Transcript Electronic PEDS:DM and PEDS

Why Screen
with Validated, Accurate
Tools: Is this Truly
Workable in Busy Clinics?
Frances Page Glascoe
Professor of Pediatrics
Vanderbilt University
Early Intervention Benefits:
Rationale For Screening
Family interest in participation
Better outcomes for participants:
Higher graduation rates, reduced teen
pregnancy, higher employment rates,
decreased criminality and violent crime
$30,000 to >$100,000 benefit to society
(1992 $$s)
For every 1$ spent on EI, society saves 17$
Early Detection/Referral
Problems!!
Only about 30% of children with substantial
delays and disabilities are detected by their
health care provider
Most of those who manage to get detected, are
not referred
Thus most children do not receive the benefits of
early intervention that can prevent school
failure, high school drop out, etc.
Early Detection Problems!!
16% - 18% of children have developmentalbehavioral difficulties and need special services
Recent research (Pediatrics, July 2008)
suggests 13% by age 2!
Only 2% - 3% are enrolled in early intervention
Only 12% enrolled in special education
Enrollment rates in EI should be closer to 8% in
the 0 - 4 age range (CDC, www.cdc.gov)
Who are these children?
Those with delays and disabilities (16% – 18%
of the population). Of this group, common
problems are:
1. language impairment (~45%)
2. learning disabilities (~30%)
3. intellectual disabilities (~20%)
4. autism, motor disorders, brain injury, etc. (~5%)
Those at-risk due to psychosocial
disadvantage, an additional (10% - 12%)
TOTAL = ~ 30%
American Academy of
Pediatrics Policy,
Pediatrics, July 2006
Screening and
Surveillance
Components of the AAP 2006
Policy Statement
Eliciting and addressing parents’ concerns
Ongoing monitoring of:
Health and family history
developmental milestones
mental health (parent/child)
parent-child interactions/psychosocial risk and
resilience factors
Developmental promotion/parent education
Periodic use of screening tests including autism
screens at 9, 18 and 24-30 months and well-visits
thereafter
Holy Smokes!
Pie in the Sky?
Won’t this ‘sink the ship’?
• What? Even more stuff to do at busy
wellvisits?
Challenges in the 2006
Statement
Aren’t some of those measures too long for
primary care?
Aren’t we already doing “surveillance”?
I’ve got good milestones and questions to
parents, aren’t those good enough?
NO!!
Why don’t informal
approaches work
1. How do you know your milestones
checklists (even if drawn from
measures like the Denver) are good
predictors of school success?
2. Are your scoring criteria accurate?
Quality measures select items that best
predict actual developmental status—
and have clear criteria for judging success
Quality Measures Have Criteria
For example, “Knows Colors” –
what exactly does this mean?
Match?
Points to when named?
Names when pointed to?
How many colors?
Why don’t informal
approaches work
Are you screening the
asymptomatic?
Why don’t informal
approaches work
Are you screening repeatedly—at all
well-visits?
Development develops! Developmental
problems do too!
Developmental Status by parent's verbal
behavior and positive perceptions*
Quotients
(Glascoe & Leew, Pediatrics, 2010)
110
105
100
95
90
85
80
75
Age in Months
0-5
06 - 11
12 - 17
18 - 24
* Talks at meals, helps child learn new things, reads aloud,
able to soothe, enjoys child, perceives child as interested in
conversing
Why don’t informal
approaches work
Are you identifying enough kids?
What’s your referral rate?
1 out of 400
1 out of 200
1 out of 100
1 out of 25
1 out of 10
1 out of 6
PREVALENCE BY AGE
4 % of 0 - 2 year olds
8% of 0 - 3 year olds
12% of 0 - 4 year olds
16%+ of 0 - 8 year olds
Why don’t informal
approaches work
Are you asking parents quality
questions?
“Your teacher wishes me to delineate those
watershed occasions in your life that have led you
to become,
slowly and inexorably,
a loose cannon.”
Sample questions to parents
that don’t work well
Do you think he has any
problems…..?
Do you have any worries
about her development?
Consumer-Driven Health Care? It
Doesn’t Work Well for All: If you don’t
ask… and ask well….
they don’t always tell!
34% of parents don’t raise developmental-behavioral
concerns without being asked
Mothers with limited education are less likely to raise
concerns spontaneously
When developmental-behavioral concerns are raised,
children with problems are 11 times more likely to be
enrolled in intervention
Quality questions about parents’ concerns equalizes ‘the
playing field’ for the ‘haves’ and ‘have-nots’
But wait a
minute!
“So many of my kids don’t qualify.”
“Many parents don’t follow through.”
“There’s nothing out there to refer to.”
Some kids don’t qualify but most still need other
kinds of help. Clinics need lists with a
wide range of referral options. THERE IS GOBS
OUT THERE TO REFER TO--HONESTLY!
Some parents need more time. Many take home
your message and just try harder to help their
child. When they discover they can’t, they’ll be
back OR head to referral resources.
BUT, if you can, make appointments for
families—that increases the likelihood of getting
there!
“Oh, by the way…..”
Using quality tools with good
questions to parents:
•Saves provider’s time
•Restrains visit length to predicted levels
•Offers greater reimbursement
•Improves detection rates
•Increases parent and provider
satisfaction and visit attendance
• Focuses developmental promotion
So… we can save time,
increase $$s, and do
best by families…. if we
conduct screening and
surveillance with
evidence and refer
promptly!!
What Tools Should We Use?
• PEDS (10 questions eliciting concerns)
at every well-visit)
• PEDS:Developmental Milestones (6 – 8
questions about milestones) at every
well visit
• The M-CHAT at 18 – 24 months (built
into PEDS:DM)
• A clinic intake form that looks at
parental depression (2 questions)
In an electronic
environment…
• Consider PEDS Online
• www.pedstest.com/online for a trial
• Site offers PEDS, PEDS:DM and the MCHAT
• Website offers downloadable clinic
intake form (for depression screening,
indicators of psychosocial risk, etc.)
• Website also has case examples,
videos, self-training information, etc.
How do we get reimbursed?
• First, you must use validated, accurate screens
• Add the – 25 modifier to your code for preventive
services
• Add 96110 (times the number of screens
administered)
• For private payers, different modifiers may be needed
• Have your clinic coordinator find out about private
payers
• Appeal all denied claims
• If a second denial, contact the AAP’s coding hotline