STRATEGIC DIRECTIONS:Key Informant Interviews with EPSDT Directors

Peggy McManus

MCH Policy Research Center

July 12-13, 2005

STRATEGIC DIRECTIONS STANDARDS & POLICIES Session Objectives:

Examine state EPSDT policies for hearing screening & follow-up

Compare with JCIH, AAP guidelines, & Healthy People 2010 objectives

Consider strategies for updating state EPSDT policies on hearing

Interview Findings: Current Picture and Strategies EPSDT standards primarily based on AAP

preventive care guidelines, with some variations

EPSDT standards on hearing focus almost exclusively on screening, not referral & follow-up

Unclear the extent to which EPSDT standards reflect JCIH guidelines

Standards & Policies: Interviews States have organized mechanisms for

regularly updating EPSDT, with input from other state agencies & key stakeholder groups

New standards & policies disseminated through provider manuals, bulletins, & newsletters

Effective ways of implementing new standards -- work closely with state AAP chapters

Standards & Policies: Interviews Less involvement with AAFP, though states

interested in more Hospital involvement critical State universal newborn hearing screening

laws – key in facilitating adoption of standards

Attention needed to address outreach, screening, & follow-up of failed screens.

Strategic Directions Information & Education Session Objectives:

Share ideas about effective educational strategies for working with PCPs, families, hospitals, MCOs, and local health departments (LHDs)

Examine potential opportunities for informing & involving key stakeholders

Information & Education: Interviews

Primary Care Physicians: No magic bullets or single approaches Very little done so far on follow-up Important to have good, actionable data about

how PCPs perform Evidence-based data also important Newsletters that profile promising practices

useful

Information & Education: Interviews

PCPs continued: Ongoing training of residents helps CME necessary, but not sufficient More needed to target PCPs in rural areas, with

small numbers of children in practice

Information & Education: Interviews

Families:

-- Work with existing family networks

-- More education is needed on follow-up, esp. with families whose children have complex health care needs

-- Follow-up telephone calls & face-to-face meetings work best

Information & Education: Interviews Use of popular media helpful Critical to have a “why” piece – explaining

why both screening & follow-up are necessary

Informing families about standard of care is important and can positively influence parent demand for services

Information & Education: Interviews Hospitals

State EHDI efforts, esp. involving on-site work, critical in implementing universal newborn hearing screening

Funding hearing aid loaner program important Need to target small, rural hospitals and move

beyond screening Perinatal conferences important Also, having short educational videos about

hearing screening for use by hospitals important

Information & Education: Interviews Local Health Departments

EPSDT outreach workers have critical role to play, but few have focused on hearing

Important to link with home visiting, case management, disease mgmt., & other initiatives involving LHDs

Regular training opportunities for LHDs, with CME important

Information & Education: Interviews Hard-to-reach groups

EPSDT outreach workers have critical role to play

Home visiting & case mgmt. programs reach high-risk groups, though hearing follow-up seldom addressed

More attn. to cultural competence to reduce families’ delays in seeking follow-up

Translation & transportation are critical

Information & Education: Interviews Overarching Comments

Comprehensive strategy needed, promoted through various channels (e.g., immunization)

Have a simple, consistent message – 1/3/6 Involve key groups at outset Address shortage of audiologists, incl. causes –

education & training, reimbursement, other Streamline & integrate hearing follow-up services

with CM, EI, WIC, 1-800 #, EPSDT outreach, etc

Strategic Directions: Quality & Financial Incentives Session Objectives

Review potential opportunities for incorporating national benchmarks from Healthy People 2010

Examine Medicaid reimbursement levels for hearing services

Consider alternative performance incentive strategies

Quality Incentives: Interviews Few EPSDT programs use or are aware of

Healthy People 2010 hearing objectives Most Medicaid quality standards from

NCQA (HEDIS), AAP Use of quality indicators (e.g., 1/3/6) could be

an effective strategy Important to have actionable data for use by

providers Comparative state data also helpful

Quality Incentives: Interviews NICHQ’s model of collaborating with

practices, conducting chart reviews, identifying improvement strategies, & providing feedback (eg, lead, immuniz)

Need to make sure hearing screening & follow-up is incorporated into EPSDT evaluations. Records could be tagged for follow-up

Quality Incentives: Interviews Consider a GPRA project (e.g., immunization) CMS could set a standard (e.g., dental care) Maintain close link with public health Issue certificates of excellence to providers scoring

95% of higher Acknowledge the good work of providers “They’re

not doing this work for the financial rewards, but for the benefits to children.”

Reimbursement Incentives: Interviews “Ha, ha, ha. Stand in line.” State Medicaid and public health funding is

already stretched to its limits Important to piggyback with existing EPSDT

administrative outreach efforts Through Medicaid’s administrative match,

possibly some potential for funding follow-up activities

Reimbursement Incentives: Interviews To claim administrative match requires

financial support from other state agencies – good luck!

To justify payment changes, evidence of cost savings needed

Professional organizations & provider groups need to advocate for rate increases showing costs not being met and access adversely affected

Reimbursement Incentives: Interviews Also, comparative state fee data useful – no one

wants to be lowest (see handouts) See examples from dental care. Also, incentives

used successfully with EPSDT visit rates, immunizations, & lead screening

Examine hospital payment mechanisms to assess where to place incentive

Consider outside foundation & community funds

Strategic Directions: Monitoring & Tracking Session Objectives

Examine existing state data sources and data-sharing arrangements to link with

Consider ways to improve accuracy & quality of reportable data on hearing screening & follow-up

Monitoring & Tracking: Interviews Accurate data depends on accurate provider

coding. Providers/office staff may need training on appropriate coding.

When hearing services bundled into a single code or folded into DRG payments, difficult to rely on claims data

Tracking hearing is much more complicated than lead screening

Monitoring & Tracking: Interviews Potential data sources: vital records, EPSDT,

EHDI tracking system, early intervention, care management, hospital databases, administrative claims, case management systems, registries

Data-sharing agreements most helpful Publish program success

Strategic Directions:Collaboration Session Objectives

Identify new & existing opportunities to effectively promote collaboration among key stakeholders

Share information about promising strategies Consider roles & responsibilities for state EHDI

programs to play with Medicaid & participating MCOs and other providers

Collaboration: Interviews Already a great deal of collaboration between

Medicaid and EHDI programs, mostly around newborn screening

Meetings at least quarterly help, involving Medicaid & other key stakeholders

Written interagency agreements useful in promoting accountability

Collaboration: Interviews Examples: MD – a portion of EHDI

coordinator’s time/salary is dedicated to working with Medicaid.

IL: “Think Tank Day” on newborn hearing projects for coming year; developed education, referral, & follow-up document; grand rounds training with AAP; newborn screening advisory group; now working on parent website

Collaboration: Interviews Linking with other screening programs, such as

electronic birth certificates, immunizations, or newborn metabolic screening, may have potential but not yet done for most part

State Early Childhood Comprehensive Systems (SECCS) grants important vehicles to link with in many states. Other initiatives – Healthy Babies/Healthy Kids& Families, Commonwealth’s ABCD program, & Early Education and Care