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Early Childhood Comprehensive Systems

Partners MeetingFriday, March 14, 2008

9:50 – 11:00 am Workshop

Implementing Developmental and Mental Health Screening:

Lessons from the ABCD Projects

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Opportunities to Link Practice and Policy Change

Lessons from the ABCD Collaborative

Jennifer MayPolicy Specialist

National Academy for State Health PolicyAssuring Better Child Health and Development (ABCD)

Initiative

Funded by The Commonwealth Fund

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About the Collaboratives• 3-year learning collaboratives of states

working to enhance developmental services to young children enrolled in Medicaid– Change in state policy and provider practice– Change in participating and non-participating

states

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Collaborative Members • ABCD I: General Development

– NC, UT, VT, WA– 2000-2003

• ABCD II: Social and Emotional Development– CA, IA, IL, MN, UT– 2004-2007

• Multi-agency teams from each state, led by Medicaid

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In the Collaboratives• Each state

– Implemented individual projects– Shared information and lessons learned from their

individual efforts

• NASHP– Provided technical assistance– Studied each state’s progress– Synthesized and disseminated states’ experience

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Building on ABCD I and II

• ABCD Screening Academy: Supporting the adoption of standardized screening tools, i.e. general developmental, social-emotional and maternal depression– ABCD Alumni engaged as faculty and topic experts– American Academy of Pediatrics: 2006 policy

statement on surveillance, resulted in active partnership for technical assistance events

– 23 states– 2007-2008

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NH MA

ME

NJ

CTRI

DE

VT

NY

DC

MD

NC

PA

VAWV

FL

GA

SC

KY

IN OH

MI

TN

MSAL

MO

IL

IA

MN

WI

LA

AROK

TX

KS

NE

ND

SD

HI

MT

WY

UT

CO

AK

AZ

NM

IDOR

WA

NV

CA

ABCD Screening Academy States

PRPR

ABCD Screening Academy States

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Common State Goals for Screening Academy states

1. Increase appropriate, effective screening by pediatricians

2. Ensure providers and families have information they need to identify, treat, and refer

3. Ensure that referrals are effective

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What did the States do during ABCD Collaborative?

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By Objective

Accomplishments and lessons in policy and practice improvement

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Foster Improved Screening• Helped primary care providers integrate the tools

into their practices– Learning collaboratives– Partnering with provider organizations that support

practices, i.e. Illinois and Iowa local AAP chapters instrumental partners

– Identify mentors to help practices integrate screening– Ongoing opportunities for practices to share experience

and lessons– Measurement supports continued improvement

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Foster Improved Screening

• Promoted pediatric provider use of screening tools– Work with physicians to identify tools and

promote their use (Utah Pediatric Partnership to Improve Quality)

– Modify Medicaid provider handbooks and websites used by provider practices

– Change payment policies

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Identified and Facilitated Referral to Follow-up Services

Identified existing resourcesFacilitated referralsUtah: learning collaboratives feature development of referral pathwaysIllinois & Iowa: identify resources to manage referralsIdentify and fill in the gapsMinnesota: New diagnostic system that better met needs of young childrenMedicaid benefit targeted to children with emotional disturbance.

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Leveraged Resources to Promote Change

• Formed partnerships– Illinois: local chapters of physician organizations sent out

letter supporting policy change

– North Carolina: Public health system (clinics) adopted menu of standardized screening tools for all young children

• Used quality improvement– Utah: EQRO implemented performance improvement

project on coordination between mental health systems and HMOs

– North Carolina: Built on PCCM delivery system in Medicaid

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Identified and Addressed Policy Barriers

• Identified policy barriers during planning, implementation, and operation of pilots

– California, Illinois, and Iowa projects developed formal mechanisms for identifying and considering changes

– Minnesota feeds project results into a group outside the project

• Policy changes in Medicaid and other agencies

– Illinois early intervention clarified eligibility policies

– Iowa and Utah provided dedicated resources to expand/build

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Lessons Learned1. Screening with a standardized tool is a critical

first step, but does little good without follow-up services

2. States can facilitate access to follow-up services

3. Demonstrations can inspire and test policy change

4. Partnering with pediatric clinicians is critical

5. Measurement is difficult but doable (and worthwhile)

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For more information:

Visit!http://www.nashp.org

http://www.abcdresources.org

Join the ABCD discussion forum!(register at

http://abcdresources.org/ScreeningAcademylogin.php )

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Developmental and Mental Health Screening

Glenace EdwallMinnesota Department of Human Services

Children’s Mental Health Division&

Maternal and Child Health Assurance Unit

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Screening: Developmental and Socio-Emotional

