Ongoing Services
- Practice Manager's Meeting March 11, Noon to 1PM @ TCH, RSVP carter.joyce@tchden.org
- Announcing an Interactive Cross-Cultural Communications Website Designed Especially for Healthcare Professionals
- Child Psychiatry Telephone Consultation on Medicaid Children
- Integrating Developmental Screening In a Pediatric Practice
- Medical Spanish Training For Your Office Staff - The Colorado Pediatric Postpartum Depression Screening and Referral Toolkit
- Child Psychiatrist Available to Provide Conferences for You In your Office
- Language as a Communication Barrier in Medical Care for Hispanic Patients Plus A Spanish Course For Providers

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The Provider Resource Helpline Helps Your Special Needs Children:
Identify and Access All Resources
Assists with Care Coordination

          The American Academy of Pediatrics has promoted the concept of providing a medical home for children with special health care needs for over a decade.  At a recent focus group of family physicians and pediatricians discussing medical home, primary care providers said that finding the available resources and coordinating care for children with multiple problems was the most challenging of the roles of a medical home.  
          The Provider Resource Helpline is a service created to address this need through a collaboration among CCHAP, Family Voices, and the Colorado Department of Health Care Policy and Financing (HCPF), which administers Medicaid and CHP+.  Family Voices of  Colorado is a chapter of the national, grassroots organization composed of families and friends who care for and about our children with special health care needs.

Provider Resource Helpline
Helping care for our children with special health care needs

information for families
valuable community resources
care coordination

1.877.731.6017

The Colorado Provider Resource Helpline is here:

• To give providers information and access to valuable community resources for children with special health care needs.
• To provide case management and care coordination services to families.
• To identify shortages in services/barriers through the data collected.
• To provide family-centered programs, training and education.

When Calling, Please Have the Following Information:

• The PCP name and office phone and fax information.  
• Name and date of birth of patient.                                
• Medical condition / disability of patient.                       
• Resource question or service need of patient/family.
• Family Contact information, if the provider wishes us to follow up directly with the family.

If the helpline can answer your question immediately, you can provide the information to the family while they are still in the office.  If we are unable to answer immediately, we will contact you with an answer as soon as possible following the patient’s visit (via phone, fax, or email). 

Download Flyer

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Non-verbal Behavior in Cross-Cultural Interactions

Written by Marcia Carteret
(Copyright © 2010. All Rights Reserved.)
 
