Changing Systems, Changing Lives by Enhancing Developmentally Oriented Primary Care February 23, 2009 Anita Berry, MSN, CNP/APN Director, Healthy Steps for Young Children Program, Advocate Health Care Scott G. Allen, MS Executive Director, Illinois Chapter, American Academy of Pediatrics

Agenda What is EDOPC? EDOPC Results EDOPC Successes and Challenges Questions and Answers

EDOPC Inspiration Unmet Needs Project –need for commercially-developed tools, better use of EI system Illinois early childhood/screening initiatives –Advocate Health Care Healthy Steps –Provider groups (ICAAP, IAFP) trainings –Ounce of Prevention Fund Provider interest State agency interest

EDOPC Inspiration (cont’d) Clinical policy recommendations –AAP developmental screening, autism policies –Holistic approach to child development National efforts –Assuring Better Child Health and Development (ABCD) –ABCD Screening Academy

Key Partners: Advocate Advocate Health Care Healthy Steps –Model/experience with practice change –Curricula/training on broad range of early childhood topics –Comprehensive approach Large healthcare system Key clinical/training staff Infrastructure (fundraising, administration)

Key Partners: ICAAP Broad membership and volunteer base Experience in academic detailing EC/developmental screening expertise –Developmental pediatricians, previous training Partnerships with advocacy, provider groups Growing systems change and policy work

Key Partners: IAFP and Ounce Illinois Academy of Family Physicians Ounce of Prevention Fund

Key Partnership Strengths Expertise in clinical topics Experience in diverse practice settings –Public/private/public, pediatric/family practice, training Experience with educational models, technical assistance Ability to engage other partners

Local Funders/Stakeholders Private Foundations State Agencies –Illinois Medicaid –Early Intervention/Title V Provider Groups –Community clinics –Training programs Advocacy Organizations

Making The Case Audiences –Medicaid, Title V –Providers –Funders Primary care systems change Better health/developmental outcomes Benefits to state systems –Duplication/coordination of effort –Cost savings

Training Academic Detailing model –Evidence Based Materials –Multidisciplinary Approach –CME and Contact Hours for Nurses –Screening Materials Available –Staff and peer speakers –Current topics of interest to wide audience

Site Champion What we look for: –Physician or Advance Practice Nurse –Clinical expertise –Authority to set up team meetings, training dates, change practice systems, influence policy and procedure changes –Interested and excited about early child development –Knowledgeable about screening, AAP Policy Statements and recommendations

Training – What’s It All About? Timing –One hour or less, generally over lunch Format –Power point, video clips, case discussion, hands on activity Content –AAP Policy or Recommendations –Current Research / Problem –Screening Tools –Team Approach –Resource Manual –Technical Assistance

15 Training Topics Developmental Screening and Referral Social Emotional Developmental Screening and Referral Identifying Postpartum Depression During Well-Child Visit: Resources for Screening and Referral Early Autism Detection Screening and Referral Domestic Violence Effects on Children Detection Screening and Referral in Primary Care Obesity Prevention in the Early Years

Developmental Screening and Referral Objectives of training - participants will be able to: Identify purpose of developmental screening and early intervention Use validated screening tools Implement referral procedures, gain knowledge regarding referral resources Employ parent/caregiver education materials Implement efficient office procedures Use, document, and bill for screening tools

Social Emotional Developmental Screening and Referral Objectives of training - participants will be able to: Define social emotional development Explain importance of screening Give examples of social emotional milestones and “red flags” Use, document, and bill for screening tools Gain knowledge regarding referral resources

Identifying Postpartum Depression During the Well-Child Visit: Resources for Screening and Referring Objectives of training - participants will be able to: Understand the difference between baby blues, peripartum depression, and postpartum psychosis. Gain knowledge regarding the impact of postpartum depression on children and families. Identify risk and protective factors Understand how to use validated screening tools Gain knowledge regarding referral resources and procedures for referrals Implement culturally-appropriate care

