Developmental & Behavioral Screening: A Quality Improvement Initiative in Primary Care Practice


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Presented at the National Academy for State Health Policy's 20th Annual State Health Policy Conference in Denver, Colorado. Author: Marian Earls

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Developmental & Behavioral Screening: A Quality Improvement Initiative in Primary Care Practice

  1. 1. Setting the Stage for Success. .. fl
  2. 2. Assuring Better Child Health 8* Development “ADCD” DEVELOPMENTAL & BEHAVIORAL SCREENING: A Quality Improvement Initiative in Primary Care Practice Marian F. Earls, MD, FAAP NASHP October 15, 2on7
  3. 3. The ‘%_F.2’C’F. /”His’cor3.. .. r ln 2000, North Carolina was one of 4 states to be awarded a grant from the Commonwealth Fund to develop and implement a program to enhance child development services. F The Commonwealth Fund, among the first private foundations started by a woman philanthropist- Anna M. Harl<ness— was established in l9 18 with the broad charge to enhance the common good. The Fund carries out their mandate by supporting independent research on health care issues 8. issuing grants for improving health care practice and policy.
  4. 4. The Challenges. . . . . . ' 44% of children in NC live in low—income families ' The use of “the most common & familiar” developmental screening tool (Denver) is both untenable in primary care practice & does not meet sensitivity & specificity ' The AAP is recommending formal screening and surveillance at well child visits. ' Limited access to professionals with 0-5 expertise ( psychiatry, psychology, counselors)
  5. 5. The Challenges Continue. .. “Division of MH, SA, and DD Reorganizing: “target” population not inclusive of children at-risk or with mild to moderate problems. “The Early Intervention (EI) eligibility criteria is changing-less children will qualify “The number of children served by (E1) was low (8-13% of the total 0-3 population could qual1]y—only 2.6% historically served. ) 3 Across Medicaid systems of care the average rate of developmental screening was low: (approximately 15.3%) . ... ... ..
  6. 6. North Carolina’s Children. . . . L ~ Economic Security: 44% of children in North Carolina live in low-income families as compared to 40% nationally. ‘i 50% of those children live in families with incomes below 100% of the federal poverty level 48% of the children living in low-income families are under the age of six
  7. 7. NC’s Children cont. . . 3 Healthcare: Over 50% of North Carolina’s 2.1 million children are eligible for special health care programs or are uninsured. Specifics include: ‘ 116,00 children (age 6- 18) are enrolled in NC’s SCHIP program, Health Choice ‘ 848,380 children are enrolled in the NC Medicaid program ‘ Approximately 264,000 children are uninsured (177,000 of these are estimated to be eligible for Medicaid/ SCHIP)
  8. 8. Quality Improvement in Primary Care Practice Developmental Screening & Surveillance. ... . 'l'heSolub"on: (2) Develop a “best practices" comprehensive community model for replication — The model builds on North Carolina’s “Physician Driven”, enhanced primary care, case management program, Community Care of North Carolina, and is characterized by two major components: ‘ Introduction & integration of a standardized, validated screening tool (ASQ) at selected well-child visits, that is practical and that works; ‘ Collaboration with local and state agency staff and families in developing this system for identifying and serving children.
