1 Beyond Developmental Screening: Ensuring Follow-Up Services for Children Identified At-RiskBekah **BEGING RECORDING** Good morning everyone and thank you for joining our webinar on ______. This webinar is part of an on-going public health and primary care series featuring public health experts offering valuable training and resources to primary care providers along with ideas and examples of how the two can work together to improve population health. March 23rd, 2017

2 We Want To Hear From You! Type questions into the Questions Pane at any time during this presentation Bekah Include “heads up” on interactive pieces – questions, polling, hand-raising, etc. Before I turn things over to our expert I want to review a few things about the technology we’re using today. Since we have so many of you on the line everyone is and will remain on mute throughout the presentations. We do have plenty of time set aside to take your questions. We welcome you to submit questions via the question pane on your control panel. You can type away and I will read your question for any of our presenters to answer. Please also feel free to send me a message via the questions pane if you have technical issues and I will do my best to assist you. Please note that we will send all webinar participants a link to the recording, slides and additional materials after the webinar.

3 Patient-Centered Primary Care InstituteOnline Modules Webinars Website Learning Collaboratives Trainings TA Network Bekah A few words first about the Patient Centered Primary Care Institute. The Institute is a public-private partnership launched in 2012 with the support of the Oregon Health Authority & Northwest Health Foundation it is currently managed by Q Corp. Together with the experts we partner with, our goal is to get primary care practices connected to a broad array of technical assistance as they work towards the patient-centered primary care home, or medical home, model of care. We work to serve practices at all stages of transformation and to build capacity and create alignment to support ongoing transformation and quality improvement in Oregon. We encourage you to visit our website (www.pcpci.org) to access resources, including previous webinars. You can sign up for our list on the website, which is how we will announce additional web-based and in person training opportunities as well as future Institute programs.

4 Learn more: http://primarycarehome.oregon.govPCPCH Model of Care Oregon’s PCPCH Model is defined by six core attributes, each with specific standards and measures Access to Care “Health care team, be there when we need you” Accountability “Take responsibility for making sure we receive the best possible health care” Comprehensive Whole Person Care “Provide or help us get the health care, information and services we need” Continuity “Be our partner over time in caring for us” Coordination and Integration “Help us navigate the health care system to get the care we need in a safe and timely way” Person and Family Centered Care “Recognize that we are the most important part of the care team - and that we are ultimately responsible for our overall health and wellness” Learn more: Bekah As I mentioned, the Institute aims to help primary care practices achieve recognition as a primary care home through Oregon’s Patient-Centered Primary Care Home, or PCPCH program. The model is a set of standards organized under six core attributes which you see here. You can visit the PCPCH program website at primarycarehome.oregon.gov to learn more.

5 Presenters Colleen Reuland, MS Director, Oregon Pediatric Improvement Partnership (OPIP) Instructor, Department of Pediatrics Oregon Health & Science University. Suzanne Dinsmore, MD Pediatrician Childhood Health Associates of Salem Colleen Reuland Director Oregon Pediatric Improvement Partnership (OPIP) Ms. Reuland is the Director of the Oregon Pediatric Improvement Partnership (OPIP), and an Instructor in the Pediatrics Department at Oregon Health & Science University (OHSU). Ms. Reuland serves as the Principal Investigator on a number of quality measurement and improvement projects focused on screening, referral, and care coordination for children at-risk for developmental, behavioral, and social delays, and medical home implementation. She has significant experience working with State Medicaid/CHIP programs and front-line practices on quality measurement and improvement activities, and has specific expertise and commitment to ensuring these measurement and improvement efforts have a patient-centered focus and that methods are used to engage and partner with patients. Ms. Reuland is also the measure steward or the CHIPRA measure focused on developmental screening, and serves as an expert reviewer for The Journal of Developmental & Behavioral Pediatrics. Suzanne Dinsmore, MD Pediatrician Childhood Health Associates of Salem MD. Suzanne Dinsmore graduated from Willamette University with a BA in She received her MD from the University of Oregon Medical School in Dr. Dinsmore completed her residency training at Michael Reese Hospital in Chicago, Illinois in Before coming to Childhood Health, Dr. Dinsmore worked for the Cook County Health Department in Chicago, and for Kaiser Permanente in Portland. She joined Childhood Health in She is board certified in Pediatrics. She is involved in the Community Connection Clinic in Salem and the Community Based Early Autism Identification Project through Oregon Center for Children and Youth with Special Health Needs.  She also serves on the Institute on Development and Disability (IDD) Advisory Board.

