Anita Berry, MSN, CNP/APN Director, Healthy Steps for Young Children Program, Advocate Health Care

2. Changing Systems, Changing Livesby Enhancing Developmentally Oriented Primary CareFebruary 23, 2009 Anita Berry, MSN, CNP/APN Director, Healthy Steps for Young Children Program, Advocate Health Care Scott G. Allen, MS Executive Director, Illinois Chapter, American Academy of Pediatrics

3. Agenda • What is EDOPC? • EDOPC Results • EDOPC Successes and Challenges • Questions and Answers

4. EDOPC Inspiration • Unmet Needs Project • need for commercially-developed tools, better use of EI system • Illinois early childhood/screening initiatives • Advocate Health Care Healthy Steps • Provider groups (ICAAP, IAFP) trainings • Ounce of Prevention Fund • Provider interest • State agency interest

5. EDOPC Inspiration (cont’d) • Clinical policy recommendations • AAP developmental screening, autism policies • Holistic approach to child development • National efforts • Assuring Better Child Health and Development (ABCD) • ABCD Screening Academy

6. Key Partners: Advocate • Advocate Health Care Healthy Steps • Model/experience with practice change • Curricula/training on broad range of early childhood topics • Comprehensive approach • Large healthcare system • Key clinical/training staff • Infrastructure (fundraising, administration)

7. Key Partners: ICAAP • Broad membership and volunteer base • Experience in academic detailing • EC/developmental screening expertise • Developmental pediatricians, previous training • Partnerships with advocacy, provider groups • Growing systems change and policy work

8. Key Partners: IAFP and Ounce • Illinois Academy of Family Physicians • Ounce of Prevention Fund

9. Key Partnership Strengths • Expertise in clinical topics • Experience in diverse practice settings • Public/private/public, pediatric/family practice, training • Experience with educational models, technical assistance • Ability to engage other partners

10. Local Funders/Stakeholders • Private Foundations • State Agencies • Illinois Medicaid • Early Intervention/Title V • Provider Groups • Community clinics • Training programs • Advocacy Organizations

11. Making The Case • Audiences • Medicaid, Title V • Providers • Funders • Primary care systems change • Better health/developmental outcomes • Benefits to state systems • Duplication/coordination of effort • Cost savings

12. Training • Academic Detailing model • Evidence Based Materials • Multidisciplinary Approach • CME and Contact Hours for Nurses • Screening Materials Available • Staff and peer speakers • Current topics of interest to wide audience

13. Site Champion • What we look for: • Physician or Advance Practice Nurse • Clinical expertise • Authority to set up team meetings, training dates, change practice systems, influence policy and procedure changes • Interested and excited about early child development • Knowledgeable about screening, AAP Policy Statements and recommendations

14. Training – What’s It All About? • Timing • One hour or less, generally over lunch • Format • Power point, video clips, case discussion, hands on activity • Content • AAP Policy or Recommendations • Current Research / Problem • Screening Tools • Team Approach • Resource Manual • Technical Assistance

15. Training Topics Developmental Screening and Referral Social Emotional Developmental Screening and Referral Identifying Postpartum Depression During Well-Child Visit: Resources for Screening and Referral Early Autism Detection Screening and Referral Domestic Violence Effects on Children Detection Screening and Referral in Primary Care Obesity Prevention in the Early Years 15

16. Developmental Screening and Referral Objectives of training - participants will be able to: • Identify purpose of developmental screening and early intervention • Use validated screening tools • Implement referral procedures, gain knowledge regarding referral resources • Employ parent/caregiver education materials • Implement efficient office procedures • Use, document, and bill for screening tools

17. Social Emotional Developmental Screening and Referral Objectives of training - participants will be able to: • Define social emotional development • Explain importance of screening • Give examples of social emotional milestones and “red flags” • Use, document, and bill for screening tools • Gain knowledge regarding referral resources

18. Identifying Postpartum Depression During the Well-Child Visit: Resources for Screening and Referring Objectives of training - participants will be able to: • Understand the difference between baby blues, peripartum depression, and postpartum psychosis. • Gain knowledge regarding the impact of postpartum depression on children and families. • Identify risk and protective factors • Understand how to use validated screening tools • Gain knowledge regarding referral resources and procedures for referrals • Implement culturally-appropriate care

19. Early Autism Detection Screening and Referral Objectives of training - participants will be able to: • Define autistic spectrum disorders, their epidemiology and etiology; • Recognize the earliest signs of autism; • Routinely assess young children for autism; • Identify common misconceptions about the causes and stereotypes of autism; • Referrals to Early Intervention, Special Education, • Team approach to diagnosis

20. Domestic Violence Effects on Children Detection Screening and Referral in Primary Care Objectives of training - participants will be able to: • Define domestic violence • Identify the cycle of violence • Understand how domestic violence affects children and families • Identify community resources

21. Obesity Prevention in the Early Years Objectives of training - participants will be able to: • Recognize and screen families for risk factors • Understand normal developmental expectations • Assess effectiveness of parent-child feeding relationships and interactions • Engage parents around feeding issues • Give age appropriate anticipatory guidance

