ml7: driving change in communities by going...

ML7: Driving Change in Communities by going Upstream

The All Children Thrive Learning Network

Uma Kotagal

Cincinnati Children’s

December 11th , 2017

Cincinnati…

53 infants died by 12 month old

730 hospitalized for psychiatric conditions

450 hospitalized for asthma

1100 not ready to learn at kindergarten

698 not reading proficiently in 3rd grade

Cincinnati – current state of health

Morbidity and Mortality• Reduce annual infant deaths in Hamilton County by 33%• Reduce disparity in hospital bed days by 10%, focusing on 2 high risk

neighborhoods (Avondale and Price Hill)

Thriving• Ensure 5 year olds have a ‘healthy mind and body’*• Increase percent of children reading proficiently by 3rd grade in

Cincinnati Public Schools from 78% to 90%

*Bundle measure: immunization, BMI, dental, behavior, vision, emergent literacy, speech, hearing

Help Cincinnati’s 66,000 kids be the healthiest in the nation through strong partnerships

All Children Thrive | Vision, Outcomes

All Children Thrive (ACT) |Mission, Principles

Help Cincinnati’s 66,000 children to be the healthiest in the nation through strong community partnerships.

Mission Bring community members - children, families, community& civic leaders, educators, social service providers, faith leaders, health care providers, researchers, and others - together to collaborate, learn from every interaction, formulate and answer questions, encourage discovery and implement findings to co-produce an environment where children thrive.

Network Principles The five principals were generated by ACT Vision Session participants in October, 2015:• Equity is foundational to improving children's health• Children are the center of our work• Relationships, trust, and working together are essential for sustainable solutions• We all teach and we all learn• Daily work is action oriented and results focused

ACT Learning Network Organization

6

Me

asu

res

Infant mortality

Bed day disparityMental, physical health at age 5

Reading proficiently at 3rd grade

Wo

rkgr

ou

ps Infant mortality Community

Connected Primary Care

Education Socialinfluences in

Neighborhoods

Adcock, Greenberg, Kelly

Crumpton, MansourBroadnax, White,

DeWittSchwab, Kahn

Core Supports

Family Centered Design

Data and Analytic Support

Community Quality Improvement Capacity

Community Activation

In Home Supports

Families &

Children

3rd grade Reading

Social Influences

in N’hoods

Infant Mortality

CommunityConnected

Primary Care

Infant MortalityCradle Cincinnati

(Adcock/Kelly/Greenberg)18 Obstetric TeamsGood Samaritan HospitalUniversity of Cincinnati HospitalEvery Child SucceedsCommunity Health Workers

Neighborhood Social Influences(Schwab/Kahn)

Place Matters/LISCGreater Cincinnati Urban LeagueCincinnati WorksSanta Maria Community SvcsThe Community BuildersLegal Aid Society Greater CincinnatiUnited Way of Greater CincinnatiJob and Family Services>20 Families

3rd Grade Reading(Broadnax/4C/Tom DeWitt)

Cincinnati Public SchoolsStrive PartnershipSuccess by Six4C for ChildrenCommunity Action Agency/Head StartPediatric Clinics

Community Connected Primary Care

(Crumpton/Mansour)

Federally Qualified Health CtrsCincinnati Health DepartmentBehavioral Health Agencies

ACT Learning Network: WorkgroupsKotagal, Iyer, Kahn, many others

ACT Learning Network: Key Driver Diagram

All Children Thrive:Our Journey So Far - January 2017

OCT

2015

NOV –

MAR

2016

Vision Session


A FUTURE WHERE CINCINNATI’S

66,000 CHILDREN THRIVE!

