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1 Standardized Developmental Screening: Assuring No Child Enters Kindergarten With an Undetected Developmental Delay For Primary Care Providers Caring for Children in Oregon

collaboration with: Multnomah Early Childhood Program; Multnomah Early

2 A Project Of The Oregon Pediatric Society Oregon Chapter of the American Academy of Pediatrics (AAP) Sponsored by: Multnomah Project LAUNCH In collaboration with: Multnomah Early Childhood Program; Multnomah Early Childhood Services; Child Care Resource & Referral of Multnomah County; 211info Family

3 DISCLAIMER The Oregon Pediatric Society (OPS), a Chapter of the American Academy of Pediatrics, has no conflict of interest, and is not affiliated with any other organization, vendor or company. Reasonable attempts have been made to provide accurate and complete information. The practitioner or provider is responsible for use of this educational material, and any information provided should not be a substitution for the professional judgment of the practitioner or provider.

4 CME This event is a joint providership between Bay Area Hospital and the Oregon Pediatric Society. Bay Area Hospital s Continuing Medical Education (CME) Program is accredited by the Oregon Medical Association to sponsor Category 1 medical education activities for physicians. As an accredited institution, Bay Area Hospital s Medical Education Committee designates this live educational activity for a maximum of 2.00 AMA PRA Category 1 Credit(s) Physicians should only claim credit commensurate with the extent of their participation in the activity. Bay Area Hospital fully complies with the legal requirements of the ADA and the rules and regulations thereof. If any participant in this educational activity is in need of accommodation, please call , x101. OPS Trainers and planners of these events have disclosed they have no financial relationship with a commercial entity producing health-care related products or services.

5 Goals & Objectives START BASIC IMPROVE developmental screening in pediatric practices ENHANCE provider understanding, utilization, and implementation of standardized screening tools EDUCATE providers in proper documentation, coding, and billing of screening tools BUILD provider awareness of local community resources for evaluation and intervention

6 AGENDA 1: The Science of Developmental Screening 2: Recommended Standardized Developmental Screening Tools 3: Community Resources 4: Implementing Standardized Developmental Screening in Your Practice 5: Complete Training Evaluation Adjourn

7 PART 1 The Science OF DEVELOPMENTAL SCREENING

behavioral in nature. 80% of parental concerns are correct and accurate.

8 Did you know? 20% of all visits to the pediatric clinician s office are developmental or behavioral in nature. 80% of parental concerns are correct and accurate. Children who fall behind in 1 st grade have a 1/8 chance of ever catching up. High school graduation rates can be accurately predicted by reading level in 3 rd grade.

9 Young Children at Risk 60-70% good enough 2-4% severe disabilities 10-14% special health care needs 20-30% developmental, behavioral, personal-social, learning problems

The Facts About Developmental Screening 23% of pediatricians reported consistently using standardized screening tools or only when parents expressed concern or child

10 The Facts About Developmental Screening 23% of pediatricians reported consistently using standardized screening tools or only when parents expressed concern or child was known to be at risk. 34% of Oregon children received standardized developmental screening 31% of children, nationally, received standardized developmental screening

The Facts About Developmental Screening 36% pediatricians

65% pediatricians report inadequate training as a barrier

42% of parents recall being told a developmental screening

12 The Facts About Developmental Screening 36% pediatricians report insufficient time as a barrier to utilization. 65% pediatricians report inadequate training as a barrier to utilization. 42% of parents recall being told a developmental screening was being done. developmental screening = higher family-centered care ratings and higher satisfaction with WCC.

13 Child Healthcare Providers THE ONE PLACE NEARLY ALL CHILDREN ARE SEEN 90% 47% Seen by primary care provider (0-5) Seen by nursery and preschool (3 & 4)

14 Detection Rates Using Standardized Screening Tools WITHOUT screening WITH screening Developmental delays 30% identified 70 89% identified Mental health problems 20% identified 80 90% identified

15 Implementing ASQ in Practice REFERRAL RATES DRAMATICALLY INCREASE At 12 months, referrals 8X higher At 24 months, referrals 2.5X higher control year screening year months 24-months

16 EARLY DETECTION & REFERRALS = SECONDARY PREVENTION Universal, routine developmental screening using a standardized tool increases early identification of developmental delays and referral.

