Ayelet Talmi

Improving Developmental Screening Documentation and Referral Completion

BACKGROUND AND OBJECTIVES: Screening, early identification, and referral improves outcomes for young children at risk for developmental delays. Effective developmental screening processes should include efforts to ensure referral completion and documentation of evaluation results and service eligibility in the child’s medical record. Our objectives were to improve provider documentation of actions taken after an abnormal developmental screening result and increase Early Intervention (State Part C) referrals. METHODS: Various strategies including an electronic medical record template, monthly clinical informatics reporting, and a phone follow-up after an abnormal screening result were implemented to enhance provider documentation of screening results and improve referral actions and outcomes. RESULTS: Of the children eligible for screening (n = 3023), 2610 (86%) were screened, with 382 (15%) scoring in the abnormal range. With phone follow-up, 50% of the abnormal screenings were referred to community resources, including 43% to Early Intervention (EI), in contrast to 20% community referrals and 13% EI referrals with the screening template only (P < .0001). Provider documentation of EI outcomes increased when screening templates and follow-up calls were implemented together (31%) as compared with using the screening template alone (15%). CONCLUSIONS: Enhanced documentation of developmental screening efforts using screening templates and clinical informatics reporting in combination with phone follow-up after an abnormal screening result improved developmental screening outcomes, including referral rates, completed evaluations, and provider documentation of EI services. Such strategies can be effectively used in pediatric primary care settings to improve screening processes and ensure that young children access appropriate services.

Commentary: Promoting Health and Well-being in Pediatric Primary Care Settings: Using Health and Behavior Codes at Routine Well-child Visits

Pediatric primary care provides an optimal setting for the practice of pediatric psychology and the use of health and behavior codes to capture this practice. Pediatric primary care settings provide continuous and comprehensive medical services that are readily accessible to the vast majority of children in the United States and their families (Centers for Disease Control, 2004). These settings are ideally suited to promote optimal development and well-being through the provision of expanded services that address parental concerns, developmental tasks, psychosocial factors, and behavioral health issues in the context of trusting relationships with familiar providers. Pediatric psychologists integrated into primary care settings are able to promote health and well-being of children and families in a manner directly aligned with the mandates and guidelines of the practice of pediatric primary care (American Academy of Child and Adolescent Psychiatry and American Academy of Pediatrics, 2009). Pediatric primary care is often the only available port of entry into service systems for vulnerable children and their families. Although the American Academy of Pediatrics (AAP) and Bright Futures provide systematic guidelines and outline methods for comprehensive surveillance and screening during well-child checks, most pediatric practices and providers are overwhelmed by the complex risk factors presented during ‘‘routine’’ visits lasting an average of 18 min (Olson et al., 2004) and may be reluctant to solicit information about behavioral and psychosocial matters because they are unable to adequately address them or receive reimbursement for treating them (American Academy of Child and Adolescent Psychiatry and American Academy of Pediatrics, 2009). Consequently, children facing significant risk factors that impinge upon development and profoundly impact family functioning remain unidentified. Even when risk or early disturbance is identified, families often have difficulty accessing necessary community resources. Pediatric psychologists in primary care engage in activities that ‘‘improve the health-related quality of life of children and their families’’ (Noll & Fischer, 2004). Such activities include: (a) promoting health and well-being and providing anticipatory guidance during routine well-child visits; (b) screening, early identification, and referral around developmental and behavioral health issues; (c) providing early treatment for issues that, left untreated, could lead to significant impairment; and (d) triaging, referring to, and coordinating with community resources when higher levels of care are necessary. Pediatric psychologists help improve adherence, promote healthy behaviors and reduce behaviors that increase health risks, and improve communication between healthcare providers and the children and families they serve (Noll & Fischer, 2004).

Ethnic differences in risk behaviors and related psychosocial variables among a cohort of maltreated adolescents in foster care.

