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Beyond the Prescription Pad:Physician Involvement in Early
Intervention
2005 OSEP National Early Childhood Conference
February 8, 2005
Corinne W. Garland Beppie j. [email protected] [email protected]
Suzanne [email protected]
Session Objectives
Participants will understand the barriers to and strategies for:
Providing a medical home for children with disabilities
Integrating physicians into community EI and ECSE service systems
Strengthening the role of physicians in early identification, referral, IFSP/IEP development, and family support
Key Question ?????
Who needs physicians to be integrated into community EI and ECSE service systems?
Parents’ Needs
Identification and referral
Communication among team members
Early Intervention Needs
State and local child find needs
Timely referrals
Referrals without anticipating service needs before assessment and IFSP (e.g., therapies)
SERVED (2003 Child Count)% of live births
In Part C
Mean: 1.99%
Range: .94% (NV)
to 7.7% (HI)
Median: 2.13%
Part B (age 3-5)
Mean: 5.04%
Range: 1.77% (DC)
to 12.58% (KY)
Median: 6.12%
Results from AAP: A Survey of Pediatricians 2002
Survey sponsored by
American Academy of Pediatrics (AAP) Medical Home Initiatives for Children with Special Needs
Office of Special Education Programs, USDOE
Maternal and Child Health Bureau OSEP-funded Child Find Consortium
Survey Methodology
One of a series of surveys by AAP
Random sample Sent to 1,617
active US AAP member physicians
Six mailings May – Sept. 2002 Return rate 55.2%
Preliminary results only presented here
Contact AAP for more information
649 pediatricians who serve babies 0-3 and who assess development
Referral to EI – What’s Working
86% have referred to EI 92% say EI helps
maximize child’s development
95% say parent concern is considered in making referral
77% know family income doesn’t matter
What are barriers to pediatricians’ participation in Early Intervention?
Barriers to Referral to EI
Don’t know EI process procedures (46%)
Lack of feedback from EI program (36%)
Don’t know eligibility (29%) Programs don’t use MD
input (23%) ? quality of EI services
(22%) Services not available
(20%)
Communication from EI program 53% not notified
when referral received
30% do not receive evaluation results
47% do not hear reasons for disposition
54% don’t hear when family is discharged
61% don’t hear if program can’t contact family
49% do not get IFSP and progress on goals
AAP: Pediatricians recommend
reprinted standard referral form (51%) Toll free number (47%) Give MD more information about EI
(81%) Single, known contact person (58%) Improve communication from EI (>90%)
Statewide Strategies:Physician Training
Enhancing Health Care Delivery Through Screening, Surveillance, and Promotion of Early Intervention in the
Medical Home in Hawaii
Beppie Shapiro, Ph.D.&
Vince Yamashiroya, MD, FAAPOSEP Early Childhood Conference 2004
Presentation Outline
The Study: Project SEEK Phase 1:
Needs assessment
Phase 2: Interventions & Outcomes
Conclusions
The Study: Project SEEK
SEEKStrategies for Effective and Efficient Keiki (child) find
Project SEEK (2)
GOAL: to ensure babies with special needs are identified and referred to EI
- Sponsors: Office of Special Education programs, USDOE, and State DOH
Definitions
Early Intervention (EI): system of services for babies under age 3 with special needs
H-KISS: Hawaii’s information and referral service, free to the public
People Involved
Beppie Shapiro, Ph.D Principal investigator
Taletha Derrington, M.A Project director
Vince Yamashiroya, M.D., FAAP Physician advisor
Many others (physicians, public health nurses, educators, parents, etc.)
Period of the Study
Phase 1: Needs Assessment Statewide surveys, focus groups 1995 to 1999
Phase 2: Intervention & Outcomes Community surveys, collection of data from
PCP’s to EI programs, and intervention strategies
1999 to 2005
Phase 1: Statewide
Phase 2:
32,664
Children 0-18 years (2000 Census)
38,805
15,434
208,525
Maui
Big Island
Kauai
Phase 1: Statewide Needs Assessment
• Identified barriers to identification and referral.
• Statewide survey of professionals who serve young children.
• Focus groups of professionals in varied communities.
PCP Survey Results
Survey mailed to M.D. Offices statewide using HAAP and HAFP lists 129 pediatricians, 71 family
practitioners
Return rate 77%!!!
Barriers to Identification Physician developmental screening practices
(most common) All groups surveyed do not understand EI
eligibility Hospital nurses, MSW, foster parents, and
child care providers do not know how to identify eligible infants and toddlers
Discomfort by all professionals in speaking to the family about child developmental delay
Barriers to Referral “Wait and see” practice of some doctors when
delay is suspected (most common) Doctors do not know services are free to
family Some doctors do not believe EI is valuable Referring professionals sometimes perceive
information & referral (H-KISS) staff as unfriendly, unhelpful
Information and referral (H-KISS) hours are not best for many doctors
Information about EI is “hidden” from public
Phase 2: Intervention & Evaluation Purpose of intervention: to increase
identification of young children with developmental delays or special needs by PCPs, and their referral to EI
Purpose of evaluation: to measure effectiveness of intervention
Promising General Strategies Knowledge
Print, video, face-to-face Attitudes and beliefs
Voices of parents, other doctors, research Practice
Developmental screening Taking parental concerns seriously Making referrals directly Do not “wait-and-see”
EI Programs
Changing EI program practices Fax referral form for information & referral
service (H-KISS) Brochure on H-KISS in doctor’s waiting
room Enhanced communications of EI programs
to PCP’s
Evaluation Design
Measurements Surveys (knowledge and attitudes) Number of children referred to EI
Evaluation design compared communities Communities needed to be similar and
isolated to strengthen research design Three types of communities
Intervention group Comparison (control) group Post-comparison (control) group
Initial strategy
Large group presentations. 3 presentations x 1 hour each. Address knowledge, attitudes and skills. Designed to attract. Respect PCP preferences/expectations. CME. Intensive recruitment.
