Best Practices for Pediatric Care Measures
Member interventions conducted in conjunction with provider interventions
1. Telephone reminders were the most effective, increasing immunization rates fivefold.1
2. Tracking and outreach and the combination of patient and provider prompts were also effective, reporting immunization rates that were more than three times higher than those of the comparison groups. 2
3. Provider interventions included feedback to providers on their well-child visits rates and encounter/claims data review for missed opportunities such as performing well-child assessments during sick visits.
Electronic tracking tools and provider prompts
1. Implementing electronic tracking tools and provider prompts were associated with greater provider satisfaction rates as well as increased well-child visit rates.3
2. Quarterly provider reports that highlight children in need of well-child visits are useful for promoting visit reminders and helping providers track their performance.
Multi-component and stepped interventions4
1. Performing language-appropriate patient reminders—including telephone calls, postcards, or letters—that vaccinations are due, or recalling patients as a reminder that vaccinations are past due.5
2. Expanding access to patients to make immunizations more convenient by offering “drop-in” clinics or an “express lane” vaccination services as well as increasing the hours during which vaccination services are provided.
1 Szilagyi, PG, Bordley, C, Vann, JC, et al. Effect of Patient Reminder/Recall Interventions on Immunization Rates: A Review. JAMA. 2000. 284(14):1820-1827.
2 Ibid.
3 Centers for Disease Control and Prevention (CDC). Epidemiology and Prevention of Vaccine-Preventable Diseases. 11th ed. Washington, DC: Public Health Foundation; 2009. Available at: http://www.cdc.gov/vaccines/pubs/pinkbook/pink-chapters.htm. Accessed on: May 18, 2010.
4 Hambridge SJ, Phibbs SL, Chandramouli V, et al. A Stepped Intervention Increases Well-Child Care and Immunization Rates in a Disadvantaged Population. Pediatrics. 2009; 124(2): 455-464.
5 American Academy of Pediatrics. Increasing Immunization Coverage. Pediatrics. 2010; 125(6): 1299-1304.
Page 1 3. Following up with non-responders by postcard and telephone for missed appointments and/or immunizations.
4. Allowing immunizations to occur in a clinical setting such as an emergency room.6
5. Offering case management and/or home visits for children still missing or behind on immunizations.
Improve access to care and transportation
1. Open access reduces well-child visit no-shows. Evening or weekend clinic hours for providers can accommodate parents who cannot take time off from work.7
2. Coordinate with community volunteers and other outreach services to provide transportation.
Partnerships with outside entities8
1. Partnering with Head Start Programs have been shown to be effective.
2. Sponsor a lead screening week.
3. Increase public and provider awareness.
4. State successfully linking surveillance databases.
5. A dental home is a source of continual, comprehensive oral health care that family members go to over time for all their dental needs.9
Alternative testing strategies
1. Sending referrals for screening directly to parents of children who have not been screened on behalf of their clinician.
2. Parents have reported that testing in a physician office is preferable than having to travel elsewhere.
6 Centers for Disease Control and Prevention. MMWR. Vaccine-Preventable Diseases: Improving Vaccination Coverage in Children, Adolescents, and Adults: A Report on Recommendations from the Task Force on Community Preventive Services. June 18, 1999/48 (RR-8);1-15 Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4808a1.htm. Accessed on: January 10, 2011.
7 Ibid.
8 Shefer A, Briss P, Rodewald L, et al. Improving Immunization Coverage Rates: And Evidence-based Review of the Literature. Epidemiological Reviews. 1999. Available at: http://epirev.oxfordjournals.org/cgi/reprint/21/1/96. Accessed on: May 18, 2010.
9 The Kaiser Commission on Medicaid and the Uninsured. Dental Coverage and Care for Low-income Children: The Role of Medicaid and SCHIP. Available at: http://www.kff.org/medicaid/upload/7681-02.pdf . Accessed on: June 25, 2010.
Page 2 3. Additional testing venues could include public health department clinics, WIC program offices, school-based health clinics, child care centers, and, where permissible, pharmacies.
Immunization registries
These benefits include: (1) reducing or eliminating the need for physician office staff to conduct manual chart abstraction to collect immunization data and (2) assisting in identifying high-risk, under-immunized patient groups, which allows providers to focus their outreach time and money on the children most in need.10
1. Incentivize providers who report to an immunization registry.
2. Providing electronic reminders to providers for needed immunizations.
3. Registries will allow for analysis of reducing the distance from vaccination settings to patient homes, increasing or changing hours to include after-hours or weekend services, and developing “drop-in” clinics or “express lane” vaccination services.11
Systematic follow-up for children with ADHD
Effective treatment for ADHD should enhance children’s functioning in academic and social areas in addition to reducing core symptoms.
