Developmental Developmental ScreeningScreening

April 4, 2009April 4, 2009

Baseball, Child Baseball, Child Advocacy, Advocacy, and the Role of CCS and the Role of CCS

Paul Russell, MDPaul Russell, MDChildren’s Medical ServicesChildren’s Medical ServicesDepartment of Public HealthDepartment of Public Health

St. Mary’s Industrial St. Mary’s Industrial SchoolSchool Foster Care Baseball Foster Care Baseball TeamTeam

1914 1914

St. Mary’s Industrial St. Mary’s Industrial SchoolSchool Foster Care,Foster Care, Pitcher, Pitcher, 19141914

World Series, World Series, 19181918

Babe RuthBabe RuthHospital VisitHospital Visit Circa 1926 Circa 1926

Child Advocacy in Child Advocacy in AmericaAmerica1927: “Crippled Children’s Services” Program 1927: “Crippled Children’s Services” Program

started in Californiastarted in California

1930: American Academy of Pediatrics founded to 1930: American Academy of Pediatrics founded to respond to the special developmental respond to the special developmental and health needs of children.and health needs of children.

1935: Title V, Social Security Act passed 1935: Title V, Social Security Act passed to promote and improve maternal and child health nationwide. Seventy-four years later, Title V remains the longest lasting public health legislation in our Nation’s history.

California Children’s California Children’s ServicesServices

CCSCCS

Medical Treatment ProgramMedical Treatment Program

Medical Therapy ProgramMedical Therapy Program

CCS Program EligibilityCCS Program Eligibility

MedicalMedical Eligibility: Diagnosis BasedEligibility: Diagnosis Based - CCS eligible condition as per Title 22, Division 2, Part 2, - CCS eligible condition as per Title 22, Division 2, Part 2,

Subdivision 7, CCS, Chapter 4, Section 41832Subdivision 7, CCS, Chapter 4, Section 41832

Residential Residential - Resident of the county- Resident of the county

- Or enrolled in public schools- Or enrolled in public schools FinancialFinancial

- M/C, HF, or Annual income under $40K- M/C, HF, or Annual income under $40K- Medical cost > 20 % of annual income- Medical cost > 20 % of annual income

CCS Referral CCS Referral ProcessProcess* Initial referral by hospital, physician, * Initial referral by hospital, physician,

family.family.

* Medical records are required by CCS; * Medical records are required by CCS; review for support of requested services. review for support of requested services.

* The family completes and submits * The family completes and submits application. application.

* Nurse, MD and/or therapy manager * Nurse, MD and/or therapy manager determine medical eligibility. determine medical eligibility.

Referral Confusion and Referral Confusion and MTP EligibilityMTP EligibilityTitle 22, Section 41517.5Title 22, Section 41517.5

““(a) CCS applicants with at least one of the (a) CCS applicants with at least one of the following following

conditions shall be medically eligible for conditions shall be medically eligible for participation in the CCS Medical Therapy participation in the CCS Medical Therapy

Program:Program:  (1) Cerebral palsy as specified in Section 41517.3(a)(2). (1) Cerebral palsy as specified in Section 41517.3(a)(2). 

(2) Neuromuscular conditions that produce muscle (2) Neuromuscular conditions that produce muscle weakness and atrophy, such as poliomyelitis, weakness and atrophy, such as poliomyelitis, myasthenias, and muscular dystrophies. myasthenias, and muscular dystrophies. 

(3) Chronic musculoskeletal and connective tissue diseases (3) Chronic musculoskeletal and connective tissue diseases or deformities such as osteogenesis imperfecta, or deformities such as osteogenesis imperfecta,

arthrogryposis, rheumatoid arthritis, amputations, and arthrogryposis, rheumatoid arthritis, amputations, and contractures resulting from burns. contractures resulting from burns. 

  (4) Other conditions manifesting the findings listed in (4) Other conditions manifesting the findings listed in section 41517.3(a) above, such as ataxias, degenerative section 41517.3(a) above, such as ataxias, degenerative neurological disease, or other intracranial processes. ”neurological disease, or other intracranial processes. ”

““(b) CCS applicants under three years of age shall (b) CCS applicants under three years of age shall be be eligible when two or more of the following eligible when two or more of the following neurological findings are present: neurological findings are present:

(1) Exaggerations of or persistence of primitive (1) Exaggerations of or persistence of primitive reflexes beyond the normal age (corrected for reflexes beyond the normal age (corrected for

prematurity); prematurity); 

(2) Increased Deep Tendon Reflexes (DTRs) that are (2) Increased Deep Tendon Reflexes (DTRs) that are 3+ or greater; 3+ or greater; 

(3) Abnormal posturing as characterized by the (3) Abnormal posturing as characterized by the arms, legs, head, or trunk turned or twisted into arms, legs, head, or trunk turned or twisted into an abnormal position; an abnormal position; 

