Washington Healthcare Improvement Network

By Pat Justis, WHIN Manager
Department of Health

The Washington Healthcare Improvement Network (WHIN) offers training, technical assistance and quality improvement supports to primary care teams working to establish or refine patient and family-centered medical homes. WHIN is an initiative of the Washington State Department of Health. WHIN serves all interested primary care practice teams and is committed to being responsive to the needs of pediatric teams, in addition to family and internal medicine. The emphasis is on practical, tangible tools and examples from peer teams with successful improvements.

WHIN works with clinics in specific regions and communities and is currently kicking off work in Whatcom County working with Whatcom Alliance for Health Advancement. An initiative in Thurston, Mason and Lewis counties will begin this spring, and WHIN is partnering with CHOICE Regional Health Network in this region. Regional and community work will continue to cycle around the state, with tentative plans to add new regions in fall, 2013.

For the state regions not currently being served by WHIN's community-based approach, a self-paced pathway to medical home called WHIN Institute offers a package of services to support medical home development. Resources are continually being developed to add to the platform. Resources available to all Institute participants include:

• Supported use of a validated assessment tool to measure the clinic's current level of medical home development. Re-measurement at six month intervals is encouraged to mark progress.
• A library of interactive e-learning modules supports clinics working on NCQA-PCMH or other medical home certifications. Most modules are designed for the entire clinic team. (Category 1 CME credit or certificate with contact hours available)
• Frequent webinars on topics customized to the group of enrolled clinics.
• Documents/toolkits provide more information on various aspects of a Patient-Centered or Family-Centered Medical/Health Home.
• Links to resources at other organizations which are high quality and useful to clinics.
• Support for population measures and quality improvement.
• Linkage to peer teams working on similar medical home improvements.

For more information please visit WHIN online, email WHIN@doh.wa.gov or call WHIN Manager Pat Justis in the Practice Improvement Section at the Department of Health at 360-236-3793.

Pesticide Exposure in Children

By Catherine Karr, MD, PhD, MS
Director, PEHSU
University of Washington

Children may encounter pesticides daily in air, food, dust, soil and on surfaces in the home or outdoor areas. Seventy-four percent of American households use some sort of pesticides, including insecticides and pet products (Pesticide Industry Sales and Usage, EPA).

While high dose/frank poisoning episodes in U.S. children are declining, a new AAP policy statement and accompanying technical report (Pesticide Exposure in Children) highlights the concerning accumulation of evidence linking low-level, chronic exposure to pesticides with some of the major health concerns facing children today. Among these are attention and learning problems, low birth weight and pediatric cancer.

Recognizing common signs of poisoning due to pesticide ingredients remains important, but pediatricians must also be able to provide effective prevention advice to families. Asking about pesticide use and storage in the home or recognizing occupational exposures a child or teen may have allows pediatricians to give families guidance on this issue.

Tips to Share with Parents
Reducing a child's exposure to pesticides can easily be achieved by the following:

• Reducing exposure in foods:
  • Children should eat a wide variety of produce. While organic food has fewer pesticides, the most important thing is that a child's diet is diverse.
  • Scrub fruits and veggies with water to remove pesticide residue from the surface.
  • Refer to the Environmental Working Group (EWG) Shopper's Guide to Pesticides in Produce.
• Reducing exposure in the child's environment:
  • Use the fewest number of pesticides in the home as possible, and the least toxic method for common household and garden pest problems. Refer to Grow Smart Grow Safe for outdoor pest problems.
  • Never use bug bombs or broad spraying pesticides; choose localized crack and crevice treatments instead.
  • Follow the directions on pesticide labels carefully if pesticides are used.
  • Store pesticides safely out of children's reach.
• If you work with pesticides, do not take them home on your clothes and shoes. Change clothes before coming home and remove and store shoes outside. If your clothes come home, wash them separately.

For additional information, see the following resources:

1. American Academy of Pediatrics: Pesticides and Children Technical Report, Policy Statement
2. American Academy of Pediatrics: Organic Foods: Health and Environmental Advantages and Disadvantages
3. Environmental Working Group: Shoppers Guide to Pesticides in Produce
4. Environmental Protection Agency: Resources for Pest Management
5. Environmental Protection Agency: Pesticides Industry Sales and Usage, 2006 and 2007 Market Estimates
6. HealthyChildren.org: Protecting Children From Pesticides
7. HealthyChildren.org: Organic Foods: Worth the Price?
8. Northwest Pediatric Environmental Health Specialty Unit

News from PROS - MOC Part 4

By Stephen Pearson, MD, FAAP

Adolescent Health in Pediatric Practice (AHIPP) is actively recruiting practitioners and practices that see a fair number of adolescent patients, some of whom smoke tobacco. The study was very recently granted the ability to award MOC Part 4 credits to the American Board of Pediatrics (ABP) for practitioners completing the study.

