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Setting the Stage for Success…

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Assuring Better Child Health & Development “ABCD”

The  NC  ABCD  Project:  2000  -­‐  Present      

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The “ABCD” History….

§  The  Commonwealth  Fund,  among  the  first  private  founda9ons  started  by  a  woman  philanthropist-­‐  Anna  M.  Harkness-­‐  was  established  in  1918  with  the  broad  charge  to  enhance  the  common  good.    The  Fund  carries  out  their  mandate  by  suppor9ng  independent  research  on  health  care  issues  &  issuing  grants  for  improving  health  care  prac9ce  and  policy.  

§  In  2000,  North  Carolina  was  one  of  4  states  to  be  awarded  a  grant  from  the  Commonwealth  Fund  to  develop  and  implement  a  program  to  enhance  child  development  services.  

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National Trends for Screening and Surveillance

§  ABCD (Assuring Better Child Health & Development) Commonwealth Fund Initiatives since 2000:

ABCD I (2000–2003) ABCD II (2003–2006) Setting the Stage for Success (2006–2007) ABCD Screening Academy (July 2007)—involving 23 states ABCD III (2009-2012)

§  AAP: 2001 & 2006 Policy Statements, Task Force on Mental Health, Bright Futures, 2007 Autism Screening Guidelines

§  Rethinking Well-Child Care (AAP and Commonwealth) §  Tiered Well-Child Care (Commonwealth) §  SAMHSA—screening for social-emotional development §  Early Childhood Comprehensive Systems Grants (MCHB) §  Medical Home (AAP)

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§  48%  of  children  in  NC  live  in  low-­‐income  families      

§   The  use  of    “the  most  common  &  familiar”        developmental  screening  tool  (Denver)  was        both  untenable  in  primary  care  pracFce  &        did  not  meet  sensiFvity  &  specificity    

§   The  AAP  was  recommending  formal          screening  and    surveillance  at  well  child  visits.    

§   Limited  access  to  professionals  with  0-­‐5          experFse  (  psychiatry,    psychology,  counselors)  

The Challenges……

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The Challenges Continue…

§ Division  of  MH,  SA,  and  DD  reorganizaFons:    “target”  populaFon  not  inclusive  of  children  at-­‐risk          or  with  mild  to  moderate  problems.  

 

§ The  Early  IntervenFon  (EI)  eligibility  criteria        changes-­‐less  children  would  qualify    

§ The  number  of  children  served  by  (EI)  was  low        (8-­‐13%  of    the  total  0-­‐3  popula9on  could  qualify–only        2.6%  historically  served.)    

§ Across  Medicaid  systems  of  care  the  average        rate  of  developmental  screening  was  low:          (approximately  15.3%)    ………  

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Strategic Components  

•  Quality  improvement  project  in  primary  care  with  quarterly  data  reporFng  and  review  

•  FormaFon  of  State  Advisory  Group  that  involved  leadership  from  the  NC  AAP  Chapter  and  AFP  Chapter  

•  Implemented  within  the  infrastructure  of  Community  Care  of  NC  (CCNC)  

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Quality Improvement in Primary Care Practice

Developmental  Screening  &  Surveillance…..  

The Solution: (1)  Develop a “best practices” comprehensive

community model for replication – The  model  built  on  North  Carolina’s  “Physician  Driven”,  enhanced  primary  care,  case  management  program,  Community  Care  of  North  Carolina,  and  characterized  by  two  major  components:    §  IntroducFon  &  integraFon  of  a  standardized,  validated  screening  tool  

(ASQ  or  PEDS)  at  selected  well-­‐child  visits,  that  is  pracFcal  and  that  works;  

 

§  CollaboraFon  with  local  and  state  agency  staff  and  families  in  developing  this  system  for  idenFfying  and  serving  children.  

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The Office Systems Approach

•  OrganizaFonal  tool:  Geang  Started  Worksheet  

 •  MulFdisciplinary:  involves  pracFce  staff  at  all  levels  

•  Networking:  guides  pracFce  in  building  relaFonships  with  community  partners  

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Sustaining Change

 New  kind  of  communicaFon  with  community  

§  RelaFonship  with  key  partners  §  Networking  to  facilitate  process  beyond  pracFce  §  Agreements  on  how  to  exchange  informaFon,  e.g.  standardized  referral  process/form  

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The Solution (cont.): (2.)  Formed  a  State  Advisory  Group  –  The  group  is  comprised  of  

leadership  from  key  agencies  who  have  the  capability  of  making  policy  changes.  

