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Setting the Stage for Success…
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Assuring Better Child Health & Development “ABCD”
The NC ABCD Project: 2000 -‐ Present
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The “ABCD” History….
§ The Commonwealth Fund, among the first private founda9ons started by a woman philanthropist-‐ Anna M. Harkness-‐ was established in 1918 with the broad charge to enhance the common good. The Fund carries out their mandate by suppor9ng independent research on health care issues & issuing grants for improving health care prac9ce and policy.
§ In 2000, North Carolina was one of 4 states to be awarded a grant from the Commonwealth Fund to develop and implement a program to enhance child development services.
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National Trends for Screening and Surveillance
§ ABCD (Assuring Better Child Health & Development) Commonwealth Fund Initiatives since 2000:
ABCD I (2000–2003) ABCD II (2003–2006) Setting the Stage for Success (2006–2007) ABCD Screening Academy (July 2007)—involving 23 states ABCD III (2009-2012)
§ AAP: 2001 & 2006 Policy Statements, Task Force on Mental Health, Bright Futures, 2007 Autism Screening Guidelines
§ Rethinking Well-Child Care (AAP and Commonwealth) § Tiered Well-Child Care (Commonwealth) § SAMHSA—screening for social-emotional development § Early Childhood Comprehensive Systems Grants (MCHB) § Medical Home (AAP)
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§ 48% of children in NC live in low-‐income families
§ The use of “the most common & familiar” developmental screening tool (Denver) was both untenable in primary care pracFce & did not meet sensiFvity & specificity
§ The AAP was recommending formal screening and surveillance at well child visits.
§ Limited access to professionals with 0-‐5 experFse ( psychiatry, psychology, counselors)
The Challenges……
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The Challenges Continue…
§ Division of MH, SA, and DD reorganizaFons: “target” populaFon not inclusive of children at-‐risk or with mild to moderate problems.
§ The Early IntervenFon (EI) eligibility criteria changes-‐less children would qualify
§ The number of children served by (EI) was low (8-‐13% of the total 0-‐3 popula9on could qualify–only 2.6% historically served.)
§ Across Medicaid systems of care the average rate of developmental screening was low: (approximately 15.3%) ………
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Strategic Components
• Quality improvement project in primary care with quarterly data reporFng and review
• FormaFon of State Advisory Group that involved leadership from the NC AAP Chapter and AFP Chapter
• Implemented within the infrastructure of Community Care of NC (CCNC)
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Quality Improvement in Primary Care Practice
Developmental Screening & Surveillance…..
The Solution: (1) Develop a “best practices” comprehensive
community model for replication – The model built on North Carolina’s “Physician Driven”, enhanced primary care, case management program, Community Care of North Carolina, and characterized by two major components: § IntroducFon & integraFon of a standardized, validated screening tool
(ASQ or PEDS) at selected well-‐child visits, that is pracFcal and that works;
§ CollaboraFon with local and state agency staff and families in developing this system for idenFfying and serving children.
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The Office Systems Approach
• OrganizaFonal tool: Geang Started Worksheet
• MulFdisciplinary: involves pracFce staff at all levels
• Networking: guides pracFce in building relaFonships with community partners
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Sustaining Change
New kind of communicaFon with community
§ RelaFonship with key partners § Networking to facilitate process beyond pracFce § Agreements on how to exchange informaFon, e.g. standardized referral process/form
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The Solution (cont.): (2.) Formed a State Advisory Group – The group is comprised of
leadership from key agencies who have the capability of making policy changes.
