Improving the Quality of Care Delivered to Children Served by State Agencies

Quality Improvement Cooperation

Presenters: Deborah Klein Walker, Ed.D., Associate Commissioner, Bureau of Family and Community Health, Massachusetts Department of Public Health, Boston, MA. Louise Bannister, B.S.N., J.D., Assistant Director, Primary Care Clinician Plan (PCCM), Benefit Plans Unit, Division of Medical Assistance (DMA), Massachusetts Executive Office of Health and Human Services, Boston, MA.

In Massachusetts, the Division of Medical Assistance and the Department of Public Health developed multiple quality improvement strategies for the programs they oversee.

• The Division of Medical Assistance (DMA) oversees Medicaid and SCHIP.
• The Department of Public Health (DPH) oversees Title V Maternal and Child Health (MCH) block grants and insurance programs for people ineligible for either Medicaid or SCHIP.

The two entities collaborated to develop performance measures that each can use. DPH implemented the measures for the FY99 Application to the MCH Block Grant and DMA used similar measures to guide the creation of annual quality improvement goals for its contracted MCOs. Both agencies conduct joint monitoring of Title V primary care contracts.

The measurement system includes 6 outcome measures and 18 performance measures in 4 areas:

• Direct health care services.
• Enabling services.
• Population-based services.
• Infrastructure building services.

DMA created the MCH Clinical Advisory Group in 1993, responding to advocates' concerns about the advent of Medicaid managed care. Meeting monthly, the group identifies areas for focus and advises the PCCM program about workplan development, implementation, and monitoring. Membership includes:

• Staff from DMA, DPH, and other State agencies.
• The Massachusetts Chapter of the Academy of Pediatrics.
• Providers.
• Child advocates.

Increasing immunization rates is one example of these quality improvement efforts. As a baseline, DMA used 1998 HEDIS® data for Medicaid managed care, which showed a mean immunization rate of 64.3 percent. Next, the State employed the Plan-Do-Check-Act cycle:

• Plan (first cycle): Identify the apparent root causes of the problem, identify initiatives to address these causes, and create a workplan.
• Do: Implement workplan activities.
• Check: The State collects HEDIS® immunization rates on a bi-annual basis. The 2000 rates showed an increase of five percentage points.
• Act: Collect additional data on causes and best practices. An external record review for a sample of members enrolled in DMA's contracted MCOs allowed planners to analyze root causes in a way HEDIS® could not. DMA and its MCOs also conducted a survey of high performing provider sites.
• Plan (second cycle): New activities have been developed to respond to new data.
• Do: Currently, DMA is implementing the new activities, including the continued link with DPH to sponsor provider training.

Other quality improvement projects and performance measures implemented by DMH and DPH with the input of the MCH Clinical Advisory Group include:

• Improving the delivery of Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT) services, in accordance with American Academy of Pediatrics or EPSDT periodicity schedules and recommended content of visits.
• Encouraging the integration of school-based health centers into Medicaid managed care, including joint DPH/DMA quality standards, and linking with EPSDT improvement goals.
• Improving services to children with special health care needs (CSHCN), including conducting a needs assessment of certain DMA providers and clients, enhancing an early intervention service system, redesigning DPH's case management services, evaluating the possibility of developing "medical homes" for CSHCN across the State, and developing special programs within MCOs for certain CSHCN.
• Assuring perinatal services are in place to decrease infant mortality.
• Increasing access to primary care for all children and youth.

Potential barriers to agency collaboration include:

• Different missions and priorities.
• Institutional cultural differences.
• Resources (time, money, personnel).
• Confidentiality and legal issues.
• Design and technological incompatibility.

The lessons learned from these activities include:

• Partnerships are key.
• Quality improvement takes time; agencies must be patient and not attempt to take on everything at once. Agencies should start small, mark successes, and build "hooks" around those successes to hold the gains and keep achievements from slipping back.
• Work out ways to share data among agencies.
• Put priorities in purchaser contract specifications.
• Allow for scarce resources.
• Get data from as close to the provider as possible.

References

Recipe for a Healthy Baby. Brochure. Boston (MA): Commonwealth of Massachusetts, Executive Office of Health and Human Services, Division of Medical Assistance; 2000, Jul.

MCAAP Immunization Plan. Boston (MA): Commonwealth of Massachusetts, Executive Office of Health and Human Services, Division of Medical Assistance; 1999, Mar.

Immunization Resource Package. Boston (MA): Commonwealth of Massachusetts, Executive Office of Health and Human Services, Division of Medical Assistance; 1999, Sep.

MassHealth: Primary Care Clinician Plan: Fiscal Year 2000 Goals. Boston (MA): Department of Health and Human Services, Division of Medical Assistance; 2000, Nov.

MassHealth: MCO Program Standard Quality Improvement Goal CY 2001: Maternal Child Health Background Statement. Boston (MA): Department of Health and Human Services, Division of Medical Assistance; 2001, Feb.

PCC Plan Quarterly, MassHealth's Primary Care Clinician Plan Newsletter. Boston (MA): Department of Health and Human Services, Division of Medical Assistance; 2000, Winter.

MassHealth: MCO Program Standard Quality Improvement Goal CY 2001: Maternal Child Health Background Statement. Boston (MA): Department of Health and Human Services, Division of Medical Assistance; 2000, Nov.

MassHealth: Goals for Pregnant Women, Children, and Adolescents. Boston (MA): Department of Health and Human Services, Division of Medical Assistance; 1999-2000.

MassHealth PCC Plan: Health Highlights. Boston (MA): Department of Health and Human Services, Division of Medical Assistance; 1999, Spring.

FY 2000: Improvement Goals. Boston (MA): Department of Health and Human Services, Division of Medical Assistance; 2000.

MassHealth PCC Plan: Health Highlights Boston (MA): Department of Health and Human Services, Division of Medical Assistance; 2000, Fall.

Massachusetts Immunization Program Jointly Sponsored Workshops for PCCs. Boston (MA): Department of Health and Human Services, Division of Medical Assistance; 2000, Apr.

Summary of the Massachusetts Adolescent Anticipatory Guidelines Public Awareness Campaign. Boston (MA): Department of Health and Human Services, Division of Medical Assistance; 2000, Apr.

Kubat H. MCAAP Immunization Initiative Letter: American Academy of Pediatrics Immunization Initiative; Waltham (MA): 2000, Jan.

Childhood Immunization Guidelines. Boston (MA): Massachusetts Department of Public Health; 2000, Feb.

Massachusetts Health Quality Partnership: Press Release and Cover Letter. Boston (MA): Massachusetts Department of Public Health; 2000, Apr.

Massachusetts Chapter of American Academy of Pediatrics Immunization Initiative: Immunization Information for Health Care Providers for the MCAAP Immunization Initiative. Shot Clock 2000, Winter; 6(1):1-12.

Neighborhood Health Plan: Tri-fold Card. Boston (MA): 2000, Fall.

Network Health: Immunization Textbox. Cambridge (MA): 2000, Fall.

---

Previous Section       Contents         Next Section

---