Communities Coordinating for Healthy

DevelopmentTraining for Clinics

Coordinating Communities for Healthy Development

The goal of the CCHD project is to create and institutionalize a feedback communication loop between clinical providers and early intervention and preschool special education providers to benefit children with developmental delays or socio/emotional or behavioral health concerns.

Training Topics

• Before you begin• Goals & Tools• How to start • Model for implementing change• Guiding the team through the process• Completing and Spreading the Work• Modifications

Before you Begin

Clinics participating in a CCHD project will need to be:

•Using an Electronic Medical Record system

•Regularly screening children for developmental delays or socio/emotional or behavioral concerns

Goals & ToolsGoal Tool

Build Relationships with Early Intervention or Preschool Special Education Providers in your area (part of the school district)

Team

Implement a Work Flow for Communication between Clinic and District Providers

Sample Work FlowTeam members

Simplify Communication Process While Following Consent Rules

Sample Referral Response FormsTeam Members

Track Referrals and Communication to Monitor Progress

Electronic Medical Records DatabaseTeam Members

Helpful Terminology

Early Intervention/Preschool Special EducationFor the purposes of this Toolkit, we will be using the term “early intervention/preschool special education” to refer to these programs that together serve children from birth – five years old. This includes:•Infant/toddler early intervention services for children birth to three, under Part C, and•Preschool Special Education services for children three to kindergarten, under Part B619.Part C and Part B619 are parts of the federal Individuals with Disabilities Education Act (IDEA), the legislation that mandates these programs.

Clinic StaffThe term “clinic staff” refers to doctors, nurses, care coordinators, administrators, and others who work at the child’s primary care facility (most likely a clinic).

Help Me GrowMinnesota’s name for the early Intervention system that includes child find, public awareness, outreach, and service delivery.

How to Start

1.Identify team members to recruit

2.Reach out through established

relationships

3.Share materials

4.Begin meeting

Helpful Terminology Cont.Evaluation -- Under Part C (0-3 years)•Procedures used by qualified personnel to determine a child’s initial and continuing eligibility under this part consistent with the definition of infant or toddler with a disability.•Initial evaluation refers to the child’s evaluation to determine his or her initial eligibility under this part.

Assessment-- Under Part C (0-3 years)•Ongoing procedures used by qualified personnel to identify the child’s unique strengths and needs and the early intervention services appropriate to meet those needs throughout the period of the child’s eligibility and includes the assessment of the child…and the family-directed assessment of the child’s family.•Initial assessment refers to the assessment of the child and the family-directed assessment conducted prior to the first IFSP meeting.

Evaluation and Assessment-- Under Part B619The definition for evaluation is very similar to the definition under Part C, however, assessment in Part B619 refers to an ongoing process as opposed to a specific part of the evaluation process.

Service PlanPlan created by early intervention/preschool special education team to provide appropriate services to student. The Individualized Family Service Plan (IFSP) is used for children 0-3 and the Individualized Education Program (IEP) is for children over 3.

Identifying Team Members• Early Intervention or Preschool Special Education

Providers – Most likely in local school district– Where do your patients go to school?

• Local public health or agencies doing childhood screening

• Parents• Other agencies involved in referral process

– Who are you currently sending referrals to?• Other providers of early childhood services such as Head

Start, ECFE• Clinicians providing medical services to your patients –

OT, PT, Mental Health

After you’ve identified potential team members…

1. Contact them, talk about the goals of the project, see if they’re

interested in meeting to discuss it or have ideas of other

people who should be included.

2. Be open to varying length of commitment – this project may

lead to long term connections, but at the same time some

team members may only be able to be involved as long as it

takes to implement the feedback cycle.

3. Share materials and resources.

4. Invite them to a launch meeting.

Suggestions for Launch Meeting

• Introductions and roles in current referral and service system in the community

• Discussion of goals for CCHD team and CCHD process

• Review of materials to learn (other trainings or toolkit)

• Set up next steps (start meeting regularly, using change model, etc.)

Model for Improvement

The team can work together to create a system for implementing the CCHD changes, or you can use the Model For Improvement. The model leads the team through testing out small changes toward big goals, in a Plan-Do-Study-Act process.More information on the Model is found in the CCHD toolkit.

Guiding the Team through the Process• Meet regularly• Identify a way to know when your team has

completed the project• At the beginning, learn how the current system

works, to identify where to approach changes• Work through modifying the tools to be useful to all

the team members• Ask the early intervention/ preschool special

education providers to start sending responses• Track the responses through clinic EMR• Report back to team on progress• Address issues and barriers• Add team members when needed or available

Creating a Workflow as a Team

Creating a work flow diagram may help your CCHD team examine all the aspects of the referral feedback loop and be able to identify areas where changes are needed. Here are examples of a few work flows that CCHD teams created in the past.

