Improving Integration of HEEADSSS Screening in Adolescent Preventative Care Visits - A Practice Improvement Project

Despite general consensus that adolescents should receive annual preventative care during which psychosocial screening and provision of pertinent anticipatory guidance is provided, studies have demonstrated that few receive this standard of care. This problem is clinically significant when you consider that lack of routine screening and anticipatory guidance increases the risk for poor lifestyle choices and associated long-term morbidity and mortality. Fortunately, the literature reveals that adolescents are more likely to be forthcoming about concerns and respond positively to anticipatory guidance when providers introduce topics privately and confidentially. As a result the American Academy of Pediatrics recommends the use of the mnemonic HEEADSSS to direct confidential psychosocial screening. If screening is improved, then anticipatory guidance could occur, thereby improving the long-term health of the adolescent population in this region. Therefore, the purpose of this project was to improve integration of HEEADSSS screening during adolescent preventative care visits at St. Luke's Clinic Physician Center. The objectives of this project included: 1) Identify barriers and strategies to improve inclusion of HEEADSSS screening, 2) Educate primary care providers regarding barriers and strategies for improvement, 3) Evaluate effectiveness of education using: retrospective chart reviews and provider surveys, 4) Disseminate findings to primary care providers at St. Luke's Clinic Physician Center. The results of the implementation and evaluation of this project are as follows: 1) An in-depth literature review was conducted along with input from content experts. Identified barriers included lack of provider training and confidence, time constraints and confidentiality. Identified strategies to overcome these barriers included pre-visit questionnaires, skills-based training, and strength-based interviewing techniques. 2) A skills-based training workshop was conducted on 1/31/14 at St. Luke's Clinic Physician Center. Information on the HEEADSSS screening tool, barriers, and strategies for inclusion were presented; with 12 of 25 primary care providers in attendance. 3) Unfortunately the workshop did not increase inclusion of HEEADSSS screening; retrospective chart reviews pre (10/2013; N=57) versus post (02/2014; N=38) workshop showed 7% decreased inclusion. However provider surveys (N=10) pre versus post workshop displayed a 23% increase in provider knowledge and a 40% increase in provider confidence with utilizing HEEADSSS. 4) The above results were disseminated to primary care providers at St. Luke's Clinic Physician Center on 3/18/14. In summary, a training workshop was implemented to improve integration of HEEADSSS screening. It resulted in improved provider knowledge and confidence, however failed to ultimately increase integration of screening. This was, in part, due to a retrospective chart review design flaw. Evaluating only providers who participated in the workshop, rather than the entire practice, would have yielded a more meaningful measurement of the workshop's effectiveness. Recommendations include re-evaluation of retrospective chart reviews using only participating providers and further integration of pre-visit questionnaires to enhance workflow inclusion.