17 EARLY INTERVENTION WORKS EI programs can help improve IQ, motor, language and academic achievement. Average total expenditure per child in EI is $15,740. Estimated cost of failing to provide intervention for children living in poverty is as high as $100,000 per child. 50% of children who receive EI services no longer need services by 3 years of age.

18 PUTTING IT ALL TOGETHER Universal standardized screening in primary care increased identification increased referrals to EI services increased access to services IMPROVE OUTCOMES for children and society

19 To ensure no child reaches kindergarten with an undetected developmental delay Surveillance vs. Screening vs. Diagnosis

20 What is surveillance? A flexible, continuous process, in which knowledgeable professionals perform skilled observations of children during child health care (in consultation with families, specialists, child care providers, etc).

21 5 Components of Surveillance 1. Eliciting and attending to the PARENT S CONCERNS 2. Maintaining a DEVELOPMENTAL HISTORY 3. Identifying the presence of RISK AND PROTECTIVE FACTORS 4. Making accurate and informed OBSERVATIONS of the child and parent-child relationship 5. Documenting the PROCESS AND FINDINGS Surveillance is NOT screening

22 What is screening? A brief, objective, and validated test differentiating between children who are "probably ok" vs. "needing additional investigation, and is performed at not only set points in time but also when a specific concern arises.

23 What is diagnosis / evaluation? 1. Accurate diagnosis is the next step done when screening identifies child as at risk 2. Diagnosis may be done by Primary Care Provider or Developmental Specialist 3. Aimed at identifying specific developmental disorders affecting the child 4. Done in conjunction with a medical diagnostic evaluation

24 AAP Algorithm for Developmental Screening and Surveillance Developmental surveillance every well child visit Standardized general developmental screening tool at 9, 18, and months Did not make specific tool suggestions

25 18 months 9 months 24/30 months SCREENING SCREENING SCREENING S U R V E I L L A N C E

26 Benefits of Screening EARLY INTERVENTION IS PREVENTION Better patient care Improved patient/family satisfaction Earlier identification & referral Improved child/family outcomes Reimbursable Cost effective CCO and medical home metric

27 Barriers to Screening Time I know it when I see it Reliance on homemade tools The wait-and-see approach Lack of knowledge of tools, methods, & billing Literacy issues (health & academic) Lack of referral resources

28 Get the right START! Universal, standardized developmental screening is standard of quality care in the medical home Required in the Patient-Centered Primary Care Home Standards for Medical Home Certification in Oregon

29 Recommended Schedule for Standardized Screening Developmental Screening (AAP 2006) 9 months ASQ/PEDS 18 months ASQ/PEDS & M-CHAT R/F 24/30 mo. ASQ/PEDS & M-CHAT R/F 3-5 years ASQ/PEDS as needed Maternal Depression Screening ** (Earls, et.al. 2010) 2 weeks Edinburgh 2 months Edinburgh 4 months as needed 6 mo./ 1 yr. as needed Social-Emotional Screening Recommendations Pending

30 PART 2 Standardized DEVELOPMENTAL SCREENING TOOLS

31 Screening Tool Requirements Sensitivity: good tool >70% Specificity: good tool >70% Easy to administer to patients Simple to score and interpret by provider or staff

32 Standardized Developmental Screening Tools Tool Types/ Staff Time To Cost/ Languages Reading Sen Spec Ages Required Score Refills Eng/Span Level ASQ Parent Para- 3 min. $295/ yes/yes 4 th -6 th 70-90% 76-91% Questionnaire (4mo-5yrs) professional Unlimited copy grade Denver Direct Trained $91 kit + yes/no n/a II 56-83% Elicitation (0-6yrs) staff min. $185 training 43-80% materials/ $26-$100 PEDS Parent Para- 5 min. $39/ yes/yes 5 th 74-79% 70-80% Questionnaire (0-8yrs) professional $30-$50 grade

33 Advantages of Using Parent- Completed Screening Tools Can focus the visit on parental concerns Enhances teachable moments Helps avoid oh, by the way questions Can provide rich information about child across settings Improves patient flow Improves patient/family satisfaction

34 Ages & Stages Questionnaire Time required Parent report tool with exercises; 10 minutes to fill out; < 3 mins. to score Cost One time purchase per practice per language; unlimited photocopying or print from CD; new online products Website

35 ASQ 2 months to 5 1/2 Years 21 age-specific questionnaires from 1 to 66 months Each questionnaire valid for period before and after indicated age items per questionnaire describing skills Taps 5 domains of development Must correct for prematurity up to 24 months