1. Physicians and/or plans should stress importance of initial and ongoing education about ADHD.12
2. Build an ADHD Tool Kit.13
Repeat information/emphasize common message
1. Educational material was available for parents at the time of a visit.
2. Gift certificates for members with documentation of a well-care visit.
10 Canavan BC. “Using registry data to improve immunization rates for children covered under Medicaid Managed Care.” Presented at the 36th National Immunization Conference of CDC. 2002. Available at: http://cdc.confex.com/cdc/nic2002/techprogram/paper_210.htm. Accessed on: June 1, 2010.
11 Centers for Disease Control and Prevention. MMWR. Vaccine-Preventable Diseases: Improving Vaccination Coverage in Children, Adolescents, and Adults: A Report on Recommendations from the Task Force on Community Preventive Services. June 18, 1999/48 (RR-8);1-15 Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4808a1.htm. Accessed on: January 10, 2011.
12 MDwise Hoosier Alliance Resource Catalog. Follow-Up Care for Children Prescribed ADHD Medication Guidelines. Available at: http://www.hoosieralliance.org/pdf/provider/provcom/quality/adhd.pdf. Accessed on: June 16, 2010.
13 Harvard Pilgrim Health Care. Network Leader: ADHD program goals: active care coordination; HEDIS best practices. Available at: https://www.harvardpilgrim.org/portal/page?_pageid=253,244914&_dad=portal&_schema=PORTAL. Accessed on: June 21, 2010.
Page 3 Page 4 Best Practices for Women’s Care Measures
Physician and patient reminders14
1. Provide a list of patients who were identified as not having received a screening within the specified time frame to physicians for follow-up.
2. Sending these missed-screening lists to both PCPs and OB/GYNs will make it harder for women to evade or ignore promptings from their physicians.15
3. Make patient reminder and/or educational materials eye-catching, timely, and personalized, such as birthday cards.
Alternative types of providers
1. Place a mobile mammography unit in community settings, such as schools, retail facilities, instead of work sites.
2. Provide direct access to OB/GYNs.16
3. Collocating gynecological services within an HIV clinic.17
Train practitioners in communication skills
1. Conducted either as an in-house program or through outside organizations in a workshop or seminar setting.18
14 Task Force on Community Preventive Services. Recommendations for Client- and Provider-Directed Interventions to Increase Breast, Cervical, and Colorectal Cancer Screening. American Journal of Preventive Medicine. 2008; 35(1 Supplement): S21-S25.
15 National Committee for Quality Assurance. Breast Cancer Screening: Raising Member and Physician Awareness. Quality Profiles. 2008. Available at: http://www.qualityprofiles.org/quality_profiles/case_studies/Womens_Health/ 1_14.asp. Accessed on: May 6, 2010.
16 National Committee for Quality Assurance. 2008. Quality Profiles. Available at http://www.qualityprofiles.org/quality_profiles/case_studies/Womens_Health/2_9.asp. Accessed September 8, 2009.
17 AHRQ Health Care Innovations Exchange. Co-locating gynecological services within an HIV clinic increases cervical cancer screening rates, leading to identification and treatment of many cancer cases. Available at http://www.innovations.ahrq.gov/content.aspx?id=2393. Accessed September 22, 2009.
18 Agency for Healthcare Research and Quality. The CAHPS Improvement Guide. Available at: https://www.cahps.ahrq.gov/QIGuide/content/interventions/Training2AdvanceSkills.aspx. Accessed on: April 26, 2010.
Page 5 2. Optional most of the time with training required for doctors who consistently receive low scores in the area of communication.19
Improving Access and Awareness20
1. Provide priority scheduling to late-entry prenatal patients.
2. Offer incentives for timely prenatal and postpartum visits.
3. Extend hours, expand network, and more female physicians.
4. Provide bus tokens or taxi vouchers.
5. Schedule postpartum appointments at 36 weeks gestation.
Physician tools and resources
1. Patient registry of females who have received screenings.
2. Copies of reminder letters sent to patients who are due for screenings.
3. List of patients, with contact information, who have not received screenings.
4. Coordinate care and validate practice guidelines.
Chlamydia educational materials developed and distributed separately
Distribution of materials for chlamydia screening occurs less frequently; the material is not as readily available, and the mailings combine many topics together.
1. Collect urine samples at the beginning of all gynecological visits.21
2. Outreach efforts should focus on the younger age group and could be tied in with efforts to increase Adolescent Well-Care Visits.
19 Agency for Healthcare Research and Quality. The CAHPS Improvement Guide. Available at: https://www.cahps.ahrq.gov/QIGuide/content/interventions/Training2AdvanceSkills.aspx. Accessed on: April 26, 2010.
20 Health Services Advisory Group. Validation of Performance and Quality Improvement Projects. Studies validated between 2004 and 2009.
21 NCQA. 2007. Improving Chlamydia screening: strategies from top performing health plans.
Page 6 Implementing standard interventions for cervical cancer screening
1. Modifying the standard interventions of health plans to reach these subgroups is an effective method for increasing screening rates.