Medicaid  Early  IntervenFon  Part  C  Public  Health  State  ICC  Department  of  Public  InstrucFon:  

 Preschool  Smart  Start  Family  Support  Network  NC  Pediatric  Society  NC  Academy  of  Family  PracFce  

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Community Care of N.C.  •  14  networks,  each  501  c  3,  100  counFes  •  pmpm  to  networks  and  to  pracFces  to  support  care  management  acFviFes  

•  Network  level  of  support  includes:  care  managers,  behavioral  care  managers,  OB  Care  Managers,  network  psychiatrist,  PharmD,  RD,  transiFonal  nurses  

•  Community  mental  health  MCO  (LME)  parFcipaFon  on  network  boards  and  medical  management  commigees  

o  Clinical  Directors-­‐  Decision-­‐Making  o  Regular  reporFng  of  data  to  networks:  Quality  Measures  &  Feedback  (QMAF)  

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Cherokee  Graham  

Swain  

Clay   Macon  Jackson  

Haywood  

Transylvania  

Madison  Buncombe  

Henderson  

Yancey  

McDowell  Rutherford  

Polk  

Avery  

Burke  

Cleveland  

Watauga  Caldwell  Alexander  

Catawba  Lincoln  Gaston  

Ashe  Wilkes  

Alleghany  Surry  

Yadkin  

Iredell  

Mecklenburg  Union  

Stanly  Cabarrus  Rowan  Davie  

Stokes  Forsyth  

Davidson  

Anson  

Rockingham  Guilford  

Randolph  

Montgomery  Richmond  

Caswell  

Chatham  

Orange  

Person  

Lee  Moore  

Hoke  Scotland  

Robeson  

Cumberland  Harnett  

Wake  

Vance  

Franklin  

Warren  

Johnston  

Sampson  

Bladen  

Columbus  Brunswick  

Pender  

Duplin  

Wayne  

Wilson  Nash  

Halifax  Northhampton  

Edgecombe  

Pitt  Greene  Lenoir  

Jones  Onslow   Carteret  

Craven  Pamlico  

Beaufort   Hyde  Martin  

Bertie  Hertford  

Gates  

Washington  Tyrrell  Dare  

Mitchell  

Alam

ance   Durham  Granville  

New  

Hanover  

Chow

an  

a   r  Pasquatank  

Source:  CCNC  2011  

Legend  AccessCare  Network  Sites          Community  Care  Plan  of  Eastern  Carolina  AccessCare  Network  CounFes        Community  Health  Partners  Community  Care  of  Western  North  Carolina      Northern  Piedmont  Community  Care  Community  Care  of  the  Lower  Cape  Fear      Northwest  Community  Care  Carolina  CollaboraFve  Community  Care      Partnership  for  Health  Management  Community  Care  of  Wake  and  Johnston  CounFes    Community  Care  of  the  Sandhills    Community  Care  Partners  of  Greater  Mecklenburg    Community  Care  of  Southern  Piedmont  Carolina  Community  Health  Partnership  

                 

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Community Care of N.C. •  Care  Managers  –  assist  with  follow-­‐up,  transportaFon,  disease  management,  hospital  transiFon;  link  families  and  PCP’s  to  services;  track  ED  usage.    

•  Web–based  Care  Manager  System  •  InformaFcs  Center  with  Provider  Portal  •  Quality  IniFaFves  –  Adult  &  Pediatric:  Asthma,  Diabetes,  CHF,  ED  UFlizaFon,  Mental  Health  IntegraFon,  ABCD,  Dental  Varnishing,  Pregnancy  Medical  Home…  

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Assuring Better Child Development (ABCD Project)

•  Began in P4HM network, now statewide •  Screening and surveillance with parents as

experts on their child •  Elicits parent concerns •  Builds ongoing relationship between parents and

the Primary Care provider •  Early Identification

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Pediatrics & Community Care of N.C.

•  Care Managers – assist with follow-up and disease management; link families and PCP’s to services for developmental & behavioral disabilities; track ED usage.