(4) Hypotonicity, with normal or increased DTRs, in (4) Hypotonicity, with normal or increased DTRs, in infants below one year of age. (Infants above one infants below one year of age. (Infants above one

year must meet criteria described in (a)(1)); or year must meet criteria described in (a)(1)); or 

Title 22 Sect. 41517.3.a.2Title 22 Sect. 41517.3.a.2“Cerebral palsy, a motor disorder with “Cerebral palsy, a motor disorder with onset in early childhood resulting from a onset in early childhood resulting from a non-progressive lesion in the brain non-progressive lesion in the brain manifested by the presence of one or manifested by the presence of one or more of the following:more of the following:

(A) Rigidity or spasticity(A) Rigidity or spasticity(B) Hypotonia, with normal or increased DTR’s, (B) Hypotonia, with normal or increased DTR’s, andand exaggeration of or persistence of primitive exaggeration of or persistence of primitive reflexes beyond the normal age rangereflexes beyond the normal age range(C) Involuntary movements that are described as (C) Involuntary movements that are described as athetoid, choreoid or dystonicathetoid, choreoid or dystonic(D) Ataxia manifested by incoordination of voluntary (D) Ataxia manifested by incoordination of voluntary movement, dysdiadochokinesia, intention tremor, movement, dysdiadochokinesia, intention tremor, reeling or shaking of trunk and head, staggering reeling or shaking of trunk and head, staggering or stumbling, and broad based gait.”or stumbling, and broad based gait.”

Diagnostic Confusion: Diagnostic Confusion:

The Hypotonic InfantThe Hypotonic Infant* Hypotonic cerebral palsy* Hypotonic cerebral palsy

* Developmental delay with * Developmental delay with

hypotoniahypotonia

* Myopathy* Myopathy

Referral Confusion: Referral Confusion: The Hypotonic InfantThe Hypotonic Infant

Less than one year:Less than one year: * hypotonia with increased DTRs….refer to * hypotonia with increased DTRs….refer to CCSCCS * hypotonia, developmental delay….refer * hypotonia, developmental delay….refer

to to Regional Center/Early StartRegional Center/Early Start * hypotonia with isolated gross motor * hypotonia with isolated gross motor delay…refer to CCS for diagnostic delay…refer to CCS for diagnostic evaluationevaluationHypotonia with exaggerated primitive Hypotonia with exaggerated primitive

reflexes at any age…refer to CCS reflexes at any age…refer to CCS

ClonusClonus

Types of CCS CasesTypes of CCS Cases

CCS only – medical case CCS only – medical case management only; no MTP management only; no MTP servicesservices

MTP only – receive PT/OT at MTU, MTP only – receive PT/OT at MTU, limited medical case limited medical case managementmanagement

CCS and MTP – therapy and CCS and MTP – therapy and medical case managementmedical case management

Medical Therapy Medical Therapy ProgramProgram

MTPMTP Physical TherapyPhysical Therapy Occupational TherapyOccupational Therapy Medical Therapy ConferenceMedical Therapy Conference

Medical Therapy Medical Therapy Conference (MTC)Conference (MTC)

Specialty team - It is the function Specialty team - It is the function of the MTC to bring together the of the MTC to bring together the expertise of combined expertise of combined professional services in order to professional services in order to bring maximum benefit to the bring maximum benefit to the child and his/her familychild and his/her family

Role - Medical Direction versus Role - Medical Direction versus

ConsultationConsultation

Medical Therapy Medical Therapy ConferenceConference

Pediatric OrthopedistPediatric Orthopedist

PediatricianPediatrician

Physical TherapistPhysical Therapist

Occupational TherapistOccupational Therapist

OrthotistOrthotist

Social WorkerSocial Worker

NutritionistNutritionist

CCS Case ManagerCCS Case Manager

MisconceptionMisconception

Therapy is good, more is Therapy is good, more is better.better.

Medically Necessary Medically Necessary TherapyTherapy

Once eligible, a therapy assessment is Once eligible, a therapy assessment is done to determine if there is a need for done to determine if there is a need for medicallymedically necessary therapy (as necessary therapy (as opposed to opposed to educationallyeducationally necessary) necessary)

Services are provided under medical Services are provided under medical direction (paneled provider)direction (paneled provider)– PrescriptionsPrescriptions– Medical reports Medical reports documenting functionaldocumenting functional gainsgains

Therapy is for habilitation and Therapy is for habilitation and rehabilitation caused by the MTP rehabilitation caused by the MTP eligible conditioneligible condition

Primary Care Physician Primary Care Physician RoleRole

Perform formal developmental Perform formal developmental

screeningscreening Refer to appropriate agencyRefer to appropriate agency Be an active member of the teamBe an active member of the team