2. Continually modify those interventions to respond to changes in subgroup behaviors.
3. Provide education to help modify attitudes and subsequent behaviors.
Page 7 Best Practices for Living with Illness Measures
Comprehensive Diabetes Care
1. Create and promote support groups22 23
a) operate under the idea that patients can learn to take responsibility for day-to-day disease management;
b) can be held face-to-face or via the Internet; and
c) encourages self-care, provide emotional support, and offer other types of support (e.g., getting groceries and medical transportation).
2. Institute a Diabetic Health Management Program24 25
a) encourages healthy eating and weight loss programs, and
b) inform providers of any member incentives.
3. Patient Outreach include:26
a) reminder systems for preventive care;
b) provider education and report cards;
c) incentives to compliant members (also informs providers); and
d) organizes follow-up system.
22 Lorig K, Sobel D, Stewart A, et al. Evidence Suggesting That a Chronic Disease Self-Management Program Can Improve Health Status While Reducing Hospitalization: A Randomized Trial. 1999. Available at: http://www.des.emory.edu/mfp/Bandura1999MC.pdf. Accessed on: September 22, 2010.
23 Agency for Healthcare Research and Quality. The CAHPS Improvement Guide. Available at: http://www.cahps.ahrq.gov/qiguide/. Accessed on: April 26, 2010.
24 National Diabetes Information Clearinghouse. What I Need to Know About Eating and Diabetes. Available at: http://diabetes.niddk.nih.gov/dm/pubs/eating_ez/index.htm. Accessed on: April 14, 2010.
25 About.com. The Health Benefits of Losing Weight. Available at: http://weightloss.about.com/library/ blhealthbenefits.htm. Accessed on: April 14, 2010.
26 Nilasena DS, Lincoln MJ. A Computer-Generated Reminder System Improves Physician Compliance with Diabetes Preventive Care Guidelines. Proceedings of the Annual Symposium on Computer Application in Medical Care. 1995. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2579172/. Accessed on: April 14, 2010.
Page 8 Controlling Blood Pressure
1. Many of the same best practices used for Comprehensive Diabetes Care may also be used as best practices for Controlling High Blood Pressure.
a) Support groups;
b) healthy eating and weight loss programs;
c) reminder systems for preventive care; and
d) patient outreach
2. Stepped care approach to anti-hypertensive drug therapy27
a) helps simplify the medication regimen; and
b) could include refill reminders.
Asthma Management
1. Focus on patient-provider relationships, medication compliance, chronic disease management, and disease self-management.
2. Use the Asthma Return on Investment Calculator, developed by the Agency for Healthcare Research and Quality (AHRQ), to assess the financial justification.28 This is an online, evidence- based tool to estimate the potential health care cost savings and productivity gains of an asthma performance improvement program for a health plan’s Medicaid or commercial members.
Antidepressant Medication Management
1. A collaborative care model is an approach that overcomes barriers to care and can increase patients’ compliance with treatment. Collaborative care includes:
a) A care manager provides close follow-up, more education, and self-management support to the patient. The care manager can also provide brief counseling and help patients who should return to PCPs or mental health facilities. For patients who show improvement, the case manager can help prevent relapse.
27 Fahey T, Schroeder K, Ebrahim S, et al. 2006. Interventions used to improve control of blood pressure in patients with hypertension. Cochrane Database of Systematic Reviews. Issue 4. Art. No.:CD005182. DOI: 10.1002/14651858.CD005182.pub3.
28 Agency for Healthcare Research and Quality. Asthma Return-on-Investment Calculator. Available at: http://statesnapshots.ahrq.gov/asthma/. Accessed on: May 24, 2010.
Page 9 b) A consulting mental health expert (psychiatrist) supervises the case manager and the case load. This team member is available for diagnostic consultation on challenging cases.
c) Systematic diagnosis and outcomes tracking such as the Patient Health Questionnaire (PHQ-9) helps make a dichotomous diagnosis and helps track depression outcomes.29
d) Step care involves altering treatment according to evidence-based algorithms. The alterations should help the patient improve. The changes should be assessed when patients reach remission, and relapse prevention information should be provided.
29 5- Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a Brief Depression Severity Measure. Journal of General Internal Medicine. 2001; 16(9):606-613.
Page 10 Best Practices for Access to Care Measures30
Educating patients on health care navigation
Establishing a member awards program
Coordinating transportation
Participating in health fairs
Providing a “medical home”
Convenient service hours
1. Additional considerations:
a) Conducting provider/office personnel in-services.
b) Providing follow-up reminder letters and phone calls.
c) Keeping wait times to a minimum.
d) Providing convenient service hours.
e) Promoting access and patient flow.
f) Keeping medical records for all family members in one folder.
g) Providing Web-based clinical guidelines.
h) Supplying a refrigerator magnet with plan contact information to members.
i) Encouraging patient-provider joint decision making through a patient action plan.
j) Providing a post-visit summary that includes the provider seen, location, diagnosis, medications being taken and/or prescribed, and referrals.
30 Silow-Carroll, S, Alteras, T, Stepnick, L. Patient-Centered Care for the Underserved Populations: Definition and Best Practices. Economic and Social Research Institute. 2006.
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