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Using Informed Clinical Opinion During Eligibility Determination

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This webinar will explore the key components of informed clinical opinion and describe its uses during the eligibility determination process. Information will include definitions and descriptions of …

This webinar will explore the key components of informed clinical opinion and describe its uses during the eligibility determination process. Information will include definitions and descriptions of informed clinical opinion, provider skills necessary for using informed clinical opinion, and the importance of the intake process in ensuring informed clinical opinion can be used effectively and appropriately for eligibility determination. Participants will have the opportunity to practice using informed clinical opinion with 3 different eligibility scenarios.

This webinar will feature Beverly Crouse and Kyla Patterson, Part C Technical Assistance Consultants.

Published in: Education, Health & Medicine

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  • Good afternoon! This is Deana Buck from Virginia’s Integrated Training Collaborative, and I am joined by Kyla Patterson  and Bev Crouse, TA Consultants, for today’s webinar on Informed Clinical Opinion During Eligibility Determination.  Thank you for joining us today.    Today’s webinar will explore the key components of informed clinical opinion and will describe its uses during the eligibility determination process.  Information will include definitions and descriptions of informed clinical opinion, provider skills necessary for using informed clinical opinion, and the importance of the intake process in ensuring informed clinical opinion can be used effectively and appropriately for eligibility determination.  You will have the opportunity to practice using informed clinical opinion with 3 different eligibility scenarios.   
  • This Fall, the TA Consultants visited with 9 local systems to learn about their intake, eligibility determination and assessment for service planning processes.  As the TAs discussed what they learned from these visits, we found there was variation in how frequently the systems were using atypical development as the sole reason for eligibility and how often the eligibility team was able to determine eligibility based on existing information.  As a result, we felt it was important to ensure a consistent understanding of what informed clinical opinion is and how it can and must be used in the eligibility determination process.  We'll also be giving you a chance to use your informed clinical opinion with 3 different eligibility scenarios.
  • Let's first look at what the federal Part C regulations say about informed clinical opinion...   The requirement to use informed clinical opinion is intended to guard against eligibility determination being based on just test scores or other information looked at in isolation.
  • The Practice Manual also speaks to informed clinical opinion.  We define the term in the Glossary, on page 189 to be specific.  Informed clinical opinion is ... (read slide)
  • Page 29 of the Practice Manual provides a description of informed clinical opinion. It says that informed clinical opinion is the result of synthesizing medical and developmental information (based on a tool, observation, parent report, medical records, etc.) with professional expertise and experience to make a determination regarding a child’s developmental status and/or eligibility.  This description expands on the definition from the glossary to specify the kinds of information the professional is reviewing in order to reach an infomred clinical opinion.
  • A 2002 NECTAC paper on informed clinical opinion provides another definition that we can look at.  (Read definition)   This definition adds that informed clinical opinion also takes into account the need for early intervention services.  The NECTAC paper suggests that the goal of using informed clinical opinion is a better match between child and family needs and services.  There's also an emphasis on using all available information (both qualitative and quantitative).
  • Using informed clinical opinion allows eligibility teams to pull together multiple sources of information in a flexible but informed and rigorous way.  There are some key components that run through each of the definitions and descriptions we just looked at that ensure the informed and rigorous piece is in place.  First, we need to be considering multiple sources of information when coming to an informed opinion -- qualitative and quantitative information; information from multiple people, like parents, referral sources, and Part C providers; and information gathered through multiple mechanisms, like screening or assessment tools, observation, and parent report. Next, there has to be the element of professional expertise and experience because that allows us to interpret the information we have.  And, finally, we have to bring all of those elements together ... the available information and our professional knowledge ... to form an opinion about the child's developmental status and/or eligibility.     
  • Now please take a moment to read the scenario ....We're going to remain silent on the line so you can concentrate and then we will  open up the poll tool and have you respond to a question. <WAIT 30 SECONDS---watch the timer> As we open the poll,  <open poll>  you will see your screen change.....that is normal.   Has this provider used informed clinical opinion?   Vote Yes or No <WAIT 30 SECONDS>  <respond to poll submissions> Ok we're going to close the poll now  <close poll>  and as we do, your screen will change again. 
  • It's important to know not only what informed clinical opinion is , but also what it isn't .  In the example, the provider didn’t really consider multiple sources of information or synthesize information from multiple people.  There was not enough information to be “informed.”  And it certainly wouldn't be appropriate for any provider in that circumstance to be telling a parent their child is on the autism spectrum. 
