9 Old Indicators

1. 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

2. 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

3. 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

4. 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

5. 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

6. 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:$4,200 However, 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

7. 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

8. 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

9. 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;123:353-66 2Castro-Rodriguez JA, & Rodrigo GJ. Arch Dis Child 2009;95: 365-70.

10. 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

11. Asthma Action Plan

12. 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

13. 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

14. 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

15. 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

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

17. 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?

18. 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!