KEY ACTIVITY #2:

Assess and Improve Reliability in Meeting Well-Child Visit (WCV) Recommendations

This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; proactive patient outreach and engagement; pre-visit planning and care gap reduction; care coordination; behavioral health integration; address social needs.

Overview

The American Academy of Pediatrics (AAP)/Bright Futures developed a set of comprehensive health guidelines for well-child care, known as the periodicity schedule. It is a schedule of screenings and assessments recommended at each well-child visit from infancy through adolescence. Each pediatric clinic should implement protocols to ensure all recommended activities and interventions for all children and families are addressed during WCVs.

Click here for the periodicity schedule detailing recommended activities at each well-child visit.

This foundational activity deals with assessing and then improving your practice’s reliability in implementing the guidelines in periodicity schedule. Of note, a recent thoughtful article published in Pediatrics proposes a population health framework to facilitate a redesign – with emphasis on care teams – for delivering the most evidence-based dimensions of pediatric preventive care. It doesn't solely rely on the traditional WCV as the sole venue in which key preventive services are delivered. The innovation proposed in this framework may prove impactful for patients and practices; currently, however, this approach does not align with the quality measurement framework of reporting the compliance rate with annual well-child visits.

Action steps and roles

1. Review current practices to identify key opportunities for improvement.

Suggested team member(s) responsible: QI lead with frontline staff (e.g., PCP, nurse, medical assistant, front desk staff).

Using the periodicity schedule as a guide, catalog the clinic’s current practices, processes and protocols related to WCVs. Identify how current practices align with the recommendations of the periodicity table and identify top opportunities for improvement.
Consider compiling additional data to determine the rate of completion of each of the recommended activities at each WCV, even if these data are from a small sample of WCVs (e.g., the next five to 10 WCVs for 15-month-olds). Review aggregated data to identify areas of strong performance to learn from and areas for improvement to prioritize. See more in Key Activity 3: Use Care Gap Reports or Registries to Identify all Patients Eligible and Due for Care.

Opportunities for improvement may include:

• Improving scheduling and completion rates for WCVs at the recommended ages.
• Introducing a practice, process or protocol that is currently not being done at all.
• Expanding the WCVs at which a practice, process or protocol is currently being done.
• Improving the quality or reliability of a current practice, process or protocol.

Of note, one of the more challenging Bright Futures and U.S. Preventive Services Task Force (USPSTF) recommendations is the initiation of fluoride varnish after the eruption of the first primary tooth. A new HEDIS measure in 2023 for fluoride varnish reads, “The percentage of members one to four years of age who received at least two fluoride varnish applications during the measurement year.” While federally qualified health centers (FQHCs) with colocated dental clinics may have additional resources and flexibility regarding integration of this key pediatric preventive service, practices without colocated dental clinics may need to employ new strategies.

2. Test new and adapted practices and processes to develop improved workflows and standard protocols for implementing recommended activities during WCVs, focusing first on prioritized areas for improvement.

Suggested team member(s) responsible: QI lead with frontline staff, as appropriate for the WCV activity of focus; patients and their families.

Consider how to use registries, the pre-visit planning process, and daily huddles to support this key activity. (Note: Other key activities are included in this guide to support these aspects.) Use the individual WCV resource pages at AAP Schedule of Well-Child Care Visits – HealthyChildren.org to design, organize and improve each WCV. Consider how to integrate a trauma-informed approach as your practice creates and tests new or adapted processes and enlist caregivers as partners in ensuring WCV activities are provided on time. HealthyChildren.org provides a caregiver-friendly version of the AAP Schedule of Well-Child Care Visits that clinics can share with parents so they know what to expect.

3. Continuously improve approach to WCVs, both overall and for key subpopulations.

Suggested team member(s) responsible: QI lead with frontline staff, as above.

Track data on completion of WCVs in real time and collect disaggregated data by race and ethnicity, as well as by language spoken and geographies, whenever possible. Advocate for strategies that address the challenges specific to subgroups, particularly those with low WCV completion rates, to drive optimal WCVs for all children and families. See more in Key Activity 10: Implement Trauma-Informed Care Approach Across the Patient Journey and Key Activity 4: Use a Systematic Approach to Decrease Inequities.

KEY ACTIVITY #3:

Use Care Gap Reports or Registries to Identify All Patients Eligible and Due for Care

This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; implement condition-specific registries; address social needs.

Overview

This foundational activity provides detailed guidance on how to reliably and efficiently develop and use a regularly updated list of all patients eligible for recommended or standard screenings or interventions through a care gap report or registry.

Care gaps are gaps between the recommended care that a patient should receive according to clinical guidelines and protocols and the care a patient has actually received. Rather than put the responsibility on the individual care team member for searching through charts or remembering which patients need further preventive care or follow-up, this key activity provides guidance for how the practice can efficiently leverage electronic health records (EHRs) and other applications or technical approaches for all its patients.

FIGURE 4: EXAMPLE IMMUNIZATION CARE GAP REPORT FOR AN INDIVIDUAL PATIENT

FIGURE 5: EXAMPLE IMMUNIZATION CARE GAP REPORT FOR A PANEL OF PATIENTS UNDER TWO YEARS OF AGE

FIGURE 6: EXAMPLE WCV CARE GAP REPORT FOR A PANEL OF PATIENTS

Action steps and roles

1. Plan the care gap report.

Suggested team member(s) responsible: Panel manager or data analyst. If it is not clear how the report can be produced, this step may involve one or more people from the practice who work on the EHR and, possibly, the EHR vendor.

As a team, decide what screenings or treatment guidelines are appropriate for your patients and prioritize the most important care gaps to run reports on. Start with the core and supplemental measures and any process measures your practice is tracking. Create care gap reports for childhood immunizations and recommended or standard well-child visits based on the Bright Futures periodicity schedule. Consider if there are any other gaps, clinical guidelines or measures your practice feels important to prioritize. See the Pre-Visit Planning: Leveraging the Team to Identify and Address Gaps in Care for a more complete list of preventive and health maintenance guidelines to consider.

Identify the inclusion criteria for each report, such as age, any exclusion criteria, and factors that make someone high risk.

For more information about California immunization requirements for school entry across childhood and adolescence, refer to Shots for School by the California Department of Public Health (CDPH). Initial efforts to develop care gap reports could focus on ensuring that pediatric patients are receiving these required immunizations.

Childhood immunizations are also tracked in the California Immunization Registry (CAIR). CAIR can link into your EHR to provide more up-to-date information for immunizations your patients received at community pharmacies or other health facilities. See Key Activity 2: Assess and Improve Reliability in Meeting Well-Child Visit (WCV) Recommendations for other tips on implementing these protocols.

2. Build the report.

Suggested team member(s) responsible: Data analyst.

Determine whether the EHR has an existing report or one that can be modified to fit the inclusion criteria. You should talk to staff who are familiar with the electronic record; in some cases, it may be necessary to consult with the EHR vendor to confirm this information and how to run the report.

The care gap format should include:

• Criteria for inclusion in the report.
• The overall compliance rate for the care gap being measured.
• All patients eligible for the screening and their addresses and phone numbers.
• The last date the screening or service was provided (if known or if applicable), the previous results, and the type of assessment used.
• Preferred method of communication (e.g., phone, email, text).

Reports should be able to display and/or disaggregate the data based on:

• Race, ethnicity and language (REAL) as well as sexual orientation and gender identity (SOGI).
• Any known social or behavioral needs.
• Communication preferences or other preferences that would inform the screening modalities offered, such as documented declination of prior screenings.
• Data on any other characteristic, including insufficient insurance coverage, that could pose a barrier to completing screening.

3. Standardize the data format.

Suggested team member(s) responsible: Panel manager and care team.

Standardizing the data format and where it is entered is critical to ensuring accuracy in the resultant report. Once you know that a report can be produced, understand the specific data elements that are needed to produce the reports.

Document how each data element must be entered into the EHR in order to populate the fields needed for reporting. In some cases, data on completion of screening must be entered by hand (e.g., when the test is performed by a lab that does not communicate with the legacy EHR). Doing this will require a decision on the part of the practice as a whole and may require staff training and reinforcement on an ongoing basis. Where issues or apparent confusion are identified, regular discussion at team huddles or staff meetings will help in maintaining a standard approach.

Tip: Assign responsibility for the initial review of the reports to confirm data integrity.

4. Use the care gap reports in service to other workflows and improvement activities (e.g., assess and improve reliability in meeting well-child visit recommendations).

Suggested team member(s) responsible: Panel manager or data analyst.

A few examples include:

• At the patient level, the care gap report can be used for or linked with reminders or alerts for clinicians, as well as for sending reminders to patients who need to come into the clinic for screening or follow-up.
• Depending on communication preferences that have been expressed by patients, the patient care gap report may be exported to an automated reminder system that can trigger reminders by phone, text, email or mail.
• As part of the practice’s preplanning process, patient care gaps could be reviewed as part of the daily huddle. See Key Activity 5: Develop or Refine and Implement a Pre-visit Planning Process for more details.

FIGURE 7: EXAMPLE POPULATION CARE GAP REPORT ON IMMUNIZATION STATUS

5. Monitor the care gap report for accuracy and completeness.

Suggested team member(s) responsible: Panel manager or data analyst.

It is critical to have bidirectional feedback with the practice’s care team about any real or potential errors in the care gap report, such as:

• Errors in how the data is entered compared to what is required under the new standardized data format.
• Patients who are eligible for and due for screening who are missing from the report.
• Patients who have recently been screened who are still listed as due for a screening.

Errors should be investigated through a chart review. If errors in the report specifications are discovered, the care gap report or process for producing the report should be modified. If the issue is incorrect documentation, staff training and reinforcement of documentation standards will be required.

Additional consideration for sustainability: Ensure there is an internal process for updating the criteria included in the EHR for care gap reports as clinical guidelines change.

KEY ACTIVITY #4:

Use a Systematic Approach to Decrease Inequities

This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; implement condition-specific registries; proactive patient outreach and engagement; pre-visit planning and care gap reduction; care coordination; behavioral health integration; address social needs.

Overview

This activity provides guidance for a systematic evidence-based approach for identifying and then reducing inequities for children. It focuses on the first primary driver in PHMI’s equity approach: Reduce inequities for populations of focus.

FIGURE 8: PHMI EQUITY DRIVER DIAGRAM

Action steps and roles

1. Build the data infrastructure needed to accurately collect REAL, SOGI and other demographic data.

Suggested team member(s) responsible: Data analyst.

The PHMI Data Quality and Reporting Guide provides guidance and several resources for collecting this information. According to this guide, the initial step in addressing disparities is to collect high-quality data that fosters a comprehensive understanding of each patient. This entails incorporating race, ethnicity and language (REAL) data, demographic data (age, gender) and social needs data. By leveraging this information, healthcare practices can gain valuable insights into disparities in access, continuity and health outcomes." Steps two to four below provide more information on this process.

Collecting REAL information allows for practices to identify and measure disparities in care, while also ensuring that practices are able to interact successfully with patients. This is done by understanding their unique culture and language preferences.^[13] KHA Quality has a toolbox that assists with REAL data collection.

The Uniform Data System (UDS) Health Center Data Reporting Requirements (2023 Manual) provides detailed guidance on REAL and sexual orientation and gender identity (SOGI). Note: While UDS does not currently require that practices report on the specific primary language of each patient, practices should make an effort to identify and record each patient’s primary language, as UDS reporting still requires for languages other than English to be reported.

Accurate collection of data requires appropriate fields and options in the EHR and other employed technologies, as well as appropriate human workflows in collecting the data. Staff responsible for data collection should be continuously trained and assessed for best practices in data collection, including promotion of patient self-report.

In addition, practices should work to ensure that patients understand the importance and use of this information to help them feel comfortable supporting its collection. Example language can be found at The MGH Disparities Solution Center. High rates of “undetermined” or “declined” in these fields may be indicative of the need to attend to these staff training needs.

Collecting this data is important, especially to obtain a complete picture of health for patients who identify as transgender. There are certain risks and condition indicators that are gender-specific, which impact how care teams provide care to a patient. By understanding the needs of patients more fully, care teams can make more informed decisions for the best treatment of their patients. The World Professional Association for Transgender Health (WPATH) has provided further guidance regarding standards of care related to gender diversity.

2. Use the practice’s EHR and/or population health management tool to understand inequitable health outcomes at your practice by stratifying your data.

Suggested team member(s) responsible: Data analyst.

This includes reviewing your care gap report or care registry and being able to stratify all of the following:

• Core measures for the population of focus.
• Supplemental measures for the population of focus.
• Process measures for the population of focus.

Stratify this data by:

• Race, ethnicity and language (REAL).
• Sexual orientation and gender identity (SOGI), when possible.
• Other factors that can help identify subpopulations in need of focused intervention to reduce an equity gap (e.g., immigrants, people experiencing homelessness, etc.).

This is not a one-time event, but rather a continuous process (see step 13 below) and should be done in tandem with step three below.

Consider reviewing data on disparities at the state and health plan level for greater context.

You might not have enough sample size in some REAL categories to identify whether a trend is significant or not. If you’re seeing something in your patient population, you can examine other known data sources, such as a recent state health disparities report, for context.

3. Screen patients for social needs.

Suggested team member(s) responsible: Care team.

Key Activity 7A: Develop a Screening Process for Social Needs and Adverse Childhood Experiences (ACESs) that Informs Patient Treatment Plans provides guidance on screening patients for health-related social needs and how the information can begin to be used to inform patient treatment plans, including referral to community-based services. This is not a one-time event, but rather a continuous process and should be done in tandem with step two above.

4. Analyze the stratified data from steps two and three to identify patterns of inequitable outcomes.

Suggested team member(s) responsible: Data analyst, QI leads, care team.

Analyze the stratified data from steps two and three to identify patterns in inequitable outcomes.

This includes:

• Utilizing tools to examine, visualize and understand disparities across different populations or subpopulations.
  • Data over time (using run charts).
• Exploring trends, patterns and significant differences to understand which demographic groups will require a focused effort to close equity gaps.

Update your practice’s measurement strategy so your practice’s improvement efforts remain centered around advancing equitable outcomes. Some examples include creating specific, measurable, achievable, relevant, time-bound, inclusive and equitable (SMARTIE) goals and updating your process and outcome measures so you can understand differences by REAL or SOGI indicators. See Appendix C: Developing a Robust Measurement Strategy for more.

This is not a one-time event but rather a continuous process (see step 13 below). Periodic review of stratified data allows for recognition of gap closures and emergence of new disparities.

