Building a System of Developmental Care for Children

1. Building a System of Developmental Care for Children Marihelen Barrett Nemours Health and Prevention Services Presented to the Delaware Early Care and Education Council February 23, 2007 Adapted from Presentation by Amy Fine, MPH at 2006 Annual NICHQ Conference

2. Ready ChildrenPhysically and Emotionally Healthy Children Eager to Learn

3. Current Trends in Pediatric Developmental Care • General move in pediatrics toward more inclusive definitions and expanded role for pediatric practices • Definitions and roles vary across practices

4. Models for Improving Developmental Care • Work by the Common Wealth Fund and Center for Healthier Children (UCLA) • Healthy Steps, 1994 • Assuring Better Child Health and Development (ABCD), 1999 • Child Health Improvement Partnerships – Vermont, North Carolina, New Mexico, Utah; 2000 - 2006

5. CWF Study by Amy Fine • What is the current state of the art for pediatric developmental care and linkage to community developmental care? • Promising and innovative models for linkage • Key strategies across models • Lessons learned

6. Practices and Programs Included in Study • Beaufort Pediatrics • Children’s Care Connection (C-3) • Developmental Services Enhancement Program (DSEP) • Enhancing Developmentally Oriented Primary Care Program (EDOPC) • Exeter Pediatric Associates • Guilford Child Health, Inc. (GCH) • Help Me Grow (HMG) • Inscription House Health Center/ Growing in Beauty (GIB) • Kaiser Permanente Northern California • Kennebec Pediatrics (KP) • Kids Get Care (KGC) • MGH Revere HealthCare Center/Healthy Steps • Phoenix Children’s Hospital/ Healthy Steps • Tufts–New England Medical Center

7. Current Trends in Pediatric Developmental Care • What is the scope of developmental care? • Physical, cognitive, behavioral, emotional development? • Who needs it? • Those with identified deficits, at risk, all children? • CSHCN, all children, families? • What is the role of the pediatric practice? • Identification of deficits, prevention, promotion?

8. Comprehensive System: Barriers • “Pediatricians are kind of trapped in a box right now: everything we need to do to get out of the box is not reimbursable.” • “The system is so fragmented that the only person who understands it is the educated parent.” Too many community organizations – don’t know who to call • Dramatic gaps in developmental and mental health services – a barrier to screening

9. Comprehensive System – Linked Pediatric and Community Care • What does good linkage look like? • “It looks like relationships, not a referral list.” • “Three legged stool: medical home, EI, and family support.” • “Linkage is facilitated by: relationships, some kind of formal mechanisms/systems, and reimbursement.”

10. System and Linkage Landscape • Many different strategies and tools • Most of the practices/programs combine multiple strategies • Some recurrent themes • No common language or framework for describing strategies

11. System and Linkage Landscape • What makes the system work? • Part of the problem is evolving definition of developmental care • Need working definitions–developmental services, focus of linkage, framework for strategies • Not yet a unified way of thinking about linkage: addressed at different levels

12. Developmental Services Framework • What all children and families need from multiple people and places • Knowledge/Information • Assessment and Monitoring • Additional Services and Supports • Follow-up Relationships and Care Coordination • Provided in smooth flow between health system, education system, community, and home Adapted from Regalado and Halfon

13. Framework: Key Developmental Services • Knowledge/Information – anticipatory guidance, info. on identified risks & deficits. • Monitoring – developmental surveillance/screening. • Additional Services and Supports – point person and pathway to additional care, as needed • Follow-up Relationships – system and point person for support and follow-up. Adapted from Regalado and Halfon

14. Linkage Definition • Connecting the child and family to needed developmental services and supports – whether within the practice setting or beyond – while also staying connected to the child

15. Systems Change: 3 Levels of Strategies • Practice-level systems change • Community partnerships – focused on relationship between practices and existing community services/supports • System-wide change – policy, population level, community-wide, state-wide change

16. Nine Key Strategies Practice Strategies • Developmental surveillance/screening & anticipatory guidance • Point person for referral/linkage & follow-up system • New/ enhanced staffing Linkage Strategies • Co-location • Co-management • Networking and information-sharing System Strategies • New/enhanced community resources • System-wide training and support • Community/state policies and protocols

17. Context for the Strategies • These are not stand alone approaches. • Most of the innovative practices and programs combine several strategies, often at different levels. • In practice, not necessarily a clean-bright line separating one strategy from another

18. Underlying Tenets • Several consistent underlying tenets or guiding principles shape the strategies • Parents as Partners – new morbidities require parents to set plan and make decisions • No Wrong Doors – any source of referral welcome • Go Where the Children Are – bring assessment to child (new technology enables this) • Referral as a First Resort – when in doubt refer

19. Level I Strategies: Practice-Based Systems Change • Developmental surveillance/screening & anticipatory guidance • Point person for referral/linkage & follow-up system • New/ enhanced staffing

20. 1: Developmental Surveillance/ Screening & Anticipatory Guidance • Practice-wide system for routine, family-centered, developmental surveillance/ screening • Surveillance/screening at each well-child visit, using validated screening tools • Anticipatory guidance tailored to meet parent concerns

21. A Referral/Linkage Point Person and Follow-up System • A designated primary contact for referral/linkage. A practice-wide system for follow-up care: • Follow-up systems – simple listing to EMR with recall system and task list • Focus of linkage – connect child to services beyond practice; in-house services • Point person – nurse, social worker, developmental specialist

