The Fiscal Impact of Lost to Documentation of Newborn Hearing Screening in Oklahoma s County Health Departments

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1 The Fiscal Impact of Lost to Documentation of Newborn Hearing Screening in Oklahoma s County Health Departments Calyn Russ, Au.D Patricia Burk, Newborn Hearing Screening Program Coordinator, M.S. CCC-SLP, LSLS Cert. AVT Dr. Andrew John, Ph.D

2 National Definitions There are no standard definitions of loss to follow up/ loss to documentation across EHDI programs in states and jurisdictions. Lost to follow up (LTF): occurs when a baby does not receive the recommended follow up services. Lost to documentation (LTD): Babies in this group are those who have received services, but results have not been reported to the EHDI program and, therefore, cannot be documented. - The NCHAM e-book

3 National Definitions Lost to follow up: For an infant who did not pass newborn hearing screening, lost to follow up refers to a failure to receive the next step of treatment, be it rescreening or comprehensive audiologic evaluation. Lost to documentation: Failure to report the results from hearing screening, rescreening, diagnostic services, and/or treatment services that are needed for comprehensive surveillance and monitoring by EHDI and the medical home - AAP EHDI LTF/LTD Workgroup

4 National Definitions Loss to follow up/loss to documentation is based on infants not passing the final or most recent hearing screening that was reported as not having a diagnosis for the reason Unable to contact/unresponsive/unknown #Unable to Contact + #Unresponsive + #Unknown x 100= # Total Not Pass Final Hearing Screening - CDC EHDI Hearing Screening and Follow-up Survey

5 Lost to Documentation vs. Lost to Follow-Up Much of the literature up to this point has focused on lost to follow-up rather than lost to documentation WHY?

6 Lost to Follow-Up Infant did not pass the hearing screening and did not get follow-up services for some reason Possible hearing loss Child needs intervention if a hearing loss is present Full diagnostic audiological evaluation Hearing aids if hearing loss is confirmed Essential for age-appropriate development of speech and language

7 Negative Effects of Loss to Documentation LTD has mostly been considered the lesser of two evils between lost to follow-up and lost to documentation Hearing screening has been completed Child is receiving services Parents are typically informed of the results immediately BUT! Providers did not report to the State Health Department

8 Detrimental Effects of Failing to Report What problems does this cause? Failing to report breaks Oklahoma State law Parent concern and confusion Missing information results in lack of continuity of care The State Health Department has not received the most recent information and as a result, unintentionally gives outdated information to parents and providers because results of the NBHS were never reported to the State Health Department

9 To Summarize A need to break apart LTD and LTF so that efforts can be placed accordingly There is a need for research regarding loss to documentation as it continues to be a large part of the lost to follow-up problem. The purpose of this study is to demonstrate the costs of LTD and the effect it has on Oklahoma families.

10 Entities Performing Newborn Hearing Screening in Oklahoma Hospitals Audiologists County Health Departments Midwives (Implemented in November 2014)

11 Oklahoma Hospital Reports When we informally asked hospitals if they were screening and reporting for all newborns, all said yes. We found that this was not the case Bloodspot filter paper If we receive the filter paper without hearing screening results, we know the child has not had a NBHS or that NBHS was completed but not reported

12 A Question If hospitals can forget to report (even though it is state law), is it possible that other providers could also forget to report?

13 Other Providers Audiologists Our research has found that Audiologists working in private entities show large numbers of LTD How do we know this? Parent phone calls Lower number diagnosed when compared to national prevalence rates SoonerStart Part C Tracking forms Indicates children with hearing loss received services Able to cross-reference to locate missing audiology data

14 Other Providers Why not track audiologist s reporting practices? The problem: Access to patient charts, databases, and appointment schedules are not available to Oklahoma EHDI for private entities Therefore, it is not possible at this time to track the reporting patterns for audiologists in the state of Oklahoma This is a possible future collaborative QI efforts to review reporting processes at the clinical level.

