First STEPS Learning Initiative: Strengthening Together Early Preventive Screening

Improving Developmental, Autism, and Lead Screening Amy Belisle, MD

May 11, 2012

Partnering Organizations: Maine Quality Counts, Maine DHHS, MaineCare, Maine CDC, Maine Immunization Program, Maine Office of Information Technology, Muskie School of Public Service, USM, Vermont Child Health Improvement Program, Maine

Chapter of the American Academy of Pediatrics, Maine Academy of Family Physicians, Maine Primary Care Association MaineHealth, Eastern Maine Health Systems, Central Maine Medical Group, MaineGeneral Health, Martin’s Point Health

Care, Maine Developmental Disabilities Council

Amy Belisle’s Disclosure

I have no relevant financial relationships with the manufacturers(s) of any commercial

products(s) and/or provider of commercial services discussed in this CME activity.

Objectives for First STEPS, Phase 2• Setting the Stage: Focusing on the PCMH, Bright Futures, and

Developmental and Autism Screening• Working Together: Developing Successful PDSA Cycles and

Learning from Autism Implementation Group• Welcoming Parent-Partners: Thinking about how to include

them in our Quality Improvement Work• Raising Rates: Improving : Improving Developmental, Autism,

and Lead Screening• Creating Next Steps

First STEPS MAINE

BBCH Pediatric and Med-Peds Clinic

Ellsworth-Maine Coast Pediatrics

Rockland- PenBay Pediatrics

Penobscot PediatricsHusson PediatricsEMMC Family Medicine

CMMC PediatricsCMMC Family Medicine

Martin’s Point Pediatrics Brunswick

Waterville PediatricsWinthrop PediatricsKennebec Pediatrics

Practices by the Numbers

• 12 outpatient groups• 45 physicians• 20,000 children with MaineCare covered by

practices by Aug 2010 numbers

Community Partners• MaineCare• Muskie School of Public Service, USM• Maine Developmental Disabilities Council• Maine Autism Society• Maine Parent Federation• Maine CDC• Child Development Services• Office of Child and Family Services• Maine Children’s Alliance• Head Start• Families and Parent Partners

Why Is this Important to Your Practice?• Developmental delays and conditions affect 10% of

children• 1/88 kids with autism*• 85% of children with lead poisoning in Maine have

MaineCare health insurance; Only 50% of children at age one are currently tested and 25% of children at age 2

• CMS requirements for lead testing vs. screening for children enrolled in MaineCare may be changing in the next 6 months- would require changes in state law

• *(March 30, 2012, MMWR, Prevalence of Autism Spectrum Disorders — Autism and Developmental Disabilities Monitoring Network, 14 Sites, United States, 2008)

Why screen for lead and developmental delays?

• Lead is toxic to the brain• Lead poisoning can negatively affect cognition,

social functioning and communication skills • Pica- kids with autism and developmental delay

may be more likely to put things in their mouths, increase risk for lead poisoning

• Early intervention and treatment can greatly improve prognosis

• Screening at similar ages

2 years

3 years

6 years

Why is this important to me?

Why is this important for families?• Hope to find answers and improve quality of life

for children and families• Early intervention• Need a more standard approach to evaluate with

screening tools- we see the kids for a few minutes in the office, parents are with the kids all the time and can provide critical information

• Need help with care coordination• Need help with finding treatment services

The American Academy of Pediatrics (AAP) Policy Statement on Identifying Infants and Young Children with Developmental

Disorders in the Medical Home

• Recommends addressing child development by including routine developmental surveillance,

• Periodic screening using standardized tools; • And if a developmental concern is identified, further

evaluation to identify specific developmental disorders. • Early identification of children with developmental

delays and subsequent intervention can improve outcomes for young children.

What is the Quality Gap?

The gap between the care we know is best and our ability to deliver it, every time, to every patient in the way they need it.

• Maine’s preventive care for children including being ranked 14th for developmental screening (only 20% screened) by the Commonwealth Fund in 2010.

Quality Gap- Providers are not using screening tools

• Many physicians and primary care providers rely on informal developmental milestones and/or observation to monitor a child’s development.

• “Clinical judgment” alone is known to capture only about 30% of the children with delays—leaving many with unidentified needs and missed opportunities for timely and beneficial intervention.

• Early developmental delays are often not identified until well beyond the period in which early intervention is most effective.

• While detection rates increase by using a standardized instrument, national data indicate a low percentage of physicians use a standardized instrument.

Source: Muskie School of Public Service, University of Southern Maine

Updated Billing Codes from MaineCare for Developmental Screening

• 96110: General Developmental Screening Tool- PEDS/ASQ ($8.99)

• 96110HI- Autism Specific Screening Tool –MCHAT 1 ($8.99)

• 96110HK- Autism Specific Screening Tool- MCHAT 2 ($86.59)

Learning from Previous Pilot and Current Autism Implementation Grant

• In 2009, a developmental screening pilot was done in Maine with 5 sites

• In 2010 DHHS’ Children with Special Health Needs (CSHN) program applied for and was awarded a three-year State Autism Implementation Grant (AIG) of approximately $300,000 annually, funded under the federal Combating Autism Act Initiative.

