Beyond the Prescription Pad:Physician Involvement in Early

Intervention

2005 OSEP National Early Childhood Conference

February 8, 2005

Corinne W. Garland Beppie j. Shapirocgarland@cdr.org beppie@hawaii.edu

Suzanne Gilchristpfs@ccboe.com

Session Objectives

Participants will understand the barriers to and strategies for:

Providing a medical home for children with disabilities

Integrating physicians into community EI and ECSE service systems

Strengthening the role of physicians in early identification, referral, IFSP/IEP development, and family support

Key Question ?????

Who needs physicians to be integrated into community EI and ECSE service systems?

Parents’ Needs

Identification and referral

Communication among team members

Early Intervention Needs

State and local child find needs

Timely referrals

Referrals without anticipating service needs before assessment and IFSP (e.g., therapies)

SERVED (2003 Child Count)% of live births

In Part C

Mean: 1.99%

Range: .94% (NV)

to 7.7% (HI)

Median: 2.13%

Part B (age 3-5)

Mean: 5.04%

Range: 1.77% (DC)

to 12.58% (KY)

Median: 6.12%

Results from AAP: A Survey of Pediatricians 2002

Survey sponsored by

American Academy of Pediatrics (AAP) Medical Home Initiatives for Children with Special Needs

Office of Special Education Programs, USDOE

Maternal and Child Health Bureau OSEP-funded Child Find Consortium

Survey Methodology

One of a series of surveys by AAP

Random sample Sent to 1,617

active US AAP member physicians

Six mailings May – Sept. 2002 Return rate 55.2%

Preliminary results only presented here

Contact AAP for more information

649 pediatricians who serve babies 0-3 and who assess development

Referral to EI – What’s Working

86% have referred to EI 92% say EI helps

maximize child’s development

95% say parent concern is considered in making referral

77% know family income doesn’t matter

What are barriers to pediatricians’ participation in Early Intervention?

Barriers to Referral to EI

Don’t know EI process procedures (46%)

Lack of feedback from EI program (36%)

Don’t know eligibility (29%) Programs don’t use MD

input (23%) ? quality of EI services

(22%) Services not available

(20%)

Communication from EI program 53% not notified

when referral received

30% do not receive evaluation results

47% do not hear reasons for disposition

54% don’t hear when family is discharged

61% don’t hear if program can’t contact family

49% do not get IFSP and progress on goals

AAP: Pediatricians recommend

reprinted standard referral form (51%) Toll free number (47%) Give MD more information about EI

(81%) Single, known contact person (58%) Improve communication from EI (>90%)

Statewide Strategies:Physician Training

Enhancing Health Care Delivery Through Screening, Surveillance, and Promotion of Early Intervention in the

Medical Home in Hawaii

Beppie Shapiro, Ph.D.&

Vince Yamashiroya, MD, FAAPOSEP Early Childhood Conference 2004

Presentation Outline

The Study: Project SEEK Phase 1:

Needs assessment

Phase 2: Interventions & Outcomes

Conclusions

The Study: Project SEEK

SEEKStrategies for Effective and Efficient Keiki (child) find

Project SEEK (2)

GOAL: to ensure babies with special needs are identified and referred to EI

- Sponsors: Office of Special Education programs, USDOE, and State DOH

Definitions

Early Intervention (EI): system of services for babies under age 3 with special needs

H-KISS: Hawaii’s information and referral service, free to the public

People Involved

Beppie Shapiro, Ph.D Principal investigator

Taletha Derrington, M.A Project director

Vince Yamashiroya, M.D., FAAP Physician advisor

Many others (physicians, public health nurses, educators, parents, etc.)

Period of the Study

Phase 1: Needs Assessment Statewide surveys, focus groups 1995 to 1999

Phase 2: Intervention & Outcomes Community surveys, collection of data from

PCP’s to EI programs, and intervention strategies

1999 to 2005

Phase 1: Statewide

Phase 2:

32,664

Children 0-18 years (2000 Census)

38,805

15,434

208,525

Maui

Big Island

Kauai

Phase 1: Statewide Needs Assessment

• Identified barriers to identification and referral.

• Statewide survey of professionals who serve young children.

• Focus groups of professionals in varied communities.

PCP Survey Results

Survey mailed to M.D. Offices statewide using HAAP and HAFP lists 129 pediatricians, 71 family

practitioners

Return rate 77%!!!

Barriers to Identification Physician developmental screening practices

(most common) All groups surveyed do not understand EI

eligibility Hospital nurses, MSW, foster parents, and

child care providers do not know how to identify eligible infants and toddlers

Discomfort by all professionals in speaking to the family about child developmental delay

Barriers to Referral “Wait and see” practice of some doctors when

delay is suspected (most common) Doctors do not know services are free to

family Some doctors do not believe EI is valuable Referring professionals sometimes perceive

information & referral (H-KISS) staff as unfriendly, unhelpful

Information and referral (H-KISS) hours are not best for many doctors

Information about EI is “hidden” from public

Phase 2: Intervention & Evaluation Purpose of intervention: to increase

identification of young children with developmental delays or special needs by PCPs, and their referral to EI

Purpose of evaluation: to measure effectiveness of intervention

Promising General Strategies Knowledge

Print, video, face-to-face Attitudes and beliefs

Voices of parents, other doctors, research Practice

Developmental screening Taking parental concerns seriously Making referrals directly Do not “wait-and-see”

EI Programs

Changing EI program practices Fax referral form for information & referral

service (H-KISS) Brochure on H-KISS in doctor’s waiting

room Enhanced communications of EI programs

to PCP’s

Evaluation Design

Measurements Surveys (knowledge and attitudes) Number of children referred to EI

Evaluation design compared communities Communities needed to be similar and

isolated to strengthen research design Three types of communities

Intervention group Comparison (control) group Post-comparison (control) group

Initial strategy

Large group presentations. 3 presentations x 1 hour each. Address knowledge, attitudes and skills. Designed to attract. Respect PCP preferences/expectations. CME. Intensive recruitment.