22. Enhanced Staffing • One or more new positions added to traditional pediatric primary care staff to enhance developmental care • Positions vary – e.g., Care coordinator, social worker, child development specialist, psychologist, developmental pediatrician, psychiatrist • Purpose varies – most often for children with risks/deficits; but some work with all children in practice in health promotion role

23. Level I Strategies: Summary • Current emphasis in pediatrics on in-house practice change, often as part of a QI systems change model • Strategies 1 (assessment) and 2 (point person for referral) are prerequisite for good linkage • Level I strategies improve quality of care. • Adding in-house staff and services eases the transition to new services for children

24. Level II Strategies: Enhanced Partnerships Between Pediatric Practice and Community • Co-location of services • Co-management • Networking and information sharing

25. 4. Co-location of Services • Location link between the pediatric practice and one or more other community service/s • Some practices share a building or office space with other services, others place community/public sector staff in practice • Provides a streamlined route for practices to connect children to additional developmental care

26. Co-management • Collaborative case management between the pediatric practice and one or more other service provider, focused on an individual child • Variations: case-by-case basis; regular meeting time for case reviews; collaborative assessment and joint problem-solving • By phone or in-person

27. Networking & Information Sharing • Includes: networking meetings, mixers, meet and greet sessions, academic detailing sessions, shared resource listings, informal outreach • Purpose varies: jump-start or sustain referral/linkage

28. Level II Strategies: Summary • Community partnership strategies help use existing resources more effectively; improve quality of care: • Reduce barriers to care – e.g., transportation, stigma • Promote early referral/linkage and follow up • Promote joint problem-solving, family-centered care • Reduce duplication and fragmentation of services. • Networking can help uncover gaps in services and promote collaborative efforts to address • Time, financing and HIPAA can be challenges

29. Level III Strategies: Changes in Community Systems • New/enhanced community resources • System-wide training • Community-wide policies and protocols Level III strategies provide a framework for a “Statewide Improvement Partnership” to Implement Delaware’s Early Childhood Plan

30. New and Enhanced Community Resources • Starts with population-based approach to assessing community needs. • Public and private sector partners • Initiatives to develop: • centralized referral/linkage resources • mid-level assessment • enhancement of intervention services for at-risk and mild/moderate delay • promotion/prevention services

31. System-wide Training & Support • Applies to system-wide training to improve developmental care and linkage by: • Change the orientation, skills and practices of pediatric primary care • Focus on pediatric healthcare and multi-sector training of pipeline • Quality improvement for established practices • Provide community/state orientation.

32. System-Wide Policies & Protocols • Community or statewide policies and protocols to promote and sustain linkage • Cross-agency protocols • Reimbursement policies • Other dedicated funding streams

33. Level III Strategies: Summary • Level III strategies focus on filling community gaps in services/linkage (e.g. mental healthcare, mid-level assessment services, intervention services for mild/moderate delay) • System-wide training provides common knowledge base for developmental care • System-wide policy changes can jump-start and/or sustain practice change • Reimbursement/financing polices are crucial

34. Cross-Level Summary • The 3 levels of strategies should not be interpreted as a hierarchy. All 3 are important • These are not stand-alone strategies • To optimize impact and resources, practices and communities need to combine strategies • There is no “one size fits all”.

35. Guiding Principles and Recommendations“ Think about the recommendations as possible steps for Delaware’s Early Childhood Action Agenda”

36. Guiding Principles • Work in partnership with families • Collaborate, integrate, and reinforce across services/supports • Use a systems-focused, QI approach

37. Guiding Principles • Shift the balance of resources from high-end to front end • For “daily dose” interventions, go where the children are

38. Guiding Principles • Use a “no wrong doors” approach • Start at whatever level, with whatever strategies are available to the practice or program

39. Recommendations:Practice Level Change • Incorporate QI-systems change at the practice level, starting with a focus on developmental care. Include: • surveillance • anticipatory guidance • point person for linkage • system for follow-up care

40. Recommendations: Practice Level Change • Broaden the focus of developmental care so that pediatric practices can substantially contribute to the promotion of healthy development (Reorient well-child care): • Early adopters devise and test strategies • Evaluate early adopter outcomes • AAP Task Force on Rethinking Well Child Care

41. Recommendations:Community Partnerships • Engage professional associations and umbrella agencies in mapping and linking developmental resources in their communities: • Identify “nodal” or “gatekeeper” resources • Host “meet and greet” sessions • Build relationships across service sectors

42. Recommendations:Community Partnerships • Promote co-location of public sector services in pediatric practices, and other innovative use of public sector resources: • Explore placement in high-volume practices • Evaluate across sectors and settings

43. Recommendations:Community Systems Change • Promote mid-level assessment and referral/linkage capacity at the community or regional level: • Better use of existing resources • Review community-wide referral/linkage and assessment models • Diffusion of effective models & components

44. Recommendations:Community Systems Change • Support training for practice-based, developmental care systems change: • Practice change learning collaboratives • CME credits • Residency training • Multi-disciple and multi-sector training

45. Recommendations:Community Systems Change • Identify and promote key policy changes: • Reimbursement policies for care coordination and co-management • Cross-sector, community protocols for delivering developmental care to children and their families