How To Make Developmental Services Easy to Use Judith S. Palfrey MD Alison Schonwald MD Children’s Hospital Boston Opening Doors Initiatives

National Center on the Ease of Use of Community Based Services Communitybasedservices.org An Opening Doors Initiative (OpeningDoorsforYouth.org): Funded by the Maternal and Child Health Bureau (MCHB), Health Resources and Services Administration (HRSA) and the National Institute on Disability Rehabilitation and Research (NIDRR), U.S. Department of Education Mission: The Center will advance policy and practice solutions that improve the ease of use of community based services for families with a child with special health care needs

Why Do We Care About Developmental Screening? Earlier the Better New Science About Brain Development Inequities in Recognition and Early Intervention At a Systems Level, Need Correction –To Improve Care for Individual Children –To Address Public Health and Inequities –To Save Our Nation $$$$$$$$$$$$$$$

Why Do We Care About Developmental Screening? Earlier the Better New Science About Brain Development Inequities in Recognition and Early Intervention THE TRIPLE AIM

Standardized developmental screening tests at 9-, 18-, and 30-month visits Autism-specific screen at 18 & 24 months Pediatrics, Vol 118, July 2006, Pediatrics, Vol 120, Nov 2007, American Academy of Pediatrics Policy

The percentage of pediatricians who report using standardized screening tools: 23% in 2002 Higher in 2009* Higher in 2009* *From the AAP Periodic Survey, 2009 is unpublished Actual Practice

Baseline 2&3yo WCC Chart Review n=331 Implementation Follow-up 2&3yo WCC Chart Review n=228 Follow-up Provider Survey Baseline Provider Survey DecemberSeptemberJanuaryMayAprilAugust 2006 Broad Developmental Screening: Effectiveness and Feasibility in CHPCC

1861 PEDS Screeners Jan-Aug 06

Changes in Identification of Behavior Concerns p=.023 p=.302

Changes in Identification of Developmental Concerns p=.208 p=.023 Schonwald A, Huntington N, Chan E, Risko W, Bridgemohan C. Routine developmental screening implemented in urban primary care settings: more evidence of feasibility and effectiveness. Pediatrics. 2009:123(2):660-8.

Provider confidence “I am confident in my ability to screen for developmental and behavioral concerns.” strongly strongly disagree agree pre 3.62 post 4.13 p=.04

Perception of Time

p= ns Schonwald A, Horan K, Huntington N. Developmental Screening: Is There Enough Time? Clinical Pediatrics. 2009:48(6): Mean Visit Time Pre- and Post-Screening

More parents Post-PEDS reported –Speaking to the provider about concerns they had about their child (74.2% v. 90.2%, p=.05) –Received answers to their concerns (89.7% v. 100%, p=.04) –Being asked about their child’s behavior (83.9% v. 100%, p=.006) Time

What happened to referred children?

71/136 (52%) of referred children were evaluated Boys were twice as likely as girls to be evaluated (χ 2,1 =8.32;p<0.004) Children whose parents had more than one concern were more likely to be evaluated than those whose parent had only one concern (χ 2,1 =3.29;p=0.07) Evaluation Completion Pediatric Academic Societies, Platform Presentation, Hawaii 2008.

New triage and scheduling system Identified and screened evaluation requests for children with high risk & need 1.Under 24 months old 2.Request evaluation for ASD Failed MCHAT, parent, EIP, PCP concern Concern on triage phone call 3.Not already diagnosed, not in services Autism Fast Track

64 Patients Wait time= 61 days 45 (70%) diagnosed with ASD Avg age 22.0 mos 78% male 19 (30%) not diagnosed with ASD Avg age 21.6 mos 68% male Autism Fast Track: First 2 Years

If parent reported the PCP was concerned with autism, the child was twice as likely to be diagnosed with an ASD Risk at Triage Pediatric Academic Societies, Platform Presentation, Vancouver 2010

Additive value of autism-specific screen Do we have to do both a broad developmental screener and an autism- specific screener at every 18 and 24 month well child visit? Yes, each picks up concerns the other misses visits PEDS visits PEDS + M-CHAT

Percentage of completed PEDS target patients over time Pediatric Academic Societies, Poster Presentation, Vancouver 2010

Next Steps

Autism Medical Home Accessible Continuous Coordinated Comprehensive Patient centered Managed centrally by a primary care physician Active involvement of non-physician practice staff

Dissemination of Findings Schonwald A, Huntington N, Chan E, Risko W, Bridgemohan C. Routine developmental screening implemented in urban primary care settings: more evidence of feasibility and effectiveness. Pediatrics. 2009:123(2): Schonwald A, Horan K, Huntington N. Developmental Screening: Is There Enough Time? Clinical Pediatrics. 2009:48(6): Schonwald A, Huntington N, Witt K, Silver T, Cox J.. Evaluation Rates Of Children Identified By Routine Developmental Screening. Pediatric Academic Societies, Honolulu, HI Cox J, Huntington N, Epee-Bounya A, Saada A, Schonwald A. Analysis of Written Parental Comments on the Parents' Evaluation of Developmental Status (PEDS) Screen. Pediatric Academic Societies, Baltimore, MD Pappas D, Huntington N, Cox J, Schonwald A. Does adding the M- CHAT to broad-based screening improve early detection of Autism? Pediatric Academic Societies, Vancouver, Canada 2010

Behavioral Health Screener Every well child visit 0 → 21 Must use one of 8 specific tools tools.pdf  Four Screening Tool Consultants MA Medicaid Regulation: Required Behavioral Health Screener