Futures) Includes aspects of care and specific
topics about which the greatest evidence and
consensus exists and on topics parents can
validly report on Extensive and ongoing
development and testing process that includes
input from experts, families, providers and
policymakers
4
Short Description of The Promoting Healthy
Development Survey (PHDS)
Designed for telephone, mail or on-line
administration 43 items -- takes 12-15 minutes
to complete Spanish translation
available Generates seven measures of care and
numerous single topic specific results PHDS with
additional items on access and use of care,
coordination and experience of care and health
status of child and mother available (PHDS-PLUS)
5
Short Description of The Promoting Healthy
Development Survey (PHDS)
Analytic items included allow for analysis of
variation for subgroups of children according to
their demographic, health care use and health
status characteristics PHDS and PHDS-PLUS include
the CSHCN Screener and the Parents Assessment of
Developmental Status tool (PEDS) PHDS-PLUS
includes maternal depression screener (Kemper)
6
Short Description of The Promoting Healthy
Development Survey (PHDS)
Fielded in four state Medicaid programs (ME, NC,
WA, VT) -- both health plan and practice level
assessments generated (N 13,000) The majority
of the PHDS incorporated into the National Survey
on Early Childhood Health (NSECH) (N
2000) Currently being tested for practice level
assessment using practice-driven and state-driven
sampling, administration and analysis protocols

7
Aspects of Care Measured
1. Anticipatory guidance and parental education
2. Provision of written/other health
information 3. Follow-up for children at risk for
development problems 4. Psychosocial assessment
of well-being and safety in the family 5.
Assessment of smoking and substance abuse in the
family 6. Provision of family centered care 7.
Helpfulness (and effect) of care provided on
knowledge and confidence of parents
8
Two models for using the PHDS for tracking and
improving quality

• Swamping the System
• Family Centered Quality Improvement

9
Swamping the System

• Measurement at multiple levels
• National, State, Health Plan, Practice Level
• Measurement for multiple purposes
• Identify and track specific areas and populations
  where provider level improvements are needed most
• Inform purchasing and contracting incentive
  programs for plans and practices
• Inform and engage families/consumers
• Shape programs and policies impacting early
  childhood preventive care

10
Family Centered Quality Improvement

• Actively involve families in assessing and
  targeting improvements in care
• Generate compatible, real-time feedback to BOTH
  families and practices
• Foster partnerships between families and
  practices
• Create transparency in care provided
• Support tailored improvements in care

11
Three Levels of Analysis to Inform Quality
Improvement
Level 1 Measures of Overall Performance Across
Domains of Care Level 2 Within Domain Measures
of Care Level 3 Hi-Low Assessments of Care
Within and Across Domains of Care
12
Level 1 Analysis
Measures of Overall Performance Across Domains
of Care 0-100 scores for each measure Percentage
of children receiving all indicated care all or
nothing model average acceptable score
model Percentage of parents wishing they had
received more information on one or more topics
(for anticipatory guidance measure
only) Percentage of parents with one or more
concerns about childs development who are ASKED
about their concerns AND receive FOLLOW-UP
13
Illustration of FindingsLevel and Variations in
Measures of Overall Performance

• Less than 25 of children receive all aspects of
  recommended care using the average acceptable
  score model
• For all measures -- more likely to receive
  indicated preventive care
• child has a personal doctor
• younger children
• healthier children
• For psychosocial and smoking/drug assessment
  measures -- more likely to received indicated
  care
• children whose mother is non-white, and/or
  unmarried and/or who has a less than high school
  education
• Cross health plan, practice and geographic area
  variation also observed

Source Bethell, Peck Do Not Cite Without
Permission
14
PHDS Measures of Care FindingsNational Survey of
Early Childhood Health
Source Bethell, Peck Do Not Cite Without
Permission
15
PHDS/PHDS-PLUS Measures of Care Findings
State-Level (Four States- Medicaid Clients)
Source Bethell, Peck Do Not Cite Without
Permission
16
PHDS Measures of Care Findings Plan-Level (12
Plans)
Source Bethell, Peck Do Not Cite Without
Permission
17
PHDS Measures of Care Findings Practice-Level
(14 Practices)
Source Bethell, Peck Do Not Cite Without
Permission
18
Level 2 Analysis

