Beyond the Prescription Pad: Physician Involvement in Early Intervention

1. 2005 OSEP National Early Childhood Conference February 8, 2005 Corinne W. Garland Beppie j. Shapiro cgarland@cdr.orgbeppie@hawaii.edu Suzanne Gilchrist pfs@ccboe.com Beyond the Prescription Pad:Physician Involvement in Early Intervention

2. Session Objectives Participants will understand the barriers to and strategies for: • Providing a medical home for children with disabilities • Integrating physicians into community EI and ECSE service systems • Strengthening the role of physicians in early identification, referral, IFSP/IEP development, and family support

3. Key Question ????? Who needs physicians to be integrated into community EI and ECSE service systems?

4. Parents’ Needs • Identification and referral • Communication among team members

5. Early Intervention Needs • State and local child find needs • Timely referrals • Referrals without anticipating service needs before assessment and IFSP (e.g., therapies)

6. In Part C Mean: 1.99% Range: .94% (NV) to 7.7% (HI) Median: 2.13% Part B (age 3-5) Mean: 5.04% Range: 1.77% (DC) to 12.58% (KY) Median: 6.12% SERVED (2003 Child Count)% of live births

7. Results from AAP: A Survey of Pediatricians 2002

8. Survey sponsored by • American Academy of Pediatrics (AAP) Medical Home Initiatives for Children with Special Needs • Office of Special Education Programs, USDOE • Maternal and Child Health Bureau • OSEP-funded Child Find Consortium

9. One of a series of surveys by AAP Random sample Sent to 1,617 active US AAP member physicians Six mailings May – Sept. 2002 Return rate 55.2% Preliminary results only presented here Contact AAP for more information 649 pediatricians who serve babies 0-3 and who assess development Survey Methodology

10. Referral to EI – What’s Working • 86% have referred to EI • 92% say EI helps maximize child’s development • 95% say parent concern is considered in making referral • 77% know family income doesn’t matter

11. What are barriers to pediatricians’ participation in Early Intervention?

12. Barriers to Referral to EI • Don’t know EI process procedures (46%) • Lack of feedback from EI program (36%) • Don’t know eligibility (29%) • Programs don’t use MD input (23%) • ? quality of EI services (22%) • Services not available (20%)

13. 53% not notified when referral received 30% do not receive evaluation results 47% do not hear reasons for disposition 54% don’t hear when family is discharged 61% don’t hear if program can’t contact family 49% do not get IFSP and progress on goals Communication from EI program

14. AAP: Pediatricians recommend • reprinted standard referral form (51%) • Toll free number (47%) • Give MD more information about EI (81%) • Single, known contact person (58%) • Improve communication from EI (>90%)

15. Statewide Strategies:Physician Training

16. Enhancing Health Care Delivery Through Screening, Surveillance, and Promotion of Early Intervention in the Medical Home in Hawaii Beppie Shapiro, Ph.D. & Vince Yamashiroya, MD, FAAP OSEP Early Childhood Conference 2004

17. Presentation Outline • The Study: Project SEEK • Phase 1: • Needs assessment • Phase 2: • Interventions & Outcomes • Conclusions

18. The Study: Project SEEK • SEEK • Strategies for • Effective and • Efficient • Keiki (child) find

19. Project SEEK (2) • GOAL: to ensure babies with special needs are identified and referred to EI - Sponsors: Office of Special Education programs, USDOE, and State DOH

20. Definitions • Early Intervention (EI): system of services for babies under age 3 with special needs • H-KISS: Hawaii’s information and referral service, free to the public

21. People Involved • Beppie Shapiro, Ph.D • Principal investigator • Taletha Derrington, M.A • Project director • Vince Yamashiroya, M.D., FAAP • Physician advisor • Many others (physicians, public health nurses, educators, parents, etc.)

22. Period of the Study • Phase 1: Needs Assessment • Statewide surveys, focus groups • 1995 to 1999 • Phase 2: Intervention & Outcomes • Community surveys, collection of data from PCP’s to EI programs, and intervention strategies • 1999 to 2005

23. Children 0-18 years (2000 Census) 15,434 32,664 208,525 Maui Big Island 38,805 Kauai Phase 1: Statewide Phase 2:

24. Phase 1: Statewide Needs Assessment • Identified barriers to identification and referral. • Statewide survey of professionals who serve young children. • Focus groups of professionals in varied communities.

25. PCP Survey Results Survey mailed to M.D. Offices statewide using HAAP and HAFP lists • 129 pediatricians, 71 family practitioners • Return rate 77%!!!

