Assuring Better Child Health & Development “ ABCD ”

1. Assuring Better ChildHealth & Development “ABCD” DEVELOPMENTAL & BEHAVIORAL SCREENING:A Quality Improvement Initiative in Primary Care Practice AMCHP Conference March 8, 2006

2. North Carolina’s Children…. Economic Security: • 44% of children in North Carolina live in low-income families as compared to 40% nationally. • 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

3. NC’s Children cont… Healthcare: Over 50% of North Carolina’s 2.1 million children are eligible for special health care programs or are uninsured. Specifics include: • Over 68,400 children are enrolled in NC’s SCHIP program, Health Choice • 736,000 children are enrolled in the NC Medicaid program • Approximately 239,000 children are uninsured Note: Data reflective of source reporting parameters.

4. NC Early InterventionResources: • Child Service Coordination • Infant Toddler & Preschool Programs • Governor Morehead School • Schools for the Deaf (2) • Universal Hearing Screening • Children’s Developmental Services Agency • Family Support Network • Beginnings

5. The “ABCD” History…. • In 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. • The Commonwealth Fund is a philanthropic foundation established in 1918 to help Americans live healthy and productive lives, and to assist specific groups with serious and neglected problems. Utah, Vermont and Washington were also awarded the grant. They are Developing or expanding existing nurse home visiting programs and/or Developing specific outreach initiatives, and assisting communities in Resource coordination.

6. The “ABCD”Challenges…. • Medicaid reports a high percentage of live births: (2000 – 40.9%, 2001 – 43.8% and 2002 – 43.0%) • The AAP is recommending formal screening & surveillance at well-child visits. • The use of “the most common and familiar” developmental screening tool was untenable in primary care practices – the Denver

7. The Challenges (cont.) …. • The number of children served by early intervention (EI) is low(1999 Legislative Study indicated between 8-13% of the total birth to three population could qualify and benefit from EI services – only 2.6% were served.) • Across Medicaid systems of care the average rate of developmental screening was low (approximately 15.3%)

8. The“ABCD”Model • 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. The Model (cont.): (2.) Formed a State Advisory Group – The group is comprised of leadership from key agencies who have the capability of making policy changes.

10. “The AAP Committee on Children with Disabilitiesrecommends the use of standardized screening tests at well visits” About 16% of children have disabilities including speech and language delays, mental retardation, learning disabilities and emotional/behavioral problems. ____________ (Only 30% are detected prior to school entrance.) ____________________

11. Limited use of screeningat well visits because… • Takes too long • Difficult to administer • Children and parents may not be receptive • Reimbursement is limited

12. What’s Possible, What Works...

13. The Office Process • Assess Current Protocols • Identify Physician Champion • Select a Screening Tool • “Map the Workflow” • Identify System Supports • Conduct Staff Orientations

15. Child Development Services:An Investment Strategy • Identify physician champion • Build on existing infrastructures • Align goals with partners • Share activities with partners • Evaluate and report data • Develop and/or change policy

16. Physician ChampionKey Characteristics • Passionate about the issues • Practicing vs. academic • Participates in professional association meetings • Advocates for children’s issues with Medicaid/Public Health/Mental Health • Understands the infrastructure

17. Build on Existing Infrastructure • Identify systems of care • “Drive” activity locally vs. from state • “Test” ideas starting small • Revise and define “best practices” • Build relationships with partners who invest in quality improvement

18. Align Goals • Community Care of NC (Foundation for Alternative Health Programs) • Private Physicians • NC Pediatric Society • Early Intervention & Family Support Network • NC Academy of Family Physicians • State Center for Health Statistics • The Center for Children's Healthcare Improvement • Public Health • Medicaid • Interagency Council • Office of Research, Demonstrations, & Rural Health Development • University of NC at Greensboro • Smart Start • Commonwealth Fund

19. Share Activities • CME Training • Material Dissemination/Shared logos • “Open Forum” Presentations • Professional Articles • Policy Development/Change • Learning Collaborative • Practice/Family Resources • Data/Evaluation/Reporting

20. Evaluate/Report Data • Define process and outcome measures • Evaluate performance • Report performance to funders/partners • Understand your partner’s data reporting requirements • Align data collection points where possible…

21. Total 1, 2 & 4 Year Olds Screened(Years 2, 3 & 4 include two additional practices)

22. Evaluation/Reporting • A standardized provider survey (Likert scale 1-5), modeled after a survey conducted by Early Intervention, was provided to 4 provider groups. Surveys were administered in 2003-2004 to 849 providers. • The groups were surveyed on their: knowledge, attitudes, and practice around early intervention and developmental screening. CME training, as an intervention, was associated with statistically significant “positive change” in provider knowledge and attitudes; therefore states or professional organizations should consider this type of intervention when trying to promote change.

23. Evaluation Cont.…… Referral Follow-up Study (Aug. 2000-Nov. 2002) 291 children referred as a result of “at risk” score on ASQ: • 94.5 % of referrals were completed • 62.9% were referred to the Early Intervention System Services started for 161 children • 26 children, having reached age three, received transition evaluation. 8 of these children had dx of Autism Spectrum - 7 referred at or before age 2

24. Develop/Change Policy • Public Health • Medicaid/EPSDT • Early Intervention

25. Products and Pearls • Practical Tools: Office Resource Guide Physician Curriculum Parent Materials • Identify Physician Champion • Build working relationships between public agencies, the medical community, and families • Align goals of working partners to maximize funding

26. Thank You for Listening! “….from birth to age 5, children can show us, if we’re looking, how to help them get where they’re meant to be…” Contact information: Sherry.Hay@ncmail.net