4/6/2017. Disclosures: Dr. Steven Wolfe is a consultant for 1 st Five and Child Health Specialty Clinics

Transcription

1 Steve Wlfe, M.D. Prfessr Emeritus University f Iwa Department f Family Medicine 1 st Five is administered by the Iwa Department f Public Health. IDPH cntracts with the University f Iwa Divisin f Child and Cmmunity Health t wrk with lcal 1 st Five cntractrs related t primary care prvider cnsultatin services. Disclsures: Dr. Steven Wlfe is a cnsultant fr 1 st Five and Child Health Specialty Clinics Utilize the pediatric peridicity schedule t ptimize well child care. Identify well child health care surveillance recmmendatins and implementatin tls. Understand bserving the child nly is nt sufficient t screen fr autism r develpmental delay. Describe autism (M-CHAT-R/F), child develpment (ASQ), and child scial-emtinal develpment (ASQ:SE) screening tls. Identify and imprve the recmmended well-child screening and surveillance prcesses fr develpmental and behaviral assessments in yur practice. 1

2 Surveillance: cntinuus, lngitudinal, cumulative prcess designed t ptimize children s health utcme. Peridicity table Bright Futures Screening: peridic, intermittent fcused assessment f a child s health. M-CHAT-R/F ASQ-3 ASQ-SE-2 2

3 Infrmal strategies dn t wrk 6-8% f pediatricians fail Insensitive in detectin N help in decisin making Lack f feedback Halfn N, Regalad M, Sareen H, et al. Assessing develpment in the pediatric ffice. Pediatrics. 24;113 : Sand N, Silverstein M, Glasce FP, Tnniges T, Gupta B, O'Cnnr K. Pediatricians' reprted practices regarding develpmental screening: are guidelines used? D they help? Presented at: annual meeting f the Pediatric Academic Scieties; May 1 4, 24; San Francisc, CA Experts requested based n this bservatin alne, wuld yu refer this child fr an autism evaluatin? Tw 1 minute vide evaluatins f 42 children fr autism utilizing ADOS tl. Experts ask t asses behavir as typical r atypical f autism. 3

4 39% false - 2% false + 11% false + PEDIATRICS, Vlume 13, number 2, February 21: Identifying Autism in a Brief Observatin; Gabrielsen, PhD, Terisa P., et. al Parents are gd bservers f their child s cmmunicatin and behavirs Sme parents are challenged by nt knwing what shuld be age apprpriate cmmunicatins and behavirs Resurces Cmmunicatin Checklist: 9-24 mnths Babies Learn at an Amazing Rate 16 Gestures by 16 Mnths Use a standardized tl : Bright Futures Iwa Child Health and Develpment Recrd 4

5 Surveillance at each visit: Age Apprpriate Fine and Grss Mtr Assessment Intellectual and Language Develpment Scial, Emtinal, and Behaviral Develpment Screening: General Develpmental Screen ASQ-3 at 9, 18, 24, and 3 mnths ASD red flags include parent cncern abut scial skills, language skills r behavir at any age. Cncerns f frequent tantrums r intlerance t change. Delayed language and scial cmmunicatin N babbling 9 mnths N pinting r gestures 12 mnths Failure t rient t name 12 mnths N single wrd 16 mnths Lack f pretend r symblic play 18 mnths. N spntaneus, meaningful (nt repetitive r echlalic) 2 wrd phrases 24 mnths Any lss f language r scial skills at any time Children with a sibling with ASD Surveillance shuld ccur at every well child visit.

6 Targeted screening using a standardized tl: ASD: M-CHAT-R/F 18 mnths and 24 mnths General Develpmental Screen: ASQ 3 Ages and Stages at 9, 18, and 24 r 3 mnths REMEMBER: PARENT CONCERNS TRUMPS ALL. **THESE ARE SCREENING NOT DIAGNOSTIC TOOLS!!! M-CHAT-R/F initial screening: Lw Risk -2: 93% Medium Risk 3-7: 6% High Risk 8-2: 1% 27% f screen psitive kids will have a develpmental delay r cncern. 1% f high risk grup had delays r cncerns which justified immediate referral. Valid tl fr screening fr autism in children 16-3 mnths f age. 6

7 Medium risk grup (3-7) require use f M-CHAT-R fllw-up. Select fllw-up items based n items failed in M-CHAT-R. Fllw frmal flwchart until arrived at Pass r Fail fr each questin repeated. If parent respnds with maybe, ask if behavir is mst ften yes r n (may still need t use yur judgment). Screen psitive if fails any 2 items referral required. Scre -1 screen negative. Child 3 initially r 2 after M-CHAT-F have a 47.% risk f being diagnsed with autism. M-CHAT-R/F can bth be cmpleted by apprpriate trained staff. M-CHAT-F can be dne either in persn r by phne. D NOT d same day as visit. Prvider shuld verify all psitive screens and decide n plan f care. DO NOT WATCH AND WAIT 7