Developmental Screening Tools• Generally discriminate those children with

developmental delays and those who appear to be developing typically

• May include numerous domains expected to be affected by developmental delay

• Identify children in need of further assessment

Screening: Developmental and Socio-emotional

Socioemotional Screening Tools• Intended to identify children whose

socioemotional development is delayed and/or whose mental health development is at risk

• May include specific aspects of social and emotional functioning, appropriately developmentally scaled

• Identify children in need of further assessment

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Screening for Socioemotional Development

• Screening is a relatively brief process designed to identify children who are at increased risk of having disorders that warrant immediate attention, intervention, or comprehensive review

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Screening, Continued

• Identifying the need for further assessment is the primary purpose for screening

• Screening instruments are never used to diagnose or “label” a child

• Screening informs parents and those working with families about aspects of development needing further assessment

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Socioemotional Screening: Current Practice

Survey by Betsy Murray, M.D. (2006):• Responses from 590 primary care providers

(38% return rate)• 80% endorsed as best practice “the use of at

least one standardized screening tool, with some frequency, with at least one age group during well or ill visits”

• Approximately one-third described selves as familiar with at least one standardized tool

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Socioemotional Screening: Current Practice

• Self-reported % of visits routinely screened, by technique (descending order)– Interview parent (>90%)– Clinical observation– Interview child– Review of systems– Denver-II– Practice-developed instrument (c. 30%)

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Socioemotional Screening: Current Practice

Identified barriers to screening:• Time (93%)• Training in screening tools (88%)• Availability of mental health providers (79%)• Lack of adequate personnel (77%)• Lack of comfort with managing identified

children (71%)• Lack of appropriate reimbursement (66%)

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Screening: Addressing the Barriers

• Choosing Tools

• Cost/Reimbursement

• Office Work Flow/Time

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Addressing Barriers: Tools

• Criteria

• Consensus

• Practice issues

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Screening Instrument Criteria

• 15 minute or less administration• Good psychometric properties• Minimal cost• Targeted• Easy scoring

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Screening Criteria, continued

• Cultural/linguistic data• Covers age span• Minimal expertise to administer• Ease of administration

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MN Recommended Developmental Screening Tools

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MN Recommended Developmental Screening Tools: At a Glance

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Minnesota Developmental Screening Task Force

• Membership: MN Departments of Health, Human Services, and Education and University of MN, Irving B. Harris Center for Infant and Toddler Development

• Recommended developmental and mental health screening tools reviewed and approved by all agencies according to agreed upon criteria

• http://www.health.state.mn.us/divs/fh/mch/devscrn/

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Early Childhood Socioemotional Screening “Synergy”

• Consensus among DHS Child Welfare Screening and ABCD II grant, MDH Follow Along Program, and Minnesota Head Start Association in endorsing Ages and Stages Questionnaire – Socioemotional (ASQ-SE)– Squires, J., Bricker, D. and Twombly, E.;

Brookes Publishing Company

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ASQ-SE, continued

• Age-specific questionnaires completed by caregivers, scored automatically or by paraprofessional

• Forms for 6, 12, 18, 24, 30, 36, 48, 60 months; each form covers +/- 3-6 months of target age

• 7 areas: self-regulation, compliance, communication, adaptive functioning, autonomy, affect, and interaction with people

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ASQ-SE, continued

• Properties:– Norms: 3,014 preschool children, representing 2000

census for family income, education and ethnicity– Reliability: test-retest = .94– Validity: average sensitivity = .78; average specificity

= .95• Low cost proprietary instrument: $125/kit, with

unlimited reproduction of forms• http://www.pbrooks.com or 800.638.3775

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Addressing Barriers: Cost/Reimbursement

• Screening Codes

• Incentives

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Developmental and Mental Health Screening Code -- 96110

• DHS pays for the 96110 code when an objective developmental or mental health screening occurs

• Both may be performed and billed on the same day

• Bill 96110 for developmental screening, 96110 w/UC modifier for mental health screening

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Developmental and Mental Health Screening Code -- 96110

• Other payers in MN also cover objective developmental & mental health screening

• Managed care contracts for 2008 include:– $20 incentive for each developmental

screening in encounter data (96110 code) above the percentage last year

– $25 incentive for each mental health screening in encounter data (96110 code w/UC modifier)

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Addressing Barriers: Office Work Flow/Time

Minnesota Pilots:• Co-located mental health professionals• Use of technology

– Tablets [Patient Tools]– CentraCare work with CHADDIS– Integration with EMR

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Addressing Barriers: Referrals

