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Policy Innovation Profile

State Partnership Supports Quality Improvement in Pediatric Practices, Leading to More Evidence-Based Care, Better Care Coordination, and High Satisfaction in Participating Practices


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Snapshot

Summary

A public–private partnership of State agencies, academic institutions, and pediatric practices, the Vermont Child Health Improvement Program supports participating practices in implementing and executing projects to improve the quality and consistency of care provided to Vermont children. The Vermont Child Health Improvement Program works closely with these stakeholders and others to design, support, and evaluate the quality improvement projects, which focus primarily on improving the provision of preventive services and management of chronic conditions. The Vermont Child Health Improvement Program also makes recommendations to State agencies, insurance companies, and other stakeholders based on the collective findings from the projects. The overall program has generated high rates of participation among eligible practices and high levels of staff satisfaction in participating organizations. Individual Vermont Child Health Improvement Program projects have increased adherence to evidence-based practices, improved care coordination, generated higher reimbursement for physician practices, and led to higher overall quality of care for children in the state. These positive results have attracted additional funders to support the Vermont Child Health Improvement Program, allowing the program to become self-sustaining after its first year in operation.

Evidence Rating (What is this?)

Moderate: The evidence consists of results from several individual VCHIP projects, typically in the form of pre- and post-implementation comparisons of various process and outcomes measures. Additional evidence includes post-implementation data and anecdotal reports on provider willingness to participate in the program and on its impact on staff satisfaction in those organizations that do participate. 
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Developing Organizations

American Academy of Pediatrics, Vermont chapter; University of Vermont College of Medicine; Vermont Department of Health
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Use By Other Organizations

Seventeen states and the District of Columbia have established programs modeled after VCHIP, with these initiatives being in various stages of development, ranging from just getting started to fully established. States with similar programs include Arizona, Idaho, Indiana, Iowa, Maine, Maryland, Minnesota, New Hampshire, New Jersey, New Mexico, New York, Ohio, Oklahoma, Oregon, Rhode Island, Utah, and West Virginia.

Date First Implemented

2000
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Patient Population

Vulnerable Populations > Childrenend pp

Problem Addressed

Since the late 1990s, private and public agencies have focused on collecting and reporting data on various measures of health care quality, with an eye toward helping health plans and provider organizations improve their performance. Emphasis on quality measurement has increased in recent years with the development of value-based reimbursement. Although health plans and provider organizations generally support these efforts, they often find participation in them to be costly or time consuming, and generally receive little guidance or assistance in carrying out quality improvement projects.
  • Increased emphasis on quality and quality measurement: Since the publication of two Institute of Medicine reports—To Err Is Human (1999) and Crossing the Quality Chasm (2001)—both private and public agencies have increasingly focused on measuring and improving health care quality. For example, accrediting organizations such as the Joint Commission began requiring that hospitals collect and report performance data on various quality measures, and the Centers for Medicare & Medicaid Services instituted penalties for hospitals that did not report quality data. At the State level, Vermont became one of the first to adapt a comprehensive approach to data collection and analysis, with the goal of monitoring and improving quality. Other states soon followed Vermont's lead, and currently nearly all states have some type of program in place to collect, analyze, and report data on health care quality.1
  • Renewed focus with advent of value-based reimbursement: As government and private payers move towards value-based rather than fee-for-service payment systems (a strategy endorsed and supported by the Affordable Care Act), providers and payers face increased pressure—and in some cases mandates—to participate in quality measurement or improvement activities.2
  • High costs of participation: Participating in quality reporting and improvement efforts requires training and takes up scarce staff time during a period when many provider organizations and physician practices already feel pressed for time. One study estimated the startup and maintenance costs as high as several thousand dollars per physician for some quality improvement programs.3
  • Little support: Early efforts to conduct quality improvement projects in provider organizations often had inadequate funding and support. Although most providers see benefits to participating, the lack of resources and support often makes doing so difficult.3

What They Did

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Description of the Innovative Activity