6 Learning Objectives Provide an overview of community-level asset mapping conducted to identify follow-up resources and supports for children identified “at-risk” on developmental screening tools.  Describe applied methods and processes patient-centered primary care homes can use to better follow-up for children identified at-risk that identifies services that are the best match for the child and family. Describe applied care coordination methods used to enhance the number of children identified at-risk for delays to receive services Note: About the Varied Audience for this Webinar and a Sweet Spot We Are Trying to Reach Given We have: Primary Care Providers Early Learning Hubs Public Health EI CCOs Other early learning systems

7 Agenda Background & contextRecommendations related to developmental screening in primary care Momentum related to developmental screening on Oregon Opportunity to focus on follow-up to developmental screening: Spotlight of an effort in three counties Data gathered and primary opportunities identified Community-level asset mapping conducted to identify follow-up resources and supports for children/families.  Pilot tools and strategies developed and being implemented by health care and early learning Sharing from the front-line – A front-line provider’s perspective from this project and lessons learned for other PCPCH practices

8 Developmental Screening Recommendations for Primary Care ProvidersBright Futures Recommendations for Primary Care Providers in the First Three Years of Life: Standardized developmental surveillance at every visit across the five domains of a child’s development Use of standardized developmental screening tool for children for whom concerns are identified Implementation of standardized developmental screening tools three times in the first three years of life 9 month visit 18 month visit 30 month visit (if practice not doing the 30 month visit, 24 month visit)

9 Momentum Around Developmental Screening In OregonCoordinated Care Organization Incentive Metric – Developmental Screening in First Three Years of Life Patient Centered Primary Care Homes (PCPCH) Standards Includes developmental screening In 2017 Standards is a component of the must pass standards Early Learning Hub Metrics Includes CCO Developmental Screening Incentive Metric

10 Children Identified “At-Risk” on Developmental Screening ToolsOpportunity to NOW Focus on Follow-Up to Developmental Screening that is the Best Match for the Child & Family Goals of screening Identify children at-risk for developmental, social/or behavioral delays For those children identified, provide 1) developmental promotion, 2) refer to services that can further evaluate and address delays Many of these services live outside of traditional health care Children Identified “At-Risk” on Developmental Screening Tools This report is focused on children identified “at-risk” that should receive follow-up services. These are children that are identified “at-risk” for developmental, behavioral or social delays on standardized developmental screening tools. In the communities of focus for this work, a majority of providers are using the Ages and Stages Questionnaire (ASQ)3. Therefore the children of focus are those identified “at-risk” for delays based on the ASQ domain level findings.

11 Coordinated Care Organizations (Including Primary Care)From Developmental Screening To Services in OREGON: Opportunity to Connect the Fantastic Individual Silos Coordinated Care Organizations (Including Primary Care) Early Learning Early Intervention

12 to achieve educational attainment goalsFrom Developmental Screening To Services in Oregon: Opportunity to Connect the Fantastic Individual Silos Coordinated Care Organizations Goals Related to: Well-Child Care Developmental Screening Coordination of Services Early Learning Goals Related to: Ensuring children are kindergarten ready Family Resource Management- Family have info and support needed Coordination of services Early Intervention Goals related to providing services to young children to achieve educational attainment goals School Readiness

