Integrating Healthcare: Teams Think PINQ
That’s the driver behind the Pediatric Improvement Network for Quality (PINQ). Because as primary care and behavioral health practitioners face the complex challenges of providing the best outcomes for kids in our region, the more brains on board, the greater the chances of finding solutions—and the faster we can spread the learning.
According to Jeff Steller, director of Population Health Research and Innovation, PINQ (pronounced “pink”) started out in September 2022 as an initiative of HealthVine, Cincinnati Children’s pediatric accountable care organization.
“Before HealthVine or Population Health existed, we were part of a collaborative called ‘Thrive at Five,’" he explains. “It was a group that met to enhance well-child visits. But as HealthVine and Population Health got up and running, we saw an opportunity to amplify the work by using a learning network model. So, the group transitioned to PINQ and recruited some additional partners. As the network grew, PINQ became a Population Health initiative, since HealthVine is specific to patients on Medicaid, and we wanted a broader focus.”
From the outset, the group enlisted the help of the Anderson Center at Cincinnati Children’s, which has pioneered and led the learning network approach for more than a decade.
“We chose to adopt this model because there is significant evidence that learning networks can move and scale quality improvement more quickly,” says Jeff. “We’re super fortunate to have the Anderson Center so we don’t have to reinvent the wheel on how to structure what we’re doing.”
Those participating in PINQ include our Community Health Services Network practices (Batesville, Greensburg, Mason, Liberty, Springdale, Kenwood, etc.), along with General Pediatrics, Adolescent Medicine and the Cincinnati Health Department. They are joined on the behavioral health side by the divisions of Behavioral Medicine/Clinical Psychology and Child and Adolescent Psychiatry. Community partners include NewPath Child and Family Solutions, Butler Behavioral Health Services, and Best Point Education and Behavioral Health. And more signups are in the works.
In the beginning, PINQ concentrated on well-child metrics, like vaccine compliance, improved lead screening, depression screening and follow-up.
Says Jeff, “Often, when a patient tests positive for depression, the primary care provider refers them to a behavioral health specialist. But it’s very difficult to know if that consultation has occurred. Likewise, behavioral healthcare providers have no idea if their patients are seeing their pediatrician for well-child care. In the inpatient world, you can look at the electronic medical record (Epic) and see images from Radiology or the notes from a psychiatric consult. We haven’t had that visibility in the community.”
The goal is to create a cohesive child health ecosystem in Greater Cincinnati that truly addresses physical and mental health needs and ensures that everyone on the care team is aware of all the pieces of a patient’s care.
Data Tells the Tale
PINQ relies on data to identify trends and gaps in care. Cincinnati Children’s practices extract their data from Epic, while external partners provide their own each month. All of it is aggregated to produce a chart that is shared with the teams. Decisions on what improvements to make are based on that chart. For example, our Northern KY primary care practice improved vaccine compliance by changing their scheduling approach, especially for patients 2 years old and younger.
“They’ve had a lot of success by scheduling the next appointment before the provider comes into the room,” says Jeff. “Evidence confirms that if you wait to do it at the end of the visit, things are more chaotic, and the caregiver is likely dealing with a crying child. The caregiver says, ‘We’ll call back,’ and they never do, so patients fall behind on important milestones. Getting families to the visit is the bigger issue.”
At Cincinnati Children’s Mason, Liberty and Springdale practices, they’ve concentrated on improving follow-ups after a positive depression screen. They hired an additional staff member to reach out to families within two weeks of the screen to make sure the patient has a behavioral health appointment scheduled. And since February, they have offered same-day scheduling.
Says Jeff, “Some families want time to process the results of the depression screen, but others take the opposite approach and say, ‘Okay, now that we have this information, let’s get Johnny in to see someone as soon as possible.’ So, we work hard to make sure they walk out of the visit with an appointment.”
Jessica McClure, PsyD
All About Access
Screening for behavioral health issues during well-child checkups is a great first step in helping kids get the care they need. But it requires backing it up with the right resources.