5. Use a root cause analysis to identify improvement approaches for subpopulations with lagging health outcomes.

Suggested team member(s) responsible: Implementation team.

Select root cause analysis approaches that work best for the equity gap you are closing:

• Engage and gather information from patients affected by the health outcome in your root cause analysis (see step six).
• Brainstorming.
• Systems thinking (understanding how interconnected social, economic, cultural and healthcare access factors may be impacting the health outcome).
• Tools that rank root causes by their impact and the feasibility of addressing them (e.g., prioritization matrix and/or an impact effort matrix).
• Visual mapping of root causes and effects (e.g., fishbone diagram).
• Perform focused investigations into selected root causes, gathering qualitative data through interviews, surveys or focus groups with the subpopulation of focus.

Present the findings to a broader group of stakeholders to validate the identified root causes and gain additional insights. Incorporate their feedback and refine the analysis, as needed.

6. Partner with patients to build successful strategies addressing inequitable outcomes.

Suggested team member(s) responsible: Care team and people with lived experience (patients representative of the population(s) of focus).

Using one or more human-centered design methods, such as focus groups, Journey Mapping, etc. (see links to these methods below), and engage patients to better understand perspectives that may influence the health outcome of interest. This may include collecting information on:

• Their assets, needs and preferences.
• Cultural beliefs, including traditional healing practices.
• Level of trust in healthcare generally and in the topic of focus specifically (e.g., immunizations, behavioral health, etc.).
• Barriers to accessing care.
• Barriers to remaining engaged in care.
• Trusted sources of information or communication mechanisms for this population.
• Their ideas for improving health outcomes.

The patients you partner with for this and other steps in this key activity may be part of a formal or informal patient group and/or identified and engaged specifically for this equity work. Fairly compensating patients for participating in improvement activities is a best practice.

Selected resources on human-centered design and co-design:

• Center for Care Innovations (CCI) Human Centered Design Curriculum via CCI Academy.
• IDEO’s Field Guide to Human-Centered Design.
• IDEO’s Design Kit: Methods.

7. Develop strategies that address or partially address the identified equity gaps.

Suggested team member(s) responsible: Care team and people with lived experience.

Based upon the insights your practice has developed for a population of focus and your root cause analysis, determine which of the key activities this guide could address or partially address the equity gap.

Most of the activities in this guide either explicitly address an equity challenge or can be adapted to better address an equity challenge. Examples of activities that can be adapted to reduce identified equity gaps include but are not limited to:

• Key Activity 9: Proactively Reach Out to Patients Due for Care.
• Key Activity 7A: Develop a Screening Process for Social Needs and Adverse Childhood Experiences (ACEs) that Informs Patient Treatment Plans, such as providing a referral for one of the Medi-Cal Community Supports.
• Key Activity 11: Coordinate Care.
• Key Activity 15: Strengthen Community Partnerships.

If one or more of your root causes cannot be addressed fully through key activities in the relevant implementation guide, use one or more human-centered design methods to develop ideas to improve health outcomes and reduce inequities among this population.

Developing these ideas is best done with representatives of the population of focus, as they have expertise and experience that may be missing from the practice's care team. During this brainstorm, you are developing ideas without immediate judgment of the ideas in an effort to generate dozens of potentially viable strategies.

8. Determine which strategies to test first.

Suggested team member(s) responsible: Care team and people with lived experience.

There are many ways to prioritize ideas. The Institute for Healthcare Improvement (IHI) often recommends a prioritization matrix and/or an impact effort matrix and offers a video on making them.

If you have organized your key activities and new ideas into themes or categories, you may choose to work on one category or select one or two ideas per category to work on.

The number of key activities and/or new ideas that you prioritize for testing first should be based on the team’s bandwidth to engage in testing. It is critical to determine the bandwidth for the team(s) who will be doing the testing so that you can determine how many ideas to test first.

9. Use quality improvement (QI) methods to begin testing your prioritized key activities and new ideas.

Suggested team member(s) responsible: Care team and people with lived experience.

Nearly all the key activities and all of your new ideas will require some degree of adaptation for use within your practice and to be culturally relevant and appropriate to your patient population.

Use plan-do-study-act (PDSA) cycles, generally starting as small as feasible. Think “ones” (e.g., one clinician, one hour, one patient, etc.) and become larger as your degree of confidence in the intervention grows.

Whenever testing a key activity or new idea, we recommend that the practice:

• Use plan-do-study-act (PDSA) cycles to test your ideas and bring them to scale. See more information on PDSAs below in the tips and resources section.
• Generally, start with smaller scale tests (e.g., test with one patient, for one afternoon, in a mailing to 10 patients, etc.). Use the chart titled “How Big Should My Test Be?” below in the tips and resources section to help you decide what size test is most appropriate.

Develop or refine your learning and measurement system for the ideas you are testing. A simple yet robust learning and measurement system will help you understand improvements, unintended secondary effects, and how implementation is going.

By working out the inevitable challenges in the idea you are testing using a smaller scale PDSA cycle, the improvement activity will ultimately work better for patients and be less frustrating to the care team. Testing and refining also can eliminate inefficient workarounds that occur when a new process or approach is imposed onto an existing system or workflow.

Select resources on quality improvement (QI):

• Institute for Healthcare Improvement’s (IHI) QI Essentials Toolkit, including details on:
  • Cause and effect diagrams.
  • Driver diagrams.
  • Failure modes and effects analysis.
  • Flowcharts.
  • Histograms.
  • Pareto charts.
  • PDSA worksheet.
  • Project planning forms.
  • Run charts.
  • Scatter diagrams.
• IHI’s Videos on the Model for Improvement (Part one and Part two).
• Rapid Experiments to Improve Healthcare Delivery.
• CCI’s ABC's of QI via CCI Academy.

10. Implement – bring to full scale and sustain – those practices that have proven effective.

Suggested team member(s) responsible: Care team.

Once an idea has been well tested and shown to be effective, it is time for your practice to hardwire the idea, approach or practice into your daily work. Consider using the MOCHA Implementation Planning Worksheet to think through:

• Measurement.
• Ownership.
• Communication (including training).
• Hardwiring the practice.
• Assessment of workload.

Sometimes implementation may require that you update your protocol and/or policies and procedures for the populations of focus.

11. Once you have tested, refined and scaled up the initially prioritized ideas, begin testing other ideas.

Suggested team member(s) responsible: Care team and people with lived experience.

This might include going back to the ideas developed previously but not prioritized and/or going back through the testing steps above to develop and prioritize new ideas and potentially for additional populations of focus.

12. Put in place formal and informal feedback loops with patients and the care team.

Suggested team member(s) responsible: Care team.

Establishing formal and informal feedback loops regarding new processes will ensure that your practice’s ideas are meeting the needs of patients and are reducing identified equity gaps. These feedback loops also ensure the changes are feasible and sustainable for your practice.

For patients, feedback loops could be created using many of the human-centered design tools used to design your improvement activity (e.g., surveys, interviews, focus groups). Feedback loops should also involve the patient satisfaction survey and grievance processes. Consider establishing a standing funded patient advisory board that is available to design, implement and evaluate all of your practice’s improvement activities.

For the care team, feedback loops might include:

• Existing or new staff satisfaction and feedback mechanisms.
• Regularly scheduled meetings and calls to obtain staff feedback on processes, methods and tools. Leverage existing meetings to mitigate staff burnout.

13. Continually analyze your data to determine if your efforts are closing equity gaps.

Suggested team member(s) responsible: Care team.

This includes regular (at least monthly) review of the key stratified measures from your measurement strategy. Share the data with patients to both show your work to decrease known equity gaps and to solicit ideas for closing them.

KEY ACTIVITY #5:

Develop or Refine and Implement a Pre-Visit Planning Process

This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; pre-visit planning and care gap reduction; care coordination; address social needs.

Overview

This key activity provides guidance for how the care team can effectively and efficiently embed preventive care measures into the practice’s pre-visit planning process (PVP). Pre-visit planning is typically driven by the medical assistant with help from other care team members and includes steps taken:

• At the end of the current visit to ensure the patient understands any actions they need to take and to schedule for any follow-up.
• Prior to a scheduled appointment, to scrub the chart and identify any pre-visit tasks per the pre-visit checklist.
• The day of an appointment, during the daily huddle and before the patient sees the PCP.

Action steps and roles

1. Assess the current state of the pre-visit planning (PVP) process across your practice.

Suggested team member(s) responsible: Implementation team or QI team.

Understand how the process currently works, for all visit types (e.g., scheduled, same-day, virtual), in light of your practice’s performance on core and supplemental measures.

Compile existing paperwork and process documentation about each visit type into one place and talk to medical assistants and other members of the care team to understand their questions and challenges around the pre-visit planning process.

Consider making current-state process maps for each visit type that communicate the major steps in the PVP process and acknowledge pain points or kinks in the process. Pain points are places where the process isn’t working well for patients, staff, or specific subpopulations or demographic groups for which your data analysis has revealed equity gaps. These pain points also likely differ by visit type. In addition, pay attention to places where staff are creating workarounds to the process. The presence of workarounds indicate that the process might need further clarification or refinement to support the care team to reliably implement it.

Your team may find it helpful to compile process maps for both the high-level pre-visit planning, as detailed in figure 6.1 of the PHMI Care Teams and Workforce Guide Resource 6: Workflow Examples, in addition to more detailed documentation for specific clinical workflows.

2. Identify where to update the PVP process to more consistently and reliably address care gaps.

Suggested team member(s) responsible: Implementation team or QI team; may include the data manager to assist with identifying patients through EHRs.

Examine where you can further incorporate or streamline your practice’s clinical protocols and standing orders into PVP, including via the PVP checklist, daily huddles, and other key clinical workflows.

This may include the following discussion points:

• Who will initiate the discussion with the patient based on the needs (e.g., primary language) and preferences of the patient.
• How and when they will plan to have the discussion during the visit.
• How they will be prepared to address any barriers.
• Educational materials available for use that are relevant to the patient.

Examples and considerations for updating the PVP process are included below.

Clinical guidelines and care gaps: Consider which preventive and maintenance services could be addressed more reliably using PVP, including those in your EHR’s care gap module. The Pre-Visit Planning: Leveraging the Team to Identify and Address Gaps in Care resource provides a more complete list of preventive services for adults and children. Figure 10 provides an example of how your EHR might be able to support flagging patients overdue for specific preventive services

FIGURE 10: PRE-VISIT PLANNING REPORT DETAILING OVERDUE SERVICES FOR AN ADOLESCENT

PVP checklist: A generic PVP checklist to be completed by the medical assistant (MA) or LVN at least one to three days before the appointment is provided in Figure 11. Most EHRs will have a health maintenance module that identifies what preventive care is due, but a printed or digital checklist provides a starting point for ensuring key steps aren’t missed.

FIGURE 11. PVP PLANNING CHECKLIST ITEMS TO ADD FOR PEDIATRICS

Chart scrub: An example chart scrub process led by the MA or LVN as part of PVP for completing open orders is detailed in Figure 12.

FIGURE 12: EXAMPLE CHART SCRUB PROCESS FOR OPEN ORDERS

Daily huddles: Design or redesign the team’s daily huddle so the care team can review prioritized action items for the list of patients scheduled to come and any further follow-up for patients seen in the previous days. For more information, see Care Team Daily Huddle Process.

The Centers for Excellence in Primary Care resource on Healthy Huddles includes tools, a video, and examples around how pre-visit planning flows into the daily huddle process, including a “Healthy Huddles Warm-Up,” which can help MAs prepare for huddles.

Patients requiring special considerations: Ensure that the PVP includes a process to flag for the care team:

• Patients requiring special attention, such as those with chronic conditions, complex needs, and recent ED visits or hospitalizations, or who are in foster care.
• Patients who need extended time or additional services during their visit (e.g., multiple vaccinations needed, translation services, mobility assistance, and screenings).

Detailed clinical workflows: Clinical workflows should be updated to describe at which step in the PVP or the patient visit a care team member will address a specific gap in care with the patient.

FIGURE 13: EXAMPLE WORKFLOW FOR SCREENING FOR ADVERSE CHILDHOOD EXPERIENCES

This example workflow for ACEs screening depends on reception staff and MAs and LVNs as core team members for ensuring the patient gets screened when they are in-office and facilitating referrals afterwards.

Planning for care after the visit: Effective PVP includes scheduling pre-visit labs and other diagnostics at the end of the current visit and care coordination for referrals for services not available at the practice. See Key Activity 11: Coordinate Care for more information. Confirm that the patient understands the purpose of any follow-up care. Ensure that the appropriate after-visit summary has been provided at the conclusion of the visit.

Example: Marin Community Clinics has their hospital-based Comprehensive Perinatal Services Program (CPSP) workers schedule both the newborn visit and three-week appointment with the PCP before the birthing person and baby are discharged from the hospital. Medical assistants have been trained to recognize this workflow to avoid confusion that could lead to mistakenly canceling the three-week appointment. If the newborn visit is kept, subsequent appointments are scheduled before the patient checks out. If the appointment is missed, medical assistants follow a missed appointment workflow. The encounter is labeled as “Well-Check No-Show” and categorized as high-risk.

Tip: The American Medical Association (AMA) has an online guide for implementing pre-visit planning, which includes forms, templates and other resources. Limited published literature on the effectiveness of pre-visit planning in the pediatric setting exists, however Samaan, et al. published this study in Pediatrics in 2016: Implementation of a preventive services bundle in academic pediatric primary care centers.

3. Test planned changes to the PVP workflows and support care teams in implementing the workflow.

Suggested team member(s) responsible: Implementation team or QI team.

Test and refine important changes to the PVP process with one or two care teams before considering rolling out the change more broadly at the practice.

Implementing the change includes updating documentation and creating a staff training schedule or “training refresher” for staff to sustain workflow changes. For example, train MA's every 6 months on the PVP. If they have difficulty, have them retake training with a different highly effective MA and monitor closely until competency in the task is reached.

Tip: Develop staff training and talking points on how to communicate about the importance of vaccinations. See more in Key Activity 9A: Providing Caregiver Support to Overcome Vaccine Hesitancy.

4. Establish a process to review and update PVP workflow.

Suggested team member(s) responsible: Care team with quality improvement manager.

Identify staff responsible for reviewing and updating the PVP process at least annually to incorporate the latest clinical guidelines and check for any workarounds that have developed.

KEY ACTIVITY #6:

Develop and Implement Standing Orders

This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; pre-visit planning and care gap reduction.