15 Other Providers County Health Departments (CHDs) Unique opportunity to review patient appointments at CHDs that are providing hearing screenings through access to PHOCIS/OSIIS

16 PHOCIS and OSIIS What is it? PHOCIS: Public Health Oklahoma Client Information System Allows the NHSP to see if a child has received services through any county health department programs such as: Women, Infants and Children Supplemental Nutrition Program (WIC) Immunizations Part C Early Intervention Children First Dates of appointments are accessible OSIIS: Oklahoma State Immunization Information System Statewide immunization registry Demographic data such as current addresses can be located to assist the NHSP in providing follow-up services. The OSIIS program is linked to PHOCIS

17 Research Question What is the fiscal impact of loss to documentation (LTD) of newborn hearing screening at county health departments in Oklahoma for the calendar year 2013?

18 Participants Babies born in 2013 receiving newborn hearing screening in the state of Oklahoma who referred or passed hearing screening with a risk factor for late onset hearing loss and visited a county health department in the state of Oklahoma for services (WIC, Part C, Children s First, Child Health)

19 Materials PHOCIS OSIIS Tracking Spreadsheet Each child that fit criteria for inclusion in the study Each service the child received as found by cross-checking PHOCIS Missing results located by county Cost Spreadsheet Three categories: 1) Equipment 2) Staff Wages 3) Materials/Supplies Associated costs for each category

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21 Methods 1) Crosschecked PHOCIS and OSIIS to see if child was seen at a county health department 2) If a discrepancy existed, ed the provider to ask for results If provider did not respond, continued to them every 2 weeks If no response after 3 s, sent to Patricia to provider Once results were received from the provider, not reported results were marked on the spreadsheet along with county name and LTD if appropriate 3) Created a cost spreadsheet: -Equipment -Staff wages -Materials and supplies

22 What did we find?

23 2013 CHD Data part time employees were hired and trained 2628 charts were reviewed Not Performed Refers Pass but at RISK All charts were compared to PHOCIS and OSIIS system CDC Budget Period 2

24 Findings PHOCIS vs. OSIIS Comparison 1600 None in PHOCIS or OSIIS Just in OSIIS 1366 Just in PHOCIS with some type of service 1400 PHOCIS , 62% In PHOCIS but no hearing screening Scheduled but NO SHOW 749, 29% 246, 9% Had hearing screening but no result reported 0 PHOCIS

25 Data Not Reported by County 1% 1% 2% 1% 2% 2% 2% 2% 2% 2% 2% 3% 3% 3% 3% 3% 3% 4% 1% 1% 1% 5% 1% 1% Total 1% 9% 7% 7% 19% 11% County A County BB County U County C County V County T County X County E County H County O County W County Y County Z County AA County L County M County G County I County J County P County Q County B County CC County D County DD County F County K County N County R County S

26 Equipment Newborn hearing screening equipment is provided by the Oklahoma State Department of Health to 50 CHDs at low or no cost Equipment types: Tympanometry screeners OAE screeners ABR screeners

27 Equipment Additional costs: Tympanometry and OAE probe tips Special probes ABR couplers Electrodes NU-prep Q-tips and alcohol pads for AABR preparation Annual calibration of equipment*

28 Equipment Cost 2013 Category Cost Hearing Devices $970,000 Additional Costs $37,908 Annual Calibration $50,805 TOTAL $1,058, Note: Hearing equipment has been purchased over 20 years utilizing federal grant fundings. A limited number of devices are purchased each year to replace aging devices or meet the needs of rural communities. Annual calibration costs are paid from multiple OSDH programs.

29 Materials/Supplies Costs associated with: Paper Toner/Ink Printer Labels with CHD information Paper folder Windowed envelopes Return envelopes Shipping PHOCIS annual fee and updates Indirect costs Fax Phone system Office supplies

30 Costs of Materials/Supplies 2013 Material Cost Office Supplies $17, Shipping $4, IT Data Costs $9,000 Proprietary Software Maintenance $82,500 GRAND TOTAL $114, Required State IT Data Costs per person - $2,250 Proprietary Software includes updates and upgrades to software for Public Health Laboratory, Newborn (Bloodspot) Screening, Newborn Hearing Screening, and Congenital Heart Defects Screening. Costs are split with the Public Health Laboratory each year.