APRIL

2016

Community QI TrainingIMPACT U

JUNE

2016

Learning Session # 1

DEC

2016

Community QI TrainingQI Bootcamp

JAN

2017

One Year of ActiveParent Partners

SEPT

2016

Community QI Training CPS & Menomonee Falls

ACT LN Cores


Community Activation

Community QI Capability Building

SP20: Changing the Outcome Together 11


SP20: Changing the Outcome Together 12


All Children Thrive Learning Network - Community Activation – Neighborhood Level

Key Driver DiagramRevision Date:

12/14/16

Goals that work for everybody

Drivers

Leaders and future leaders from the community

CHILD HEALTH OUTCOMES

Help Cincinnati’s 66,000 children be the healthiest in the nation through strong community partnerships

GLOBAL AIM

• Decrease Inpatient bed days

• Reduce Infant Mortality

• Increase Thrive by 5• Increase Third Grade

Reading• Address Social

Determinants

All involved celebrate children and success

Mutual respect, trust, communication and relationships

SMART AIM

Increase the number of community members**

actively participating in, contributing to and owning to*** improve the health of children in their community of Avondale and Price Hill by 50% at 3 levels:

•Participation from 2980 to

4470•Contribution from 150 to 225•Ownership from 76 to 114

By June 2017. Understanding what is good and the needs of the community

Parents and residents improve and advocate for all children to be healthy

**parents/family, provider/organizational leaders, neighborhood/community

***active participation includes measuring participation, contribution, and ownership (does not include awareness)

Everyone feels included and like they belong

In Progress

Community protects, provides and values the potential that every child has to be thriving, healthy and successful*

*Parenting, Housing,

Safety, ECT.

VISION

Interventions

1

2

3

4

5

6

7

Recipe for family activation & inclusion

Family members attending IPBD/Community meetings

Prototype Development

Community Handwashing Campaign

Community Leadership Training

Avondale and Price Hill Community and Partnership Committee’s

Integrating Into Work Streams

Capacity Building Grants

Community Activation - Key Driver Diagram

Community activationLevel of

Activation

Definition Examples Baseline

FY16

FY17 Target

(50%

Increase)

Awarenesspassive receipt of

information

number of people who

receive flyers, brochures or

handouts; number

connected via social media,

email, website

Participationuse of existing

tools or events

number of people attending

community outreach events,

learning sessions, network

meetings, courses, number

of people adopting changes

2980 4470

Contribution

improving existing

tools, knowledge

or resources

presenting at events,

number of people involved

in quality improvement at

sites, number of people

posting to sites, number of

people serving on

committees

150 225

Ownership

creating new

resources / tools

or leading

initiatives

testing new ideas, co-

leaders of work streams,

parent leaders of activation

projects

76 114

PDSA RAMP

Family Invitation Process

Community activation

SMART AIMS

INTERVENTIONS

Meet prioritized basic needs*

for a total of 25 families from

Price Hill (10 ) and Avondale

(15) by June 2017.

Guiding Principle: These

families’ children are on a

trajectory to thrive.

Key

Gray shaded box = completed intervention

Green shaded box = what we’re working on right now

LOR # = Level of Reliability Number, e.g., LOR 1

ACT LN Social Influences and Self SufficiencyKey Driver Diagram (KDD)

Project Leader(s): Rob Kahn, Kathy Schwab QIC: Shari Wooton

Revision Date:

1/19/2017

Help Cincinnati’s 66,000

children be the healthiest in the

nation through strong

community partnerships

GLOBAL AIM

Invitation to families & build

relationshipsTrusted relationships

Agencies willing to partner, break

rules, & change systems

“Whatever It Takes” service

mentality

Sustainable Solutions

PRIMARY DRIVERS

Family identifying needs both

urgent and sustainable (long term)

Family & trusted partner prioritize

needs

Family & trusted partner identify

agency partnerships

Agency/Family huddle to solve for

families

Families learn contingency planning

skills

Identify common system issues

become new interventions

Families with advocacy skills

Identify and address a common

system issue by June 2017.

Well-being of children measure

YOUR IDEA HERE!!!!

