Description

Spring 2010 SODBP Newsletter

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ABCD (Assuring Better Child Health & Development): Screening & Surveillance, Referral, and Linkages to Community Resources in Primary Care

 

Since 2000, there have been a growing number of activities at the state and national level to promote integration of developmental and behavioral services in primary care.

National trends for screening and surveillance include:

• ABCD (Assuring Better Child Health & Development) Commonwealth Fund Initiatives since 2000:
  • ABCD I (2000–2003) (4 states)
  • ABCD II (2003–2006) (5 states)
  • Setting the Stage for Success (2006–2007) (5 states)
  • ABCD Screening Academy (July 2007)—involving 23 states
  • ABCD III (2009-2012) (5 states)

• AAP: 2001 & 2006 policy statements, Task Force on Mental Health, Bright Futures, 2007 autism screening guidelines
• Rethinking Well-Child Care (AAP and Commonwealth Fund)
• Tiered Well-Child Care (Commonwealth Fund)
• Substance Abuse and Mental Health Services Administration: screening for social-emotional development
• Early Childhood Comprehensive Systems Grants (Maternal and Child Health Bureau)
• Medical Home (AAP)
• National Initiative for Children’s Healthcare Quality (NICHQ) Healthy Development Learning Collaborative (North Carolina and Vermont) 2004
• Early Developmental Screening and Intervention (EDSI), University of California at Los Angeles and First 5, 2006-2010

 The ABCD projects have been sponsored by The Commonwealth Fund and coordinated by the National Academy for State Health Policy (NASHP).   These projects have specifically involved state Medicaid agencies and AAP chapters, as well as Part C programs. In some projects state American Academy of Family Physicians (AAFP) chapters, Divisions of Mental Health, and Divisions of Public Health have been involved.   These projects focus, not only on change in practice, but also are targeted toward policy change. The ABCD I states began by working on general developmental and behavioral screening, surveillance, and referral.   ABCD II states built on the work of the ABCD I states and added a focus on early childhood mental health.   The Setting the Stage for Success Project offered technical assistance and training to 5 states, bringing together Medicaid, the AAP chapter, Part C,  the Early Childhood Comprehensive Systems grant staff and others in each state to strategize a process to train primary care practices, establish a State Advisory Group, spread change, and set state policy. A state manual was developed out of this project. The ABCD III states are just getting started on projects that have a focus on Medical Home – establishing relationships and linkages among practices, community resources, and parents. For descriptions of ABCD state activities, materials, data, policy changes, and lessons learned, go to www.abcdresources.org.

           
North Carolina was 1 of the 4 ABCD I states that received the grant after responding to the request for proposals sent to state Medicaid agencies to develop and enhance a program to provide child development services. Utilizing the infrastructure of the Medicaid Community Care Networks (then called ACCESS II/III), the North Carolina ABCD Project began as a quality improvement initiative, piloting in one network of practices initially, rapidly expanding to networks covering 11 counties by the third year of the grant, and in the years since encompassing the entire state.

North Carolina ABCD history

The project developed a “best practice” comprehensive community model for replication that had 2 components:

• Introduction and integration of a standardized, validated screening tool (Ages & Stages Questionnaire - ASQ), that is practical and that works, at selected well-child visits;
• Collaboration with local and state agency staff and families in developing this system for identifying and serving children.

Shortly after the practices began integrating the screening tool, a State Advisory Group was formed of representatives from key agencies who could assist with removal of barriers and facilitation of policy change. This group continues to meet quarterly, which has enabled the project to be expanded and enhanced to include social-emotional screening, maternal depression screening, and autism screening. The Office of Rural Health and Community Care has been the convener of this group. The advisory group includes representatives from Office of Rural Health and Community Care, Medicaid, North Carolina Pediatric Society, North Carolina Academy of Family Practice, Part C (Early Intervention), ICC (Interagency Coordinating Council), the Department of Public Instruction – Preschool, Public Health, Smart Start, and the Family Support Network.

 

Data on outcomes drives policy change

According to the North Carolina 1999 Early Periodic Screening, Diagnosis, and Treatment (EPSDT) audit, the rate of developmental screening throughout the North Carolina Medicaid systems (ACCESS I, ACCESS II/III, and HMO) averaged 15% for children by age 2 years. After just 1 year, in the pilot practices the rate was 70%. These results led to policy change, both in Public Health and Medicaid. North Carolina Public Health (Child Health) transitioned clinics and community nursing to a menu of standardized, valid, developmental screening tools in 2003.  Medicaid changed EPSDT (Health Check) policy, effective 7/1/2004, requiring a valid, standardized developmental screening tool when screening children at the 6, 12, 18 or 24 months, and 3, 4, & 5 year old visits. The ABCD work group wrote an article describing the project – the implementation of screening, referral, and follow-up in primary care practice, accomplished through utilization of the Community Care of North Carolina (CCNC) infrastructure, which uses a Medicaid primary care case management model, as a quality improvement initiative. It was published in Pediatrics in July 2006.1