In recent newsletters, we explored using informed generalizations to learn about cultural differences. This concept certainly applies to learning about non-verbal behaviors. There is no quick and easy-to-use reference guide for culturally-based behaviors and lists of cultural dos and don’ts are ineffective. Even if it were possible to assemble a truly comprehensive list of facts for each culture, memorizing such information and keeping it straight is unrealistic– and people don’t really use lists, anyway. You can’t find them when you need them, and you can’t carry them around with you. Perhaps most important, interactions between people happen within a given context, and relying on lists actually distracts a person from the immediacy of each encounter.
When using dimensions of culture – time control, status, individualism, etc. – we understand that these dimensions point to probabilities about cultures that are worth paying attention to – and the word probability is key.  The same is true when we observe non-verbal behavior and attempt to decipher its meaning. We must always allow for the ambiguous nature of communication between people. Observing ourselves and becoming more aware of the assumptions we make about other people’s behaviors helps us be less reactive. We begin to see the individual in each encounter rather than just our interpretation of the situation.
Non-verbal Behaviors
The most important thing to keep in mind about non-verbal behaviors is that they do not translate across cultures easily and can lead to serious misunderstanding. Human behaviors are driven by values, beliefs, and attitudes, and it is helpful to consider how these invisible aspects of culture drive the behaviors we can see.
Eye Contact: Americans typically look directly into each other’s eyes when talking, conveying informality, spontaneity, and equality in their exchange of glances. When eyes shift and avoid meeting those of the other person, Americans may sense disinterest or perhaps even deception. However, a lack of consistent and strong eye contact may be a sign of respect or humility in other cultures. In some Asian cultures, eyes may be downcast or sweeping, and this often disturbs Americans. “He wouldn’t look me in the eye!” In Hispanic culture, direct eye contact is used far less and direct disagreement with a provider is uncommon.
Head Nodding: Nodding of the head may be a sign of acknowledgement rather than agreement in some cultures. The nod may be saying, “Yes, I am listening to you intently” rather than “yes I understand what you are saying and I agree.” The usual response to a decision with which the patient or family disagrees is silence and noncompliance. So, nodding and silence may mean “I am listening…but I am not in agreement.” The only way to know is to ask in a respectful manner if they understand or have any concerns. You may have to ask more than once – even somewhat emphatically! Asking open-ended questions will elicit more thorough answers and reduce deferential head nodding.
Taking Turns in Conversation & Use of Silence: The way conversation gets passed between people varies greatly between cultures, and it is the length of sustained eye contact that cues conversational turn taking. Americans tend to make medium-length eye contact before looking away, and they use a longer direct gaze to cue changing speakers. In other cultures, where a direct gaze may be confrontational, lack of eye contact may make it awkward for Americans to pass conversation back and forth. Being generally uncomfortable with any period of silence in conversation, Americans will tend to rush through pauses and quickly complete sentences that dangle. As a result, people from less direct cultures may struggle to participate equally in conversation with Americans, an obvious hindrance in successful patient-provider exchanges. The solution is to practice allowing silence, which necessitates slowing down conversation and more careful listening as well. Being a task-oriented culture, Americans tend to want conversation to get to the point, where other cultures will use it to build relationship. The use of silence suggests really hearing, considering, and valuing what is being said by the other person and is critical in cross-cultural interactions to establish trust.
Expressiveness & Gesturing: Americans tend to be moderately expressive when it comes to body language, gesturing freely compared to most Asians, but seeming constrained when compared to some Latin or Arab cultures. An American might misread an exaggerated use of hands or arms in conversation as an indication of excitability or distress in a person when, if fact, it means nothing of the sort. Keeping this in mind, providers should stay aware of how their own gesturing could be interpreted. Moving hurriedly and gesturing broadly might create discomfort for an Asian patient/parent but go relatively unnoticed by someone from the Middle East. Similarly, a western provider may over- or underestimate a patient’s level of pain based on the presence or absence of loud complaint, gesticulations, and other expressions of pain which are closely tied to a person’s culture. (Refer to the November 2009 newsletter for more on  the cultural aspects of pain management.)
Use of Humor, Smiling, and Laughter: A wise interpreter will avoid translating humor for the good reason that jokes and sarcasm don’t translate well across cultures. In some cultures, humor can even be seen as aggression or dominance. Americans, because we are individualistic and confident, tend to do a lot of put-down humor. We love to poke fun at ourselves and others. This can be confusing for people from other cultures where close attention is paid to preserving the dignity of all people in a given interaction – in Asian cultures this is called saving face. A well-intentioned provider, whose position automatically conveys status, would confuse some families by poking fun at himself. It could easily disrupt the sense of trust vested in him or her, especially for patients from formal cultures.
Finally, in American culture, there’s a big difference between a wry smile and happy smile, just as in many Asian cultures a ‘masking smile,’ with corners of the mouth turned down, is a polite way of letting you know what you are doing is not appropriate. Similarly, in many Asian cultures laughter can be a sign of embarrassment rather than a response to humor as it typically is in the US. Healthcare workers interacting with patients from Asian cultures need to remember the difference between high and low context cultures. Reading facial expressions, body language, etc. is second nature to people from Asian cultures, but goes unnoticed by many Americans unless they make a concerted effort to pay closer attention in cross-cultural situations.
For more detailed examples of culturally-based non-verbal behaviors visit www.dimensionsofculture.com and click on the Provider’s Guide on the homepage menu. Under patient/provider interactions select “Non-verbal Communication.”
Summary: Keep in mind - it can’t be overstated – that any guidelines for non-verbal communication should be applied as informed generalizations. In most instances, following the patient’s lead is best. For example, if the patient moves closer or touches you in a casual manner, you may do the same. Developing a cross-cultural mindset requires being more observant and demonstrating a willingness to adjust your own behavior. With experience, you will develop your own practical style that demonstrates greater sensitivity and awareness and ultimately contributes to better communication and health outcomes for all patients.
 
For more information on this and related topics visit www.dimensionsofculture.com.

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Quality Improvement: What Other Practices are Doing

To date, 54 practices have completed the Medical Home Index (MHI) (33 pediatric practices, 21 family practices). Of those practices, 20 practices have implemented 24 Quality Improvement projects and  15 practices are currently planning Quality Improvement projects.

• 58% of QI projects involve Age Appropriate Preventative Care and Screening
• 25%  of QI projects involve improving practice Family Centeredness
• The remaining 17% involve Evidence-based diagnosis and treatment, Cultural Competence, or Care Coordination.

These QI activities meet the QI requirement by the American Board of Pediatrics or the American Board of Family Medicine for recertification.

There are a number of reasons that Age Appropriate Preventive Care and Screening Quality Improvement projects are the first choice of practices.

• Age appropriate screening improves outcomes for children.
• There are resources available to help with implementation:
  
  • Eileen Auer Bennett, the Colorado State ABCD Coordinator, and her team are available to assist in the implementation of a standardized tool such as the ASQ or PEDS. Support will also be given to front/back office staff on how to implement the use of a standardized developmental screening tool into the current office work flow. See chapter 11 of the CCHAP on-line Orientation Manual for more information.
  • Cavity Free at Three provides training and technical assistance to dental and medical providers in the community interested in performing oral health assessments, counseling to primary caregivers as well as risk assessment skills. The comprehensive oral health training provided by the Cavity-Free at Three Program consists of an on-line component and a practical hands-on session. Please contact Anita Rich at Rich.Anita@tchden.org for more information, or see chapter 16 of the CCHAP on-line orientation manual.
  • The Quality Improvement Coach from CCHAP - at no cost to your practice - is available to help you decide what QI project your practice would like to work on, develop strategies for making the changes you want to make, and measure the effectiveness of the resultant changes.
• Medicaid reimburses very well for certain preventive care services:
  
  • Cavity Free reimburses $29.64 per oral screen and counseling, and an additional $15.60 per varnish application for children under the age of 5.  If completed once a year, a practice with 100 kids under the age of 5 could bill an additional $4,525.00 for the year. 
  • Practices that provide standardized developmental screening at preventive care visits for Medicaid children can bill for this service and will be reimbursed an additional $36.50 for this screening. A practice with 100 kids between the ages of 24 months and 6 years, assuming that all of the children come in for one well child visit a year, could bill an additional $3,650.00 for the year. Reminder: Developmental Screening can begin at 2 months of age, and can be completed and billed for at each well child visit.   For a list of approved screening tools, see http://www.colorado.gov/cs/Satellite?c=Page&cid=1218622605039&pagename=HCPF%2FHCPFLayout

How can you implement an Age Appropriate Preventive Care and Screening Project? It’s as Easy as 1 …2 … 3!

