Early Childhood Comprehensive Systems Partners Meeting

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Early Childhood Comprehensive Systems Partners
Meeting

• Friday, March 14, 2008
• 950 1100 am Workshop
• Implementing Developmental and Mental Health
  Screening
• Lessons from the ABCD Projects

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Opportunities to Link Practice and Policy Change
Lessons from the ABCD Collaborative

• Jennifer May
• Policy Specialist
• National Academy for State Health Policy
• Assuring Better Child Health and Development
  (ABCD) Initiative
• Funded by The Commonwealth Fund

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About the Collaboratives

• 3-year learning collaboratives of states working
  to enhance developmental services to young
  children enrolled in Medicaid
• Change in state policy and provider practice
• Change in participating and non-participating
  states

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Collaborative Members

• ABCD I General Development
• NC, UT, VT, WA
• 2000-2003
• ABCD II Social and Emotional Development
• CA, IA, IL, MN, UT
• 2004-2007
• Multi-agency teams from each state, led by
  Medicaid

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In the Collaboratives

• Each state
• Implemented individual projects
• Shared information and lessons learned from their
  individual efforts
• NASHP
• Provided technical assistance
• Studied each states progress
• Synthesized and disseminated states experience

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Building on ABCD I and II

• ABCD Screening Academy Supporting the adoption
  of standardized screening tools, i.e. general
  developmental, social-emotional and maternal
  depression
• ABCD Alumni engaged as faculty and topic experts
• American Academy of Pediatrics 2006 policy
  statement on surveillance, resulted in active
  partnership for technical assistance events
• 23 states
• 2007-2008

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ABCD Screening Academy States
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Common State Goals for Screening Academy states

• Increase appropriate, effective screening by
  pediatricians
• Ensure providers and families have information
  they need to identify, treat, and refer
• Ensure that referrals are effective

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What did the States do during ABCD Collaborative?
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By Objective

• Accomplishments and lessons in policy and
  practice improvement

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Foster Improved Screening

• Helped primary care providers integrate the tools
  into their practices
• Learning collaboratives
• Partnering with provider organizations that
  support practices, i.e. Illinois and Iowa local
  AAP chapters instrumental partners
• Identify mentors to help practices integrate
  screening
• Ongoing opportunities for practices to share
  experience and lessons
• Measurement supports continued improvement

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Foster Improved Screening

• Promoted pediatric provider use of screening
  tools
• Work with physicians to identify tools and
  promote their use (Utah Pediatric Partnership to
  Improve Quality)
• Modify Medicaid provider handbooks and websites
  used by provider practices
• Change payment policies

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Identified and Facilitated Referral to Follow-up
Services

• Identified existing resources
• Facilitated referrals
• Utah learning collaboratives feature development
  of referral pathways
• Illinois Iowa identify resources to manage
  referrals
• Identify and fill in the gaps
• Minnesota
• New diagnostic system that better met needs of
  young children
• Medicaid benefit targeted to children with
  emotional disturbance.

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Leveraged Resources to Promote Change

• Formed partnerships
• Illinois local chapters of physician
  organizations sent out letter supporting policy
  change
• North Carolina Public health system (clinics)
  adopted menu of standardized screening tools for
  all young children
• Used quality improvement
• Utah EQRO implemented performance improvement
  project on coordination between mental health
  systems and HMOs
• North Carolina Built on PCCM delivery system in
  Medicaid

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Identified and Addressed Policy Barriers

• Identified policy barriers during planning,
  implementation, and operation of pilots
• California, Illinois, and Iowa projects developed
  formal mechanisms for identifying and considering
  changes
• Minnesota feeds project results into a group
  outside the project
• Policy changes in Medicaid and other agencies
• Illinois early intervention clarified eligibility
  policies
• Iowa and Utah provided dedicated resources to
  expand/build

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Lessons Learned

• Screening with a standardized tool is a critical
  first step, but does little good without
  follow-up services
• States can facilitate access to follow-up
  services
• Demonstrations can inspire and test policy change
• Partnering with pediatric clinicians is critical
• Measurement is difficult but doable (and
  worthwhile)

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For more information

• Visit!www.nashp.org
• www.abcdresources.org
• Join the ABCD discussion forum!
• (register at http//abcdresources.org/ScreeningAca
  demylogin.php )

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Developmental and Mental Health Screening

• Glenace Edwall
• Minnesota Department of Human Services
• Childrens Mental Health Division
• Maternal and Child Health Assurance Unit

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Screening Developmental and Socio-Emotional