•  Pregnancy Medical Home •  Health Check Coordinators (EPSDT) •  Care Coordination for Children, 0-5 (CC4C) •  CHIPRA Quality Demonstration Grant •  Initiatives – Developmental Screening and Surveillance

(ABCD), Asthma, Diabetes, Dental Varnishing, Mental Health Integration, Obesity, ADHD, EPSDT, psychosocial/social-emotional screening for school-age and adolescent; Medical Home for children & youth in Foster Care

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Strategic Factors for Spread

•  Data:  8  years  of  claims  reporFng,  incorporated  into  CCNC’s  QMAF  in  2012  

•  Policy  Change  •  EvaluaFon  and  publicaFons  •  Aligning  goals  with  state  partners:  Part  C,  Preschool  and  Department  of  Public  InstrucFon,  Smart  Start  

•  Standardized  referral  protocols  and  forms    

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Access I10/1/99 -3/31/00CCNC 10/1/99 -3/31/00

HMO 10/1/99 -3/31/00

P4HM Baseline10/1/99 -3/31/00P4HM 10/1/01 -3/31/02

cc

Developmental Screening: Percentage of 0-24 Month Health Checks with a Screening during a 6 Month Period

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NC Policy Change

§ Medicaid  changed  EPSDT  policy  (Health  Check),          effecFve  7/1/2004,  requiring  a  valid,  standardized      developmental  screening  tool  when  screening        children  at  the  6,  12,  18  or  24months  and      3,  4,  &  5  year  old  visit.    The  medical  record        should  contain  results  &  96110-­‐EP  should        be  on    the  claim.  § EffecFve  7/1/2010  AuFsm  screening  with  MCHAT                                    

 required  at  18  and  24  month  well-­‐visits  

§ Public  Health  system  (Child  Health)  transiFoned        clinics  to  a  menu  of    standardized,  valid,        developmental  screening    tools  in  2003  

 

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Currently in NC EPSDT  quarterly  report  on  96110  

•  Greater  than  90%  of  primary  care  pracFces  are  screening.  

•  75%  of  EPSDT  exams  for  0-­‐5  year  olds  include  a  developmental  screening  

•  Increase  in  referrals  to  Part  C  since  2003  from  3400  to  >20,000  annually  

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35%

19% 19%

16% 11%

Physicians Parents/Caregivers Social Services Hospitals/NICUs Local Public Health

Current Top 5 Referral Sources NC Infant-Toddler Program

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NC ABCD Evaluation & Publications

•  Earls,  MF,  Andrews,  JE,  Hay,  SS,  “A  Longitudinal  Study  of  Developmental  &  Behavioral  Screening  and  Referral  in  North  Carolina’s  Assuring  Beger  Child  Health  and  Development  ParFcipaFng  PracFces,”  Clinical  Pediatrics,  Vol.  48,  No.8,  Oct  2009,  pp.  824-­‐33.  

•  Earls,  M,  Hay,  S,  “Seang  the  Stage  for  Success:  ImplementaFon  of  Developmental  and  Behavioral  Screening  and  Surveillance  in  Primary  Care  PracFce,  The  North  Carolina  Assuring  Beger  Child  Health  and  Development  (ABCD)  Project,”  Pediatrics,  Vol.  118,  No.  1,  July  2006.  

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Referral Form Developmental Screening & Surveillance

Name of Child:______________________________________________________ Date of Birth:____/___/_____Age____________ _Sex________________________ Address:____________________________________________________________ Medicaid#:_________________Insurance___________ Social Security__________ Parent/ Guardian Name:________________________________________________ Home Phone:____________________ Work Phone:__________________________ Race:_________________________ Primary Language:________________________

Developmental/Interdisciplinary Referral: Concerns: Screening Tool: ¨ ASQ ¨ PEDs ¨ MCHAT ¨ ASQ-SE ¨ Other _________________ (Please Name) The ASQ or PEDS and/or MCHAT scoresheet is attached, if completed. I have discussed this referral with parent(s) Referred By: Phone: PCP Office: Fax:

(Insert Letterhead Identification Here)

ACCESS II & IIIACCESS II & III

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From There...

