Developing population health in Cincinnati

1. Population and Community Health: A
Quality Improvement Approach
Robert Kahn, MD MPH
Anderson Center
General and Community Pediatrics
Nov 20, 2013

2. Overview of Community Health
Asthma
– health inequities, community partnerships,
community capacity
Infant prematurity
– total population, common metrics, user centered
design
Early child development
– Kindergarten readiness; alignment strategies –
model and narratives; community dashboard

3. Population
Hamilton County: 190,000 children age birth -17yrs
Goal and Initiatives
Purpose
Lead, advocate and collaborate to measurably improve the health of
local children and reduce disparities in targeted populations
High Level Measures
By June 30 2015,
• Reduce the occurrence of unintentional pediatric injuries 30%
• Reduce infant mortality by 15%, 20 infant deaths per year
• Reduce the use of the ED and inpatient services by 20% in children with
asthma covered by Medicaid
• Reverse the trend of increasing childhood obesity in grades K-3

4. Drafted:
Key Driver Diagram
GLOBAL AIM
Lead, advocate &
collaborate to
measurably improve the
health of local children
and reduce disparities
in targeted populations.
AIM
By 2015:
• Reduce the
occurrence of
unintentional
pediatric injuries 30%
• Reduce infant
mortality 15%
• Reduce the use of
the ED and inpatient
services by asthmatic
children 20%
• Reverse the trend of
increasing childhood
obesity
KEY DRIVERS
Highly effective organizational
capacity aligned with existing
hospital, community assets
Community listening, engagement, leadership, oversight
Trust, relationship, and partnership building
Mechanism for shared resource allocation
Sense of urgency to act and learn
•
•
•
•
•
Transparent measurement and
results sharing that drives
continuous learning
Effective, efficient and reliably
linked services and supports for
families to ensure EVERY
child’s needs are met
SECONDARY DRIVERS
•
•
•
•
Shared vision, leadership, and
accountability to improve
outcomes, experience, and cost
Parents and communities
empowered to meet families’
health needs
June 2011
Measure and share performance data monthly
Reliable data systems and IT platform
Involve families, community leaders on improvement teams
Customized QI support to teams to optimize learning
Best practices for knowledge sharing
•
•
•
•
•
Reduce social and physical barriers to optimal child health
Enhanced parental self management and caregiving capacity
Promoting collective efficacy of neighborhood s around health
Shifting cultural norms to promote health and well being
Parents, communities “owning” health data & results
•
•
Evidence based inventory of key system components
Highly reliable application of evidence based practice in all
system components
High connectivity between services, supports for families
Risk segmentation and shared population management
•
•
•
•
•
•
CCHMC alignment with Board, TCHRF, Divisions, CTSA,
Community Relations, Community Benefits
Strong functioning condition teams co-led w community
Development of core teams for QI, measurement, community
engagement, administration, and academics
Community leaders trainined in quality improvement

5. Model for Improvement
What are we trying to
accomplish? AIM
How will we know that a change
is an improvement? MEASURES
What change can we make that
will result in improvement? IDEAS
Act
Plan
(Adopt, Adapt or
Abandon)
Study
Langley et al. 1996
Do
Action Learning
Alignment
Capability
Capacity
Resources
Data comfort
Interfaces

