By Martha Hostetter
The Issue: Research has shown that the sooner developmental problems are identified and addressed, the better the outcomes for children and their families. Yet, current rates of detection are much lower than the actual prevalence of developmental problems among young children, indicating that many potential concerns are not being identified and addressed.
The American Academy of Pediatrics (AAP) has called for the routine use of validated screening instruments to identify developmental problems during well-child visits. When pediatricians rely on their observations or impressions of a child, rather than completing formal screening tools, their estimates of the child's developmental status are much less accurate. [1]
Organization and Leadership: Oxford Pediatrics has five physicians and two nurse practitioners in its main office, located in Oxford, Ohio. Providers also work out of two satellite facilities in Ross, Ohio, and Brookville, Ind. All together, the practice has about 22,000 patients in its database.
Amy Driscoll, M.D., one of the practice's three physician owners, has been with Oxford Pediatrics since 2001. She sits on the AAP's Quality Improvement Innovation Network steering committee, whose members take part in discussions and activities focused on improving various areas of pediatric practice.
Target Population: Oxford's initial intervention focused on the use of developmental screening for children from birth to 18 months. The practice currently performs regular screenings for children up to age five.
Process of Change: From November 2004 to September 2005, Oxford Pediatrics took part in an AAP-led demonstration project to implement Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. These guidelines were developed by the Maternal and Child Health Bureau to provide pediatricians and family physicians with comprehensive health supervision advice, including recommendations on immunizations, routine health screenings, and anticipatory guidance.
The demonstration project focused on six practice areas: use of a preventive services prompting system, implementation of structured developmental assessments, evaluation of parents' needs and use of strength-based approaches, use of reminder systems for appointments or follow-up care, development of links to community resources, and creation of a registry of patients with special heath care needs. Oxford Pediatrics participated in all aspects of the demonstration project; this case study focuses on their implementation of a structured developmental assessment tool.
In January 2005, two Oxford providers began using a standardized developmental screening tool, the Ages and Stages Questionnaires (ASQ), as a routine part of preventive care visits. There are different versions of the ASQ tailored for children at various ages, from four months to five years. Each has 30 questions, to be answered by parents, which assess five areas of children's development: gross motor skills, fine motor skills, communication, problem solving, and social behaviors.
Oxford chose to use the ASQ screening tool for several reasons. First, it has a one-time purchasing fee, after which practices are free to copy and use the survey as many times as needed. Oxford's providers also appreciated its high level of detail and the fact that it was designed to enable parents to work on at home.
"In completing the survey, parents are supposed to try out different activities with their children," says Driscoll. For example, parents assess young children's motor skills through activities such as stacking blocks. Older kids might be asked to hop on one foot or cut with scissors. "Ideally, kids should be happy and relaxed—which is not always the case at pediatric visits. Also, parents can try the activities more than once."
Oxford's two participating providers incorporated the age-appropriate version of the ASQ into their six-, 12-, and 18-month well-child visits. Using the practice's electronic medical records, office staff identified families with upcoming visits and then mailed them the survey two weeks in advance of their scheduled appointment.
Parents were asked to bring the completed surveys to the visit. If they forgot to do so, they were given an opportunity to complete the ASQ in the waiting room, where a box of toys was provided to help them try the activities with their children. Medical assistants scored the surveys, a process that takes about two minutes, and recorded the results on the child's medical chart for providers to review.
Providers generally took the following steps if a child's survey results pointed to a potential developmental delay:
- Verify that a delay exists. Providers reviewed the survey results and discussed them with parents. "In some cases, a child had never tried a particular activity before," says Driscoll. "That may explain why they had problems with it on the survey. That's not as concerning as a child who has been trying to do something for a while—such as a preschooler trying to cut with scissors—and hasn't been able to master a particular skill." Providers then used their judgment to decide whether to immediately refer children for developmental services or to take time for further observation and revisit the issue during the next encounter.
- Complete ASQ activity sheets. Providers might recommend that parents use the ASQ activity sheets, which are designed to help cultivate particular age-appropriate skills. Suggested activities for infants (four to eight months) include filling an empty tissue box with strips of paper and letting them practice pulling the strips out. For an older child (24 to 30 months), activities include making an obstacle course out of household items such as pillows and boxes and letting them crawl over, through, and around these items. A five-year-old might practice writing skills by drawing letters on a cookie sheet smeared with pudding.
