2. Amy Belisle’s Disclosure I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity.

3. Objectives for First STEPS, Phase 2 Setting the Stage: Focusing on the PCMH, Bright Futures, and Developmental and Autism Screening Working Together: Developing Successful PDSA Cycles and Learning from Autism Implementation Group Welcoming Parent-Partners: Thinking about how to include them in our Quality Improvement Work Raising Rates: Improving : Improving Developmental, Autism, and Lead Screening Creating Next Steps

4. First STEPS MAINE BBCH Pediatric and Med-Peds Clinic Ellsworth- Maine Coast Pediatrics Rockland- PenBay Pediatrics Penobscot Pediatrics Husson Pediatrics EMMC Family Medicine CMMC Pediatrics CMMC Family Medicine Martin’s Point Pediatrics Brunswick Waterville Pediatrics Winthrop Pediatrics Kennebec Pediatrics

5. Practices by the Numbers 12 outpatient groups 45 physicians 20,000 children with MaineCare covered by practices by Aug 2010 numbers

6. Community Partners MaineCare Muskie School of Public Service, USM Maine Developmental Disabilities Council Maine Autism Society Maine Parent Federation Maine CDC Child Development Services Office of Child and Family Services Maine Children’s Alliance Head Start Families and Parent Partners

7. Why Is this Important to Your Practice? Developmental delays and conditions affect 10% of children 1/88 kids with autism* 85% of children with lead poisoning in Maine have MaineCare health insurance; Only 50% of children at age one are currently tested and 25% of children at age 2 CMS requirements for lead testing vs. screening for children enrolled in MaineCare may be changing in the next 6 months- would require changes in state law *(March 30, 2012, MMWR, Prevalence of Autism Spectrum Disorders — Autism and Developmental Disabilities Monitoring Network, 14 Sites, United States, 2008)

8. Why screen for lead and developmental delays? Lead is toxic to the brain Lead poisoning can negatively affect cognition, social functioning and communication skills Pica- kids with autism and developmental delay may be more likely to put things in their mouths, increase risk for lead poisoning Early intervention and treatment can greatly improve prognosis Screening at similar ages

9. 2 years 3 years 6 years Why is this important to me?

10. Why is this important for families? Hope to find answers and improve quality of life for children and families Early intervention Need a more standard approach to evaluate with screening tools- we see the kids for a few minutes in the office, parents are with the kids all the time and can provide critical information Need help with care coordination Need help with finding treatment services

11. The American Academy of Pediatrics (AAP) Policy Statement on Identifying Infants and Young Children with Developmental Disorders in the Medical Home Recommends addressing child development by including routine developmental surveillance, Periodic screening using standardized tools; And if a developmental concern is identified, further evaluation to identify specific developmental disorders. Early identification of children with developmental delays and subsequent intervention can improve outcomes for young children.

12. What is the Quality Gap? The gap between the care we know is best and our ability to deliver it, every time, to every patient in the way they need it. Maine’s preventive care for children including being ranked 14 th for developmental screening (only 20% screened) by the Commonwealth Fund in 2010.

13. Quality Gap- Providers are not using screening tools Many physicians and primary care providers rely on informal developmental milestones and/or observation to monitor a child’s development. “Clinical judgment” alone is known to capture only about 30% of the children with delays—leaving many with unidentified needs and missed opportunities for timely and beneficial intervention. Early developmental delays are often not identified until well beyond the period in which early intervention is most effective. While detection rates increase by using a standardized instrument, national data indicate a low percentage of physicians use a standardized instrument.