Multiple models:• Co-located mental health professional or

care coordinator• Central point of access in community• Establishing relationships with community

providers

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Contact InformationGlenace Edwall, DirectorChildren’s Mental Health Division651.431.2326glenace.edwall@state.mn.us

Susan Castellano, ManagerMaternal & Child Health Assurance651.431.2612susan.castellano@state.mn.us

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Implementing Screening: Pediatric Settings

Penny Knapp MDMedical Director

California Department of Mental Health

ECCS Partners Meeting3/13/08

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Topics for today- Practitioner resistance to identifying

concerns

- What to do when concerns are identified: the continuum from reassurance to referral

- What can specialty mental health offer?

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Practitioner resistance to identifying concerns 1

Confidence:• “I really know my patients,” (v.s. shorter

visits, push to “productivity”)• Tradition of developmental surveillance

(misses 60-70% of developmental problems)

• Capitation: forced choices for limited time and fixed resources (HEDIS measures asthma, immunizations, follow-up for hospitalization for mental disorders)

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Practitioner resistance to identifying concerns 2

• Reluctance to label• Uncertainty about definition of problem• Cannot provide services directly • Cannot obtain services by referral

undocumented children, • Who is my patient? (e.g. How to serve

depressed mothers who don't meet medical necessity criteria for specialty mental health services?)

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Current changing trends 1

• 2006 AAP policy statement requires 3 screenings w. standardized screening tool at ages 9, 18, and 24 or 30 months.

• AAP Task Force on Mental Health developing parallel algorithms for mental health at infant/pre-school, school-age & adolescent levels.

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Current changing trends 2

• CAPTA (2003) and IDEA (2004) require developmental screening in Child Welfare system and for children w. prenatal drug exposure.

• Head Start (reauthorized 2008) requires high-quality developmental screening

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UNIVERSAL: - e.g. Screening, Case management, Parenting Education,

Promotion

SELECTIVE: e.g. Risk-specific assessment, preventive intervention

SELECTIVE: e.g. Diagnostic Assessment,

Direct Infant or early childhood services

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Locating the problem- where does screening fit?

• Universal (Primary)

• Selective (secondary)

• Indicated (Tertiary)

• Health & development screening

• Parenting education

• Risk-specific assessment

• Diagnostic assessment

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The continuum from reassurance to referral 1

THE INFANT or CHILD

• Watch and wait• Offer anticipatory guidance• Encourage community links and supports• Refer for assessment to EI • Refer for treatment

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The continuum from reassurance to referral 2

THE PARENT

• Offer anticipatory guidance, focused on parent stress

• Encourage community links and supports• Refer for assessment (local variation in

availability) • Refer for treatment (if parent has eligibility for

services)

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Maternal depression: 1

27% of women w. clinically significant scores on EPDS in first postpartum year

• Previous history --> 6x increased likelihood of recurrent depression

• Universal screening in postnatal care --> three-fold recognition of maternal depression

• Screening in pediatric well-child visits --> five-fold recognition.

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Maternal depression: 227% of women w. clinically significant scores on EPDS in

first postpartum year• 33% of women have persisting symptoms, 26%

develop high symptoms after the first 3 months; 44% (less than half) improve after the first 3 months.

• child(ren) have a higher risk of behavioral (3x) or other (8x) social-emotional problems

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Effects of treatment - STAR*D

• Depression remitted in 33% within 3 months

• Rates of DSM-IV diagnoses in children decreased from 35% to 24%

• (In untreated controls, rates increased to 43%)

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Effects of treatment - STAR*D• Duration of the mother’s depression

correlated with the child’s baseline symptoms, and magnitude of improvement in the mother correlated with the child’s improvement.

• Weissman MM et al. Remissions in maternal depression and child psychopathology: A STAR*D-child report. JAMA 2006 Mar 22; 295:1389-98.

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Interventions• Universal

(Primary)

• Selective (secondary)

• Indicated (Tertiary)

• Well child visits (1ary care)• Bright Futures model

• Early intervention• Connection to community

resources

• Referral for specialized infant mental health services

• Treatment, parent & child

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Lessons from ABCD

• Screening in pediatric primary care well accepted by parents and providers.

• Time for screening (minutes) offset by saved time in visit due to better focus on concerns.

• Cost-neutral in capitated settings.

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Next steps

• Extend from early adopters to universal practice• Extend access to and range of community

support services (not only EI)• Extend screening to include maternal depression

(and/or substance abuse, other mental disorders): The Illinois model.

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Questions?