  9. 9. Thesolufion (cont): (2.) Formed a State Advisory Group — The group is comprised of leadership from key agencies who have the capability of making policy changes. Medicaid Early Intervention Public Health State ICC Department of Public Instruction: Preschool Smart Start Family Support Network NC Pediatric Society NC Academy of Family Practice
  10. 10. Community Care of North Carolina 0 15 local networks, 100 counties 0 Each network a 501 c 3 0 Network receives $2.50 pmpm for care managers who work directly with/ in practices. They assist with referrals, linking families with resources. 0 Local networks manage care for Medicaid, SCHIP, and often uninsured 0 Statewide MIS system- Care Manager
  11. 11. fi CunnuI1nil_v Cure of North Curulilm A . n. 'v's' ll and Ill . '. ;twnrl« I : ‘ in-1 nl . .cc. --uL‘u. - . 'c"Ior| a 3I. s . n-<4-I ‘ tv . rlc ‘T I u' on xnman’ lirunr rl 'o‘o<-an ‘(int Iiwmlln l‘V"%' I411‘: -'. vn~rl'. vvpa~‘r-I-r Gris. .. ‘. .I‘. ~I. ... ..‘. ..-(‘. . . ... .. a, 17.. v . Jinn ‘u a mu; IF--. . -L "mu -1 - .3 "wruml 7:: I It I11 '1‘: nu-R ', ILIJIJIII - Inn: to IA; .1 . rlIl.201uI lluun vs , (I11l'v1rI: ‘I0Wlrt: Itr‘LtJu‘ :1 '_u. nA. uLnr. :~' (Lu: l'4.| J Z74:Iun , uJu. n - nvwu 'uru. u Irv llu II: I'm: u- . o‘: .)cnI l‘. ¢v. finom t-ranxuk (Au a‘:1t. ‘.vA'iv>m mu-‘"1 uv Isu-IIII . ~’rltn rrlvk F1: Ilmlw Im'¢g1n<nt xu~. I.IsI, n-nllnnufi l. v. ‘.~h~ath K‘ h’_. ~‘_“__ Q Itlltll Pmhnnnt " vrlnu um‘ GIN Hun
  12. 12. CCNC (cont. ) 0 Quality Improvement protocols include asthma, diabetes, ED utilization, developmental & behavioral screening (ABCD), mental health integration in primary care, CHF, IPIP (Improving Performance in Primary Care). 0 Clinical Directors- Decision—Making 0 Regular reporting of data to networks.
  13. 13. CCNC Quality I mprovcmcnt Model Pilot network(s) (early adopters) initiate new protocol Pil0t(s) develop, test, and refine process Replication in rest of networks Network care coordinators in the practices to assist with office process and facilitate care coordination Pilot practices use office systems approach
  14. 14. Keys to Success - Engage physicians in the process from the beginning - Recognize practice concerns re: time, office flow, cost/ resources, and referrals - Use an Office Systems approach - Assure data collection and management
  15. 15. Engaging Physicians 0 Practice “champion” on work group 0 Input of physicians and other key practice staff on flow process 0 Include in data collection discussions
  16. 16. Recognize Practice Concerns Cl Takes too long D Difficult to administer D Children may not cooperate D Reimbursement is limited
  17. 17. The Office Systems Approach - Organizational tool: Getting Started Worksheet 0 Multidisciplinary: involves practice staff at all levels ° Networking: guides practice in building relationships with community partners
  18. 18. The Office Process Assess Current Protocols Identify Physician Champion Select a Screening Tool “Map the Workflow” Identify System Supports Networking is key 0 Conduct Staff Orientations . .
  19. 19. NC Earlg Intervention Resources: 7 ' Child Service Coordination f ' Infant Toddler (CDSA) & Preschool Programs (local school system) ' Governor Morehead School ' Preschool services for Deaf & HOH ' Schools for the Deaf (2) ' Parents as Teachers
  20. 20. Resources (cont) ‘Family Support Network ' Beginnings ‘Universal Hearing Screening
  21. 21. Assist with Data Collection and Feedback ‘‘If you measure, it will improve” Measurement — 0 drives the process at the practice level 0 drives policy change 0 increases credibility for replication and spread
  22. 22. Practice l_/ I-3.£5L’i res Screening rate - # 96110 codes / # well- visits. Monthly and share with providers to see progress. Referral rate — # referrals/ # screens done Referral sites - # and type P Provider survey I Parent Survey
  23. 23. The Value of Data: NC Evaluations I Process Evaluation-PEDIATRICS July 2006; 118;183-188 Quarterly screening rates Referral rates Office Process- “Pearls” from successful pilots I Referral Study-tracking 291 children from 2000 to 2003 to determine if referrals were completed, types of services received, etc 94.5% made it to initial referral 2% DNQ, 14% declined services, 9.9% lost to f/ u 58% received EI services 53% of children referred were 12 months or younger (NC statistic was 40% were 12 months or younger)
  24. 24. Developmental Screening: Percentage of 0-24 Month Heolth Checks with 0 Screening during 0 6 Month Period 60 50 AC‘ 30 20 10 M 70 Cl Access I 10/1/99 - 3/31/00 ’ CCNC10/1/99 - 3/31/00 4 HMO 10/1 /99 - 3/31/00 P4HM Baseline 10/1/99 - 3/31/00 :1 P4HM 10/1/01 - 3/31/02
  25. 25. Policg Change ‘Public Health system (Child Health) transitioned clinics to a menu of standardized, valid, developmental screening tools in 2003 ‘Medicaid changed EPSDT policy (Health Check), effective 7/1/2004, requiring a valid, standardized developmental screening tool when screening children at the 6, 12, 18 or 24months and 3, 4, & 5 year old visit. The medical record should contain results & 96110-EP should be on the claim.