14. Source: Muskie School of Public Service, University of Southern Maine

15. Updated Billing Codes from MaineCare for Developmental Screening 96110: General Developmental Screening Tool- PEDS/ASQ ($8.99) 96110HI- Autism Specific Screening Tool – MCHAT 1 ($8.99) 96110HK- Autism Specific Screening Tool- MCHAT 2 ($86.59)

16. Learning from Previous Pilot and Current Autism Implementation Grant In 2009, a developmental screening pilot was done in Maine with 5 sites In 2010 DHHS’ Children with Special Health Needs (CSHN) program applied for and was awarded a three-year State Autism Implementation Grant (AIG) of approximately $300,000 annually, funded under the federal Combating Autism Act Initiative. Maine is in the middle of a 3 year pilot with 2 sites (Bangor and Portland) to work on an Autism Implementation Grant with the Maine Developmental Disabilities Council. – Improve Screening – Promote the medical home and care coordination – Connect to evaluation and intervention services for children

17. Phase 2 Aim statement Improve the rate of developmental, autism, and lead screening for children according to the Bright Futures Recommendations for Pediatric Preventive Care by 50% from May 2012 to December 2012.

18. Goals 75% of children have a documented developmental screening using a validated tool (ASQ or PEDS) at the 9 mo, 12- 23 mo, and the 24 -36 mo well child visits 75% of children have a documented autism screening (MCHAT1 or MCHAT2) between 16 -24 months 75% of children identified with a concern or developmental delay have a documented follow-up plan (observation, recheck in office, or referral) 75% of all children will have a lead risk screening questionnaire to determine a child’s level of risk at 12 mo 75% of all children will have a lead risk screening questionnaire to determine a child’s level of risk at 24 mo

19. Office System Goals Incorporating screening tools in your office flow Work on referral tracking for all patients Develop list of community and medical resources for families and patients Think about care coordination and care plans for families Involve families in your quality improvement efforts

20. Office Systems Survey Fast Facts… 92% respondents have standard approach to developmental surveillance When surveillance completed – 73% at all well visits – 18% at well and sick visits – 9% at selected visits 100% use standard tool

24. More OSS Fast Facts 100% respondents screen for autism (M-CHAT) and 18% use lead screen questionnaire When children referred for diagnosis and treatment as a result of a positive developmental or autism screen, evaluation for majority happens between 2-5 months. Only 16% respondents have care coordinator to assist with referrals and f/u Only 8% of respondents involve parent partners 33% perform staff training for developmental screening & surveillance

25. In Summary… There are lots of opportunity for change and improvement!

26. Let’s make it fun! Games and Prizes! Prize Categories for Today: Prize for Best Slogan for Learning Collaborative Prize for Best Theme Song Drawing for Completed Evaluation Form Draw name of practice that brought a parent partner

27. First Teams to Win: On time data submission On time office system survey 1 st team to enroll in the Learning Session: 1 st team to submit completed Office system survey:

28. Tell us what you think! Local Evaluators- Sherrie Winton would like to talk with volunteers about First STEPS- sign up and enter to win a prize National Evaluators- may be coming this summer Nancy Cronin is working on adding autism/developmental screening to the Child Link registry Eric Frohmberg-building info into Lead Database

29. Next STEPS Amy Belisle, MD

30. Next STEPS Proposals for Next 2 Coaching Calls: June 14th: July 12th: Data Cycles: 15 th of the month- next June Provide Feedback to Evaluators! Next Learning Session- Sept 14 th, Freeport Celebration Dinner- Sept 14 th, 5-7 pm at the Harraseeket with Phase 2 LS 2

31. Phase 2 Timeline in Packet

32. Contact Info / Questions Amy Belisle, MD, 207-829-8444 Director of Child Health Quality Improvement, Maine Quality Counts, abelisle@mainequalitycounts.org Sue Butts-Dion, 207-283-1560 First STEPS Program Manager, Quality Specialist, Maine Quality Counts, sbutts@maine.rr.comsbutts@maine.rr.com Nancy Cronin, MA, ASD Systems Change Coordinator, Maine Developmental Disabilities Council,207-287-4214, Fax: 287-8001, Nancy.E.Cronin@maine.gov Barbara Farrell 207-622-3374 ext. 218, First STEPS Administrative Assistant, Membership & Events Coordinator, Maine Quality Counts, FAX 207-622-3332 bfarrell@mainequalitycounts.org Catherine Gunn, 207-780-5576 First STEPS Data Collector, Cutler Institute for Health and Social Policy Muskie School of Public Service FAX 207-228-8083 cgunn@usm.maine.edu.