Setting the Stage for Success

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Setting the Stage for Success
Marian Earls, MD, FAAPGuilford Child Health,
Inc., Greensboro, North CarolinaJune 6, 2007
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I have no relevant financial relationships with
the manufacturers of any commercial products
and/or provider of commercial services discussed
in this CME activity.
I do not intend to discuss an unapproved/investiga
tive use of a commercial product/device in my
presentation.
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Integrating Screening Surveillance in Primary
Care Practice
Marian Earls, MD, FAAP June 6,2007
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What We Know

• Impact of experience on brain development.
• Growth, development, and behavior are
  inextricably linked.
• Emotional development occurs in the context of a
  relationship (bonding, attachment, reading cues).

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Prevalence and Risk

• About 16 of children have disabilities including
  speech
• and language delays, mental retardation, learning
• disabilities and emotional/behavioral problems.
• ____________
• (Only 30 are detected prior to school entrance.)
• ____________________

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Prevalence and Risk

• 13 of preschool children have mental health
  problems.
• This rate increases with the co-occurrence of
  other risk factors

• Poverty
• Maternal depression
• Substance abuse
• Domestic Violence
• Foster care

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Are we looking?

• Poor rates of screening in PCPs office for
• Development and behavior
• Maternal depression
• Family risk factors

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Under-detection Eliminates the Possibility of
Early Intervention... _____________________

• No point in waiting to screen until
• the problem is observable.
• Dont ignore screening results
• there is no value to wait and see.
• Informal checklists have no
• validated criteria for referral.

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Limited use of screening at well visits because
_________________________________

• Takes too long
• Difficult to administer
• Children may not cooperate
• Reimbursement is limited

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So. What Should We Do?

• Use new, brief, accurate tools
• Use parents
• Use Family Centered principles

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Using Effective Screens

Accuracy, meaning specificity (at least 70 of
normal children correctly detected) and
sensitivity (at least 70 of children with
disabilities correctly detected)
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Does Screening Mean Becoming an Expert in
Evaluating a Childs Development? NO

• Screening is looking at the whole population
  to identify those at risk. Identified children
  are referred for assessment. Assessment
  determines the existence of delay or disability
  which generates a decision regarding
  intervention.
• Screening is optimized by
  Surveillanceperiodic screening gives a
  longitutidinal perspective of a childs
  developmental progress.

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Excluded Tests

• PDQ
• Denver-II
• Early Screening Profile
• DIAL-III
• Early Screening Inventory
• ELM
• Gesell

Due to absence of validation, poor validation,
norming on referred samples, and/or poor
sensitivity/specificity
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Strengths of Tools Using Parent Report
Give parents and providers information on
childrens actual skillsHelp parents learn
important developmental milestonesIllustrate
strengths and weakness in developmentFree
professional time for more important things like
helping familiesGive providers confidence in
decision-making
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Strengths of Tools Relying on Parents Concerns
Help focus encounters on issues of importance to
familiesCreate a teachable momentEnhance
parents sense of a true collaboration with
professionalsIncrease positive parenting
practicesMake it easier to give difficult
newsReduce oh by the way concernsIncrease
attendance at well-visitsand perhaps
parent-teacher conferences
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Family Psychosocial Screens

• Variety of tools ranging from very brief to
  multi-item.
• Most screen for maternal depression, domestic
  violence, substance abuse individual area or
  several.
• Considered best practice, but limited validation
  data, etc.
• Examples are KemperKelleher, Edinburgh

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Oh, by the way..
Reduces doorknob concerns Shortens visit
length/focuses visit Facilitates patient
flow Improves parent satisfaction and positive
parenting practices Increases provider
confidence in decision- making
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The Office Process

• Assess Current Protocols
• Identify Physician Champion
• Select a Screening Tool
• Map the Workflow
• Identify System Supports
• Networking is key
• Conduct Staff Orientations

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Creativity a Key

• Use growth tool for developmental surveillance
• Some tools can be photocopied so laminate a set
  for each exam room
• Use lab labels on the screening tool to eliminate
  handwriting of demographic information
• Measure performance and offer feedback to staff.

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Creativity a Key

• Use posters in your waiting room to explain the
  developmental screening process to families
• Use a combination of tools for different ages.
  (e.g.. 0-24 months use ASQ older children use
  PEDS)
• Obtain free stuff, e.g. ABCD anticipatory
  guidance brochures, for families to promote
  healthy development

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The Creativity continues

• Invite your community partners, (EI Specialists,
  etc.) to your office for a social or open house
  (Talk about your respective goals and align goals
  wherever possible.)
• Immerse yourself into community/state meetings
  where policy issues affecting families are
  discussed
• Sponsor family events with your community
  partners, e.g. health dept.- health fairs

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Partner with Parents to Do Screening
Surveillance

• Primary Care Medical Home
• Head Start
• Child Care
• Preschools

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Assuring Better ChildHealth Development
ABCDthe North Carolina Experience
DEVELOPMENTAL BEHAVIORAL SCREENINGA Quality
Improvement Initiative in Primary Care Practice



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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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Practice/Parent Surveys Summary

• Instrument Questionnaires were disseminated to
  Guilford Child Health staff (three sites) in 2001
  and Moses Cone Family staff in 2002. Questions
  were designed to yield qualitative information. A
  27 and 26 response rate was achieved
  respectively.

• Conclusions Staff.
• agree the ASQ is an effective assessment
  tool and would
• recommend it to other providers
• generally use the ASQ as a guide for
  discussing
• developmental issues with parents
• agree it somewhat impacts office workflow
  so attention
• needs to be given to where and when parents
  complete the
• questionnaire
• parents appreciate the additional time staff
  spend assessing
• their childs development

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Policy Change

• Public Health system (Child Health) transitioned
• clinics to a menu of standardized, valid,
• developmental screening tools in 2003

• Medicaid changed EPSDT policy (Health Check),
• effective 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.

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Lessons Learned

• Keep it tops on the provider, family,
• and state agenda
• Build on existing infrastructures and align goals
  with partners who invest in quality improvement
• Optimize funding by sharing activities with
  partners
• Evaluate and report data
• Develop and change policy

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Screening Surveillance Resources
www.dbpeds.org www.nashp.org www.cmwf.org ASQ
www.brookespublishing.com PEDS www.pedstest.com
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Anticipatory Guidance Resources

• NC ABCD disk
• Bright Futures www.brightfutures.aap.org
• AAP www.aap.org
• CDC www.cdc.gov/actearly
• Zero to Three www.zerotothree.org
• Parents as Teachers www.ncpat.org
• Family Voices www.familyvoices.org
• Kids Growth www.kidsgrowth.com