This study examined the cross-ethnic equivalence of measures and the relationships between psychosocial variables and risk behaviors in an ethnically diverse sample of maltreated adolescents 6 years after their placement in foster care. Overall, there was cross-ethnic measurement equivalence, except for the self-destructive behavior and perceived opportunities constructs, which did not demonstrate internal consistency for African American youth. The authors found few differences between White (non-Latino), Hispanic, and African American youth on levels of engagement in risk behaviors and across domains of psychosocial functioning. The relationships between the psychosocial variables and risk behaviors were then examined across ethnic groups. The pattern of results was different as a function of ethnicity, as fewer of the psychosocial variables were significantly related to the risk behavior variables for African American youth. Possible explanations for these differences are presented and implications for intervention discussed.

Trifecta Approach to Breastfeeding: Clinical Care in the Integrated Mental Health Model

The breastfeeding experience for the mother and infant is often complicated by a constellation of challenges that are difficult for lactation consultants alone to treat. To address this issue, a breastfeeding consultation clinic at Children’s Hospital Colorado developed a multidisciplinary team: a pediatrician specializing in breastfeeding medicine, a lactation consultant, and a clinical psychologist specializing in infant mental health and child development. This Trifecta Breastfeeding Approach meets families’ needs by addressing the infant’s medical care, functional breastfeeding challenges, and the developing mother–infant relationship, and by screening for concurrent pregnancy-related mood disorders. The Approach also recognizes family dynamics and the transition to parenthood within the breastfeeding consultation. Issues of lost expectations, grief, infertility, high-risk infants, and fussiness often need to be addressed. Case examples here illustrate the benefits of this multidisciplinary, integrated health model. This type of integrated care will likely have an increased presence in health care systems as reimbursement for psychologists’ fees and innovative models of care continue to emerge.

Lost in Translation: Identifying Behavioral Health Disparities in Pediatric Primary Care

Although care within a medical home increases parental satisfaction with health care services and improves health care utilization, significant racial/ethnic and language disparities persist in health care settings. Integrated, team-based approaches can decrease health disparities. The current study examines medical records of 2,353 youth who received a behavioral health consultation in an urban, residency training pediatric primary care clinic. A three-phase, mixed-method approach was used to examine whether differences in clinician-identified presenting concerns and recommendations were present across English-, Spanish-, and Other-language-speaking families. Findings reveal disparities among language groups in presenting concerns and referral to behavioral health services. Factors in medical record documentation also differed across language groups and by provider type. Recommendations for further research, identification, and assessment of psychosocial concerns for families with limited English proficiency (LEP) and development of evidence-based approaches for families with LEP in primary care are discussed.

What we talked about at the pediatrician's office: Exploring differences between healthy steps and traditional pediatric primary care visits†

Healthy Steps for Young Children (HS) is a program designed to enhance pediatric primary care experiences for children birth to 3 years and their families by pairing a developmental specialist with a pediatric provider during well-child visits. This study examined the impact of HS on content discussed during well-child visits by providers, HS Specialists, and families. The impact of HS on pediatric outcomes, including timeliness of well-child visits and immunizations, also was examined. Using retrospective medical review, records of 40 children enrolled in HS were compared with records of 36 demographically matched controls. A developmental topics checklist was used to analyze content of well-child visits. Attendance at well-child visits, receipt of immunizations, and healthcare utilization also was evaluated. Important developmental topics were discussed more often during well-child visits of children enrolled in HS than for children who were not enrolled. Children enrolled in HS received timelier well-child visits and immunizations. No differences between groups were found in the number of sick or emergency room visits. Integrating HS Specialists into pediatric primary care well-child visits allows for discussion of important developmental topics while also impacting pediatric health outcomes.