26. Barriers to Identification • Physician developmental screening practices (most common) • All groups surveyed do not understand EI eligibility • Hospital nurses, MSW, foster parents, and child care providers do not know how to identify eligible infants and toddlers • Discomfort by all professionals in speaking to the family about child developmental delay

27. Barriers to Referral • “Wait and see” practice of some doctors when delay is suspected (most common) • Doctors do not know services are free to family • Some doctors do not believe EI is valuable • Referring professionals sometimes perceive information & referral (H-KISS) staff as unfriendly, unhelpful • Information and referral (H-KISS) hours are not best for many doctors • Information about EI is “hidden” from public

28. Phase 2: Intervention & Evaluation • Purpose of intervention: to increase identification of young children with developmental delays or special needs by PCPs, and their referral to EI • Purpose of evaluation: to measure effectiveness of intervention

29. Promising General Strategies • Knowledge • Print, video, face-to-face • Attitudes and beliefs • Voices of parents, other doctors, research • Practice • Developmental screening • Taking parental concerns seriously • Making referrals directly • Do not “wait-and-see”

30. EI Programs • Changing EI program practices • Fax referral form for information & referral service (H-KISS) • Brochure on H-KISS in doctor’s waiting room • Enhanced communications of EI programs to PCP’s

31. Evaluation Design • Measurements • Surveys (knowledge and attitudes) • Number of children referred to EI

32. Evaluation design compared communities • Communities needed to be similar and isolated to strengthen research design • Three types of communities • Intervention group • Comparison (control) group • Post-comparison (control) group

33. Result: not good. • Only 1 or 2 MD’s showed up. Initial strategy • Large group presentations. • 3 presentations x 1 hour each. • Address knowledge, attitudes and skills. • Designed to attract. • Respect PCP preferences/expectations. • CME. • Intensive recruitment.

34. Complementary strategy • Mailed postcards • Respects PCP time & attention constraints • Inexpensive way to reach PCP’s • Could incorporate messages to address knowledge and attitudinal barriers

35. One card/month x 7 months Different topic on each • Result: not good • MD’s did not remember what was on the postcards Postcards

36. Revised Strategy Selected (1) • Enhanced communications to PCPs by EI programs, about PCP’s patients • Evidence from multiple sources of poor feedback of EI programs to doctors • Natural opportunity to address knowledge, attitudes and work in EI

37. Enhanced Communications by EI • “Thank you for your referral” • Referral status • Screening/assessment reports • Invitation to attend or provide input for IFSP • Copy of IFSP • Discharge notice

38. Evaluation of enhanced communications by: • EI staff: referral status and discharge notices • PCPs: • thank you cards, IFSP invitations • Remembered but not in detail, valuable, could be streamlined

39. Revised Strategy (2) • Individual presentations at MD practice • 2 presentations, 1 hour each • Flexible schedule • Designed to attract • Intensive recruitment

40. Result: GOOD!!! Individual Presentations • First Community (16 PCP’s) • 94% (15) received at least half of content • 81% (13) received all content • Second Community (19 PCP’s) • 84% (16) received at least half of content • 68% (13) received all content

41. Survey Return Rates

42. Results: Surveys • Survey was designed to measured attitudes, knowledge, and practice about the EI system. • Survey in the intervention group showed a significant improvement in all three areas from pre- to post. • Survey in the comparison group did not show any improvement on the three areas from pre- to post. • Survey by itself had no effect in increasing 3 areas: post–only comparison group had similar scores to comparison group.

43. Number of Referrals Intervention Comparison 120 100 80 60 40 20 0 1995 1996 1997 1998 00-01 Results: Referrals First Set of Communities: Second Set of Communities: Intervention Intervention

44. Results: Referrals (2) • Effects on physicians (PCP’s). • Intervention PCP’s made significantly more referrals after outreach than before, and very significantly more than comparison PCP’s. • No significant change in referrals among comparison PCP’s from pre to post, which means surveys alone did not raise awareness.

45. Results: EI Programs • Effects on EI programs • Communications to PCP’s were bolstered

46. Conclusions • Base strategies on evidence such as needs assessments • Continually evaluate implementation & effectiveness of strategies • Providing information and persuasive messages can change physician practice • Inexpensive changes to EI program practices can provide feedback and information to PCPs • These practice changes can increase the number of babies with special needs identified by PCPs and referred to early intervention programs

47. Conclusions (Continued) • Is it sustainable? • Enhanced communications were generally accepted and implemented by programs. Most are still using these, even though we’ve finished study implementation. • Hawai‘i’s DOH is encouraging EI program staff to do short, less informal presentations to PCP’s.

48. Mahalo! Beppie Shapiro, Ph.D. beppie@hawaii.edu Project SEEK

49. Caring for Infants and Toddlers with Disabilities:New Roles for Physicians CFIT Child Development Resources Norge, VA

50. Philosophical Foundations • Family-Centered • Community-Based • Coordinated and Comprehensive • Benefits of collaborative relationships among families, early intervention providers, and physicians