• Maine is in the middle of a 3 year pilot with 2 sites (Bangor and Portland) to work on an Autism Implementation Grant with the Maine Developmental Disabilities Council. – Improve Screening– Promote the medical home and care coordination– Connect to evaluation and intervention services for children

Phase 2 Aim statement

• Improve the rate of developmental, autism, and lead screening for children according to the Bright Futures Recommendations for Pediatric Preventive Care by 50% from May 2012 to December 2012.

Goals• 75% of children have a documented developmental screening

using a validated tool (ASQ or PEDS) at the 9 mo, 12- 23 mo, and the 24 -36 mo well child visits

• 75% of children have a documented autism screening (MCHAT1 or MCHAT2) between 16 -24 months

• 75% of children identified with a concern or developmental delay have a documented follow-up plan (observation, recheck in office, or referral)

• 75% of all children will have a lead risk screening questionnaire to determine a child’s level of risk at 12 mo

• 75% of all children will have a lead risk screening questionnaire to determine a child’s level of risk at 24 mo

Office System Goals• Incorporating screening tools in your office flow• Work on referral tracking for all patients• Develop list of community and medical

resources for families and patients• Think about care coordination and care plans

for families• Involve families in your quality improvement

efforts

Office Systems Survey Fast Facts…

• 92% respondents have standard approach to developmental surveillance

• When surveillance completed– 73% at all well visits– 18% at well and sick visits– 9% at selected visits

• 100% use standard tool

9 m

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18 m

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24 m

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0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

When do you currently perform developmental screening in your practice? (check all that apply)

ASQ

PED

S

Bri

ght

Futu

res

Denver

II

PD

Q

BIN

S

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

Which developmental screening tool(s) do you currently use? (check all that apply)

Cost of tool

Lack of staff

Lack of time

Lack of training on performing screening

No referral source in the community

Overall cost to practice

Screening interrupts the flow of patients at the practice

Other (please rank and specify below)

0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50

Please rate, on a scale of 1-5, to what degree the following items are barriers to implementing developmental screening in your practice (5= strongly agree it is a bar-

rier and 1=strongly disagree that it is a barrier).

More OSS Fast Facts• 100% respondents screen for autism (M-CHAT) and

18% use lead screen questionnaire• When children referred for diagnosis and treatment as

a result of a positive developmental or autism screen, evaluation for majority happens between 2-5 months.

• Only 16% respondents have care coordinator to assist with referrals and f/u

• Only 8% of respondents involve parent partners• 33% perform staff training for developmental

screening & surveillance

In Summary…

• There are lots of opportunity for change and improvement!

Let’s make it fun! Games and Prizes!Prize Categories for Today:• Prize for Best Slogan for Learning Collaborative• Prize for Best Theme Song • Drawing for Completed Evaluation Form• Draw name of practice that brought a parent

partner

First Teams to Win:• On time data submission• On time office system survey• 1st team to enroll in the Learning Session:• 1st team to submit completed Office system

survey:

Tell us what you think!

• Local Evaluators- Sherrie Winton would like to talk with volunteers about First STEPS- sign up and enter to win a prize

• National Evaluators- may be coming this summer• Nancy Cronin is working on adding

autism/developmental screening to the Child Link registry

• Eric Frohmberg-building info into Lead Database

Next STEPS

Amy Belisle, MD

Next STEPS• Proposals for Next 2 Coaching Calls: June 14th: July 12th:• Data Cycles: 15th of the month- next June• Provide Feedback to Evaluators!• Next Learning Session- Sept 14th, Freeport• Celebration Dinner- Sept 14th, 5-7 pm at the

Harraseeket with Phase 2 LS 2

Phase 2 Timeline in Packet

Contact Info / Questions

• Amy Belisle, MD, 207-829-8444 Director of Child Health Quality Improvement, Maine Quality Counts, abelisle@mainequalitycounts.org

• Sue Butts-Dion, 207-283-1560 First STEPS Program Manager, Quality Specialist, Maine Quality Counts, sbutts@maine.rr.com

• Nancy Cronin, MA, ASD Systems Change Coordinator, Maine Developmental Disabilities Council,207-287-4214, Fax: 287-8001, Nancy.E.Cronin@maine.gov

• Barbara Farrell 207-622-3374 ext. 218, First STEPS Administrative Assistant, Membership & Events Coordinator, Maine Quality Counts, FAX 207-622-3332 bfarrell@mainequalitycounts.org

• Catherine Gunn, 207-780-5576 First STEPS Data Collector, Cutler Institute for Health and Social Policy Muskie School of Public Service FAX 207-228-8083 cgunn@usm.maine.edu.