13 OPIP Projects Focus on Community- and Population Based Projects Focused on Enhancing Follow-Up Key Components of the Projects Stakeholder Engagement & Community Asset Mapping Engaging stakeholders in the community Examining data related to where children identified at-risk “fall out” of the pathway to receiving services Based on this stakeholder engagement and data, development of current and potential pathways from screening to services Includes WHICH services WHO to refer HOW to refer Develop and pilot new methods to improve follow-up, communication and coordination. Three Priority Areas of Focus: Primary Care Practices – Enhanced Medical Decision Tree Early Intervention – Methods to enhance coordination and communication Priority early learning services identified by community: Home visiting, parenting supports, mental health – Methods to refer to these services, enhanced coordination

14 Stakeholder Engagement in Marion, Polk, and Yamhill Counties to Inform Community Asset MappingCCOs (WVCH, YCCO) Medical Director Metrics Staff Practice Support Staff Mental Health Director Staff that oversee services for children Liaison to Early Learning Hubs OHA Innovator Agent Primary Care Practices that see large number of children and are doing developmental screening Practice staff engaged included: Physician Care Coordinator Referral Coordinator Practice Manager EI & Education EI/ECSE Program Coordinator EI Referral Intake Coordinator School District Representative Early Learning Hub (Yamhill Early Learning Hub, Marion and Polk Early Learning Hub) Director or Executive Director Community Engagement Staff Staff involved in efforts around developmental screening Home Visiting and Head Start/Early Head Start Centralized home visiting referral programs Public Health/ CaCoon/ BabiesFirst Healthy Families Other community services that provide home visiting Early Head Start and Head Start Child Care and Parenting Supports Childcare Resource and Referral Center Childcare Centers conducting screening Oregon Parenting Education Collaborative entities

15 Stakeholder Engagement: Current Systems and Processes Related to Follow-Up to Developmental Screening Individual interviews and engagement: Those screening, what is your follow-up; Those who could provide follow-up, what do you provide and how to people refer to you Recruited three parent advisors whose children went through systems Periodic group-level stakeholder meetings to provide updates and obtain community-level input and guidance Early Learning Hubs (Yamhill Early Learning Hub & Marion and Polk Early Learning Hub) were critical partners Leveraged shared table and relationships they have created within Early Learning System Engaged new stakeholders with the Early Learning Hub groups Leveraged Early Learning Hub parent advisory groups get feedback from parents

16 Community Asset Mapping and Pathway: Example from Marion and Polk County

17 Template for Community Asset Mapping Your CommunityBarebones Template Located Here: Step 1: Identify the specific programs that provide the specific services noted in the map. Step 2: Identify the specific connection and feedback loops between the different entities. Using the arrows within the Legend, create connections among the providers you have listed above and clarify if there are existing referral forms, methods, and communication feedback loops, and for whom How are children referred to the other boxes? Does this happen in a standardized way? Which children get referred? Is there communication back to the referring entity? Is this communication only for children that access the service?

18 Examination and Use of Data About Developmental Screening and Follow-Up for Children 0-3 to Understand Current Processes and Needs CCO level data about developmental screening Total number of children screened as defined by claims Screening rates by practices to which children 0-3 are assigned Examining data for disparities by race ethnicity Pilot Practice-level data Of developmental screens conducted, how many identify a child at-risk for delays Of developmental screens where child identified at-risk for delays, follow-up steps Early Intervention data Referrals Evaluation Results

19 Identifying Infants and Young Children with Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening. Council on Children with Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee and Medical Home Initiatives for Children with Special Health Needs Project Advisory Committee. Pediatrics. 2006: 118;405

20 If follow-up to developmental screening is occurring, shouldn’t the slope of the lines should be similar? Number of Children 0-3yrs Screened (According to 96110) in WVCH Number of Children Found Eligible To Receive EI Services in Marion & Polk Counties 2013 vs. 2015: Total Improvement: 79% (N=2440 Children) 2013 vs. 2015: Total Improvement: 10% (N=26 Children) Marion: 10% (N=21) Polk: 11% (N=5)