31 Staff Wages Only 4 employees to: Track approx. 53,000 babies born in Oklahoma each year Follow-up with hospitals Track down results (Midwives, hospitals, audiologists, CHDs) Enter results (hospital, rescreen, diagnostics) received Send letters to PCPs and families/return Mail Call families and assist with follow-up Hospital and CHD employee training and in-services Managing and troubleshooting 1000 pieces of audiology equipment at 57 hospitals and 50 CHDs Partnering with providers and parents statewide (ex. OKAT) Closing Charts/Cross referencing LTF/LTD with other programs Grants and national statistics And much more!!!

32 Staff Wages Newborn hearing screening runs on an extremely small staff Some states have the same number of staff with half the # of babies At the time data was collected, there was no follow-up coordinator When providers don t report, it takes time to track down results Approximately 154 not reported children for CHDs in 2013 Important to remember that this project is analyzing not reported rates for CHDs only» Hospitals» Audiologists» Midwives Takes time away from phone calls to Oklahoma families whose child/children are truly LTF

33 Staff Wages 2013 Staff Quantity Salary/Fringe Indirect Costs Follow-Up Coordinator 1 $76, per year $23, GALT employees 2 $22, per year $ Administrative Assistant 1 $51, per year $15, TOTAL $150,518 $46,269 GRAND TOTAL $196,787 Fringe benefits for all program personnel are based upon Oklahoma State Merit System contributed policies according to negotiated yearly schedules. Existing rates for State FY 2013 are calculated at 50% salary and longevity. Indirect Costs: 30.74% x staff member salary

34 Results How many CHD screenings were not reported in 2013? 154 (~9%) of hearing screenings performed by CHDs were not reported Equipment at 50 county location sites 30 sites did not report consistently (Closure Process) Costs for 2013 for: Equipment Materials/Supplies Staff

35 Fiscal Impact for 2013 $150, $114, $1,058, Materials Equipment Staff Grand total: $1,323,329.95

36 Summarizing the Costs Fiscal If CHDs followed state law by reporting, what else could we use our time and resources for? Emotional cost Families are scared and confused PCP confusion when reporting different results to families Inconsistency from provider to provider Reduces validity of hearing screening and diagnosis process Second guess the audiologist, EI provider, hospital, PCP, and/or the state Reduces consistency of vision and mission

37 The Impact Not using this info to embarrass CHDs but to help them improve reporting practices The info from this study is intended to: Use in collaboration with CHD partners to enhance program system and processes Use in future educational staff training sessions Remind external providers (ex. audiologists) about the importance of consistent state reporting Improve LTF caused by LTD Enhance NHSP tracking and surveillance efforts

38 How to Report Providers can find the newborn hearing screening form online at: 1) Mail: 1000 NE 10 th St Rm. 709, Oklahoma City, OK ) Fax: )

39 QUESTIONS

40 References Documented Status of Infants Not Passing Hearing Screening, United States (2014, December 1). Retrieved from Early Hearing Detection and Intervention. (n.d.). Retrieved from Newborn Infant Hearing Screening Act, Ok. Stat (1982). Summary of 2013 National CDC EHDI Data. (2015, April 1). Retrieved from Winston, R., & Hoffman, J. (n.d.). Chapter 2: Newborn Hearing Screening. In The NCHAM e-book (pp. 1-14). Winston, R., & Hoffman, J. (n.d.). Chapter 3: Tracking, Reporting, and Follow-up. In The NCHAM e-book (pp. 3-18). Schmeltz, L., & Fritzler, J. (n.d.). Chapter 31: EHDI Information Management. In The NCHAM e-book (pp. 1-20).