6. Asthma
– health inequities
– community partnerships
– community capacity

8. 25
20
10
0
Camp Washington
Winton Hills
Over The Rhine
Walnut Hills
Avondale
Mt. Auburn
Fay Apt.
Lower Price Hill/Queensgate
Bond Hill
W. End
S. Cumminsvil-Millvale
Elmwood Plc.
N. Fairmount-English Woods
Evanston
Hartwell
Lincoln Hts.
Northside
Winton Place
Mt. Airy
College Hill
Evanston-E.Walnut Hill
W. Price Hill
Westwood
Roselawn
S. Fairmount
Kennedy Hts.
Fairview-Clifton
Carthage
Mt Healthy
N. Avondale-Paddock Hills
E. Price Hill
Riverside-Sayler Park
Golf Manor
Madisonville
Norwood
Forest Park
Sedamsville-Riveside
Springfield
Linwood-E. End-California
Cheviot
N. College Hill
Fairfax
Woodlawn
Pleasant Ridge
Corryville
Lockland-Arlington Hts.
Crosby
Mt. Washington
Springdale
Greenhills
Columbia
Silverton
Colerain
Sharonville
CBD Riverfront-Mt. Adams
Clifton
Delhi
St. Bernard
Oakley
Cleves
Mariemont
Wyoming
Harrison
Reading
Amberley Village
Univ. Heights
Sycamore
Green
Deer Park
Miami
Anderson
Blue Ash
Hyde Park
Symmes
Evendale
Whitewater
Newtown
Madeira
Glendale
Mt. Lookout
Montgomery
Harrison Twp.
Indian Hill
Addyston-N. Bend
Loveland
Mt. Lookout-Columbia…
Terrace Pk.
30
Asthma admission rate in Hamilton County, by n’hood
(Per 1000 children, avg over 2010-2012)
CCHMC has 90+% of all asthma admissions in county
Quintile 1:
• 18 admits among 29,000 kids
• 0.6 per 1000
• 17% of pop’n with 2% of admissions
15
Quintile 5:
• 299 admits among 17,900 kids
• 16.7 per 1000
• 11% of pop’n with 35% of admissions
5

9. Readmission and race
1.0
Percent notof not being readmitted
Probability yet readmitted
365 Days
0.9
White
0.8
African American
0.7
•
•
•
•
•
0.6
0.5
0
100
Difficulty readmitted at 12 months
• 19% making ends meet
Looking for work but being unable to find
• 23% of African American children
Financial11% of White rent or utilities
• difficult with children
Had to move in with others
No home/car ownership
200
300
400
500
Days from index admission
Days from index admission
Race
White
Black
600
700
Beck
800

10. Who are the critical partners?
•
•
•
•
•
•
Home health care
Pharmacies
Cincinnati Public Schools
Cincinnati Health Department
Legal Aid Society
Community health workers

11. Missed days of day care or school
(n=774)
30.0%
25.1%
25.0%
20.0%
23.5%
19.5%
15.0%
12.4%
10.0%
8.9%
4.8%
5.0%
3.1%
0.0%
Does not attend/work 0
1 to 3
4 to 6
7 to 10
11 to 15
2.7%
16 to 30
30+

14. Rapid Cycle Improvement Collaborative (RCIC)
Difficulty connecting to provider
Why ?
Get frustrated with appointment system
Don’t get the results they need
Why ?
Why ?
Conflict between what school nurse says regarding urgency of appointment
and what scheduling gives them. Parents feel “in the middle”
Limited contact between school nurse & provider re: urgency of appt
Why ?
Why ?
Caution: If your
last answer is
something you
cannot control, go
back up to previous
answer
No established process for communication between school nurse & providers
Root Cause

15. INTERVENTIONS
Process Name:
Student
asthma
education
Parent
asthma
education
CURRENT
PROCESS
Asthma data
validation
Student
identified with
Asthma
No health
history
FAILURE MODES
Parents misunderstand
diagnosis
Old or
incorrect
diagnosis
ACT
screening
training for
nsg students
Mass ACT
screenings
using CCHMC
protocol
ACT
obtained
Students
absent or
difficult to
locate
Questionable
skill level of
screeners
School admin
push-back
Physical
space
limitations
Breathing Room – CPS Health Team
ACT score
education
ACT score
validation &
respiratory
assessment
ACT score
<20
Fitness
levels
Illness
Unable to
reach parent
Discrepanci
es between
child &
parent ACT
staffing
Research re:
current Asthma
Action Plans.
Parent Inquiry
re:recent medical
visits (using #
from PS);
Ramp:student
interviews for #
Identify
Medical Home
Contact
identified
providers to
establish
expedited
appt process
Ramp:
contact all
named
providers
Care
Coordination
Comprehensive
process to
assure appt
scheduled &
completed at
established
medical home
Connection to
Medical Home
Lack of
monitoring
process
Unable to
reach
parents
No
transportation
No health hx
Insurance
issues
Info not in
PowerSchool
Transience
of students
Limited
provider
availability
No ongoing
care
No show
policies
Difficulty
getting appts
Staffing
caseload
HIPAA
Parent
doesn’t
consider
priority
No
emergency
meds/EAPs
Sustainability
issues