A public–private partnership of State agencies, academic institutions, and pediatric practices, the Vermont Child Health Improvement Program (VCHIP) supports participating practices in implementing and executing projects to improve the quality and consistency of care provided to Vermont children. VCHIP works closely with these stakeholders and others to design, support, and evaluate projects, which focus primarily on improving the provision of preventive services and the management of chronic conditions. VCHIP also makes recommendations to State agencies, insurance companies, and other stakeholders based on the collective findings from these projects. Key elements of VCHIP policies and activities are outlined below:
  • Collaborative organizational structure, with input from key players: VCHIP is built on the premise that a collaborative effort among State agencies, academic institutions, medical societies, and pediatric practices will result in more effective quality improvement efforts. To that end, whereas VCHIP operates as part of the University of Vermont, the commissioners of both Public Health and Medicaid, the Vermont chapter of the American Academy of Pediatrics, and local insurers set priorities that inform project development.
    • Advisory committee: The VCHIP executive director meets regularly with an advisory committee made up of representatives from the State agency for human services, the State health department (Maternal and Child Health and Early Periodic Screening, Diagnosis, and Treatment administration), the local chapters of the American Academy of Pediatrics and the American Academy of Family Physicians, and university research faculty. The committee also includes a parent representative. Meetings initially occurred every other week and now take place on a monthly basis. During these sessions, the group discusses potential projects and funding sources, the ramifications of any proposed or recently passed legislation at the State and Federal level, and challenges practices face in carrying out quality improvement projects.
    • Voluntary participation of providers serving children: All primary care providers who treat children in Vermont have the option to participate in the program by signing a business associate agreement with VCHIP. The contract outlines the practices’ responsibilities with respect to collecting information and allowing VCHIP access to that information to measure and track performance over time. As part of the agreement, VCHIP agrees to adhere to the security and privacy provisions of the Health Insurance Portability and Accountability Act, and agrees not to publicly report data, although participating practices can publicly display their own data.
    • Continuing medical education (CME) and maintenance of certification (MOC) credits: Through its affiliations with the University of Vermont and the national accreditation boards, VCHIP offers CME and MOC credits to participating providers, thus helping them meet ongoing requirements related to State licensure and board certification.
  • Design, support, and systematic evaluation of projects: VCHIP selects and designs quality improvement projects based on input from State agencies, private insurers, and other stakeholders (including participating health care providers) and then works with participating practices to implement and evaluate them. To date, VCHIP has designed, supported, and evaluated more than 40 such projects, primarily focusing on different aspects of preventive services and management of chronic conditions. VCHIP uses established quality improvement protocols to support implementation and evaluation, including the Breakthrough Series model (a team-based improvement technique developed by the Institute for Healthcare Improvement) and academic detailing (in which trained professionals meet with clinicians to provide evidence-based information and discuss ways to improve performance). Depending on the method used, the projects may include the following:
    • Educational outreach and training: Virtually all projects incorporate educational outreach to participating practices in the form of one-on-one meetings between VCHIP staff and providers, conference calls, or state-wide learning sessions attended by teams of physicians, nurses, and administrative staff from participating practices. In addition to the practice-based teams, representatives from Medicaid, private insurers, and public health agencies may also attend learning sessions to share their perspectives and learn from each other.
    • Supporting materials: Based on content from learning sessions and feedback from providers, VCHIP develops supporting materials to reinforce learning or help practices increase adherence to evidence-based care standards. For example, VCHIP might develop and distribute forms that remind providers to ask patients certain screening questions and document their answers.
    • Rigorous measurement and evaluation: Each project includes rigorous measurement and evaluation of the implementation process and of the program's impact on specific process and outcomes measures. Each evaluation depends on the nature and format of the project. For example, VCHIP may choose to focus on the effectiveness of provider training programs or measure the effect of a program on screening rates, adherence to evidence-based practices, or certain health outcomes. Typically, VCHIP staff perform chart audits at the beginning of each project to establish baseline data and then do so again at various points during the project to track progress towards goals; they chart audits again at the end of the project to gauge final outcomes. Although many practices have electronic health records, VCHIP staff still travel to the practice sites and use a scientific method for manually pulling and reviewing charts at the practice.
    • Benchmarking data: VCHIP offers participating practices the opportunity to receive data on their performance compared with that of similar practices throughout the state. For example, for lead screening, VCHIP generates a chart that shows the average (mean) screening rate for the state, along with dots that show the performance for each of the 39 participating practices. Although individual practices are not identified on the chart, each participant can see how it ranks in relationship to the State average and to the other practices. VCHIP does not make this information public, but the practices are free to do so.
      Presentation of findings and recommendations: Based on findings from the projects, VCHIP periodically develops reports that review the effectiveness of various programs and that outline recommendations for policy or procedural changes. VCHIP shares these reports with State officials and insurance companies. These reports have led to changes in State policies or insurance company procedures, including changes in reimbursement and reporting requirements.