– Result: not good.•Only 1 or 2 MD’s showed up.
Complementary strategy
Mailed postcards Respects PCP time & attention constraints Inexpensive way to reach PCP’s Could incorporate messages to address
knowledge and attitudinal barriers
Postcards
One card/month x 7 months
Different topic on each
• Result: not good–MD’s did not remember what was on the postcards
Revised Strategy Selected (1)
Enhanced communications to PCPs by EI programs, about PCP’s patients Evidence from multiple sources of poor
feedback of EI programs to doctors Natural opportunity to address knowledge,
attitudes and work in EI
Enhanced Communications by EI “Thank you for your
referral” Referral status Screening/assessment
reports Invitation to attend or
provide input for IFSP Copy of IFSP Discharge notice
Evaluation of enhanced communications by: EI staff: referral status and discharge
notices PCPs:
thank you cards, IFSP invitations Remembered but not in detail, valuable,
could be streamlined
Revised Strategy (2)
Individual presentations at MD practice 2 presentations, 1
hour each Flexible schedule Designed to attract Intensive
recruitment
Individual Presentations
First Community (16 PCP’s) 94% (15) received at least half of content 81% (13) received all content
Second Community (19 PCP’s) 84% (16) received at least half of content 68% (13) received all content
• Result: GOOD!!!
Survey Return Rates
Survey Intervention Community
Comparison Community
Post-Comparison Community
TOTAL
Pre-Intervention
84% 88% N/A 86%
Post-Intervention
75% 78% 77% 77%
Results: Surveys Survey was designed to measured attitudes,
knowledge, and practice about the EI system. Survey in the intervention group showed a
significant improvement in all three areas from pre- to post.
Survey in the comparison group did not show any improvement on the three areas from pre- to post.
Survey by itself had no effect in increasing 3 areas: post–only comparison group had similar scores to comparison group.
Results: Referrals
Number of Referrals
0
20
40
60
80
100
120
1995 1996 1997 1998 00-01
Intervention
Comparison
First Set of Communities: Second Set of Communities:
Intervention Intervention
Number of Referrals
0
20
40
60
80
100
120
1995 1996 1997 1998 00-01
Intervention
Comparison
Number of Referrals
0
20
40
60
80
1998 1999 2000 2001
Intervention
Comparison
Results: Referrals (2)
Effects on physicians (PCP’s). Intervention PCP’s made significantly more
referrals after outreach than before, and very significantly more than comparison PCP’s.
No significant change in referrals among comparison PCP’s from pre to post, which means surveys alone did not raise awareness.
Results: EI Programs
Effects on EI programs Communications to PCP’s were bolstered
Conclusions
Base strategies on evidence such as needs assessments
Continually evaluate implementation & effectiveness of strategies
Providing information and persuasive messages can change physician practice
Inexpensive changes to EI program practices can provide feedback and information to PCPs
These practice changes can increase the number of babies with special needs identified by PCPs and referred to early intervention programs
Conclusions (Continued)
Is it sustainable?• Enhanced communications
were generally accepted and implemented by programs. Most are still using these, even though we’ve finished study implementation.
• Hawai‘i’s DOH is encouraging EI program staff to do short, less informal presentations to PCP’s.
Beppie Shapiro, [email protected]
Caring for Infants and Toddlers with Disabilities: New Roles for Physicians
CFITCFIT
Child Development ResourcesNorge, VA
Philosophical Foundations
Family-Centered Community-Based Coordinated and Comprehensive
Benefits of collaborative relationships among families, early intervention providers, and physicians
Key Aspects
Partnerships with Part C agency, Academies
Needs-based
AAP competencies
CFIT MODEL
State Planning Introductory Seminar
Parents, MDs, EI
Independent Study Manual & audiotapes Family Story
CME credits
CFIT Evaluations Competency Measures
Knowledge Measures
Average Rating Competency Measure
Pre & Post Test
Domain
States
Model Replication
Pre Post Pre Post
Child Find 2.92 4.11 3.20 4.32
Assessment 2.86 3.91 3.24 4.12
IFSP 2.48 3.92 2.78 4.10
Transition 2.39 3.81 2.83 4.01
TOTAL 2.69 3.94 3.00 4.10
Average Percentage CorrectKnowledge Measure
Pre & Post Test
Domain
States
Model Replication
Pre Post Pre Post
Child Find 53.3 64.7 53.4 62.5
Assessment 60.3 80.8 63.0 74.8
IFSP 68.1 94.7 69.0 81.5
Transition 66.7 71.1 79.3 81.6
TOTAL 57.4 74.6 55.0 65.8
Contact information:
Sheri Osborne Project DirectorCFIT Physicians
Child Development ResourcesP O Box 280
Norge, VA 23127Phone: 757-566-3300
E-mail: [email protected]