Cincinnati: ~66,000 children in

Cincinnati

Project: ~50 children

POPULATION

Common Definition of Need: Arizona Self Sufficiency matrix (tested and validated for reliability and widely accepted). Advantages: ➢ Provides a matrix/ domain to

identify ONE need and associate a score for that

➢ Develop list of associated needs for a NEED and the system level issues

➢ Aligned with local strategy (United Way)

Predicted Learnings: ➢ Pareto of system level issues-

recognize system level processes that need to be fixed

➢ Time (from identifying a need and fulfilling them)

Social Influences and self sufficiency: Data approach

Jobs and Family Services (JSF)

Legal Aid

YWCA

Free Store Food Bank

Cincinnati Works

Urban League

Others – TBD based on learnings

The Community Builders (TCB)

Healthy Homes (Block

by Block)

United Way -STEPS

Pediatric Primary

Care Center (PPC)

Social Influences and Self Sufficiency

Learning Structure

• Four frontline teams aim to

address individual families’

needs and also surface

key systems issues

• Systems issues, such as

insufficient bus routes,

burdensome processes,

accessing benefits will

then be shared with critical

local leadership to identify

areas for systems change

School system

Getting deposits, vouchers, safety outside, dishonest landlords

Social influences and self sufficiency

Legal Aid Housing Cases Mapped Against Neighborhood Asthma Hotspots: Shared Purpose

Avondale

FRONT LINE IMPROVERS/TEAMS

(RCIC, BootCamp, Menominee Falls, On-Line Modules)

Social Workers, Teachers, Nurses, Residents

MESO/MICRO System Leaders*

(Impact U)

Program Leaders, Reading Specialists,

Clinicians, Lawyers

MACRO SYSTEM

LEADERS

Executive Directors,

Principals, Medical

Directors,

Foundation Leaders,

Political Leaders

SYSTEMS

LEADERSHIP*

(Boards on Board

Training)

All Children Thrive

Network

Advanced

Improvement

Methods*

(AIM)

AIM

Faculty and

Researchers

COMMUNITY

Intermediate

Improvement

* All multi-sector

Community QI Capability Building

Held 1st Sessions, Planning 2nd

Neighborhood Government

Infrastructure

Obstetrics Clinics

Community Health

Home Visiting

Primary Care Clinics

Residents

Community Leaders

Social Service Organizations

Childcare Providers

Early Childhood Centers

Schools (K-3) 1

1

2

2

2

2

0

3

5 25

6

4

13

3

8

1

5

4

300

30

20

20

5

40

23

25

300k

60

39

25

20**

49

126

483

174

58

Community Capability Scale Plan

Scale - Children (0-9)39,203

2016 2017

2020

Scale Cincinnati

ACT Learning Network Outcomes

Morbidity and Mortality1. Reduce annual infant deaths in Hamilton County by 33%2. Reduce disparity in hospital bed days by 10%, focusing on 2

high risk neighborhoods (Avondale and Price Hill)

Thriving3. Ensure 5 year olds have a ‘healthy mind and body’*4. Increase percent of children reading proficiently by 3rd

grade in Cincinnati Public Schools from 78% to 90%

1. Reduce annual infant deaths in County by 33% to 5.98 death per 1000 live births

Cradle Cincinnati

Infant Mortality Learning Collaborative Measures

Measure Category

Infant Mortality Learning Collaborative Measures to Improve

(28 OB and CHW/HV teams)

OB Teams

Community Teams

Early Access Measures

% New OB Patients (non-transfer) First Prenatal Visit <= 12 weeks X

% First OB Visits <= 4 Days of Initial ContactX

Smoking Measures

% New OB Patients Received “ASK” Step at First OB Visit X

% Patients Received “ASSIST” Step at First OB VisitX

% Patients Smoking at 28 Week Visit (CRITICAL OUTCOME MEASURE) X

Trusted Relationships

Measures

% New OB Patients Referred to CHW, HV, CM <= 2 days After First OB Visit X

% Clients with Completed First CHW, HV, or CM visit <= 10 days of Receipt of Referral X

0

1

2

3

4

5

6

7

8

9

10

200

9-Q

1 (

n=

40)

2009-Q

2 (

n=

58)

200

9-Q

3 (

n=

58)

200

9-Q

4 (

n=

63)

201

0-Q

1 (

n=

37)