§  ParFcipaFon  on  ECCS  planning/implementaFon  teams    

§   ParFcipaFon  in  development  of  the  New  Kindergarten  Health  Assessment  to  include  developmental  screening  

§ Mental  health  integraFon  iniFaFves  in  the  state-­‐using  other  screening  tools,  e.g.  Edinburgh  for  maternal  depression  &  ASQ-­‐SE  in  primary  care      § A  resource  to  Health  Check  (EPSDT)  for  seminars,  surveys,  and  as  quesFons  arise  from  the  provider  community  

§   “ABCD”  Quality  Improvement  Group  meets  quarterly  to  exchange  resources,  etc.  

§ ABCD  State  Advisory  Group  meets  quarterly  to  strategize  and  facilitate  spread              

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Smart Start & ABCD Smart  Start  staff  person  working  within  pracFces  to  develop/enhance  systems  for  screening,  referral,  and  community  linkages  

o  2001  “Region  A”  –  7  westernmost  counFes  approximately  150  pracFces  

o  2003  &  2005  2  counFes  o  2007-­‐2008  four  Smart  Start  Partnership  Grants,  8  addiFonal  counFes;  6  more  counFes  covered  by  local  Partnership  funding  

o  2009  –  9  ABCD  grants  o  2010  –  NCPC  Board-­‐conFnued  investment  in  ABCD  grants.    Currently  6  posiFons,  serving  10  counFes.  

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Evaluation of Smart Start ABCD Project FY2007-2011  

     •  Targeted  PopulaFon:  

–  139  primary  care/pediatric  pracFces  –  11,995  chart  audits  reviewed/analyzed  

•  Services  Provided  by  SS  ABCD  Coordinators:  –  Training  and  technical  assistance  to  medical  providers  in  the  use  and  integraFon  of  standardized,  validated  developmental  screening  tools  at  well-­‐child  visits  (AAP  recommended)  

–  InformaFon  on  where  and  how  to  refer  “at-­‐risk”  children  to  appropriate  early  intervenFon  (EI)  agencies  and  community  programs  

   

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Smart Start Outcomes/Results Over Three Years

–  Increase  in  the  percent  of  children  (from  80%  to  99%)  who  received  developmental  screenings  at  their  most  recent  well-­‐child  visits  

–  Increase  in  the  percent  of  children  (from  64%  to  95%)  who  received  all  possible  screenings  at  well-­‐child  visits  

–  Increase  in  the  percent  of  “at-­‐risk”  children  (from  44%  to  67%)  who  were  referred  to  the  appropriate  EI  agency  for  services  

–  Increase  in  the  percent  of  referred  children  (from  40%  to  50%)  who  were  documented  as  having  received  follow-­‐up  services    

   

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Further Developments •  Training  of  Smart  Start  ABCD  staff  and  QI  group  on  auFsm  screening  and  maternal  depression  screening  

•  CME  sessions  for  NCPS  and  NCAFP  on  auFsm  screening  and  referral  

•  January  2009:  Medicaid  opens  a  new  code,  99420,  for  ASQ-­‐SE,  MCHAT,  PSC  

•  2012  NC’s  Race  to  the  Top  Grant  specifies  funding  for  expansion  of  Smart  Start  ABCD  Coordinators  to  cover  every  CCNC  network  

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ABCD: Integral to Child Health Care Quality

•  Coaching  and  data  sharing  in  networks  and  pracFces:  Pediatric  QI  coaches  and  Smart  Start  ABCD  coordinators    

•  EPSDT  quarterly  report  on  96110  and  99420  (auFsm  screening)  part  of  the  CCNC  QMAF  reporFng  to  networks  and  pracFces.  

•  Mental  Health  IntegraFon  in  primary  care  pracFces:  developmental  &  behavioral,  social-­‐emoFonal  screening  

•  CHIPRA  Child  Health  Quality  DemonstraFon  Grant  

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ABCD: Integral to Child Health Care Quality (2)  

•  CHIPRA  Core  Quality  Measure  #  8  (24  CQM’s  from  CMS  and  AHRQ)  

•  CHIPRA  Grant  Medical  Home:  2  cohorts  of  pracFces  in  learning  collaboraFve,  8  CCNC  networks,  27  pracFces;  developmental/behavioral/social-­‐emoFonal  screening,  referral,  and  community  linkages  for  ages  0-­‐20  years  

•  CHIPRA  implementaFon  in  Pediatric  EHR  format  as  structured,  reportable  data;  HIE  

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