powerpoint presentation€¦ · clarksville, tn • 28.5% population change 2000-2010 vs. 11.5% tn...

1/25/2012

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Early MIECHV Successes

and Challenges:

Tennessee’s Experience with

Continuous Quality Improvement

and Engaging Military Families

Cathy R. Taylor, DrPH, MSN, RN

Michael D. Warren, MD, MPH

Bridget K. McCabe, MD, MPH

Marilyn D. Stephenson, MSN, RN (Moderator)

Part I

Engaging New Stakeholders –

Working with Military Families in

Tennessee (Fort Campbell)

Cathy R. Taylor, DrPH, MSN, RN

Dean, College of Health Sciences and Nursing, Belmont

University

Former Assistant Commissioner, TN Department of

Health

[email protected]

Objectives

1. Describe Tennessee’s opportunities to

engage new stakeholders during the

MIECHV process - Tennessee’s Military

Families

mailto:[email protected]

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Ft. Campbell

Ft. Campbell

• Army’s most deployed contingency forces

• 101st Airborne

• 2 Special Operations Command Units

• 86th Combat Support Hospital

• Provides training and mobilization support

for Army National Guard and Reserve units

• Supports active and reserve component

units, Army civilians, Army Families,

retirees and veterans

Ft. Campbell, KY

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Clarksville, TN

• 28.5% Population change 2000-2010 vs. 11.5% TN

• 28% <18 years old vs. 23% TN average

• Per capita income $21,000 vs. $23,000 TN

• Higher than TN averages

• Adult smoking

• Obesity

• Excessive drinking

• Sexually transmitted infections

Serving Military Families in TN

• Behavioral Health

• WIC

• Existing family planning, home visitation

and care coordination efforts

• Creating new opportunities

• Opening doors

• Partnering with existing programs

• Tailoring interventions to special needs

Part II

Leveraging MIECHV Initiatives to

Enhance Existing Early Childhood

Systems and Engage Stakeholders

in Tennessee

Michael D. Warren, MD, MPH, FAAP

Director, Title V/Maternal & Child Health

Tennessee Department of Health

[email protected]


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Objectives

1. Describe pre-MIECHV home visiting

initiatives in Tennessee

2. Outline challenges and opportunities

associated with MIECHV implementation in

Tennessee

Pre-MIECHV in Tennessee

• CHAD (Child Health and Development) • Mandated in statute (1979)

• Based on Vanderbilt Peabody research model

• 22 counties in East and Northeast TN

• Operated by county health departments

• Funded with interdepartmental funds from

Children’s Services (Social Services Block Grant)


• Healthy Start • Mandated in statute (1994)

• Utilize Healthy Families America model

• 31 counties throughout TN

• Operated by community non-profit agencies

• Funded with interdepartmental funds from

Children’s Services (ACF Promoting Safe and

Stable Families Funds)

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• HUGS (Help Us Grow Successfully) • Began in 1990’s

• Care coordination program with home visiting

component

• Present in all 95 counties

• Operated by county Health Departments

• Funded by state Medicaid program (TennCare)


• Nurse Home Visitor Program • Mandated in statute (2010)

• Utilizes Nurse Family Partnership (NFP) model

• Operated by community non-profit agency

• Located in Shelby County


• Statewide interest in evidence-based

programming • Commitment by state agencies and statewide

home visiting collaborative

• 2010 legislation requiring Department of Health to

annually report on evidence-based practices

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• Department of Health efforts to collect

continuous quality improvement (CQI) data

for HUGS • Standard administrative platform used by all 95

county health departmentsallows for uniform data

collection across state

• Data collection began in 2009

• Collaboration with Department QI staff


• Statewide Home Visiting Collaborative • Includes program representatives from across state

• Public and private agencies represented

• Strategize how to build more integrated system of

home visiting services


LEGEND

HUGS

HFA

NFP

PAT

CHAD

Healthy Start

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Tennessee Population Density