201

0-Q

2 (

n=

39)

2010-Q

3 (

n=

51)

201

0-Q

4 (

n=

45)

201

1-Q

1 (

n=

52)

201

1-Q

2 (

n=

54)

201

1-Q

3 (

n=

49)

201

1-Q

4 (

n=

53)

201

2-Q

1 (

n=

50)

201

2-Q

2 (

n=

46)

201

2-Q

3 (

n=

45)

201

2-Q

4 (

n=

48)

201

3-Q

1 (

n=

49)

201

3-Q

2 (

n=

55)

201

3-Q

3 (

n=

51)

201

3-Q

4 (

n=

62)

201

4-Q

1 (

n=

43)

201

4-Q

2 (

n=

45)

201

4-Q

3 (

n=

56)

201

4-Q

4 (

n=

58)

2015-Q

1 (

n=

55)

201

5-Q

2 (

n=

53)

201

5-Q

3 (

n=

42)

201

5-Q

4 (

n=

48)

201

6-Q

1 (

n=

51)

201

6-Q

2 (

n=

48)

201

6-Q

3 (

n=

55)

201

6-Q

4 (

n=

37)

Pe

rce

nt

bo

rn <

28

we

ek

sResident singleton births < 28 weeks gestation

ZIP Code 45229 (Avondale-North Avondale), by quarter, 2009-2016(Obstetric estimate of gestation )

Quarterly Percent Baseline Average Percent Control Limits

Source: Hamilton County Public Health. Updated by J. Besl 1/27/17

StartStrong Initiative7/2013 - StartStrong launch in Avondale.

12/2013 - Active QI testing at UCMC & GSH

1/2014 - StartStrong mom's group.

3/2014 - ECS home visits

6/2014 - CHW begins. Community Feast

Lau

nch

0

1

2

3

4

5

6

7

8

9

10

200

9-Q

1 (

n=

63

)

200

9-Q

2 (

n=

57

)

200

9-Q

3 (

n=

78

)

200

9-Q

4 (

n=

71

)

201

0-Q

1 (

n=

65

)

201

0-Q

2 (

n=

55

)

201

0-Q

3 (

n=

51

)

201

0-Q

4 (

n=

61

)

201

1-Q

1 (

n=

61

)

201

1-Q

2 (

n=

64

)

201

1-Q

3 (

n=

72

)

201

1-Q

4 (

n=

69

)

201

2-Q

1 (

n=

50

)

201

2-Q

2 (

n=

54

)

201

2-Q

3 (

n=

68

)

201

2-Q

4 (

n=

70

)

201

3-Q

1 (

n=

67

)

201

3-Q

2 (

n=

49

)

201

3-Q

3 (

n=

77

)

201

3-Q

4 (

n=

52

)

201

4-Q

1 (

n=

58

)

201

4-Q

2 (

n=

54

)

201

4-Q

3 (

n=

62

)

201

4-Q

4 (

n=

59

)

201

5-Q

1 (

n=

47

)

201

5-Q

2 (

n=

59

)

201

5-Q

3 (

n=

48

)

201

5-Q

4 (

n=

61

)

201

6-Q

1 (

n=

59

)

201

6-Q

2 (

n=

49

)

201

6-Q

3 (

n=

58

)

201

6-Q

4 (

n=

60

)

Pe

rce

nt

bo

rn <

28

we

ek

sResident singleton births <28 weeks gestation

ZIP Code 45206 & 45207 (Walnut Hills-Evanston), by quarter, 2009-2016(Obstetric estimate of gestation <28 weeks)

Comparison Neighborhoods

Quarterly Percent Baseline Average Percent Control Limits

Source: Hamilton County Public Health. Updated by J. Besl 1/27/17

0

20

40

60

80

100

120

July

n=1

54

7

Au

g n

=15

55

Sep

t n

=1

55

4

Oct

n=1

56

9

No

v n

=1

54

2

De

c n

=15

29

Jan

n=

Feb

n=

Mar

n=

Ap

r n

=

May

n=

Jun

n=

Be

d D

ays

pe

r 1

00

0 P

atie

nts

FY 17 Month and Population

CCHMC Inpatient Days-Excludes Mental HealthYTD Inpatient Days per 1000 Population

