States are increasingly interested in working with physicians, provider organizations, and other entities to support efforts aimed at improving the quality of children's health care, particularly for those children who are underserved and members of at-risk populations. States are primarily interested in supporting these efforts as a means to improve both the quality and coordination of care. However, they also view such quality improvement partnerships as an opportunity to shift their relationship with the provider community from that of regulator to that of collaborator. Providers engaged in these activities note that working collaboratively with states on these initiatives can indeed lead to improved quality and coordination of care and to more productive relationships with state officials.
A recent survey by the National Academy for State Health Policy found that half of all states provide some resources or materials to primary care providers to encourage them to focus on young children's early mental health development. An additional 13 states indicate that they are "planning for the future" to implement such activities. Medicaid agencies have often been the most involved state players, but other agencies—among them public health, early intervention, and maternal and child health—are also interested in working with and supporting physicians in their efforts to enhance the quality of care delivered to young children. In addition, state agencies are partnering with other organizations in their states to support primary care providers seeking to enhance the quality of care they deliver to children. These partners include state chapters of the American Academy of Pediatrics and the American Academy of Family Physicians, state infant or child mental health associations, university-associated academic medical centers, Head Start, and advocacy groups.
These partnerships are not always easy to establish and maintain. Physicians who have participated in them note that it can be difficult to overcome long-held assumptions about government bureaucracies, and state officials report that working with busy physicians can pose challenges. Meetings and calls cannot be quickly scheduled, and practices may not have sufficient time to focus on a specific quality improvement initiative. Also, partners often come to the table with different goals and priorities, and these differences can slow or stop progress.
The survey reveals that while many of the formats adopted or supported by states and their partners are fairly traditional, new models are emerging: some in response to past experience, some based on research on physician behavior change, and others based on quality improvement principles or new technologies that have made it possible to deliver information in new ways. A number of states have begun to adopt these newer models which include:
- Learning collaboratives. A learning collaborative is a long-term effort (often a year or more) that brings together a number of practice teams that are seeking improvement in a focused topic area. Learning collaboratives feature multiple learning sessions, ongoing technical assistance, and frequent small-scale measurement to help determine whether the intervention needs to be modified. This model was popularized by the Breakthrough Series developed by the Institute for Healthcare Improvement (www.ihi.org). National Academy for State Health Policy © April 2006
- Modified learning collaboratives. Modified learning collaboratives differ from formal learning collaboratives in a variety of ways. They typically involve fewer or shorter learning sessions; less frequent support and technical assistance; and less stringent evaluation protocols than more traditional collaboratives. These adaptations are often made in response to financial or geographic limitations.
- Practice-based seminars. These programs are typically developed in consultation with physicians, teach multidisciplinary teams within medical offices, and are taught by peer educators (i.e., practicing health care providers). Practicality dictates that sessions are brief, typically 60 to 90 minutes. Programs are often followed by some form of technical assistance.
- Off-site workshops. A number of states have instituted off-site workshops designed to support or reinforce state policies and initiatives. These workshops are typically held in local communities and attended by clinicians and office staff from multiple practices.
- Models that use technology. Several states and state-supported partnerships have begun developing comprehensive Web-based resources that are designed to support providers and their efforts to improve the quality of services delivered to young children.
Each of the models profiled in this report is significantly different from the others and offers unique lessons for those interested in replicating them. However, a number of lessons were common to most, if not all, of the models. Among them:
- States that have been successful in supporting efforts aimed at improving the quality of children's health care appear rarely—if ever—to act alone. The involvement of the physician community in all aspects of the development and implementation of these programs has been critical to their success.
- States emphasize that partnering with health care providers is essential to these initiatives and that the needs and interests of providers must be central to all efforts.
- States also note the importance of helping physicians connect with community resource agencies as part of their efforts to work with physicians to enhance the quality of care for very young children, as these are the agencies to which physicians will refer families in need of follow-up services.
- States interested in partnering with providers have found success by starting with a small group of physicians or practices, tracking the progress of the initiative, ironing out the kinks, and building both support and demand for the work.
- Those working with physicians to support improvements in the quality of children's health care note the importance of building flexibility into their efforts. Each model must be flexible enough to account for and meet the various needs of different practices.