1. Michigan’s Assuring Better Child Development (ABCD) Project Update for Early On Conference Teresa Holtrop MD November 5, 2009

2. Objectives Review the history of ABCD in Michigan Provide insight into the frustrations of pediatric clinicians

3. Parents and pediatric clinicians recognize the importance of greater emphasis on developmental and behavioral issues Increasingly pediatric clinicians are using standardized screening tools in order to systematically identify problems. Practice work flow changes are sometimes necessary in order to incorporate this change in provision of care Well-Child Care as Viewed by Families and Clinicians: A Discussion in the Journal Pediatrics. Pediatrics, September 2009 124(3):849–57 and 858–65

4. Most residency training programs emphasized surveillance, rather than standardized developmental screening: evidence suggests that surveillance does not identify most children with delays Until now, most children with developmental delays have not been identified until after age 3, and many not until school entry Standardized developmental screening significantly increases detection of children with delays in primary care, and thereby has the potential to increase early treatment, leading to improved outcomes for children and families What Has Been The Norm?

7. Why do screening? Best practice (AAP 2006 policy statement), standard of care Improved parental satisfaction (parents are giving feedback to health care provider, feel empowered) Improved efficiency in work flow

8. AAP Policy Statement July 2006 Developmental surveillance at every well child visit –Surveillance is continuous Formal developmental screening at 9, 18, and 30 months* –Screening is periodic If screening shows risk, Evaluate (diagnosis and treatment). In 0-3 y/o done by Early On

9. Developmental Screening: The Asterisk* (AAP 2006) Because the 30-mo visit is not yet a part of the preventive care system and is often not reimbursable by third-party payers at this time, developmental screening can be performed at 24 months of age. In addition, because the frequency of regular pediatric visits decreases after 24 months of age, a pediatrician who expects that his or her patients will have difficulty attending a 30-month visit should conduct screening during the 24- month visit.

10. How is this working? Current reliance on developmental surveillance (monitoring) is not producing desired result Many children are not being referred to Early On or other early treatment services For many children with developmental conditions, parents have a concern for over a year before concern is acted on (often by someone other than pediatrician) (Slide taken with permission from presentation by Laura Sices MD. Data source: Palfrey et al. 1987; Shevell et al 2001)

11. Ages of Children with Developmental Delays for Events Related to Early Intervention Services 1 st Concern Diagnosis or Identification EI ReferralIFSP Final Report of the National Early Intervention Longitudinal Study, January 2007 7 8 9 10 11 12 13 14 15 16 Child’s Age (Months)

12. Formal Screening – What does this mean? Use a validated tool with high sensitivity and specificity Denver has high sensitivity but low specificity (tends to over-identify kids) ABCD Project recommends several screening tools other than the Denver

13. Examples of good screening tools ASQ PEDS PEDS-DM Other screening tools for social/emotional issues (ASQ-SE, MCHAT, maternal depression screener)

14. ABCD Screening Academy NASHP grant to MI Medicaid Historical Overview 1/07 2/07 4/07 5/09 Today Setting the Stage for Success, Commonwealth Fund grant to MIAAP, 6 statewide pilot practices recruited to start screening AAP CATCH Planning grant, MIAAP, focus on Detroit/Wayne County. Recruited 5 practices in Detroit July ‘07 Vermont Child Health Improvement Partnership (VCHIP) grant to MI 6/07 Today Training completed in Shiawasee, Wayne/Oakland/Macomb Contract from MI Medicaid for ABCD spread

15. ABCD Pilot Practices as of 4/2008

16. Lessons Learned Choosing a screening tool Clinic Flow Early On referrals Developmental specialist referral Privacy laws

17. Lesson Learned All WCE 4-60 months get the Developmental Screen

18. Parent Can Complete tool while waiting in the exam room

22. Medicaid Policy Improvement Medicaid policy changes include: –List of recommended validated standardized screening tools in the EPSDT Policy –Recommended use of approved guidelines and minimal screening standards based on AAP policy and Bright Future Guidelines –Clarification of Medicaid billing process for developmental screening (i.e., coding and reimbursement) in the form of a provider letter.

23. What are the frustrations of pediatric clinicians? Don’t understand the interface between the medical world and the educational world For example: 1.What is Early On?

25. Early On Referral Process in Wayne County PCP refers a child to Early On Referral received by Wayne RESA Referral sent to Early On Provider agencies or school districts* Provider assigns service coordinator, who explains Early On to family If family agrees; evaluator assigned; patient evaluation within 45 days Not Eligible; community resources Great Parents, parent child groups, etc..** Monthly calendar is shared (www.resa.net/earlychildhood/) Part C only IFSP written Service coordinator writes IFSP & sends feedback to PCP; services begin; 6 mo/1yr review by service coordinator** Part B and C IEP & IFSP written Service coordinator writes IFSP and school district staff write IEP, send feedback to PCP; weekly home visits & services begin; 6 mo &1yr review by service coordinator** Part C first, Part B later IFSP written first, IEP added later Service coordinator writes IFSP and later the school district writes an IEP; both eventually provide service. 6 mo & 1yr review by service coordinator** * RESA refers to following Early On providers based on location, and reason for referral: ACCESS, DHWP, Development Center Inc CMH, Wayne County Dept of Human Services, Guidance Center, Early Head Start programs, Wayne County Health Department. The following district schools provide direct Early On services: Gross Pointe, Plymouth, Redford Union, Detroit, Brownstown Woodhaven, Wayne Westland **When a child has more than one type of delay, and is determined eligible for special education, an IEP is written. Only school staff write IEPs. The child will also have an IFSP. Abbreviations: PCP = Primary Care Provider; RESA = Regional Educational Service Area; IFSP = Individualized Family Service Plan; IEP= Individualized Educational Program

26. What are the frustrations of pediatric clinicians? For example: 2.Why does the child in Early On not get PT/OT as often as s/he needs it? (Funding issues!) –Why can my CSHCS patient get speech therapy paid for by Medicaid but my Medicaid HMO patient can’t? –Why does speech therapy for my CSHCS pt stop at 5 y/o?

27. What are the frustrations of pediatric clinicians? For example: 3.What happens after the child has reached his/her 3 rd birthday?

28. What are the frustrations of pediatric clinicians? For example: 4.Why can’t I get feedback from Early On?

29. ABCD Workgroup MDCH, MDE Early On, MIAAP –Developed several referral algorithms –Tested these out on Henry Ford Health System docs –Tweaked forms multiple times –STILL A WORK IN PROGRESS

35. What are the frustrations of pediatric clinicians? (cont) Don’t understand the interface between the medical world and the mental health world Don’t understand the interface between the mental health world and maternal/infant support services

36. Potential Synergies Regional Great Start Collaboratives –Can be a good way to link physicians with Early On, Mental Health, Head Start, etc –Physicians in the trenches have little connection to Great Start efforts and don’t understand the complexities of the system, need way to connect –Great Start Collaboratives can smooth bumps in the road, make referral protocols simpler, measure outcomes, push for more resources