How To Make Developmental Services Easy to Use

Judith S. Palfrey MDAlison Schonwald MD

Children’s Hospital BostonOpening Doors Initiatives

National Center on the Ease of Use of Community Based Services

Communitybasedservices.org

An Opening Doors Initiative (OpeningDoorsforYouth.org): Funded by the Maternal and Child Health Bureau (MCHB), Health Resources and Services Administration (HRSA) and the National Institute on Disability Rehabilitation and Research (NIDRR), U.S. Department of Education

Mission: The Center will advance policy and practice solutions that improve the ease of use of community based services for families with a child with special health care needs

Why Do We Care About Why Do We Care About Developmental Screening? Developmental Screening?

Earlier the BetterEarlier the Better

New Science About Brain DevelopmentNew Science About Brain Development

Inequities in Recognition and Early Inequities in Recognition and Early InterventionIntervention

At a Systems Level, Need Correction At a Systems Level, Need Correction – To Improve Care for Individual ChildrenTo Improve Care for Individual Children– To Address Public Health and InequitiesTo Address Public Health and Inequities– To Save Our Nation $$$$$$$$$$$$$$$To Save Our Nation $$$$$$$$$$$$$$$

Why Do We Care About Why Do We Care About Developmental Screening? Developmental Screening?

Earlier the BetterEarlier the Better

New Science About Brain DevelopmentNew Science About Brain Development

Inequities in Recognition and Early Inequities in Recognition and Early InterventionIntervention

THE TRIPLE AIM THE TRIPLE AIM

Standardized developmental screening tests at 9-, 18-, and 30-month visits

Autism-specific screen at 18 & 24 months

Pediatrics, Vol 118, July 2006, 405-420

Pediatrics, Vol 120, Nov 2007, 1183-1215

American Academy of Pediatrics Policy

The percentage of pediatricians who The percentage of pediatricians who report using standardized screening tools:report using standardized screening tools:

23% in 2002 23% in 2002

Higher in 2009* Higher in 2009*

*From the AAP Periodic Survey, 2009 is unpublished

Actual Practice

Baseline 2&3yo WCC Chart Review

n=331

Implementation

Follow-up 2&3yo WCC Chart Review

n=228

Follow-up Provider Survey

Baseline Provider Survey

DecemberSeptember January MayApril August2006

Broad Developmental Screening:Effectiveness and Feasibility in CHPCC

1861 PEDS Screeners Jan-Aug 06

80%4%

8%

8% Already inservices- no newconcern

New concern perPEDS

New Concern noton PEDS

No concern orservices

Changes in Identification of Behavior Concerns

8.97.1

10.614.2

0

10

20

30

40

2 yr olds 3 yr olds

% of 2 and 3 yo's

identified with

concerns

PrePEDS

PostPEDS

p=.023 p=.302

Changes in Identification of Developmental Concerns

11.2

30.2

34.6

19.2

0

10

20

30

40

50

2 yr olds 3 yr olds

% of children

identified with

concerns

PrePEDS

PostPEDS

p=.208 p=.023

Schonwald A, Huntington N, Chan E, Risko W, Bridgemohan C. Routine developmental screening implemented in urban primary care settings: more evidence of feasibility and effectiveness. Pediatrics.

2009:123(2):660-8.

Provider confidence

“I am confident in my ability to screen for developmental and behavioral concerns.”

strongly 1 2 3 4 5 strongly

disagree agree

pre 3.62

post 4.13

p=.04

Perception of TimePerception of Time

174

0

20

40

60

80

100

% of staff who

agree

Takes Too MuchTime!

PrePEDS

PostPEDS

15.67

14.86

17.75

17.84

0 5 10 15 20

Visit Time in Minutes

Pre-PEDSWave 1Wave 2Wave 3

p= ns

Schonwald A, Horan K, Huntington N. Developmental Screening: Is There Enough Time? Clinical Pediatrics. 2009:48(6):648-55.

Mean Visit Time Pre- and Post-Screening

More parents Post-PEDS reported–Speaking to the provider about concerns they

had about their child (74.2% v. 90.2%, p=.05)–Received answers to their concerns

(89.7% v. 100%, p=.04)–Being asked about their child’s behavior

(83.9% v. 100%, p=.006)

Time

What happened to referred children?

71/136 (52%) of referred children were evaluated

Boys were twice as likely as girls to be evaluated

(χ2,1=8.32;p<0.004)

Children whose parents had more than one concern were more likely to be evaluated than those whose parent had only one concern

(χ2,1=3.29;p=0.07)

Evaluation Completion

Pediatric Academic Societies, Platform Presentation, Hawaii 2008.

New triage and scheduling system

Identified and screened evaluation requests for children with high risk & need

1. Under 24 months old

2. Request evaluation for ASD Failed MCHAT, parent, EIP, PCP concern

Concern on triage phone call

3. Not already diagnosed, not in services

Autism Fast Track

64 PatientsWait time= 61 days

45 (70%) diagnosed with ASDAvg age 22.0 mos

78% male

19 (30%) not diagnosed with ASDAvg age 21.6 mos

68% male

Autism Fast Track: First 2 Years

If parent reported the PCP was concerned with autism, the child was twice as likely

to be diagnosed with an ASD

Risk at Triage

Pediatric Academic Societies, Platform Presentation, Vancouver 2010

Additive value of autism-specific screen

Do we have to do both a broad Do we have to do both a broad developmental screener and an autism-developmental screener and an autism-specific screener at every 18 and 24 specific screener at every 18 and 24 month well child visit?month well child visit?

Yes, each picks up concerns the other misses

2006

262 visitsPEDS

2009

198 visitsPEDS + M-CHAT

Percentage of completed PEDS target patients over time

Pediatric Academic Societies, Poster Presentation, Vancouver 2010

90.4

38.2

0102030405060708090

100

2006 2009

Next StepsNext Steps

Autism Medical Home

Accessible

Continuous

Coordinated

Comprehensive

Patient centered

Managed centrally by a primary care physician

Active involvement of non-physician practice staff

Dissemination of FindingsSchonwald A, Huntington N, Chan E, Risko W, Bridgemohan C. Routine developmental screening implemented in urban primary care settings: more evidence of feasibility and effectiveness. Pediatrics. 2009:123(2):660-8.Schonwald A, Horan K, Huntington N. Developmental Screening: Is There Enough Time? Clinical Pediatrics. 2009:48(6):648-55.Schonwald A, Huntington N, Witt K, Silver T, Cox J.. Evaluation Rates Of Children Identified By Routine Developmental Screening. Pediatric Academic Societies, Honolulu, HI. 2008. Cox J, Huntington N, Epee-Bounya A, Saada A, Schonwald A. Analysis of Written Parental Comments on the Parents' Evaluation of Developmental Status (PEDS) Screen. Pediatric Academic Societies, Baltimore, MD. 2009 Pappas D, Huntington N, Cox J, Schonwald A. Does adding the M-CHAT to broad-based screening improve early detection of Autism? Pediatric Academic Societies, Vancouver, Canada 2010

Behavioral Health Screener

Every well child visit 0 → 21

Must use one of 8 specific toolshttp://massscreen.ehs.state.ma.us/screeningtools.pdf

Four Screening Tool Consultants

MA Medicaid Regulation:

Required Behavioral Health Screener

www.autismscreening.org