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Building a System of Developmental Care for

Children

Marihelen Barrett

Nemours Health and Prevention Services

Presented to the Delaware Early Care and Education Council

February 23, 2007

Adapted from Presentation by Amy Fine, MPH

at 2006 Annual NICHQ Conference

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Ready Children

Physically and Emotionally Healthy

Children Eager to Learn

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Current Trends in Pediatric Developmental Care

General move in pediatrics toward more inclusive definitions and expanded role for pediatric practices

Definitions and roles vary across practices

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Models for Improving Developmental Care

Work by the Common Wealth Fund and Center for Healthier Children (UCLA) Healthy Steps, 1994 Assuring Better Child Health and

Development (ABCD), 1999 Child Health Improvement Partnerships –

Vermont, North Carolina, New Mexico, Utah; 2000 - 2006

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CWF Study by Amy Fine

What is the current state of the art for pediatric developmental care and linkage to community developmental care? – Promising and innovative models for

linkage– Key strategies across models– Lessons learned

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Practices and Programs Included in Study

Beaufort Pediatrics Children’s Care Connection (C-3) Developmental Services Enhancement Program (DSEP) Enhancing Developmentally Oriented Primary Care Program (EDOPC) Exeter Pediatric Associates Guilford Child Health, Inc. (GCH) Help Me Grow (HMG) Inscription House Health Center/ Growing in Beauty (GIB) Kaiser Permanente Northern California Kennebec Pediatrics (KP) Kids Get Care (KGC) MGH Revere HealthCare Center/Healthy Steps Phoenix Children’s Hospital/ Healthy Steps Tufts–New England Medical Center

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Current Trends in Pediatric Developmental Care

What is the scope of developmental care?

– Physical, cognitive, behavioral, emotional development?

Who needs it?

– Those with identified deficits, at risk, all children?

– CSHCN, all children, families?

What is the role of the pediatric practice?

– Identification of deficits, prevention, promotion?

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Comprehensive System: Barriers “Pediatricians are kind of trapped in a box

right now: everything we need to do to get out of the box is not reimbursable.”

“The system is so fragmented that the only person who understands it is the educated parent.” Too many community organizations – don’t know who to call

Dramatic gaps in developmental and mental health services – a barrier to screening

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Comprehensive System – Linked Pediatric and Community Care

What does good linkage look like?

– “It looks like relationships, not a referral list.”

– “Three legged stool: medical home, EI, and family support.”

– “Linkage is facilitated by: relationships, some kind of formal mechanisms/systems, and reimbursement.”

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System and Linkage Landscape

Many different strategies and tools

Most of the practices/programs combine multiple strategies

Some recurrent themes

No common language or framework for describing strategies

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System and Linkage Landscape

What makes the system work? – Part of the problem is evolving definition of

developmental care– Need working definitions–developmental

services, focus of linkage, framework for strategies

– Not yet a unified way of thinking about linkage: addressed at different levels

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Developmental Services Framework

What all children and families need from multiple people and places

Knowledge/Information – Assessment and Monitoring – Additional Services and Supports– Follow-up Relationships and Care Coordination

Provided in smooth flow between health system, education system, community, and home

Adapted from Regalado and Halfon

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Framework: Key Developmental Services

1. Knowledge/Information – anticipatory guidance, info. on identified risks & deficits.

2. Monitoring – developmental surveillance/screening.

3. Additional Services and Supports – point person and pathway to additional care, as needed

4. Follow-up Relationships – system and point person for support and follow-up.

Adapted from Regalado and Halfon

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Linkage Definition

Connecting the child and family to needed developmental services and supports – whether within the practice setting or beyond – while also staying connected to the child

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Systems Change: 3 Levels of Strategies

I. Practice-level systems change

II. Community partnerships – focused on relationship between practices and existing community services/supports

III. System-wide change – policy, population level, community-wide, state-wide change

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Nine Key StrategiesPractice Strategies1. Developmental surveillance/screening &

anticipatory guidance2. Point person for referral/linkage & follow-up system3. New/ enhanced staffingLinkage Strategies3. Co-location 4. Co-management5. Networking and information-sharingSystem Strategies6. New/enhanced community resources7. System-wide training and support8. Community/state policies and protocols

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Context for the Strategies

These are not stand alone approaches.

Most of the innovative practices and programs combine several strategies, often at different levels.

In practice, not necessarily a clean-bright line separating one strategy from another

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Underlying Tenets

Several consistent underlying tenets or guiding principles shape the strategies – Parents as Partners – new morbidities require

parents to set plan and make decisions

– No Wrong Doors – any source of referral welcome

– Go Where the Children Are – bring assessment to child (new technology enables this)

– Referral as a First Resort – when in doubt refer

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Level I Strategies:

Practice-Based Systems Change

1. Developmental surveillance/screening & anticipatory guidance

2. Point person for referral/linkage & follow-up system

3. New/ enhanced staffing

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1: Developmental Surveillance/ Screening & Anticipatory Guidance

Practice-wide system for routine, family-centered, developmental surveillance/ screening

Surveillance/screening at each well-child visit, using validated screening tools

Anticipatory guidance tailored to meet parent concerns

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2. A Referral/Linkage Point Person and Follow-up System