Overview

A standing order is a pre-approved clinician order to perform a specific intervention for any patient who meets the criteria for the order and is used when the step in the workflow specifically requires the order of a qualified clinician. Standing orders describe the action to be taken and identify who on the care team is authorized to complete the order. Standing orders are designed to enable care team members other than the primary care provider (PCP) to initiate specific clinical actions to provide timely screening and care, provided that specific criteria are met. Common standing orders include preventive measures, such as immunization, to be prepared for, or potentially conducted ahead of the clinician’s time with the patient.

To limit the potential for errors and ensure patient safety, standing orders should be carefully designed, regularly reviewed and revised as necessary. They should be based on evidence-based recommendations and best practices, and they should have broad support from the medical director, practice manager, physicians and other staff. Assessment of current attitudes and strategies to respond to them should inform the testing and adoption process. For more discussion of these matters, see the AAP publication Use of Standing Orders for Vaccination Among Pediatrics. In addition, standing orders should outline the criteria for initiating, modifying or discontinuing a particular course of action or treatment for a patient.^[15]

Action steps and roles

Outlined below are the actions and steps required to create standing orders and are adapted from the University of California, San Francisco (UCSF) Center for Excellence in Primary Care.^[16]

1. Review and understand the latest clinical guidelines for the required standing order and your practice’s already established protocols.

Suggested team member(s) responsible: Quality improvement lead and panel manager, data analyst, or medical director (or equivalent).

Standing orders for recommended immunizations are based on the CDC Child and Adolescent Immunization Schedule by Age.

For some vaccines, clinics need to pay careful attention to how the standing orders are generated. For example, vaccines for diseases such as rotavirus follow a specific timeline; if kids don't receive their first vaccine by a certain age, they are no longer eligible for the vaccine. For other diseases, such as hepatitis A, the vaccine doses must be given six months apart. Additionally, patients who are following a modified or catch-up schedule will receive immunizations on a different timeline than those who are receiving them on the standard recommended timeline.

Consider creating standing orders for additional well-care visit activities (e.g., the periodicity schedule). Some screenings, such as postpartum depression screening, do not require a physician order and are often integrated into clinic workflows and pre-visit planning without utilizing standing orders. However, the distinction between a standing order and a protocol can have different meanings and implications for different teams, so there are instances where practices find it useful to create standing orders for these screenings as a way to support the care team to provide evidence-based care.
 

2. Translate the appropriate clinical guidelines into a standing order.

Suggested team member(s) responsible: Panel manager or data analyst.

The standing order will follow the relevant clinical guidelines and be updated whenever clinical guidelines are updated. It will generally allow the following:

• Registered nurses (RNs) and/or medical assistants (MAs) with proper training may initiate the agreed upon standing order process when patients meet the agreed upon criteria for initiating screening, and do not have any clinical history that may require a PCP to address the concern.
  • Tip: Verify if carrying out standing orders falls within the legal scope of practice for the supportive clinical staff intended to carry them out.
• This may include initiating an order, initiating a referral or notifying the PCP of the need for screening and testing.

Immunize.org has an array of resources for developing and implementing standing orders for use in pediatrics. Many materials on the site can be adapted for other types of standing orders.

In addition to the written standing order, the practice should develop a process map or update other documentation outlining how and when the standing order is to be implemented in the practice’s current workflows.
 

3. Obtain approval for standing orders from clinical leadership.

Suggested team member(s) responsible: Panel manager or data analyst and medical director (or equivalent).

For the standing order to be valid and in effect, it must be approved by clinical leadership at the practice, signed by a designated valid signatory (e.g., medical director or other physician) and dated, and it must include the effective date for the standing order. Practices should consider including an expiration date and flagging this date in their system to help ensure that the standing order is reviewed and updated regularly. As the clinical guidelines change or other components are updated, the standing order should be signed and dated again by the appropriate party with an effective date for the revision.
 

4. Train practice staff on how to use standing orders and include this training in clinical onboarding of new staff.

Suggested team member(s) responsible: Medical director or equivalent.

It is critical that practice staff, both those directly named in the standing order and other members of the care team, receive training on the use of this standing order. Such training should include a thorough review of the written standing order and ensure that practice staff understand all of its aspects, including the associated workflow and any additional materials related to the workflow, such as patient education or instructional materials, that include nuances that the care team will need to understand.
Training should be provided on each standing order at least annually, retraining should be provided before the effective date on any revisions, and the training should be part of the orientation for all new members of the practice care team.

Based on feedback from the staff, the standing order can be refined to make the instructions clearer (e.g., during training several staff members were confused by a specific instruction, indicating that the instruction needed to be revised).
 

5. Institute mechanisms to ensure the proper use of the standing order and its effectiveness.

Suggested team member(s) responsible: Clinical director or equivalent or their designee.

It is likely that one or more aspects of the standing order will not work as planned. For example, the practice’s workflow may not fully support the standing order, the wording may be confusing to one or more staff members, or the standing order’s protocol may not be regularly followed exactly (e.g., staff are using workarounds). The practice should routinely check for these and other common challenges and revise and update the standing order as needed to ensure that it works for the practice and meets all applicable regulations and guidelines.

Complete an annual review of the immunization schedule, WCV activity, and key screenings recommendations to ensure standing orders align with the most up-to-date recommendations from the American Academy of Pediatrics and the Centers for Disease Control and Prevention.

KEY ACTIVITY #7:

Attend to Social and Emotional Development in WCVs

This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; behavioral health integration; address social needs.

Overview

This activity outlines how practices can support social and emotional development of their patient population, as well as screen for and respond to children with social and emotional development needs.

Action steps and roles

1. Review current practices to identify key opportunities for improvement.

Suggested team member(s) responsible: QI lead and staff.

Catalog and map the clinic and healthcare team’s current practices and processes related to social and emotional development support, screening and referrals.

Also examine staff’s current comfort with knowledge, tools and communication about social and emotional development.
 

2. Identify materials and resources for educating about and supporting healthy social-emotional development in childhood.

Suggested team member(s) responsible: Staff.

Review existing materials and explore new sources for educating families about social and emotional development. Select and test materials and resources with a small number of families.
 

3. Identify social and emotional development screening tools and processes.

Suggested team member(s) responsible: QI lead with staff and families.

Review currently used tools and consider exploring new or other tools for screening social and emotional development during well-child visits (WCVs). Select and test tools with a small number of families. Bright Futures provides a list of links to tools for use at specific Bright Futures visits, as well as screening and assessment tools for use at the discretion of the health care professional: Bright Futures Developmental, Behavioral, Psychosocial, Screening and Assessment Forms.

Please note that some of the tools provided in the link above are free to use. Others, such as the Ages and Stage Questionnaire: Social-Emotional (ASQ:SE-2), require a nominal fee. Again, as mentioned above, Bright Futures has also developed age-specific pre-visit questionnaires for ready adoption, freely, readily accessible online.
 

4. Develop standard processes for incorporating social and emotional development education, screening and referrals during WCVs.

Suggested team member(s) responsible: Care team.

Test adaptations to current practices and processes to work towards high-quality social and emotional development education, screening and referrals during every WCV. Depending on the need, referral sources range from behavioral health clinicians, development pediatricians, speech and language therapists, early intervention, and the local school system. Having an accessible list of contact information for these resources is an important first step for developing a closed loop referral process. Consider testing different versions of who does what, where, when and how. Create and adapt a process map to standardize and optimize workflow.
 

5. Focus on the medical care team.

Suggested team member(s) responsible: Director.

Ensure that the medical care team is comfortable addressing socioemotional development education, screening and referrals. Support the care team with education, training and practice delivering sensitive information and supporting parents. Engage behavioral health colleagues who are trained in pediatric care to aid in this work.

KEY ACTIVITY #7A:

Develop a Screening Process for Social Needs and Adverse Childhood Experiences (ACEs) that Informs Patient Treatment Plans

This key activity involves all seven elements of person-centered population-based care: behavioral health integration; address social needs.

Overview

This activity provides guidance on screening for health-related social needs and adverse childhood experiences (ACEs) and for beginning to use the data to inform patient treatment plans, including referral to community-based services.

Social needs are defined as individual material resources and psychosocial circumstances required for long-term physical and mental health and well-being, such as housing, food, clean water and air, sanitation and social support. ACEs are the potentially traumatic events that occur before the age of 18 years and are associated with toxic stress that can contribute to adverse health and social outcomes.^[21] More specifically, the term ACEs refers to ten categories of adversities across three domains identified in the landmark 1998 study by the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente.^[22][23]

There is not yet consensus or uniform endorsement regarding screening for social needs, due at least in part to a lack of high-quality evidence on the risks, benefits and best practices of screening and response.^[24] The AAP/Bright Futures currently includes select social needs in its recommendations. Findings from the recent Centers for Medicare and Medicaid Services (CMS) Accountable Health Communities (AHC) Model indicate that the social needs screening and navigation services reduced ED utilization and may have reduced expenditures but did not appear to increase patient’s connection to community services or resolve the patient’s social needs.^[25] Other possible ways social needs screening can support attending to social needs include strengthening the patient-provider relationship,^[26] destigmatizing social services, tailoring care, and – at a population level – increasing social investment.^[27]

Screening for ACEs is neither a recommendation of Bright Futures nor USPSTF. However, California Medi-Cal providers can be reimbursed for ACEs screening when they first complete a mandatory two-hour training. Additionally, DHCS encourages providers to conduct ACEs screening.

Action steps and roles

1. Select one or more validated, standardized screening instruments to use and establish how screening results are documented.

Suggested team member(s) responsible: Clinical leadership.

Pick standardized screening tools that fit your organizational environment and the context of your patient population.

• For health-related social needs, the Social Interventions Research and Evaluation Network (SIREN) conducted a review of social needs screening tools and provides a comparison and search tool for different tools for children including Income, Housing, Education, Legal Status, Literacy, Personal Safety (IHELLP) Questionnaire, Safe Environment for Every Kid (SEEK), Survey of Well-being of Young Children (SWYC) and WeCare, as well as tools that are nonspecific to an age including Protocol for Responding to and Assessing Patients’ Assets, Risks and Experiences (PRAPARE), the screening toolkit by Health Leads and several others. The Center for Child Health Policy and Advocacy at Texas Children’s Hospital also has a helpful guide comparing and selecting a screening tool for a pediatric setting.
• For ACEs, consider using a Medi-Cal qualified screener like Pediatric ACEs and Related Life-events Screener (PEARLS) provided for the caregiver for ages zero to 19 years and/or the patient for ages 12 to 19.

Work with your clinical informatics team to determine how staff will document screening results in your EHR. Consider documenting the results of screening for ACEs in a structured EHR field to facilitate reporting and trending at the practice level. Additionally, since screening for ACEs is reimbursable by both Medi-Cal and California commercial health plans since the passage of S.B. 428, ACEs Equity Act (CA 2021), providers should submit the appropriate billing code for reimbursement and to fulfill Medi-Cal managed care reporting requirements to DHCS. Specifically, HCPCS Code G9919 is used when screening yields an ACE score of four or higher; G9920 is used when the ACE score is between zero and three. Some EHR systems have screening tools already embedded and many are moving quickly to incorporate screening; some EHRs may be able to auto-populate Z codes based on screening results. Your managed care plans may offer additional guidance or support and can be a resource to connect your practice to other organizations who have experience with screening instruments and technology tools. By using the same screening tools and/or information technology platforms, the consistency and quality of care delivery can be enhanced.

For the patient’s problem list for health-related social needs, DHCS provides a list of 25 Priority Social Determinants of Health (SDOH) Codes to focus on. This shorter list of codes is intended to capture areas where the health system may have the greatest impact on identifying and addressing social needs.

2. Understand resources and community referrals for positive social needs screens.

Suggested team member(s) responsible: Referral manager, community health workers.

Through CalAIM, the California Department of Health Care Services (DHCS) has taken steps to ensure that Medi-Cal members have access to social support that can impact health outcomes. Connect with your managed care plan (s) (MCPs) and regional area consortia to understand what services and resources they have in place to support patient access to community-based social services. Many MCPs are developing relationships with social services agencies to meet the needs of their members. For Medi-Cal members with the highest level of social needs, MCPs offer Enhanced Care Management (see Key Activity 19: Provide Care Management) and some or all of 14 Community Supports: these provide resources to address social needs such as housing navigation, recuperative post-hospitalization care, and medically tailored meals. Some MCPs use the new CalAssist tool for Medi-Cal members to self-identify whether they are eligible for any of the 14 CalAIM Community Supports and generate a referral to the applicable provider.

Many patients will screen positive for social needs and will benefit from connection to resources that are not part of Community Supports. Contact your MCP to see if they have established relationships with providers who connect individuals to social services. Health plans may contract with an online provider or with a social services network lead entity that can connect you with existing community-based organizations and public agencies in the area. These contracted services will often include a process for making closed loop referrals, where the referring provider is notified if the patient has successfully accessed the referral. Closed loop referrals are a best practice in care coordination that leads to higher levels of patient and provider satisfaction.^[33]

Key services to catalog include nutrition assistance, employment readiness, childcare support, postpartum paid family leave, rent and utility assistance, and resources for transportation. Other places to look to build sources for local community referrals include:

• Your current social work staff and/or community health workers, who may have many go-to resources already identified.
• Free online aggregators for local community services in California such as findhelp.org.
• 2-1-1, a free telephone number providing access to local community services for housing, utility, food and employment assistance.
• Resource networks maintained by a local hospital or larger health system in your area.

For going deeper in this area, practices can consider prioritizing quality improvement activities that establish new or previously underutilized community resources to address specific social needs as part of your systematic approach to decrease inequities. See Key Activity 4: Use a Systematic Approach to Decrease Inequities for more information. Case studies provided in the resources linked below provide examples these improvement initiatives.

3. Establish a workflow for screening and referrals.

Consider screening before the patient meets with the PCP and have a workflow in place for follow-up of positive screen (e.g., meet with the care coordinator or care management staff who will facilitate referral). Take steps to flag the positive screen so the PCP is aware and can address any positive screen during the visits.

Train staff in the new workflows and how to provide trauma-informed screening. Several resources are provided below. Staff often initially resist screening if there is a sense they feel they don’t have the tools to help address positive screens.

Following screening, ask patients for their prioritized need and whether they would like assistance before making a referral. Providing a written script for staff and accompanying signage can build confidence in dealing with the challenging circumstances many patients experience.

4. Provide person-centered care that acknowledges social needs.

Suggested team member(s) responsible: PCPs, expanded care team.

Information about a patient’s social needs and ACEs can be used to provide tailored, person-centered care and treatment plans that patients are more likely to follow and benefit from. For example, if a patient and their family screen positive for food insecurity, that could influence details around advice given for healthy weight management.

