QI Learning Collaborative to Improve the Documentation of

Quality Improvement Learning Collaborative to
Improve the Documentation of BMI and
Nutrition and Activity Counseling
Ann Vodacek
Parent QI Representative
Twelve Corners Pediatrics
Stephen Cook MD MPH
Jan Schriefer DrPH
Assistant Professors, Pediatrics
Golisano Children’s Hospital at University of Rochester
Rochester, NY
Identify 2-3 learning objectives for your session, After this
presentation you will be able to:
Understand how to establish a multidisciplinary project which
includes parental input for improving systems within pediatric
practices to better assess and manage obesity
Describe the use of motivational interviewing skills and apply the use
of the pocket cards in a brief practice session and discuss ways to
implement in their own organizations?
Develop, outline, and design a PDSA cycle to test at home related to
care management for obesity
Thank You!!!!!!!!!!
Greater Rochester Health Foundation
NYS Chapter of the AAP
NICHQ
17 local Pediatric Practices
PARENTS from the practices
GROC Breakthrough Series
(12 Months)
How well do
successful teams
“hold the gains”
after LS3?
Participants
Select
Topic
Pre-work
Expert
Meeting
Develop
Framework
& Changes
Planning
Group
P
A
P
D
S
LS 1
D
S
LS 2
Stages of Improvement
LS 3
Supports
-test
-Emails
-implement
-Office Visits
-hold the gain
-spread
Borrowed from IHI
A
Beyond
LS 3
-Phone Conferences
-Monthly Team Reports
-Assessments
Project Team
Ann Vodacek, Parent Representative
PI – Steve Cook MD MPH
NICHQ Directors: Pat Heinrich
Community Physician Lead: Sanford Mayer, MD
Quality Improvement Advisor: Jan Schriefer, DrPH
Adolescent Medicine: Shelly Yussman, MD
Coordinators: Corinne Ulrich & Debbie Fredley
Dietician: Kathy Ippolito,RD
Educator/Evaluator: Connie Baldwin
How many children are obese in the United States?
20
18.8
17.4
18
16 16
16
% Obese
14
11 11
12
10
8
6
6-11 Years
12-19 Years
7
6
4
5
4
5
4
2
0
19631970
19711974
19761980
19881994
19992002
20032004
JAMA, April 5, 2006, Vol 295, No. 13, 1549-1555
NYSED Recommended
Student Health Appraisal Form
GROC Project Timeline 2008 to 2009
July 2008 – recruited 9 practices
August 2008 – Expert Panel
September 2008 – 1st meeting of teams
“kickoff”
October 2008 – Grand Rounds on Obesity
November 2008 – Coaching visits started
December 2008 – 2nd meeting of teams
GROC Timeline 2009 to 2010
January 2009 – Team Conference Calls monthly
February 2009 – Motivational Interviewing Course
March 2009 – 3rd meeting of teams
April 2009 – Photo documentation of efforts and Pecha Kucha development
May 2009 – Pediatric Academic Society poster
June 2009 – 4th meeting of teams and 1st for year 2 practice teams
September – 2nd meeting for year 2 teams
2010 - January – 3rd meeting for year 2 practice teams
2010 April – 4th meeting for year 2 teams, 1st meeting for year 3 practice teams
Ground Rules for Practice Teams
Feel free to ask any question, at any time – email, phone call, etc.
Share as much as possible with each other
Cell phones and pagers on vibrate at meetings
Full day attendance at meetings
Coaching visits ~monthly
Conference calls monthly
Chart reviews monthly ~15
Healthy Kids ROC! Collaborative
Parent Partner Job Description
Position Summary:
Serve as a resource to our practice team as we work to prevent,
identify and treat childhood obesity.
The parent will be asked to join four 1-day Learning Collaborative
workshops scheduled every three months for one year.
They will also be asked to participate in monthly phone calls with
the Learning Collaborative teams.
Parent Requirements
Participate in developing patient and family tools and educational handouts
Join site visits and/or focus groups with GROC Project team on a monthly
basis
Gather information about services available in your area and how to access
those services
Actively work to promote a positive, effective partnership between the
parents, children and providers
Provide a parent perspective
Support the goals the GROC team is trying to accomplish
Join quality improvement team meetings by phone once a month
Total time requirement for one year:
–Approximately 4 hours/month
–Four full day workshops every three months
Qualifications
Parent of one or more child currently or previously cared
for by our practice
Able to represent perspectives of other families in
addition to his/her own
Practices in the 1st cycle of GROC
Pathway Pediatrics
Genesis Pediatrics
Sunrise Pediatrics
Genesee Health
Service
Rochester General
Pediatric Associates
Twelve Corner
Pediatrics
Pittsford Pediatrics
Bay Creek
Pediatrics
Westside Pediatrics
Practices in the 2nd cycle of GROC
Fairport Pediatrics
Penfield Pediatrics
Strong Pediatric
Practice
Threshold
Jordan Health Center
Panorama Pediatrics
Westfall Pediatrics
Highlights
High level of adoption by teams
Innovative practice teams
All practices have parents involved
Group motivational interviewing training
Developing local faculty resources
Partner with Peds Endocrinology for dietary
consult for practices
Food Models Given to Each Team
Many Waiting Rooms have been redecorated!
Patient Journal included
Posters…
They are
EVERYWHERE!
All Teams Made
Drink Displays
Quality Improvement Learning Collaborative To Improve the
Documentation of BMI and Nutrition and Activity Counseling
Percentage of Charts with Physical Activity and Nutritional Counseling
Documented (n=1,152)
p < 0.001
100%
80%
60%
40%
Median
Linear (Median)
20%
0%
August
September
PAS Mtg May 2009
October
November
December
January
February
March
Was BMI Plotted?