8 Bill is a 24 mnth ld male being evaluated fr surveillance and screening. Parents vice cncerns abut the child s develpment since his last 18 mnth exam. He was brn ne mnth premature and develped nenatal jaundice which required pht therapy. An lder sibling has develped nrmally. Physical exam is nrmal. Respnds negatively t being examined. M-CHAT-R: Parents respnd Yes t questin 2. Parents respnd N t questins 4, 8, 2. Scre 4 mderate autism risk 3-7. Recmmended fllw-up? Administer M-CHAT-F questins 2, 4, 8, Is interested in ther children? 8

9 M-CHAT-F Questin 2 PASS Questin 4 PASS Questin 8 PASS Questin 2 FAIL Scre 1 negative screen Schedule 3 mnth surveillance visit and assess develpment unless parent s cncerns require earlier visit. A missed item may need clinical evaluatin even if the child is screen negative n the M-CHAT-R/F. US Preventive Services Task Frce, JAMA. 216: 31(7): US Preventive Services Task Frce, JAMA. 216: 31(7):

10 American Academy f Pediatrics, Pediatrics. 26: 118: 4-42 Ages and Stages 3 (ASQ-3) Ages and Stages:SE-2 (Scial and Emtinal) Written 4 th t 6 th grade level Parent cmpleted: 1-2 minutes Scred by trained persnnel: minutes Screen children ages 1-66 mnths 21 questinnaires ages 2-6 mnths dmains with abut 6 questins per dmain and an verall sectin which elicits parent s cncern Questins scred as: Yes, Smetimes, N 8% sensitivity and specificity 1

11 Cmmunicatin: babbling, vcalizatins, listening, and understanding Grss mtr: arms, bdy, legs Fine mtr: hands, fingers Persnal Scial: slitary scial play and playing with tys and thers Prblem-slving: learning and use f tys Parental cncerns ASQ-3 3 Mnth Questinnaire

12 ASQ-3 3 Mnth Questinnaire 1 2 ASQ-3 3 Mnth Questinnaire 1 ASQ-3 3 Mnth Questinnaire 12

13 ASQ-3 3 Mnth Questinnaire Supplement t ASQ 3 9 questinnaires age 2-6 mnths screening ages 1-66 mnths Cmpleted by caregiver with 1-2 hurs per week f cntact with a child Questins are nt arranged by cnstructs/dmains 13

14 Prematurity: If a child is <24mnths at the time f screening AND was brn >3wks premature, yu need t crrect Subtract # weeks premature frm current age t get crrected age and the apprpriate ASQ-3 frm Unanswered Questins: D NOT scre sectin if mre than 2 items are left unanswered If 1 r 2 items skipped, can create an adjusted ttal scre Take ttal scre divided by # f questins answered t get average scre. Add average scre fr mitted item t ttal scre fr adjusted ttal area scre ASQ-3 3 Mnth Questinnaire items/questins; 3 pen-ended questins per screening tl One single scre nly, cutff scre abve which a child requires further evaluatin. Scred: Often r Always, Smetimes, Rarely r Never Intermediate scre which requires either mnitring, further evaluatin, r referral. 14

15 X = 1 V = Z = Cncern = Self-regulatin: child s ability r willingness t calm r settle dwn, r adjust t physilgical r envirnmental cnditins/stimulatin Cmpliance: child s ability r willingness t cnfrm t the directin f thers and fllw rules Cmmunicatin: child s ability r willingness t respnd t r initiate verbal r nnverbal signals t indicate feelings, affective, r internal states Adaptive functining: child s success r ability t cpe with physilgical needs (e.g., sleeping, eating, eliminatin, safety) Autnmy: child s ability r willingness t self-initiate r respnd withut guidance (i.e., mving t independence) Affect: child s ability r willingness t demnstrate his r her wn feelings and empathy fr thers Interactin with peple: child s ability r willingness t respnd t r initiate scial respnses t parents, ther adults, and peers Parental cncern 1