ACEs Aware offers two asynchronous online courses as well as periodic live recorded webinars for safety net organizations to screen for ACEs and treat toxic stress.

In developing shared plans of care, use trauma-informed ways of engaging patients in their own care, including developing shared goals, providing self-management support, and using communication techniques such as motivational interviewing. See Key Activity 10: Implement Trauma-Informed Care Approach Across the Patient Journey.

The desires and goals of the patient will inform how and when to move ahead in addressing social needs. It is important to support patients through motivational interviewing and trauma-informed practices to create a person-centered care plan. Having processes in place to support ongoing person-centered care planning, such as a warm handoff to a care coordinator or a documented plan to follow up on issues discussed at the next visit, will help to build trust and support connection to community referrals when the patient is ready.

KEY ACTIVITY #8:

Provide Dyadic Care: Screen for Postpartum Depression

This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; pre-visit planning and care gap reduction; behavioral health integration.

Overview

California created a dyadic services Medi-Cal benefit effective January 2023. The dyadic services benefit allows Medi-Cal to cover behavioral health and wellness visits that focus on the individual child and their surrounding environment, including caregiver wellness, all within the context of the child’s medical appointment. Dyadic services provide reimbursement for evidence-based health promotion and primary prevention supports that can be brief in duration. Covered behavioral health services include screening for behavioral health problems, interpersonal safety, tobacco and substance misuse, and health-related social needs and referrals for appropriate follow-up care.

This foundational activity provides guidance on screening for postpartum depression (PPD) in a pediatric setting. Currently, the American Academy of Pediatrics (AAP) recommends that pediatric care providers screen mothers for postpartum depression at the infant's one-, two-, four-, and six-month well-child visits (WCVs). Repeated screening at these visits allows for a birthing person who may not be comfortable disclosing initially to do so at a later visit, and it maximizes the opportunity to engage a dyad that may miss one or more of the recommended well-infant visits. AAP also recommends use of community resources for the treatment and referral of the birthing person with depression and providing support for the maternal/child dyad relationship, including breastfeeding support. Of note, some advocates are encouraging screening the partner for postpartum depression as well.

Action steps and roles

1. Understand current recommendations for perinatal depression screening compared to the baseline screening rate.

This 2019 article in the American Academy of Pediatrics includes the current recommendations.

Establish a baseline by assessing the current PPD screening rate compared to the guideline (e.g., PPD screening was documented at 63% of the visits at one to six months). If these data are not available in a format amenable to a care gap report, consider gathering data prospectively by tracking how often PPD screening occurs during recommended visits over the next two to four weeks).

2. Flag all eligible patients for postpartum depression screening and administer screening.

To screen for depression, consider:

• During pregnancy: Patient Health Questionnaire-2 (PHQ-2) or Patient Health Questionnaire-9 (PHQ-9). (PHQ-2 In Spanish; PHQ-9 in Spanish.)
• During postpartum: Edinburgh Postnatal Depression Screen (EDPS). (EPDS in Spanish). Note this is included in some pediatric screening tools, including SWYC.

Care teams may administer depression screening in various ways: verbally by rooming staff, by paper screener at check-in, virtually through tablets at check-in, or as part of a pre-visit screening packet sent via text or email. Regardless of the method, clinic teams must have a process for reviewing the results in a timely fashion on the day of the visit and initiating the next step in the workflow, namely: if the score is positive, the rooming staff would hand off information to the medical or behavioral health staff.

Resources for empathic, trauma-informed screening and responding to positive screens are provided below:

• Postpartum depression and anxiety: How to start the conversation from the AAP.
• Empathic Connections: Follow-Up Conversations on Sensitive Screens.

3. Support access to postpartum mental health services.

If screening results are positive, the pediatric care provider can conduct an assessment or bring in a member of the behavioral health team to do an evaluation and discuss appropriate timing of the best next steps, including combination of the following:

• Watchful waiting.
• Behavioral health referral.
• Medication management.

Ensure staff can activate an immediate suicide risk assessment and response protocol, as needed, for patients with identified suicidal ideation, significant risk of harm to self and/or others, or psychosis. The PHMI People with Behavioral Health Conditions Guide provides more information about implementing a suicide response protocol.

Under the Medi-Cal dyadic care benefit, the caregiver does not need to be enrolled in Medi-Cal or have other coverage, so long as the care is for the direct benefit of the child. This benefit includes services provided to the caregiver during a child’s visit including brief emotional and behavioral assessment, depression screening, and psychiatric diagnostic evaluation. Other relevant dyadic benefits for postpartum depression include dyadic comprehensive community supports services to help the caregiver gain access to needed services and family therapy to improve parent/child relationships and encourage bonding, resolve conflicts, and create a positive home environment.

Case example: In response to a review of their practice’s data showing Hispanic patients were less likely to be screened for maternal PPD, a pediatric practice developed a campaign to better support these patients. Educational materials were created in Spanish to address frequently asked questions and concerns about depression and the need for depression screening, especially during the prenatal and postpartum periods. The screening workflow was altered, so the educational materials were provided alongside the paper screening tool when patients and their families checked in for their appointments. To improve reliability, the practice decided to administer the tool for all visits for children aged one to six months, including both WCVs and sick visits. Care teams were retrained on the process for PPD screening and referrals, including how to respond empathically to achieve positive results.

KEY ACTIVITY #9:

Proactively Reach Out to Patients Due for Care

This key activity involves all seven elements of person-centered population-based care: proactive patient outreach and engagement, pre-visit planning and care gap reduction.

Overview

Conducting proactive outreach can ensure patients follow through on recommended care. Outreach activities for the pediatric population will almost always be directed towards the parent, legal guardian, or foster parent or caregiver. There may be incidences where a practice outreaches to an older teen, but that would depend on individual or unique circumstances.

As part of pre-visit planning (PVP) and other clinical workflows, your practice should be conducting some level of outreach to provide patients with information they may need to prepare for upcoming visits or engage in follow-up care plans determined during the visit. In addition, most electronic health records (EHRs) can be integrated with an automated reminder system for upcoming appointments and for patients who appear to have gaps in care. Patient outreach also occurs as a part of care coordination, especially around supporting patients to engage in external referrals and in follow-up to a hospital admission or discharge. See Key Activity 11: Coordinate Care for further information.

Proactive outreach to patients due for care focuses on identifying subpopulations among the patients assigned to a care team that may benefit from additional outreach and implementing more personalized reminders and touches for them to engage in care. Of note, multiple outreach modalities exist, including but not limited to phone, text, mail, email, and patient portal, and different modalities may be preferred or more effective with different subpopulations. Consider learning from others (e.g., research, campaigns, AAP recommendations), from your practice’s own experience and from testing various approaches in your QI work.

Outreach to people who are not yet actively engaged in care goes beyond this foundational activity. See going deeper Key Activity 15: Strengthen Community Partnerships for more about identifying trusted messengers in your community.

Action steps and roles

1. Identify subpopulations who may benefit from outreach.

Suggested team member(s) responsible: Population health staff, care managers, data analysts, community health workers.

• Start with frequent no-show patients and seek to understand their root causes, which may be related to social health-related needs or health literacy issues.
• Ask your care teams to identify patients they consider high-risk patients who have been lost to care.
• Use care gap reports to identify patients who are behind on screening or who have missed a follow-up visit. See Key Activity 3: Use Care Gap Reports or Registries to Identify All Patients Eligible and Due for Care.

2. Establish the outreach model for your practice.

Suggested team member(s) responsible: Practice leadership.

One outreach model commonly used is to hire dedicated staff as population health specialists. This person would be responsible for using care gap reports to conduct proactive outreach to patients and schedule needed follow-up. See more about this in the care team duties and recommended education resource.

However, different teams may adjust this role to fit their context. An alternative model ensures each care team includes staff with knowledge of the local environment and available resources to conduct telephonic outreach to higher needs patients and their families.

Train all outreach staff in cultural humility, motivational interviewing skills, and in the use of trauma-informed care. See Key Activity 10: Implement Trauma-Informed Care Approach Across the Patient Journey.

3. Supplement your reminder system for contacting various subpopulations.

Suggested team member(s) responsible: Population health specialist with guidance from implementation team and IT staff.

Reminders should be sent to all persons with an upcoming scheduled appointment. The clinic scheduling system will likely have a function for generating automated reminders with an option for patients to cancel or reschedule if they cannot keep the appointment. Reminders should also be sent to all patients who appear to have gaps in care and missed appointment reports. See more about updating your See Key Activity 3: Use Care Gap Reports or Registries to Identify All Patients Eligible and Due for Care to learn more about enabling setting up automated reminders.

Automated reminder systems can support efficiency and reliability. However, more intensive reminders where the patient receives a personalized telephone call from their care team may help patients who are at higher risks of nonattendance or being lost to care.^[35]

FIGURE 14: EXAMPLE OF PROACTIVE OUTREACH AND ENGAGEMENT

 
Peer example – outreach call script: San Francisco Health Network’s primary care provider visit call script for pediatric care. This script can be adapted or used to make outreach calls to schedule patient appointments.

Utilize multiple pathways to reach and engage patients. For example, a Swiss clinic used sequential appointment reminders consisting first of a phone call and, secondly, of an text massage, if patients did not answer the phone after three attempts. If the patient had no phone number listed, they received a reminder by mail two days prior to their appointment. The reminder system significantly reduced the rate of missed appointments and allowed the clinic to reallocate 28% of the canceled appointments.

Tip: Consider scheduling these outreached patients on days when you might experience a lower volume of activity in order to level the demand on the care team.

• Whether automated or manual, reminders should accommodate language requirements, as well as stated patient communication preferences (text, email, mail or phone). Reminders that include more than date, time and place and also include an orientation about what to expect and supporting clinical information may be more effective.^[36]

4. Use touches that provide alternatives to the traditional office visit.

Suggested team member(s) responsible: IT staff, care coordinators, care team members.

Assess what types of interaction or care can be provided outside this setting and collaborate with patients as part of initial care planning to understand their preferences for communication and care team interactions. Examples include:

• Virtual visits with a provider or nurse.
• Group visits.
• Pharmacy visits.
• Digital communication through emails, texts and patient portals.
• Newsletters focusing on a specific condition.
• Social media that includes discussion groups relative to the management of conditions of focus.
• Home visits for high-risk, historically marginalized or mobility-challenged patients.
• Other technological solutions, such as apps focused on patient conditions which provide a vehicle for ongoing engagement.

5. Establish a process for engaging patients assigned to your practice by their managed care team who have not yet been seen by the practice.

Suggested team member(s) responsible: Multidisciplinary implementation team.

Depending on your agreement with the health plans, it is important for practices to make a proactive plan to build capacity to accommodate assigned-but-not-yet-seen patients in the clinic. Practices should develop strategies for outreach and engagement with these populations in order to shift them from not yet seen to fully engaged in primary care, as well as a process for not-yet-seen patients for whom outreach may be unsuccessful. These patients may be getting their pediatric care elsewhere though still assigned to the practice.

6. Continuously reassess outreach approaches with a goal of improvement.

Suggested team member(s) responsible: Community health workers, outreach workers and navigators, community partners.

• Test your co-designed outreach approaches and measure the effectiveness of your approaches. Review data (e.g., missed appointments, numbers lost to follow up, etc.).
• Survey patients to obtain retrospective and prospective feedback on outreach efforts.
• Regularly update outreach strategies based on community feedback and changing demographics.

KEY ACTIVITY #9A:

Provide Caregiver Support to Overcome Vaccine Hesitancy

This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; proactive patient outreach and engagement; address social needs.

Overview

Vaccine hesitancy has been described as a behavior influenced by a number of factors. Vaccine-hesitant individuals are a diverse group with varying degrees of indecision about specific vaccines or vaccinations in general. Clinics may take many approaches to support vaccine-hesitant families of their patients to boost participation rates in well-child visits (WCVs) and immunizations.

FIGURE 15: EXAMPLE OF DOCUMENTING REASON FOR VACCINE DECLINATION IN EHR

Action steps and roles

Adapted from: Ensuring COVID-19 Vaccine Equity for Children: Considerations for Pediatric Teams and Community Partners - CHCS Blog [Internet]. Center for Health Care Strategies. 2021. Available from: https://www.chcs.org/ensuring-covid-19-vaccine-equity-for-children-considerations-for-pediatric-teams-and-community-partners/

1. Determine current immunization completion rates by age group, by key sociodemographic characteristics, and by vaccine.

Suggested team member(s) responsible: Data manager or QI lead.

Segment the practice’s data on immunization and WCV completion rates to identify groups of children who are not meeting goals.

2. Listen to families, communities and clinic staff.

Suggested team member(s) responsible: QI lead and staff.

Identify barriers to immunization completion, including vaccine hesitancy and strengths-based, family-driven solutions, through trusted and authentic partnerships with families and communities. See Figure 16 for a compendium of reasons for vaccine hesitancy.

Also, examine the staff’s current comfort both with immunizations and with addressing parental concerns. Providing a psychologically safe environment for staff to express their own hesitancies and engage in respectful education and dialogue about immunizations can yield greater understanding, buy-in, and support from practice staff.

3. Review current practices to identify key opportunities for improvement.

Suggested team member(s) responsible: QI lead with care team and families.

Catalog and develop process maps for the clinic and care team’s current practices related to presenting and educating caregivers and families on immunizations, addressing concerns and vaccine hesitancy, using support materials related to vaccine hesitancy, and tracking effectiveness of current practices. Consider how the use of standing orders integrates with this process.
 

4. Share information effectively to build vaccine confidence.

Suggested team member(s) responsible: Care team.

Develop clear, concise and accessible messaging to discuss vaccine safety and efficacy with families and to counteract persistent misinformation campaigns. When possible, review sources of information and misinformation with families who express hesitancy.

One way to quickly incorporate effective communication is to adapt language that has already been crafted to address families' concerns about immunizations. Use culturally sensitive language and tailor existing resources to reach specific communities, including Black and Hispanic or Latino/a communities, as well as refugee, immigrant and migrant communities. See Figure 17 for communication highlights related to vaccine hesitancy, as well as resources for this activity below.

5. Focus on the care team.

Suggested team member(s) responsible: Director.

Ensure that the care team is comfortable addressing vaccine hesitancy and other family concerns to foster an environment where all families feel supported. Consider offering training, such as the teach-back method.

Help staff vaccinate their own families by offering vaccine drives or additional paid time off. Offering opportunities for the care team to vaccinate their own families provides a space for staff to talk about the experience of vaccinating their families with the community they serve and signals the practice’s commitment to vaccination.