1. Contact your Quality Improvement Coach to get started! Angie can be reached at Angie@cchap.org.
2. Meet with your QI Coach to plan and implement a project – including the use of applicable resources, as outlined above. Develop a QI plan using the Plan, Do, Study, Act (PDSA) cycle of improvement. Your QI Coach will assist. Plan-Do-Study-Act (PDSA) is a widely accepted model for the implementation of a QI project.  PDSA is a relatively simple and effective way to evaluate and improve current or future processes by planning what you want to do, implementing the plan, studying the results, and then acting on your findings in order to produce better outcomes.
3. Study the results of your change package, and consider next steps: Did you reach your goal? How can you improve the outcomes of your QI project? What’s your action plan?

EXAMPLE QI PLAN

As always, your QI Coach will be there to help take the hassle out of QI by offering FREE technical assistance. Practices will be assisted in developing continuous quality improvement programming and making any changes they feel they want to make to improve efficiency or to improve their “medical home-ness.”

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Practice Manager’s Corner - March

Kevin Heckman

Add-A-Baby Process Update
Medicaid has experienced a significant increase in the number of requests to add newborns to Medicaid and CHP+ Prenatal mom’s cases. In December there were 1,106 requests, January 1,531 requests and as of February 23rd, there are 1,244 requests. There were over 300 duplicate requests submitted in January from the same provider for the same child. This has added more processing time – each request is researched before it is identified as a duplicate. The current processing time is approximately 10 business days.

Medicaid is working on adding resources to the program to accommodate the increased volume. Please note that processing times are affected by state staff furlough days and holidays. If you have an emergent request, please contact Shawna Moreno at 303-866-4456.

THE BEST METHOD FOR REPORTING A NEWBORN IS THE ONLINE FORM SUBMISSION PROCESS FOUND HERE:
www.colorado.gov/hcpf > Clients & Applicants (box upper left) > Click on Report the birth of a Medicaid or CHP+ baby online > follow the link to the online form.  

Nurse Advice Line 1-800-283-3221
The Nurse Advice Line is available for Medicaid clients in the fee-for-service program 24 hours each day, seven days per week at 1-800-283-3221. The line is staffed by registered nurses who assist clients with their health care questions. Calling the Nurse Advice Line may help reduce avoidable emergency room visits for families and can save time and money.

Clients enrolled in Medicaid managed care programs can call the following numbers for after-hour care:
Kaiser Advice Line – 303-338-4545 metro or 1-800-218-1059
Denver Health Advice Line – 303-739-1211
Rocky Mountain Health Plan (RMHP) – Call your RMHP primary care doctor
Colorado Access – Call your primary care doctor

For more information, please contact Medicaid Customer Services at 303-866-3513 in Metro Denver or toll-free at 1-800-221-3943.

Medicaid Provider Bulletin
Don’t forget to read the monthly Provider Bulletin published by HCPF.  The bulletins can be accessed at:
www.colorado.gov/hcpf
Click on the “Providers” box in the upper left > then click on “Provider  Services” >  then click on “Bulletins”

Other Important Reminders

Do we really have to do lead levels on children covered by Medicaid?

The short answer is yes, at both the one-year well child visit and the two-year well child visit.  And if you are seeing an older child who has not had at least one lead level done, that child should have one done.  

Why do we have to do this, when the incidence of lead poisoning is very low in Colorado?  It is a federally mandated requirement, because elsewhere in the country the incidence is high; and those states where the incidence is low are not given a choice by the Federal Medicaid program.

Colorado Medicaid has asked to have this requirement waived in our state and we were denied.   Sorry……..

 
Reminder:  Only bill Medicaid for developmental screening at well child visits between 2 months and 6 years

It has come to our attention that some practices are billing for developmental testing (the code is 96110) at all visits.  Medicaid only pays for developmental testing at the regular well child visits (2m, 4m, 6m, 9m, 12m, 18m, 2y, 3y, 4y, 5y)  Note Medicaid does not pay for a well child visit or developmental screening at 2 ½ years, even though a 2 ½ year visit is recommended by the AAP.    

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How to Refer Infants and Toddlers for Early Intervention Services

Bill Campbell

This is a quick reminder that for children suspected of having developmental delays, the referral resources depend on the age of the child.   Refer  infants and toddlers to Early Intervention Colorado if they are suspected to have significant developmental delays, or if they have any health conditions associated with a high probability of developmental delay.  Refer preschoolers and children not already enrolled in public school to Child Find for similar concerns.  For families whose children are already enrolled in public school, the parents have the right under special education law to request a comprehensive educational evaluation, but it’s best if they start by request a formal meeting with school staff, including the teacher, a special educator, and a school administrator.  At the end of this article you’ll find a link to a referral flow chart that outlines the decision-making process for referring children of different ages for developmental and educational assessments, but the following paragraphs will focus on how to refer infants and toddlers for early intervention services.