  26. 26. Replication ‘Replicated model to other Community Care practices and some non-CCNC practices throughout the state to include practices in 11 plus counties ‘Replicated to largest CCNC network which could included practices in an additional 32 counties ‘Replicated to other practices after policy change both in Public Health and Medicaid. ... ‘D
  27. 27. Maintenance of Spread ‘ Encourage practices to measure their progress, however simple: e. g. 3 of 96110 billed/ month, a tracking list of those referred, and/ or a registry. ‘ Provide opportunities for practices in different communities to share their experiences and successful strategies: e. g. at professional society meetings, or group similar to the NC ABCD QI quarterly meeting ‘ At the state level align goals with partners such as Part C or EPSDT to share data and provide feedback.
  28. 28. Prom There. .. g % ‘Healthy Development Learning Collaborative (NC & VT) “Medical home for children with special health care needs- Title V and Catch grants (Practices in Guilford, Orange, Pitt, Qualla Boundary) i Medical home grant (Title V) for children with hearing loss provides equipment (OAE), training, and consultation to practices--Piloting new hearing screening guidelines in infancy and toddler hood. “Smart Start is working with practices in approximately ten NC counties ref: Medical Home/ “ABCD”
  29. 29. Activities Continue. . . . . . “ Collaborate with Nurse Family Partnership in one county with hopes of replicating to others Participate on ECCS planning/ implementation teams 1 The NC Institute of Medicine Task Force on Child Abuse Prevention promoted “ABCD” in primary care practice as an approach to primary prevention i Serve as a resource to Health Check (EPSDT) for seminars, surveys, and as questions arise from the provider community
  30. 30. Activities Continue. . . New Kindergarten Health Assessment being piloted in Guil ord and Wake counties Four mental health initiatives in the state-using other screening tools, e. g. Edinburgh for maternal depression & ASQ-SE in primary care “ABCD” tools used in Healthy Steps residency trainin pro ram Duke, Wake Forest, Carolinas Medic , C, an East Carolina)-Funded by Duke Endowment Formed “ABCD” Quality Improvement Group meets quarterly to exchange resources, etc.
  31. 31. Lasons Learned ‘ Keep it “tops” on the provider, family, and state agenda ‘ Build on existing infrastructures and align goals with partners who invest in quality improvement ‘ Optimize funding by sharing activities with partners ‘ Evaluate and report data ‘ Develop and change policy
  32. 32. ‘iv/ ’,. .. _ , - ? .~‘« ': ':'fi , ,.I. ~J «I . -35‘JD. If1 Jill; iFQID«y A Identify/ Maintain Physician “Champion” and Coordinator to be involved in issues affecting children (National & State) A Promote awareness to investors in quality improvement and prevention A Identify what motivates providers and “dove tail” those interests A Promote families “asking” for service Determine what needs sustaining and build on existing infrastructure. ..
  33. 33. build on Existirig lnl-irastructure Identify systems of care A if" P “Drive” activity locally vs. from state 3 , Distribute/ manage funds-501-C “Test” ideas starting small Revise and define “best practices” Build relationships with partners who invest in quality improvement 3