Journal of Pediatric Nursing (2015) 30, 416–420

TECHNOLOGY DEPARTMENT Editor: Karen Goldschmidt MSN, RNC

Karen Goldschmidt MSN, RNC

Developing a Statewide Electronic Public Health Care Coordination Tracking System Kathleen Bowers BSN, MA ⁎, Brenda Carradus RN, Camela Hinkeldey BSN, Peg Macek ARNP, Sharon Rettinger FN, Mary Tanner MSW, Melanie Tietz LBSW, Deanna Wahl University of Iowa Hospital & Clinics, Stead Family Department of Pediatrics, Division of Child and Community Health, Child Health Specialty Clinics Received 10 December 2014; accepted 10 December 2014

Sally and her family first came to Child Health Specialty Clinics (CHSC) when she was in 5th grade. She had a history of defiant and oppositional behaviors, had been seen by three different child psychiatrists, and experienced mostly fragmented care. At CHSC, Sally received a comprehensive assessment and was diagnosed with hyperactivity disorder, oppositional disorder, depression, and learning difficulties. CHSC’s care coordination team helped Sally and her family access an Intellectual Disability Home and Community Based Waiver, worked with school personnel to develop an Individualized Education Program, and provided ongoing medication management. Utilizing an electronic Care Coordination Tracking Log, the CHSC team members were able to integrate their efforts, work efficiently to coordinate Sally’s plan of care, and avoid duplication of services. With this steady support, Sally has matured into a healthy and positive student ready to transition into the adult world of care coordination.

Care coordination is “a patient- and family-centered, assessment-driven, team-based activity designed to meet the needs of children and youth while enhancing the caregiving capabilities of families” (Antonelli, McAllister, & Popp, 2009, p. 1). According to the American Academy of Pediatrics (AAP, 2014) care coordination is particularly important for children and has been identified as an important component of improving population health by ⁎ Corresponding author: Kathleen Bowers, BSN, MA. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.pedn.2014.12.005 0882-5963/© 2015 Elsevier Inc. All rights reserved.

the Institute for Health Care Improvement's [IHI] Triple Aim Initiative (2014a). Child Health Specialty Clinics As there was an increas(CHSC) is a community-based pubing need for measuring lic health agency that serves Iowa care coordination using children and youth with special electronic data, Child health care needs. CHSC recognizes Health Specialty Clinics the importance of the family, the developed an electronic school, and the community in the care coordination trackchild's life, and seeks to promote the ing system for their full potential of every child by organization. addressing their physical, emotional, intellectual, cultural, and social needs. This article describes how CHSC developed an electronic care coordination tracking log to capture the activities and time associated with care coordination. The electronic care coordination tracking log provided a mechanism through which all care is coordinated and documented, thus enabling a means to justify third party reimbursement.

Child Health Specialty Clinics There are an estimated 105,800 children in the state of Iowa who have special health care needs including chronic physical, developmental, behavioral, and emotional concerns. CHSC partners with families, communities, service providers, policymakers, and state agencies to ensure that Iowa's

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children receive services in a coordinated manner. CHSC is part of the Division of Child and Community Health in the Stead Family Department of Pediatrics at the University of Iowa. CHSC is also Iowa's Title V agency for children and youth with special health care needs (CYSHCN), and is funded through the Maternal and Child Health Block Grant (The U.S. Department of Health and Human Services, n.d.). Enacted in 1935 as a part of the Social Security Act, the Title V Maternal and Child Health Program is the nation's oldest federal-state partnership; Title V converted to a block grant program in 1981. CHSC has a network of 13 regional centers located in communities across Iowa and serves approximately 6,500 children and youth annually through several different programs (Figure 1). Staff members include registered nurses (RN), advanced registered nurse practitioners (ARNP), family navigators, social workers, and registered dietitians, all of whom use Epic, the University of Iowa's Electronic Medical Record (EMR). CHSC's care coordination activities include connecting families to community-based resources, empowering parents to advocate for their children at school, and coordinating services among primary care and specialty providers. CHSC needed to develop an effective, user-friendly method to capture care coordination activities.

Development of the Electronic Care Coordination Tracking Log As a first step, CHSC examined existing care coordination models to more comprehensively define care and to determine the most important elements to track. CHSC also developed care coordination standards (Figure 2) in accordance with the Standards for Systems of Care for Children and Youth with Special Health Care Needs (Association of Maternal and Child Health Programs [AMCHP], 2014). AMCHP is a national resource, partner and advocate for state public health

Figure 1

leaders and others working to improve the health of women, children, youth and families, including those with special health care needs. These standards provided the basis upon which the tracking log was built, with additional input from clinicians, care coordinators and program coordinators.

Evolution of the Tracking Log The initial tracking log captured the amount of time spent on chart review and care coordination, the number and types of referrals made for each patient, and the specific care coordination activities completed. The earliest versions of the tracking logs were developed using Microsoft Excel © and Microsoft Access © and were piloted by staff at one CHSC regional center. It was then rolled out to the other centers over a four month time period. Staff reported the original logs to be cumbersome; subsequently the care coordination team decided to embed the log into the EMR, Epic. The Epic-embedded electronic care coordination tracking log proved to be an easier method for providers to enter clinical notes. It allowed staff to easily query and report data (Figure 3). Using the Plan, Do, Study, Act (PDSA) quality improvement methodology (Institute of Health Care Improvement [IHI], 2014b), the care coordination team continued to meet during the implementation phase to evaluate the log and make necessary changes. Additional elements were added including referral sources and recent hospitalizations. Because it was important to capture and link data for reimbursement of CHSC services, the electronic care coordination tracking log was revised to be relational with billing procedures by defining billable and non-billable services using criteria needed to report outcomes to payers.

