Quality Improvement for a
Healthy Minnesota
Kim McCoy, Minnesota Department of Health
Sandy Tubbs, Douglas County Public Health
Exploring
Accreditation
http://www.phaboard.org
2
Voluntary Accreditation Goal
To improve and protect the health of the public by
advancing the quality and performance of state and local
public health departments
Exploring Accreditation Final Report, p. 4
3
Partners in Accreditation
NACCHO, ASTHO, APHA, and NALBOH moved to
y Endorse the recommendations of the Exploring Accreditation
Steering Committee, and
y Lead the development and implementation of a national voluntary
accreditation program that will drive continuous quality
improvement.
4
Eligible Applicants
y State health departments
y Territorial/regional health departments
y Local (city and county) health departments
y Tribal health departments
5
The Value of Accreditation
y
y
y
y
y
y
y
6
Improved Public Health Outcomes
Quality and Performance Improvement
Accountability
Credibility
Recognition of Excellence
Clarification of Expectations
Increased Visibility
Timeline
2007
1
2
3
2008
4
1
2
3
2009
4
1
2
3
2010
4
1
2
3
2011
4
1
2
3
Applications
18 Month Beta test
Assessment
Processes
Standards and
Measures
Internal Operations
7
4
Public Health Accreditation
Board
y
y
y
y
y
y
501c3 incorporated in May 2007
15-member Board of Directors
State, local and tribal health directors
Academia
Professional associations
Private consultants
Public Health Accreditation
Board
y
y
y
y
y
y
Standards development
Equivalency recognition
Assessment process
Research and evaluation
Fees and incentives
Public outreach
Multi State Learning
Collaborative
By 2015 60% of the US population will be served
by an accredited health department.
Robert Wood Johnson Foundation
Multi-State Learning
Collaborative
y Funded by Robert Wood Johnson Foundation
y Managed by National Network of Public Health Institutes
y Advance accreditation and quality improvement strategies
in public health departments
y http://www.nnphi.org/mlc
Minnesota and MLC
y Joined in second phase (MLC-2)
y Partnership among the Minnesota Department of Health,
Local Public Health Association, University of Minnesota
School of Public Health
y Facilitated 8 local quality improvement projects
y Strengthened public health performance management
system
Minnesota Public Health
Collaborative for Quality
Improvement
y 8 projects, 34 local health departments
y Based on the Model for Improvement
y Plan-Do-Study-Act (PDSA) cycle
y Project teams:
y Local public health staff
y MDH public health nurse consultant
y SPH faculty and graduate student
y Others impacted by the issue
Kittson
Roseau
Lake
of the
Woods
Marshall
Koochiching
Beltrami
Pennington
Cook
Red Lake
Polk
Norman
Clay
Becker
Otter Tail
Wadena
Wilkin
NE Region
Dental Varnish
Hubbard
Central Region
WIC Appointment
Participation
Mahnomen
St. Louis
Itasca
Clearwater
Cass
Aitkin
Crow
Wing
Carlton
Pine
Todd
Grant Douglas
Benton
Stearns
Mille Lacs
Morrison
Douglas County
Public Health
Traverse
Pope
Child Mental
Stevens
Health Screening
Big
Lake
Sherburne County
Public Health
PCA Reassessments
Kanabec
Sher- Isanti Chisago
burne
Anoka
KandiSwift
Wright
Washington
yohi Meeker
Ramsey
Chippewa
Lac Qui
Hennepin
McParle
Carver
Leod
Renville
Yellow
Dakota
Medicine
Scott
Sibley
Lin- Lyon
Nicollet Le- Rice GoodRedwood
coln
Sueur
hue Wabasha
Brown
Stone
SW/SC/WC Regions
Data Integration for
Improved
Immunization Rates
MN Counties Computer
Cooperative
Latent TB Treatment
Pipe- Murray Cotton- WatBlue Wa- Steele
Olmsted
stone
Earth
seca
Winona
Dodge
wood onwan
Rock
Noble Jackson Martin Faribault Freeborn
Carver County
Public Health
Health Alert Network Testing
Mower
Fillmore Houston
Olmsted County
Public Health
Workforce Competency
Minnesota Public Health
Collaborative for Quality
Improvement
y Learning sessions
y Aim statements
y Performance measures
y Tools (Public Health Memory Jogger)
y Monthly reports
y Monthly conference calls
y Showcase and training conference
y Evaluation
Outcomes
y 70% reduction in staff time devoted to Health Alert
Network testing
y Over 100% increase in leadership understanding of public
health competencies
y Over 100 children enrolled in dental varnish treatment
program
y 60% increase in timely completion of Personal Care
Assistant reassessments
Children’s Mental Health Collaborative
Douglas County, Minnesota
The History of the Collaborative
Partnership
y Formed in 2000
y 5 required partners (Public Health, Social
Services, Schools, Mental Health, and
Corrections)
y Goal was to develop a county-wide integrated
mental health service system for children and
their families
Previous Efforts Included:
y Home Visiting
y School based Mental Health
y Pre-school social-emotional screening & follow-up
y Child Psychiatric services & consultation
y Parent education & family interaction
y Summer partnership with community based recreation
The Way it Was…..
