Why Screen
with Validated, Accurate
Tools
Frances Page Glascoe
Professor of Pediatrics
Vanderbilt University
Outline
1.
2.
3.
4.
5.
Who are we detecting
Outcomes of Early Intervention
Prevalence and detection/referral rates
AAP Policy for primary care
Challenges from informal approaches/Why
quality screens improve detection rates
6. Why trans-disciplinary efforts are needed
to improve early detection in primary care
7. How/what quality measures work well in
busy clinics
1. Who are we detecting?
Those with significant 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, are an additional (10% - 12%)
TOTAL = ~ 30%
2. Early Intervention Benefits*
Family interest in participation
Better 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$
* Includes IDEA and Head Start programs
3. Prevalence/Detection Issues
16% - 18% of children have developmentalbehavioral 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)
3. Detection/Referral Issues!!
Only about 30% of children with substantial
delays and disabilities are detected by their
health care provider
Many of those 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.
4. Components of the AAP 2006
Policy Statement
Eliciting and addressing parents’ concerns
Ongoing monitoring of:
Health and family history
developmental milestones
mental health (parent/child)
parent-child interactions/psychosocial risk and
resilience factors
Developmental promotion/parent education
Periodic use of screening tests including autism
screens at 9, 18 and 24-30 months and well-visits
thereafter
Holy Smokes!
• What? Even more stuff to do at busy
wellvisits?
5. Challenges in the 2006
Statement
Aren’t we already doing “surveillance”?
I’ve got good milestones and questions to
parents, aren’t those good enough?
So you’re saying I have to screen AND
perform surveillance?
NO!!
With Evidence….
• Surveillance and screening can be
accomplished with the same tools
Without Evidence…..
• Many many problems with early detection
5 (A)
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?
5 (A)
Sample Checklist—age 4
Uses hungry, tired, thirsty
Climbs stairs without holding on
Stacks 10 blocks
Knows colors
Dresses self completely
Plays games with rules
5 (A)
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?
5 (A)
Quality measures select items that best
predict actual developmental status—
and have clear criteria for judging success
5 (B)
Why don’t informal
approaches work
Are you screening the
asymptomatic?
5 (C)
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*
Quotients
(Glascoe & Leew, Pediatrics, 2010)
110
105
100
95
90
85
80
75
Age in Months
0-5
06 - 11
12 - 17
18 - 24
* Talks at meals, helps child learn new things, reads aloud,
able to soothe, enjoys child, perceives child as interested in
conversing
5 (D)
Why don’t informal
approaches work
Are you identifying enough kids?
What’s your referral rate?
1 out of 400
1 out of 200
1 out of 100
1 out of 25
1 out of 10
1 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
5 (E)
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?
5 (D)
If you don’t ask… and ask well….
they don’t always tell!
34% of parents don’t raise developmentalbehavioral concerns without being asked
Parents 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’
But wait a
minute!
“Refer without a diagnosis? NNNNNNN”
“There’s nothing out there to refer to.”
“So many of my kids don’t qualify.”
“Many parents don’t follow through.”
“I never know what happens after I refer”
5 (E)
REFERRAL CHALLENGES
• > 80% of referrals from primary care
providers made only to familiar
services
(Glade, Forrest et al Amb Peds, 2002)
• Nonmedical providers often fail to
respond like the ideal subspecialist
(Forrest et al APAM, 1999)
• Clinicians often unfamiliar with service
options (and with good tools)
6
When Non-Medical Providers
Detail Primary Care
Enrollment in EI increased from 2% to
12% --commensurate with
prevalence
ABCD Project, Commonwealth Fund (2007)
70% increase in ASD dx in ages 0 - 3
Minnesota Dept of Education, Pediatrics, 2004
244% increase in referrals to EI
Hix-Small et al, Pediatrics,- 2007
How Non-Medical Providers Improved
Detection and Referral Rates
Arranged a series of short lunch visits
Provided laminated lists of local
resources for each exam room
Called clinics back when referrals were
made and after testing
Collaborated on finding alternative
services
 Established two-way- consent forms
How Non-Medical Providers Improved
Detection and Referral Rates
Showed options among time-saving tools
relying on information from parents
Explained billing/coding for optimal
reimbursement
 Described State mandates (and essential
record keeping for Medicaid audits)
Helped with implementation and work
flow issues
-
7
What Kinds of Tools
are Most Effective for
Primary Care and
Why?
7
“Oh, by the way…..”
Using quality tools with good
questions to parents:
•Saves providers’ time
•Restrains visit length to predicted levels
•Ensures reimbursement
•Improves detection rates
•Increases parent and provider
satisfaction and visit attendance
• Focuses developmental promotion
7
What Tools are Workable for
Primary Care?
• PEDS (10 questions eliciting concerns)
• PEDS:Developmental Milestones (6 – 8
questions about milestones)
• Ages and Stages Questionnaire-3 (30
questions about milestones)
• Ages and Stages: Social-Emotional (30
questions about temperament, mental
health, etc.)
• The M-CHAT at 18 – 24 months
What PEDS adds to results of
skills-focused screens
SKILL FOCUSED:
Does your child use three words at a time?
YES
CONCERNS FOCUSED:
Do you have concerns about how your child
talks and makes speech sounds?
“Yes…. only says the same three words,
Wheel of Fortune” over and over.”
7
What Else Do Clinicians Need
in Their Armamentarium?
• The Family Psychosocial Screen --A good
intake form with questions about parental
depression (4 items) and psychosocial risk
(repeated in the 2nd year of life)
• A resilience measure indicating the need for
parent-training, such as the Brigance ParentChild Interactions Scale (6 items)
administered in the 1st and 2nd year of life.
Online Screening Helps!
PEDS Online
(www.pedstest.com/online)
Provides automated scoring
Writes referral letters, parent summary
reports in Spanish and English
Generates billing codes
Parents can complete at home or in waiting
rooms prior to the encounter.
Offers PEDS, PEDS:Developmental
Milestones, and the M-CHAT.
Summary
Good tools for primary care are
available
Health care providers should avoid
ad hoc approaches (and
inaccurate measures)
Non-medical providers need to
collaborate and communicate
about early detection and
referrals
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