CHSC regional centers.

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K. Bowers et al.

Figure 2

CHSC care coordination standards.

Integration With Epic CHSC incorporated the information tracking log into the EMR as a “NoteWriter,” a form within Epic. This process required several months of work with the Epic developers, but once fully implemented enabled all staff to electronically document quantitative data elements and progress notes within the same system. The care coordination team developed a comprehensive training manual for the tracking log including step-by-step instructions and a question and answer section to provide users with a reference and operational prompts. A training DVD was also created and the care coordination team held webinars and conference calls with staff for ongoing troubleshooting. The training investment and additional staff feedback resulted in better consistency in data entered. The care coordination team has begun to use a peer review process in order to improve the quality of clinical notes and will continue to look for opportunities to improve the tracking. As new data collection requirements are introduced, a policy was implemented that changes could only be made to the NoteWriter once each quarter. This gives enough time to update the guidelines and distribute the information to staff in a timely manner.

In order to find experts in the area of care coordination standards and measurement to provide technical assistance to our team, CHSC applied for a technical assistance grant from the Maternal and Child Health Bureau. The grant was recently approved, and two experts on care coordination from the Stanford University Center for Health Policy/Center for Primary Care and Outcomes Research came to Iowa in October 2014 and provided two days of technical assistance to CHSC. The Stanford researchers helped the care coordination team determine how well CHSC's standards align with national guidelines, determine measurement systems for use in evaluating CHSC's care coordination efforts, and determine best practices for evaluating CHSC's care coordination from the data that is collected from the NoteWriter Care Coordination Tracking Log.

Future Plans Through recent strategic planning, including the technical assistance from the Stanford experts, CHSC identified opportunities to further refine the electronic care coordination tracking log, and to leverage the tool to enable performance

DEVELOPING A STATEWIDE PUBLIC HEALTH

Figure 3

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A screen shot of the CHSC Electronic Care Coordination Tracking Log data within Epic.

measurement and improve care delivery. High priority is to develop standard care plans for all patients and their families. These might be tracked using the tracking log, or some elements of the care plans might be populated using information from the log, such as, documenting contacts with families and coordination activities. Another area identified for future development is reporting on the process, quality, and value of care coordination using data from the tracking log. Because no measures exist off-the-shelf that would enable such reporting, organization-specific measures will likely need to be developed based on current care coordination frameworks, CHSC needs and goals, and data available within the electronic care coordination tracking log currently or in future iterations.

Summary CHSC is a community-based public health agency that serves Iowa CYSHCN. In order to develop standards for care coordination among CHSC's diverse programs and to quantify the time spent and specific activities associated with care

coordination, the electronic care coordination tracking log was embedded into the University of Iowa's EMR. Widespread use of the electronic tracking log has allowed for uniform data collection and reporting on a quarterly basis. The collection of robust care coordination data is an essential component of high-quality, family-centered care and is necessary for obtaining reimbursement from both public and private payers. This process resulted in an effective tracking tool and handbook to guide data collection and quality improvement as CHSC collaborates with partners across the state to better serve Iowa CYSHCN and their families. Members of the care coordination team hope that other organizations may benefit by using the CHSC model.

Acknowledgments We gratefully acknowledge the following individuals for their professional expertise with this project: Barbara Khal, MA, Executive Director of CHSC and Dr. Debra Waldron, MD, MPH, FAAP, Director of the Division of Child & Community Health at Stead Department of Pediatrics at the University of Iowa. We would like to have additional acknowledgement for her administrative assistance to Phyllis Wood.

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References American Academy of Pediatrics (AAP) (2014). Proven coding guidance from the American Academy of Pediatrics. American Academy of Pediatrics Coding Newsletter, 10 (Retrieved from http://coding.aap.org). Antonelli, R. C., McAllister, J. W., & Popp, J. (2009). Making care coordination a critical component of the pediatric health care system: A multidisciplinary framework. New Institute for Health Care Improvement’s (IHI). Association of Maternal and Child Health Programs [AMCHP] (2014). Standards for systems of care for children and youth with special health

K. Bowers et al. care needs. Lucile Packard Foundation for Children’s Health (Retrieved from http://www.amchp.org/AboutAMCHP/Newsletters/member-briefs/ Documents/Standards%20Charts%20FINAL.pdf). Institute of health Care Improvement [IHI] (2014). How to improve. Retrieved from http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx The U.S. Department of Health and Human Services ()). Title V Maternal and Child Health Services Block Grant Program. Retrieved from http:// mchb.hrsa.gov/programs/titlevgrants/index.html Triple Aim (2014). The IHI Triple Aim Initiative. Retrieved from York, NY: The Commonwealth Fund (http://www.ihi.org/engage/initiatives/ TripleAim/Pages/default.aspx).

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