6. Measure progress, consider equity, and continuously improve your approach overall and for key subpopulations.

Suggested team member(s) responsible: Data manager or QI lead.

Whenever possible, track vaccination data in real time and collect disaggregated data by race and ethnicity, as well as by language spoken and geographies. Advocate for practices and policies that drive vaccine equity and benefit all families.

Special consideration for human papillomavirus (HPV): One special circumstance worth noting is the potential divergence between parental and adolescent immunization preferences with respect to HPV vaccination. The adolescent may, unknown to the parent, wish HPV vaccination, but the parent may not provide consent. Practices should adopt a consistent and systematic approach to when and how adolescent HPV immunization will be provided without parental consent, given existing CA law that permits this. Practices may want to be familiar with existing literature on adolescent consent for the human papillomavirus vaccine, including ethical, legal and practical considerations, and the HPV vaccine and parental consent. Most importantly, practices should be aware that California law allows adolescents to consent to HPV vaccination without parental consent.

Evidence base for this activity

• Edwards KM, Hackell JM. Countering Vaccine Hesitancy. PEDIATRICS [Internet]. 2016 Aug 29;138(3):e20162146–6. Available from: https://pediatrics.aappublications.org/content/138/3/e20162146
• Gilmour J, Harrison C, Asadi L, Cohen MH, Vohra S. Childhood Immunization: When Physicians and Parents Disagree. Pediatrics [Internet]. 2011 Nov [cited 2019 May 5];128(Supplement 4):S167–74. Available from: https://pediatrics.aappublications.org/content/128/Supplement_4/S167
• Maglione MA, Das L, Raaen L, Smith A, Chari R, Newberry S, et al. Safety of Vaccines Used for Routine Immunization of US Children: A Systematic Review. PEDIATRICS [Internet]. 2014 Jul 1;134(2):325–37. Available from: https://pediatrics.aappublications.org/content/134/2/325
• Byington CL. Vaccines: Can Transparency Increase Confidence and Reduce Hesitancy? Pediatrics [Internet]. 2014 Aug 1;134(2):377–9. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4187240/
• Sahni V, Lai FY, MacDonald SE. Neonatal Vitamin K Refusal and Nonimmunization. Pediatrics. 2014 Sep 1;134(3):497–503. Available from: https://pubmed.ncbi.nlm.nih.gov/25136042/
  Summary: Children whose parents refused vitamin K at birth are 14.6 times more likely to be unimmunized by age 15 mo. This provides an opportunity to identify a subset of likely vaccine-hesitant parents at birth and engage them with information in a focused effort.
• Hendrix KS, Finnell SME, Zimet GD, Sturm LA, Lane KA, Downs SM. Vaccine Message Framing and Parents’ Intent to Immunize Their Infants for MMR. PEDIATRICS [Internet]. 2014 Aug 18 [cited 2020 Jan 20];134(3):e675–83. Available from: https://pediatrics.aappublications.org/content/134/3/e675
  Summary: A survey found that parents who were informed about the MMR vaccine’s direct benefits to their child, rather than the vaccine’s benefits to society as a whole, were more likely to immunize.

KEY ACTIVITY #10:

Implement Trauma-Informed Care Approach Across the Patient Journey

This key activity involves all seven elements of person-centered population-based care: proactive patient outreach and engagement; care coordination; behavioral health integration; address social needs.

Overview

This activity provides guidance on concrete actions that practices can take to embed trauma-informed care into their daily workflows and interactions with patients.

Action steps and roles

1. Build awareness and generate buy-in for a trauma-informed approach.

There are many ways to become a trauma-informed organization, and the process does not have to be a burden to adopt. Foundational steps that organizations can take to move toward fully adopting a trauma-informed approach to care include:

• Using existing meetings and initiatives to build awareness and generate buy-in for a trauma-informed approach.
• Supporting a culture of staff wellness.
• Hiring a workforce that embodies the values of trauma-informed care.
• Creating a safe physical, social and emotional environment.

The Trauma-Informed Care Implementation Resource Center, Center for Health Care Strategies, and the California Academy of Family Physicians provide a range of guidance and tools for getting started.

2. Provide TIC training to all staff.

Incorporate TIC training into new hire orientation, and require all staff to complete TIC training. Training sessions should include role play, patient and family testimonials, and reflection by staff members. Include examples of trauma-informed approaches in all staff roles, and discuss how specific practices may hinder patients’ and families’ resilience. Include focus on team members’ own well-being. The practice’s QI lead should include pre- and post-training feedback, including questions on staff confidence in implementing TIC practices.

The California ACEs Aware website has online access to free trainings.

A potential list of introductory topics could include:

• Introduction to trauma-informed care:
  • What is trauma? Definition, types, and prevalence.
  • The physical, emotional and psychological effects of trauma.
  • Design principles and core values of trauma-informed care.
  • How patients and the care team benefit from trauma-informed care.
  • Trauma-informed care at a Community Health Center.
• Recognizing and responding to trauma:
  • Trauma-sensitive communication: Effective ways to interact with trauma survivors.
  • Signs and symptoms of trauma.
  • Link between trauma and physical health conditions.
  • Recognizing potential triggers for trauma survivors.
• Creating a trauma-informed environment:
  • Establishing a safe and trusting atmosphere.
  • Strategies to prevent retriggering trauma.
  • Understanding the impact of cultural differences on trauma experiences.
  • Ensuring patients have a say in their care.
• Trauma-informed practices at our practice:
  • Screening for trauma.
  • Trauma-informed intake.
  • Trauma-informed care planning with patients.
  • Linkage and referrals to experts on trauma-informed care.

3. Provide ongoing support to promote resilience among all staff.

Suggested team member(s) responsible: Human resources.

The practice’s human resources lead should periodically remind all staff of the array of confidential employment assistance available to them, as staff may be experiencing the impacts of childhood ACEs or ongoing sources of trauma, which will affect their health and well-being, as well as likely impact their ability to approach patients in a trauma-informed way. Likewise, personal development, team building, and practices aimed at boosting joy in work, if leveraged in trauma-informed ways, are all likely to support staff and limit the effects of trauma.

4. Provide ongoing supervision to all staff.

Suggested team member(s) responsible: Director.

Ideally, each staff member should have supervision time (perhaps twice monthly) with a TIC-trained direct supervisor to surface bright spots and challenges and work through questions toward professional development. Behavioral health and human resources leaders should assess supervisors’ ability to engage with patients, families and staff in trauma-informed ways, as well as guide others to do the same.

When one-on-one supervision time is lacking, explore ways to develop other supports around TIC implementation. This could include devoting portions of regular staff meetings to surface TIC implementation challenges and bright spots, leveraging and highlighting standout workers’ skills and capacities to support the wider staff’s ability to implement TIC, or incorporating short training modules during staff meetings.

5. Partner with patients and families to identify trauma-informed practices that support your patient populations and improve existing practices, including eliminating practices that reinforce trauma.

Suggested team member(s) responsible: QI lead.

As a foundational step, clinic leaders should invite families to shape TIC training topics and practices, with attention given to making it easy to participate in these sessions. This may mean scheduling after-hours, offering refreshments and childcare, and paying family representatives for their time.

Going deeper, your practice can work with experts, patients and families on eliminating practices that create or reinforce trauma and replacing them with trauma-informed practices. The Center for Care Innovations (CCI) offers guidance on becoming a healing organization. Consider using the capacity assessment tool for trauma and resilience-informed pediatric care. The Trauma-Informed Care Information Resource Center also offers an analysis of a host of tools to assess an organization’s uptake of trauma-informed practices.

6. Improve the clinic’s physical environment.

Suggested team member(s) responsible: Director, human resources staff, caregiver representatives.

The American Academy of Pediatrics recommends creating a safe environment using engagement strategies to build trust, focusing on strengths to empower patients and families, and having brief office-based approaches to promote a growth mindset.

Ensure that the clinic offers well-lit spaces from the parking lot to the examination rooms, that noise levels are low in the waiting room and all patient areas, that security is sufficient, and that decor integrates warm colors and gentle images.^[51]

Partnering with caregivers to assess the current state, identify improvement opportunities, and shape improvements will build relevance and ownership of the changes.

7. Track the results of TIC training and implementation.

Suggested team member(s) responsible: QI lead, director.

QI leads should include pre- and post-training feedback, including questions on staff confidence, in their ability to recognize signs of trauma and implement TIC practices. Patient experience surveys should include questions about the patient’s and family’s level of comfort at the practice and their ability to get the care and support that they want and need when they want and need it. Rather than creating your own survey, consider implementing an existing survey.

Consider how you will track results. One option is to track the percentage of respondents who respond favorably, and responses could be segmented to identify groups of patients and families who respond negatively or less positively than others.

8. Develop formal and informal feedback loops with patients and the care team to understand the effectiveness of your approach to TIC.

Suggested team member(s) responsible: QI lead, director.

To help ensure that your approach is meeting the needs of patients and is consistently feasible for the care team, it is important to have both formal and informal feedback loops.

For patients, feedback loops might include:

• Patient satisfaction surveys (or similar).
• Follow-up calls with a subset of patients to understand what has been going well and what could be improved.
• Patient focus groups.
• Feedback from the practice’s patient advisory board (or similar).

Having an accessible, safe and robust patient complaint process is also a critical dimension to practice learning about TIC opportunities in conjunction with formal patient experience surveys. At the minimum, educate Medi-Cal patients about their rights to submit a grievance to the Medi-Cal managed care plan and submit complaints about discrimination to the DHCS Office of Civil Rights. However patients choose to express dissatisfaction, it is important to assure them that they will not experience any retaliation from their providers or health plan.

For the care team, feedback loops might include:

• Daily huddles.
• Existing or new staff satisfaction and feedback mechanisms.
• Supervisors and managers eliciting feedback and experiences from staff during one-on-one meetings.
• Regularly scheduled meetings and calls to get staff feedback on processes, methods and tools.

9. Align trauma-informed care and equity efforts.

Trauma-informed care and a trauma-informed culture must, by definition, also be equity-informed. Racism and discrimination are risk factors for toxic stress and have long-term health consequences. Additionally, through implicit bias and systemic racism, people of color have often been harmed in healthcare and social care systems. TIC efforts that are aligned with organizational equity efforts, such as diversity, equity and inclusion (DEI) work, and efforts to eliminate health disparities will strengthen both. Strategies include:

• Align and cross-support TIC task force aims with the DEI committee’s aims.
• Include anti-bias training for staff and providers within TIC training.
• Frame cultural humility as a central part of TIC.

Integrating trauma-informed care across care delivery

Coordinated care delivery that is trauma-informed may include:

• Screening for ACEs and recording screening results in the EHR. See more in Key Activity 7A: Develop a Screening Process for Social Needs and Adverse Childhood Experiences (ACEs) that Informs Patient Treatment Plans.
• Referring patients needing further support to specialist providers internal or external to the practice and/or to community organizations which can support social needs.
• Performing warm hand-offs of patients to needed providers of specialist or social support.

Importantly, there is no one workflow for implementing a TIC approach in the patient care journey within a practice. Rather, this endeavor requires proactively and intentionally integrating a TIC approach across all activities and interactions in patient care. While the awareness, training and support efforts may look similar across different sites of care, the starting place for implementing a TIC approach – and the subsequent opportunities for implementation – will likely be different across sites. For example, one clinic may choose to start by first implementing a TIC approach in their check-in process, whereas another clinic may choose to start with their newborn WCVs.

KEY ACTIVITY #11:

Coordinate Care

This key activity involves all seven elements of person-centered population-based care: proactive patient outreach and engagement; pre-visit planning and care gap reduction; care coordination; behavioral health integration; address social needs.

Overview

This activity will help you provide care that is person-centered and coordinated across all internal and external providers involved with the patient.

Action steps and roles

1. Establish a call to action for care coordination.

Suggested team member(s) responsible: Medical lead, care coordination staff, or QI staff.

To achieve effective care coordination, your practice needs to see yourself as a hub or center for coordination of patient care. While all providers within a patient’s support network need to collaborate, your practice should view itself as accountable for care coordination for empaneled patients and patients who have been assigned to your practice by their managed care plan.

• Identify a care coordination team who will be responsible for leading the evaluation, assessment and implementation of care coordination activities.
• Share with the care coordination team, why care coordination is important.
• Some areas to address:
  • What is care coordination?
  • Why does care coordination benefit staff and patients?
  • Review proposed framework (assess, develop strategy, implement, monitor) to develop the care coordination activity.
  • Identify and share some initial projects directed at enhancing care coordination.
  • Invite and engage staff and patients to provide input on how they think care coordination can be enhanced.
  • Discuss how to best incorporate feedback from patients.
• Use feedback from this activity and incorporate it into the assessment below.

2. Assess your practice’s current state of care coordination activities.

Suggested team member(s) responsible: Panel manager, QI lead.

• Begin by asking and answering the following questions:
  • What does the practice hope to achieve by implementing interventions to change the care coordination process?
  • Which patient needs are the responsibility of the practice to provide (e.g., care coordination within the practice)?
  • Which patient needs will need to be addressed through external referral and collaboration (care coordination with entities outside the practice)?
  • What resources are needed to improve the current state (e.g., data, input from care team members, input from care partners, such as hospitals, specialty, behavioral health, social needs)?
• Gather stakeholder input.
  • Conduct interviews or surveys with patients and community members to understand their perspectives on current care coordination processes, challenges and areas for improvement.
  • Conduct interviews with your care team to understand their perspectives on current care coordination processes, challenges, and areas for improvement.
• Analyze existing systems and processes.
  • Review existing care coordination protocols, technologies and resources utilized by health centers.
  • Explore how technology is currently being used to support care coordination. Then explore how technology could be harnessed to streamline care coordination, improve data sharing, and/or enhance communication among providers.
  • Review existing formal and informal linkage agreements.
  • Conduct an analysis to determine patient needs not yet fully addressed by existing agreements.
  • Assess data on patient outcomes, satisfaction, and any existing quality improvement initiatives.
  • The following resources can help your practice assess its current state:
    • PhmCAT: Sections on population-based care, social health and behavioral health.
    • Care Coordination Maturity Assessment: This resource addresses multiple domains that may be impacted as care coordination activities are undertaken.

3. Develop and implement a care coordination improvement strategy.

Suggested team member(s) responsible: Panel manager, QI lead.

