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Early Childhood Comprehensive Systems Partners Meeting

Early Childhood Comprehensive Systems Partners Meeting. Friday, March 14, 2008 9:50 – 11:00 am Workshop Implementing Developmental and Mental Health Screening: Lessons from the ABCD Projects. Opportunities to Link Practice and Policy Change Lessons from the ABCD Collaborative.

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Early Childhood Comprehensive Systems Partners Meeting

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  1. Early Childhood Comprehensive Systems Partners Meeting Friday, March 14, 2008 9:50 – 11:00 am Workshop Implementing Developmental and Mental Health Screening: Lessons from the ABCD Projects

  2. Opportunities to Link Practice and Policy Change Lessons from the ABCD Collaborative Jennifer May Policy Specialist National Academy for State Health Policy Assuring Better Child Health and Development (ABCD) Initiative Funded by The Commonwealth Fund

  3. About the Collaboratives • 3-year learning collaboratives of states working to enhance developmental services to young children enrolled in Medicaid • Change in state policy and provider practice • Change in participating and non-participating states

  4. Collaborative Members • ABCD I: General Development • NC, UT, VT, WA • 2000-2003 • ABCD II: Social and Emotional Development • CA, IA, IL, MN, UT • 2004-2007 • Multi-agency teams from each state, led by Medicaid

  5. In the Collaboratives • Each state • Implemented individual projects • Shared information and lessons learned from their individual efforts • NASHP • Provided technical assistance • Studied each state’s progress • Synthesized and disseminated states’ experience

  6. Building on ABCD I and II • ABCD Screening Academy: Supporting the adoption of standardized screening tools, i.e. general developmental, social-emotional and maternal depression • ABCD Alumni engaged as faculty and topic experts • American Academy of Pediatrics: 2006 policy statement on surveillance, resulted in active partnership for technical assistance events • 23 states • 2007-2008

  7. WA ME ND MT OR VT ID MN NH MA WI NY SD MI WY RI CT PA IA NJ NE NV OH UT IN DE IL MD CO CA WV VA DC KS MO KY NC TN AZ OK SC AR NM GA AL MS TX LA AK FL PR PR HI ABCD Screening Academy States ABCD Screening Academy States

  8. Common State Goals for Screening Academy states • Increase appropriate, effective screening by pediatricians • Ensure providers and families have information they need to identify, treat, and refer • Ensure that referrals are effective

  9. What did the States do during ABCD Collaborative?

  10. By Objective Accomplishments and lessons in policy and practice improvement

  11. Foster Improved Screening • Helped primary care providers integrate the tools into their practices • Learning collaboratives • Partnering with provider organizations that support practices, i.e. Illinois and Iowa local AAP chapters instrumental partners • Identify mentors to help practices integrate screening • Ongoing opportunities for practices to share experience and lessons • Measurement supports continued improvement

  12. Foster Improved Screening • Promoted pediatric provider use of screening tools • Work with physicians to identify tools and promote their use (Utah Pediatric Partnership to Improve Quality) • Modify Medicaid provider handbooks and websites used by provider practices • Change payment policies

  13. Identified and Facilitated Referral to Follow-up ServicesIdentified existing resourcesFacilitated referralsUtah: learning collaboratives feature development of referral pathwaysIllinois & Iowa: identify resources to manage referralsIdentify and fill in the gapsMinnesota: New diagnostic system that better met needs of young childrenMedicaid benefit targeted to children with emotional disturbance.