A designated primary contact for referral/linkage. A practice-wide system for follow-up care:– Follow-up systems – simple listing to EMR with

recall system and task list– Focus of linkage – connect child to services

beyond practice; in-house services– Point person – nurse, social worker,

developmental specialist

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3. Enhanced Staffing

One or more new positions added to traditional pediatric primary care staff to enhance developmental care

Positions vary – e.g., Care coordinator, social worker, child development specialist, psychologist, developmental pediatrician, psychiatrist

Purpose varies – most often for children with risks/deficits; but some work with all children in practice in health promotion role

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Level I Strategies: Summary

Current emphasis in pediatrics on in-house practice change, often as part of a QI systems change model

Strategies 1 (assessment) and 2 (point person for referral) are prerequisite for good linkage

Level I strategies improve quality of care. Adding in-house staff and services eases the

transition to new services for children

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Level II Strategies: Enhanced Partnerships Between Pediatric Practice and Community

4. Co-location of services

5. Co-management

6. Networking and information sharing

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4. Co-location of Services

Location link between the pediatric practice and one or more other community service/s

Some practices share a building or office space with other services, others place community/public sector staff in practice

Provides a streamlined route for practices to connect children to additional developmental care

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5. Co-management

Collaborative case management between the pediatric practice and one or more other service provider, focused on an individual child

Variations: case-by-case basis; regular meeting time for case reviews; collaborative assessment and joint problem-solving

By phone or in-person

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6. Networking & Information Sharing

Includes: networking meetings, mixers, meet and greet sessions, academic detailing sessions, shared resource listings, informal outreach

Purpose varies: jump-start or sustain referral/linkage

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Level II Strategies: Summary

Community partnership strategies help use existing resources more effectively; improve quality of care:– Reduce barriers to care – e.g., transportation,

stigma– Promote early referral/linkage and follow up– Promote joint problem-solving, family-centered

care– Reduce duplication and fragmentation of services.

Networking can help uncover gaps in services and promote collaborative efforts to address

Time, financing and HIPAA can be challenges

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Level III Strategies: Changes in Community Systems

7. New/enhanced community resources

8. System-wide training

9. Community-wide policies and protocolsLevel III strategies provide a framework for a “Statewide Improvement Partnership” to Implement Delaware’s Early Childhood Plan

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7. New and Enhanced Community Resources

Starts with population-based approach to assessing community needs.

Public and private sector partners Initiatives to develop:

– centralized referral/linkage resources – mid-level assessment– enhancement of intervention services for

at-risk and mild/moderate delay – promotion/prevention services

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8. System-wide Training & Support

Applies to system-wide training to improve developmental care and linkage by:

– Change the orientation, skills and practices of pediatric primary care

– Focus on pediatric healthcare and multi-sector training of pipeline

– Quality improvement for established practices

– Provide community/state orientation.

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9. System-Wide Policies & Protocols

Community or statewide policies and protocols to promote and sustain linkage

Cross-agency protocols

Reimbursement policies

Other dedicated funding streams

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Level III Strategies: Summary

Level III strategies focus on filling community gaps in services/linkage (e.g. mental healthcare, mid-level assessment services, intervention services for mild/moderate delay)

System-wide training provides common knowledge base for developmental care

System-wide policy changes can jump-start and/or sustain practice change

Reimbursement/financing polices are crucial

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Cross-Level Summary The 3 levels of strategies should not

be interpreted as a hierarchy. All 3 are important

These are not stand-alone strategies To optimize impact and resources,

practices and communities need to combine strategies

There is no “one size fits all”.

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Guiding Principles and Recommendations

“ Think about the recommendations as possible steps for Delaware’s Early Childhood Action Agenda”

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Guiding Principles

Work in partnership with families

Collaborate, integrate, and reinforce across services/supports

Use a systems-focused, QI approach

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Guiding Principles

Shift the balance of resources from high-end to front end

For “daily dose” interventions, go where the children are

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Guiding Principles

Use a “no wrong doors” approach

Start at whatever level, with whatever strategies are available to the practice or program

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Recommendations:Practice Level Change

1. Incorporate QI-systems change at the practice level, starting with a focus on developmental care. Include:

• surveillance • anticipatory guidance • point person for linkage • system for follow-up care

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Recommendations: Practice Level Change

2. Broaden the focus of developmental care so that pediatric practices can substantially contribute to the promotion of healthy development (Reorient well-child care):

• Early adopters devise and test strategies• Evaluate early adopter outcomes• AAP Task Force on Rethinking Well Child

Care

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Recommendations:Community Partnerships

3. Engage professional associations and umbrella agencies in mapping and linking developmental resources in their communities:

• Identify “nodal” or “gatekeeper” resources

• Host “meet and greet” sessions

• Build relationships across service sectors

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Recommendations:Community Partnerships

4. Promote co-location of public sector services in pediatric practices, and other innovative use of public sector resources:

• Explore placement in high-volume practices

• Evaluate across sectors and settings

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Recommendations:Community Systems Change

5. Promote mid-level assessment and referral/linkage capacity at the community or regional level:

• Better use of existing resources• Review community-wide referral/linkage

and assessment models• Diffusion of effective models &

components

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Recommendations:Community Systems Change

6. Support training for practice-based, developmental care systems change:

• Practice change learning collaboratives

• CME credits

• Residency training

• Multi-disciple and multi-sector training

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Recommendations:Community Systems Change

7. Identify and promote key policy changes:

• Reimbursement policies for care coordination and co-management

• Cross-sector, community protocols for delivering developmental care to children and their families