21 For Those Children Identified “At-Risk” and Referred to Early Intervention Services, Improvement Opportunities Exist Within pilot primary care practices, a majority of children identified “at-risk” had no documented follow-up 60-70% of those identified at risk were not referred to Early Intervention (Bright Futures Pathway) Of children identified as “at-risk” that were referred to Early Intervention(915): 562 (61%) were able to be evaluated. Reasons for the 39% of referrals not being evaluated: Parental delay (18.6%), an inability to contact the family (16.8%), and the family declining the evaluation (2.4%). Of the children able to be evaluated (562), 347 (62%) were found to be eligible for services, meaning 38% were ineligible for services.

22 Qualitative Findings Related to Follow-Up to Developmental Screening for Young ChildrenFollow-up to screening in primary care Confusion and lack of awareness within primary care about difference between recommendations for when to refer to EI vs EI Eligibility Perception that many children referred will not be eligible impacts if and when they refer Parent push back on referrals, cultural variations Need for referral criteria that take into account child and family factors, particularly for those children for whom the delay may be because of lack of exposure to the developmental tasks asked about in the ASQ Lack of awareness of resources within Early Learning and/or WHEN to refer to them Need for parent supports Developmental promotion that could in occur in the home Education about referrals when provided Parent support in navigation

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24 Three Priorities Areas Identified for WHERE to Focus Improvement PilotsFor primary care practices conducting developmental screening, enhance follow-up for children identified Part 1: Develop a follow-up medical decision tree that is based on ASQ and child and family factors and goes beyond developmental evaluation and EI Part 2: Develop Parent supports in navigating referral process For Early Intervention, enhance referral pathways, coordination and communication with the entity that referred the child; follow-up steps for EI ineligible Within early learning, pilots of referrals from primary care to home visiting programs, parenting classes, and other supports

25 Early Intervention (EI) CaCoon/Babies First Part 1: Primary Care Providers Need a Follow-Up Medical Decision Tree To Identify Best Match for the Child/Family and is Anchored to Services in the Community Based on data and community engagement, six priority referrals are included in the medical decision tree: Medical and Therapy Services (developmental evaluation and therapy services) Early Intervention (EI) CaCoon/Babies First Centralized Home Visiting Referral (Includes Early Head Start and Head Start) Parenting Classes Mental Health

26 Example Follow-Up Medical Decision Tree for a Practice in Marion and Polk County

27 Anchored to Child and Family Factors and Potential Needs Left Side: Anchored to ASQ Scores Developmental promotion that should happen that day When and who to refer to Early Intervention (EI) When and who to refer to a Developmental Pediatrician for evaluation When and who to refer to Mental Health Right Side Anchored to Child and Family Factors and Potential Needs Referral to early learning services to support child and family: Babies First!/CaCoon, Home Visiting, Parenting Classes

28 ASQ Learning Activities for the specific domains Vroom!Developmental Promotion: Options to Provide to All Children Identified at Risk ASQ Learning Activities for the specific domains Vroom!

29 Referral Pathways by TOTAL Score Across Five Domains

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31 Key to Referral to Early Intervention

32 Pilot of EI Communication When Unable to Evaluate: Goal is to Reduce the 2 in 5 Children Referred by Not Evaluated Feedback to Referring Provider When they sent the “closure” letter If they referred to FamilyLink Completed Example:

33 Referral to Developmental Behavioral PediatricianThe ASQ domains which put the child “at-risk” matter in terms of whether you should refer to Developmental Behavioral Pediatrician After consultation with experts in the field, the children most likely to be delayed in getting a medical evaluation and/or will not receive robust enough services from EI to address their needs: Intellectual disability Autism Flags for these under-identified children are Delays in communication (always one of the factors) And Delays in problem solving or social emotional