– Result: not good.•Only 1 or 2 MD’s showed up.

Complementary strategy

Mailed postcards Respects PCP time & attention constraints Inexpensive way to reach PCP’s Could incorporate messages to address

knowledge and attitudinal barriers

Postcards

One card/month x 7 months

Different topic on each

• Result: not good–MD’s did not remember what was on the postcards

Revised Strategy Selected (1)

Enhanced communications to PCPs by EI programs, about PCP’s patients Evidence from multiple sources of poor

feedback of EI programs to doctors Natural opportunity to address knowledge,

attitudes and work in EI

Enhanced Communications by EI “Thank you for your

referral” Referral status Screening/assessment

reports Invitation to attend or

provide input for IFSP Copy of IFSP Discharge notice

Evaluation of enhanced communications by: EI staff: referral status and discharge

notices PCPs:

thank you cards, IFSP invitations Remembered but not in detail, valuable,

could be streamlined

Revised Strategy (2)

Individual presentations at MD practice 2 presentations, 1

hour each Flexible schedule Designed to attract Intensive

recruitment

Individual Presentations

First Community (16 PCP’s) 94% (15) received at least half of content 81% (13) received all content

Second Community (19 PCP’s) 84% (16) received at least half of content 68% (13) received all content

• Result: GOOD!!!

Survey Return Rates

Survey Intervention Community

Comparison Community

Post-Comparison Community

TOTAL

Pre-Intervention

84% 88% N/A 86%

Post-Intervention

75% 78% 77% 77%

Results: Surveys Survey was designed to measured attitudes,

knowledge, and practice about the EI system. Survey in the intervention group showed a

significant improvement in all three areas from pre- to post.

Survey in the comparison group did not show any improvement on the three areas from pre- to post.

Survey by itself had no effect in increasing 3 areas: post–only comparison group had similar scores to comparison group.

Results: Referrals

Number of Referrals

0

20

40

60

80

100

120

1995 1996 1997 1998 00-01

Intervention

Comparison

First Set of Communities: Second Set of Communities:

Intervention Intervention

Number of Referrals

0

20

40

60

80

100

120

1995 1996 1997 1998 00-01

Intervention

Comparison

Number of Referrals

0

20

40

60

80

1998 1999 2000 2001

Intervention

Comparison

Results: Referrals (2)

Effects on physicians (PCP’s). Intervention PCP’s made significantly more

referrals after outreach than before, and very significantly more than comparison PCP’s.

No significant change in referrals among comparison PCP’s from pre to post, which means surveys alone did not raise awareness.

Results: EI Programs

Effects on EI programs Communications to PCP’s were bolstered

Conclusions

Base strategies on evidence such as needs assessments

Continually evaluate implementation & effectiveness of strategies

Providing information and persuasive messages can change physician practice

Inexpensive changes to EI program practices can provide feedback and information to PCPs

These practice changes can increase the number of babies with special needs identified by PCPs and referred to early intervention programs

Conclusions (Continued)

Is it sustainable?• Enhanced communications

were generally accepted and implemented by programs. Most are still using these, even though we’ve finished study implementation.

• Hawai‘i’s DOH is encouraging EI program staff to do short, less informal presentations to PCP’s.

Beppie Shapiro, Ph.D.beppie@hawaii.edu

Caring for Infants and Toddlers with Disabilities: New Roles for Physicians

CFITCFIT

Child Development ResourcesNorge, VA

Philosophical Foundations

Family-Centered Community-Based Coordinated and Comprehensive

Benefits of collaborative relationships among families, early intervention providers, and physicians

Key Aspects

Partnerships with Part C agency, Academies

Needs-based

AAP competencies

CFIT MODEL

State Planning Introductory Seminar

Parents, MDs, EI

Independent Study Manual & audiotapes Family Story

CME credits

CFIT Evaluations Competency Measures

Knowledge Measures

Average Rating Competency Measure

Pre & Post Test

Domain

States

Model Replication

Pre Post Pre Post

Child Find 2.92 4.11 3.20 4.32

Assessment 2.86 3.91 3.24 4.12

IFSP 2.48 3.92 2.78 4.10

Transition 2.39 3.81 2.83 4.01

TOTAL 2.69 3.94 3.00 4.10

Average Percentage CorrectKnowledge Measure

Pre & Post Test

Domain

States

Model Replication

Pre Post Pre Post

Child Find 53.3 64.7 53.4 62.5

Assessment 60.3 80.8 63.0 74.8

IFSP 68.1 94.7 69.0 81.5

Transition 66.7 71.1 79.3 81.6

TOTAL 57.4 74.6 55.0 65.8

Contact information:

Sheri Osborne Project DirectorCFIT Physicians

Child Development ResourcesP O Box 280

Norge, VA 23127Phone: 757-566-3300

E-mail: sherio@cdr.org