Better Developmental Outcomes for Children: An Interview with Colorado ABCD

​NaRCAD: Hi, Meagan and Mindy—thanks for taking the time to talk with us about your clinical outreach education programming at Colorado ABCD. Can you give us an overview about ABCD and its mission to improve child development?

Meagan Shallcross: Colorado Assuring Better Child Health & Development (ABCD) works with community partners, pediatric healthcare providers, early learning providers, and families across Colorado communities. The goal is to strengthen systems and identify children with developmental delays, connecting them with community services as early as possible.

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ABCD’s primary focus has been on increasing rates of standardized screening for developmental delay and autism using validated tools and improving rates of referral completion. We’re also moving into working to improve screening and referral for pregnancy related depression (PRD), as PRD can impact children’s developmental outcomes.

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"The goal isn’t to do all the work, but to help the practice find capacity to do it themselves." 

Meagan Shallcross, MPH

NaRCAD: Tell us a bit about your backgrounds. How did you each get into healthcare improvement?
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Meagan: My background in public health, along with experience working in clinical settings and behavioral science research, developed my interest in healthcare improvement that aims to bridge community work and clinical practice, standardize clinical workflows, and ultimately improve experiences and outcomes for patients and families

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Mindy Craig, PA-C, M.S.

Mindy Craig: My path to healthcare improvement is a little different than what you might expect.  I worked for Northwest Airlines as a flight attendant for several years straight out of college.  At that time the airline industry was losing a large amount of money and needed to find a new way of operating.  They decided to utilize a Total Quality Management approach and enlisted people from every department to undergo training in TQM and then facilitate small departmental groups in quality efforts.  It was through this process that I began to understand the importance of doing business with a quality framework.

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Learn more at coloradoabcd.org.

Eventually, I left Northwest and started working in a Neurology clinic while going back to school with the goal of becoming a PA.   After completing my degree I worked in primary care settings for about 10 years.  I participated in small clinic QI efforts over the years and continued to be interested in quality improvement.

I was hired by ABCD 8 years ago to bring a clinical perspective to their physician outreach.   It was a natural progression for me to start approaching our work at ABCD with a quality improvement framework.  The power of engaging front line staff to implement changes that result in improvement remains as strong as it was when I worked in the airline industry. 
 
NaRCAD: Talk with us about your academic detailing programming at ABCD—you’ve been doing this for about 10 years, right?

Mindy: We started our work  encouraging the use of standardized developmental screening tools in the primary care settings.  This was supported by the American Academy of Pediatrics policy statement in 2006 recommending the use of these tools at well child visits.  We offered informal outreach to physicians providing instructions on screening tools, billing information, AAP recommendations and information on referral resources.
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We quickly recognized that screening alone wasn’t sufficient and began talking about the referral process and how to ensure successful referrals were being made.  At around this time, research was showing us that only about 50% of children referred for Early Intervention services were actually connecting to that referral.  It was easy to identify children with concerns but not as easy to ensure they received needed support.
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We decided to try formalizing our approach to outreach by offering Continuing Medical Education [CME] credits.  While we didn’t change content, offering CME changed the way providers saw us as detailers.  We appreciated the new credibility, but still struggled with recruiting new practices.

NaRCAD:  Recruiting practices to participate is a challenge for many programs. How did this struggle transform into quality improvement?

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Mindy: The progression to QI really came out of a need to reach more physicians.  We hypothesized that offering Maintenance of Certification Part 4 credit would be a substantial motivator for physician participation.  This turned out to be true and it additionally gave us the opportunity to develop stronger relationships with the physicians who participate.  Doing our outreach under the MOC Part 4 umbrella has been very successful for ABCD.

​"We're very passionate about making sure the connection with community and health care occurs."

We now offer Quality Improvement [QI] and MOC projects for implementing developmental screening, autism screening and postpartum depression screening in addition to a project that aims to increase the percentage of children who successfully connect with Early Intervention when referred from their primary care provider.  We have been thrilled with the response from physicians for participating in these projects and just received funding to continue and grow our outreach efforts. 

NaRCAD: What have been some other challenges you’ve faced when going in to talk to clinicians about implementing developmental screening?

Mindy:  I started working at ABCD unsure of how to provide physician outreach, so I naturally modeled my efforts on the one successful approach I knew very well, which was pharmaceutical sales.  As the recipient of pharmaceutical detailing, it was pretty easy to begin my outreach efforts in a similar fashion.  I quickly learned how it feels to be a detailer.  Front office staff rejected me repeatedly, I made hundreds of phone calls that didn’t get returned, and when I did get to speak to a provider I had to speak quickly and to the point to keep their attention.  The challenge of gaining access was the biggest barrier I confronted early on and remains at the top of the list.

"Providers are overwhelmed [...] and adding anything new to their plate can be daunting."​

Another huge challenge has been the convincing providers that this new screening recommendation is important enough to add to the list of the many other screenings they do every day.  Providers are overwhelmed right now and adding anything new to their plate can be daunting. ​

A key challenge: gaining access to clinicians.

​NaRCAD: When dealing with those challenges, what’s helped you to build relationships with clinicians in order to gain commitment?