• Developmental Screening Tools
• Generally discriminate those children with
  developmental delays and those who appear to be
  developing typically
• May include numerous domains expected to be
  affected by developmental delay
• Identify children in need of further assessment

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Screening Developmental and Socio-emotional

• Socioemotional Screening Tools
• Intended to identify children whose
  socioemotional development is delayed and/or
  whose mental health development is at risk
• May include specific aspects of social and
  emotional functioning, appropriately
  developmentally scaled
• Identify children in need of further assessment

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Screening for Socioemotional Development

• Screening is a relatively brief process designed
  to identify children who are at increased risk of
  having disorders that warrant immediate
  attention, intervention, or comprehensive review

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Screening, Continued

• Identifying the need for further assessment is
  the primary purpose for screening
• Screening instruments are never used to diagnose
  or label a child
• Screening informs parents and those working with
  families about aspects of development needing
  further assessment

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Socioemotional Screening Current Practice

• Survey by Betsy Murray, M.D. (2006)
• Responses from 590 primary care providers (38
  return rate)
• 80 endorsed as best practice the use of at
  least one standardized screening tool, with some
  frequency, with at least one age group during
  well or ill visits
• Approximately one-third described selves as
  familiar with at least one standardized tool

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Socioemotional Screening Current Practice

• Self-reported of visits routinely screened, by
  technique (descending order)
• Interview parent (gt90)
• Clinical observation
• Interview child
• Review of systems
• Denver-II
• Practice-developed instrument (c. 30)

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Socioemotional Screening Current Practice

• Identified barriers to screening
• Time (93)
• Training in screening tools (88)
• Availability of mental health providers (79)
• Lack of adequate personnel (77)
• Lack of comfort with managing identified children
  (71)
• Lack of appropriate reimbursement (66)

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Screening Addressing the Barriers

• Choosing Tools
• Cost/Reimbursement
• Office Work Flow/Time

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Addressing Barriers Tools

• Criteria
• Consensus
• Practice issues

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Screening Instrument Criteria

• 15 minute or less administration
• Good psychometric properties
• Minimal cost
• Targeted
• Easy scoring

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Screening Criteria, continued

• Cultural/linguistic data
• Covers age span
• Minimal expertise to administer
• Ease of administration

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MN Recommended Developmental Screening Tools
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MN Recommended Developmental Screening Tools At
a Glance
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Minnesota Developmental Screening Task Force

• Membership MN Departments of Health, Human
  Services, and Education and University of MN,
  Irving B. Harris Center for Infant and Toddler
  Development
• Recommended developmental and mental health
  screening tools reviewed and approved by all
  agencies according to agreed upon criteria
• http//www.health.state.mn.us/divs/fh/mch/devscrn/

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Early Childhood Socioemotional Screening Synergy

• Consensus among DHS Child Welfare Screening and
  ABCD II grant, MDH Follow Along Program, and
  Minnesota Head Start Association in endorsing
  Ages and Stages Questionnaire Socioemotional
  (ASQ-SE)
• Squires, J., Bricker, D. and Twombly, E. Brookes
  Publishing Company

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ASQ-SE, continued

• Age-specific questionnaires completed by
  caregivers, scored automatically or by
  paraprofessional
• Forms for 6, 12, 18, 24, 30, 36, 48, 60 months
  each form covers /- 3-6 months of target age
• 7 areas self-regulation, compliance,
  communication, adaptive functioning, autonomy,
  affect, and interaction with people

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ASQ-SE, continued

• Properties
• Norms 3,014 preschool children, representing
  2000 census for family income, education and
  ethnicity
• Reliability test-retest .94
• Validity average sensitivity .78 average
  specificity .95
• Low cost proprietary instrument 125/kit, with
  unlimited reproduction of forms
• www.pbrooks.com or 800.638.3775

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Addressing Barriers Cost/Reimbursement

• Screening Codes
• Incentives

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Developmental and Mental Health Screening Code --
96110

• DHS pays for the 96110 code when an objective
  developmental or mental health screening occurs
• Both may be performed and billed on the same day
• Bill 96110 for developmental screening, 96110
  w/UC modifier for mental health screening

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Developmental and Mental Health Screening Code --
96110

• Other payers in MN also cover objective
  developmental mental health screening
• Managed care contracts for 2008 include
• 20 incentive for each developmental screening in
  encounter data (96110 code) above the percentage
  last year
• 25 incentive for each mental health screening in
  encounter data (96110 code w/UC modifier)

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Addressing Barriers Office Work Flow/Time

• Minnesota Pilots
• Co-located mental health professionals
• Use of technology
• Tablets Patient Tools
• CentraCare work with CHADDIS
• Integration with EMR