           
The North Carolina ABCD Project is a physician-developed quality improvement project within CCNC.  The practice-team trainings, the office process strategies, parent handouts, office tools, and office resource guide were developed during the initial 3 grant years by the ABCD work group of pediatricians, CCNC early intervention care coordinator, IT consultant, and Office of Rural Health staff. Spread to all networks and primary care practices occurred at the time of the Medicaid policy change in 2004.  The CCNC care managers were trained to help many practices integrate screening in many more networks.  Throughout the project, the ABCD work group has taken every opportunity to align goals with state partners to support expansion and enhancement.  The early example of this was the partnership with Early Intervention in the first regional trainings.  Aligning goals in this way has allowed advancement of the quality of screening and referral in counties that were not the early adopters in CCNC, and thus did not have the advantage of the practice team trainings that were provided to many areas around the state.  Over 90% of primary care practices (including Family Medicine) are screening and over 86% of all EPSDT claims include developmental screening at the appropriate ages.   Physicians are now the largest single referral source to Part C. North Carolina is the top state in the nation for developmental screening at well visits according to the recently released National Survey of Children's Health.

           

North Carolina ABCD has been seen as a national model by The Commonwealth Fund.   North Carolina consulted with the ABCD II states.  The NC lead physician and the coordinator from Office of Rural Health were offered a grant by The Commonwealth Fund in 2006 to provide technical assistance to 5 states in the Setting the Stage for Success project.  The North Carolina ABCD project directors also were faculty for the ABCD Screening Academy in 2007.  

 

Lessons learned: State and chapter level

With the North Carolina experience it became clear that involving the Medicaid Agency and the state AAP chapter in all ABCD projects has helped provide the infrastructure for successful system change. The significance of the CCNC infrastructure emerged as a key factor in the success of ABCD in North Carolina.  Three factors provided through CCNC stand out: 1) practices that have experience with quality improvement, 2) care coordination made possible through the network care managers, and 3) a culture of using data to drive best practice and improvement.  

 

Ongoing communication among practices and networks about successful strategies, barriers and new directions, such as occurs with the ABCD quality improvement group, is valuable for sustaining and enhancing the activities in practice.  A state advisory group that engages leadership of state organizations and agencies facilitates removal of barriers and changes in policy.  Standardization of referral and communication processes assists practices and agencies in all communities in the state and helps assure implementation.   The North Carolina State Advisory Group was able to achieve consensus for simple, state-wide referral and feedback forms to Part C (0-3 year olds) and to Department of Public Instruction preschool (3-5 year olds) for use by primary care practices.

 

Lessons learned: Practice level

Integrating screening and surveillance into the office process and flow is crucial for successful implementation of screening programs.

Steps include:

1. Assess protocols for developmental and behavioral screening already in use in the practice.  These may be changed or eliminated, creating new time efficiencies for office flow.
2. Map the workflow. This process needs to include the physician, nursing staff, and the office manager, and should be tailored to the practice. For example, the nurse may give the screening tool to the parent at intake, to be completed in the exam room and ready for the physician to review and score when (s)he comes into the room.
3. Select a tool or tools. Primary developmental and behavioral screens and psychosocial screening can be interwoven into the schedule of well-child visits and into the growing relationship with the family.
4. Identify system supports for parent education, referral, and community services.
   1. Meet with key partners. It is a good idea to invite community partners to a lunch meeting at the practice to share screening plans and align goals.
   2. Establish a process for referral and communication.
5. Orient all staff to new procedures.

One-day practice trainings for practice teams of physician, nurse, manager, and billing staff facilitated the above steps, and these practices had successful implementation of screening.

 

The primary care provider does not need to become an expert at diagnosing and managing developmental and behavioral disorders. However, the provider is a resource for referrals for further assessment and interventions, a partner in finding information, a sounding board, and a facilitator to negotiate the system.  The provider reviews and discusses the screen with the parent at the time of the visit. The screen provides a template for anticipatory guidance, facilitates patient flow (by reducing “doorknob concerns” as the provider leaves the exam room), and improves patient and provider satisfaction.

 

In addition to general developmental and behavioral screening, practices are successfully implementing maternal postpartum depression screening with the Edinburgh Postnatal Depression Scale (at 2, 4, and 6 months) and autism screening with the Modified Checklist for Autism in Toddlers (MCHAT) (at 18 and 24 months), as well as secondary screens, such as the ASQ:Social-Emotional after a positive Edinburgh, positive ASQ, or other psychosocial concerns.  The primary care clinician may schedule a follow-up visit for such secondary screens, or if the practice has integration of mental health services, an LCSW may provide these at the same visit or at a follow-up visit.

ABCD has challenged practices to network with new community partners: Part C (Early Intervention), preschool programs including Head Start, nurse home visitors from Public Health, community mental health providers, and family support groups. 

 

Throughout the North Carolina ABCD project, data has been used to drive improvement and policy change.   Practices have been able to see their rates of screening and referral, and to get information on children who were referred.

 

The experience of ABCD for practices who serve young children has moved them well on their way to meeting the criteria for a medical home. Use of parent-completed screening tools includes parents as experts on their children (family-centered). Practices have become more comprehensive in the care of children at risk for developmental and behavioral problems and they have learned to coordinate care in the community.

 

References

 

1.  Earls,M, Hay,S. Setting the stage for success: Implementation of developmental and behavioral screening and surveillance in primary care practice. The North Carolina Assuring Better Child Health and Development (ABCD) Project. Pediatrics. 2006;118(1): e183-e188.

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Publication date: May 6, 2010
Revise date: May 6, 2010
TextID: 660

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