  • Given the key components of informed clinical opinion, there are certain skills a provider must have in order to effectively and appropriately use informed clinical opinion.  The provider needs:  appropriate training; previous experience with determining eligibility, conducting observation, screening, assessment; awareness of and sensitivity to cultural needs and norms; ability to gather and use family perceptions.    
  • Given those necessary skills, how would you rate your own ability to effectively and appropriately use informed clinical opinion? I'm going to open up a poll <open poll>  so you can respond. You will see your screen change.  <re-read question & options> Indicate your ability as Very skilled, skilled, somewhat skilled, or not yet skilled. A ll poll responses are anonymous. <WAIT 30 SECONDS>  <respond to poll submissions> Ok we're going to close the poll now  <close poll>  and as we do, your screen will change again.  I'm now going to turn this over to Kyla who will talk about appropriate and effective use of informed clinical opinion in determining eligibility. 
  • Thanks, Bev.  I'm going to be talking about a number of aspects of using informed clinical opinion in determining eligibility, and then you'll have the chance to practice using your informed clinical opinion with 3 different eligibility scenarios.   Informed clinical opinion happens at both the individual and team levels.  As professionals, we use informed clinical opinion everyday… when we conduct screenings or assessments for service planning and as part of ongoing assessment with children we are serving.  We use our experience with children and families and our disciplinary expertise to interpret what we observe, what we read in reports from other professionals and what we hear from parents in order to form opinions about the child’s developmental status in a particular area of development, the child’s response to intervention, or the child’s ongoing eligibility.  That's using informed clinical opinion on an individual level.   As individual professionals, we then bring the information we have about the child and the opinions we’ve formed based on that information to the teams we serve on … eligibility determination teams, assessment for service planning teams, IFSP teams, etc.  The team we’re focusing on today is the eligibility determination team.  The eligibility determination team works together to synthesize the information and the informed opinions of the team members to reach a team decision on the child’s eligibility.  The team comes to an informed opinion about the child’s eligibility.
  • As I mentioned, one way that informed clinical opinion is used is to determine a child's status in each area of development.   If we were limited to just looking at how a child performs on a screening or assessment tool, we would have incomplete information, particularly with the age group we see and for children who have developmental challenges or medical issues.  How would we know how the child functions across settings?  What would we do with a child who is on the border between age levels?  What happens when the screening or assessment tool doesn’t fully cover a developmental area?  And then there are those areas of development that are hard to measure anyway (like articulation??).  Or sometimes a child’s behavior or medical condition makes an area difficult to measure using a screening or assessment tool.  What about those situations where what you’re observing doesn’t match up with what the assessment tool tells you?    It’s in these situations where our informed clinical opinion is so critical.  We can move beyond the black-and-white of testing protocols to be sure we have a complete picture of the child’s developmental status.
  • Informed clinical opinion is also used to determine a child's eligibility for Part C.   Using informed clinical opinion to determine eligibility occurs as part of a team process and involves working towards a consensus decision.  Once the team makes a decision about eligibility, then the team’s decision, including the use of informed clinical opinion, is documented on the Eligibility Determination Form.  This form should clearly document the sources of information considered by the team and the reasons for the eligibility decision.  It needs to connect the dots ... we looked at these peices of information, we interpreted them this way based on our informed clinical opinion and we came to this conclusion about the child's eligibility.
  • Using informed clinical opinion for eligibility determination allows teams often to make an eligibility decision based on existing developmental and health information without the need for further assessment.  The eligibility determination team will have multiple sources of existing information, like parent observation and report, information from the referral sources, medical and health information, screening results and the observations of the provider who conducts the screening and/or intake visit.  That information combined with the professional expertise and experience of the 2 EI Professionals who make up the eligibility determination team is often enough for an informed opinion about eligibility.
