6 18 a2 duncan and frankowski nasbhcjune 2010

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Bright Futures Tool and Resource KitBright Futures Tool and Resource Kit

Bright Futures Tool + Resource Kit Measuring and Improving

Preventive Services

Paula Duncan, MD FAAPBarbara Frankowski MD MPH FAAP

June 2010

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I I do notdo not intend to discuss an intend to discuss an unapproved/investigative use of a commercial unapproved/investigative use of a commercial

product/device in my presentation.product/device in my presentation.

I f th dit f Th B i ht F tI f th dit f Th B i ht F t

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I am one of the editors of The Bright Futures I am one of the editors of The Bright Futures Guidelines. I acknowledge that today’s activity Guidelines. I acknowledge that today’s activity is certified for CME credit and thus cannot be is certified for CME credit and thus cannot be

promotional. I will give a balanced promotional. I will give a balanced presentation about well child care using the presentation about well child care using the

best available evidence to support my best available evidence to support my conclusions and recommendations.conclusions and recommendations.


ObjectivesParticipants will be able to : Participants will be able to :

Discuss measurable implementation of the 2008 preventive Discuss measurable implementation of the 2008 preventive services guidelinesservices guidelines

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Use the new Bright futures toolkit and other strategies for Use the new Bright futures toolkit and other strategies for quality improvement of preventive servicesquality improvement of preventive services

Incorporate the assessment of youth development and the Incorporate the assessment of youth development and the use of strength based approaches, including shared decisionuse of strength based approaches, including shared decision‐‐making making

2000 &

2002

…is a set of principles, strategies and tools that are theory ‐ based, evidence ‐ driven, and systems ‐ oriented, that can be used to improve the health and well‐being of all children through culturally appropriate

h ddinterventions that address the current and emerging health promotion needs at the family, clinical practice, community, health system and policy levels.

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Periodicity Schedule

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Procedures & Sensory Screening

• Dyslipidemia once between 18‐21 years of age

• Hearing screening recommended at:

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Hearing screening recommended at:

–8, 10 years of age

• Vision screening recommended at:

– 8, 10, 12, 15, 18

• BMI for all ages 2 years and above


Risk Assessments

• Hearing age 11 and up

• Vision at other years

• Anemia

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• Sexually Transmitted Infections *chlamydia

• *Cervical Dysplasia Screening

• Alcohol & Drug Use Assessment

• Tuberculosis Screening


Making the Most of the Bright Futures Guidelines

• The Guidelines provide the background and all the details.

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• The question is:

– How can you incorporate all that into a typical 15‐minute office visit?

• Therapeutic relationship is still the key

• Respect, confidentiality, explanations, listening

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Bright futures Priorities

• Patient concerns and question

• Physical Growth and Development

• Social/academic competence

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• Social/academic competence

• Emotional wellbeing

• Risk reduction

• Violence and injury prevention


Home belonging(connection)

individual decision-making

Education mastery(competence)

Eating

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Activities helping others, phy act

Drugs

Safety

Sexual Activity

Suicide coping, resilience, self conf

Reif, CJ, Elster, AB, Adolescent Preventive Services. Primary Care: Clinics in Office Practice, Vol 25, No 1, March 1998, WB Saunders, Philadelphia.Goldenring JM, Cohen E. Getting into adolescent heads. Contemp Pediatr 1988;5(7):75-90.


• Here’s How the Bright Futures Guidelines Translate Into the

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Bright Futures Tools …….


Meet Tiffany!

• Tiffany is 17

• Living in 5th Foster Home

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• 12th Grade, failing math

• Past H/O tobacco, etoh, marijuana use

• Sexually active w/o protection

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Core Tools

• Previsit Questionnaires

• Documentation Forms

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• Parent/Patient Handouts


Core Tool: Previsit Questionnaires• Parent/adolescent patient fills out

before seeing practitioner

• The questionnaires:

– ask risk‐assessment questions, thereby triggering recommended medical

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screening

– ask about Bright Futures 5 priority topics for that age‐based visit

– allow parent/patient to note any special concerns

– gather developmental surveillance information


Core Tool: Documentation Forms• Practitioner uses during visit to

document activities • Forms guide practitioner on what

questions to ask/issues to address based on child’s age and visit priorities

• Forms include sections for each component of visit:

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component of visit:– History– Surveillance– Physical exam– Screening– Immunizations– Anticipatory guidance


Setting the agenda

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Medical Screening

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Setting the agendaPRIORITIES

Physical growth and development

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Social and academic competence

Emotional well-being

Risk reduction

Violence and injury prevention


Developmental Tasks of Adolescence

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2020

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Documenting Parental Concern

Bright Futures Priorities

Pre-visit Questionnaire Reviewed

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Screening

Psychosocial Risk Assessment


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Screening


• The Tool and Resource Kit also contains supplementary materials:– Additional Parent/Patient Handouts

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– Developmental, behavioral, and psychosocial screening and assessment tools

– Practice management tools for preventive care

– Information on community resources

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The Bright Futures Tool and Resource Kit

• it helps you provide individualized care– Forms allow parent/patient priorities and concerns to surface, giving you opportunities to tailor care and anticipatory guidance

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• AND It helps you provide standardized care– All the forms are closely linked to Bright Futures visit components and priorities, making clinical activities and messages consistent throughout

– Completed Documentation forms help you track care over time, ensuring that all patients receive recommended exams, screenings, and immunizations


Bright Futures and the Electronic Health Record (EHR)

• The templates, questionnaires, handouts, and forms from the Bright Futures Resource and Tool Kit form a structured knowledge base that can be used in EHRs.

