Thrive by Five Collaborative Mona Mansour, MD Marilyn

Thrive by Five Collaborative Mona Mansour, MD Marilyn

Thrive by Five Collaborative Mona Mansour, MD Marilyn Crumpton, MD Community Connected Primary Care Why this Collaborative? Together we represent ~80% of the 0-5 years of age Medicaid population in Cincinnati June 2017 Ensuring ALL 5 year olds have a Healthy Mind and Body All Children Thrive Cincinnati Who we are POWERFUL IMPACT IF WE ALL WORK TOGETHER 9 clinics participating: 6 CHD teams and 3 CCHMC teams versus as INDEPENDENT CLINICS Teams working on one of the following measures: Lead Immunizations ASQ Dental All Children Thrive Cincinnati System Level Key Driver Diagram: Community Connected Primary Care hampions: Marilyn Crumpton, MD & Mona. Mansour, MD Vision Help Cincinnatis 66,000 children be the healthiest in the nation through strong community

partnerships Mission Attain community connected primary care (CCPC) in the Greater Cincinnati Area CCPC is a community driven primary care system that proactively identifies patients health and wellness needs, effectively connects the patients and their caregivers to the right resources when and where they need them, and ensures every child is not only free from harm, but thriving, and system reduces cost of care What are we trying to accomplish? Reduce inpatient bed days per 1,000 for children ages 0-17 living in Avondale, East & Lower Price Hill from 93.3 to 90 by June 2020 Percent of General Pediatric patients turning 66 months who have received all Thrive at Five bundle elements (full immunizations, no cavities, normal socialemotional screen, normal speech) from 13.4% to 40% by June 2020 Thrive by 5 Collaborative AIM increase the percentage of preventive elements given (lead, ASQ, vaccines) from 60%

to 70% in 0-27 month children by June 30, 2019. Revision Date: 6-13-18 Primary Drivers FY19 Improvement Projects The entire health system and community have a shared vision, are engaged and activated and demonstrate accountability for improving outcomes Inpatient Bed Days (Asthma Standardization, Transitions of Care, Outreach- Specialty Clinics, Care Management) AIM: Reduce inpatient bed days per 1,000 for children ages 0-17 living in Avondale, East & Lower Price Hill from 93.3 to 90 by June 2020 Leaders: Andy Beck and Kristy Anderson Thrive by Five Bundle (Visit Level, Literacy, Inreach, Outreach -Population Mgmt/Care Gaps/Community Connections) AIM: Percent of General Pediatric patients turning 66 months who have received all Thrive at Five bundle elements (full immunizations, no cavities, normal socialemotional screen, normal speech) from 13.4% to 40% by June 2020 Leaders: Zeina Samaan, Courtney Brown and Amy Haering Trust and respect exists between community members and the providers that serve them There are no economic and psychosocial obstacles to care Caregivers are healthy Children and families receive the right care at the right time in the right place (System is capable) Optimal Clinical Functioning Care is easy to navigate for families (System connectivity communication and information sharing) Proactive Population Management Models of payment support population management Data availability and transparency Thrive by Five Collaborative AIM: increase the percentage of preventive elements given (lead, ASQ, vaccines) from 60% to 70% in 0-27

month children by June 30, 2019, by June 30, 2019, TBD 2020 goal Leaders: Marilyn Crumpton and Mona Mansour Behavioral Health AIM: 55% of children ages 0-5 years will be seen by a psychologist during WCC at Hopple Street Clinic, and 80% of children ages 0-5 years will be screened with ASQ: SE2 and SDQ Leaders: Lori Stark School Based Health Discharge Follow-up AIM: Spread process of school nurse communication with family after hospital discharge from 6-8 schools to Y number of CPS schools. Increase the percent of CPS patients with hospitalization with follow up by school nurse from X percent to Y percent. Leaders: Stacey Willis All Children Thrive Cincinnati Just some of our HIGHLIGHTS Elm Street Clinic developed an integrated Dental and Well Child Check visit, the knee to knee exam Braxton Cann and Northside Clinics are working on a proactive outreach strategy helping kids stay on track with their check ups PPC developed dental maps and a comprehensive dental resource guide for the collaborative Price Hill Clinic is extending their ASQ work and are preparing now to take on literacy in 2019 Hopple Clinic is also measuring downstream clinic response to elevated lead and lead levels returning to normal Millvale Clinic and CCHMC SBHC both have positive trends in their population data All Children Thrive Cincinnati Our Dashboardtracking our progress All Children Thrive Cincinnati How many care gaps are we closing? All Children Thrive Cincinnati Thrive by Five Collaborative Teams NORTHSIDE LAST NAME Bonner Horne Duskin Goode Pearson Toole FIRST NAME Sheila

Susan Crystal Geneva LaShanta Alexandra ROLE RN RN MA RN Sup. Tech Dentis t BRAXTON CANN LAST NAME Blistan Campbell Herndon Law Strawther White FIRST NAME Bobbie Brandi Britnie Dawnielle Antwanette Lasheena ROLE RN MA Mgr MA MA MA PRICE HILL LAST NAME Cunningham Dreyfus Moore Rice Tarai Watson FIRST NAME Tina Debra Tosha Angela Sarah Jakki

ROLE RN RN Mgr MA MA MD MA FIRST NAME Deb Amy Michelle Julie ROLE RN RN MA RN PPC LAST NAME Fieglein Haering Harrison Kleiman HOPPLE LAST NAME Burkhardt Mescher MILLVALE LAST NAME Britton Daniels Dunbar Kanu Leary Ross Blair ELM STREET LAST NAME Childress Funk Hallums Novais Robinson Saker Spears Wadhwa McClanahan Massaro FIRST NAME

Mary Carol Anne ROLE MD RN FIRST NAME ROLE Keysha MA Michelle RN Janicyn RN Hazel MD Kimberley RN Alvenia Registration Fredresha MA FIRST NAME Toshia Hollin VaLinda Anna Sharma Denise Sandra Gauri Kelsey Zella ROLE MA RN Admin Dentis t RN MD Front Mgr Hygienist SW SBHC CCHMC: Rockdale and S. Avondale LAST NAME FIRST NAME ROLE Crosby Lisa APN

Pleasant Felicia ASR SBHC CHD LAST NAME Jones O'Leary Rudy Thamann-Raines Wills FIRST NAME Victoria Marybeth Allison Lauren Stacey ROLE MA RN APN APN RN CHD QI Team LAST NAME Doll Mullins Mussman Silas FIRST NAME Paula Angela Grant Jackie ROLE RN RN MD RN a shout out to all our teams! All Children Thrive Cincinnati

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