Transcript Slide 1

Implementing
Developmental Screening
in the Medical Home
Medical Home Implementation Teleconference Series
April 20, 2009
11:00 am CT
Paul H. Lipkin, MD
Kennedy Krieger Institute
Johns Hopkins University School of Medicine
Timothy Geleske, MD
North Arlington Pediatrics, IL
Tracy M. King, MD, MPH
Johns Hopkins University School of Medicine
The speakers 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.
Session Objectives
1.
Understand the motivation and planning of practices
choosing to implement the AAP's policy statement on
developmental surveillance and screening.
2.
Utilize the wide range of implementation strategies
used by D-PIP practices, and to illustrate some of the
challenges faced by practices in adopting these
strategies.
3.
Describe the implications of these findings for the
sustainability of developmental surveillance and
screening efforts within the medical home.
Pediatrics 2006; 118: 405-420
The 2006 AAP Policy Statement on
Surveillance and Screening: Goals


Increase identification of children with
developmental disorders by child health
professionals
 Improved
surveillance and screening
 Concrete
guidelines (algorithm)
 Eliminate
barriers (e.g. reimbursement, time)
Improve medical assessment
Definitions (AAP, 2006)

Developmental surveillance
 “A
flexible, longitudinal, continuous, and cumulative
process whereby knowledgeable health care
professionals identify children who may have
developmental problems”

Developmental screening
 “The
administration of a brief standardized tool
aiding the identification of children at risk of a
developmental disorder”
 Not diagnostic!

Developmental evaluation
 “Aimed
at identifying the specific developmental
disorder or disorders affecting the child ”
Developmental Surveillance
9 mo
18 mo
24/30 mo
Developmental Screening
Policy Statement Recommendations
 Developmental

surveillance
Every well-child visit
 Developmental
screening using
a standardized screening tool


9, 18, and 30* months
When concern is expressed
 Autism

screening
18 (and 24) months
Why screen at
9, 18 and 30 months?





Time availability
Limited other requirements
Key developmental stages
Early Intervention
Medical interventions
When screening results concerning:
Referrals

Developmental evaluations
 Identify

disability
Medical evaluations
 Identify
etiology
 Counsel around diagnosis/prognosis
 Genetics and family planning issues
 Implement medical treatments

Early intervention/other services
 Service
delivery
Developmental Screening
Instruments
Domains



General
Domain-specific
(motor, language)
Disorder-specific
(autism)
Administration


Parent-completed
Directly administered
Acceptable sensitivity and specificity: 70%-80%
Algorithm:
Surveillance
to
Screening
to
Referral
So, what’s
next?
Implementation!
Why an implementation
project?
Quality improvement framework
 To see if guidelines can be effectively
implemented in a variety of practice
settings, specifically with regards to:

 Developmental
Surveillance
 Developmental Screening
 Referral Practices
Developmental Surveillance and Screening
Policy Implementation Project (D-PIP)

Aim:
Implement

policy statement in pilot practices
Goals:
Determine
if the policy statement is efficiently
and effectively implemented into practice
Recognize strategies for implementation
Examine outcomes of implementation

Pilot sites to serve as best-practice sites
Participating Sites
Setting:
•
•
•
9 urban
5 suburban
3 rural
Practice type:
•
•
•
7 private practice
5 residency programs
5 community health centers
Training of Practices
Pre-Implementation Workshop
3
members from each practice
(pediatrician, office staff, other)
 Review of AAP guidelines
 Screening test examples
 Principles of implementation
(Bright Futures, Medical Home models)
Developmental
Screening
One practice’s experience
North Arlington Pediatrics
Primary care pediatric practice in a middle
class suburban setting
 Five full-time and three part-time
physicians
 Emphasis on surveillance with health
maintenance visits at months 1-6, 8, 10,
12, 15, 18, 24, 30, and 36 months, and
yearly after that
 No standardized developmental screening
performed

North Arlington Pediatrics
Developmental Screening Policy
Implementation Project (D-PIP) sponsored
by the AAP - Spring 2006
 Implementation team: nurse, front office
staff and physician champions
 Developmental screening introduced in
July of 2006 by utilizing PDSA cycles and
small tests of change

PDSA – Plan, do , study, act
Plan
Do
Act
Study
PDSA – Plan, do , study, act
P
D
A
S
P
D
A
S
P
D
A
S
P
D
A
S
Incremental Improvement
Developmental Screening
Implementation

Ages and Stages was chosen because of
its high sensitivity and specificity and its
relative ease of use in the practice setting

Parents receive the screener upon arriving
at the office and fill out in the waiting or
exam room. Nursing scores the screener
before the physician enters the room
Developmental Screening
Implementation
Started July 2006 with one physician and
expanded accordingly
 By November 2006 all 10, 18 and 30
month old infants were routinely screened
using Ages and Stages Questionnaires
 Developmental screens were performed at
other visits based on surveillance
according to the Developmental Screening
Algorithm

Impact on Referrals

To determine referral patterns, we looked
at the total number of referrals to early
intervention, sub-specialists or other
diagnostic evaluations in our practice