36 Preparing Parents & Caregivers Explain tool and purpose to parents Discourage assumption of a problem Assess ability to complete tool properly

37 Ages & Stages Sample Item 9 Month Questionnaire - Scoring 1. While your baby is on her back, does she put her foot in her mouth? Yes Sometimes Not Yet Does your baby drink water, juice, or formula from a cup while you hold it? Yes Sometimes Not Yet 5

38 Ages & Stages Questionnaire Scoring Activity Case Example: L.R. 9 Month Questionnaire 9 Month ASQ Information Summary (on last page) Tool Time : 2 Minutes Score L.R. s Screening Tool Interpret Results

39 ASQ Scoring & Interpreting Assign values 10 to yes, 5 to sometimes, 0 to not yet. Add scores Record totals in the space provided for each area. Indicate child s total Fill in the appropriate circle on the scoring form, giving totals for each area.

40 ASQ Scoring Be sure each item has been answered. Corrections can be made if two or less items are left blank. The scoring grid below shows the cutoff score for each domain, indicated by the dark bar. Any score touching or in the dark bar indicates further evaluation is needed. Gray area corresponds to 1.5 SD below mean, black area corresponds to 2.0 SD below mean

41 Score Adjustment Table Area score Adjusted 1 item missing Adjusted 2 items missing

42 Information Summary OVERALL SECTION 1. Uses hands and Yes No legs equally well? Comments: 2. Baby s feet flat Yes No on the surface? Comments: Likes to stand on toes 3. Too quiet or does Yes No not make sounds? Comments: 4. Family history of Yes No hearing impairment? Comments: 5. Vision concerns? Yes No Comments: 6. Recent medical Yes No problems? Comments: Allergy/Asthma 7. Behavior concerns? Yes No Comments: 8. Other concerns? Yes No Comments: Growth

43 LR s Score & Interpretation Validate answers for any areas of concern before deciding on a referral.

44 Follow-up/Referral Criteria Above Cutoff points: Close to Cutoff points: Below Cutoff in 1 or more area: Provide follow-up activities to parents Provide follow-up activities for parents, focus on domains/ skills of concern Refer to appropriate agencies for diagnostic assessment Continue routine screening periodicity Instruct parents on skillbuilding Community referrals, as appropriate Rescreen in 1-3 months, sooner if necessary Parental Concerns: Respond to all concerns and refer if necessary.

45 Modified Checklist for Autism in Toddlers-Revised with Follow-Up (M-CHAT-R/F) The M-CHAT-R/F Questionnaire and Follow-Up Parent Interview can be downloaded for free at Assess risk of autism spectrum disorder 2-Stage parent report: (1) screening tool PLUS (2) Follow Up Parent Interview Ages months Available in 9 languages (including English) to date, with more language translations in process In the interim, clinics decide if they implement M-CHAT-R/F in English before other languages become available

46 M-CHAT-R/F 20 yes-no questions convert to pass/fail Sen ( ) Spec ( ) PPV 0.138; NPV PLUS Follow Up Parent Interview Sen ( ) Spec ( ) PPV 0.475; NPV 0.999

47 M-CHAT-R/F SCORING: No responses convert to fail (risk of ASD) EXCEPT Questions #2, 5, and 12 reverse-scored; yes converts to fail.

48 Total Score 0-2 Low Risk (93%*) M-CHAT-R/F Interpretation Administer at all 18m & 24m WCC Total Score 3-7 Medium Risk (6%*) Total Score 8-20 High Risk (1%*) Robins, et al., 2014

49 M-CHAT-R/F Interpretation - Low Risk Administer at all 18m & 24m WCC Total Score 0-2 Low Risk Total Score 3-7 Medium Risk Total Score 8-20 High Risk No Action Required Unless surveillance indicates risk for ASD Robins, et al., 2014

50 M-CHAT-R/F Interpretation - High Risk Administer at all 18m & 24m WCC Total Score 0-2 Low Risk Total Score 3-7 Medium Risk Total Score 8-20 High Risk Robins, et al., 2014 Refer

51 M-CHAT-R/F Interpretation - Medium Risk Total Score 3-7 Administer Follow-Up parent interview Score after Follow-Up 0-1 Score after Follow-Up 2 or more Robins, et al., 2014 No Action Required Unless surveillance indicates ASD risk