• Develop your high-level care coordination improvement strategy.
  • The high-level strategy is based on the results and insights from your care coordination assessment and your practice’s capacity or bandwidth.
  • Establish clear objectives.
  • Define specific, measurable, achievable, relevant, time-bound, inclusive and equitable (SMARTIE) goals for enhancing care coordination.
  • Ensure that these goals align with the overall mission and values of your practice.
  • Prioritize areas for improvement: Identify a limited set of key focus areas based on the assessment findings and your practice’s bandwidth, such as communication protocols, technology integration, staff training or patient engagement strategies.
  • The following resources can help your practice develop your care coordination improvement strategy:

• • • NCQA Care Coordination Web Page.
    • HEDIS Measures - Transitions of Care (ToC).
    • HEDIS Measures - Follow-Up Care After.

• Identify resources and infrastructure.
• • As part of the implementation of the strategy, identify the resources and infrastructure needed to support care coordination at your practice.
  • We have included in Figure 19 below some considerations by resource as you develop your care coordination implementation plan. Some of the resources may not apply to your practice.

FIGURE 19: CONSIDERATIONS FOR IDENTIFYING CARE COORDINATION (CC) RESOURCES

• Develop staffing for care coordination.
  • Determine who at your practice will be involved in care coordination.
  • The PHMI Care Teams and Workforce Guide provides an overview on care coordination using a care coordinator or referral manager.
  • Based on the population of focus and the intervention, develop staffing requirements and any job description changes to embed care coordination into your practice.
  • The responsibilities of a person or people fulfilling care coordination roles should include, at a minimum:
    • Manage the referral process.
    • Assist patients with transitions; such as those to and from hospitals and other institutions.
    • Help patients resolve logistical, financial and/or other barriers to a successful referral.
    • Link patients with community resources.
    • Follow up with patients within a few days of an emergency room visit, hospital discharge or discharge from a treatment facility.
    • Ensure the safe transfer of patient data.
    • Track progress (e.g., referral milestones).
    • Assist patients who are having difficulties.
    • Schedule follow-up and specialty appointments for and with patients
  • Formalize this role through a job description or position description.
  • Sample referral coordinator position description.
  • Provide regular training and support to the care coordinator or referral coordinator (or similar).
• Develop or refine your policies and procedures for care coordination.
  At a minimum, include all of the following:
  • Identifying patients who are eligible for care coordination.
  • Defining the activities that are associated with care coordination (e.g., outreach, engagement, assessment, desired outcome).
  • Managing the referral process.
  • Ensuring the safe transfer of patient data.
  • Tracking progress through closed loop referral (see referral milestones above).
  • Identifying patients who would benefit from higher levels of care coordination, such as care management interventions, like Enhanced Care Management (ECM) (see the Key Activity 19: Provide Care Management).
• Develop or refine your referral protocols.
  • Develop clear guidelines for when and how to make clinical referrals.
    • Include criteria for urgent vs. nonurgent referrals.
  • For each provider your practice will be referring to:
    • Identify the information, format and process the provider requires to receive a referral.
    • Share the information you will need back from the provider when the referral has been successfully made and/or once the service or support has been provided to ensure continuity of care and nonduplication of services.
    • Formalize this through a written agreement or compact to ensure expectations on both sides of a referral are understood.
  • In working with community agencies or organizations that provide social support, the specific information that can and should be shared will depend on the service. It is important to have a mutual understanding about that information, using a written agreement where possible. At minimum, if the referral did not include a warm handoff, there should be an expectation that the practice hears back from the organization to let them know whether the patient followed up on the referral. Sample primary care checklist suggestions for assessing referral process.
  • An interoperable referral management system can help practices streamline the intake process, communicate with other providers and social service agencies, track the status and outcomes of referrals, and ensure that patients receive the appropriate level of care and support.
• Address connectivity.
  For any providers that you are exchanging patient data with, your practice should develop formal agreements and processes. Here are some considerations to facilitate information sharing among providers involved in an individual’s care:
  • Integrate documentation platforms, where possible, and standardize how documentation is included in patient records.
  • Ensure that behavioral health records are integrated into the overall EHR system to the extent permitted by law.
  • Enable providers to access comprehensive patient information.
  • Identify and assess participation in health information exchanges and/or social health information exchange systems, where feasible, to facilitate seamless sharing of patient information between clinicians. These exist in some communities and will develop over time. This explainer series from the California Health Care Foundation describes the new statewide health information exchange coming into effect in 2024.
  • Understand when patient consent is required to ensure compliance with privacy regulations, such as HIPAA. Include consent processes in the referral protocols.
  • Set expectations about the information that should be shared and develop processes for facilitating that exchange. As data that is used in a clinical setting will likely be different than information that is shared by community agencies or social support networks, it is imperative to have clear parameters around what types of information can be exchanged between your practice and your partners.
  • Leverage community health information exchanges (HIE) to gain access to admission, discharge and transfer information. Absent being able to access an HIE, establish relationships with your local hospitals to be able to gain daily notification of your patients being discharged.
• Provide care coordination to patients.
  • Provide care coordination to patients who need it in accordance with your care coordination policies and procedures and referral protocols.
  • Embed care coordination into your practices daily workflow, including pre-visit planning. See Key Activity 5: Develop or Refine and Implement a Pre-Visit Planning Process.
    • Sample care coordination task plan and weekly schedule.
  • Provide referrals to care management (discussed in going deeper Key Activity 19: Provide Care Management), such as ECM for patients who require more intensive support.
  • Discuss each referral with the patient to ensure the patient understands the reason for the referral.

Below is an example of a care coordination quality improvement strategy.

FIGURE 20: EXAMPLE OF CARE COORDINATION, QUALITY IMPROVEMENT STRATEGY

4. Monitor: Continuous quality improvement of care coordination.

Suggested team member(s) responsible: QI lead.

• Develop both formal and informal mechanisms to obtain feedback from providers, staff and patients on the effectiveness of your practice’s care coordination efforts and to identify areas for improvement.
• Establish key performance indicators related to care coordination. Consider using the Agency for Healthcare Research and Quality (AHQR)’s Care Coordination Quality Measures in Primary Care (CCQM-PC). Your performance indicators will vary based upon your improvement strategy and the needs of patients, but may include metrics, such as:
  • Number of assigned patients engaged in care.
  • Number of individuals with hypertension whose blood pressure (BP) is controlled.
  • Percent of closed loop referrals by referral entity. Monitor and analyze metrics to gauge the effectiveness of your internal systems and how well each referral partner is promoting coordination and collaboration.
• Continue to build relationships with providers and community support agencies that are available to provide services to Community Health Center (CHC) patients.
• Consider developing and using a care coordination variance report. Here is a sample patient care coordination variance report.

KEY ACTIVITY #12A:

Provide Clinic Hours Beyond the Typical Work Day

This key activity involves all seven elements of person-centered population-based care: address social needs.

Overview

Practices may take many approaches to provide family-friendly access to care. A potentially transformative approach is to shift clinic hours beyond the typical work hours. For example, you may choose to offer early morning hours or evening hours at your clinic a couple of days a week, as needed.

Telehealth technology may also be used to supplement and provide flexible hours, as clinicians or other staff may be more able or willing to work early or late hours from their homes. By enabling clinicians to see patients remotely or off-site, telehealth also can reduce the overhead costs of running the practice for longer hours.

Action steps and roles

1. Review current clinic operating hours and available data on missed appointments.

Suggested team member(s) responsible: Director or QI lead

The practices’ data manager or QI lead should stratify the data on WCV completion and immunization rates to identify groups of children who are not meeting goals. Be sure to filter the data by patient demographics to identify subpopulations of children who are unable to keep appointments in the current system.

2. Learn family preferences about clinic hours.

Suggested team member(s) responsible: Staff member

Practice leadership should identify a staff member or peer leader who is very skilled in empathic listening to reach out to parents and families to learn what gets in the way of children participating in WCVs and being immunized. Ask open-ended questions about families’ preferences for accessing care. You could include specific questions about times that would be convenient to the family.

3. Query staff to learn their preferences about working hours.

Suggested team member(s) responsible: Human resources staff or clinic leadership.

Clinic leadership or human resources staff may query the staff team along similar lines, asking about their perception of what gets in the way of families participating in care and their preferences about working hours.

4. Test flexible clinic hours.

Suggested team member(s) responsible: Director

Review what you learned and run a small-scale test, scheduling families to fill slots in one or two shifts of the preferred flexible clinic hours. Continue testing different time slots until the team is satisfied that you have learned as much as you need to designate an expanded clinic schedule. Be aware that this step may need to be repeated at intervals to gauge emerging preferences of patients and staff.

5. Designate an expanded clinic schedule and track the results.

Suggested team member(s) responsible: Director, human resources staff, QI lead

Implement a clinic schedule that incorporates the most-attended appointment windows. Draw staff time based on staff preferences to the extent possible and partner with staff to minimize disruptions in work/life balance. QI lead should review the rate of kept appointments during the flexible hour windows, and compare them to the rate of kept appointments during usual business hours.

For additional interventions to improve appointment access, consider open access scheduling and/or same-day appointments, using a similar careful testing and implementation approach.

KEY ACTIVITY #12B:

Incorporate Prevention Activities within Sick Visit Appointments

This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; behavioral health integration; address social needs.

Overview

Ensuring that prevention activities are incorporated into sick visit appointments expands access to care and facilitates a whole-person care approach. This creates opportunities to build interventions that are responsive to patients’ and families’ needs and preferences for engaging in the health system.

Sick visits provide a chance for pediatric care providers to incorporate elements of well-care visits:

• Health history.
• Physical developmental history.
• Mental development history.
• Complete physical exam.
• Health education and anticipatory guidance.

The American Academy of Pediatrics and the American Academy of Family Physicians recommend that children with mild illnesses receive vaccinations on schedule. Importantly, there is no health benefit to waiting to vaccinate, if a child has a mild illness. In fact, it is vital that children receive recommended vaccines on time so they are protected against serious disease.

Children can still be vaccinated if they have:

• A low-grade fever.
• A cold, runny nose, or cough.
• An ear infection (otitis media).
• Mild diarrhea.

Action steps and roles

1. Consider providing additional time for sick visits that will include WCV activities when scheduling the appointment.

The office staff who are scheduling sick visits can be helpful at that by identifying that the child is due or overdue for well-child care and booking the visit as a well-child visit and problem-directed visit and providing a longer visit. Additionally, office staff can use patient messages, medication refill requests, and phone calls as touchpoints to screen for preventive care needs and opportunities.

2. Use pre-visit planning.

Suggested team member(s) responsible: QI lead, care team lead, frontline staff.

Use a pre-visit planning process to identify which patients with scheduled sick visits would benefit from the inclusion of well-care visit (WCV) activities. Determine priority WCV activities to include for each sick visit, such as administration of recommended immunizations. See Key Activity 5: Develop of Refine and Implement a Pre-Visit Planning Process for more information.

3. Empower rooming staff to engage patients in the decision to do the preventive care activity.

Suggested team member(s) responsible: Director or care team lead.

Screenings, especially behavioral health screenings, require rooming staff to read the room to decide whether to go ahead with the screening. Considerations include that screenings can lengthen a visit and/or raise topics that patients may not be prepared to tackle when feeling unwell. Parents may also be more stressed, sleep-deprived or worried during a sick visit, potentially biasing results of screening. Care team leaders can empower rooming staff to offer screenings and to express the importance of patients’ own priorities, especially if patients feel limited by their time or are feeling too unwell to complete screenings.

4. Test new and adapted practices and processes to develop improved workflows and standard protocols for implementing WCV activities during sick visits, focusing first on prioritized areas for improvement.

Suggested team member(s) responsible: QI lead with frontline staff (as appropriate for the WCV activity of focus) and patients their families.

Coordinate with the clinic’s efforts to improve reliability in meeting WCV recommendations. Consider using the individual WCV resource pages at AAP’s parent-facing website HealthyChildren.org to design, organize, and improve the inclusion of WCV activities during sick visits. Consider testing different versions of who does what, where, when, and how, and you might be able to leverage technology to automate or partially automate some of WCVs. See Key Activity 2: Assess and Improve Reliability in Meeting Well-Child Visit (WCV) Recommendations.

Ensure that your practice is benefiting from billing for a concurrent WCV and evaluation and management (E/M) services, for which higher reimbursement is available, if correctly coded.

You may also consider extending these workflows and protocols to implement WCV activities during other visit types as well, including nonurgent follow-up visits for chronic conditions (e.g., asthma, ADHD).

Peer example: At Children’s Hospital Primary Care Clinic (CHPCC) at Vanderbilt, a quality improvement team developed key drivers and used a people-process-technology framework to devise three interventions to reduce missed opportunities for WCVs at acute visits for patients overdue for those services. Key drivers included: an electronic indicator based on novel definitions of early and periodic screening, diagnosis and treatment (EPSDT) status (e.g., up-to-date, due, overdue, no EPSDT); a standardized scheduling process for acute visits based on EPSDT status; and a dedicated nurse practitioner to provide WCVs at acute visits. Data were collected for one year after full implementation. Implementation of interventions focused on people, process and technology significantly increased WCVs at acute visits within a feasible and practical model that may be replicated at other academic general pediatrics practices.

KEY ACTIVITY #13:

Coordinate Care with Home and Community Visiting Services

This key activity involves all seven elements of person-centered population-based care: proactive patient outreach and engagement; care coordination; address social needs.

Overview

This key activity provides tips and considerations for expanding access to home visiting services, which may be available to patients as a managed care plan benefit or through other public services.

Home visiting is an evidence-based strategy in which a professional or paraprofessional renders a service in a community or private home setting. Home visiting programs employ home visitors as a central component of a comprehensive service plan and vary widely with regard to population of the focus and goals. Home visiting initiatives are most effective when they are components of a comprehensive community-level early childhood system that reaches families as early as possible with needed services; accommodates children with special needs; respects the cultures of the families in the communities; and ensures continuity of care in a continuum from prenatal life to school entry.^[55] As of 2020, 21 home visiting models met the criteria of the U.S. Department of Health and Human Services for evidence of effectiveness through the Home Visiting Evidence of Effectiveness (HomVEE) review.^[56]

KEY ACTIVITY #14A:

Provide Proactive Inreach and Outreach to Help Adolescents Engage in Behavioral Health Care

This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; behavioral health integration.

Overview

The COVID-19 pandemic spurred rising rates of mental health disorders and distress, including a marked increase in adolescent emergency room (ER) visits for mental health conditions.^[61] This reality heightens the need for effective inreach and outreach to adolescents needing behavioral health services.