  14. Leveraged Resources to Promote Change • Formed partnerships • Illinois: local chapters of physician organizations sent out letter supporting policy change • North Carolina: Public health system (clinics) adopted menu of standardized screening tools for all young children • Used quality improvement • Utah: EQRO implemented performance improvement project on coordination between mental health systems and HMOs • North Carolina: Built on PCCM delivery system in Medicaid

  15. Identified and Addressed Policy Barriers • Identified policy barriers during planning, implementation, and operation of pilots • California, Illinois, and Iowa projects developed formal mechanisms for identifying and considering changes • Minnesota feeds project results into a group outside the project • Policy changes in Medicaid and other agencies • Illinois early intervention clarified eligibility policies • Iowa and Utah provided dedicated resources to expand/build

  16. Lessons Learned • Screening with a standardized tool is a critical first step, but does little good without follow-up services • States can facilitate access to follow-up services • Demonstrations can inspire and test policy change • Partnering with pediatric clinicians is critical • Measurement is difficult but doable (and worthwhile)

  17. For more information: Visit!http://www.nashp.org http://www.abcdresources.org Join the ABCD discussion forum! (register at http://abcdresources.org/ScreeningAcademylogin.php )

  18. Developmental and Mental Health Screening Glenace Edwall Minnesota Department of Human Services Children’s Mental Health Division & Maternal and Child Health Assurance Unit

  19. Screening: Developmental and Socio-Emotional Developmental Screening Tools • Generally discriminate those children with developmental delays and those who appear to be developing typically • May include numerous domains expected to be affected by developmental delay • Identify children in need of further assessment

  20. Screening: Developmental and Socio-emotional Socioemotional Screening Tools • Intended to identify children whose socioemotional development is delayed and/or whose mental health development is at risk • May include specific aspects of social and emotional functioning, appropriately developmentally scaled • Identify children in need of further assessment

  21. Screening for Socioemotional Development • Screening is a relatively brief process designed to identify children who are at increased risk of having disorders that warrant immediate attention, intervention, or comprehensive review

  22. Screening, Continued • Identifying the need for further assessment is the primary purpose for screening • Screening instruments are never used to diagnose or “label” a child • Screening informs parents and those working with families about aspects of development needing further assessment

  23. Socioemotional Screening: Current Practice Survey by Betsy Murray, M.D. (2006): • Responses from 590 primary care providers (38% return rate) • 80% endorsed as best practice “the use of at least one standardized screening tool, with some frequency, with at least one age group during well or ill visits” • Approximately one-third described selves as familiar with at least one standardized tool

  24. Socioemotional Screening: Current Practice • Self-reported % of visits routinely screened, by technique (descending order) • Interview parent (>90%) • Clinical observation • Interview child • Review of systems • Denver-II • Practice-developed instrument (c. 30%)

  25. Socioemotional Screening: Current Practice Identified barriers to screening: • Time (93%) • Training in screening tools (88%) • Availability of mental health providers (79%) • Lack of adequate personnel (77%) • Lack of comfort with managing identified children (71%) • Lack of appropriate reimbursement (66%)

  26. Screening: Addressing the Barriers • Choosing Tools • Cost/Reimbursement • Office Work Flow/Time

  27. Addressing Barriers: Tools • Criteria • Consensus • Practice issues

  28. Screening Instrument Criteria • 15 minute or less administration • Good psychometric properties • Minimal cost • Targeted • Easy scoring

  29. Screening Criteria, continued • Cultural/linguistic data • Covers age span • Minimal expertise to administer • Ease of administration

  30. MN Recommended Developmental Screening Tools

  31. MN Recommended Developmental Screening Tools: At a Glance

  32. Minnesota Developmental Screening Task Force • Membership: MN Departments of Health, Human Services, and Education and University of MN, Irving B. Harris Center for Infant and Toddler Development • Recommended developmental and mental health screening tools reviewed and approved by all agencies according to agreed upon criteria • http://www.health.state.mn.us/divs/fh/mch/devscrn/

  33. Early Childhood Socioemotional Screening “Synergy” • Consensus among DHS Child Welfare Screening and ABCD II grant, MDH Follow Along Program, and Minnesota Head Start Association in endorsing Ages and Stages Questionnaire – Socioemotional (ASQ-SE) • Squires, J., Bricker, D. and Twombly, E.; Brookes Publishing Company