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Addressing Barriers Referrals

• Multiple models
• Co-located mental health professional or care
  coordinator
• Central point of access in community
• Establishing relationships with community
  providers

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Contact Information

• Glenace Edwall, Director
• Childrens Mental Health Division
• 651.431.2326
• glenace.edwall_at_state.mn.us
• Susan Castellano, Manager
• Maternal Child Health Assurance
• 651.431.2612
• susan.castellano_at_state.mn.us

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Implementing Screening Pediatric Settings

• Penny Knapp MD
• Medical Director
• California Department of Mental Health
• ECCS Partners Meeting
• 3/13/08

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Topics for today

• - Practitioner resistance to identifying concerns
• What to do when concerns are identified the
  continuum from reassurance to referral
• What can specialty mental health offer?

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Practitioner resistance to identifying concerns 1

• Confidence
• I really know my patients, (v.s. shorter
  visits, push to productivity)
• Tradition of developmental surveillance (misses
  60-70 of developmental problems)
• Capitation forced choices for limited time and
  fixed resources (HEDIS measures asthma,
  immunizations, follow-up for hospitalization for
  mental disorders)

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Practitioner resistance to identifying concerns 2

• Reluctance to label
• Uncertainty about definition of problem
• Cannot provide services directly
• Cannot obtain services by referral undocumented
  children,
• Who is my patient? (e.g. How to serve depressed
  mothers who don't meet medical necessity criteria
  for specialty mental health services?)

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Current changing trends 1

• 2006 AAP policy statement requires 3 screenings
  w. standardized screening tool at ages 9, 18, and
  24 or 30 months.
• AAP Task Force on Mental Health developing
  parallel algorithms for mental health at
  infant/pre-school, school-age adolescent levels.

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Current changing trends 2

• CAPTA (2003) and IDEA (2004) require
  developmental screening in Child Welfare system
  and for children w. prenatal drug exposure.
• Head Start (reauthorized 2008) requires
  high-quality developmental screening

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Locating the problem- where does screening fit?

• Universal (Primary)
• Selective (secondary)
• Indicated (Tertiary)

• Health development screening
• Parenting education
• Risk-specific assessment
• Diagnostic assessment

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The continuum from reassurance to referral 1

• THE INFANT or CHILD
• Watch and wait
• Offer anticipatory guidance
• Encourage community links and supports
• Refer for assessment to EI
• Refer for treatment

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The continuum from reassurance to referral 2

• THE PARENT
• Offer anticipatory guidance, focused on parent
  stress
• Encourage community links and supports
• Refer for assessment (local variation in
  availability)
• Refer for treatment (if parent has eligibility
  for services)

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Maternal depression 1

• 27 of women w. clinically significant scores on
  EPDS in first postpartum year
• Previous history --gt 6x increased likelihood of
  recurrent depression
• Universal screening in postnatal care --gt
  three-fold recognition of maternal depression
• Screening in pediatric well-child visits --gt
  five-fold recognition.

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Maternal depression 2

• 27 of women w. clinically significant scores on
  EPDS in first postpartum year
• 33 of women have persisting symptoms, 26
  develop high symptoms after the first 3 months
  44 (less than half) improve after the first 3
  months.
• child(ren) have a higher risk of behavioral (3x)
  or other (8x) social-emotional problems

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Effects of treatment - STARD

• Depression remitted in 33 within 3 months
• Rates of DSM-IV diagnoses in children decreased
  from 35 to 24
• (In untreated controls, rates increased to 43)

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Effects of treatment - STARD

• Duration of the mothers depression correlated
  with the childs baseline symptoms, and magnitude
  of improvement in the mother correlated with the
  childs improvement.
• Weissman MM et al. Remissions in maternal
  depression and child psychopathology A
  STARD-child report. JAMA 2006 Mar 22
  2951389-98.

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Interventions

• Universal (Primary)
• Selective (secondary)
• Indicated (Tertiary)

• Well child visits (1ary care)
• Bright Futures model
• Early intervention
• Connection to community resources
• Referral for specialized infant mental health
  services
• Treatment, parent child

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Lessons from ABCD

• Screening in pediatric primary care well accepted
  by parents and providers.
• Time for screening (minutes) offset by saved time
  in visit due to better focus on concerns.
• Cost-neutral in capitated settings.

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Next steps

• Extend from early adopters to universal practice
• Extend access to and range of community support
  services (not only EI)
• Extend screening to include maternal depression
  (and/or substance abuse, other mental disorders)
  The Illinois model.

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• Questions?