  • I want to point out that the proposed Part C regulations stated that ... (read slide).  Although those proposed regulations were withdrawn, this language clearly indicates the intent that informed clinical opinion is adequate justification for eligibility.  Remembering, of course, that the informed opinion is based on multiple sources of information.    One instance where we know this comes into play is with atypical development.  In Virginia, a child can be found eligible for Part C based on atypical development even when there is no actual delay in any area of development.  The January Talks on Tuesday that focused on prematurity described a number of ways in which a child who was born prematurely could likely be found eligible based solely on atypical development.  For very young pre-term infants, there are limited items on screening and assessment tools, so documenting a 25% developmental delay based on an instrument can be difficult.  Similarly, the age adjustment for premature children may also mean that the child does not demonstrate a 25% developmental delay.  Observation and our informed clinical opinion, though, can be used to document atypical development and therefore eligibility for Part C.
  • I'm interested in knowing whether you have participated in an eligibility determination meeting where the child was found eligible based only on atypical development (e.g., no developmental delay or diagnosed condition)?   I'm going  to open the poll   <open poll>  so you can respond   and I'd like you to indicate yes or no. <re-read question & options> <WAIT 30 SECONDS>    <respond to poll submissions> Ok we're going to close the poll now  <close poll>  and you will see your screen change again. 
  • Since using informed clinical opinion requires access to multiple sources of information, the intake process is critical.  Among the 9 local systems the TAs visited, there were some consistent success factors observed in those local systems where eligibility determination was based on existing information, without the need for assessment, for a large percentage of children.     The first of those factors was training.  And this was training related to Practice Manual requirements, using  a specific screening tool or tools, gathering information from families, etc.  The goal of the training was to ensure consistency among staff who conduct intake and to ensure complete and appropriate information is available to the eligibility determination team.   And that's really the next success factor - consistency of process and practices.  Again, consistency with regard to the intake process.  But also consistency in terms of eligibility determination.    
  • Those systems where the eligibility determination process is going more smoothly also spent time ensuring complete documentation.  When we looked at the records in these systems, we found that the screening tool didn't just have check marks for skills completed it also had notes in the margins describing the provider's observations and the parent's comments.  Contact notes and other documentation were appropriately focused on the information the eligibility determination team would need in order to do its job.   There was also strong communication between the intake person and the eligibility determination team.    These success factors held true regardless of whether the intake person was a service coordinator, an individual who serves in a  dual role as a service coordinator and another discipline, or a provider other than a service coordinator.    Next we're going to move to some eligibility scenarios.
  • We have created 3 different scenarios to help you practice using your informed clinical opinion to determine eligibility based on existing information.  We recognize that this is an artificial situation ... normally you would work as a team to determine eligibility (and we encourage you to work on this as a team if you're in a room with other providers from your local system) and normally you would probably have more information to work with (rather than just a summary).  But we hope that these scenarios can still give a you a sense of how informed clinical opinion is used in eligibility determination.     For each of the scenarios, pretend you are a member of an eligibility determination team.  The service coordinator has gathered all available information for the team's review, and given the team this summary. 
  • Let's take a look at Scenario #1. I'm going to read it in case anyone is having technical trouble with seeing the slide.    If you're following along on a print-out, we're on slide #26.   <READ THE SLIDE>   I'll give you about 30 seconds now to look over it again before we move to our poll question.   <WAIT 30 SECONDS>  
  • Now we'd like to know, based on the information you just read in the summary, would you find Drake to be eligible for Part C, ineligible for Part C or would you need more information in order to determine eligibility.   We're going to open up the poll so you can respond . All polls are anonymous, so please don't need to worry that your answer might be different than others.  Use this as a chance to practice and learn. <open poll>   Now you should be seeing the poll.  To respond to the question, click the box next to the option you would choose.   <WAIT 30 SECONDS>    Some information that indicates the child is eligible: Significant delay in rolling over and other gross motor skills - greater than 25% Absence of these skills is noted consistently across settings and by mutliple people (pediatrician, family, service coordinator). Ok we're going to close the poll now  <close poll>  . 