      Context of the Innovation

      VCHIP was conceived in the late 1990s and established in 2000 as a public–private partnership to promote health care quality improvement by supporting practices in conducting and evaluating research projects. The impetus for the program came from several events and activities at both the State and national level; see the Planning and Development Process section below for more details.

      Did It Work?

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      Results

      The overall program has generated high rates of participation among eligible organizations, along with high levels of staff satisfaction in participating practices. Individual VCHIP projects have increased adherence to evidence-based practices, improved care coordination, and generated higher reimbursement for physicians, leading to higher overall quality of care for children in the state.
      • High rates of participation: Although the program is strictly voluntary, nearly every eligible organization participates in it, including 90 percent of the state’s pediatric practices (which collectively serve 80 percent of children younger than age 5 in the state), almost 80 percent of its family medicine practices, and all of its hospitals and Federally Qualified Health Centers.
      • Higher staff satisfaction: Anecdotal evidence suggests that participating practices have more satisfied staff. In other words, working together on projects that improve systems and patient outcomes appears to enhance job satisfaction.
      • Greater adherence to evidence-based practices: Individual VCHIP projects have raised awareness of and adherence to evidence-based practices, as outlined below:
        • Prenatal care: In 2011, the March of Dimes gave Vermont an "A," ranking it number one in the country on its Prematurity Report Card. The organization credited VCHIP's Late Preterm Infant Initiative for this strong performance; this program reduced use of elective inductions and cesarean sections, thus allowing more full-term babies to be delivered.
        • Adolescent screenings: One VCHIP project led to a 46-percent increase in screening for risk-related behaviors and a 34-percent increase in screening for developmental delays and strengths. Blue Cross Blue Shield of Vermont has credited a different VCHIP project with raising rates of Chlamydia screening among sexually active teens.
        • Preventive care: VCHIP projects have increased access to preventive care, especially for chronically ill children. For example, one project increased the influenza vaccination rate from 53 percent to 73 percent among children seen at specialty clinics for pediatric diabetes, nephrology, and cystic fibrosis.
      • More coordinated care: Several projects have enhanced coordination of care. For example, one project addressed an overlap in services in two areas of the state through creation of standardized consent forms and testing protocols. Another trained staff at community hospitals on how to provide evidence-based care to infants born to opiate-dependent mothers, allowing these babies to receive care in their local communities rather than far-away facilities.
      • Higher reimbursement for providers for evidence-based care: VCHIP findings have led to changes in State and other payer reimbursement policies for certain services. For example, Medicaid originally did not offer reimbursement for screening for autism or other developmental delays. A VCHIP project that showed patients identified early had better outcomes was a significant contributing factor to subsequent coverage by Medicaid for screenings conducted with standardized tools. Through collaboration with the state's Blueprint for Health, VCHIP assists practices to become recognized as patient-centered medical homes by the National Committee for Quality Assurance, leading to a $1.87 increase in per-patient per-month payments to these practices. This increase helped to fund care coordination programs and other patient services not previously available.
      • Top-ranking state for health of residents: Since 2007, Vermont has ranked number one in America's Health Rankings.4 In 2011, the state ranked number three in the nation in child health system performance.5 Although many factors go into these high rankings, many in the state believe that the cooperation and collaboration fostered by VCHIP contributed to improvements in child health outcomes.

      Evidence Rating (What is this?)

      Moderate: The evidence consists of results from several individual VCHIP projects, typically in the form of pre- and post-implementation comparisons of various process and outcomes measures. Additional evidence includes post-implementation data and anecdotal reports on provider willingness to participate in the program and on its impact on staff satisfaction in those organizations that do participate. 

      How They Did It

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      Planning and Development Process