16. Rapid Cycle Improvement Collaborative (RCIC)
100
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
PDSA #6
persistant phone contact w/family &
provider
PDSA#5
visit medical home site
PDSA #4
Modify expedited process
PDSA#3
schedule appts
utilizing expedited
process
06/05/13 (n=49)
05/29/13 (n=49)
05/22/13 (n=48)
05/15/13 (n=48)
05/08/13 (n=48)
05/01/13 (n=48)
04/24/13 (n=48)
04/17/13 (n=47)
04/10/13 (n=46)
04/03/13 (n=46)
03/27/13 (n=46)
03/20/13 (n=45)
03/13/13 (n=45)
03/06/13 (n=45)
02/27/13 (n=45)
02/20/13 (n=42)
02/13/13 (n=39)
02/06/13 (n=39)
PDSA#2
develop expedited
PDSA #1
appointment
verification of medical home
process
with parent/AAP
01/30/13 (n=36)
% of students with ACT <20 with completed
medical home visits
Breathing Room:
% of students with poorly controlled asthma who completed medical
home visit (March 6--June 5, 2013)
weekly count of students with ACT score <20
cumulative percentages
median
Goal (60)

17. Cincinnati Asthma Admissions and
Neighborhood Asthma Hotspots

18. Legal Aid Housing Cases Mapped
Against Neighborhood Asthma Hotspots

19. James M. Anderson Center for
Health Systems Excellence
Percent of handoffs successful
Handoffs from pediatrics to legal aid
100%
80%
60%
40%
20%
0%
Jul-12
Rate
# of Referrals
Aug-12 Sep-12
Oct-12
Nov-12 Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13 Jun-13
83%
100%
100%
94%
94%
98%
100%
100%
100%
100%
100%
100%
64
57
49
71
67
46
73
57
43
53
81
60

20. James M. Anderson Center for
Health Systems Excellence
CCHMC-Health Department Referrals

21. James M. Anderson Center for
Health Systems Excellence
CCHMC-Health Department Referrals

24. Network of care for children with
chronic illness
community
health worker
schools
pharmacy
Figure. Collaborations between agencies serving children with complex chronic
conditions. Acad Ped 2012

25. Focus on the System
“Every system is perfectly
designed to get the results it gets.”
Paul Batalden
25

26. James M. Anderson Center for
Health Systems Excellence
Prematurity
• total population
• value of common metrics
• user centered design

28. Preterm birth in Hamilton County
All births
Preterm births*
National
Hamilton County
%
11.5
10,782
1460
13.5
Avondale
206
36
17.5
East, Lower Price Hill
356
64
18.0

29. James M. Anderson Center for
Health Systems Excellence
Local area preterm birth rates:
Developing interventions to cool ‘hotspots’

30. James M. Anderson Center for
Health Systems Excellence
Two smaller communities:
Smaller learning system then test scale
Target
Communities
Avondale
Price Hill
Totals
Total
Population
Women
15-44 yr
Annual Births
2009-2012
12,466
16,415
28,881
3,219
3,750
6,969
206
356
562
Annual Preterm
Births
2009-2012
36
64
100
Good Sam
Births
UH
Births
83
143
226
82
167
249
• In 2011 in these 3 zip codes 15 infants died
• Annually ~100 infants born <37 weeks gestation (17.8%)
• In Avondale alone, 5 infants at <30 weeks GA