A retrospective chart review of all health
maintenance visits at 10, 12, 15, 18, 24,
and 30 months from March 2006 served
as baseline data
Impact on Referrals

Data was collected for D-PIP by keeping a
running tally of referrals

A chart review of all health maintenance
visits at 10, 12, 15, 18, 24 and 30 months
from March 2007 was also performed to
assure no referrals were missed

The tally from March 2007 was compared
with March 2006
Impact On Referrals
Identification and Referral Comparison
300
2
250
4
200
12
29
Referred
150
Observed
264
199
100
50
0
March 2006
March 2007
Seen Not Referred
Impressions

To determine the impressions of
participants in the developmental
screening process, a questionnaire was
distributed to physicians, nursing and
office Staff, and families at the conclusion
of D-PIP
Impressions
Overall Impression of Developmental Screening Tool
5
4
3
2
1
0
Physicians
Nursing Staff
5=Very Helpful, 1=Very UnHelpful
Families
Physicians’ Impressions

Overall, found screening tool helpful and
viewed parents’ impressions as favorable

Of those physicians who believed that their
referral patterns had changed, referring
sooner was given as area of change

Provided parental reassurance

Allowed more time to be spent on parents
questions and less time spent on
surveillance
Nurses’ Impressions

Generally had a favorable impression of
developmental screening, found it easy to
score, and viewed parent’s impression as
favorable
Nurses’ Impressions

Generally had a favorable impression of
developmental screening
 Easy
to score
 Viewed parent’s impression as favorable

Identified challenges, opportunities to improve
 May
reassure or make parent anxious.
 Parents may not understand questions or
intent of screening
 Not enough time to complete
 Difficult
to fill out and watch child/children
 Nurse needs to come back to room to score
Families’ Impressions

Overall, parents had a favorable impression
and found it to be helpful in understanding
their child’s development

Parents felt they had enough information
about their child’s development to adequately
complete the screener

Rated it as easy to complete

Expressed desire to experiment with
questions ahead of time
Conclusion
 Referrals
and patients identified for
potential referral to early intervention
increased with developmental
screening
 Physicians, nursing staff, and families
found Developmental Screening to be
helpful
D-PIP Results
Data Collection
Quantitative:
 Screening (test chosen, frequency of screening)
 Frequency of referral
Qualitative:
 3 representatives from each practice
 2 time points (mid-, post-implementation)
 Analysis
RESULTS:
RESULTS:
QUANTITATIVE
QUANTITATIVEDATA
DATA
General developmental screening instruments
(n=17 practices)
Instrument
Used for
Used for
surveillance* screening*
Ages and Stages Questionnaires (ASQ)
10
Parents’ Evaluation of Developmental
Status (PEDS)
2
6
Denver II
2
1
2
1
Pre-screening Developmental
Questionnaire (PDQ)
Bayley Infant Neurodevelopmental
Screener (BINS)
1
*includes use of multiple instruments by some practices
Rates of screening
100%
80%
60%
40%
20%
0%
July Aug Sept Oct
2006
Nov Dec Jan Feb Mar
2007
Rates of referral
(among children with failed screens)
100%
80%
60%
40%
20%
0%
July Aug Sept Oct
2006
Nov Dec
Jan Feb
2007
Mar
Medical
Non-medical
Referral Sites
Referral Site
Early Intervention
% Total
61
Audiology
Speech
PT or OT
13
9
4
Psychology
Developmental Pediatrics
Orthopedics
Ophthalmology/Vision
2
6
2
2
Neurology
0.4
(N=214 total referrals, all 9 months)
RESULTS:
QUALITATIVE INTERVIEWS
Theme:
Considerations in
choosing screening
instruments
Concerns about clinic flow
“[We chose the PEDS] because of the
simplicity of it…we’ve got a busy practice [and]
you’ve got to move fast or you’ll get trampled.”
“We’ve been real happy with the Ages and
Stages because it hasn’t slowed us down
significantly, it’s easy to score…once we
became familiar with it, then it’s made using
the tool very easy.”
Alignment with
community-based programs
“The biggest reason we went with [the
ASQ] is because it’s currently used by
[our state early intervention program] and
so we thought if we were using the same
tool we would have some consistency
with them.”
Support of teaching
“[The ASQ] gives [us] a little more
opportunity for teaching…both teaching
parents and teaching students about
appropriate developmental
expectations.”
Theme:
Need for practice-wide
implementation systems
Distributing responsibilities
among multiple staff
“Our front desk staff puts the screener in
the chart…and then the nurses [are] just
giving out the screener, going back and
checking and scoring it.”
Modifying implementation in
response to data
“I was looking at the [numbers] and the
forms weren’t getting back… [so] I was
asking front desk staff and they said, well,
we’re so busy checking insurance that we
just can’t always get those forms in here ….
taking it off of them and putting it [with
nursing] seemed to work better.”
Theme:
Frequent challenges in
implementation
Capturing children
at target visits
“…that was the hardest piece, absolutely
by far…was to remember [to screen] in
those isolated 3 visits.”
Keeping up screening
during busy times
“...toward the winter months when we
started getting a lot of sick kids coming
in and it got very crazy …sometimes
[we] would just forget.”
Coping with staff turnover
“When the staff changed the office was
obviously in chaos…so I had to put
[screening] on a back burner.”
Theme:
Deviations from
the AAP algorithm
Not implementing
a 30 month visit
“We’re not doing a two-and-a-half year
checkup because insurance companies
won’t reimburse for it.”
Not screening when
surveillance suggests delays
“If there’s something there [on
surveillance], we go right to a referral.”
Stratifying referrals (1)
“We try to refer directly to [early intervention]
if it’s multiple significant developmental
delays. If it’s just speech and language then
we will refer for a hearing screen and speech
and language therapy, but not to [early
intervention].”
Stratifying referrals (2)
“If it seems like it’s something that is
relatively minor, and it’s not going to entail
that much of evaluation, then we go with our
state [early intervention] program. If it seems
more serious, more concerning, we may start
doing some work up and tests on our own,
while we get them lined up to go in and see a
developmental pediatrician.”
Theme:
Lessons learned from
referral tracking efforts
Referrals cannot be tracked
without a system
“[We were] just putting the referral in the
chart, no follow up, no nothing….we just
didn’t know [what happened] because it was
only in the chart, and of course the chart
doesn’t speak for itself.”
Referral tracking requires
people and time
“Unfortunately, we lose track [of many
referrals].…We don’t have the …number of
people [we need] to make sure that these
families follow up.”
Many families don’t follow
through with referrals
“I did keep a list of who was referred…[but
when I] got around to following up … [I
found out that] a lot of people didn’t bother
with it, contacting early intervention.”
Families often don’t understand
why they’re being referred
“They [didn’t] understand who exactly was
calling them. So sometimes we have to reexplain the process, that [these are] the people
we talked to you about that are going to help
you and evaluate the baby….Usually once the
docs call again and re-explain, then they are
pretty good to go with it… but it sometimes
requires additional reassurance on our part.”
Tracking leads to better
communication
“I can tell you I get a lot more stuff back
from [early intervention] than I ever had
before….And I think it’s because we put
that referral piece in place.”
Tracking can show that more
children are being identified
“We know that [we’re identifying more
children] based on our referrals to early
intervention being increased by 60% with
no decline in eligibility.”
IMPLICATIONS
Implications for practices