Funding, Financing, and Investing in Integrated Early Childhood Mental Health Services in Primary Care Settings

Integrating early childhood mental health services into primary care settings holds promise for increasing access to high quality healthcare services. Such services have the potential to prevent the development of later difficulties, promote health and well-being, identify early difficulties and address them when they first emerge, and treat disruptions and disorders in early childhood, including family-level factors that impact development. Establishing sustainable integrated early childhood behavioral health services requires leveraging resources and braiding and blending funding streams to create a comprehensive model of care that will meet the needs of young children and their families. Long-term sustainability depends upon advancing the “Four Ps”: procedures, practice, payment, and policy. This chapter details procedures for service delivery and billing that comply with healthcare regulations and allow continued growth and program innovation and characterizes the unique elements within the practice of integrated early childhood mental health services including a focus on prevention, health promotion, and universal access to high-quality care. In the current landscape of rapid healthcare reform and transformation, payment and compensation for services rendered and future innovations in service delivery are integrally linked to policy changes that are designed to secure integrated early childhood services. Beyond fee-for-service options, truly sustainable integrated early childhood behavioral health will likely rely on bundled payment models where early childhood mental health services are packaged within high-quality primary care for children, and capitated/per member per month (PMPM) rates reflect investments in prevention, health promotion, psychosocial screening processes, and interventions.

Sustaining integrated behavioral health practice without sacrificing the continuum of care.

This article describes how an innovative model of practice transformation, used by 4 integrated pediatric primary care practices over a 2 year grant period, promoted the practice of integrated primary care (IPC) behavioral health services. Practice transformation was possible through the implementation of an alternative billing strategy to enhance sustainability, effective utilization of clinical productivity to provide meaningful patient services, and the identification of strategies to further the practice of IPC. Specifically, we provide: (a) a description of the diversity of billing strategies typically used by pediatric practices utilizing integrated care and how those strategies are impacted by state health care policies; (b) a description of the grant, including the service delivery model, implementation phase, and data collection procedures; (c) results of implementation and billing/reimbursement data that were collected across the 4 practices; (d) an analysis of how billing strategies are critical in defining implementation strategies within pediatric integrated care; and (e) lessons learned about how billing strategies must be flexible and amenable to change over time to stay current with ever-changing health care policies and reimbursement models.

Early childhood behavioral health integration activities and HealthySteps: Sustaining practice, averting costs.

The practice of early childhood behavioral health (ECBH) integration in primary care settings promotes optimal care for families with young children while simultaneously improving health care utilization and averting unnecessary health care expenditures. Implementing ECBH integration activities across four domains—screening processes, prevention and health promotion, case-based consultation and intervention, and care coordination—has the potential to enhance the lifelong health and well-being of children and families. Unfortunately, billing and reimbursement for activities focused on prevention, early identification, and early childhood intervention in primary care settings presents challenges. The current article describes a financial analysis of a grant-funded project focused on ECBH activities delivered by pediatric psychologists and psychology fellows. A business case for HealthySteps (HS), an evidence-based intervention to enhance primary care in early childhood, was applied in a site serving a high risk pediatric population. Delivering HS in this pediatric primary care setting yielded significant cost aversion across both maternal and child level interventions. Estimated costs averted exceeded the program operating costs of HS implementation in this setting. In a changing health care landscape that is shifting away from volume-based, fee-for-service models to value-based, cost-control models, optimizing the potential of primary care for early childhood populations is necessary to improve health outcomes and reduce the total cost of care across the life span.

Public Health, Mental Health and PrimaryCare Differences in Urban and Rural Countiesin a System of Care for Children with SpecialHealthcare Needs

Background: Collaboration among partners in a health system of care (SOC) has many benefits. In large and complex systems, the role of public health, mental health, and primary care play critical roles in the provision of care. How these systems vary across urban and rural settings is understudied. Understanding of perceived roles and ongoing collaboration across these sectors in urban and rural communities is needed. Methods: We assessed geographic and sector of care differences among members of a SOC providing care to CHSNC. In this study, dyadic data (n=698) from a 2013 statewide SOC for CSHCN were analyzed to explore the relationships between sectors (mental health, public health and primary care) and geographic settings (urban, rural, mixed). Results: The majority of partnerships were reported among urban partners (n=484), followed by mixed (n=136) and rural (n=78). Significant variation was found in frequency (p<0.001) and level of involvement by geographic setting (p<0.001). Resource contribution, frequency of interaction, involvement, reliability, geographic setting, and mission congruence significantly differed across sectors. Conclusions: This research indicates there are opportunities to strengthen primary care and public health relationships as well as leverage limited but valued mental health resources to further improve the care provided to CSHCN.