Why Screenwith Validated, Accurate Tools: Is this Truly Workable in Busy

Clinics?

Frances Page GlascoeProfessor of PediatricsVanderbilt University

Early Intervention Benefits: Rationale For Screening

Family interest in participationBetter outcomes for participants: Higher graduation rates, reduced teen pregnancy, higher employment rates, decreased criminality and violent crime$30,000 to >$100,000 benefit to society

(1992 $$s)For every 1$ spent on EI, society saves 17$

Only about 30% of children with substantial delays and disabilities are detected by their health care provider

Most of those who manage to get detected, are not referred

Thus most children do not receive the benefits of early intervention that can prevent school failure, high school drop out, etc.

Early Detection/Referral

Problems!!

16% - 18% of children have developmental-behavioral difficulties and need special services

Recent research (Pediatrics, July 2008) suggests 13% by age 2!

Only 2% - 3% are enrolled in early intervention

Only 12% enrolled in special education

Enrollment rates in EI should be closer to 8% in the 0 - 4 age range (CDC, www.cdc.gov)

Early Detection Problems!!

Who are these children?Those with delays and disabilities (16% – 18% of the population). Of this group, common problems are: 1. language impairment (~45%)2. learning disabilities (~30%)3. intellectual disabilities (~20%)4. autism, motor disorders, brain injury, etc. (~5%)

Those at-risk due to psychosocial disadvantage, an additional (10% - 12%)

TOTAL = ~ 30%

American Academy of Pediatrics Policy,

Pediatrics, July 2006

Screening and Surveillance

Components of the AAP 2006 Policy Statement

Eliciting and addressing parents’ concernsOngoing monitoring of: Health and family history developmental milestones mental health (parent/child) parent-child

interactions/psychosocial risk and resilience factors Developmental promotion/parent

educationPeriodic use of screening tests

including autism screens at 9, 18 and 24-30 months and well-visits thereafter

Holy Smokes!

Pie in the Sky?

Won’t this ‘sink the ship’?

• What? Even more stuff to do at busy well-visits?

Aren’t some of those measures too long for primary care?Aren’t we already doing

“surveillance”?I’ve got good milestones and questions to parents, aren’t

those good enough?

NO!!

Challenges in the 2006 Statement

Why don’t informal approaches work

1. How do you know your milestones checklists (even if drawn from measures like the Denver) are good predictors of school success?

2. Are your scoring criteria accurate?

Quality measures select items that best predict actual developmental status—

and have clear criteria for judging success

Quality Measures Have Criteria For example, “Knows Colors” –what exactly does this mean?

Match?Points to when named?Names when pointed to?How many colors?

Why don’t informal approaches work

Are you screening the asymptomatic?

Why don’t informal approaches work

Are you screening repeatedly—at all well-visits?

Development develops! Developmental problems do

too!

Developmental Status by parent's verbal behavior and positive

perceptions* (Glascoe & Leew, Pediatrics, 2010)

75

80

85

90

95

100

105

110

0 - 5 0 - 11 12 - 17 18 - 24

Quotients

6 - 11

Age in Months

* Talks at meals, helps child learn new things, reads aloud, able to soothe, enjoys child, perceives child as interested in conversing

Why don’t informal approaches work

Are you identifying enough kids?

What’s your referral rate?

1 out of 4001 out of 2001 out of 1001 out of 251 out of 101 out of 6

PREVALENCE BY AGE

4 % of 0 - 2 year olds

8% of 0 - 3 year olds

12% of 0 - 4 year olds

16%+ of 0 - 8 year olds

Why don’t informal approaches work

Are you asking parents quality questions?

“Your teacher wishes me to delineate those watershed occasions in your life that have led you to become,

slowly and inexorably,a loose cannon.”

Sample questions to parents that don’t

work well

Do you think he has any

problems…..?Do you have any

worries about her development?

Consumer-Driven Health Care? It Doesn’t Work Well for All:

If you don’t ask… and ask well….

they don’t always tell!34% of parents don’t raise developmental-behavioral concerns without being asked

Mothers with limited education are less likely to raise concerns spontaneously

When developmental-behavioral concerns are raised, children with problems are 11 times more likely to be enrolled in intervention

Quality questions about parents’ concerns equalizes ‘the playing field’ for the ‘haves’ and ‘have-nots’

“So many of my kids don’t qualify.” “Many parents don’t follow through.”

“There’s nothing out there to refer to.”

But wait a minute!

Some kids don’t qualify but most still need other kinds of help. Clinics need lists with awide range of referral options. THERE IS GOBS OUT THERE TO REFER TO--HONESTLY!

Some parents need more time. Many take home your message and just try harder to help their child. When they discover they can’t, they’ll be back OR head to referral resources.

BUT, if you can, make appointments for families—that increases the likelihood of getting there!

“Oh, by the way…..”

•Saves provider’s time•Restrains visit length to predicted levels•Offers greater reimbursement•Improves detection rates•Increases parent and provider satisfaction and visit attendance• Focuses developmental promotion

Using quality tools with good questions to parents:

So… we can save time, increase $$s, and do best by families…. if

we conduct screening and

surveillance with evidence and

refer promptly!!

What Tools Should We Use?• PEDS (10 questions eliciting concerns) at

every well-visit)• PEDS:Developmental Milestones (6 – 8

questions about milestones) at every well visit

• The M-CHAT at 18 – 24 months (built into PEDS:DM)

• A clinic intake form that looks at parental depression (2 questions)

In an electronic environment…

• Consider PEDS Online• www.pedstest.com/online for a trial• Site offers PEDS, PEDS:DM and the M-CHAT• Website offers downloadable clinic intake

form (for depression screening, indicators of psychosocial risk, etc.)

• Website also has case examples, videos, self-training information, etc.

How do we get reimbursed?

• First, you must use validated, accurate screens• Add the – 25 modifier to your code for preventive services • Add 96110 (times the number of screens administered)• For private payers, different modifiers may be needed• Have your clinic coordinator find out about private payers• Appeal all denied claims• If a second denial, contact the AAP’s coding hotline