- Make referrals as needed to early intervention services or specialty care. For example, families might be referred to speech therapists, physical therapists, or occupational therapists; or to audiology exams, preschool-based programs, or Head Start. In some cases, they might be referred to neurology specialists or developmental clinics at a children's hospital.
Oxford also created a master "referral book" to track referrals to early intervention and specialty services and ensure appropriate follow-up care. When a provider referred a child, they filled out a page in the book listing the family's contact information, identified developmental concern, and where the child was sent for further evaluation and/or treatment. A staff member then completed the health insurance forms and forwarded the child's medical records to the appropriate location.
At regular intervals, staff members reviewed the referral book to check whether they had a report back from providers to whom children were referred. If a report had not been received, a staff person would reach out to the families to see if they pursued the care, or if they needed help in securing appointments. If a child had received care, they would ask for a report back so that the child's pediatrician was informed of their progress and could follow-up with the family during the next well-child visit.
Key Measures: To monitor the effects of implementing the screening tool, Oxford Pediatrics tracked:
- the number of developmental screenings performed, and
- the length of well-child visits before and after implementation.
By July 2005, ASQs were being used in conjunction with 80 percent of the designated well-child visits. This number fell a bit over the next few months, but it was still 75 percent by the end of the Bright Futures project, in October 2005. In some cases, surveys were not completed because parents declined to participate—either because they said they were certain their child was "doing fine" or did not want to pay for the assessment if their insurance did not cover it. To help address these issues, the practice sent parents a cover letter along with the survey to explain the importance of developmental screening, let them know this service might not be covered by their insurance, and encourage them to check with their insurance provider before the visit. In other cases, medical assistants forgot to have parents who had not brought a completed assessment with them fill out the survey in the waiting room.
To respond to providers' concerns that developmental screening would lengthen their well-child visits, Oxford conducted time trials of 100 visits before and after implementing the ASQ. It found that using an ASQ did not add to the length of an average well-child visit.
Today, all Oxford providers have incorporated the ASQ screening tool into their office visits for children at age 9 months, 15 months, two years, and four or five years, for a pre-kindergarten screening, following the process described above. According to a chart review in April 2008, the surveys are used in nearly 100 percent of visits.
Oxford's positive experience with the ASQ has led them to adopt or consider adopting other developmental tools. In March 2008, providers began using the Modified Checklist for Autism in Toddlers (M-CHAT) during the 18-month visit, as recommended by the AAP. They are considering adopting the ASQ tool used to detect psychosocial problems in older children, because they are seeing more school-age kids with behavioral problems. In addition, they may begin to screen for maternal depression, another determinant of a child's development, during an infant's one-month visit using the Edinburgh Postnatal Depression Scale.
Implications: Use of a parent-completed screening tool can engage families in their children's developmental issues, providing reassurance or helping to address their concerns. "Most parents like filling out the survey," says Driscoll. "It teaches them a little bit about development. They can say, 'Oh yes, my child is doing these things,' which confirms for them that he or she is progressing. Or they might be surprised to hear about a delay. One of the most common things the screening will pick up is a fine motor skill delay—it's hard for parents to notice this, especially before kids are in school or involved with structured activities."
Using a standardized screening tool did not prolong the length of an average well-child visit. Instead of trying to assess the spectrum of developmental issues, providers were able to focus on areas of concern identified by the screening. Oxford Pediatrics found it helpful to launch the ASQ with two providers; these individuals were then able to share their experiences with other providers and convince them of the benefits of this approach. "It's important to make certain all staff are aware of the changes being implemented, how they are being done, who is responsible for which tasks, and what the benefits are," says Driscoll.
Regular use of developmental screening tools can elicit concerns that might not emerge through clinical observation or unstructured communications with families. Driscoll points in particular to the benefits of giving parents time to reflect on their child's development. "Occasionally, parents will write in something that they might not have brought up during a visit," she says. "I had one mother who noted on her ASQ that her child's leg was bowed. It turned out that the child had Blount's disease, a progressive growth disorder that needed to be addressed."
Providers use a standard billing code (96110) for developmental screening. While most insurance companies reimburse for this service, the amount varies greatly and can be quite low. Driscoll says payers typically reimburse Oxford providers from $3 to $40 for developmental screening. "So there is a little bit of a financial incentive to do it," she says. "But it also makes the pediatricians' job easier—it's thorough and it allows you to focus on areas of concern."
For Further Information: Contact Amy Driscoll, M.D., at [email protected].
Reference
[1] P. H. Dworkin (1992) "Developmental Screening: Still Expecting the Impossible?" Pediatrics 89, 1253–1255.