Outreach consists of identifying the behavioral health (BH) care needs of adolescents in the community, while inreach involves identifying the same among your practice’s adolescent patients. An initial step in both inreach and outreach is communicating with the community and your adolescent patients and their families about behavioral health conditions and the availability of BH services.

In California, a large statewide investment for providers of pediatric services to be aware of is the Children and Youth Behavioral Health Initiative (CYBHI), which is aiming to expand access to school-based mental health counseling, as well as virtual behavioral health services and e-consults, regardless of insurance coverage. See the resources below for more information about this initiative.

How are inreach and outreach different for adolescents?

Adolescence and early adulthood is a time in life when mental health problems may arise for the first time, though the age of onset varies with the particular behavioral health diagnosis.^[62] While significant numbers of adolescents experience behavioral health needs, young people seeking care from mental health professionals often report that their concerns are invalidated by healthcare practitioners.^[63][64] Contact with mental health and health care providers can threaten young people’s sense of agency, turning them away rather than towards connecting with mental health services. School-based counselors can be instrumental in providing effective outreach and inreach to adolescents.

These help-seeking patterns are complicated by the fact that many adolescents may be struggling with multiple sensitive issues, including but not limited to substance use, emerging ideas about sexual orientation and gender identity, bullying and abuse, body dissatisfaction, relationship issues, and changing physical development. Unfortunately, these are topics that not all adults feel comfortable discussing.

Implementation considerations

Rather than make singular recommendations regarding inreach and outreach to adolescents, teams should consider the combination of their patient and family needs and staff capacity. Adolescence is not a single entity. The social and emotional needs of a patient at age 12 differ from that of a 17-year-old and, therefore, their relationships to family and peers change, as well. Additionally, not all adolescents' developmental stages correlate with their chronological ages. Teams should consider opportunities for inreach and outreach that reflect these variations and nuances, especially when determining whether or not outreach is directed at the family unit or to the individual adolescent.

Inreach (reaching adolescents within the practice):

• Train primary care providers and medical assistants in nonjudgmental, empathic communication in order to increase the likelihood of adolescents disclosing when they are having mental health or other difficulties.
• Develop patient-facing materials for adolescents, including posters in the waiting room and brochures in exam rooms, affirming the confidentiality of disclosures made to the healthcare team and behavioral health services available at the practice. Additional considerations and resources around consent for adolescents are discussed in Key Activity 14C: Manage Treatment of Adolescents’ Behavioral Health Needs in Integrated Person-Centered Ways.
• Universal screening for behavioral health difficulties is a core part of an inreach strategy. See Key Activity 14B: Screen Adolescents for a Range of Behavioral Health Needs.

Outreach:

• As suggested above, many adolescents do not seek help for behavioral health from their primary care provider. The practice may consider partnering or building on existing partnerships with organizations such as schools, churches or community centers to promote the availability of behavioral health services and care. Potential community partners will vary based on a clinic’s setting and should be contextually driven.
• Practices can offer community presentations, workshops or classes directed at parents within the community to share supportive information and resources for families with adolescents.

KEY ACTIVITY #14B:

Screen Adolescents for a Range of Behavioral Health Needs

This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; behavioral health integration.

Overview

This activity provides general recommendations on screening for behavioral health needs for adolescents (ages 12 to 18 years). This guide uses depression as an example, as most practices begin behavioral health screening with depression. As the clinical team develops skills and familiarity with screening adolescents for depression and staffing on teams includes individuals with expertise in treating and supporting adolescents with their mental health needs, the goal is to incorporate additional behavioral health screening strategies, such as screening for anxiety, suicide and unhealthy substance use. Patient concealment about depression, substance use and previous trauma history can be high for fear that report of such experiences will lead to emergency response and/or reporting to protective services. Developing trust with adolescents can be effective in combating this common and understandable inclination. Additionally, as mentioned elsewhere, giving adolescents the option to engage or not in screening and a further option to answer screeners through self-report via methods, such as tablet that protect confidentiality, may help.

Implementation considerations

Implement universal screening and follow-up for adolescents, starting with depression screening.

As with depression screening for adults, the most commonly used instrument for depression screening in adolescents is the PHQ-9. Teams often start with one depression screening questionnaire for all age groups and then, as they develop skills and internal capacity at screening and managing behavioral health care, they consider utilizing tools specific to different age groups or populations. The PHQ-A is an adolescent-specific version of the PHQ-9 and, therefore, is a natural tool to transition to when seeking a screening tool more specific to adolescents. There are two HEDIS measures for depression screening, one specific to a validated measure of depression and another specific to the PHQ-9. While, in general, PHMI advocates the use of the PHQ-2 or PHQ-9 for depression screening, more generally, there are some practices who have developed familiarity and ease with utilizing other validated tools. For a summary of additional validated tools for mental health screenings for adolescents, the American Academy of Pediatrics compiled this table. As with depression screening for adults, it is important to use a validated tool for which staff have been adequately trained to administer, score and interpret.

For adolescents, screening responses can come from the patient or their caregiver but ideally adolescents are interviewed separately from their parents/caregivers. All positive screening results should lead to additional assessments to confirm diagnosis, determine symptom severity, assess suicide risk and identify comorbid psychological problems.

While it is an important practice to screen for depression, not all young people at risk for suicide will endorse or experience symptoms of depression. Depression screening is best utilized alongside suicide risk screening; for instance, using the PHQ-A and the Ask Suicide-Screening Questions (ASQ). As mentioned above, screening for suicide alongside depression screening may be achievable as your integrated behavioral health care model evolves or may be something that your team is ready to test now.

As your team develops confidence to assess and manage depression, expand to screen for other BH needs, such as anxiety and attention deficit hyperactivity disorder (ADHD). Consider tools, such as the adverse childhood experiences screen for adolescents (PEARLS), the Pediatric Symptom Checklist (PSC) and/or the CRAFFT for substance use.

Evidence base for this activity

• Garcia JL. Historical Trauma and American Indian/Alaska Native Youth Mental Health Development and Delinquency. New Directions for Child and Adolescent Development. 2020 Jan;2020(169):41–58.
• Patra KP, Kumar R. Screening For Depression and Suicide in Children [Internet]. PubMed. Treasure Island (FL): StatPearls Publishing; 2022. Available from: https://www.ncbi.nlm.nih.gov/books/NBK576416/
• Viswanathan M, Wallace I, Middleton JC, Kennedy SM, McKeeman J, Hudson K, et al. Screening for Depression, Anxiety, and Suicide Risk in Children and Adolescents: An Evidence Review for the U.S. Preventive Services Task Force [Internet]. PubMed. Rockville (MD): Agency for Healthcare Research and Quality (US); 2022. Available from: https://www.ncbi.nlm.nih.gov/books/NBK585407/
• Zuckerbrot RA, Cheung A, Jensen PS, Stein REK, Laraque D. Guidelines for adolescent depression in primary care (GLAD-PC): Part I. practice preparation, identification, assessment, and initial management. Pediatrics [Internet]. 2018 Feb 26;141(3):1–21. Available from: https://pediatrics.aappublications.org/content/141/3/e20174081

KEY ACTIVITY #14C:

Manage Treatment of Adolescents’ Behavioral Health Needs in Integrated, Person-Centered Ways

This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; behavioral health integration.

Overview

This activity provides general recommendations on treatment of adolescents’ behavioral health needs in integrated and person-centered ways. As with adults, evidence-based care practices include the following singularly or in combination:

• Psychopharmacology, including referring out or leveraging same-day consults with child psychiatrists (described below) when needed.
• Behavioral health interventions such as Motivational Interviewing, Acceptance and Commitment Therapy, Problem Solving Therapy-Primary Care, Cognitive Behavioral Therapy, Interpersonal Counseling, Behavioral Activation, Dialectical Behavior Therapy (DBT), and Acceptance and Commitment Therapy (ACT).
• Peer support.

For additional information regarding behavioral treatment in general, please refer to the PHMI People with Behavioral Health Conditions Guide activity around embedding evidence-based care practices. The provision of these services differs for adolescents, as it is ideally provided by clinicians who have training, experience and comfort in responding to the behavioral health needs of adolescents.

Model recommendations for treatment that resonate with youth include:

• Involving youth as partners in project design.
• Implementing and monitoring recommendations made by youth.
• Considering the ways that a fundamental understanding and respect for youth can be incorporated into ongoing outreach efforts.

Confidentiality and adolescent care

Youth list concerns about confidentiality as the number one reason they might forego medical care. For this reason, youth need assurances of privacy and confidentiality from their healthcare providers. However, many providers feel overwhelmed or in the dark about the myriad of laws governing confidentiality and their responsibilities in minor consent laws and reporting child abuse. It is beyond the scope of this activity to include all relevant details, but it is encouraged that teams take advantage of resources, such as Understanding Confidentiality and Minor Consent in California: An Adolescent Provider Toolkit and familiarize themselves with charts, such as California Minor Consent and Confidentiality Laws. Given that parents’ rights to access adolescent medical records depend upon the health service provided, who consented or could have consented for the service, and the service provision site, in most cases, parents will have a right to access their child’s records. However, in some cases, parents cannot access records until their teen provides them with written authorization.

Teams need to consider what processes and workflows are necessary to maintain confidential records in the EHR setting. This includes training staff to know how to document in a manner that maintains adolescent confidentiality. In addition, they should provide education about parental access to medical record information to adolescents and their families. As communication such as texting and portal emailing become more ubiquitous, teams must consider alternative mechanisms by which to communicate with adolescents about the elements of their medical record that they want to be kept confidential.

Evidence base for this activity

Zuckerbrot RA, Cheung A, Jensen PS, Stein REK, Laraque D. Guidelines for adolescent depression in primary care (GLAD-PC): Part I. practice preparation, identification, assessment, and initial management. Pediatrics [Internet]. 2018 Feb 26;141(3):1–21. Available from: https://pediatrics.aappublications.org/content/141/3/e20174081

KEY ACTIVITY #15:

Strengthen Community Partnerships

This key activity involves all seven elements of person-centered population-based care: proactive patient outreach and engagement; care coordination; address social needs.

Overview

Strengthening partnerships with community-based organizations that share the practice’s vision and goals for their patient population enables the practice to provide more holistic care to patients and leverage many of the strengths and resources available in the community. These partners provide various services and programs to the community, such as education, housing, food, transportation, employment and social support.

This activity provides considerations and tips for strengthening partnerships, although note that deep engagement in this work can require significant resources from your practice.

Action steps and roles

1. Start by understanding the resources and partnerships available through Medi-Cal.

Suggested team member(s) responsible: Clinic operations and leadership staff who will liaise with community partners.

Resources include supports that are available to all Medi-Cal patients, such as transportation to medical appointments, as well as Medi-Cal Community Supports for eligible individuals with higher levels of social needs. The following is a list of social support resources that are available to Medi-Cal patients when eligibility criteria are met.

• Transportation to medical and other Medi-Cal-covered appointments.
• In-home supportive services, such as personal home care assistance for those who qualify.
• Community-based adult services, such as day programs outside the home for individuals who need assistance with activities of daily living.

For individuals with the highest needs, the 14 Medi-Cal Community Supports are:

• Housing transition navigation services.
• Housing deposits.
• Housing tenancy and sustaining services.
• Short-term post-hospitalization housing.
• Recuperative care (medical respite).
• Day habilitation programs.
• Caregiver respite services.
• Nursing facility transition or diversion to assisted living facilities.
• Community transition services or nursing facility transition to a home.
• Personal care and homemaker services.
• Environmental accessibility adaptations (home modifications).
• Medically supportive food and meals or medically tailored meals.
• Sobering centers.
• Asthma remediation.

For specific providers in your area, contact the provider services department of your Medi-Cal managed care plan to learn more about the providers of these services. With a list of contracted community-based organizations, your practice can start to build relationships and support ongoing social needs for your patients.

For an overview, DHCS has provided information about the current state of Enhanced Care Management and Medi-Cal Community Supports in the Community Supports Year 1 Summary and the Enhanced Care Management Year 1 Summary.

2. Complete an environmental scan to understand who your patients identify as trusted messengers and resources in their community.

Suggested team member(s) responsible: Health center leadership, community health workers, care coordination staff.

This can be completed by interviewing patients and families, especially with the assistance of community health workers as adept listeners. Confirm existing partner relationships. After that, a stakeholder map and community profile of key current and prospective partners can be developed.

For pediatric populations, key community partners include schools, libraries, child welfare agencies, food assistance programs, and community-based programs (e.g., early literacy, youth activities).

3. Convene partners as a work group to develop strategies and interventions to address health-related social needs.

Suggested team member(s) responsible: Health center leadership.

In some cases, your practice may serve as a convener, bringing partners together for collaboration to avoid relying on individual relationships with external organizations. Be clear on your asks and offers to ensure the relationship will be mutually beneficial.

Develop a shared aim statement with your partners as to why this work is important and your vision of what you hope to achieve. Following the aim statement and formalize your structure and system of collaboration accountability for progress in the form of ongoing pacing of meetings on a regular basis rather than relying on transactional relationships.

To ensure proper understanding of expectations, roles and commitments, memorandums of understanding should be developed. Of note, California has data-sharing requirements for clinics and community-based organizations that help with referrals, coordination and data-sharing. Some organizations will be required to share data through the California Data Exchange Framework (DxF) starting in January 2024.

4. Collaborate with your partners to co-develop and deliver on a shared set of strategies on a community approach to address health-related social needs.

Suggested team member(s) responsible: Health center leadership.

The practice should benchmark and collate approaches to identify potential interventions for addressing health-related social needs. Developing a driver diagram can help guide your efforts and to set priorities. Leverage CalAIM resources as part of your intervention plans.

Use workflow mapping tools, swim lane diagrams and checklists that clarify roles and plan initiatives. This allows for the practice to develop clear action plans clarifying leaders of intervention strategies, timetables and measures of progress and success.

KEY ACTIVITY #16:

Offer Nonpractice-Based Access to Immunizations

This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; proactive patient outreach and engagement; address social needs.

Overview

Reliable, timely access to immunizations remains difficult for many patients and families for a variety of reasons. During the COVID-19 pandemic, childhood immunization rates declined, particularly for children in families living below the federal poverty limit and in rural areas. Practices can consider promoting vaccinations at community-based pharmacies or developing mobile vaccination centers as potential strategies to provide access to recommended immunization for children and youth.

Leveraging this intervention to improve equitable health outcomes and social needs

Children from families with lower socioeconomic status are less likely to complete all well-child visits (WCVs) and therefore less likely to benefit from vaccination strategies that revolve around use of WCVs. Providing alternate means for vaccination reduces barriers to access and can contribute to mitigating inequities in health and well-being experienced by children based on race, ethnicity, and class. This intervention may be particularly relevant for children living in rural areas, given that they have experienced lower childhood immunization rates than children living in non-rural areas.