Developmental delay is common among infants and toddlers (at least 10 percent of infants and toddlers have delays in one or more areas of development).  Early intervention services have been shown to be effective in helping children with developmental delays, particularly children with autism spectrum disorders and other communication handicaps.  All 50 states have developed early intervention programs in accordance with Part C of the Individuals with Disabilities Education Act.  All 50 states also have special education procedures and services for preschoolers and school-age children.  

Colorado’s early intervention program is called Early Intervention Colorado (formerly Early Childhood Connections), or “EI Colorado” for short.  It’s designed to promote the best possible outcomes for infants and toddlers (birth up to 36 months of age) who have significant developmental delays (or health conditions associated with a high probability of developmental delay).  In order to take advantage of early intervention services during this critical developmental period, families need to know how to access them.  The following paragraphs explain this, and additional information can be found in the “Make a Referral” section at www.eicolorado.org.

While anyone – including the parents -- can refer a family to EI Colorado, primary care providers (PCPs) are the main source of referrals.   And using a standardized screening test is the most reliable way to identify children with delays.   A recent quality improvement initiative in the Denver metro area suggests that infants and toddlers are more likely to proceed through the evaluation phase if the PCP sends a referral form to the local EI Colorado program, in addition to having the family call the referral contact person there.
The PCP should inform the family that further evaluation is recommended to see if the child and family may benefit from early intervention services.  You can give the family an early intervention flier or panel card that briefly explains this, and also tells the family how to contact their local EI Colorado program.  These informational cards can be obtained for free from your local EI Colorado program office (e.g., from Denver Options for those residing in Denver), or you can order panel cards for free on the EI Colorado website (www.eicolorado.org) by clicking the “order public awareness materials” link on the home page or in the “Make a Referral” section.  You’ll find a lot of other information in the “Make a Referral” section, such as explanations of the early intervention assessment process and even links to professional medical society recommendations for the medical evaluation of children with developmental delay.

The process for having the infant or toddler evaluated begins with making a referral to EI Colorado.  The referral form should be completed by the PCP office during the visit, and the parent or legal guardian should be asked to sign the consent to release medical information at the bottom of the referral form.  You can obtain referral forms in English and Spanish for free from the EI Colorado website.  Or you can access the referral forms specific to your local EI Colorado program in the “Make a Referral” section of the website by clicking on the “Make a Referral” link and then scrolling down to the link that says: “To refer to Colorado's early intervention system click here to locate the appropriate Community Centered Board! (includes referral form)”.  You’ll then be taken to a page where you can enter or search for the specific local EI Colorado program, which will then take you to a page with that program’s contact information and links to referral forms with preprinted local program name and fax number.  I’ve found it easiest to keep preprinted referral forms handy rather than printing a form for every referral.

If the child was referred because of concerns on standardized developmental screening, please document the tool you used and fax the screening instrument along with the referral form; this will help the evaluation team understand the screening results and develop an assessment plan without repeating the screening.  I should mention at this point while the evaluations are conducted by Child Find teams from the local school districts or BOCES, the local EI Colorado programs arrange these and provide coordination throughout the process, so please refer infants and toddlers to the local EI Colorado programs directly (a service coordinator will be assigned and contact the local Child Find team within a couple of days).

Provide the family with a copy of the referral/consent form and the contact information for the local EI Colorado program, and arrange a follow-up visit for about 2 months later.  Explain to the family that a service coordinator will be assigned within a couple of days of the referral to help the family through the next steps; the developmental assessment should be completed within 45 calendar days, as well as the Individualized Family Service Plan (IFSP) if the child is found to be eligible for services (both are at no cost to the family).  Ask the family to bring copies of the IFSP and any evaluation reports.  Even though the Early Intervention and Child Find teams do not provide medical diagnoses, their findings can be important to you in helping the family understand the significance of the developmental delays and in guiding further appropriate medical evaluations.

Speaking of medical evaluations, you may have already initiated some when you first became concerned about possible developmental delays.  For example, children with language delay should be referred for formal audiology evaluations.  You don’t need to wait for audiology or other medical evaluations or treatments to be completed before referring to EI Colorado for early intervention evaluations and services.  The link to the referral flow chart at the end of this article illustrates the parallel processes for medical and developmental evaluations.  Professional medical society recommendations during recent years have offered specific recommendations regarding the medical evaluation and follow-up by primary care physicians/clinicians for children with developmental delay, cerebral palsy, and autism spectrum disorders.

And speaking of developmental evaluations, you can usually wait for the results of the early intervention or special education evaluations before referring for diagnostic medical developmental evaluations, such as those done in the Child Development Unit at The Children’s Hospital.  But if an autism spectrum disorder is suspected, then you should refer simultaneously to EI Colorado (for early intervention services) and to a medical center or clinic with special expertise in autism spectrum disorders (for the diagnostic medical evaluation).  The referral flow chart below gives other examples of where to refer children for medical or behavioral evaluations and treatment.

Click here to view the referral flow chart

I hope this information is helpful to you in getting early intervention services for infants and toddlers as soon as possible, and in getting preschoolers and school age children the help they need.

Please feel free to call me with any questions at 720-777-6632, or email me at Campbell.william@tchden.org.

