1. Easing the Transition from Early Intervention to Preschool-Based Services PDSA Project Washington Heights Family Health Center 2005-2006

2. Why did we choose this PDSA project? Many kids seemed to “fall through the cracks” after Early Intervention expired at the age of three Familiarize providers about the transition process between early intervention and school-based services Further allow this transition to be as uninterrupted as possible

3. Background: Early Intervention Program (EIP) Age eligibility: 0-3 years EIP must provide a service coordinator to ensure that services are provided year-round and an Early Intervention Official (EIO) to help ease the transition to pre-school An Individualized Family Service Plan (IFSP) details all of the services to be provided for each referral Children eligible for pre-school special education can stay enrolled in EIP until their third birthday

4. Background: Preschool-aged Special Education Age eligibility: >3 years Patients are deemed eligible by the Committee on Preschool Education (CPSE) and must have documented disability within an Individualized Education Plan (IEP)

5. Background: Transition Process Begin EARLY! At 2 ½ years of age! A transition plan should be incorporated into the IFSP by the service coordinator Obtaining written parental consent is an integral step in the transition process – Parent must report to regional CPSE office with EI exit evaluation and MD- endorsed health form

6. PDSA Cycle 1: Pre-intervention chart review 12 total well-child visits of children 3 years old with a diagnosis of developmental, speech, or language delay were reviewed 50% had documentation of transition to school-based services – Documentation was non-uniform – Attendings and third year residents were most likely to document school transition

7. Project Goals 1. To improve MD discussion of transition process to 80% of eligible children 2. To educate at least 75% of parents of eligible children about the transition process 3. To document the transition to a school-based service (or at least document the completion of an intermediate step for at least 50% of eligible children)

8. Develop lecture series of background information Meetings held with Evelyn Batista, MSW and Dr. Harriet McGurk to gather information Lectures given (during block 4) to all providers during afternoon resident didactic session

9. Develop EI folder to be placed in all provider rooms Contents determined from prior research EI folder holds the following useful tools: – “MD Information Sheet” highlighting critical steps in transition process – Map of educational districts with contact information – List of organizations who provide direct advocacy assistance for individual students with school problems District map also displayed in resident room

10. PDSA Cycle 2: Develop EI sticker EI sticker to be used in the charts of patients between ages two and three who are EI participants and will be transitioning Prompts the provider to collect information about the officials responsible for the transition process Prompts the provider to ask about parent-participation Reminds the provider of their role in the transition process

11. First Draft of EI Sticker EI Service Coordinator EI Srvcs Continue Thru[ ]8/31 (turning 3 between 1/1-8/31) [ ]12/31 (turning 3 between 9/1-12/31) CPSE Region & District (see map) Region _____ District_____ Phone Number _____________ CPSE Referral Status[ ] EI has referred child to CPSE for evaluation [ ] Parent has signed consent for CPSE evaluation [ ] Evaluation has been scheduled [ ] Parent attended meeting about their child’s IEP and/or signed a consent agreeing with the IEP [ ] Placement will be at ____________________ Provider Action[ ] Completed health forms for CPSE eval [ ] Asked parent to bring a copy of the IEP [ ] Other: Abbrevs: EI= Early Intervention, CPSE= Committee on Preschool Education, IEP= Individualized Education Program

12. PDSA Cycle 2, cont’d: EI Sticker Critique/Feedback from Providers Add place for signature of provider Delete line with abbreviations and format to fit sticker size Sign-up list placed in resident room with medical record number and provider for each new sticker placement (to track progress)

13. Second Draft of EI sticker EI Service Coordinator EI Srvcs Continue Thru[ ]8/31 (turning 3 between 1/1-8/31) [ ]12/31 (turning 3 between 9/1-12/31) CPSE Region & DistrictRegion ____ District_____ Phone # ____________ CPSE Referral Status[ ] EI has referred child to CPSE for evaluation [ ] Parent has signed consent for CPSE evaluation [ ] Evaluation has been scheduled [ ] Parent attended meeting about their child’s IEP and/or signed a consent agreeing with the IEP [ ] Placement will be at ____________________ Provider Action[ ] Completed health forms for CPSE eval [ ] Asked parent to bring a copy of the IEP [ ] Other: Signature:Date:

