1. Change Package
Your Team Name: Community Prevention Partnership of Berks County/NFP and PAT teams
Topic Area:. DSS
Name of the Intervention: Development of an ASQ-3 Referral Matrix
Primary Driver: Reliable and effective systems for referral and follow-up

2. Definition of the Intervention
Team developed and tested a decision tree for actions/interventions/referrals based on ASQ-3 scores Team developed an ASQ-3 and ASQ-SE summary sheet to document strengths, concerns, intervention activities or referrals Summary sheet is given to parents and a copy is placed in the chart

3. Description of the Intervention

4. Description of the Intervention
ASQ-3 and ASQ-SE Summary
Home visitors screen the growth and development of children on a regular basis. They share the results with families , suggest appropriate learning activities and make referrals to Early Intervention Services as needed.
Date of screening ____________
Age of child at screening __________
ASQ-3 _______ months
ASQ-SE ______ months
Child’s Strengths
_____________________________________________________________________________________
Areas of Concern
No developmental concerns were identified.
My child’s score was close to the cutoff. My home visitor suggested the following:
__________________________________________________________________________
A referral to Early Intervention was recommended.
____ I received a copy of my child’s screening summary.
(Initials)
_____ I give permission to share results of my child’s screening with Early Intervention for further
(Initials) evaluation.
_____ I give permission to share the results of my child’s screening with my child’s doctor.
_____ My home visitor recommended a referral to Early Intervention and I declined the referral for my child.
_______________________________ ____________________________ _________________
(Parent/ Guardian name- printed ) (Parent/guardian signature) Date
(Home visitor name- printed ) (Home visitor signature) Date

5. Description of the Intervention
Child’s name
Date
ASQ-3/ ASQSE
Timeframe
(ie. 2 month, 6 month etc.)
Results:
Above the cutoff
Near the cutoff
Below the cutoff
Family was presented with EI referral information?
Family consented to referral?
Date referral was made
Evaluation/follow-up notes and information
N/A
yes or no
Family is being provided with specific activities, guidance etc regarding developmental concern or delays
Child already receiving EI

6. How is the intervention carried out?
Complete ASQ-3/ASQ SE at intervals suggested by NFP or PAT model
Score the screenings and review results with parent/caregiver
Record the results on the ASQ-3 and ASQ-SE Summary Sheet
Provide the parent/caregiver with the Summary Sheet
Place one copyof the Summary Sheet in the client’s chart
Discuss children with scores “below cutoff” or with concerns during reflective supervision
NFP-enter screenings and results on monthly tracking sheet
PAT-enter screening results into data base
CQI team will track screening results/interventions and referrals
CQI team will provide feedback summary to staff

7. Evidence that the intervention is effective
95 % of PAT and NFP children with an ASQ-3 or ASQ/SE a score near or below the cutoff *have :
Specific activities/plan of care aimed at addressing concern or delay
Are already receiving EI services
Have had a referral for EI evaluation
* screenings October 2014 through August 2015

8. Evidence that the intervention is effective Nurse-Family Partnership
ASQ-3 and ASQ/SE Screenings NFP Berks County PA
October 2014 through August 2015
472 screenings
18 (3.8 %) children “below cutoff”
5 of the 18 (27.7 %) were provided with specific activities to support development
8 of the 18 children (44.4%) were already referred to EI and were receiving services
5 of the 18 (27.7 %)were new referrals to EI

9. Evidence that the intervention is effective Nurse-Family Partnership
ASQ-3 and ASQ/SE Screenings NFP Berks County PA
October 2014 through August 2015
472 screenings
60 (12.7 %) children “near cutoff”
49 of the 60 (81.6 %) were provided with specific activities to support development
9 of the 60 children (15%) were already referred to EI and were receiving services
1 of the 60 (1.6 %)was a new referral to EI
1 family moved out of the area

10. Evidence that the intervention is effective Parents as Teachers

11. Evidence that the intervention is effective Parents as Teachers

12. Evidence that the intervention is effective Parents as Teachers

13. Evidence that the intervention is effective Parents as Teachers

14. Pre-requisites for the intervention
What is needed in order to have success with this intervention?
Collaboration with EI
Education of team members regarding importance of proper screening, accurate scoring, linking families to referral system
Revising tools and tracking sheets
Strategies for motivating families to allow EI evaluation
Strategies to educate home visitors to refer concurrently with suggesting activities/developing plan of care to support development

15. Advice Barriers / Challenges Key advice to overcome barriers
Reluctance of families to accept referral suggestion
Build home visitor skills on MI approaches to facilitate acceptance of referral
Reluctance of home visitors to refer for a “concern”
Team meetings, educational sessions and sharing of “success” stories
Adequate documentation of plan of care, referral and follow-up
Ongoing; address during supervison, CQI meetings and sharing of results/data with team