• Within Domain Measures of Care
• Example Anticipatory Guidance Measure
• Injury Prevention
• Growth and Development
• Nutrition
• Routines
• Behavior and Social Issues
• Example Psychosocial Assessment
• Maternal depression
• Gun safety
• Social support

19
Level 3 Analysis

• Hi-Low Assessments of Care Within and Across
  Domains of Care Assessed
• Example Anticipatory Guidance
• Needs most improvement
• Talk about guidance and discipline techniques to
  use with your child
• Highest quality of care observed
• Talk about behaviors parent can expect to see in
  child

20
Key Opportunities for Improvement

• Parents want more information to help children
  develop
• 20 of parents report discussing each of a basic
  set of topics (nutrition, safety, growth,
  development, learning, sleep, communication and
  behavior)
• 67 of parents NOT discussing basic topics
  indicate needing more information, especially
  about their childs behavior, communication and
  the achievement of developmental milestones such
  as toilet training

21
Key Opportunities for Improvement

• Parents concerns are often not addressed
• 40 of parents indicate one or more potentially
  serious concerns about their childs development
  and only 50 get the information they need about
  their concerns
• 42 of parents indicate never being asked about
  concerns about their childs development.
• 65.7 of parents asked about their concerns got
  the information they needed to address these
  concerns
• Only 40 of parents with children identified as
  being at-risk for developmental, behavioral or
  social delays received some type of follow-up

22
Key Opportunities for Improvement

• Children with development or health problems need
  special attention
• Only 14 of children identified as being at-risk
  developmental, behavioral or social delays
  received quality services across each of the
  seven aspects of care assessed in the PHDS-PLUS
• 30 of mothers of children with special health
  care needs experience depression

23
Key Opportunities for Improvement

• The well-being of parents and families is often
  overlooked
• 36 of parents say their childs doctors or
  other health care providers NEVER ask them how
  they are doing as a parent
• 50 of parents say they are NEVER asked about
  their emotions, moods or depression
• Nearly 30 of parents indicate not being asked
  about alcohol or drug use in the family
• Mothers at high-risk for depression are less
  likely to receive preventive care for their
  children on all but one of the seven aspects of
  care measured in the PHDS-PLUS.

24
Key Opportunities for Improvement

• Having a personal doctor makes a difference
• Parents of children with a personal doctor or
  nurse were more likely to receive recommended
  anticipatory guidance, be screened for
  psychosocial issues, receive family centered care
  and indicate that the care was helpful

25
Key Opportunities for Improvement

• Providers can not rely on instincts to target
  care to parents with greatest need
• Parents reporting 4 or more concerns about their
  childs development were not more likely to be
  asked about their concerns compared to parents
  with only 1-2 concerns
• Parents of younger children and first born
  children were more likely to receive recommended
  anticipatory guidance. Yet, parents of other
  children were more or just as likely to indicate
  having unmet needs for information

26
Specific examples of using the PHDS of QI

• Program-Level QI
• WA, VT, NC PHDS provided baseline information to
  inform their ABCD implementation efforts
• ME Addressed program-level issues related to
  referral services and coverage for developmental
  screening Confirmed usefulness of Bright Futures
  encounter forms
• Health-Plan Level QI
• WA Nine-health plan level reports, highlighted
  areas for improvement
• Practice-Level QI
• ME Practice-level reports yielded valuable,
  practice level information for quality
  improvement purposes Primary Care Case
  Management (PCCM) Provider Newsletter
• ME Did a Provider Survey to learn about
  effective ways they could further improve

27
Specific examples of using the PHDS of QI

• Parent-based surveys can inform parents about the
  kind of care they should expect their child to
  receive
• Community Outreach
• Inform parents about what to expect (Well-Child,
  MA)
• Encourage parents to talk about their concerns
  Encourage parents to talk about their childs
  growth and development (Children Now)
• Findings noted in the PCCM Newsletter (ME)

28
Next Steps

• CAHMI State Learning Network (CSLN)
• Facilitate learning, action and success within
  and among States
• Find innovative, sustainable and efficient
  methods for quality measurement, reporting and
  improvement
• Currently accepting applications for States
  interested in being Learning Partners
• Practice-Level Application of the PHDS
• Implement the PHDS in practices
• Provide and assess impact of feedback to health
  care providers
• Provide and assess impact of feedback to parents

29
To Learn More
www.cahmi.org cpeck_at_facct.org Pediatrics article
May 2001 (Bethell, Peck, Schor)