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Cavity-Free at Three

Cavity Free at Three is a statewide effort aimed at improving oral health in children and pregnant women.  We are working with CCHAP to offer our program model to interested participants.  Recent Medicaid guidelines allow primary caregivers to provide oral health counseling along with fluoride varnish application and receive reimbursement for these services.  In order to participate, the medical provider as well as staff members involved in this provision of care should complete online training through the Smiles for Life Curriculum.  

Simply visit  http://www.smilesforlife2.org, and complete Module 2:Child Oral Health and Module 6: Fluoride Varnish.   After the online process is completed, we plan a coordinated effort for site visit based training opportunities offering hands on demonstrations as well as follow up and support of our program.

We are in the process of coordinating training opportunities throughout the state of Colorado beginning early 2010.  This will allow for representatives from your group to attend trainings in your area.  If you are interested in hosting a training, or learning more about Cavity Free at Three opportunities, please contact Anita Rich at rich.anita@tchden.org.  If you have questions specific to our program, please contact karen.savoie@ucdenver.edu or visit  http://cavityfreeatthree.org. Thank you.

Announcements:

Thank you to Pediatric Partners of Glenwood Springs, particularly Brian McGill, for coordinating a Cavity Free Training on February 16th.  15 people attended.  That is a great turnout.  

More training is scheduled for March. March 18th in Durango hosted by Pediatric Partners of the Southwest and on March 26th hosted by Miramont Family Medicine in Ft. Collins.

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INTRODUCING THE CCHAP QUICK REFERENCE LINK!

Do you need to know the one telephone number to call for a Medicaid mental health referral?  Want to reach the CCHAP social worker?  Need help in finding resources for a special needs child?  Having trouble remembering all of the 14 support services CCHAP provides for your practice?   We have a quick reference link for your desk top!  For these things and many more…

Recently, our advisory group of physicians and practice administrators suggested an idea for a quick and easy way to access CCHAP affiliated resources for frequently used contacts and services.  We liked the idea and have developed a web link that will quickly access a single page that contains contact information as well as additional links to documents and web pages.  The goal is to have a computer desktop shortcut that, with just a click or two, will provide CCHAP affiliated providers and staff with the information you need, when you need it.  

Because this new tool is for you, we want it to be pertinent and efficient.  So please, if you have ideas as to how to improve on this, contact Kevin Heckman heckman.kevin@tchden.org or 720.777.6309, our Program Administrator, with your feedback and suggestions.  Thanks!

INSTRUCTIONS:

1. Click on this link http://www.cchap.org/qr/ to open the Quick Reference Link web page (Note: you can also type this address into a web browser manually).
2. In your browser window menu (upper left corner) click File>Send>Shortcut to Desktop. 
3. The Quick Reference Link is available from any computer with internet access.

Kevin C. Heckman
Program Administrator
CCHAP
720.777.6309

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Medical Home Certification

Around 50 of the 150 pediatric and family practices that CCHAP currently works with are in the process of obtaining “medical home certification.”    The Colorado Department of Health Care Policy and Financing (HCPF), which administers Medicaid in Colorado, is directed by  Senate Bills 07-130 and 07-211 to document that children on Medicaid receive care in a quality medical home.  So, HCPF is asking practices that are receiving the enhanced reimbursement (as a CCHAP – affiliated practice) to obtain Medical Home Certification to document the quality of the medical home they provide to children on Medicaid.  Practices that have affiliated with CCHAP in the past 8 months have already begun the certification process.  The remaining CCHAP-affiliated practices will be asked to begin the certification process very soon.  

Medical home certification is a three step process.  The CCHAP orientation is step one.  The following are the two steps needed for medical home certification for practices that were oriented in the past and are already receiving the enhanced reimbursement.  Each CCHAP-affiliated practice will be asked to:

• Conduct a self-assessment survey of practice staff and providers called the Medical Home Index.  This brief survey seeks to determine your perception of how well you are doing in providing a medical home.  The survey also will be given to some parents in your practice.
• After reviewing your survey results, you will be asked to select some aspect of “medical home-ness” to improve using a quality improvement process.  CCHAP staff is available to coach you through the quality improvement process if you wish and we have QI projects already prepared for you to implement easily in your practice if you wish.  You may already have QI projects going, which will likely meet this objective.

Medical Home
The American Academy of Pediatrics and the American Academy of Family Practice have promoted the concept of a medical home for many years now.  A recent combined statement by the two academies reaffirmed their support of the concept.  The Academies believe that all children should have a medical home where care is accessible, family-centered, continuous, comprehensive, coordinated, compassionate and culturally effective.  For a reminder of the American Academy of Pediatrics and the American Academy of Family Medicine description of a medical home for children, click here. 
And if you want someone to come to your office to present a more description of what a medical home is and does, please contact: Anita Rich (Rich.Anita@tchden.org) or Angie Goodger (angela@cchap.org) for more information.

Medical Home Index
Starting in April 2009, recently oriented CCHAP practices began the process of Medical Home Certification.  The Medical Home Index is completed at a group meeting of your practice with as many of the practice staff and providers as possible. During this meeting the group will complete a Medical Home Index self-assessment, discuss how each indicator rated relates to a quality Medical Home.  The facilitator will conduct informal interviews of families coming to your practice that day asking them to assess the practice’s medical “homeness.”  For a look at the medical home index, click here.

