Why Screen with Validated, Accurate Tools: Is this Truly Workable in Busy Clinics? Frances Page Glascoe Professor of Pediatrics Vanderbilt University

1
Why Screenwith Validated, Accurate Tools Is
this Truly Workable in Busy Clinics?Frances
Page GlascoeProfessor of PediatricsVanderbilt
University
2
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 gt100,000 benefit to society (1992 s) For
every 1 spent on EI, society saves 17
3
Only about 30 of children with substantial
delays and disabilities are detected by their
health care providerMost 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/Referral Problems!!
4
16 - 18 of children have developmental-behaviora
l difficulties and need special servicesRecent
research (Pediatrics, July 2008) suggests 13 by
age 2!Only 2 - 3 are enrolled in early
interventionOnly 12 enrolled in special
educationEnrollment rates in EI should be
closer to 8 in the 0 - 4 age range (CDC,
www.cdc.gov)
Early Detection Problems!!
5
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

6
American Academy of Pediatrics Policy,
Pediatrics, July 2006

• Screening and Surveillance

7

• 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

8
Holy Smokes!
9
Pie in the Sky?
10
Wont this sink the ship?
11

• What? Even more stuff to do at busy
• well-
• visits?

12
Challenges in the 2006 Statement

• Arent some of those measures too long for
  primary care?
• Arent we already doing surveillance?
• Ive got good milestones and questions to
  parents, arent those good enough?
• NO!!

13
Why dont informal approaches work

• 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?

14
Quality measures select items that best predict
actual developmental status and have clear
criteria for judging success
X O C A Z B T K D M
15
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?
16
Why dont informal approaches work

• Are you screening the asymptomatic?

17
(No Transcript)
18
(No Transcript)
19
Why dont informal approaches work

• Are you screening repeatedlyat all well-visits?

Development develops! Developmental problems do
too!
20
(No Transcript)
21
Developmental Status by parent's verbal behavior
and positive perceptions (Glascoe Leew,
Pediatrics, 2010)
Quotients
6 - 11

• Age in Months
• Talks at meals, helps child learn new things,
  reads aloud, able to soothe, enjoys child,
  perceives child as interested in conversing

22
Why dont informal approaches work

• Are you identifying enough kids?

23
Whats 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
24
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

25
Why dont informal approaches work

• Are you asking parents quality questions?

26
Your teacher wishes me to delineate those
watershed occasions in your life that have led
you to become,slowly and inexorably,a loose
cannon.
27
Sample questions to parents that dont work well

• Do you think he has any problems..?
• Do you have any worries about her development?

28
(No Transcript)
29
Consumer-Driven Health Care? It Doesnt Work Well
for All If you dont ask and ask well. they
dont always tell!

• 34 of parents dont raise developmental-behaviora
  l 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

30
But wait a minute!
So many of my kids dont qualify. Many
parents dont follow through. Theres nothing
out there to refer to.
31
Some kids dont 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 cant, theyll be back OR head to
referral resources. BUT, if you can, make
appointments for familiesthat increases the
likelihood of getting there!
32

• Saves providers time
• Restrains visit length to predicted levels
• Offers greater reimbursement
• Improves detection rates
• Increases parent and provider satisfaction and
  visit attendance
• Focuses developmental promotion

Oh, by the way..
Using quality tools with good questions to
parents
33
So we can save time, increase s, and do best
by families. if we conduct screening and
surveillance with evidence and refer promptly!!
34
(No Transcript)
35
What Tools Should We Use?

• PEDS (10 questions eliciting concerns) at every
  well-visit)
• PEDSDevelopmental Milestones (6 8 questions
  about milestones) at every well visit
• The M-CHAT at 18 24 months (built into PEDSDM)
• A clinic intake form that looks at parental
  depression (2 questions)

36
In an electronic environment

• Consider PEDS Online
• www.pedstest.com/online for a trial
• Site offers PEDS, PEDSDM and the M-CHAT
• Website offers downloadable clinic intake form
  (for depression screening, indicators of
  psychosocial risk, etc.)
• Website also has case examples, videos,
  self-training information, etc.

37
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 AAPs coding
  hotline