y Two Primary Care Clinics in Alexandria
y Alexandria Clinic
y Broadway Medical Center
y Douglas County Hospital – Mental Health Unit
y 3-child/adolescent psychiatrists providing 6 days per month
of service
y Additional children’s mental health professionals
The Way It Was…Continued
y The Other Players
y Douglas County Children’s Mental Heath Case
Managers
y School District Counselors and Social Workers
y Multiple independent Mental Health Professionals
y Multiple child and family support service providers
y Health Plans
In many ways…
we were rich!
y Children’s Mental Health Collaborative
y Primary and specialty care services
y Community support organizations
y School-based social worker and counseling
services
But…
That wasn’t the whole story
y Restricted availability of child-adolescent
psychiatric care
y Emphasis on deep-end treatment and not frontend early intervention: No system for early
identification of children with mental health
impairments
y Not a parent-child friendly system
y We didn’t talk to each other
So What Did We Do?
y We defined and re-defined the problem
y We checked what others were doing…looking for an easy
fix
y We attended the St. Cloud Hospital’s Child and
Adolescent Psychiatry Practical Review held in Two
Harbors Minnesota where Dr. Read Sulik presented the
Centracare Integrated Behavioral Health Initiative which
provided us a strong framework to begin
y We developed partnerships with all the players…primary
care, child psychiatrists
y We developed a vision
y Local Collaborative Time Study (LCTS) funding was
drastically cut back
y Loss of 2 contract days/month of child psychiatric services
y Pediatricians and Family Practice physicians suddenly
faced with managing psychiatrically complex children they panicked
y And the opportunity to get much-needed support for
system change through Multi-State Learning
Collaborative Quality Improvement Project
IMPLEMENT A SHARED CARE
MODEL AS A DEMONSTRATION
PROJECT
Spectrum of Collaborative Care
for Child and Adolescent
Depression
Primary Care with
Consultation
Primarily Primary Care
Shared Care and Higher
Levels of Care
Shared Care
Primarily Mental
Health Care
*Read Sulik MD, Centracare Integrated Behavioral Health Initiative
GOAL:
y Expand the focus to the front end of the children’s mental
health service delivery system and ultimately realize less
demand for child-adolescent psychiatry services
y Targeted Early Intervention:
Reduce the need for services
rather than just trying to meet the
need.
Opportunities
y Partners were highly motivated to move toward a solution
y Access to child-adolescent psychiatrist (Dr. Read Sulik)
who was highly knowledgeable and supportive of this
model
y Local Health plan invested in the model with financially
and human resources
y Experience with social-emotional screening
y Technical assistance and consultation from QI Project
staff
Anticipated Outcomes
REDUCTION IN LEVEL OF IMPAIRMENT
OR INCREASE IN FUNCTIONING AS
EVIDENCED BY
y Frequency in ER visits
y Frequency in Hospitalizations
y Frequency in Out of Home Placement
y Follow-up Screeners
PARTNERS
y Collaborative Partners
y Public Health
y Mental Health
y Clinic
y Insurance provider
y School
y And the list continues to grow
Overview of Model
Child & Parent – Primary Care Setting
Complete Screen (ASQ-SE, PSC)
Screen Identifies Social Emotional Concerns
Refer for Diagnostic Assessment
D.A. Reviewed -Treatment Needs determined
Triage to
Community Agency
• Education
• Skills Training
• Therapy
Primary Care
Consultation
Treat
w/Psychiatry
Psychiatry
How do we get from here to there?
Is this your systemic change process?