14. PDSA Cycle 3: Formal EI sticker evaluation Second chart review conducted to determine whether providers are using the sticker, and if not, why? – 5 of 6 residents and 9 of 12 attendings surveyed Of 14 surveyed, 6 use the sticker, and 8 admit to not using it at all. – When asked why nonusers decline using the stickers, the answers were: “The patient did not fit the criteria to benefit for special education services” “I did not know about it”

15. PDSA Cycle 4: Assess parental knowledge of transition process Resident called seven parents from patients listed on sign-up sheet Parents are unaware of the transition process and assume that it “just happens automatically” Parents are surprised that we may play a role in easing this transition – “¿Doctora, porque Ud quiere a ayudarme con esto?” Parents want our help in knowing how to advocate for their children

16. PDSA Cycle 5: Interview with EI Coordinator Spoke with an EI service coordinator to gain insight into reasons why the transition process may fail: – Lack of parental consent for CPSE evaluation – Not receiving the CPSE packet in the mail – Not responding to the packet – Misunderstandings about the evaluation – Social stigmata of special education – CPSE refuses to provide services

17. PDSA Cycle 6: Interim Review Chart review: Patients seen between 12/1/05 and 3/1/06 with primary diagnosis of developmental delay or speech delay – 25 charts reviewed, 15 of these patients fit criteria for sticker placement, but only 4 had a sticker in their chart (26.6%) – 3 additional charts had written documentation but no sticker – Higher percentage of sticker usage among residents than attendings (33% vs 22%)

18. PDSA Cycle 6, cont’d: Provider Feedback on Interim Chart Review EI sticker should be used with each initial referral Sticker should be modified to include the date of initial referral

19. PDSA Cycle 7: Chart review to assess sticker usage in new referrals Chart review: Charts from patients seen in 2/06 were examined to see if there was documentation of a new EI referral with a sticker – Nine charts reviewed, three were new referrals – Of these three, only one had a sticker documenting the date of the initial referral (33.3%)

20. Third and Final Draft of EI sticker Date of Initial Referral EI Service Coordinator EI Services Continue Through [ ]8/31 (turning 3 between 1/1-8/31) [ ]12/31 (turning 3 between 9/1-12/31) CPSE Region & DistrictRegion ____ District_____ Phone # ____________ CPSE Referral Status[ ] EI has referred child to CPSE for evaluation [ ] Parent has signed consent for CPSE evaluation [ ] Evaluation has been scheduled [ ] Parent attended meeting about their child’s IEP and/or signed a consent agreeing with the IEP [ ] Placement will be at ____________________ Provider Action[ ] Completed health forms for CPSE eval [ ] Asked parent to bring a copy of the IEP [ ] Other:

21. PDSA Cycle 8: Final Chart review 18 charts reviewed with diagnosis of either developmental delay or speech delay of patients seen between 3/1/06 and 3/29/06; seven met criteria: – Three new EI referrals (all resident patients) Two with stickers, one without – Two in EI → CPSE transition (one resident, one attending) Both with stickers – One EI Re-evaluation (attending patient) with sticker – One Follow-up EI (resident patient) without sticker

22. PDSA Cycle 8: Data from Final Chart Review

23. Conclusions Sticker usage has improved among attendings and residents (>50% as in initial project goals) Providers have become better informed about the transition process Sticker usage should continue to be encouraged because it: – Acts as a reminder for the provider to address these issues during a well-child encounter – Encourages families to view us as another resource to advocate for their child. Format EI sticker in future Eclypsis system

24. References Dr. Harriet McGurk Evelyn Batista, MSW Elba Moreira, EI Assistant Director of Service Coordination www.insideschools.org www.health.state.ny.us/community/infants_c hildren/early_intervention www.vesid.nysed.gov

25. Acknowledgements Dr. Adriana Matiz Dr. Mariellen Lane Dr. Daniel Hyman Dr. Harriet McGurk Evelyn Batista, MSW Dr. Teresa Lee Dr. Monique Collier Dr. Matt Laurich Dr. Maria Kim Dr. Eliza Auerbach Dr. Sarah Shrager Dr. Ray Liu Dr. Paola Ayora Dr. Dawn Wetzel Dr. Rachel Salguero Dr. Rachelle Gandica Dr. Maja Castillo