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• Depending on your specific EHR system, import the documents or use them as a guide in setting up customized health supervision visit templates and previsit questionnaires


Using the questionnaire

• Tiffany was in a juvenile detention facility for a couple of weeks three months ago.

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• Her diet was almost exclusively vegetarian and some times she didn’t really have enough to eta when she was “ couch surfing”. She took no vitamins or iron supplements.


Home belonging(connection)

individual decision-making

Education mastery(competence)

Eating

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Activities helping others, phy act

Drugs

Safety

Sexual Activity

Suicide coping, resilience, self conf

Reif, CJ, Elster, AB, Adolescent Preventive Services. Primary Care: Clinics in Office Practice, Vol 25, No 1, March 1998, WB Saunders, Philadelphia.Goldenring JM, Cohen E. Getting into adolescent heads. Contemp Pediatr 1988;5(7):75-90.

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SEARCH FOR STRENGTHS• Risks need to be identified

• BUT:• Strengths are an essential part of health

• Look for Resiliency and Strengths: ask about strengths at every encounter!

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• Promoting strengths will enhance interactions with parents

• Search for strengths

• Connection

• Competence/ Mastery

• Independent decision‐making

• Generosity


• Cares about friends & boyfriend

• Knows how to take care of herself, get around

M k d i i

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• Makes many decisions on her own

• Sense of belonging with foster family, case worker, friends

• No tobacco, etoh, drugs


Enabling Positive Change• This youth needs to make some important

changes. Shouldn’t I point that out?– All adolescents can use encouragement and

improvement.

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– A shared decision making approach involves allowing the adolescent to recognize and take steps towards healthier behavior (motivational interviewing).

tVERMONT CHILD HEALTH IMPROVEMENT PROGRAMVERMONT CHILD HEALTH IMPROVEMENT PROGRAM


You’re worried about her risky sexual behaviors.....

• Do you really want to have a baby?

• What choices can you

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ymake? Consequences?

• Make a plan

• Follow up

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What about Parents/Guardians ?

• Questionnaires

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• Handouts

• Partners


• What about Youth with Special

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health care Needs?


• Here’s How Bright Futures

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gTranslate into QI Activities ….


80%

100%

Anticipatory Guidance Received in Adolescent Preventive Care Visits 2009

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0%

20%

40%

60%

Eating Healthy Exercise Seat Belt Use Helmet Use Secondhand Smoke

Irwin CE, JR., Adams SH, Park MJ, Newacheck PW. Preventive Care for Adolescents: Few Get Visits and Fewer Get Services. Pediatrics. April 1, 2009; 123(4) e565‐572

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60%

80%

100%

Counseling Rates

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Ozer E, Adams SH, Lustig JL, Gee S, Garber AK, Gardner LR, Rehbein M, Addison L, Irwin, CE. Increasing the Screening and Counseling of Adolescents for Risky Health Behaviors: A Primary Care Intervention. Pediatrics. 2005;115;960‐968

0%

20%

40%

Tobacco Alcohol Drugs Sexual Behavior

Seatbelt Helmet Total Counseling

Comparison Group

Intervention Group


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80

100

Preventive Service Delivery Before and After GAPS Implementation

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Klein J, Allan MJ, Arthur EB, Eslter DS, Cox C, Herdberg VA, Goodman, RA. Improving Adolescent Preventative Care in Community Health Centers Pediatrics 2001;107;318‐327

0

20

40

Pre‐GAPS

Post‐GAPS


50%

60%

Adolescent Reported Increases in Discussion with Providers After GAPS Implementation

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0%

10%

20%

30%

40%

Pre GAPS

Post Gaps

Klein, J. D., M. J. Allan, et al. (2001). "Improving Adolescent Preventive Care in Community Health Centers." Pediatrics 107(2): 318-327.