52 M-CHAT-R/F Interpretation - Medium Risk Total Score 3-7 Administer Follow-Up parent interview Score after Follow-Up 0-1 Score after Follow-Up 2 or more Robins, et al., 2014 Refer

53 M-CHAT-R/F Exercise Sally 18-month WCC What is the M-CHAT-R score? What is the risk category?

54 Sally s Failed Questions 8. Is your child interested in other children? (For example, does your child watch other children, smile at them, or go to them?) Yes No (Failed) 12. Does your child get upset by everyday noises? (For example, does your child scream or cry to noise such as a vacuum cleaner or loud music?) 20. Does your child like movement activities? (For example, being swung or bounced on your knee) Yes No (Failed) (reverse scored) Yes No (Failed) Total: 3 failed responses Moderate Risk What next?

55 Use The M-CHAT-R/F Follow-Up Interview For All Failed Items M-CHAT-R alone Positive Predictive Value (PPV) = M-CHAT-R/F PPV = Robins 2014

56 Autism Screening Not all children who fail their autism screening will meet diagnostic criteria for autism spectrum disorder - discuss with parents (M-CHAT-R/F PPV=0.475)

Autism Screening Nearly all children who fail their autism screening WILL meet diagnostic criteria for some developmental delay - discuss importance of

57 Autism Screening Nearly all children who fail their autism screening WILL meet diagnostic criteria for some developmental delay - discuss importance of follow through with parents. (PPV for any DD or concern 0.946) Robins 2014 Remember to refer for BOTH ASDspecific diagnostic evaluation AND Early Intervention

58 Basic Developmental Screening Autism screening does not replace general developmental screening. AAP screening guidelines recommend BOTH general development screening AND screening for ASD at 18-month well child visit. Practices not doing 30-month well child visits will do BOTH screenings at 24-month visit.

59 Surveillance Is Important Continue diligent surveillance and screening Standardized screening for ASD in conjunction with routine developmental surveillance optimizes early detection of ASD. Robins, et al Pediatrics

60 Differential Diagnosis (partial list) Presenting signs concerning for possible ASD overlap with other disorders: Intellectual Disability/Global Developmental Delay Selective mutism Language disorder Sensory integration problems Anxiety Adjustment disorder Disruptive behavioral disorder Hearing impairment

61 When ASD Screen Is POSITIVE Next steps Explain screening as separate from the diagnostic process Highlight Refer for: autism-specific multidisciplinary team evaluation formal audiology evaluation to early intervention agency Consider referral to private therapy (speech and occupational)

62 Common Referral Form Oregon ABCD EI/ECSE Referral Form Helps providers capture important referral information Streamlines referral and evaluation process Authorizes dual consent to enhance communication between providers and EI/ECSE

63 Next Steps Encourage communication and follow-up on referrals Use the Common Referral Form and establish a feedback loop with referral agencies Attend new START trainings

64 PART 4 Community Partners & Resources

65 Early Intervention Early Childhood Special Education Multnomah Early Childhood Program phone fax (the referral form)

66 Public Health Home Visiting Early Childhood Services Multnomah County Health Department phone fax children-special-health-care-needs

67 Childcare Resource And Referral The connecting link between families, child care providers, and the health community Phone: Website:

68 211info Every week parents ask us hundreds of questions about their kids for free Info Text: children to Website:

69 OPAL-K Oregon Psychiatric Access Line about Kids A mental health telephone consult line for primary care clinicians in Oregon who serve children and adolescents 9am to 5pm, M-F Contact OPAL-K to register or for more information: OPALK@ohsu.edu Oregon provider guide available now at: ohsu.edu/opalk Washington provider guide available at:

70 PART 3 Implementing Standardized Developmental Screening in Your Practice

71 Getting STARTed with Screening Tools Small Steps QUESTIONS: How do you make time for screening? Who administers the screening, scores the tests, and communicates results? Who else needs to be involved in the screening and referral process?

72 Improvement Methods (from IHI) What are we trying to accomplish? How will we know that a change is an improvement? Act Study Plan Do What changes can we make that will result in improvement?