The aims of the study include demonstrating providers' fidelity to guidelines for tobacco counseling and delivering cessation interventions. Practitioners will be randomized by practice to receive training about tobacco screening along with a brief counseling intervention OR training about media use screening along with a brief counseling intervention based on AAP guidelines on media use.

Practices will be asked to recruit and obtain consent from at least 100 adolescents (14 years of age or older). The adolescents will then fill out a baseline questionnaire at the time of the visit. All self-reported smokers and 10 percent of non-smokers will be asked to participate in three follow-up phone calls after the initial visit, at: 1) Four to six weeks, 2) six months, and 3) 12 months. These phone calls will be made by PROS staff/contractors, not by the practice or practitioner.

This is the first PROS study to be endorsed by the ABP for MOC Part 4 credit. AHIIP has been developed, extensively tested and refined over a number of years. Both the study arm and control groups will receive the credit since the control is actually an intervention.

Here in Washington State there are a number of counties where the teen smoking rate is over 15 percent. There is no implied commitment to remain in PROS after completion of the study. Please contact Judy Gorzkowski, Program Assistant, American Academy of Pediatrics (1-800-433-9016, ext. 7126, or email jorzkowski@aap.org) to enroll in the program or for more information. Information can also be obtained by visiting PROS online.

A fully developed QA intervention for MOC Part 4 credit already vetted in practice, with follow-up calls and data analysis by PROS - what a deal! On the PROS home page there is an audio-visual description of the study as well as the aims, methodology and design.

Early Brain and Child Development for Pediatricians:
Building Brains, Forging Futures

By Danette Glassy, MD, FAAP

This newsletter series is adapted from a presentation by Dr. Andrew Garner reviewing Developmental Science. See wcaap.org for the entire series.

Part 2: Emotional Buffers Mitigate the Effects of Toxic Stress
Adverse Childhood Experiences (ACEs) are experiences, not events, because there is huge individual variability in the perception of what is stressful. One child finds a barking dog engaging, while another is terrified for months. This variability suggests that the measure of stress cannot really be the occasion of the stressor, but the individual's physiologic response or REACTIVITY to those stressors.

The National Scientific Council on the Developing Child has proposed the following categories of stress based on the measurable, physiologic response to the stress:

• Positive: brief, infrequent, mild to moderate intensity. Most normative childhood stress falls within this category, such as the inability of the 15-month-old to express their desires, beginning school or child care, that big middle school project. Positive stress is not the absence of stress. It builds motivation and resiliency.
• Tolerable: no physiologic response.
• Toxic: long lasting, frequent, or strong intensity. More extreme precipitants of stress (ACEs) such as physical, sexual, emotional abuse; physical, emotional neglect; household dysfunction. This can potentially cause permanent changes in the brain with long-lasting effects.

It is the physiologic response to that stress that can make it tolerable or toxic. Social-emotional buffers allow a return to baseline or reduce the long-lasting effects of toxic stress. The social-emotional buffers are when caregivers respond to the child's non-verbal cues, offer consolation, reassurance, or assistance in planning. The hallmark of toxic stress is the inability to return to baseline due to insufficient social-emotional buffering.

To read more about a pediatrician addressing ACEs to improve her patient's health see this article.

MOC Part 4 - Your Chance to Improve Pediatric Care

By Stephany Speck
American Board of Pediatrics

The American Board of Pediatrics (ABP) Maintenance of Certification (MOC) process is more than just renewing your certificate - it's about staying current with medical knowledge, continuously growing and developing professionally, and committing to improving care for your patients through Quality Improvement (QI).

Part 4 of the MOC process is your opportunity to make changes - big or small - in your practice, measure the outcomes and improve how you deliver care to children. It facilitates improvement through systematic measurement in a variety of activities and collaborative efforts.

There are three options for getting involved:

1. Approved QI Activities
   The ABP approves a wide range of established QI projects. These tend to be more integrated into practice than other Part 4 options, involving physician teams in a collaborative setting. For many of these projects, experienced coaches help guide these multi-practice improvement projects.View Approved QI Collaboratives
2. Approved Web-based Activities
   These are self-paced initiatives based on successful QI efforts that physicians can complete within their own practice, incorporating patient involvement through the use of surveys. The ABP offers an array of these free activities - tailored to your area of interest or specialty. Utilize the Part 2 and 4 Search Tool within your ABP Portfolio to choose an activity that interests you. View Approved Web-based Activities
3. Credit for Published QI Articles
   You can also receive credit for authorship of published articles relating to QI activities in health care based on SQUIRE Guidelines.Learn more about Credit for Published QI Articles

Don't wait to get started on making an impact and tracking your progress - some Part 4 activities take six weeks to one year to complete!