Quality Measures for Preventive Services• Parental /youth questions and concerns • Screening and follow‐up

– Risk Assessment – Developmental Tasks of Adolescents– Chlamydia *

BMI percentile*

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– BMI percentile*• Anticipatory Guidance• Immunizations*• Physical Exam

• Strength based approaches• Identify CSHCN• Recall and reminder system • Yearly visit*

*HEDIS Measures

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AIMSAIMSAssist pediatric and family medicine practices to:

Make office‐based systems changes promoting comprehensive screening and counseling for risks and developmental tasks

Brief office intervention and referral

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RISKS

Substance Abuse

Sexual Behavior

Unhealthy Nutrition

Inadequate Physical Activity

Safety

Mental Health

DEVELOPMENTAL TASKS

Relationships

Competence

Independent Decision‐Making

Generosity


VERMONT CHILD HEALTH IMPROVEMENT PROGRAM VERMONT CHILD HEALTH IMPROVEMENT PROGRAM Date_____Date_____

NutritionNutrition

Screening Reminder Sticker

Generosity

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Check indicates a preventive Check indicates a preventive screening/counselingscreening/counseling

Physical ActivityPhysical Activity

Substance AbuseSubstance Abuse

Sexuality Related Sexuality Related

BehaviorBehavior

Unintentional InjuriesUnintentional Injuries

Emotional Health/SuicideEmotional Health/Suicide

y Independence Mastery Belonging

CRAFFT? Y / N CRAFFT? Y / N 2+ or 2+ or --

Office Intervention Y/ NOffice Intervention Y/ NReferral Y / NReferral Y / N

Copyright University of VermontCopyright University of Vermont


Documenting Parental Concern

Bright Futures Priorities

Pre-visit Questionnaire Reviewed

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Screening

Risk Assessment


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Screening

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Date of Screening_____Date of Screening_____

HEEADSSS AssessmentHEEADSSS Assessment

HomeHome (connection/independent decision(connection/independent decision--making)making)

Check Indicates a Preventative Screening Check Indicates a Preventative Screening

VisionVision

HearingHearing

A iA i

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Education Education (competence)(competence)

Eating Eating

Activities Activities (physical activity, helping out)(physical activity, helping out)

DrugsDrugs

SexSex

SafetySafety

Suicide Suicide (coping, resiliency, self confidence)(coping, resiliency, self confidence)

AnemiaAnemia

CholesterolCholesterol

TBTB

STISTI

PAPPAP

PregnancyPregnancy

CRAFFT? Y / NCRAFFT? Y / N +2+2

Office Intervention Office Intervention Y/ NY/ NReferral Y / NReferral Y / N


Tips from other practices• Patient walk through – with cycle time

• Nurses/medical assistants review

• Planned visit model

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• Message handling ‐ Interruptions

• Sports physicals

• Universal urines


A New Vision for Well‐ Adolescent CareReady for Implementation

• Use youth to answer questions/impart information

• Structured assessment prior to visits, e.g. CRAFFT

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• Include strength /developmental task of adolescents

• Model problem solving skills (MI)

• Risk categories/ customize screening

• Serve as consultants to schools, juvenile justice , community agencies

• Specific office hours for adolescents


A New Vision for Well‐child CareRequiring additional resources

• Multidisciplinary teams –dev/MH services• Co‐location• Care coordinator

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Care coordinator• Practice/community partnerships obesity

prevention• Take place same day –open access

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So You Want To Improve Your Preventive So You Want To Improve Your Preventive Services Services –– Your Adolescent Visits Your Adolescent Visits

•• Take the QuizTake the Quiz

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•• Use the toolkit or parts of itUse the toolkit or parts of it

•• Review the toolkit and update your forms Review the toolkit and update your forms


So You Want To Improve Your Preventive So You Want To Improve Your Preventive Services Services –– Your Adolescent Visits Your Adolescent Visits

–– NASBHC QI activities NASBHC QI activities

–– AAP equip modelAAP equip modeli f ifi i (MOC)i f ifi i (MOC)

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•• maintenance of certification(MOC)maintenance of certification(MOC)

–– Work with your AAP chapter or improvement Work with your AAP chapter or improvement partnership on an improvement collaborativepartnership on an improvement collaborative

–– Consider educational office visit projectConsider educational office visit project


How does a Bright Futures Translate into QI Activities

Gather your practice team Assess your current method of preventive services delivery Elicit support from practice leaders Select an area to start Think through practice flow

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g p Eg . Determine when parent will receive the questionnaire

Test tool on small scale Make changes if necessary Plan for needed resources/referrals Measure success


References

• Frankowski, B, Leader, I Duncan P. Adolescent Strength Based Interviewing Adolescent Medicine State of the Art Reviews, April 2009, p352.

h

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• Duncan,P,Shaw,J, Gottesman,MM, Swanson,JHaganJ ,Pirretti, A Bright Futures Tool and Resource Kit Elk Grove Village American Academy of Pediatrics, October 2009

• Duncan P and Pirretti A. Using Bright Futures with Adolescents Adolescent Updates AAP News American Academy ofPediatrics November 2009

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References

Hagan JF, Shaw JS, Duncan PM, eds. 2008. Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents Third Edition Elk Grove Village IL: American

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Adolescents, Third Edition. Elk Grove Village, IL: American Academy of Pediatrics

Duncan PM, Garcia AC, Frankowski BL et al. Inspiring healthy adolescent choices: A rationale for and guide to strength promotion in primary care. J Adol Health 41 (2007) 525‐535.

Ginsburg KR. Engaging Adolescents and Building on their strengths.Adoelsc Health Update. 2007;19(2).

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