  34. ASQ-SE, continued • Age-specific questionnaires completed by caregivers, scored automatically or by paraprofessional • Forms for 6, 12, 18, 24, 30, 36, 48, 60 months; each form covers +/- 3-6 months of target age • 7 areas: self-regulation, compliance, communication, adaptive functioning, autonomy, affect, and interaction with people

  35. ASQ-SE, continued • Properties: • Norms: 3,014 preschool children, representing 2000 census for family income, education and ethnicity • Reliability: test-retest = .94 • Validity: average sensitivity = .78; average specificity = .95 • Low cost proprietary instrument: $125/kit, with unlimited reproduction of forms • http://www.pbrooks.com or 800.638.3775

  36. Addressing Barriers: Cost/Reimbursement • Screening Codes • Incentives

  37. Developmental and Mental Health Screening Code -- 96110 • DHS pays for the 96110 code when an objective developmental or mental health screening occurs • Both may be performed and billed on the same day • Bill 96110 for developmental screening, 96110 w/UC modifier for mental health screening

  38. Developmental and Mental Health Screening Code -- 96110 • Other payers in MN also cover objective developmental & mental health screening • Managed care contracts for 2008 include: • $20 incentive for each developmental screening in encounter data (96110 code) above the percentage last year • $25 incentive for each mental health screening in encounter data (96110 code w/UC modifier)

  39. Addressing Barriers: Office Work Flow/Time Minnesota Pilots: • Co-located mental health professionals • Use of technology • Tablets [Patient Tools] • CentraCare work with CHADDIS • Integration with EMR

  40. Addressing Barriers: Referrals Multiple models: • Co-located mental health professional or care coordinator • Central point of access in community • Establishing relationships with community providers

  41. Contact Information Glenace Edwall, Director Children’s Mental Health Division 651.431.2326 glenace.edwall@state.mn.us Susan Castellano, Manager Maternal & Child Health Assurance 651.431.2612 susan.castellano@state.mn.us

  42. Implementing Screening: Pediatric Settings Penny Knapp MD Medical Director California Department of Mental Health ECCS Partners Meeting 3/13/08

  43. Topics for today - Practitioner resistance to identifying concerns • What to do when concerns are identified: the continuum from reassurance to referral • What can specialty mental health offer?

  44. Practitioner resistance to identifying concerns 1 Confidence: • “I really know my patients,” (v.s. shorter visits, push to “productivity”) • Tradition of developmental surveillance (misses 60-70% of developmental problems) • Capitation: forced choices for limited time and fixed resources (HEDIS measures asthma, immunizations, follow-up for hospitalization for mental disorders)

  45. Practitioner resistance to identifying concerns 2 • Reluctance to label • Uncertainty about definition of problem • Cannot provide services directly • Cannot obtain services by referral undocumented children, • Who is my patient? (e.g. How to serve depressed mothers who don't meet medical necessity criteria for specialty mental health services?)

  46. Current changing trends 1 • 2006 AAP policy statement requires 3 screenings w. standardized screening tool at ages 9, 18, and 24 or 30 months. • AAP Task Force on Mental Health developing parallel algorithms for mental health at infant/pre-school, school-age & adolescent levels.

  47. Current changing trends 2 • CAPTA (2003) and IDEA (2004) require developmental screening in Child Welfare system and for children w. prenatal drug exposure. • Head Start (reauthorized 2008) requires high-quality developmental screening

  48. UNIVERSAL: - e.g. Screening, Case management, Parenting Education, Promotion SELECTIVE: e.g. Risk-specific assessment, preventive intervention SELECTIVE: e.g. Diagnostic Assessment, Direct Infant or early childhood services

  49. Universal (Primary) Selective (secondary) Indicated (Tertiary) Health & development screening Parenting education Risk-specific assessment Diagnostic assessment Locating the problem- where does screening fit?

  50. The continuum from reassurance to referral 1 THE INFANT or CHILD • Watch and wait • Offer anticipatory guidance • Encourage community links and supports • Refer for assessment to EI • Refer for treatment

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