16 Develpmental screen & scre ---includes MCHAT R/F, ASQ r G41 MCOs paid: $2-61 fr MD/DO/PA, $2 fr NP Private insurance paid: $-$19 fr MD/DO, $-1 fr NP/PA Brief Emtinal/Behaviral Assessment & scring includes ASQ-SE2, PHQ MCOs paid: $2-61 MDs/DOs/PAs, $2 fr NPs Private insurance paid: $-22 fr MD/DOs*, $-9 fr NPs/PAs *minimal data available Medicaid: 2 mdifier t preventive service r E&M cde --example: Z.129/2, 9611 Attach 9 mdifier if using mre than ne screen --example: develpmental screen and autism screen Check with yur payer! M-CHAT-R/F, ASQ-3, ASQ-SE-2 Visin & Hearing evaluatin Review Newbrn screening results & Grwth chart Review PMH, family histry, scial, envirnmental factrs Metablic testing & Lead levels The tl is NOT the challenge in implementing the screening prcess in the ffice. It is changing the wrkflw. 16

17 Apprach as Q/I prject Present as a revenue generating prcess - BUSINESS CASE Champin and Implementr f change Decide best methd fr yur ffice paper with EHR dcumentatin summary fully integrated int EHR nline autism screening Autism Speaks pay third party: Child Health and Develpment Interactive System (CHADIS) Screening tl t begin t implement: start with ne patient and ne prvider Design and define wrkflw and rles and respnsibilities Design and Define ffice wrkflw and rles/ respnsibilities (Tasks) Pre-visit: Registry and patient ntificatin Visit: Receptinist/Scheduler Nursing Clinician Billing Pst Visit: NEXT STEPS additinal/repeat testing Referral care crdinatin If nt already ding develpmental surveillance at all Well Child visits, start using Bright Futures tls If already ding surveillance but n screening, cntact yur 1 st Five Site Crdinatr t schedule a sessin fr her t walk yu and yur staff thrugh the ASQs and/r MCHATs. 17

18 If familiar with ASQs and/r MCHATs but are nt sure hw yu are ging t fit these screens int yur busy wrkflw, please reach ut t yur Site Crdinatr wh can cnnect yu t the 1 st Five Peer Cnsultants Medical cnsultants: Dr. Steven Wlfe-Family Practice Cheryl Jnes, ARNP-Pediatric Nurse Practitiner Dr. Meredith Fishbane-Grdn-Pediatrician 1 st Five Early Access Blank Children s Hspital ChildServe Child Health Specialty Clinics UI Center fr Disabilities and Develpment University f Iwa Children s Hspital Bright Futures: Iwa Early And Peridic Screening Diagnsis And Treatment: Child Health And Develpment Interactive System: Mdified Checklist fr Autism in Tddlers, Revised with Fllw-up (M-CHAT-R/F): 18

19 References Cuncil n Children with Disabilities, et al. Identifying infants and yung children with develpmental disrders in the medical hme: An algrithm fr develpmental surveillance and screening. Pediatrics. 26;118(1):4-42. Glasce FP. Screening fr develpmental and behaviral prblems. Ment Retard Dev Disabil Res Rev. 2;11(3): Jhnsn CP, Myers SM. Identificatin and Evaluatin f children with autism spectrum disrders. Pediatrics. 27;12(): Mackrides PS, Ryherd SJ. Screening fr develpmental delay. Am Fam Physician. 211;84(): Rbins DL, Casagrande K, Bartn M, Chen CA, Dumnt-Mathieu T, Fein D. Validatin f the Mdified Checklist fr Autism in Tddlers, Revised With Fllw-up. Pediatrics. 214;133(1):37-4. References The Adverse Childhd Experiences Study: ACEs 36 Iwa: Health in Iwa, Annual Reprt frm the Behaviral Risk Factr Surveillance System, Iwa 212: Center f the Develping Child at Harvard University: Natinal Scientific Cuncil n the Develping Child (2). Excessive Stress Disrupts the Architecture f the Develping Brain: Wrking Paper N. 3 Retrieval frm: Nadine J. Burke et al. The impact f adverse childhd experiences n an urban pediatric ppulatin. Child Abuse and Neglect 3(211) Michael Silverstein, MD, MPH; Jenny Radesky, MD. Embrace the Cmplexity: The US Preventative Services Task Frce Recmmendatin n Screening fr Autism Spectrum Disrder. JAMA 216; 31(7): Albert L. Siu, MD, MSPH; USPSTF; Screening fr Autism Spectrum Disrder in Yung Children: US Preventative Services Task Frce Recmmendatin Statement. JAMA 216; 31(7): Validatin f the Mdified Checklist fr Autism in Tddlers, Revised, with Fllw-up (M-CHAT-R/F), Diana L. Rbins, et al., Pediatrics 214;133;37. FIRST WORDS Prject., Questins and Cmments? 19