• Over 7,400 families served in FY10

• Services available in all 95 counties

• Few counties serve more than 5.6% of the 0-5

population1

1. Source: Tennessee Commission on Children and Youth, 2011 Resource Map of Expenditures for Tennessee Children.

Tennessee MIECHV Timeline

• Summer 2010: Initial State Plan

• Fall 2010: Statewide Needs Assessment

• Summer 2011: Updated State Plan • June 8: Updated State Plan

• June 21: Competitive FY11 application

• July 1: FY11 formula application

• July 1, 2011: MIECHV Grantee Startup

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Tennessee MIECHV Programs

• Healthy Families America • Davidson County

• Maury County

• Montgomery County (*focus on military families)

• Shelby County

• Nurse Family Partnership • Campbell County

• Shelby County

• Parents as Teachers • Hamilton County

• Shelby County

Post-MIECHV in Tennessee

LEGEND

HUGS

HFA

NFP

PAT

CHAD

Healthy Start

MIECHV

Challenges

• Rapid turnaround (applications/planning) • Summer 2011 plan/grant submissions

• TN unable to outsource plan development/grant

writing

• Extensive benchmark data collection • Home visitors concerned about balance between

data collection with service provision

• Different data systemsduplicate data entry

• Multiple models • Each with different data collection requirements

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Opportunities

• New staff • Administrator (also ECCS Director)

• Epidemiologist

• Program Director

• Better integration in MCH • Linkages to other programs (Injury, Family

Planning, CSHCN, ECCS)

• Integrated funding

Tennessee Home Visiting Team

Healthier Beginnings

• Public/Private Partnerships • Ongoing collaboration with Home Visiting

Collaborative

• Development of uniform intake/referral system

• Efforts with military families • HFA administered by local non-profit

• Engagement of staff from Fort Campbell

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Early Childhood System

• ECCS is building on the federal investment in

home visiting through: • Support for statewide home visiting collaborative

• Development of core competencies for Home Visitors

• Support for training related to early childhood

activities (including home visiting)

• Contributing to sustainable resources for all early

childhood professionals like

www.parentsknowkidsgrow.org

• Working to build capacity of 211 to respond to referral

requests for families with young children

Early Childhood System

• Working to build connections among early

childhood professionals around health and

development topics • Infant Mortality (Safe Sleep)

• Medical Homes (for All Children including Children &

Youth with Special Health Care Needs)

• Infant & Early Childhood Mental Health (Social &

Emotional Development and Challenging Behaviors)

• Developmental Screening and Assessment

What’s Ahead...

• Integrated data system • Across state-run programs

• Available to community agencies

• Shared benchmarks

• Rollout of core competencies • Requirement for all state-run programs

• Available to community agencies

• Increased collaboration • Emphasis on “raising the sea level”

• Attempt to make resources (particularly training)

available broadly

http://www.parentsknowkidsgrow.org/

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Part III

Embedding Continuous Quality

Improvement in MIECHV Initiatives –

Lessons Learned from Integration into

a Statewide Home Visiting Program

Bridget K. McCabe, MD, MPH

Director, Quality Improvement

Tennessee Department of Health

[email protected]

Objectives

1. Discuss how Continuous Quality

Improvement (CQI) is being intertwined into

public health initiatives in Tennessee – Home

Visiting

2. Outline prior experiences in CQI that have

shaped the direction of CQI in MIECHV

3. Discuss challenges and opportunities

associated with CQI in Tennessee

What is Continuous Quality

Improvement (CQI)?

1) Focus on underlying organization processes and

systems as causes for successes or failures

2) Use of structured problem solving approaches

3) Use of cross-functional employee teams

4) Employee empowerment to identify problems and

opportunities for improved care

5) Explicit focus on both internal and external customers

(Shortell, SM, et al., 1995)


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Ways to explain CQI through

examples

1) Grocery shopping and the

grocery list

2) Scheduling appointments

via mobile phones

3) Organizing charts or

records so that information

is stored in the same place

every time

Image: Ambro /FreeDigitalPhotos.Net

Image: winnond/FreeDigitalPhotos.Net

An Example of a System

Toothpaste

Pencils

Popcorn Yogurt

Tomatoes

Dental Floss

Envelopes

Crackers

Milk Orange

Juice

Shampoo

Tape

An Improvement to a System

Personal Hygiene

Items

Office Supplies

Snacks Dairy Items

Produce

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Terminology

“CQI Methodologies”

