Building a System of Developmental Care for Children

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Building a System of Developmental Care for
Children
Marihelen Barrett Nemours Health and Prevention
Services Presented to the Delaware Early Care
and Education Council February 23, 2007 Adapted
from Presentation by Amy Fine, MPH at 2006
Annual NICHQ Conference
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Ready ChildrenPhysically and Emotionally
Healthy Children Eager to Learn
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Current Trends in Pediatric Developmental Care

• General move in pediatrics toward more inclusive
  definitions and expanded role for pediatric
  practices
• Definitions and roles vary across practices

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Models for Improving Developmental Care

• Work by the Common Wealth Fund and Center for
  Healthier Children (UCLA)
• Healthy Steps, 1994
• Assuring Better Child Health and Development
  (ABCD), 1999
• Child Health Improvement Partnerships Vermont,
  North Carolina, New Mexico, Utah 2000 - 2006

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CWF Study by Amy Fine

• What is the current state of the art for
  pediatric developmental care and linkage to
  community developmental care?
• Promising and innovative models for linkage
• Key strategies across models
• Lessons learned

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Practices and Programs Included in Study

• Beaufort Pediatrics
• Childrens Care Connection (C-3)
• Developmental Services Enhancement Program (DSEP)
• Enhancing Developmentally Oriented Primary Care
  Program (EDOPC)
• Exeter Pediatric Associates
• Guilford Child Health, Inc. (GCH)
• Help Me Grow (HMG)
• Inscription House Health Center/ Growing in
  Beauty (GIB)
• Kaiser Permanente Northern California
• Kennebec Pediatrics (KP)
• Kids Get Care (KGC)
• MGH Revere HealthCare Center/Healthy Steps
• Phoenix Childrens Hospital/ Healthy Steps
• TuftsNew England Medical Center

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Current Trends in Pediatric Developmental Care

• What is the scope of developmental care?
• Physical, cognitive, behavioral, emotional
  development?
• Who needs it?
• Those with identified deficits, at risk, all
  children?
• CSHCN, all children, families?
• What is the role of the pediatric practice?
• Identification of deficits, prevention,
  promotion?

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Comprehensive System Barriers

• Pediatricians are kind of trapped in a box right
  now everything we need to do to get out of the
  box is not reimbursable.
• The system is so fragmented that the only person
  who understands it is the educated parent. Too
  many community organizations dont know who to
  call
• Dramatic gaps in developmental and mental health
  services a barrier to screening

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Comprehensive System Linked Pediatric and
Community Care

• What does good linkage look like?
• It looks like relationships, not a referral
  list.
• Three legged stool medical home, EI, and family
  support.
• Linkage is facilitated by relationships, some
  kind of formal mechanisms/systems, and
  reimbursement.

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System and Linkage Landscape

• Many different strategies and tools
• Most of the practices/programs combine multiple
  strategies
• Some recurrent themes
• No common language or framework for describing
  strategies

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System and Linkage Landscape

• What makes the system work?
• Part of the problem is evolving definition of
  developmental care
• Need working definitionsdevelopmental services,
  focus of linkage, framework for strategies
• Not yet a unified way of thinking about linkage
  addressed at different levels

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Developmental Services Framework

• What all children and families need from multiple
  people and places
• Knowledge/Information
• Assessment and Monitoring
• Additional Services and Supports
• Follow-up Relationships and Care Coordination
• Provided in smooth flow between health system,
  education system, community, and home
• Adapted from Regalado and Halfon

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Framework Key Developmental Services

• Knowledge/Information anticipatory guidance,
  info. on identified risks deficits.
• Monitoring developmental surveillance/screening.
  
• Additional Services and Supports point person
  and pathway to additional care, as needed
• Follow-up Relationships system and point person
  for support and follow-up.
• 
  
  Adapted from Regalado
  and Halfon

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Linkage Definition

• Connecting the child and family to needed
  developmental services and supports whether
  within the practice setting or beyond while
  also staying connected to the child

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Systems Change 3 Levels of Strategies

1. Practice-level systems change
2. Community partnerships focused on relationship
   between practices and existing community
   services/supports
3. System-wide change policy, population level,
   community-wide, state-wide change

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Nine Key Strategies

• Practice Strategies
• Developmental surveillance/screening
  anticipatory guidance
• Point person for referral/linkage follow-up
  system
• New/ enhanced staffing
• Linkage Strategies
• Co-location
• Co-management
• Networking and information-sharing
• System Strategies
• New/enhanced community resources
• System-wide training and support
• Community/state policies and protocols

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Context for the Strategies

• These are not stand alone approaches.
• Most of the innovative practices and programs
  combine several strategies, often at different
  levels.
• In practice, not necessarily a clean-bright line
  separating one strategy from another

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Underlying Tenets

• Several consistent underlying tenets or guiding
  principles shape the strategies
• Parents as Partners new morbidities require
  parents to set plan and make decisions
• No Wrong Doors any source of referral welcome
• Go Where the Children Are bring assessment to
  child (new technology enables this)
• Referral as a First Resort when in doubt refer

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Level I Strategies Practice-Based Systems
Change

• Developmental surveillance/screening
  anticipatory guidance
• Point person for referral/linkage follow-up
  system
• New/ enhanced staffing

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1 Developmental Surveillance/ Screening
Anticipatory Guidance

• Practice-wide system for routine,
  family-centered, developmental surveillance/
  screening
• Surveillance/screening at each well-child visit,
  using validated screening tools
• Anticipatory guidance tailored to meet parent
  concerns

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A Referral/Linkage Point Person and Follow-up
System