General Pediatric Patients Age 0 up to 18 Residing in AvondaleExcludes Patients with LOS > 14 Days

Green Threshold Yellow Threshold YTD Bed Days per 1000 Target Based on Sustaining 10% Reduction from FY 15

Month Bed Days Patients in a Bed

July 4.8 4

Aug 5.2 3

Sept 16.1 6

Oct 12.7 8

Nov 10.4 7

Dec 10.3 6

2. Reduce Inpatient Bed Days 10% in 2 N’borhoods

Expected annual inpatient bed-days

FY 17 inpatient bed-days goal

0

10

20

30

40

50

60

70

80

90

July

Au

g

Sep

t

Oct

No

v

De

c

Jan

Feb

Mar

Ap

r

May Jun

Be

d D

ays

pe

r 1

00

0 P

atie

nts

FY 17 Month

CCHMC Inpatient Days-Excludes Mental Health and LOS >14 DaysYTD Inpatient Days per 1000 Population

Patients Age 0 up to 18 Residing in Walnut Hills, Winton Hills, OTR, and Evanston

Green Threshold Yellow Threshold YTD Bed Days per 1000 Target Based on 11% Reduction from FY16 Baseline

Month Bed Days Patients in a Bed

201607 50.1 24

201608 30.3 23

201609 48.6 25

201610 73.6 36

201611 50.2 25

201612 47.0 28

Comparison Neighborhoods

#ACTNOWCINCY

PHYSICAL HEALTH

Fully vaccinated: patient has received all state-required vaccines for Kindergarten entry

Healthy teeth: patient free of dental pain at most recent well child visit, per parent report. “In the past two months, has your child had pain in the teeth, mouth, or jaws?” [Options: yes, no, I don’t know.]

Healthy vision: patient has a normal vision screen since their 4th birthday (screened with or without corrective lenses)

Healthy hearing: normal hearing screen in primary care or audiology since their 4th birthday

Healthy weight: patient has had a healthy range of BMI (<85th percentile and >3rd percentile) recorded since their 4th birthday

LANGUAGE/COMMUNICATION/COGNITIVE DEVELOPMENT

Normal speech: Normal communication domain on developmental screening (ASQ) in primary care at age 4 years

Normal literacy: Normal early literacy screen at 4 year well child visit using validated screener “Get Ready to Read” (short form)

SOCIAL COMPETENCE AND EMOTIONAL MATURITY

Mental, emotional, and behavioral health: Normal social-emotional screen (ASQ-SE/SDQ) in primary care since their 3rd birthday

3. Increase Healthy Mind and Body at Age Five

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%1

2/2

01

4 (

n=1

85

)

1/2

01

5 (

n=1

90

)

2/2

01

5 (

n=1

97

)

3/2

01

5 (

n=1

87

)

4/2

01

5 (

n=1

95

)

5/2

01

5 (

n=2

30

)

6/2

01

5 (

n=2

31

)

7/2

01

5 (

n=1

83

)

8/2

01

5 (

n=2

04

)

9/2

01

5 (

n=2

15

)

10

/20

15

(n

=19

7)

11

/20

15

(n

=18

7)

12

/20

15

(n

=17

1)

1/2

01

6 (

n=1

96

)

2/2

01

6 (

n=2

43

)

3/2

01

6 (

n=2

30

)

4/2

01

6 (

n=2

03

)

5/2

01

6 (

n=2

17

)

6/2

01

6 (

n=2

44

)

7/2

01

6 (

n=2

25

)

8/2

01

6 (

n=1

79

)

9/2

01

6 (

n=2

19

)

10

/20

16

(n

=22

8)

11

/20

16

(n

=21

1)

Percent of Gen Peds Patients Thriving at 66 Months of Age

All Bundle Elements Centerline Control Limits

Updated by Allison Glance, Analyst James M Anderson Center for Health Systems Excellence on 12/9/2016