      Key steps included the following:
      • Development and adaptation of Medicaid guidelines for pediatric preventive care: In the mid-1990s, Vermont’s Department of Health and the Vermont chapter of the American Academy of Pediatrics brought together a multidisciplinary group of clinicians to adapt Medicaid’s Early Periodic Screening, Diagnosis, and Treatment program (EPSDT) for Vermont. The group agreed on a schedule for the appropriate delivery of EPSDT-covered services but wanted to put in place a mechanism to ensure that practices adhered to these guidelines and recommendations for all children, not just those on Medicaid. In addition, clinicians sought technical assistance with implementation, including available tools for measuring and improving the care they delivered.
      • Passage of Rule 10: In 1997, the Vermont legislature passed Rule 10, which established a set of guidelines to evaluate the quality of care provided by health plans and insurers. It also required plans and insurers to undertake quality improvement projects.
      • Riding wave of quality improvement: In 1999, the IOM released To Err Is Human, its landmark report on medical errors. This report brought the importance of quality improvement to the forefront. That same year, the David and Lucile Packard Foundation provided funding to launch the National Initiative for Children’s Healthcare Quality (NICHQ). The Foundation also decided to fund a statewide quality improvement effort aimed at pediatric patients.
      • Identification of Vermont as pilot site: As a small state with an established interest in health care quality improvement, Vermont represented an ideal place to conduct a pilot test. NICHQ and Packard Foundation leaders approached the pediatrics chair at the University of Vermont about serving as a pilot site.
      • Establishment of a formal program, not a project: The pediatrics chair approached the same organizations that adapted the EPSDT schedule to gauge their interest in participating. Leaders of the health department and the American Academy of Pediatrics expressed a desire to do so, but they wanted to set up a self-sustaining program rather than a one-time project. To that end, the University of Vermont College of Medicine agreed to establish a new faculty position for a director of the new program and to fund that position for 3 years if the program did not become self-sustaining after the initial funding.
      • Hiring executive director: The university hired an executive director for the organization, who then established the advisory group and started developing the program based on the group's input and her expertise and research.
      • Rapid achievement of self-sustainability: VCHIP ended up becoming self-sustaining in just 1 year, as the results outlined earlier attracted the attention of various funders, including insurers, foundations, and State and Federal agencies.

      Resources Used and Skills Needed

      • Staffing: VCHIP's full-time staff ranges from 25 to 35, depending on the number of projects under way at any one time. Each project has a faculty adviser from the Departments of Pediatrics, Family Medicine, Obstetrics/Gynecology, or Psychiatry; a project director; a project coordinator; and a measurement expert. Centralized staff oversee budgeting, finance, and logistics for the projects.
      • Costs: Total costs range from $3 to $5 million a year, depending on the number of ongoing projects. This budget covers compensation for VCHIP staff and all project-related costs, including but not limited to face-to-face meetings, travel, training, materials, and office supplies.
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      Funding Sources

      Centers for Medicare and Medicaid Services; MVP Health Care; March of Dimes; CIGNA; Commonwealth Fund; Vermont Department of Health; American Academy of Pediatrics, Vermont chapter; University of Vermont College of Medicine; Vermont Department of Health Access; Blue Cross Blue Shield of Vermont; CIGNA Behavioral Health; Magellan Behavioral Health; Vermont Health Plan
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      Tools and Other Resources

      A practical guide to setting up this type of program (Establishing a Child Health Improvement Partnership: A How-To Guide) is available at: http://www.healthandwelfare.idaho.gov/Portals/0/Medical/MedicaidCHIP
      /EstablishingAChildHealthIPGuide.pdf
      (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

      The VCHIP Web site, which has a list of tools and resources developed by the organization that can assist in carrying out quality improvement projects, is available at: http://www.uvm.edu/medicine/vchip/.

      Adoption Considerations

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      Getting Started with This Innovation

      • Establish advisory group of diverse stakeholders, tailored to state: Put together a core advisory group made up of partners that have a vested interest in the goals of the program. Located in a small state, VCHIP made a conscious decision to maintain a small advisory group made up of representatives of the organizations that conceived the vision for the program. This decision meant that representatives from private businesses (including insurance companies) would not be part of the advisory board but would often participate in project-specific advisory groups. A different structure may make sense in a bigger state with more large, influential companies and key players.
      • Consult advisers regularly: As noted, the VCHIP advisory board met every other week by telephone in the beginning. The executive director believes that these frequent meetings contributed to the rapid success of VCHIP, as sessions provided a forum to discuss important issues in a timely fashion.
      • Emphasize measurement and results: The State Medicaid program has a mandate to ensure the health of the population. VCHIP's ability to show concrete results in support of that mission helped to ensure ongoing State endorsement of the program. Measurable results also captured the attention of other funders, thus allowing the program to quickly become self-sustaining.
      • Be patient in building credibility and trust with practices: VCHIP worked closely with the chapters of the American Academy of Pediatrics and the American Academy of Family Physicians to get a foot in the door with practices. Some practices disputed the results generated by early VCHIP projects, claiming the data were not accurate. Provisions of the business associate agreement signed by practices allow VCHIP staff to tell the practices which charts it had pulled for its evaluation, thus allowing the practices to verify the information. Once they saw that the results were in fact accurate, the practices began to trust VCHIP as a source of information and support.