31. James M. Anderson Center for
Health Systems Excellence
Measurement
Improve maternal and infant health with a focus on
prematurity and early infant ED usage
•
•
•
•
Percent of all pregnancies identified each month
Earlier gestational age at entry to prenatal care
Earlier gestational age at first prenatal home visit
Day of life for first newborn visit to health care

32. James M. Anderson Center for
Health Systems Excellence
Portfolio of Measures and Projects
• Percent of all new pregnancies identified each month
– Identify and link all prenatal care providers serving a region
– Begin collecting geographic identifiers for all patients
• Gestational age at entry to prenatal care
– Same day access for pregnancy test and 1st PN visit
– Community engagement – ethnography, community organizing
• Gestational age at first prenatal home visit
– Increase % of all eligible that are enrolled
– Improved engagement and referral strategies
• Day of life for first newborn visit to health care
– Electronic health record registry based on zip codes
– Test welcome call scripts, resource offerings

33. James M. Anderson Center for
Health Systems Excellence
Partnerships to reduce prematurity
Housing, partner violence, legal assistance, food assistance, mental health svcs
Prenatal1
Prenatal2
University Hospital
Pediatrics1
Prenatal3
Pediatrics2
Prenatal4
Pediatrics3
Prenatal5
Prenatal6
Good Samaritan
Hospital
Home visiting

34. 30
09/27/10
10/15/10
10/22/10
10/26/10
11/10/10
11/18/10
11/24/10
12/03/10
12/11/10
12/23/10
01/05/11
01/10/11
01/14/11
01/19/11
01/25/11
02/01/11
02/17/11
02/25/11
03/05/11
03/17/11
03/24/11
04/15/11
04/22/11
04/28/11
05/05/11
05/12/11
06/01/11
06/17/11
07/06/11
07/11/11
07/15/11
08/01/11
08/11/11
08/13/11
09/04/11
09/22/11
09/28/11
10/05/11
10/14/11
10/21/11
11/09/11
11/17/11
12/2/2011
12/19/2011
01/03/12
01/10/12
02/07/12
01/22/12
2/2/2012
2/11/2012
02/26/12
03/06/12
3/15/2012
3/28/2012
4/11/2012
4/16/2012
04/18/12
4/27/2012
5/3/2012
5/12/2012
5/21/2012
5/25/2012
6/7/2012
6/20/2012
06/28/12
7/9/2012
7/17/2012
7/19/2012
07/27/12
08/01/12
08/10/12
08/21/12
08/29/12
09/02/12
09/25/12
10/05/12
10/08/12
Age in Days
James M. Anderson Center for
Health Systems Excellence
Handoffs from birth hospital to clinic
90
80
C. Brown
70
RN welcome calls begin
60
50
40
14.4
20
10.1
10
0
Date of Birth
Age in Days
Average Age in Days
Control Limits

35. James M. Anderson Center for
Health Systems Excellence
Handoffs from pediatrics to home visiting
C. Brown
25
Newborn
Coordinators
Started
ECS Grand
Rounds,
Talking points
rolled out
20
15
10
5
Monthly Number of Referrals
08/01/13
07/01/13
06/01/13
05/01/13
04/01/13
03/01/13
02/01/13
01/01/13
12/01/12
11/01/12
10/01/12
09/01/12
08/01/12
07/01/12
06/01/12
05/01/12
0
04/01/12
Monthly Number of Referrals
30
Median

36. James M. Anderson Center for
Health Systems Excellence

37. James M. Anderson Center for
Health Systems Excellence
Early Child Development
• population of kindergarteners
• alignment strategies
• community dashboard