73 The PDSA Cycle Act Meet objective Plan What changes are to be made? Develop questions & predictions (why) Next cycle? Create plan to carry out the cycle (who, what, where, when) Complete the analysis of the data Compare data to predictions Carry out the plan Document problems and unexpected observations Study Summarize what was learned Begin analysis of the data Do

74 Continuous PDSA Cycles ACT PLAN ACT PLAN STUDY DO ACT STUDY PLAN DO STUDY DO Changes that result in improvement Hunches, theories, ideas

75 Coding and Documentation of Developmental Screening Coding is vitally important for tracking screening rates, CCO and PCPCH metrics To submit code for reimbursement or not? Requires careful consideration of pros and cons by each clinic. (See OPIP resource) Typically reported when performed during preventive service visit Scoring done by physician, nurse, MA; discussion with family must be done by medical provider Document the tool administered, total score, interpretation (pass / fail) and discussion with family

76 Billing Decision to bill or not and amount must be applied to all insurance types. To not bill uniformly is typically unacceptable billing practice may be billed multiple times during a visit if more than one tool is used Attach -25 modifier to well child code Attach -59 modifier to code only if multiple codes billed If claim is rejected, send AAP letter (see resources) to Medical Director of insurance plan along with copy of AAP guidelines

77 References Olson AC. How to establish family professional partnerships. Presented at: International Family Centered Care Conference September 5, 2003; Boston, MA Facts About Childhood Literacy, Education Commission of the States, 2001: Last accessed 10/20/11 at http// Annie E. Casey Foundation, 2012 Kid s Count Data Book National Survey of Children's Health. NSCH 2011/12. Data query from the Child and Adolescent Health Measurement Initiative, Data Resource Center for Child and Adolescent Health website. Retrieved 5/6/13 from Journal of Developmental/ Behavioral Pediatrics 24: , 2003 Halfon, N., Regalado, M., Sareen, H., et al. (2006). Assessing Development in the Pediatric Office. Pediatrics 113(6); VanLandeghem, K., (2002). Reasons and strategies for strengthening childhood development services in the healthcare system. National Academy for State Health Policy: The Commonwealth Fund. Hollie Hix-Small, Kevin Marks, Jane Squires and Robert Nickel, Impact of Implementing Developmental Screening at 12 and 24 Months in a Pediatric Practice, Pediatrics 2007;120;381 Barnett, W. S. (1995). Long-term effects of early childhood programs on cognitive and school outcomes. The Future of Children Long- Term Outcomes of Early Childhood Porgrams 5(3), Castro, G. & Mastropieri, M. A. (1986). The efficacy of early intervention programs: A meta-analysis. Exceptional Children, 52, Hebbeler, K., Spiker, D., et al. (2007). Early intervention for infants and toddlers with disabilities and their families: Participants, services, and outcomes, NEILS Final Report. Accessed November 3, 2011 at Palfrey, J. S., Hauser-Cram, P., Bronson, M. B., Warfield, M. E., Sirin, S., & Chan, E. (2005). The Brookline early education project: A 25-year follow-up study of a family-centered early health and development intervention. Pediatrics, 116(1), Retrieved December 21, 2006, from White, K.R., (1985). Efficacy of early intervention. Journal of Special Education 19(4), SM Dworkin, A Shannon, and P Dworkin. ChildServ Curriculum. Center for Children s Health and Development, St. Francis Hospital and Medical Center; 1999; Hartford, CT. AAP Policy - Pediatrics 2006; 118;

78 PART 5 Complete TRAINING EVALUATION

79 CME Information This START training is eligible for a maximum of 2.0 hours AMA PRA Category 1 Credit(s) You will receive a START CME completion certificate via when you complete the follow-up survey

80 MOC Part IV for Pediatricians MAINTENANCE OF CERTIFICATION FOR THE AMERICAN BOARD OF PEDIATRICS START is an established quality improvement project for MOC Part IV credits. Talk to START staff if you are interested Peg King, START Program Manager x101

81 Other START Training Modules Adolescent Depression Screening Adolescent SBIRT with CRAFFT Autism Spectrum Disorder 101 Behavioral Health Integration Peripartum Mood Disorders Screening ACEs/Trauma-Informed Care To schedule a training, please contact Peg King, START Program Manager margaret.king@oraap.org x101

82 To find out more about the Oregon Pediatric Society please visit:

83 Thank you.

Peripartum Mood Disorders and Postpartum Depression Screening: For Primary Care Providers Caring for Children in Oregon

Peripartum Mood Disorders and Postpartum Depression Screening: For Primary Care Providers Caring for Children in Oregon A Project Of The Oregon Pediatric Society Oregon Chapter of the American Academy