• A designated primary contact for
  referral/linkage. A practice-wide system for
  follow-up care
• Follow-up systems simple listing to EMR with
  recall system and task list
• Focus of linkage connect child to services
  beyond practice in-house services
• Point person nurse, social worker,
  developmental specialist

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Enhanced Staffing

• One or more new positions added to traditional
  pediatric primary care staff to enhance
  developmental care
• Positions vary e.g., Care coordinator, social
  worker, child development specialist,
  psychologist, developmental pediatrician,
  psychiatrist
• Purpose varies most often for children with
  risks/deficits but some work with all children
  in practice in health promotion role

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Level I Strategies Summary

• Current emphasis in pediatrics on in-house
  practice change, often as part of a QI systems
  change model
• Strategies 1 (assessment) and 2 (point person for
  referral) are prerequisite for good linkage
• Level I strategies improve quality of care.
• Adding in-house staff and services eases the
  transition to new services for children

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Level II Strategies Enhanced Partnerships
Between Pediatric Practice and Community

• Co-location of services
• Co-management
• Networking and information sharing

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4. Co-location of Services

• Location link between the pediatric practice and
  one or more other community service/s
• Some practices share a building or office space
  with other services, others place
  community/public sector staff in practice
• Provides a streamlined route for practices to
  connect children to additional developmental care

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Co-management

• Collaborative case management between the
  pediatric practice and one or more other service
  provider, focused on an individual child
• Variations case-by-case basis regular meeting
  time for case reviews collaborative assessment
  and joint problem-solving
• By phone or in-person

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Networking Information Sharing

• Includes networking meetings, mixers, meet and
  greet sessions, academic detailing sessions,
  shared resource listings, informal outreach
• Purpose varies jump-start or sustain
  referral/linkage

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Level II Strategies Summary

• Community partnership strategies help use
  existing resources more effectively improve
  quality of care
• Reduce barriers to care e.g., transportation,
  stigma
• Promote early referral/linkage and follow up
• Promote joint problem-solving, family-centered
  care
• Reduce duplication and fragmentation of services.
• Networking can help uncover gaps in services and
  promote collaborative efforts to address
• Time, financing and HIPAA can be challenges

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Level III Strategies Changes in Community
Systems

• New/enhanced community resources
• System-wide training
• Community-wide policies and protocols
• Level III strategies provide a framework for a
  Statewide Improvement Partnership to Implement
  Delawares Early Childhood Plan

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New and Enhanced Community Resources

• Starts with population-based approach to
  assessing community needs.
• Public and private sector partners
• Initiatives to develop
• centralized referral/linkage resources
• mid-level assessment
• enhancement of intervention services for at-risk
  and mild/moderate delay
• promotion/prevention services

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System-wide Training Support

• Applies to system-wide training to improve
  developmental care and linkage by
• Change the orientation, skills and practices of
  pediatric primary care
• Focus on pediatric healthcare and multi-sector
  training of pipeline
• Quality improvement for established practices
• Provide community/state orientation.

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System-Wide Policies Protocols

• Community or statewide policies and protocols to
  promote and sustain linkage
• Cross-agency protocols
• Reimbursement policies
• Other dedicated funding streams

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Level III Strategies Summary

• Level III strategies focus on filling community
  gaps in services/linkage (e.g. mental healthcare,
  mid-level assessment services, intervention
  services for mild/moderate delay)
• System-wide training provides common knowledge
  base for developmental care
• System-wide policy changes can jump-start and/or
  sustain practice change
• Reimbursement/financing polices are crucial

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Cross-Level Summary

• The 3 levels of strategies should not be
  interpreted as a hierarchy. All 3 are important
• These are not stand-alone strategies
• To optimize impact and resources, practices and
  communities need to combine strategies
• There is no one size fits all.

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Guiding Principles and Recommendations Think
about the recommendations as possible steps for
Delawares Early Childhood Action Agenda
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Guiding Principles

• Work in partnership with families
• Collaborate, integrate, and reinforce across
  services/supports
• Use a systems-focused, QI approach

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Guiding Principles

• Shift the balance of resources from high-end to
  front end
• For daily dose interventions, go where the
  children are

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Guiding Principles

• Use a no wrong doors approach
• Start at whatever level, with whatever
  strategies are available to the practice or
  program

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RecommendationsPractice Level Change

• Incorporate QI-systems change at the practice
  level, starting with a focus on developmental
  care. Include
• surveillance
• anticipatory guidance
• point person for linkage
• system for follow-up care

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Recommendations Practice Level Change

• Broaden the focus of developmental care so that
  pediatric practices can substantially contribute
  to the promotion of healthy development (Reorient
  well-child care)
• Early adopters devise and test strategies
• Evaluate early adopter outcomes
• AAP Task Force on Rethinking Well Child Care

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RecommendationsCommunity Partnerships

• Engage professional associations and umbrella
  agencies in mapping and linking developmental
  resources in their communities
• Identify nodal or gatekeeper resources
• Host meet and greet sessions
• Build relationships across service sectors

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RecommendationsCommunity Partnerships

• Promote co-location of public sector services in
  pediatric practices, and other innovative use of
  public sector resources
• Explore placement in high-volume practices
• Evaluate across sectors and settings

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RecommendationsCommunity Systems Change

• Promote mid-level assessment and referral/linkage
  capacity at the community or regional level
• Better use of existing resources
• Review community-wide referral/linkage and
  assessment models
• Diffusion of effective models components

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RecommendationsCommunity Systems Change

• Support training for practice-based,
  developmental care systems change
• Practice change learning collaboratives
• CME credits
• Residency training
• Multi-disciple and multi-sector training

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RecommendationsCommunity Systems Change

• Identify and promote key policy changes
• Reimbursement policies for care coordination and
  co-management
• Cross-sector, community protocols for delivering
  developmental care to children and their families