38. Birth to kindergarten readiness
Transforming Early Childhood Community Systems (TECCS)
• Goal: improve developmental and physical health outcomes
for children 0-5 years with focus kindergarten readiness
• Collaboration of all committed disciplines:
– physicians, early childhood education providers, social service
agencies, home visiting agencies, public, parochial schools
• Clear shared objectives, improvement science methods
• Partners - United Way, Kellogg Foundation, UCLA
• Begin in East, Lower Price Hill – but focus on spreadable
strategies

40. Kindergarten Readiness Assessment – Neighborhood Profile
40

41. Who is in - Child Denominators
“EVERY CHILD” (not „every child we serve‟)
M+F
All ages
M+F
0 to 5
Births
Hamilton County
802,374
58,104
11,373
East/Lower Price
16,415
1,745
339
East Price Hill
15,340
1,594
305
Lower Price Hill
1,075
151
34
41

42. PRICE HILL IMPROVEMENT COLLABORATIVE
Key Driver Diagram
GLOBAL AIM
Improve early childhood
physical
health, language, cognitiv
e, and social and
emotional development for
all children 0-5 in East and
Lower Price Hill
KEY DRIVERS
Leadership that builds shared purpose to
improve outcomes
Reliable linkages between services and
supports for children and families
AIM
Goals: (by 12/31/2013)
Outcome Measures:
•<30% of children score
”vulnerable” on one or more
EDI domains at kindergarten
•>3 percentage point increase
in children who score 19 or
above on the K-RAL
•<15% of children score as
moderate risk on the 36 mo
ASQ
•<20% of children score as at
risk on the ASQ:SE at 36 mo
•>10% annual increase in the
percentage of families read to
children daily
Parents empowered to meet their
child's, family’s and community’s needs
Effective and efficient services and
supports for families with young children
Transparent measurement and data
sharing to drive continuous learning and
application of QI
System of care meets the needs of every
child in East and Lower Price Hill
INTERVENTIONS
Drafted:
Revised:
Sept 19, 2011
May 6, 2011
• Align all participants around a compelling vision
• Build leadership knowledge, skills, and commitment
• Assume responsibility to drive outcomes
• Advocate for policy or community systems change
•Standardize referral and feedback process with mutually
understood eligibility criteria
•Enhanced communication to manage support for children at risk
• Enable new and better ways for parents to promote health
development
• Elicit parent concerns about learning development and behavior
• Provide parent education tailored to increase knowledge, self
confidence, and health promoting behavior
• Expanded, tailored parents services designed to build
parental capacity to meet needs of their families
• Promote and strengthen early literacy programs
• Improve capacity by better matching child need and existing
programs
• Expanded, tailored, office and home-based services focused on
development and health (e.g., ECE, medical, HV,, WIC, agency)
• Increase efficiency
• Measure and share performance data monthly to promote
learning
• Involve families on improvement teams
• Provide customized QI support to teams
• Develop data collection system to monitor progress
• Peer-to-peer communication facilitated by technology to share
knowledge and best practices
• Tailor care to needs and risks using stratification (e.g
low, medium, high)
• Define and develop core services and supports based on risks
and need (e.g., content/frequency/follow-up)
• Utilize a shared population registry across services/supports
• Optimize preventive and chronic care
(prevention, asthma, injury, obesity)

43. 43

44. Shared Mental Model:
In depth parent interviews, Why are you here?
Positives
•
•
•
•
•
•
GED/college aspirations
Literacy interests (supermarket coupons)
Pride: Staying “because I grew up here”
Strong matriarchy
Volunteerism – safety, community action teams
Existing parent groups – supported by nurse visitors, Santa Maria, Life Point
•
•
•
•
•
•
•
•
•
Periods of unemployment
Limited mental health services, dental care or regular adult HC
Safety/security issues
Perceived racism
Social isolation
Lack of afterschool opportunities
Possible lack of knowledge re Rec ctr, Boys and Girl Club opportunities
Self-reliance/trust issues – caregiver needing to be a ‘rock’
Homeless stretch
Why are YOU here?