23. Technical Assistance • Who, What, Where, Why • Who: All Training Recipients • What: Organizational assistance after training to promote implementation of screening into routine practice • Where: Onsite, Phone, Email, Team Meetings, Chart Reviews, Teleconference Calls, Website • Why: Difficult for a Champion to promote on their own

24. Feedback to Sites • Team Meetings • Working with Champion • Chart Reviews • State Data • Comparison to other FQHC’s

25. EDOPC at a Glance Goals • Improve delivery and financing of preventive health and developmental services for children birth to three • Build on existing programs to develop a range of strategies for primary care settings

26. EDOPC at a Glance:Geographical Locations

27. EDOPC at a Glance:Site Types

28. EDOPC at a Glance:Who Has Been Trained

29. EDOPC at a Glance Objective 1 Site-based training and technical assistance model will be accepted by practices in the Chicago metropolitan area and throughout the state of Illinois to provide a foundation for ongoing collaboration to promote optimal child development.

30. EDOPC at a Glance Objective 2 Training will increase knowledge regarding key topics identified as priority areas for the developmental care of young children among providers of primary care to young children.

31. Training Topics Knowledge Outcomes 2006, 2007 and 2008 • 2545 attendees completed evaluation data • Pre/Post testing, 6 questions on each topic • In all three years results showed a statistically significant difference in knowledge gained by attendees: • 2006: (pretest mean 5.97, posttest mean 6.58) • 2007: (pretest mean 4.24, posttest mean 4.65) • 2008: (pretest mean 4.12, posttest mean 4.98)

32. EDOPC at a Glance Objective 3 Training will improve the confidence of primary care providers regarding the identification of developmental issues or delays, perinatal depression, and domestic violence.

33. Provider Self-Reporting: Training Enhanced Ability To IdentifyIssues (% agreed)

34. EDOPC at a Glance Objective 4 EDOPC training will improve primary care providers’ knowledge of referral resources and procedures for developmental issues and perinatal depression.

35. Self-Reporting: Training Enhanced Referral Resources (% agreed)

36. EDOPC at a Glance Objective 5 EDOPC training and technical assistance will increase the proportion of young children screened for developmental issues and the proportion of mothers screened for perinatal depression.

37. Screening Practice at Pretest and Posttest (%)

38. Percentage of developmental screenings using the Ages and Stages Questionnaire by the 1-year well-child visit, by site, 2004–2008

39. Percentage of developmental screenings using the Ages and Stages Questionnaire by the 2-year well-child visit, by site, 2004–2008

40. Percentage of social/emotional screenings using the Ages and Stages Questionnaire: Social/Emotional within 2-year well-child visits, 2004–2008

41. Percentage of PPD screenings using the Edinburgh Postnatal Depression Scale by the 6-month well-child visit, by site, 2004–2008

42. 500 Providers (Individual& Clinic) 400 <12 mos 300 12-24 mos 200 24-36 mos 100 0 FY03 FY04 FY05 FY06 FY07 State Fiscal Year Illinois Medicaid Unique Providers Billing Dev Screening(96110 from FY03–07)

43. Developmental Assessments and Screenings Illinois Children Ages 0–3 under Medicaid 90,000 80,000 70,000 60,000 50,000 Assessments 40,000 Screenings 30,000 20,000 10,000 0 SFY 2003 SFY 2004 SFY 2005 SFY 2006 SFY 2007* State Fiscal Year Developmental Assessments and Screenings:Illinois Children Ages 0–3 under Medicaid * provisional data for 2007. Providers currently have one year to bill HFS for services under Medicaid so final numbers may be greater than those reflected in this analysis, which was based on billings received by 9/07.

44. Assessment 4,000 3,500 3,000 2,500 2,000 1,500 1,000 500 0 SFY 2003 SFY 2004 SFY 2005 SFY 2006 SFY 2007* State Fiscal Year Initial referrals to Early Intervention subsequent to96110 encounter (Developmental Screening)/96111 encounter * provisional data for 2007. Providers currently have one year to bill HFS for services under Medicaid so final numbers may be greater than those reflected in this analysis, which was based on billings received by 9/07.

45. EDOPC at a Glance Objective 8 EDOPC will develop a toolkit for use in training of resident physicians in family medicine and pediatrics, nurse practitioners, and physician’s assistants.

46. Toolkit • FQHCs CD-ROM including all EDOPC topics • Pediatric Residency, NP, PA Programs CD-ROM Healthy Steps and EDOPC topics • Best Practice Document • Tools for incorporating into practice

47. EDOPC at a Glance Objective 9 EDOPC provides training and technical assistance to help sites problem-solve and overcome barriers to the implementation of routine screening.

48. Best Practice Document Best Practices Summary Best Practices Detail General Office Systems Screening Policies, Procedures, and Tools Staff Education Patient/Parent Education Referral to Community Agencies and Other Resources Coding and Billing Description of Tools Additional Resources

49. EDOPC at a Glance Objective 10 Barriers to effective communication and collaboration between providers of diagnostic and treatment services and pediatric care providers will be identified through focus groups and/or interviews with community agencies (including EI)

50. Referral Results in New Challenges • Challenges in communication • Busy practices, overburdened EI systems • Cultural divide • Identified needs • Increase in depth of understanding, trust • Communication and referral systems • Communication tools