Sample Internal Referral FeedbackWorkflow for Screening at Clinic

Nurse or other clinic staff score the questionnaire and give results to the child’s practitioner

Family arrives for visit and either gives check in staff the completed questionnaire or completes one in the lobby

Prior to office visit, clinic administrative staff send screening questionnaire to family

Practitioner determines if a referral is needed, notifies the family and asks clinic staff to make the referral

Referral is made to Help Me Grow (state referral system)

Help Me Grow funnels referral to appropriate school district for early intervention or preschool special education evaluation

Family consent to report back to clinic is obtained

Early intervention or preschool special education program staff send referral report form back to clinic via fax

Administrative staff receive report by fax, give to practitioner

Practitioner reviews report, highlights any issues, and gives it to care coordinator

Support staff files in medical record

Care coordinator reviews report to identify any follow up needs to act on and gives it to support staff

Clinics will vary in which staff will perform which of these functions. As part of the CCHD project, it will be important to identify these staff and engage them in the improvement process.

Early Intervention/ Preschool Special Education Referral Report Workflow

Clinic sends referral directly to early

intervention office at school district

Clinic sends referral to the Help Me Grow

state online system

HMG determines appropriate district,

sends them the referral

District receives referral, assigns to staff for evaluation

Evaluators contact

family and set up

meeting

Family refuses evaluation or is

unable to be contacted, referral is

closed

Student is determined to be

eligible for services

Student comes in for evaluation, consent to

send results back to clinic is requested.

Family accepts, service plan is

created, student

begins to receive services

Family refuses services, referral is

closed

Student is determined to be ineligible for services, is

given alternative resources, possibly signed up for Follow Along Program

Child visits clinic, completes a

screening tool with a score that triggers a referral

District sends this information back to

the clinic

District WorkflowReferral Report Opportunity

Clinic/Community Workflow for Early Intervention and Preschool Special Education Referrals

Follow Along Program•Tracks children with potential concerns•Sends both a monthly list of enrollees and abnormal screening reports to clinic

Developmental Screening Coordinator (DSC) (part of clinic staff)•Enters reports and consent forms into medical records•Sends electronic update messages to providers•Responds to information requests from community partners (when consent is provided)

Clinic: Primary Care Provider•Reviews reports received from DSC•Conducts screenings with patients•Sends recommendations to DSC to follow up or call family

Early Childhood Screening•Screens children for concerns•Screening forms are sent to the clinic, along with consent forms

School District Early Intervention or Preschool Special Education Staff•Receives referrals from DSC and conducts evaluations with children•When an evaluation is completed, and the child is a clinic patient who has consented to share information, sends a report back to the DSC

Completing and Spreading the Work

• Complete when you’ve met your team goals.

• Celebrate!• Tell others about your

work, to encourage spreading the CCHD project to other communities, clinics, and families.

Modifications• Health Care Homes/ Medical Home Model:

completing the CCHD project can help your clinic prepare for HCH certification in MN. Contact information for HCH is found on the CCHD website.

• MOC 4 Project: The first round of CCHD projects applied for and received MOC 4 certification from the Academy of Physicians. Data run charts used in that process are available in the toolkit.

Technical Assistance Available

The CCHD website has sample referral communication forms, examples of work flow diagrams, and links to many resources to support the project.

You can also email CCHD.Info@state.mn.us .

www.dhs.state.mn.us/cchd

Resources• Developmental Screening Overview:

http://www.health.state.mn.us/divs/fh/mch/devscrn/• Developmental Screening Tools:

http://www.health.state.mn.us/divs/fh/mch/devscrn/instruments.html• Online Developmental Screening Training Module:http://www.health.state.mn.us/divs/fh/mch/webcourse/devscrn/index.cfm• Institute for Healthcare Improvement’s Model for Improvement:

http://www.ihi.org/knowledge/Pages/HowtoImprove/default.aspx• Information for Parents and overview of MN’s online referral system:• www.mnparentsknow.org . Follow the button in the top right hand corner to Help

Me Grown, the online referral page.• Online trainings for practitioners, with CME Credits: www.edopc.net, go to training

page and look for “Coordinating Care Between Early Intervention and the Primary Care Practices”

• Helpful Toolboxes for Clinicians www.nashp.org

Communities Coordinating for Healthy Development

Funded by a grant from The Commonwealth Fund and supported by the National Academy for State Health Policy

Created in cooperation with the Minnesota Department of Education and the Minnesota Department of Health.

www.dhs.state.mn.us/cchd