  • Let's take a look at Scenario #2. I'm going to read it in case anyone is having technical trouble with seeing the slide. This is Slide #28.  <READ THE SLIDE>     I'll give you about 30 seconds now to look over it again before we move to our poll question.   <WAIT 30 SECONDS>
  • Now we'd like to know, based on the information you just read in the summary, would you find Sarah to be eligible for Part C, ineligible for Part C or would you need more information in order to determine eligibility.   We're going to open up the poll <open poll> again so you can respond.   <WAIT 30 SECONDS>   Reasons we may have different opinions about this one: Different levels of experience with ED, Doing it as individual instead of team, Different disciplinary backgrounds and levels of experience.  We felt this one might need more information because: There was some conflicting information about how many sounds the child was making, Based on the ASQ scores, it was a little hard to tell whether there was really a 25% delay in communication or personal-social development, and There was not enough observation detail to help further clarify the child's status in those 2 areas of development or to indicate atypical development.  This doesn’t mean that it would be wrong for a team to find this child eligible with this existing information, especially since you would generally have more of that detailed information from observations than we could provide here in this short summary. Ok we're going to close the poll now  <close poll> 
  • Share some of your thoughts in the chat box. <WAIT 30 SECONDS> <RESPOND>
  • Let's take a look at Scenario #3. I'm going to read it in case anyone is having technical trouble with seeing the slide. This is Slide #31.   <READ THE SLIDE>     I'll give you about 30 seconds now to look over it again before we move to our poll question.   <WAIT 30 SECONDS>
  • Now we'd like to know, based on the information you just read in the summary, would you find Betsy to be eligible for Part C, ineligible for Part C or would you need more information in order to determine eligibility.   We're going to open up the poll  <open poll>  again so you can respond.     <WAIT 30 SECONDS>   Some of the information that indicates the child is not eligible: Hearing, vision and developmental screening results all indicate no reason for further assessment or monitoring. Observation by SC and mom indicate Betsy is expanding her vocabulary, is effectively getting her needs met through verbal and non-verbal communication, and that she is socially engaged. There were no indications of atypical development and no medical diagnosis. Ok we're going to close the poll now  <close poll> 
  • We'd now like to open this up for some questions.  If you have a question, please type it in the chat area at the bottom right corner of your screen. <WAIT 60 SECONDS>
  • Again, thank you for joining us for today’s webinar. You will be receiving your survey following the webinar and we welcome your feedback and suggestions. Please let you colleagues who couldn’t join us today know that this webinar will be archived within the next few weeks and will be available on the Virginia Early Intervention Professional Development Center website: www.eipd.vcu.edu Have a wonderful afternoon!
  • Transcript

    • 1. Kyla WELCOME Deana Bev This presentation has been modified for use on slideshare.
    • 2. Purpose
        • Define informed clinical opinion 
        • Explain its use in eligibility determination 
        • Provide a chance to practice with some examples
    • 3. Part C Regulations
      • Evaluation (for eligibility determination) & assessment must be based on informed clinical opinion.   
      303.322(c)(2
    • 4. Definition - Practice Manual
      • Informed clinical opinion:  The outcome of using information gathered through eligibility determination and/or assessment for service planning methods combined with professional expertise and experience to determine the child’s developmental status and eligibility under Part C.
      Page 189 of Practice Manual
    • 5.
      • Informed clinical opinion is the result of synthesizing medical and developmental information (based on a tool, observation, parent report, medical records, etc.) with professional expertise and experience to make a determination regarding a child’s developmental status and/or eligibility.
      Description - Practice Manual Page 29 of the Practice Manual
    • 6.
      • “ Informed clinical opinion makes use of qualitative and quantitative information to assist in forming a determination regarding difficult-to-measure aspects of current developmental status and the potential need for early intervention services.”
      Definition – NECTAC Notes 2002 Informed Clinical Opinion , Jo Shackelford NECTAC Notes, Issue No. 10 May 2002
    • 7. Key Components
        • Multiple sources of information
        • Expertise and experience
        • Synthesizing
    • 8.
      • A 2-year-old child is referred by his child care center because he is “not talking as much as the other kids and doesn’t really interact with others.”  A provider goes to the family’s house for intake.   After 5 minutes of watching the child and trying to talk to him and without getting information from the mom about the family’s observations and concerns about the child, the provider tells the mom that her son is on the autism spectrum.
      Check Your Understanding your screen will change as we open/close the poll 
    • 9.
      • Informed clinical opinion is not “eyeballing” a child for a few minutes and deciding whether or not he/she is eligible.
      What It Isn’t!
    • 10.
      • The ability to use informed clinical opinion requires:  
      •  
          • Appropriate training;
        •  
          • Previous experience;
        •  
          • Cultural sensitivity; and
        •  
          • Ability to gather and use family perceptions
      •  
      Provider Skills Needed
    • 11.
      • Given those necessary skills, how would you rate your own ability to effectively and appropriately use informed clinical opinion? 
      •  
      •  
      •  
      Consider This… your screen will change as we open/close the poll
    • 12.
