The Minnesota ABCD III Initiative aims to improve care coordination for children's health development across four pilot sites. It establishes teams of primary care, mental health, and other professionals to better link services. The initiative uses a model of iterative testing and improvement. It also develops patient databases to help care coordinators track activities and carry out follow-ups. The goal is that care coordination efforts under this initiative will help pilot sites achieve certification as Minnesota Health Care Homes for ongoing sustainability.

1. Minnesota’s ABCD III Initiative: Communities Coordinating for Healthy Development May 23, 2011

2. Communities Coordinating for Healthy Development (CCHD) Project Activities Four pilot sites Teams consist of primary care, mental health, Early Intervention, school districts, public health, Head Start, parents State and local level activities Linkages between Departments of Education and Human Services, MN Help Me Grow, universal consent forms, policy changes, MOC4 Learning collaboratives, webinars, site visits, team meetings, use of referral/feedback forms

3. Model for Improvement Using Plan-Do-Study-Act (PDSA) cycles Methods project staff have used Aim Statement worksheets PDSA cycles Learning collaboratives Attend team meetings as invited Significant time spent on: Supporting teams in planning and implementing PDSA cycles Assisting teams in mapping workflow/protocol

4. Example PDSA Cycle Aim statement Using a revised Help Me Grow referral form will increase the number of outcomes the clinic receives back from Help Me Grow. Test of change (Who, What, When, How) Clinic will send the next 5 Help Me Grow referrals (birth-5 yrs) using the revised referral form. Form is faxed to Help Me Grow and the outcome of referral/assessment will be faxed back to clinic within 2.5 months of referral date. Measure Percentage of referral outcomes received back at clinic within designated time frame

5. Care Coordination Pilot sites expected to provide care coordination as part of CCHD initiative Designated care coordinator in the clinic Tracking care coordination activities (via patient database) Measuring level of care coordination Care plan one component of care coordination; can be informal

6. Patient Database Access database developed by the Minnesota Department of Human Services Stores information about the child that is needed for care coordination Multi-tabbed sections include: patient information, demographics, screening section, referral to Help Me Grow, referral to agency, specialist/ provider, care plan, communication with the family

7. Patient Database How the database supports care coordination activities Report function allows care coordinator to do his/her work Provides clinics with ‘ticklers’ to alert the care coordinator to any necessary follow-up Helps to carry out activities around new concepts of “follow-up” and “population level tracking”

9. Minnesota Health Care Homes Most pilot sites interested in MN Health care Home (HCH) certification CCHD expectations around care coordination, care plans and tracking set-up to parallel requirements of HCH Care coordination exists on a continuum Patient database can be used for more than just ABCD III activities Sustainability – HCH certification to reinforce communication and care coordination efforts

10. Contact Information Ruth Danielzuk [email_address] Meredith Martinez [email_address] Glenace Edwall [email_address] Susan Castellano [email_address] Catherine Wright [email_address]