Quality Improvement Projects
Within a few weeks after the practice takes the MHI, you will be contacted by a Quality Improvement Coach with CCHAP. At that time, you will receive your Medical Home Index results, as well as guidance as to how to interpret the results. HCPF asks that you select an element of being a medical home that your practice wishes to work on.   The Quality Improvement Coach from CCHAP – at no cost to your practice – is available to help you decide what your practice would like to work on, develop strategies for making the changes you want to make, and measure the effectiveness of the resultant changes.   

The higher reimbursement practices receive for preventive care is the reward for your practice’s commitment to providing a quality Medical Home for children on Medicaid.


AAP and AAFP Board Certification for pediatricians and family physicians
Both the AAP and the AAFP require that all physicians, when they recertify, develop a quality improvement project in their practice as part of their recertification.  So, CCHAP is helping you obtain both professional board certification and Colorado Medicaid medical home certification.

For more information
Shortly, we will be expanding the Medical Home Certification process to all CCHAP practices.  More information will follow. You may also contact Anita Rich (Rich.Anita@tchden.org) or Angie Goodger (angela@cchap.org) for more information.

Quality Improvement Coach
Your CCHAP Quality Improvement Coach is Angie Goodger. Angie holds masters degrees in Public Health and Healthcare Administration.  Angie comes to us from Minnesota where she previously worked as a home healthcare manager. Angie is very excited about working with your practice using Quality Improvement methods to work on those issues you want to address.

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Announcing an Interactive Cross-Cultural Communications Website
Designed Especially for Healthcare Professionals

dimesionsofculture.com

 
Register now! Click the link above and get full access
with your own secure login and password!

A Website to Support On-going Training for Healthcare Professionals in Colorado

Because culture can have important clinical consequences, this website is devoted to supporting the self- development of healthcare professionals in basic cross-cultural communication competencies that impact health outcomes for patients. In place of the typical "diversity training" approach, practical communication strategies are emphasized that can be put to use immediately in private practices, clinics, and hospital settings.

An Interactive Website for Building a Learning Community
 
The content of this cross- cultural communications website focuses on reinforcing key concepts presented in cross-cultural communication trainings by Marcia Carteret. Additionally, this site presents the opportunity for physicians and staffs in multiple healthcare settings to interact with one another through threaded discussions. Because nothing can replace real life experience in the learning process, a virtual learning community will make it possible to share true stories and post useful questions while culture and medical experts facilitate discussions.
 
Website Features
 
Listed here are the pages that currently make up dimensionsofculture.com. Please note that some pages require a login and password because only select groups of healthcare professionals, including all CCHAP pediatric practices, will have full access to the “community” pages.

Public Pages

• Home Page
• Greetings from the Site Editor
• Culture Calendar- Monthly religious and cultural holidays
• Culture Quest – Information about cultural happenings in our community, as well as statewide and nationally.

Healthcare Community Pages (Login/Password Protected)

• Newsletters – Monthly articles addressing key cross-cultural communication topics written by Marcia Carteret and other guest contributors.
• Interactive Forums– an interactive on-line community dialogue between healthcare professionals about communicating with patients from different cultural backgrounds. 
• Provider Profiles– An ongoing series of profiles introducing some of the dynamic and culturally diverse doctors working in the CCHAP network of pediatric practices
• Culture Ambassadors – A panel of representatives from cultures around the globe, with a strong focus on the cultures most heavily represented across out state.

This website is designed to meet the needs of the healthcare community served by Colorado Children’s Healthcare Access Program. If you are a participating CCHAP provider or staff member and have suggestions for the website, please contact Marcia Carteret at mcarteret@gmail.comor 720-777- 3124. Your comments and suggestions will help make dimensionsofculture.com an effective tool for learning and community building.

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The Colorado Pediatric Postpartum Depression Screening and Referral Toolkit

Developed by Brian Stafford, MD, MPH
Medical Director, Perinatal Mental Health Program, The Children’s Hospital

Click here to download the complete toolkit to enable a primary care practice
to recognize and refer women with post-partum depression.    

Why should every pediatric and family practice implement this toolkit?

•  Postpartum depression is a serious medical and psychiatric illness and a significant health concern.
• Approximately 12% of all new mothers develop symptoms consistent with a major depression in the post-partum period
• If left untreated, half of these mothers, about half will continue to have symptoms that last greater than1 year.
• These symptoms include sadness, lack of energy and pleasure, irritability, guilt, anxiety, as well as thoughts of wanting to harm the infant.
• Several lines of research have shown that post-partum depression has significant risk for the child’s cognitive, social, and emotional development and may impact school readiness.
• In addition, the depressive symptoms lead to difficulties in the mother-infant and parental relationship.
• The depressive symptoms are also associated with excessive urgent care and emergency room visits as well as missed scheduled routine pediatric visits.
• Providing pediatric anticipatory guidance to a depressed caregiver does not change any parental behaviors in regard to safety, sleep, nutrition, reading, and interaction.
• Pediatric care providers of infants are in a strategic position to screen and refer depressed mothers for behavioral health evaluation and support.
• Pediatric provider inquiries about maternal health have been viewed as appropriate by mothers.
• Pediatricians, historically, like other primary care providers, have low rates of detecting maternal depression and few pediatricians have a systematic approach to screening for maternal depression.