Says Stephanie Eberle, director, Population Behavioral Health Programs, “As a nation and as a region, we’re in a really dark place in terms of youth mental and behavioral health. Everybody knows we’re facing a crisis—the emergency departments are overwhelmed. There are no inpatient beds. Kids wait for weeks or months to get the care they need. I believe the work we’re doing could be transformative. It’s an opportunity to address the challenges at the system level because the volume and acuity of behavioral health concerns has increased dramatically, and providers tell us they feel they are swimming upstream.”
This past September PINQ began taking primary care/behavioral health integration further by incorporating community behavioral health organizations into the learning network.
Jessica McClure, PsyD, medical director of Population Behavioral Health, explains, “Having behavioral health integrated with primary care allows us to intervene early. We can put preventative measures in place even before a diagnosis emerges so that we can work upstream and address things like self-regulation, parent confidence or signs of potential mental health concerns.”
Meeting patients and families where they are—at the primary care visit—eliminates a lot of the barriers to access and reduces the stigma of mental illness by making assessment and treatment part of the routine.
“The primary goal is to make sure youth have access to the right level of care. If we can help them manage their symptoms earlier on, we can prevent them from reaching a crisis stage where they end up in the ED or needing hospitalization,” says Jessica.
Moving patients through treatment more efficiently also improves access by freeing up care providers’ time to see the next round of kids coming in.
Outpatient and school-based therapists involved in PINQ are being trained to use a measurement-based care approach. This approach employs a brief patient-reported outcome survey, consisting of three questions developed at Cincinnati Children’s, to assess treatment progress.
“We’ll be measuring the length of time it takes to get kids to a more functional level of mental health,” says Jessica. “The literature shows that use of this tool reduces the length of treatment so kids can return to school and their community more quickly.”
But that’s not the only benefit of this approach. Pre-emptive, efficient care helps retain staff.
Says Jessica, “Lack of access is due in part to individuals leaving the behavioral health workforce because of burnout. So, we hire more and more people, but they are just starting their careers, and after a few years, they burn out too. If we can do a better job of retaining the workforce we train, then the level of care will improve, access will improve, and clinical outcomes will improve. It’s all tied together.”
PINQ will be incorporating a model for retention that has been successful in our community practices.
“We started a program for integrated behavioral health therapists in 2019,” says Jessica. “They get weekly group case consultations with doctoral level psychologists. It helps them feel connected to the rest of their team, and it gives them access to an expert if they have a tough case or encounter a clinical issue that they haven’t seen before. Since the program started, we’ve had 100% retention.”
Equity and Innovation
Providing support for staff is only one aspect of PINQ. They also include the voice of the family, which has proved to be a tremendous asset.
Says Jeff, “There have been multiple times when we’ve thought about testing an improvement, and our families have said, ‘We hear what you’re suggesting but here’s why that’s not going to work from a family perspective.’ It’s saved teams from heading down a path to a dead end.”
Family involvement is a bit more sensitive on the behavioral health side, where there could be 40 people on a call, he admits. “But we’d like to make sure that they are represented in that work too.”
PINQ also has an explicit focus on equitable outcomes and interventions.
“As we work to integrate primary care and behavioral health, we recognize that social determinants of health play a huge role in access to care and outcomes,” says Jeff. “We encourage teams to make sure that when they’re designing interventions, they consider if they are leaving anyone out. For example, telehealth is a phenomenal tool, but it relies on families having either a smartphone or reliable access to broadband internet. Before we implement anything, we need to ask if we’re exacerbating an existing inequity or creating a new one.”
The PINQ team is very proud and excited about how they can transform care for patients and families.
“We’ve done a lot of intensive research, and we believe that nothing like the behavioral health arm of PINQ exists in the U.S. right now," says Jeff. "We are bringing groups to the table in a way that’s truly cutting edge and groundbreaking. I am very confident that, within a couple of years, other health systems will be replicating something similar.”