Minimizing Loss To Follow Up: Supporting Physicians

Dr Shirley Russ MB ChB MRCP FRACP MPH

AAP Chapter 2 Champion on EHDI

Life of California Physician

• Fast Cars?

Life of California Physician

• Big Luxury Homes with Swimming Pools?

Life of California Physician

• Lots of time off to catch a few?

Life of California Physician

• Overworked• Underpaid• Drowning in paperwork• Less than 14 mins. to

see each well child• Very nice people• Very supportive of

hearing screening

Physician Struggles with Follow-Up Activities

• Limited training in hearing loss issues.• Screen “refers” and children with

hearing loss remain rare in individual practices.

• Care coordination activities (obtaining results, authorizations) not reimbursed.

• Children change providers and insurers often - results don’t always catch up.

Linkage with Intervention

• Eligibility criteria for intervention programs unclear/confusing.

• Physician may not know who to call.• Lack of comprehensive knowledge of all

intervention options within a given geographic area.

• Physicians vary in beliefs about extent of benefit of early intervention.

Theoretical Models of Child Development

Neoromaturational Model Neurological functions are set at birth and

unfold over time.Vs.

Transactional Model (Sameroff and Fiese)Neurological,Social and Psychological

Functions are dynamic, influenced by child-caregiver environment.

Life Course Health Development Framework

• A person’s health takes on a trajectory resulting from the cumulative influence of multiple risk and protective factors operating during critical periods in development. (Halfon & Hochstein 2002)

• Evidence for critical window for language development.

Physician beliefs

• Physicians who embrace Transactional Model, and Life Course Health Development Framework are more likely to be engaged with early screening and intervention efforts.

• Strong belief in “critical window” for language development may lead to “sense of urgency” about follow up.

Physicians and NHSP

• Physician beliefs -Grand Rounds-Journal Articles-Stronger Evidence

• Systems Issues-Require a multidisciplinary, cross-sector approach.-Must involve insurers, national, state and local agencies.-Need data

What providers want

• True Universal (100%) screening.• Linkage to medical home.• Quick and easy way to get results.• Know who to call.• Feedback on performance.• Know when cases are missed.• Evidence that this is improving outcomes.

Aim:100% Screening

• Physicians engaged.• California:concerned re inequity (Only CCS-

approved hospitals screening).• Voluntary screening programs in non-CCS

approved hospitals.• Four Chapter Champions (Russ, Kukreja,

Miller, Powers) active at local and state levels.

Physicians listen to

• Good Quality Data

• League Tables

• Rankings e.g. Concerns re California’s“Unsatisfactory” Rating from World Council on Hearing Health.

State Rankings by % Newborns Screened (2004)

Rank State Total # annual births

Percent screened

1 IN 85,081 99.9%

2 CT 42,001 99.8%

49 CA 529,357 66.0%

50 OH 148,720 33.0%

State Rankings by Number of babies screened per year

Rank State Annual Births

% Screened

No. screened

1 TX 372,450 99.0 368,725

2 CA 529,357 66.0 349,376

49 WY 6,550 98.0 6,419

50 VT 6,387 95.0 6,067

Linkage to Medical Home

• CA 2004 -of newborns who failed screening and needed diagnostic evaluation:

84% WBN had identified PCP

77% NICU had identified PCP

81% overall had identified PCP

Linkage to Medical Home

• For 20% babies, no PCP for HCCs to communicate with.

• Lost opportunity for PCP liaison.

• Need for better identification and documentation of PCP at time of discharge.

Obtaining Results

• Instant web access ideal.

• Need for parent written permission (HIPAA) introduces delay.

• HCC in CA invaluable “back-up”

• HCC tracking activities contribute to low loss to follow up.

Feedback on Performance

• Local- Hospital scorecards, final hearing status of babies, missed cases.

• State- Champions work with NHSP staff to review data and identify problems e.g. NICU babies not screened prior to step-down unit.

• Brainstorm solutions e.g. work with CAN.

Are We Improving Outcomes?

• Need to measure outcomes at population level.

• Process measures useful e.g. % screened, ages at diagnosis and intervention.

• Do we need a state/ national registry of children with hearing loss(confidentiality)?

• Can we link existing datasets e.g. NHSP, Early Start and Dept of Ed. Data to determine if children are receiving needed services?

Recommendations

• Improve connectivity between services and disciplines e.g. SECCS Initiative, personal relationships.

• Earlier identification of PCP-(Obstetricians).• Statewide electronic data tracking with real

time analysis and feedback of results.• Better outcome measures for children with

hearing loss e.g. Quality of Life