Meagan: To deal with the challenges that arise, we have found that it helps to get creative in our approach to gain access to clinicians and add credibility to our messages. A barrier we have encountered when trying to schedule times to meet with clinicians is the expectation that we will provide food. Our funders and budgets do not allow us to pay for food, so we have opted to provide other incentives for clinicians, such as CME or MOC credit. Not only is offering CME/MOC credits an educational incentive for providers, but it lends credibility to our messages. We facilitate our QI projects through multiple meetings at the practice and have found that, by developing relationships and a presence in the office, we can overcome clinicians’ resistance to implementing screening or other changes in their practice. 

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Building rapport and credibility with clinicians is crucial to gaining commitment to change, and as emphasized through the academic detailing approach, making multiple in-person visits really enables this by allowing us to learn about and be responsive to the practice’s unique strengths and needs.

​"Building rapport and credibility with clinicians is crucial to gaining commitment to change."

Resource and best practices exchange at #NaRCAD2015

NaRCAD: We were happy to see you at our 3rd International Conference on Academic Detailing here in Boston a few months ago. Tell us more about how the conference helped you think about your work in a different way.

Mindy:  We were thrilled to be able to attend the conference and came away very energized.  We highly recommend the conference to anyone doing similar work.  Some of our key “take-aways” were around the fundamentals of academic detailing, including the need for profession materials and repeated visits to develop relationships.  We came home committed to find money for developing professional materials and to attend the two-day intensive training offered by NaRCAD.

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​"We were thrilled to be able to attend the [NaRCAD] conference and came away very energized." 

One thing that I came away from the conference thinking about was how the work we are doing fits into the new landscape of practice facilitation around payment reform.  There are many efforts in our state looking at models of payment reform that intersect with the work we are doing at ABCD.   Some of the measures that practices are asked to provide data on will be around developmental and mental health screening.  There is clearly a need to provide practice facilitation on meeting these and other measures as practices try to navigate the transition to new payment models.

However, I’ve struggled with our role as a non-profit in meeting these needs.  Up to this point, ABCD has utilized a very hands-on approach.  We plan meetings, take notes, write up PDSA cycles, make “To Do” lists – anything we can do to make the process easy for the practice and allow the providers to concentrate on patient care.  A true practice facilitation model is more concerned with increasing the capacity of the practice to continue quality improvement work after the facilitation had ended. The goal isn’t to do all the work, but to help the practice find capacity to do it themselves.  ​​

NaRCAD:  What other advice would give to a new and emerging AD program that’s just getting started, or that you’d give yourself if you could go back in time 10 years?

Meagan: We have found NaRCAD’s training and tips to be very helpful, so we would recommend that new clinical educators attend a NaRCAD techniques training to hone their skills in communicating their messages with clinicians and gaining commitment to behavior change. One of our main takeaways from the NaRCAD conference was the importance of high-quality, professional materials, so we would recommend that new programs budget for the development of professional materials as well as food, which can be an incentive when setting up meetings with clinicians.

Over the years, we’ve realized how critical it is to work with community partners before going into healthcare practices to ensure that clinical workflows, such as processes for making referrals to external agencies, are aligned with community-defined processes and so that clinicians are aware of the resources available to patients and families in their communities.

NaRCAD: Thanks so much for sharing important insights from your program to improve childhood health outcomes. We look forward to seeing you at a future training and hearing more about your program's future successes!

Biographies

Mindy Craig, PA-C, M.S., Director of Physician Outreach, has been with the ABCD team for 8 years and brings with her experience in the clinical setting.  She earned her physician assistant degree at the University of Colorado Health Science Center’s Child Health Associate/Physician Assistant program in May 2000.  Concurrently, she completed additional course work and research to earn her Master of Science degree in Pediatrics.  Ms. Craig worked as a physician assistant in a number of settings for ten years prior to joining the ABCD team.  Her medical career has included a variety of medical office positions from medical records clerk to practice manager.  This range of experience positions her to fully understand the unique dynamics and flow in a typical office, which allows her to deliver technical assistance to practices at a meaningful level.
 
Ms. Craig’s quality improvement experience began in the business sector where she was extensively trained on Total Quality Management (TQM) at Northwest Airlines.  She worked at the airline as a facilitator, training inflight and ground personnel in the principles of quality improvement.  This experience with quality continued in the clinical setting, as she has participated in and/or chaired a number of quality improvement projects over her career as a physician assistant. In addition to her work at ABCD, Ms. Craig also does consulting work for organizations needing assistance with physician outreach and education. 

Meagan Shallcross, MPH, Healthy Steps/Physician Outreach Coordinator, joined the ABCD team in June 2015 as the Healthy Steps and Physician Outreach Coordinator. Meagan is passionate about building systems and environments that support children’s healthy development through clinical-community partnerships and integrated care delivery approaches. Meagan earned a Master of Public Health degree at the University of Michigan, where she supported Patient and Family Centered Care projects at the university health system and was involved with community-based participatory research addressing health equity, as well as research focused on provider-patient communication. 

Learn more at www.coloradoabcd.org. All photos used with permission.