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Abe Grinberg MD, FAAP MPH
   

Language as a Communication Barrier in Medical Care for Hispanic Patients

           Communication with patients and their families is essential in providing quality medical care. Cultural and language barriers create a void in the delivery of safe health care, customer satisfaction and quality of care. The public debate on how to bridge cultural and language barriers has a long history. The use of formal interpreters and translators is associated with the ability to eliminate these barriers; however, the ability to communicate directly with health professionals in a common language is associated with an increase level of trust in medical settings.

             There are 7 important points to have in mind when addressing cultural and language barriers with the Hispanic patients and their families:

1. The number of people speaking a language other than English at home and the number of Americans Limited in English Proficiency (LEP) in the United States is significant. It is expected that the total number of people in these two groups will continue to increase at a faster rate than the one of the general population in the USA. About two thirds of them are Spanish speaking individuals (₁) (₂).
2. Multiple studies document that quality of care can be seriously compromised when Spanish LEP patients need but do not get translation and interpretation services (₃) (₄).
3. Studies also document that the quality level of interpretation offered by bilingual providers and professional hospital interpreters is high. However, the quality of interpretations offered by hospital employees who are not professional interpreters, family members, relatives, friends, and ad-hoc translators are many times incorrect and of poor quality (₅).
4. Interpretation errors are common. About 60% of the errors have potential clinical consequences. Even professional interpreters commit significant errors about 50% of the time (₅).
5. Patients, who interact with a bilingual provider, frequently rate them as more friendly, respectful, and concerned when compared to those who interact with a translator or interpreter. Patients and families who are taken care by a provider who speaks their own language frequently have a more accurate recall of critical information about the encounter than those who interact with a provider who uses a translator or an interpreter(₆)(₇).
6. There are data that suggest that the length of hospital visits, the incidence of any testing, the cost per visit and the number of hospital admissions are decreased in those patients who interact with a provider who speaks their own language when compared to those providers who use a translator or interpreter during the course of the medical encounter (₈). 
7. There is evidence that courses in Medical Spanish can help health care professional achieve fluency in Spanish at the functional level and promote cultural awareness that strengthen communication skills. The promotion of such courses is associated with decreased interpreter use and increased patient and family satisfaction (₉).

          Bear in mind that Hispanics embrace people when they make an effort to speak their own language. They tend to be tolerant and have a tendency to develop relationships that are based on friendship and respect. You will make them fill comfortable and help them feel that you are concerned about their medical care.
 
          “Dele a un hombre un pescado y él comerá por un día. Enséñele cómo pescar y comerá por el resto de su vida” (Lao Tzu. Filósofo Chino).

1. 1. Flores Glenn. 2005. The Impact of Medical Interpreter Services and the Quality of Health Care: A Systematic Review. Medical Care Research and Review 62: 255- 299
2. Colorado Alliance for Immigration Reform. U.S Immigration Data, Projections and Graphs. Retrieved: October 2, 2008. http://www.cairco.org/data/data_us.html
3. Flores, Glen., Abreu, Milagros., Schwartz, Ilan., and Schwartz, MD, and Hill, Maria. (2000). The importance of language and culture in pediatric care: Case studies from the Latino community. The Journal of Pediatrics. 137 (6): 842-848
4. Flores G. Language Barriers to Health Care in the United States. NEJM 2006; 355:229-23
5. Flores G., M.B. Laws., S.J. Mayo., B. Zuckerman., M. Abreu., L. Medina and E. J. Hardt. 2003. Errors in clinical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics 111: 6- 14
6. Baker, David W., Hayes, Risa., and Puebla Julia. 1998. Interpreter Use and Satisfaction with Interpersonal Aspects of Care for Spanish-Speaking Patients. Medical Care. 36(10):1461-1470 
7. Seijo, R., H. Gomez and J Frienderber. 1995. Language as a communication barrier in medical care for Hispanic patients. In. Hispanic Psychology_Critical issues in theory and research, edited by A.M. Padilla, 169-181. Thousand Oaks,Ca: Sage.
8. Hampers, L. C and., McNulthy, J.E. 2002. Professional Interpreters and Bilingual Physicians in a Pediatric Emergency Department. Arch Pediatr Adolesc Med. 156:1108-1113.
9. Suzan S. Mazo., Louis C. Hampers., Vidya T. Chande. Steven E. Krug. (2002).Teaching Spanish to Pediatric Emergency Physicians: Effects on Patient Satisfaction. Arch Pediatr Adolesc Med 156: 693-695

Course in Medical Spanish customized for pediatric care providers. Once a week for 12 weeks (2 hour class), includes also 6 month internet access to “Spanish for health care course”. Flexible schedule to accommodate participants’ preferences; Classes take place at the providers’ office for groups of 8-12 students.
$ 389 dollars per student. Includes 6 month internet access to the on line training course.
          Contact: Abe Grinberg MD (720) 748-7669.
          abe@bilingualmed.com my web-site www.bilingualmed.com

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Child Psychiatrist Available to Provide Conferences for You In your Office

Rick March, MD is a child psychiatrist at the Mental Health Center of Denver.  He is available to provide teaching on a variety of child Psychiatry topics (below) in your office.  He is also willing to discuss cases with you, as well.  Please contact him to take advantage of this wonderful opportunity.
He can be reached at Rick.March@MHCD.org

Here are some of the topics he can cover for you.