KEY ACTIVITY #17:

Expand Dyadic Care to Provide More Comprehensive Social and Behavioral Health Services

Overview

The Center for Advancing Dyadic Care in Pediatrics offers the following summary of dyadic care: “Infant and early childhood practitioners recognize the inextricable link between a young child and their caregiver and caregiving environment, making the relationship between the child and their caregiver and environment the focus of interventions. Dyadic care in pediatric primary care means expanding the focus of pediatric visits to include screening and support for caregivers, families and other environmental factors that will inevitably impact child health. Typically, dyadic care is provided by another member of the healthcare team, such as a licensed behavioral health provider or a community health worker who works alongside a pediatric healthcare provider.^[67]

Why this matters

Dyadic care supports child development and mental health by treating children and caregivers together. Dyadic therapy models, such as HealthySteps and child parent psychotherapy (CPP) have a strong evidence base^[68][69] for focusing on the dyadic infant and caregiver relationship to mitigate effects of trauma and adversity experienced in early childhood.

Technology Considerations

Technology-enabled screening can be utilized to screen caregivers directly in the EHR, in applications used by care coordinators, and directly to patients via patient-facing outreach and engagement technologies.

Screening results may already exist for caregivers who are already enrolled patients. Health centers will need to determine a strategy to link results to the pediatric record and, where possible, to the caregiver’s record and manage any needed referrals.

KEY ACTIVITY #18:

Continue to Develop Referral Relationships and Pathways

This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; pre-visit planning and care gap reduction; care coordination; address social needs.

Overview

Delivery of primary health care encompasses not only preventive services and coordination of medical and behavioral healthcare but also referrals for social supports, dental care and other needs of patients, such as weight management or parenting programs. As a result, coordination of care is more complex and often involves referrals outside the practice structure. Examples include referrals from the practice to a provider, such as medical specialty providers, behavioral health, and social services providers, such as the Supplemental Nutrition Program for Women, Infants, and Children (WIC), CalFRESH, CalEarn, the Employment Development Department (EDD) for paid family leave or to a program which will support health and well-being. A referral network also includes acute and subacute facilities, such as hospitals, emergency departments and residential treatment facilities where a patient may receive treatment and the outcome of treatment is necessary for the ongoing care of the patient in the practice.

This activity addresses common steps that your practice can take to optimize both the referral pathways and outcomes. The practice of closed loop referrals in which there is a feedback mechanism to ensure that a referral made by one provider to another is completed and followed up appropriately leads to greater patient and provider satisfaction. This activity builds on an inventory of existing referral services outside the clinic and identifies steps that can be taken to support the systematic management of the referral process.

Action steps and roles

1. Identify types of referral partners that your practice needs and gaps in resource availability.

• Some examples to consider: High volume specialties (e.g., allergy, behavioral health, occupational therapy, physical therapy, pulmonology), parenting support programs, and social services providers.
• In areas where you have gaps in referral providers, telehealth services may be an option. For further information on telehealth services, including e-consult, synchronous, asynchronous, and e-visits, contact your managed care plan and/or refer to Telehealth Reimbursement Guide (Pages 14-16). Referral processes and tracking are also important to establish for telehealth as well as in-person services.
• Note that there is a shortage of behavioral health clinicians in many parts of California. As you continue to expand your network of off-site behavioral health providers to meet pressing behavioral health needs, also consider behavioral health integration strategies, including expanding your practice’s capacity for providing integrated behavioral health services. See the PHMI People with Behavioral Health Conditions Guide for more about deepening and expanding integrated care.
• Work with the pediatric care teams to identify gaps in referral resources that could enhance implementation of evidence-based care.
• Use social health screening results that have been disaggregated by REAL and SOGI alongside patient and family feedback to identify unmet needs for which resource relationships have not been established.

2. Assess what tools would be beneficial for the core elements of your referral process.

Examples include (see resources below):

• Referral request form.

Determine what information is required for the provider who is receiving the referral. Information may include the requested service, timing (urgent vs. standard), minimum necessary information, such as patient contact information and applicable demographics, and appropriate clinical and social support questions.

• Referral tracking spreadsheet or software.

Information in a tracking system can include the date of referral, appointment status, and whether follow up is needed. Reach out to your Medi-Cal managed care plans as you are developing referral tracking processes. The MCPs are required to show that Medi-Cal patients are being connected to the services that they are eligible for and referred to; this includes preventive services, specialty services and social services. The MCP may be a good resource for tools such as those needed for tracking and reporting.

• Referral workflow diagram.

A visual representation or workflow diagram can support staff in the referral process. IHI’s Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era provides a visual 9-step closed loop referral process for specialty referrals as well as suggestions for improving the process.

3. Assess what tools would be beneficial in enhancing and tracking your referral process.

• Referral guidelines:
  • For social services, positive responses to screening questions and tools may be the prompt for referral.
  • Other types of referrals may be optimized by having documented referral guidelines, such as information needed by specialty provider in order to best answer referral questions.
• Communication templates:
  • For high volume or frequent referral types, a standardized template for communication between the clinic and referral staff can help ensure that that essential information is conveyed efficiently. Examples may include referral letters, progress notes, post visit summaries of plan of care.
• Patient education materials (develop in conjunction with referral network):
  • Educational materials and resources for patients that explain the referral process and what to expect can enhance patient understanding and support referral completion. In addition, consider training medical assistants as well as any dedicated care coordination staff in evidence-based communication techniques such as teach-back or motivational interviewing to leverage team based-care in supporting the patient to follow through with the referral after the visit.

4. Develop approaches to fill resource gaps.

• Outreach to your Managed Care Plan (MCP) to understand what resources are available. MCPs are required to have on-line provider directories which include specialists, which can be a resource used by a clinic to help find contracted specialists near the patient's home. In addition to comprehensive networks of over a dozen core specialty providers and information on behavioral health and substance use resources, many MCPs are building links to access community based resources in addition to the 14 Medi-Cal Community Supports through referral platforms that act as a “hub” to coordinate social needs for patients.
• Identify external providers and community resources that can serve as partners in care, and use the established referral process to fill gaps in care they can address.
• Meet/schedule time with high volume providers, including community based organizations to develop a mutual understanding of goals of referrals and opportunities for development of shared process (e.g. referral form).
• The American Academy of Pediatrics offers a sample tool to develop a resource list.

5. Regularly review and update the referral processes and network.

• As new patient needs are identified, use that opportunity to identify potential resources and expand the referral network. If practices have trouble accessing a contracted specialist for their patient because of either overly long wait times or that they are longer accepting new patients, the MCP is required to approve an out-of-network referral to a more available specialist.
• On a periodic basis, review referral tracking reports to identify referral resources that are used most frequently and use that information to reinforce the relationships and provide feedback on value.
• Review referral tracking reports to identify resources for which loop closure is lacking or from whom required information is not being received on a regular basis. Outreach to these organizations to reinforce expectations or if necessary, identify a replacement resource for the network
• For going deeper in tracking quality improvement metrics, practices can develop metrics to assess the effectiveness of the referral network. This might include tracking referral completion rates, patient satisfaction, and time from referral to specialist appointment.

KEY ACTIVITY #19:

Provide Care Management

This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; proactive patient outreach and engagement; care coordination; behavioral health integration; address social needs.

Overview

Led by a care manager – a licensed clinician or a nonlicensed trained individual under clinical supervision – care management is an intervention intended to support the highest need individuals within your practice. Typically, these are individuals with multiple complex chronic illnesses and/or comorbid chronic medical and behavioral conditions. The services are more focused, require the development of a person-centered care plan, and are of higher intensity than care coordination services. A patient must consent to participate in care management activities. A care manager works directly with the patient and multidisciplinary care team members to identify, plan and implement person-centered goals and care. The care manager supports the individual in identifying and coordinating resources and referrals, as well as supporting self-management activities to attain optimal wellness.

There are varieties of care management, which differ in the population of focus, goals and intensity of support. The National Committee for Quality Assurance (NCQA) designates the following designations for care management programs:

• Complex case management.
• Transitional case management.
• High-risk and high utilization.
• Hospital case management.
• Organization-defined programs.

The DHCS Enhanced Care Management benefit is available to a range of high needs Medi-Cal MCP enrollees. With respect to pediatrics, children who are eligible for ECM have complex physical, behavioral, developmental and/or oral health needs (e.g., California Children Services, foster care, youth with clinical high-risk syndrome or first episode of psychosis).

Evidence base for this activity

• Chuang E, Pourat N, Haley LA, O’Masta B, Albertson E, Lu C. Integrating Health And Human Services In California’s Whole Person Care Medicaid 1115 Waiver Demonstration. Health Affairs. 2020 Apr 1;39(4):639–48.
• Tomoaia-Cotisel A, Farrell TW, Solberg LI, Berry CA, Calman NS, Cronholm PF, et al. Implementation of Care Management: An Analysis of Recent AHRQ Research. Medical Care Research and Review. 2016 Oct 23;75(1):46–65.

KEY ACTIVITY #20:

Strengthen a Culture of Equity

This activity builds off of Key Activity 4: Use a Systematic Approach to Decrease Inequities to provide strategies and in-depth resources that can help create or strengthen a culture of equity in your practice. The PHMI Equity Framework and Approach emphases that achieving long-term and sustainable improvements to health and racial equity for patients and the broader ecosystem requires a transformational shift at the organizational level. The following strategies can help practices strengthen a culture of equity:

• Demonstrate senior leadership ownership for and commitment to improving health equity.
• Understand and address internalized, personally mediated and institutionalized racism.
  • This should include ongoing learning and development activities on the full range of health equity topics (e.g., anti-bias, structural racism, race-based algorithms).
• Build organizational capacity to support efforts to improve health equity.
• Establish practices and policies to promote workforce diversity and provide culturally and linguistically appropriate care.
• Support policy efforts to eliminate inequities driven by social drivers of health.
  • This can take the form of joining advocacy efforts or participating in benefits created by recent policy reforms, such as connecting patients with Medi-Cal Community Supports for housing, asthma remediation or medically tailored meals. See Key Activity 7A: Develop a Screening Process for Social Needs and Adverse Childhood Experiences (ACEs) that Informs Patient Treatment Plans for a discussion on social needs.

APPENDIX A:

Sample Idealized System Diagram

FIGURE 21: WEAVING YOUR MEASUREMENT STRATEGY AND LEARNING SYSTEM INTO PRACTICE OPERATIONS

The below graphic provides an example to visualize the flow of information between a practice’s measurement strategy and actions at the practice and care team levels, including how to use the information for continual learning and improvement.

APPENDIX B:

Theory of Change

The key activities in this guide align with the PHMI theory of change for how practices can increase children’s immunization and well-child visit rates through three main drivers:

• Effective implementation of well-visit protocols.
• Patients eligible and due for visits and immunizations have the information, education and access needed for screening.
• Practices have needed resources and support.

FIGURE 22: PHMI CHILDREN DRIVER DIAGRAM

APPENDIX C:

C: Developing a Robust Measurement Strategy

FIGURE 23: DEVELOPING YOUR MEASUREMENT STRATEGY MILESTONES

The visual below illustrates the key milestones in the development of a robust measurement strategy.

FIGURE 24: DEFINITION AND EXAMPLES FOR MEASUREMENT STRATEGY MILESTONES

Figure 24 provides guidance on each of these milestones as you work to put in place a robust yet practical measurement strategy.

POPULATION HEALTH GUIDE FOR UNDERTAKING 3 PART DATA REVIEW

The three part data review is a tool that can be used to advance work related to population health. It draws on asset-based inquiry, to surface to identify needs and opportunities to understand the ways in which systems have discarded or undervalued the assets of individuals and communities. Groups can then work together to ensure that all can contribute to advancing population health and well-being and dismantling inequities. Access the full resource.

APPENDIX D:

Guidance on Technological Interventions

EHRs were primarily designed to manage individual patients rather than groups of patients. However, over time EHRs have increasingly added functionality for population-level quality reporting and management and some degree of care planning and care coordination, especially to support value-based care tracking and reporting. Practices should evaluate your EHR capabilities against specifically designed population management applications. While these applications require interface with the EHR, they generally offer additional functionality. While EHR solutions are integrated with EHR data, they still usually require import of data from outside sources to be optimally useful. Managed care organizations may provide care coordination and population management applications, but usually only for their own enrolled patients. EHR-based solutions may also pose challenges where groups of practices using different EHR solutions are collaborating in value-based care contracts.

In value-based care arrangements, practices are responsible for attributed patients who may have never been seen. Since these patients do not have records in the EHR, practices need to consider how they can manage these patients to engage them into care at the practice in the absence – at least initially – of the patients having records within the EHR. If your practice is using freestanding applications for this, they need the capacity to handle these attributed patients who have not been registered as patients.

FIGURE 25: CORE POPULATION HEALTH MANAGEMENT FUNCTIONALITY REQUIREMENTS

Figure 25 includes the technical functionalities required to support population management for pediatrics. These requirements can guide the evaluation of existing solutions or guide the development of requirements in evaluating potential new applications. The table also indicates the data sources required to enable the functionality.

FIGURE 26: USE OF TECHNOLOGY FOR RECOMMENDED SCREENING FOR FOUNDATIONAL KEY ACTIVITIES

This table identifies strategies for using digital tools to complete appropriate screeners as recommended by clinical guidelines. Using technology to facilitate screening may streamline the workflow and preserve patient confidentiality where necessary.

*A workflow for identifying emergent behavioral health risks and a workflow for preserving patient confidentiality should be codified.

FIGURE 27: USE OF TECHNOLOGY FOR PATIENT OUTREACH AND PRE-VISIT PLANNING FOR FOUNDATIONAL KEY ACTIVITIES

This table outlines the use of technology to facilitate specific activities and potential technology solutions that can optimize the uptake and efficiency of in-office visits.

FIGURE 28: USE OF TECHNOLOGY FOR ENHANCED PATIENT ENGAGEMENT AND VIRTUAL CARE FOR GOING DEEPER ACTIVITIES

The table identifies technology solutions to engage patients asynchronously from office visits for a variety of use cases to enhance care and patient experience.

FIGURE 29: USE OF TECHNOLOGY FOR INNOVATIONS IN CARE DELIVERY FOR ON THE HORIZON ACTIVITIES

The table describes technology strategies that can enhance care delivery by using artificial intelligence and advanced technology tools.