Post on 26-Dec-2015
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How To Make Developmental Services Easy to Use
Judith S. Palfrey MDAlison Schonwald MD
Children’s Hospital BostonOpening 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 Why Do We Care About Developmental Screening? Developmental Screening?
Earlier the BetterEarlier the Better
New Science About Brain DevelopmentNew Science About Brain Development
Inequities in Recognition and Early Inequities in Recognition and Early InterventionIntervention
At a Systems Level, Need Correction At a Systems Level, Need Correction – To Improve Care for Individual ChildrenTo Improve Care for Individual Children– To Address Public Health and InequitiesTo Address Public Health and Inequities– To Save Our Nation $$$$$$$$$$$$$$$To Save Our Nation $$$$$$$$$$$$$$$
Why Do We Care About Why Do We Care About Developmental Screening? Developmental Screening?
Earlier the BetterEarlier the Better
New Science About Brain DevelopmentNew Science About Brain Development
Inequities in Recognition and Early Inequities in Recognition and Early InterventionIntervention
THE TRIPLE AIM 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, 405-420
Pediatrics, Vol 120, Nov 2007, 1183-1215
American Academy of Pediatrics Policy
The percentage of pediatricians who The percentage of pediatricians who report using standardized screening tools:report using standardized screening tools:
23% in 2002 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*From the AAP Periodic Survey, 2009 is unpublished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
DecemberSeptember January MayApril August2006
Broad Developmental Screening:Effectiveness and Feasibility in CHPCC
1861 PEDS Screeners Jan-Aug 06
80%4%
8%
8% Already inservices- no newconcern
New concern perPEDS
New Concern noton PEDS
No concern orservices
Changes in Identification of Behavior Concerns
8.97.1
10.614.2
0
10
20
30
40
2 yr olds 3 yr olds
% of 2 and 3 yo's
identified with
concerns
PrePEDS
PostPEDS
p=.023 p=.302
Changes in Identification of Developmental Concerns
11.2
30.2
34.6
19.2
0
10
20
30
40
50
2 yr olds 3 yr olds
% of children
identified with
concerns
PrePEDS
PostPEDS
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 1 2 3 4 5 strongly
disagree agree
pre 3.62
post 4.13
p=.04
Perception of TimePerception of Time
174
0
20
40
60
80
100
% of staff who
agree
Takes Too MuchTime!
PrePEDS
PostPEDS
15.67
14.86
17.75
17.84
0 5 10 15 20
Visit Time in Minutes
Pre-PEDSWave 1Wave 2Wave 3
p= ns
Schonwald A, Horan K, Huntington N. Developmental Screening: Is There Enough Time? Clinical Pediatrics. 2009:48(6):648-55.
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
(χ2,1=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
(χ2,1=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 PatientsWait time= 61 days
45 (70%) diagnosed with ASDAvg age 22.0 mos
78% male
19 (30%) not diagnosed with ASDAvg 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 Do we have to do both a broad developmental screener and an autism-developmental screener and an autism-specific screener at every 18 and 24 specific screener at every 18 and 24 month well child visit?month well child visit?
Yes, each picks up concerns the other misses
2006
262 visitsPEDS
2009
198 visitsPEDS + M-CHAT
Percentage of completed PEDS target patients over time
Pediatric Academic Societies, Poster Presentation, Vancouver 2010
90.4
38.2
0102030405060708090
100
2006 2009
Next StepsNext 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 FindingsSchonwald 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.Schonwald A, Horan K, Huntington N. Developmental Screening: Is There Enough Time? Clinical Pediatrics. 2009:48(6):648-55.Schonwald A, Huntington N, Witt K, Silver T, Cox J.. Evaluation Rates Of Children Identified By Routine Developmental Screening. Pediatric Academic Societies, Honolulu, HI. 2008. 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. 2009 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 toolshttp://massscreen.ehs.state.ma.us/screeningtools.pdf
Four Screening Tool Consultants
MA Medicaid Regulation:
Required Behavioral Health Screener
www.autismscreening.org