• Diagnosing Depression in Children and Adolescents
• SSRI’s and Black Box warnings
• Suicide and self-abuse
• Diagnosing Bipolar Disorder in Children and Adolescents (including differential diagnosis)
• Atypical Antipsychotics
• Mood Stabilizers and Antidepressants
• Pediatric Psychopharmacology and the FDA
• Kids with ADHD who don't get better on stimulant medication
• Psychosis in Children and Adolescents

And, remember there is a child psychiatrist on call available by phone for your Medicaid children…..

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All CCHAP-affiliated Practices Now Can Receive
TELEPHONE CONSULTATION ON MENTAL HEALTH ISSUES
FOR CHILDREN ON MEDICAID

Rick March is a child psychiatrist who has received grant monies to provide phone consultation regarding children and adolescents with mental health problems throughout Colorado.  He has over twenty years experience in child psychiatry and is available weekdays during regular business hours.  If you do not reach him directly, he would be able to speak with you, at the outside, by the next business day.  Dr. March is at the Mental Health Center of Denver which provides services for children who live in Denver County.  However, he may be able to arrange to see other patients outside this catchment area, possibly in your practice in very difficult cases.  He is also available to provide educational presentation for your providers on a wide variety of mental health topics.

His direct line is 303-504-1500

So, telephone consultation from a child psychiatrist for Medicaid children cared for in a CCHAP-affiliated practice is now available in all counties in Colorado.  

For Boulder and Jefferson Counties – Don Bechtold, MD – 303-432-5172
For Adams, Arapahoe and Douglas Counties – Joe Pastor, MD – 303-853- 3888
For all other counties (including Denver) – Rick March, MD – 303-504-1500

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Integrating Developmental Screening
Into a Pediatric Practice

• The Colorado Assuring Better Child Health & Development (ABCD) project has received a three year grant to provide training and technical assistance to providers to implement a “validated” developmental screening tool at well child visits for infants/toddlers birth to five.
• The ABCD project is partnering with CCHAP to provide training and support to pediatric practices to implement developmental screening.
• Medicaid will reimburse $34.00 to providers if you use a standardized, validated developmental screening test at an EPSDT visit.
• The Colorado Chapter of the AAP supports the ABCD project.
• Early detection and intervention improves outcomes.  Many delays in children’s development are missed in the first 4-5 years of life without a standardized, validated screening test. 
• The most time-efficient tool is one in which the parent completes a questionnaire.
• To comply with 2010 recertification guidelines by the American Board of Pediatrics, documentation will be required to show levels of involvement in practice improvement initiatives. By implementing the use of a “validated” developmental screening with a sensitivity and specificity rating of 70% or greater like the ASQ or PEDS, practices are taking steps to integrate quality improvement into their practices.
• What providers are saying about implementing either the ASQ or the PEDS parent questionnaire developmental screening tools:
  •  
    • It takes 1-2 minutes for an MA, LPN or RN to score.
    • It takes less than a minute of the provider’s time if the MA, LPN or RN scores the questionnaire.
    • In many instances, it reduces the length of the visit.
    • It helps providers concentrate on the concerns/priorities of the parents.
    • It reduces the number of concerns that come up as you are walking out the door at a well care visit.
    • It improves patient satisfaction.
    • It promotes positive parenting practices.
    • It increases provider confidence in decision-making for when to refer a child for further developmental evaluation.
• Eileen Auer Bennett, the Colorado State ABCD Coordinator and her team are available to assist providers in getting started. Training and technical assistance will be provided to practices to implement a standardized tool such as the ASQ or PEDS. Support will also be given to office staff on how to incorporate a standardized developmental screening tool into the current office work flow.

For more information, please contact:
            Eileen Auer Bennett
            720-333-1351
            ileanben@yahoo.com

The Ages & Stages Questionnaire (ASQ) is a well respected screening tool.  It has the best sensitivity and specificity.  It is standardized across various common minorities.   Health care providers have identified the following advantages:

• Parent completed—Parents are partners in their child’s
  assessment and intervention activities.
• Serves as a talking guide with parents identifying a
  child’s strengths as well as things the child is not
  doing yet.
• Practical—Scoring takes 1-2 minutes and can be done
  by paraprofessionals.
• Cost-efficient—May be photocopied repeatedly.
• Scoring is simple—Only three responses:
  1. Sometimes, occasional or emerging response from
     child = 5 points
  2. Yes, child performs specified behavior = 10 points
  3. Not Yet = 0 points
• If the child’s total score falls in a shaded area of the bar
  graph for any developmental area, further diagnostic
  assessment is recommended.

• Developed out of four cross-validation studies on a
  nationally representative sample of families.
• Uses parent concerns or judgments about the child’s
  development and behavioral status.
• Easy to score—two minutes to elicit and interpret.
• Enables health care providers to determine the need to
  refer and where.

Visit www.pedstest.comto view and order the PEDS tool online.

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Spanish Interpretation Training for Pediatric Practices

An assessment of each individual’s skill level will be done during a 5-10 minute phone call prior to first telephone conference/class.  Maria will contact you to schedule this initial individual telephone call upon receipt of your registration email.  A certificate of completion will be given after completion of all 6 sessions. The faculty is Maria Soto, a certified Spanish interpreter and trainer with International Language Services.

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Copyright 2010 Colorado Children's Healthcare Access Program and other entities as noted.

 CCHAP Home > Newsletter Articles > Newsletter 36, March 2010