Thriving=• Immunization up to date• Healthy BMI• Normal/corrected vision• Normal hearing• Passed social-emotional screen• Not yet included:

• Free of dental pain• Emergent literacy• Normal speech/language

2016 – 13% meet all measured criteria2020 Goal – 40% meet all criteria

74%

0

10

20

30

40

50

60

70

80

90

100

200

5-2

00

6 (

n=

233

4)

200

6-2

00

7 (

n=

232

9)

200

7-2

00

8 (

n=

231

4)

200

8-2

00

9 (

n=

227

2)

200

9-2

01

0 (

n=

223

1)

201

0-2

01

1 (

n=

225

4)

201

1-2

01

2 (

n=

218

7)

201

2-2

01

3 (

n=

220

7)

201

3-2

01

4 (

n=

234

7)

201

4-2

01

5 (

n=

262

4)

Perc

en

t

Reading 3rd Grade % at or above by school year Average Proportion of Defects Control Limits

4. Increase percent of children reading proficiently by 3rd grade in Cincinnati Public Schools from 78% to 90%

Source: Ohio Department of Education

Increase percent of children reading proficiently by 3rd

grade in Cincinnati Public Schools from 78% to 90%

Cincinnati Preschool Mississippi Map Estimated # of 3 & 4 Year Olds = 9,150

Center-based

Providers

174 Programs/7,215

Slots

ODJFS

Licensed

127 / 5,059

slots

CPS + Head

Start

47 / 2,156

slots

Not

Rated

95 /

3,217

1 – 2

Stars

17 /

727

3 – 5

Stars

15 /

1,115

1 Star

10 /

464

2

Stars

7 /

263

3

Stars

3 /

240

4

Stars

3 /

325

5

Stars

9 /

550

CPS

CAA

Head

Start

Population based on ACS 1-Year 2014 Estimates

Ratings and Capacity from November 2015 – 4C Database & Center Surveys

*

*

Family Child Care

483 Providers

Child Care Providers

in the CPS District

918 Programs

Not

Rated

459

1 – 2

Stars

23

3 – 5

Stars

1

1 Star

14

2

Stars

9

5

Stars

1

*

4C Two QI Boot Camp Teams:One Center identified in each of

these buckets to get to 1 Star

Infant

Mortality

3rd Grade

ReadingThriving at 5

Bed Day

Disparity

Social Influences in Neighborhood

Child Poverty Collaborative

Infant MortalityCommunity

Primary Care3rd Grade Reading

All Children Thrive and Mayor’s Child Poverty Collaborative

Outcomes

Workgroups

All C

hild

ren

Thrive

LN

Vision: No one in our community lives in poverty.

Purpose:

In collaboration with families and community partners, the

CPC seeks to ensure that people currently living in

poverty move toward achieving and maintaining self-

sufficiency. Our goal is to move 5,000 families and 10,000

children out of poverty in 5 years.

We will lead, partner and support system changes to

reduce poverty and improve children’s lives.

Called for by Mayor John Cranley

Cincinnati Child Poverty Collaborative: Vision + Purpose

#6. Cincinnati

39%children in

poverty

39% of children in

Cincinnati live in families

below 100% FPL. For a

family of 3, that is with

income of $19,078.

This is better than 2014 when that number was 44%.

Cincinnati ranks #6 in

child poverty

Poverty Rate for Children

SYSTEM OF POVERTY

CPC Commitments

1. Catalyze an effort called “One-To-One” which will partner families and coaches to build the capacity for individuals to overcome barriers getting in their way.

2. Convene an Employer Roundtable of Human Resource Professionals and other executives to share ideas and best practices for how companies can improve employment opportunities for entry-level employees.

3. Shine a light on and mobilize to change legislative policies and practices to empower more people to move from poverty to self-sufficiency.

4. Serve as an important convener in the community and will lead, partner, and/or support advocacy items

5. Support a New Direction for the United Way whose primary focus is expanding opportunity for families in poverty.

ml7: driving change in communities by going...

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