To fully implement the AAP policy
statement, practices need two distinct
implementation systems
Screening
Referral

Implementation requires consistent and
ongoing monitoring
Implications for policymakers

Guidelines are not enough to ensure
widespread adoption of new guidelines
 Tools/toolkits
 Technical
assistance/mentoring
 Ongoing revision of guidelines to reflect
new knowledge (especially regarding
implementation)
Implications for researchers

Prior research has failed to link universal
developmental screening with improved
outcomes for children
 Do
failures in the referral process (partially)
account for this gap in evidence?
 How can gaps in referrals be minimized in
future research efforts?

AAP Policy Revision Committee









John Duby, MD
Michelle Macias, MD
Lynn Wegner, MD
Paula Duncan, MD
Joseph Hagan, Jr., MD
W. Carl Cooley, MD
Nancy Swigonski, MD
Paul Biondich, MD, MS
Acknowledgments

S. Darius Tandon, PhD
 17 Practice site personnel










Thomas Tonniges, MD
Stephanie Skipper, MPH
Jill Ackermann Healy, MS
Holly Griffin
Amy Brin, MA
Mary Crane, PhD, LSW
Amy Gibson, MS, RN
Darcy Steinberg, MPH
Ginny Chanda
PRC Liaisons and Consultant
Donald Lollar, EdD- Centers for
Disease Control and Prevention
 Bonnie Strickland, PhD- Maternal
Child Health Bureau
 Melissa Capers, MA, MFA

American Academy of Pediatrics

D-PIP Studies

Other

Ed Schor, MD-CommonwealthFund
Residency Programs
Charter Oak Health Center
Hartford, CT
 Children’s Hospital of
Pittsburgh Primary Care
Center
Pittsburgh, PA
 Marshall University
Pediatrics
Huntington, WV
 Wishard Primary Care
Center
Indianapolis, IN
 Ypsilanti Health Center
Ypsilanti, MI

Private Practices
Alexandria-Lake Ridge Pediatrics
Alexandria, VA
 Children’s Clinic
Muskogee, OK
 Children’s Clinic La Jolla
La Jolla, CA
 New Ulm Medical Center
New Ulm, MN
 North Arlington Pediatrics
Arlington Heights, IL
 Ohio Pediatrics, Inc.
Huber Heights, OH
 South Valley Pediatrics
Hamilton, MT

Community Health Centers
Boys Town Pediatrics
Omaha, NE
 The Children’s Clinic, Serving
Children and Their Families
Long Beach, CA
 Hospital of Saint Raphael
Pediatric Primary Care Center
New Haven, CT
 Kids’ Clinic
Lawrenceville, GA
 Midland Community
Healthcare Services
Midland, TX

Questions?