It’s All in the Aim Statement!
y The Question: What are we trying to
accomplish?
y Be very clear about the desired end of the
effort!
y Break it down into bite-size pieces….
y Define the target population, the time line,
and the indicators that you seek to change
The Importance of
Process Mapping
y Improving Public Health is dependent on
improving processes
y A good process must be:
y Simplified
y Deliberately and rationally designed
y Implemented with great attention to detail
y Properly maintained
Plan, Do, Study, Act
y Plan:
y Implement the process change in a small setting
y Provide education and information to everyone
involved
y Establish the timeline for the trial
y Do:
y Work with willing and positive participants
y Provide support and encouragement during the trial
y Be ready to address unexpected problems
Plan, Do, Study, Act
y Study:
y Reflect on the test of the change
y Consider 3 questions:
y Did we do what we intended to do?
y Did the change have the desired effect?
y Can the change be implemented in other settings?
ƒ Act:
ƒ Only if the process change was successful
ƒ If not, return to Plan and repeat the process
Identified Target Population
Children between ages 6 mos.-16 years
currently on PrimeWest Health and
seen by the Alexandria Clinic’s
pediatricians
The Need for a Standardized
Screening Process
y Studies show that pediatricians are not adequately trained
to deal with psychosocial problems nor do they have time
during the routine office visits
y Identification of screening tools that have reliability and
validity for appropriate developmental ages
y Help providers utilize limited time in office during visits
to screen patients for psychosocial concerns
y Screening will enable clinicians to recognize problems
quickly and will help provide services and interventions at
an earlier and more effective point
ASQ-SE (Ages and Stages QuestionnaireSocial/emotional)
y Ages 6 months to 5 years
y Low-cost screening instrument
y Parents complete screen
y Reliability & Validity studied with the rates
acceptable to identify children in need of
further evaluation
y Permission and license required (Brookes
Publishing)
Pediatric Symptom Checklist
(PSC)
y Ages 6 yrs-16 years
y Parental completion or self completion
y Free to use (no licensing required)
y Easy to score, Simple to complete
Preparation and Training
y Collaborate and develop agreement with a primary care
clinic
y Develop a plan for implementation
y Develop a specific policy and procedure for each
departments role
y Individual training sessions
y Implemented Plan/Do/Check/Act cycle and evaluate
y Identified process issues and changed process accordingly
Triage
y How bad is it?
y Symptoms
y Impairment in functioning
y Suffering
y What is the acuity?
y Emergent – safety is concern (suicidal)
y Urgent – referral needed, child is not functioning
y Routine – follow up needed
y No referral or follow up
*Read Sulik MD, Centracare Integrated Behavioral Health Initiative
Triage & Referral
y PrimeWest Health hired a clinic care coordinator and placed
them in the clinic
y Clinic care coordinator schedules child for a diagnostic
assessment with a mental health professional that takes place at
the clinic
y Mental Health professional provides recommendations to the
child’s parents at an explanation of findings meeting (care
coordinator present at this meeting)
y Care coordinator follows up with the family on the
recommendations providing assistance as needed
y Diagnostic assessment is part of the clinic record within 7 days.
Role of the Care Coordinator
y Designated liaison between patients, mental health
providers, primary care physicians, community providers,
and health plan
y Follow-up with the patients on recommendations made by
the mental health provider in their assessment
y Provide communication avenue with the parents and
providers
y Support role for the parents and child(ren)
Barriers & Challenges
y Inclination to move too quickly towards
implementation without adequate planning of
the details
y Ability to adequately educate and engage all of
the clinic staff that would need to be involved
in the process
y Unanticipated number of children scoring
above the cut-off at the onset
y The increased need for diagnostic assessments
Challenges of the diagnostic
assessments
y Ability of the existing system to meet the demand for ageappropriate diagnostic assessments in a timely manner
y Multiple agencies being utilized for diagnostic
assessments in order to assure rapid response to the needs
of children of all ages
y Inconsistent quality of diagnostic assessments
y Acknowledgement that a diagnostic assessment in and of
itself is not the answer nor is it necessarily the first step
toward recovery
So What Did We Learn?
Patient Data
y 303 children were offered the screen
y 210 completed the screen
y 25% of children that completed the screen were identified
as having social-emotional concerns
AGE GROUPS
<36 months
13
24%
3-5
15
30%
6-10
16
30%
11-13
1
<1%
14-16
7
13%
The Learning Never Stops
y Assumptions about perceived barriers and hurdles did
not always play out that way in implementation
y Buy-in of all major parties is essential to success
y All partners do not speak the same language
y Measure effort and effect. We have set up processes
for measuring the effect of these processes
y We learned that we are still learning
y Doctors love the process
y Other partners are knocking at the door