• PDSA – Plan-Do-Study-Act Cycle

• Lean – Toyota Production System

By measuring it, you say it is important…

• Outcome measure

• Process measure

CQI in the grand scheme of a program

Values & Beliefs

Evidenced-Based Home Visiting

Goals

Actions

System of Care Outcomes

Process Measures Outcome Measures

o Short o Intermediate o Long-term

HUGS Home Visiting

(Local System of Care)

System Information Infrastructure Capacity System Attributes

Evaluation System Continuous and well integrated with daily work flow Functions to support:

o Feedback and Improvement Loops (PDSA Cycle) o Needs Assessment o Monitoring & Accountability o Quality Review & Program Clarification o Stakeholder Engagement

Grant Funds and Requirements Program and Evaluation Technical

Assistance Peer Learning Network

P D A S

P D A S

Adapted from Hodges et al., 2007and Hargreave, 2009

First, define your mission… Then, the

processes that get you to your goals

Objectives drive your outcome and process

measures.

1) Create a Logic Model

2) Create a “Process Map”

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Logic model (The What)

Process map (The How)

Risk/Need Identified

Intervention(s)

Treatment(s)

Risk Reduced

Need Met

Outcome Achieved

Screen for

Risk/Need

Directly Provide

Intervention OR

Referral

Monitor Success of

Intervention

Outcome Achieved

Aligning mission/goals/objectives with actions and how you measure success. (Outcome Measures and Process Measures)

Embedding and Integrating CQI

It is a journey with no end…

Enjoy the process of trying

to improve…

Sayings to keep you on the journey: 1) Do the basics well (know your mission). 2) “You eat an elephant one bite at a time.” (African

Proverb) 3) Don’t let the perfect be the enemy of the good.

(Voltaire – 1700’s)

Image: nuttakit / FreeDigitalPhotos.net

Make it part of the process of daily

work…

Double/Triple Duty Tools:

When possible, work with relevant

screening and monitoring tools that serve

the client as well as to evaluate a program

CQI then becomes part of the day’s work… • Examples:

1) Car seat evaluation (e.g. PRAMS Questionnaire)

2) Developmental screens (e.g. ASQ®)

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Consider population surveillance systems in

your service area (Benchmark)

• Behavioral Risk Factor Surveillance System (BRFSS, CDC)

• Pregnancy Risk Assessment and Monitoring System

(PRAMS, CDC)

• State Vital Records – Birth and Death Files

• State Hospital Discharge Data

• State Birth Defects Registries

• State Newborn Screening Program

Allows you to compare to a larger population.

Question: Are you seeing your target population (i.e. with

more at-risk factors)?

How a Statewide Home Visiting Program’s

Participants Compare to the State Population

(82%)

Benchmarking Opportunities!

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Everyone has a Role/Responsibility

in CQI

(Top down, bottom up, and across.)

Commitment by and professional development of

the entire workforce is required.

• Leadership must be in support of empowering

all levels of staff to make improvement

changes

• Field staff must feel supported in order to

engage in the process of CQI

Workforce Training – Remote Experiential

Learning

• Embedded into work schedule

• Protected time to learn and work through

QI projects

• Short duration but frequent (1 hour every

few weeks)

• Remote to cover large geographical area

• Engage groups to tackle small QI projects

• Technical support from State Agency

(Handout with Curriculum Overview Provided)

Sample Tool: PDSA Worksheet from Institute for Healthcare Improvement

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http://www.ihi.org/knowledge/Pages/Tools/PlanDoStudyActWorksheet.aspx

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Embracing Quality in

Local Public Health:

Michigan’s Quality

Improvement

Guidebook

http://accreditation.localhealth.net/MLC-2%20website/Michigans_QI_Guidebook.pdf

The Public Health

Memory JoggerTM II

Quick Reference for

Quality Improvement

techniques

http://www.phf.org/resourcestools/Pages/Public_Health_Memory_Jogger_II.aspx

The Public Health

Quality Improvement

Handbook

Public Health Foundation

(PHF) in collaboration with

American Society for Quality

(ASQ)

http://www.phf.org/resourcestools/Pages/PublicHealthQIHandbook.aspx

http://accreditation.localhealth.net/MLC-2 website/Michigans_QI_Guidebook.pdf







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Example Experiential Learning:

Documentation Committee

• Gathered front line staff/leadership for about 12 months

• Meeting every 3 weeks

Achievements:

1. Revised Documentation Record to streamline documentation

2. Revised ASQ schedule to reduce burden while still adhering to best practice (surveillance and screening)

3. Developed a medical verification form and guidelines for use to reduce burden of contacting medical providers

Summary Exercise for CQI Initiatives

Some Lessons Learned

• Invest in a core team that will support CQI training and

use throughout your organization (SUSTAINABILITY)

• Dedicated support to translate the data collected into

information that can drive decisions and CQI (strong

analytical skills)

• Current efforts in TN – lead epidemiology/biostatistician

position learning the ropes of QI; working with TN QI group

and with HRSA’s technical expertise

• Start small… “Low Hanging Fruit”

Effo

rt

Return on Investment

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Challenges and Opportunities

TN’s Biggest Challenges: • Rapid deployment

• CQI staffing resources are stretched thin

• Legacy statewide IT system – IT resources stretched thin

TN’s Biggest Opportunities: • Only state with border to border public health IT system

• Connects to other public health programs: WIC; Family Planning; etc.

• Hybrid system – mostly centralized

• Rural Regions – under state agency authority

• Metro Regions – contracted under state agency

Thank you

¿Questions?

Dru Potash Ellen Omohundro Gary Self John Hutcheson Kathy Shearon Susannah Craig Michael Crieghton Lacy Lesmeister Ernest Miser Maternal and Child Health Team at the Tennessee Department of Health

Other resources on the WWW • Association of State and Territorial Health Officers

(ASTHO) • http://www.astho.org/Programs/Accreditation-and-Performance/Quality-

Improvement/

• National Association of City and County Health Officials

(NACCHO) • http://naccho.org/toolbox/

• National Network of Public Health Institutes (NNPHI) –

Multi-State Learning Collaborative • http://www.nnphi.org/program-areas/accreditation-and-performance-

improvement

• Public Health Foundation (PHF) • http://www.phf.org/Pages/default.aspx

• Institute for Healthcare Improvement (IHI) • http://www.ihi.org/Pages/default.aspx

http://www.astho.org/Programs/Accreditation-and-Performance/Quality-Improvement/







http://naccho.org/toolbox/

http://www.nnphi.org/program-areas/accreditation-and-performance-improvement









http://www.phf.org/Pages/default.aspx

http://www.ihi.org/Pages/default.aspx

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References • Plan-Do-Study-Act (PDSA) Worksheet for Testing Change. Retrieved February 25,

2009 from the Institute for Healthcare Improvement Web site:

http://www.ihi.org/knowledge/Pages/Tools/PlanDoStudyActWorksheet.aspx

• Tews DS, Sherry MK, Butler JA, Martin A. Embracing Quality in Local Public Health: Michigan’s Quality Improvement Guidebook; 2008.

http://accreditation.localhealth.net/MLC-2%20website/Michigans_QI_Guidebook.pdf

• Michael Brassard (Author), Diane Ritter (Author), Francine Oddo (Editor), Janet

MacCausland (Illustrator), Michele Kierstead (Illustrator), Deborah Crovo (Illustrator). The Public Health Memory Jogger II: A Pocket Guide of Tools for Continuous

Improvement and Effective Planning; Goal/QPC; 1st edition (March 31, 2007); 165 pages


• Public Health Quality Improvement Handbook. Bialek R, Moran JW and Duffy GL

(editors). Public Health Foundation. 2008.









powerpoint presentation€¦ · clarksville, tn • 28.5% population change 2000-2010 vs. 11.5% tn...

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