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Transforming Community Health in the District of Columbia

Are we making a difference? Are there outcome measures for primary care?

For children enrolled in Medicaid, a key outcome measure of primary care is successful delivery of EPSDT services. CMS requires each state Medicaid program, including the DC Department of Health Care Finance, to provide a comprehensive program of Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services to its Medicaid enrollees. These EPSDT services are based on “best practice” recommendations and clinical guidelines from the American Academy of Pediatrics and Bright Futures developmental screening and counseling.

A Community Health Improvement Story

Providing all the recommended EPSDT services is a huge challenge – especially for the underserved children covered in Medicaid. In a landmark legal decision, Salazer vs District of Columbia, U.S. District Judge Gladys Kessler ordered the District of Columbia to improve delivery of comprehensive EPSDT services to its Medicaid enrollees.

For more than ten years, DC’s Department of Health (DOH), Medical Assistance Administration [now the DC Department of Health Care Finance, DCHF], health plans, and provider community have struggled to improve documentation of EPSDT care. Unfortunately, this often translated into increasingly burdensome documentation requirements for frontline providers – redirecting precious resources away from actual care delivery.

In 2002, Children’s National Medical Center (CNMC) pediatricians, Drs. Mark Weissman, Nathaniel Beers, and Denice Cora-Bramble, petitioned to meet with Judge Kessler to identify a more constructive approach. Following an unprecedented meeting with DC’s pediatric provider community in her chambers, Judge Kessler approved an innovative collaborative quality improvement approach to improving EPSDT delivery.

Modeled after DC’s successful immunization registry, the provider community proposed to partner with DC’s DHCF, and the plans to develop and implement city-wide “standardized medical record forms” (SMRFs) to guide and document a comprehensive “HealthCheck” EPSDT visit. Copies of SMRFs have been submitted to DC’s DHCF for entry into one of the nation’s first comprehensive child health data registries. Key child health data will then be available to improve point-of-service care and continuity as well as track outcomes and identified improvement initiatives. Provider participation and registry use will be encouraged through provider quality report cards and pay-for-performance (P4P) – also among the nation’s first for Medicaid.

Progress and Accomplishments

Late in 2005, the Goldberg Center received start-up funding from the Commonwealth Fund, National Initiative for Children’s Healthcare Quality, and Children’s National Medical Center to formally establish the DC Partnership for Children’s Healthcare Quality (DC PICHQ) – with the EPSDT improvement as its initial quality improvement initiative. DC PICHQ has engaged an unprecedented collaboration of public health, managed care organizations, academic health centers, community pediatric providers, and parent advocates.

DC PIHCQ Collaborative Partners

American Academy of Pediatrics – DC Chapter
Bright Futures at Georgetown University
Chartered Health Plan, Inc.
Children’s National Medical Center
District of Columbia Department of Health
DC Department of Health Care Finance
George Washington University School of Medicine
Health Services for Children with Special Needs (HSCSN), Inc.
Howard University
MEDSTAR – Georgetown University Medical Center
Unison Health Plan, Inc.

This past year has seen remarkable progress and national recognition for the DC PICHQ and its city-wide improvement activities. In 2006, the DC PICHQ presented at key national forums – including the American Academy of Pediatrics’ National Legislative Conference, the AAP Council on Federal and Government Affairs, and the NICHQ 6th Annual Forum. DC PICHQ has leveraged its quality improvement expertise and infrastructure to facilitate and mentor DC DHCF-provider team participation in national quality improvement learning collaboratives (Medical Home for Children with Special Health Care Needs and Improving Awareness and Access to Care for Children and Youth with Epilepsy).

DC PICHQ has contracted with all four DC Medicaid plans to support on-going EPSDT improvement activities (practice recruitment and provider training; annual EPSDT providers updates at local DC AAP and MCO meetings). The PICHQ has collaborated with DHCF to pilot and launch the DC HealthCheck Registry to capture EPSDT documentation. By the end of 2006, over 20,000 completed EPSDT visits had been entered into the new DC HealthCheck child health data registry. Preliminary data demonstrates:

DC PICHQ has recruited, trained, and implemented EPSDT SMRFs in more than 60% of DC Medicaid’s provider community – representing close to 75% of DC Medicaid patient enrollees.
Complete and comprehensive EPSDT documentation for well-child visits has improved from an initial 30% chart audit benchmark (2002) to over 90% (2006).
Children in DC’s Medicaid program are now documented as receiving the nation’s most comprehensive EPSDT visits.

DC PICHQ efforts in 2007 will focus on expanding city-wide practice implementation, registry functionality, and further improving provider documentation through P4P report cards.

Community Health Improvement: Looking Forward

The future for data-driven community health improvement looks even more exciting. Early data “snapshots” from the registry reveal significantly more detailed health information and the opportunity to target and measure key child health issues, populations and outcomes longitudinally over time. For example, while there is widespread recognition that childhood obesity is epidemic, increasing and disproportionately represented in poor and minority populations – detailed obesity information for children in Washington, DC is limited to small surveys. The DC PICHQ and DHCF were able to look at BMI data for an initial cohort of registry submissions – providing confirmation in much greater detail that 40% of DC’s children in Medicaid are overweight (18% with BMI > 85th percentile) or obese (22% with BMI > 95th percentile).

This successfully demonstrates how key child health data can be captured and shared (at the provider and community level) to guide targeted improvement and improve community health. The DC PICHQ looks forward with great anticipation to expanding its city-wide practice-based collaboration quality improvement model, infrastructure, and expertise to a city-wide obesity initiative to be launched in 2007.

DC PICHQ Executive Committee

Mark Weissman, MD, Chief, General Pediatrics & Community Health, Children’s National Medical Center
Nathaniel Beers, MD, Medical Director, Children’s Health Center, Children’s National Medical Center and President-Elect, DC Chapter, American Academy of Pediatrics
Vincent Schuyler, Program Director, DC Partnership to Improve Children’s Healthcare Quality, Goldberg Center for Community Pediatric Health
Danny Bellamy, Chief Operating Officer, Health Services for Children with Special Needs, Inc.
Colleen Sonosky, JD, DC Department of Health Care Finance
Cyd Campbell, Chief Medical Officer, Health Services for Children with Special Needs, Inc.
Joan Christopher, JD, Family Advocate and LEND Fellow, Children’s National Medical Center
Matthew Levy, MD, Medical Director, Community Pediatrics, MEDSTAR – Georgetown University Hospital
LavDena Orr, MD, Chief Medical Officer, Chartered Health Plan, Inc.
John Richards, MA, Program Director, Bright Futures at Georgetown University
Tamara Smith, JD, President and Chief Executive Officer, Chartered Health Plan, Inc.
Robert Watkins, Chief Operating Officer, Chartered Health Plan, Inc.