Conference Goals

• Understand the need for validated and routine developmental screening;

• Become familiar with screening tools that can be used in primary care;

• Choose strategies for implementing a new tool in the primary care setting;

• Overcome obstacles integrating routine screening into practice;

• Create a referral system for management of children identified with possible developmental needs.

Conference Goals

Only 57% of parents surveyed reported that their child’s development was ever assessed in a pediatric visit.

• Parents who report receiving developmental assessments are more likely to report other anticipatory guidance (reading, toilet training, discipline) and are more satisfied with pediatric care.

Source: Halfon, Pediatrics, 2004

Conference Goals – Dr. Tyler

• Studies demonstrate the need for developmental screening.

• While 12 to 18% of US children have a developmental disorder, fewer than 30% of these children are identified by clinician judgment before entering school.

• Developmental screening can boost this identification rate considerably.

Conference Goals – Dr. Tyler

• It’s reasonable to question the value of incorporating a new screening procedure when we are pressed on time and resources. And since most of us already use milestone checklists and our clinical judgment, you may wonder if that isn’t enough.

Conference Goals – Dr. Tyler

While we are picking up the more impaired children, we’re missing many who have more subtle issues, children who may be great responders to intervention.

• We can’t possibly review language, social, fine motor, gross motor, functional, and behavioral development with the same thoroughness for every child at every visit.

• Though most of us use checklists of developmental skills, these do not provide standardized cut-offs for the number of missed milestones that indicate a need for referral. Validated tools, by contrast, provide standardized data to guide practice and assure uniform care for all patients.

Conference Goals – Dr. Tyler

Though most of us use checklists of developmental skills, these do not provide standardized cut-offs for the number of missed milestones that indicate a need for referral. Validated tools, by contrast, provide standardized data to guide practice and assure uniform care for all patients.

Conference Goals – Practical Implementation

• Given our limited time and resources in primary care, there are understandable reservations about adding yet another step to well child visits.

• But developmental screening ends up saving us time and improving the care we provide.

Conference Goals – Early Intervention

• Fortunately, the tools that help us identify children at risk for developmental delays finally exist. These tools enable early intervention, which in turn helps your practice.

• Early intervention has been shown to limit long term morbidity. Participants have higher graduation rates, higher employment rates, and less criminality than those who did not receive early intervention.

• It’s important to note that developmental screening boosts the identification rate at low cost to time and budget.

Conference Goals – Early Intervention

• Despite the obstacles we all face, validated screening can be integrated into primary care practice to improve care of our most vulnerable patients.

Screening Tools

Dr. Rachelle Tyler

UCLA

How To Implement

Dr. Chris Landon ModeratorDirector PDC Practice Based Research Network

Dr. Rekha KrishnankuttyConsulting Pediatrician Sierra Vista Family Medical Center

Dr. Andrei BobrowConsulting Pediatrician Las Islas Family Medical Clinic

Dr. Michelle LabaMandalay Bay Women and Children’s Medical Group

Dr. Heather NicholsSanta Paula West Pediatric Clinic

Why Do We Emphasize PEDS Implementation?

• The PEDS is a validated parental survey tool that is designed to detect children eligible for special education. It identifies developmental, academic, and behavioral issues.

• Survey consists of ten carefully constructed questions that target parental concerns

• Parent completes form in 5 minutes • Providers score and interpret the results in 2

minutes • Sensitivity 74-79% • Specificity 70-80% across age levels

Why Do We Emphasize PEDS Implementation?

• The PEDS poses ten questions that target parental concerns. The form is translated into many languages and is written at a 5th grade reading level; but even so, parents with literacy limitations may need support.

The Process

1.The office staff responsible for handing out the survey pulls the form, the clipboard, and the pen from the supply area near check-in or the weight room.

2.This person gives the tool to the parent (or responsible family member) and briefly explains that the provider wants to know how the child is doing and if the parent has any concerns.

3.The parent completes the form before provider enters the exam room so the provider can review it during the visit.

The Process

The survey becomes the structure of your discussion about the child’s behavior and development. Providers often start visits asking for parent concerns, and now they have it written up and covering each developmental realm.

• Sounds simple, but survey completion is our biggest obstacle. The parent may lose it or just not complete it. We’ve learned that incomplete forms may be due to language and literacy barriers and placed blank forms in convenient places for providers to use.

The Process

• Scoring is completed by the provider and takes just a few moments. Concerns registered in the survey generally correspond to checkboxes on the scoring form. If the parent has noted a concern but hasn’t left any comments, there may be a literacy problem on the part of the parent. At that point we review all the questions for more detail.

• No parent concerns are ignored, even if the parent is not concerned after discussing it with the provider and even if the concern doesn’t correspond directly to a developmental issue.

• This is one of the unexpected benefits of screening – we are finding concerning issues that previously were not on our radars.

• Scoring forms are kept in the patient’s medical record and are tracked with each visit. An electronic version is available but we STILL use paper charts!

The Process

• No parent concerns are ignored, even if the parent is not concerned after discussing it with the provider and even if the concern doesn’t correspond directly to a developmental issue.

• This is one of the unexpected benefits of screening – we are finding concerning issues that previously were not on our radars.

• Scoring forms are kept in the patient’s medical record and are tracked with each visit. An electronic version is available but we STILL use paper charts!

The Process

Implementation In Different Practice Settings

• Identify practice champions• Introduce the idea to your practice• Share web sites with previous practice

experience• Elicit ideas, concerns, and suggestions from

all staff members• Acknowledge that change is hard• Choose a tool• Review the available tools• Pick one for trial that matches practice needs

Implementation In Different Practice Settings

• Train appropriate staff in administering, scoring and interpreting

• Consider methods of implementation• At what visits will screening be included?• How will tool be distributed - in the office, via mail, or posted

electronically online?• What will you do with completed screens?• Discuss operations - identify the person(s) who will...• Purchase and reorder the tool• Maintain supplies• Hand out (or mail) the tool and explain it to parents• Be responsible for scoring• Document findings and plan in the medical record• Return pens and clipboards to storage site• Where will supplies be stored?

Implementation In Different Practice Settings

• Referral system• Will you need a new system?• Is your system paper-based,

electronic, or both?• Who will maintain it?

Implementation In Different Practice Settings

• Practice run • Assign one staff member to be a "parent"• Starting at the front desk, have them walk through the

typical visit,with the screening steps now included• Assign another staff member to be the "provider" and/or

support staff,and walk through the steps of interpreting, scoring, and acting on the results

• Fix any operational glitches you find• Communicate consistently• Request regular feedback from all staff - particularly, but

not only, after the practice run• Give staff regular feedback on their successes and the

changes you believe necessary