Early Autism Detection Screening and Referral Objectives of training - participants will be able to: Define autistic spectrum disorders, their epidemiology and etiology; Recognize the earliest signs of autism; Routinely assess young children for autism; Identify common misconceptions about the causes and stereotypes of autism; Referrals to Early Intervention, Special Education, Team approach to diagnosis

Domestic Violence Effects on Children Detection Screening and Referral in Primary Care Objectives of training - participants will be able to: Define domestic violence Identify the cycle of violence Understand how domestic violence affects children and families Identify community resources

Obesity Prevention in the Early Years Objectives of training - participants will be able to: Recognize and screen families for risk factors Understand normal developmental expectations Assess effectiveness of parent-child feeding relationships and interactions Engage parents around feeding issues Give age appropriate anticipatory guidance

Technical Assistance Who, What, Where, Why –Who: All Training Recipients –What: Organizational assistance after training to promote implementation of screening into routine practice –Where: Onsite, Phone, , Team Meetings, Chart Reviews, Teleconference Calls, Website –Why: Difficult for a Champion to promote on their own

Feedback to Sites Team Meetings Working with Champion –Chart Reviews –State Data –Comparison to other FQHC’s

EDOPC at a Glance Goals –Improve delivery and financing of preventive health and developmental services for children birth to three –Build on existing programs to develop a range of strategies for primary care settings

EDOPC at a Glance: Geographical Locations

EDOPC at a Glance: Site Types

EDOPC at a Glance: Who Has Been Trained

EDOPC at a Glance Objective 1 Site-based training and technical assistance model will be accepted by practices in the Chicago metropolitan area and throughout the state of Illinois to provide a foundation for ongoing collaboration to promote optimal child development.

EDOPC at a Glance Objective 2 Training will increase knowledge regarding key topics identified as priority areas for the developmental care of young children among providers of primary care to young children.

Training Topics Knowledge Outcomes 2006, 2007 and attendees completed evaluation data Pre/Post testing, 6 questions on each topic In all three years results showed a statistically significant difference in knowledge gained by attendees: –2006: (pretest mean 5.97, posttest mean 6.58) –2007: (pretest mean 4.24, posttest mean 4.65) –2008: (pretest mean 4.12, posttest mean 4.98)

EDOPC at a Glance Objective 3 T raining will improve the confidence of primary care providers regarding the identification of developmental issues or delays, perinatal depression, and domestic violence.

Provider Self-Reporting: Training Enhanced Ability To Identify Issues (% agreed) Topic Developmental 100%86%94%92% Social- emotional 94%91%92%94% PPD 84%91%94%96%

EDOPC at a Glance Objective 4 EDOPC training will improve primary care providers’ knowledge of referral resources and procedures for developmental issues and perinatal depression.

Self-Reporting: Training Enhanced Referral Resources (% agreed) Topic Developmental 75%90%95%96% Social- emotional 60%90%92%94% PPD 95%92%94%92%

EDOPC at a Glance Objective 5 EDOPC training and technical assistance will increase the proportion of young children screened for developmental issues and the proportion of mothers screened for perinatal depression.

Screening Practice at Pretest and Posttest (%) Topic2005 Pretest 2005 Posttest 2006 Pretest 2006 Posttest 2007 Pretest 2007 Posttest 2008 Pretest 2008 Posttest Dev Screening 50%100%50%93%41%86%42%92% Soc/Em Screening 33%100%35%94%47%95%28%96% PPD 14%93%58%92%29%95%22%94% Domestic Violence 18%88%28%92%

Percentage of developmental screenings using the Ages and Stages Questionnaire by the 1-year well-child visit, by site, 2004–2008

Percentage of developmental screenings using the Ages and Stages Questionnaire by the 2-year well- child visit, by site, 2004–2008