100%
90%
80%
95%
95%
95%
76%
Percentage
70%
60%
All Charts
50%
Goal
40%
30%
22%
20%
10%
3%
0%
Yes
No
Missing
Was Weight Status Documented
100%
90%
95%
95%
95%
80%
Percentage
70%
60%
50%
49%
51%
All Charts
Goal Line
40%
30%
20%
10%
0%
0%
Yes
No
Missing
Did Provider Counsel on Nutrition and Physical
Activity?
100%
90%
95%
95%
95%
95%
95%
80%
Percentage
70%
60%
All Charts
50%
39%
Goal
40%
30%
27%
20%
20%
13%
10%
1%
0%
Nutrition
Physical
Activity
Both
Neither
Missing
Weight Status Calculated by BMI Percentile for Well
Child Checks Between August 2008 - May 2009
(n = 1471)
100%
Percentage
80%
59%
60%
BMI
Percentilies
of Children
40%
20%
14%
8%
9%
9%
Obese
Morbidly
Obese
Missing
1%
0%
Underweight
Normal
Weight
Overweight
Percentage of Charts With BMI Plotted
98.3%
95.4%
100%
95%
94.1% 94.4%
93.5% 95%
91.7%
88.3%
92.0%
83.3%
80%
60%
Cycle 1
Goal (95%)
40%
20%
ay
M
pr
il
A
ar
ch
M
Ja
nu
ar
y
Fe
br
ua
ry
O
r
ct
ob
er
N
ov
em
be
r
D
ec
em
be
r
S
ep
te
m
be
ug
us
t
0%
A
Percentage
70.7%
Percentage of Charts With a Completed
Healthy Lifestyle Survey
100%
95%
95%
60%
50.4%
37.8%
40%
51.3%
44.4%
41.4%
34.3%
55.4%
40.4%
30.1%
20%
M
ay
pr
il
A
ch
M
ar
ry
br
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Fe
ra
ry
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m
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er
O
ct
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r
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te
S
ug
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be
r
0.0%
t
0%
A
Percentage
80%
Cycle 1
Goal (95%)
Percentage of Charts Where Provider
Counseled on Nutrition And Physical Activity
100%
95%
95%
79.5%
80%
77.1%
69.4%
60.7% 62.2% 64.8%
Cycle 1
61.5%
60%
Goal
40%
41.4%
20%
M
ay
pr
il
A
ch
M
ar
ry
br
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ar
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m
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be
r
be
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er
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O
ct
m
be
ob
N
S
ep
te
ug
us
t
0%
A
Percentage
74.0% 74.0%
Percentage of Charts With Weight Status Documented
100%
95%
85.5%
80%
77.6%
73.7%
85.4%
86.9%
95%
93.4%
83.3%
73.3%
40%
42.5%
Cycle 1
Goal
20%
M
ay
pr
il
A
ch
M
ar
Fe
br
ua
ry
ry
ua
Ja
n
m
ec
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D
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m
be
r
be
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er
O
ct
ob
r
m
be
ep
te
S
ug
us
t
0%
A
Percentage
63.4%
60%
Self Audits and Feedback
Change Behavior
Can we get kids
to eat Five
servings of
Fruits &
Vegetables
per Day?
BMI percentile Assessment at WCC for 2-18 yr olds
Counseling for Physical Activity at WCC for 2-18 yr olds
Counseling for Nutrition counseling at WCC for 2-18 yr olds
– Chart review
– Claims data
– Codes you can use
HEDIS measures 2009
 V85.51 BMI, pediatric, < 5th %tile for age
 V85.52 BMI, 5th to < 85th %tile
 V85.53 BMI, 85th to < 95th %tile
 V85.54 BMI, > 95th %tile
ASK—Don’t Tell
Ask permission—Would you be willing to spend a few minutes discussing
Stage of Readiness
Key Questions
ways tostay healthy and energized?
Ask open-ended questions, listen & summarize—How do you
feel about your weight? What have you tried so far to work toward a healthier
weight?
Share BMI—Optional—Your current weight puts you at increased risk for
developing heart disease & diabetes.
Your BMI is at the __%. The recommended level for your age is __%.
What do you make of this?
Negotiate the agenda—There are a number of ways to help you achieve a
healthy weight—5210. Is there one of these you’d like to discuss further today?
Assess readiness—On a scale of 0—10, how ready are you to consider
Not Ready 0-3
Raise awareness
Elicit change talk
Advise & encourage
Unsure 4—6
Evaluate ambivalence
Elicit change talk
Build readiness
____ ? Why a __(#chosen)__? Why are you a __ and not a (backward)(forward)?
Explore ambivalence—Normalize the behavior. What are the things you
like /
dislike about____? What are the advantages of keeping things the same /
making a change?
Summarize—Let me see if I understand what you have told me so far. Did I
get it all? Did I get it right?
Close the encounter—Show appreciation. Offer advice,
emphasize choice, express confidence. Our time is almost up. Thank
you for being willing to discuss____. I strongly encourage you to____. The
choice is of course entirely yours. I am confident that if you decide to ____ you
can be successful.
Confirm next steps—Follow up appointment / Referral to specialist.
Ready 7—10
Strengthen
commitment
Elicit change talk
Facilitate action
planning
Would you be interested in knowing more
about ways to stay healthy?
• How can I help?
• What might need to be different for you to
consider a change in the future?
Where does that leave you now?
• What do you see as your next steps?
• What are you thinking/feeling at this
point?
• Where does ____ fit in your future?
•
Why is this important to you now?
• What are your ideas for making this
work?
• What might get in the way? How might
you
work around the barriers?
• How might you reward yourself along the
way?
•
Coaching and Motivational Interviewing is like a dance between the
care team and parent…ALWAYS follow their lead