Setting the Stage for Success…

1. Setting the Stage for Success… Marian Earls, MD, FAAPGuilford Child Health, Inc., Greensboro, North CarolinaJune 6, 2007

2. I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

3. Integrating Screening & Surveillance in Primary Care Practice Marian Earls, MD, FAAP June 6,2007

4. What We Know • Impact of experience on brain development. • Growth, development, and behavior are inextricably linked. • Emotional development occurs in the context of a relationship (bonding, attachment, reading cues).

5. Prevalence and Risk 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.) ____________________

6. 13% of preschool children have mental health problems. This rate increases with the co-occurrence of other risk factors: Poverty Maternal depression Substance abuse Domestic Violence Foster care Prevalence and Risk

7. Are we looking? Poor rates of screening in PCP’s office for: • Development and behavior • Maternal depression • Family risk factors

8. “Under-detection …Eliminates the Possibility of Early Intervention...” _____________________ • No point in waiting to screenuntil • the problem is observable. • Don’t ignore screening results; • there is no value to “wait and see.” • Informalchecklists haveno • validated criteriafor referral.

9. Limited use of screening at well visits because… _________________________________ • Takes too long • Difficult to administer • Children may not cooperate • Reimbursement is limited

10. So…. What Should We Do? • Use new,brief,accurate tools • Use parents • Use Family Centered principles

11. Using Effective Screens: Accuracy, meaningspecificity(at least 70% of normal children correctlydetected) andsensitivity (at least 70% of children with disabilities correctly detected)

12. Does Screening Mean Becoming an Expert in Evaluating a Child’s Development?NO… Screening is looking at the whole population to identify those at risk.Identifiedchildren are referredfor assessment. Assessment determinestheexistence of delay or disability which generates a decision regarding intervention. Screening is optimized bySurveillance……periodic screening gives a longitutidinal perspective of a child’s developmental progress.

14. Excluded Tests: PDQ Denver-II Early Screening Profile DIAL-III Early Screening Inventory ELM Gesell Due to absence of validation, poor validation, norming on referred samples, and/or poor sensitivity/specificity

15. Strengths of Tools Using Parent Report Give parents and providers information on children’s actual skillsHelp parents learn important developmental milestonesIllustrate strengths and weakness in developmentFree professional time for more important things… like helping familiesGive providers confidence in decision-making

16. Strengths of Tools Relying on Parents’ Concerns Help focus encounters on issues of importance to familiesCreate a “teachable moment”Enhance parents’ sense of a true collaboration with professionalsIncrease positive parenting practicesMake it easier to give difficult newsReduce “oh by the way” concernsIncrease attendance at well-visits…and perhaps parent-teacher conferences

18. Family Psychosocial Screens • Variety of tools ranging from very brief to multi-item. • Most screen for maternal depression, domestic violence, substance abuse: individual area or several. • Considered best practice, but limited validation data, etc. • Examples are Kemper&Kelleher, Edinburgh

19. “Oh, by the way…..” Reduces “doorknob concerns” Shortens visit length/focuses visit Facilitates patient flow Improves parent satisfaction and positive parenting practices Increases provider confidence in decision- making

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

22. Creativity a Key…… • Use growth tool for developmental surveillance; • Some tools can be photocopied so laminate a set for each exam room; • Use lab labels on the screening tool to eliminate handwriting of demographic information; • Measure performance and offer feedback to staff.

23. Creativity a Key…… • Use posters in your waiting room to explain the developmental screening process to families; • Use a combination of tools for different ages. (e.g.. 0-24 months use ASQ; older children use PEDS); • Obtain free stuff, e.g. “ABCD” anticipatory guidance brochures, for families to promote healthy development

24. The Creativity continues… • Invite your community partners, (EI Specialists, etc.) to your office for a social or open house (Talk about your respective goals and align goals wherever possible.) • Immerse yourself into community/state meetings where policy issues affecting families are discussed • Sponsor family events with your community partners, e.g. health dept.- health fairs

25. Partner with Parents to Do Screening & Surveillance • Primary Care Medical Home • Head Start • Child Care • Preschools

26. Assuring Better ChildHealth & Development “ABCD”the North Carolina Experience DEVELOPMENTAL & BEHAVIORAL SCREENING:AQuality Improvement Initiative in Primary Care Practice

27. Developmental Screening: Percentage of 0-24 Month Health Checks with a Screening during a 6 Month Period

28. Practice/Parent Surveys Summary • Instrument:Questionnaires were disseminated to Guilford Child Health staff (three sites) in 2001 and Moses Cone Family staff in 2002. Questions were designed to yield qualitative information. A 27% and 26% response rate was achieved respectively. • ConclusionsStaff…. • agree the ASQ is an effective assessment tool and would • recommend it to other providers; • generally use the ASQ as a guide for discussing • developmental issues with parents; • agree it “somewhat” impacts office workflow so attention • needs to be given to where and when parents complete the • questionnaire; • parents appreciate the additional time staff spend assessing • their child’s development

30. Policy 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 avalid, 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.

31. Lessons 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. Screening & Surveillance Resources www.dbpeds.org www.nashp.org www.cmwf.org ASQ:www.brookespublishing.com PEDS: www.pedstest.com

33. Anticipatory Guidance Resources • NC ABCD disk • Bright Futures www.brightfutures.aap.org • AAP www.aap.org • CDC www.cdc.gov/actearly • Zero to Three www.zerotothree.org • Parents as Teachers www.ncpat.org • Family Voices www.familyvoices.org • Kids Growth www.kidsgrowth.com