Medicaid Early IntervenFon Part C Public Health State ICC Department of Public InstrucFon:
Preschool Smart Start Family Support Network NC Pediatric Society NC Academy of Family PracFce
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Community Care of N.C. • 14 networks, each 501 c 3, 100 counFes • pmpm to networks and to pracFces to support care management acFviFes
• Network level of support includes: care managers, behavioral care managers, OB Care Managers, network psychiatrist, PharmD, RD, transiFonal nurses
• Community mental health MCO (LME) parFcipaFon on network boards and medical management commigees
o Clinical Directors-‐ Decision-‐Making o Regular reporFng of data to networks: Quality Measures & Feedback (QMAF)
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Cherokee Graham
Swain
Clay Macon Jackson
Haywood
Transylvania
Madison Buncombe
Henderson
Yancey
McDowell Rutherford
Polk
Avery
Burke
Cleveland
Watauga Caldwell Alexander
Catawba Lincoln Gaston
Ashe Wilkes
Alleghany Surry
Yadkin
Iredell
Mecklenburg Union
Stanly Cabarrus Rowan Davie
Stokes Forsyth
Davidson
Anson
Rockingham Guilford
Randolph
Montgomery Richmond
Caswell
Chatham
Orange
Person
Lee Moore
Hoke Scotland
Robeson
Cumberland Harnett
Wake
Vance
Franklin
Warren
Johnston
Sampson
Bladen
Columbus Brunswick
Pender
Duplin
Wayne
Wilson Nash
Halifax Northhampton
Edgecombe
Pitt Greene Lenoir
Jones Onslow Carteret
Craven Pamlico
Beaufort Hyde Martin
Bertie Hertford
Gates
Washington Tyrrell Dare
Mitchell
Alam
ance Durham Granville
New
Hanover
Chow
an
a r Pasquatank
Source: CCNC 2011
Legend AccessCare Network Sites Community Care Plan of Eastern Carolina AccessCare Network CounFes Community Health Partners Community Care of Western North Carolina Northern Piedmont Community Care Community Care of the Lower Cape Fear Northwest Community Care Carolina CollaboraFve Community Care Partnership for Health Management Community Care of Wake and Johnston CounFes Community Care of the Sandhills Community Care Partners of Greater Mecklenburg Community Care of Southern Piedmont Carolina Community Health Partnership
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Community Care of N.C. • Care Managers – assist with follow-‐up, transportaFon, disease management, hospital transiFon; link families and PCP’s to services; track ED usage.
• Web–based Care Manager System • InformaFcs Center with Provider Portal • Quality IniFaFves – Adult & Pediatric: Asthma, Diabetes, CHF, ED UFlizaFon, Mental Health IntegraFon, ABCD, Dental Varnishing, Pregnancy Medical Home…
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Assuring Better Child Development (ABCD Project)
• Began in P4HM network, now statewide • Screening and surveillance with parents as
experts on their child • Elicits parent concerns • Builds ongoing relationship between parents and
the Primary Care provider • Early Identification
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Pediatrics & Community Care of N.C.
• Care Managers – assist with follow-up and disease management; link families and PCP’s to services for developmental & behavioral disabilities; track ED usage.
• Pregnancy Medical Home • Health Check Coordinators (EPSDT) • Care Coordination for Children, 0-5 (CC4C) • CHIPRA Quality Demonstration Grant • Initiatives – Developmental Screening and Surveillance
(ABCD), Asthma, Diabetes, Dental Varnishing, Mental Health Integration, Obesity, ADHD, EPSDT, psychosocial/social-emotional screening for school-age and adolescent; Medical Home for children & youth in Foster Care
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Strategic Factors for Spread
• Data: 8 years of claims reporFng, incorporated into CCNC’s QMAF in 2012
• Policy Change • EvaluaFon and publicaFons • Aligning goals with state partners: Part C, Preschool and Department of Public InstrucFon, Smart Start
• Standardized referral protocols and forms
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Access I10/1/99 -3/31/00CCNC 10/1/99 -3/31/00
HMO 10/1/99 -3/31/00
P4HM Baseline10/1/99 -3/31/00P4HM 10/1/01 -3/31/02
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Developmental Screening: Percentage of 0-24 Month Health Checks with a Screening during a 6 Month Period
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NC Policy Change
§ Medicaid changed EPSDT policy (Health Check), effecFve 7/1/2004, requiring a valid, standardized developmental screening tool when screening children at the 6, 12, 18 or 24months and 3, 4, & 5 year old visit. The medical record should contain results & 96110-‐EP should be on the claim. § EffecFve 7/1/2010 AuFsm screening with MCHAT
required at 18 and 24 month well-‐visits
§ Public Health system (Child Health) transiFoned clinics to a menu of standardized, valid, developmental screening tools in 2003
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Currently in NC EPSDT quarterly report on 96110
• Greater than 90% of primary care pracFces are screening.
• 75% of EPSDT exams for 0-‐5 year olds include a developmental screening
• Increase in referrals to Part C since 2003 from 3400 to >20,000 annually
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35%
19% 19%
16% 11%
Physicians Parents/Caregivers Social Services Hospitals/NICUs Local Public Health
Current Top 5 Referral Sources NC Infant-Toddler Program
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NC ABCD Evaluation & Publications
• Earls, MF, Andrews, JE, Hay, SS, “A Longitudinal Study of Developmental & Behavioral Screening and Referral in North Carolina’s Assuring Beger Child Health and Development ParFcipaFng PracFces,” Clinical Pediatrics, Vol. 48, No.8, Oct 2009, pp. 824-‐33.