      Sustaining This Innovation

      • Avoid "turf wars" with other organizations: In a small state like Vermont, it becomes easy for one organization to move in on the territory of another, particularly when it comes to fundraising. Before pursuing funding opportunities, VCHIP leaders consider whether the project is right for the state, whether some other organization is already pursuing the funding, and, if not, whether VCHIP or another organization should take the lead in applying for support.
      • Look for ways to increase incentives for participation: When VCHIP started, the only incentive for providers to join was the offer of technical assistance and CME credits. However, after the American Board of Medical Specialties (which includes the American Board of Pediatrics) began requiring participation in quality improvement activities to maintain board certification, VCHIP received approval to offer MOC-approved quality improvement projects. This change increased incentives for pediatric and family practices to participate.
      • Align projects with State and Federal requirements: Practices already have a heavy reporting burden. Aligning projects with the requirements of private insurers and State and Federal agencies allows practices to participate without substantially increasing this burden.
      • Look for ways to get results published: Although several VCHIP projects have been published in peer-reviewed journals, many projects with important results have not been widely disseminated. Though every VCHIP project has a faculty representative from the College of Medicine, these individuals often have busy practices in addition to their university responsibilities and, hence, do not have time to write up and publish the results. A possible solution to this may be to engage those who may be more motivated to publish important public health findings, such as faculty at a local school of public health.

      Use By Other Organizations

      Seventeen states and the District of Columbia have established programs modeled after VCHIP, with these initiatives being in various stages of development, ranging from just getting started to fully established. States with similar programs include Arizona, Idaho, Indiana, Iowa, Maine, Maryland, Minnesota, New Hampshire, New Jersey, New Mexico, New York, Ohio, Oklahoma, Oregon, Rhode Island, Utah, and West Virginia.

      More Information

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      Contact the Innovator

      Judith Shaw, EdD, MPH, RN, FAAP
      Executive Director, Vermont Child Health Improvement Program
      Associate Professor of Pediatrics and Nursing
      University of Vermont College of Medicine
      N329 Courtyard at Given
      89 Beaumont Avenue
      Burlington, VT 05405
      (802) 656-8319
      E-mail: judith.shaw@uvm.edu

      Innovator Disclosures

      Dr. Shaw reported that she and VCHIP have received consulting fees, honoraria, and travel support related to this program and that VCHIP has received grants from several states and organizations interested in replicating the approach.

      References/Related Articles

      Smith S. Baby monitors: Minnesota is borrowing a page from Vermont on how to improve the quality of pediatric care. Minnesota Medicine. March 2009.

      Gorman RM. A system of quality. Vermont Medicine. Summer 2005.

      Footnotes

      1 Hurtado MP, Swift EK, Corrigan JM. Envisioning the National Health Care Quality Report. Washington, DC: National Academies Press; 2001. Available at: https://download.nap.edu/catalog.php?record_id=10073.
      2 U.S. Department of Health and Human Services. Administration implements new healthcare reform provision to improve care quality, lower costs. Washington, DC: U.S. Department of Health and Human Services, April 2011. Available at: http://www.healthcare.gov/news/factsheets/2011/04/valuebasedpurchasing04292011a.html.
      3 Halladay JR, Sloane PD, Lefebvre A, et al. Should your practice participate in a quality-reporting program? Fam Pract Manag. 2011;18(1):9-14. Available at: http://www.aafp.org/fpm/2011/0100/p9.html. [PubMed]
      4 United Health Foundation. America's health rankings, 2012 Edition. December 2012. Available at: http://www.americashealthrankings.org/Reports.
      5 How SK, Fryer A, McCarthy D, et al. Securing a healthy future: the Commonwealth Fund State Scorecard on Child Health System Performance, 2011. New York, NY: The Commonwealth Fund, 2011. Available at: http://www.commonwealthfund.org/Publications/Fund-Reports/2011/Feb/State-Scorecard-Child-Health.aspx.
      Comment on this Innovation

      Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

      Original publication: June 05, 2013.
      Original publication indicates the date the profile was first posted to the Innovations Exchange.

      Last updated: October 02, 2013.
      Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.