Percentage of social/emotional screenings using the Ages and Stages Questionnaire: Social/Emotional within 2-year well-child visits, 2004–2008

Percentage of PPD screenings using the Edinburgh Postnatal Depression Scale by the 6-month well-child visit, by site, 2004–2008

Illinois Medicaid Unique Providers Billing Dev Screening (96110 from FY03–07) FY03FY04FY05FY06FY07 State Fiscal Year <12 mos mos mos Providers (Individual& Clinic)

Developmental Assessments and Screenings: Illinois Children Ages 0–3 under Medicaid * provisional data for Providers currently have one year to bill HFS for services under Medicaid so final numbers may be greater than those reflected in this analysis, which was based on billings received by 9/07. Developmental Assessments and Screenings Illinois Children Ages 0–3 under Medicaid 0 10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000 90,000 SFY 2003SFY 2004SFY 2005SFY 2006SFY 2007* State Fiscal Year Assessments Screenings

Initial referrals to Early Intervention subsequent to encounter (Developmental Screening)/96111 encounter * provisional data for Providers currently have one year to bill HFS for services under Medicaid so final numbers may be greater than those reflected in this analysis, which was based on billings received by 9/07. Assessment ,000 1,500 2,000 2,500 3,000 3,500 4,000 SFY 2003SFY 2004SFY 2005SFY 2006SFY 2007* State Fiscal Year

EDOPC at a Glance Objective 8 EDOPC will develop a toolkit for use in training of resident physicians in family medicine and pediatrics, nurse practitioners, and physician’s assistants.

Toolkit FQHCs CD-ROM including all EDOPC topics Pediatric Residency, NP, PA Programs CD-ROM Healthy Steps and EDOPC topics Best Practice Document Tools for incorporating into practice

EDOPC at a Glance Objective 9 EDOPC provides training and technical assistance to help sites problem-solve and overcome barriers to the implementation of routine screening.

Best Practice Document Best Practices Summary Best Practices Detail General Office Systems Screening Policies, Procedures, and Tools Staff Education Patient/Parent Education Referral to Community Agencies and Other Resources Coding and Billing Description of Tools Additional Resources

EDOPC at a Glance Objective 10 Barriers to effective communication and collaboration between providers of diagnostic and treatment services and pediatric care providers will be identified through focus groups and/or interviews with community agencies (including EI)

Referral Results in New Challenges Challenges in communication –Busy practices, overburdened EI systems –Cultural divide Identified needs –Increase in depth of understanding, trust –Communication and referral systems –Communication tools

Coordinating Care Project Funded by The Commonwealth Fund, Objectives –increased referrals to EI from primary care providers –decreased time required for EI case coordinators to receive information from primary care practices –increased satisfaction with patient referral procedures among both EI staff and primary care medical professionals –tool/training development

EDOPC Policy Medicaid –New guidelines and tools, including social emotional tools –Clarified unbundling for well-child visit –Added reimbursement for PPD screening as a risk assessment –Supported developmental screening as bonus measure Early Intervention –Clarified child as automatically eligible if primary caregiver diagnosed with a severe mental disorder –Clarified that children 0-3 are eligible to receive EI services if only delay is social-emotional

EDOPC Policy (cont’d) Other State Programs/Agencies –Clarified Family Case Management protocol –Expanded allowable screening tools for health departments –Partnered on funding requests for children’s mental health services Miscellaneous –Supported Postpartum Mood Disorders Prevention Act –Advocated for payment with private insurers –Partnered with diverse advocacy organizations on mental health, early learning, etc.

Future Policy Goals Enhances coordination of activities among service providers, advocacy organizations, and families Continue work with Illinois Medicaid and private insurers to develop incentives and address barriers to screening Continue to use expertise in primary care to inform the activities of relevant statewide systems/efforts

Accomplishments and Challenges Accomplishments –Expertise –Infrastructure and collaboration –Direction Challenges –Integration –Sustainability –Maintaining Quality

Questions?