34 Consider Referral to Developmental Behavioral PediatricianKid “In the BLACK” in the Communication domain AND either the Personal-Social domain or Problem Solving Domain Or if the child is in the Black on 2 or more other domains and has any of the following presenting concerns: Kids with overall DD (or intellectual disability) or ASD who do not have identified cause, (may be seen initially by genetics instead) Kids who are not progressing in services as expected or recent increase in symptoms Kids who have challenging behaviors with inadequate response to behavioral interventions or medication. Kids with secondary medical issues that are not responding to usual treatments (including feeding and nutrition) Kids with rare/unusual genetic/chromosomal disorders (after initial visit with medical genetics) Kids with other chronic conditions that require inter-disciplinary team management (eg, child with CP, TBI etc) Kids who may be experiencing traumatic events

35 Follow-Up Based on EI EvaluationIf Eligible for Early Intervention Review Pilot Form of EI Services Receiving (Newly developed as part of this pilot) Consider Supplementing for Services Under Insurance Coverage (CCO Summaries Newly Developed as part of the pilot)

36 Pilot EI Communication Form to Inform Possible Secondary Referral Being Developed (Likely in Place by March ‘17)

37 WVCH Summary of Services Related to Follow-Up

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39 Referral Pathways Based on Score to Just Social-Emotional Domain

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41 Right Side of Medical Decision TreeFor ALL children identified at-risk, consideration of three community-level resources

42 Child and Family Factors Listed on the Back of the Decision Tree: Tied to Eligibility and Priority Criterion Within This Community Feels Depressed or Overwhelmed Isolation/Lack of Support Support with Parenting Has Disability Teen/Young Parent First Time Parent Tobacco Use Domestic Violence (present or history of) Alcohol/Drug Use Lack of Food/ Clothing/Housing Incarceration/Probation Low Income Migrant/Seasonal Worker Unemployed Homeless Receives TANF/SSI/SNAP Lack of Prenatal Care Support with Breastfeeding Support with Infant Care Drug Exposed Infant/Pregnancy Support with Attachment/Bonding Has Disability Born Premature Home Environment Concerns Development Concerns Social/Emotional Concerns Behavior Concerns Feeding Concerns Health Concerns Weight Concerns

43 Follow-Up Medical Decision Tree to Determine “Best Match” for Services for the Child/FamilyDisclaimer: This is Version 1.0 Goal is to learn from this pilot experience and understand what works and doesn’t work (Funding ends June ‘17) We are also tracking data to assess for capacity AND refinements to the process We can only provide information about need for services if we have concrete data on children identified that SHOULD be referred me if you are interested in receiving a version knowing: We are learning from this pilot They need to be customized for each community We are exploring funding to support this customization, training and implementation support

44 Part 2: Care Coordination Supports to the FamilyInformed by parent advisors, developed tools and processes to better support families Information Sheet (Developed through this project), Providers ended up using this to ensure shared decision making on referrals Phone Follow-up (Developed through this project)

45 Pilot Education Sheet for Parents To Explain Referrals

46 2 in 5 children referred to EI don’t get evaluated Phone Follow-Up: Developed it because 39% of referred children not able to be evaluated 2 in 5 children referred to EI don’t get evaluated Some studies show that families make a decision on a referral in the first 48 hours Researchers in Illinois found that phone follow-up (not necessarily contact) within two days of the referral significant increased follow through Phone calls can also identify barriers to obtaining the evaluation

47 Pilot: Phone Follow-Up Script for Referred Children

48 Hearing from the Front Line: Experience of a Primary Care Practice in These Improvement Efforts Suzanne Dinsmore, MD Child Health Associates of Salem (CHAoS)

49 Childhood Health Associates of Salem10 MD, 4PA, 2NP, 1 LCSW and 2 PsyD’s 2 RN Care Coordinators and 2 Referral Coordinator 16,000 kids AllScripts HealthMatics 60% Medicaid, 35% commercial, 6% uninsured