• Earls, M, Hay, S, “Seang the Stage for Success: ImplementaFon of Developmental and Behavioral Screening and Surveillance in Primary Care PracFce, The North Carolina Assuring Beger Child Health and Development (ABCD) Project,” Pediatrics, Vol. 118, No. 1, July 2006.
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Referral Form Developmental Screening & Surveillance
Name of Child:______________________________________________________ Date of Birth:____/___/_____Age____________ _Sex________________________ Address:____________________________________________________________ Medicaid#:_________________Insurance___________ Social Security__________ Parent/ Guardian Name:________________________________________________ Home Phone:____________________ Work Phone:__________________________ Race:_________________________ Primary Language:________________________
Developmental/Interdisciplinary Referral: Concerns: Screening Tool: ¨ ASQ ¨ PEDs ¨ MCHAT ¨ ASQ-SE ¨ Other _________________ (Please Name) The ASQ or PEDS and/or MCHAT scoresheet is attached, if completed. I have discussed this referral with parent(s) Referred By: Phone: PCP Office: Fax:
(Insert Letterhead Identification Here)
ACCESS II & IIIACCESS II & III
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From There...
§ ParFcipaFon on ECCS planning/implementaFon teams
§ ParFcipaFon in development of the New Kindergarten Health Assessment to include developmental screening
§ Mental health integraFon iniFaFves in the state-‐using other screening tools, e.g. Edinburgh for maternal depression & ASQ-‐SE in primary care § A resource to Health Check (EPSDT) for seminars, surveys, and as quesFons arise from the provider community
§ “ABCD” Quality Improvement Group meets quarterly to exchange resources, etc.
§ ABCD State Advisory Group meets quarterly to strategize and facilitate spread
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Smart Start & ABCD Smart Start staff person working within pracFces to develop/enhance systems for screening, referral, and community linkages
o 2001 “Region A” – 7 westernmost counFes approximately 150 pracFces
o 2003 & 2005 2 counFes o 2007-‐2008 four Smart Start Partnership Grants, 8 addiFonal counFes; 6 more counFes covered by local Partnership funding
o 2009 – 9 ABCD grants o 2010 – NCPC Board-‐conFnued investment in ABCD grants. Currently 6 posiFons, serving 10 counFes.
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Evaluation of Smart Start ABCD Project FY2007-2011
• Targeted PopulaFon:
– 139 primary care/pediatric pracFces – 11,995 chart audits reviewed/analyzed
• Services Provided by SS ABCD Coordinators: – Training and technical assistance to medical providers in the use and integraFon of standardized, validated developmental screening tools at well-‐child visits (AAP recommended)
– InformaFon on where and how to refer “at-‐risk” children to appropriate early intervenFon (EI) agencies and community programs
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Smart Start Outcomes/Results Over Three Years
– Increase in the percent of children (from 80% to 99%) who received developmental screenings at their most recent well-‐child visits
– Increase in the percent of children (from 64% to 95%) who received all possible screenings at well-‐child visits
– Increase in the percent of “at-‐risk” children (from 44% to 67%) who were referred to the appropriate EI agency for services
– Increase in the percent of referred children (from 40% to 50%) who were documented as having received follow-‐up services
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Further Developments • Training of Smart Start ABCD staff and QI group on auFsm screening and maternal depression screening
• CME sessions for NCPS and NCAFP on auFsm screening and referral
• January 2009: Medicaid opens a new code, 99420, for ASQ-‐SE, MCHAT, PSC
• 2012 NC’s Race to the Top Grant specifies funding for expansion of Smart Start ABCD Coordinators to cover every CCNC network
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ABCD: Integral to Child Health Care Quality
• Coaching and data sharing in networks and pracFces: Pediatric QI coaches and Smart Start ABCD coordinators
• EPSDT quarterly report on 96110 and 99420 (auFsm screening) part of the CCNC QMAF reporFng to networks and pracFces.
• Mental Health IntegraFon in primary care pracFces: developmental & behavioral, social-‐emoFonal screening
• CHIPRA Child Health Quality DemonstraFon Grant
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ABCD: Integral to Child Health Care Quality (2)
• CHIPRA Core Quality Measure # 8 (24 CQM’s from CMS and AHRQ)
• CHIPRA Grant Medical Home: 2 cohorts of pracFces in learning collaboraFve, 8 CCNC networks, 27 pracFces; developmental/behavioral/social-‐emoFonal screening, referral, and community linkages for ages 0-‐20 years
• CHIPRA implementaFon in Pediatric EHR format as structured, reportable data; HIE
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