        • Individual - Develops an informed opinion about child’s development and need for EI services
      •  
        • Team – Synthesizes info from all members to determine eligibility
      Individual and Team Level
    • 13.
      • Across settings 
      • On the border
      • Instrument does not fully cover
      • Difficult to measure
      • Observations don’t match measurement
      To Determine Status in Each Area
    • 14.
        • Team process 
        • Consensus decision-making 
        • Documenting decision
      Determine Eligibility
    • 15.
        • Parent observation and report
        • Information from referral source
        • Medical and health information
        • Screening results
        • Provider observation
      Use of Existing Information
    • 16.
      • Informed clinical opinion may be used by qualified personnel to establish a child’s eligibility even when other instruments do not establish eligibility.
      Atypical Development
    • 17.
      • Have you participated in an eligibility determination meeting where the child was found eligible based only on atypical development (e.g., no developmental delay or diagnosed condition)? 
      Poll your screen will change as we open/close the poll
    • 18.
        • Training
      •  
          • Practice Manual
      •  
          • Screening tool
      •  
          • Gathering information from families
      •  
        • Consistency of process, practices
      Importance of Intake
    • 19.
        •   Documentation
      •  
          • On the screening tool
      •  
          • Contact notes
      •  
        •   Communication with eligibility determination team
      Importance of Intake
    • 20. Practice Sessions
    • 21.
      • Drake is an 8-month-old who was referred to the local system by his pediatrician because Drake is not yet rolling over.  During the intake visit, Drake’s mom confirms that he has not rolled over yet from back to front or front to back, and she comments that he often feels kind of floppy when she holds him.  The hearing and vision screenings completed during intake indicate no reason for further hearing or vision evaluation.  The service coordinator completes the ASQ for gross motor development and finds that Drake is not yet doing any of the skills on the 8-month questionnaire for gross motor development.
      Scenario 1
    • 22.
      • Based on the Scenario #1 summary, would you find Drake???
      your screen will change as we open/close the poll Poll
    • 23.
      • Sarah is 10 months, 10 days old.  She was referred to the local system by the local Department of Social Services which is involved with Sarah’s family because of concerns about neglect   During the intake visit, all areas of the ASQ-III were administered using the 10-month questionnaire.  Hearing and vision screenings were also completed.  Sarah’s scores on the ASQ were as follows:  Communication = 30 (in the grey/monitor column); Personal-Social = 35 (grey/monitor), Gross Motor = 60 (white/above cut score column), Fine Motor = 50 (white/above cut score), Problem-Solving = 50 (white/above cut score).  The hearing and vision screenings indicated no reason for further hearing or vision evaluation.  During intake, the service coordinator observed that Sarah still drinks from a bottle and makes few playful sounds.  The referring DSS worker had also noted that Sarah rarely uses sounds, but Sarah’s mom reports that she does make more sounds when it’s just the two of them.  No physician report is available.
      Scenario 2
    • 24.
      • Based on the Scenario #2 summary, would you find Sarah???
      your screen will change as we open/close the poll Poll
    • 25.
      • What might have been done differently at referral and/or intake to provide the eligibility determination team with enough information?
      Could You Have Had Enough Info? Use Chat to Respond
    • 26.
      • Betsy is a 20-month-old who was referred to the local system by her mother because she is concerned that Betsy is not talking nearly as much as her older brother did at the same age.  Medical records indicate no health concerns.  The hearing and vision screenings indicate no reason for further hearing or vision evaluation.  The ASQ indicates that Betsy is at or above age level in all areas of development.  The service coordinator observes that the words Betsy uses are fairly easy to understand, that Betsy follows directions well and that she tried to imitate 2 new words during the Intake visit.  Although Betsy’s mom reports that Betsy uses fewer words than her brother did at that age, she states that Betsy is adding more words and, even in situations where Betsy doesn’t use her words, she is very good at communicating her needs and wants through gestures and sounds.  Betsy is engaged and routinely interacts with her family during the day and with other children at the Church day care center on Sundays.
      Scenario 3
    • 27.
      • Based on the summary, would you find Betsy???
      your screen will change as we open/close the poll Poll
    • 28. Questions?
    • 29. THANK YOU www.eipd.vcu.edu Virginia Early Intervention Professional Development Center a recording will be available on our website in approximately 10 days