45. Brown

46. Getting to the whole denominator
EVERY baby born into Lower and East Price Hill…
• To ensure each gets to his/her newborn visit, and connects
long term to a medical home
• Aligning clinics that see ~65% of babies born in the area
• Redesigning medical roles to reach out to new parents
PPC 110 babies/yr
Hopple 80 babies/yr
Price Hill HC ~160 babies/yr

47. 80
60
50
30
20
05/31/12 (n=09)
06/07/12 (n=08)
06/14/12 (n=05)
06/21/12 (n=08)
06/28/12 (n=11)
07/05/12 (n=05)
07/12/12 (n=09)
07/19/12 (n=09)
07/26/12 (n=07)
08/02/12 (n=07)
08/09/12 (n=03)
08/16/12 (n=06)
08/23/12 (n=05)
08/30/12 (n=16)
09/06/12 (n=07)
09/13/12 (n=11)
09/20/12 (n=16)
09/27/12 (n=09)
10/04/12 (n=11)
10/11/12 (n=08)
10/18/12 (n=14)
10/25/12 (n=07)
11/01/12 (n=13)
11/08/12 (n=13)
11/15/12 (n=15)
11/22/12 (n=06)
11/29/12 (n=05)
12/06/12 (n=10)
12/13/12 (n=09)
12/20/12 (n=03)
12/27/12 (n=01)
01/03/13 (n=16)
01/10/13 (n=14)
01/17/13 (n=13)
01/24/13 (n=10)
01/31/13 (n=09)
02/07/13 (n=12)
02/14/13 (n=06)
02/21/13 (n=05)
02/28/13 (n=06)
03/06/13 (n=11)
03/13/13 (n=07)
03/20/13 (n=10)
03/27/13 (n=10)
04/02/13 (n=06)
04/09/13 (n=10)
04/16/13 (n=06)
04/23/13 (n=12)
04/30/13 (n=12)
05/07/13 (n=12)
05/14/13 (n=09)
05/21/13 (n=04)
05/28/13 (n=05)
06/03/13 (n=17)
06/10/13 (n=14)
06/17/13 (n=12)
06/24/13 (n=17)
07/01/13 (n=06)
07/08/13 (n=12)
07/15/13 (n=05)
07/22/13 (n=07)
07/29/13 (n=14)
08/05/13 (n=10)
08/12/13 (n=17)
08/19/13 (n=11)
08/26/13 (n=04)
09/02/13 (n=13)
09/09/13 (n=10)
09/16/13 (n=08)
09/23/13 (n=10)
09/30/13 (n=07)
10/07/13 (n=09)
10/14/13 (n=18)
10/21/13 (n=15)
10/28/13 (n=06)
11/04/13 (n=09)
11/11/13 (n=06)
11/18/13 (n=11)
11/25/13 (n=15)
12/01/13 (n=07)
12/08/13 (n=10)
12/15/13 (n=11)
12/22/13 (n=06)
Percent Attending
C. Brown
Percentage of PPC Patients 0-3 Years Old Referred to CCHMC
Audiology or Speech Therapy Who Attend an Initial Appointment
within 60 Days
100
90
Clinic-wide
testing

Same day
eval

70
40
Weekly Percent Attending
Coordinate
speech/audio
scheduling


Improvement
project began
Glitch
in referral
report fixed
Schedule
from exam room
Referral
coordinator
started
Median
47
Goals
Epic
changes
live
Staff
retrained

Calls to
parent
10
0
Week that 60 Day Referral Window Ends
= Window not yet
closed, data point can still

48. Place based literacy: Program inventory
48

49. 49

50. James M. Anderson Center for
Health Systems Excellence
Overview of Community Health
Asthma
– QI for health inequities, community
partnerships, community QI capacity
Infant prematurity
– QI for the total population, common metrics, user
centered design
Early child development
– QI for population of kindergarteners; trajectories
and overlap; alignment strategies –model and
narratives; community dashboard