50 Focus of Our Improvement Efforts Within Childhood Health Associates of SalemExamination of our practice-level data and the need for improvement, provision of our data to inform the community-level conversations Implementing OPIP’s Pilot Medical Decision Referral Algorithm Incorporates ASQ, child and family risk factors Goes beyond just developmental evaluation and EI, includes community based resources Pilot with FamilyLink (Centralized home visiting referral) Refined Process for EI Referrals Follow-up phone script and process Process for using communication back from EI Child not able to be evaluated Child not eligible Child eligible, but on what Parent Support – Using the Education Sheet Value of it to facilitate shared decision making with families Value of it from information management

51 An Applied Example from One of Our Primary Care Pilot SitesNumber of ALL Children in Clinic (Publicly and Privately Insured) WHO RECEIVED A DEVELOPMENTAL SCREEN IN ONE YEAR: N=1431 Of the children who received a developmental screen, 28% identified at-risk for delays for which developmental promotion should occur Number of children who were identified at-risk and SHOULD HAVE BEEN TO REFERRED TO EI: N=401 NUMBER REFERRED TO EI based on their developmental screen : N= 1431 N= 401 N= 76 81% NOT REFERRED Data Source: Data provided by Childhood Health Associates of Salem, Aug. & Jan 2017

52 Parent Education Sheet:Useful Tool to Use in Shared Decision Making with the Family Helps guide primary care provider on the resources available Provides contact information and online resources for parents to learn more

53 Helpful guide to further refine the Bright Future guidelines to be more realisticCreated pathways by which we do follow-up for all children, reduction of “watchful waiting”

54 Had some awareness of some of the community-resourcesDecision tree helpful for us to know WHICH kids should we refer and HOW

55 Efforts are Engaging Primary Care in the Early Learning Efforts in Our Community1) Enhanced awareness of the Early Learning System & Early Learning Hub Obtained specific information about resources we had not known about, specific pathways for referral and follow-up Parenting Education Collaborative VROOM ASQ Learning Activities Centralized Home Visiting – Family Link Pilot PCIT for Privately Insured Kids Participated on community-level meetings focused on this population Engagement of the CCO is different than engagement with the PCP given competing demands 2) For Early Learning Hubs: Leverage primary care given we see young children 11 times in the first three years of life for well-child care alone Unique opportunity to partner with parents and connect Unique opportunity to gather data to inform discussions about capacity Based on the numbers through this project, already clear that there is not capacity within the systems for all the children we identify Disparity in services available for working poor

56 What Questions Do You Have?Type questions into the Questions Pane at any time during this presentation We welcome you to submit questions via the question pane on your control panel. You can type away and I will read your question for any of our presenters to answer. Please note that we will send all webinar participants a link to the recording, slides and additional materials after the webinar.

57 Spotlights Presented Today Are from Past OPIP Projects: Thank you to the Funders of This Work Oregon Health Authority contracted with OPIP to provide consulting and technical assistance to Yamhill Early Learning Hub and Yamhill CCO on a community pilot focused on ensuring children identified at-risk for developmental, behavioral, and social delays receive follow-up services. (January-December ‘16) Supported by Funding Opportunity Number CMS-1G from the U.S Department of Health and Human Services, Centers for Medicare & Medicaid Services Willamette Education Service District contracted with OPIP to lead efforts in Marion, Polk and Yamhill County (May ‘16-June ‘17) In 2015 the Oregon Legislature directed Oregon Department of Education (ODE) to identify pathways from developmental screening to appropriate early learning services

58 Resources & Thanks! http://oregon-pip.org/focus/FollowUpDS.htmlDocuments Loaded to the Webinar Progress Report Early Childhood Mental Health Codes Blank Template for Community Asset Mapping Phone Follow-Up Script Questions or follow-up Colleen Reuland Thanks! Please complete post-webinar survey