Beyond the Prescription Pad: Physician Involvement in Early Intervention

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Beyond the Prescription PadPhysician
Involvement in Early Intervention

• 2005 OSEP National Early Childhood Conference
• February 8, 2005
• Corinne W. Garland Beppie j.
  Shapiro
• cgarland_at_cdr.org
  beppie_at_hawaii.edu
• Suzanne Gilchrist
• pfs_at_ccboe.com

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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

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Key Question ?????

• Who needs physicians to be integrated into
  community EI and ECSE service systems?

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Parents Needs

• Identification and referral
• Communication among team members

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Early Intervention Needs

• State and local child find needs
• Timely referrals
• Referrals without anticipating service needs
  before assessment and IFSP (e.g., therapies)

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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

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Results from AAP A Survey of Pediatricians 2002
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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

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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

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Referral to EI Whats Working

• 86 have referred to EI
• 92 say EI helps maximize childs development
• 95 say parent concern is considered in making
  referral
• 77 know family income doesnt matter

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What are barriers to pediatricians participation
in Early Intervention?
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Barriers to Referral to EI

• Dont know EI process procedures (46)
• Lack of feedback from EI program (36)
• Dont know eligibility (29)
• Programs dont use MD input (23)
• ? quality of EI services (22)
• Services not available (20)

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Communication from EI program

• 53 not notified when referral received
• 30 do not receive evaluation results
• 47 do not hear reasons for disposition

• 54 dont hear when family is discharged
• 61 dont hear if program cant contact family
• 49 do not get IFSP and progress on goals

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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 (gt90)

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Statewide StrategiesPhysician Training
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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, FAAP
• OSEP Early Childhood Conference 2004

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Presentation Outline

• The Study Project SEEK
• Phase 1
• Needs assessment
• Phase 2
• Interventions Outcomes
• Conclusions

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The Study Project SEEK

• SEEK
• Strategies for
• Effective and
• Efficient
• Keiki (child) find

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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

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Definitions

• Early Intervention (EI) system of services for
  babies under age 3 with special needs
• H-KISS Hawaiis information and referral
  service, free to the public

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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.)

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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 PCPs
  to EI programs, and intervention strategies
• 1999 to 2005

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Phase 1 Statewide
Phase 2
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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.

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PCP Survey Results

• Survey mailed to M.D. Offices statewide using
  HAAP and HAFP lists
• 129 pediatricians, 71 family practitioners

Return rate 77!!!
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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

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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

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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

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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

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EI Programs

• Changing EI program practices
• Fax referral form for information referral
  service (H-KISS)
• Brochure on H-KISS in doctors waiting room
• Enhanced communications of EI programs to PCPs

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Evaluation Design

• Measurements
• Surveys (knowledge and attitudes)
• Number of children referred to EI

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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

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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.

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Complementary strategy

• Mailed postcards
• Respects PCP time attention constraints
• Inexpensive way to reach PCPs
• Could incorporate messages to address knowledge
  and attitudinal barriers

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Postcards

• One card/month x 7 months
• Different topic on each

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Revised Strategy Selected (1)

• Enhanced communications to PCPs by EI programs,
  about PCPs patients
• Evidence from multiple sources of poor feedback
  of EI programs to doctors
• Natural opportunity to address knowledge,
  attitudes and work in EI

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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

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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

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Revised Strategy (2)

• Individual presentations at MD practice
• 2 presentations, 1 hour each
• Flexible schedule
• Designed to attract
• Intensive recruitment

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Individual Presentations

• First Community (16 PCPs)
• 94 (15) received at least half of content
• 81 (13) received all content
• Second Community (19 PCPs)
• 84 (16) received at least half of content
• 68 (13) received all content

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Survey Return Rates
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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 postonly comparison group had similar
  scores to comparison group.

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Results Referrals
First Set of Communities
Second Set of Communities
Intervention
Intervention
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Results Referrals (2)

• Effects on physicians (PCPs).
• Intervention PCPs made significantly more
  referrals after outreach than before, and very
  significantly more than comparison PCPs.
• No significant change in referrals among
  comparison PCPs from pre to post, which means
  surveys alone did not raise awareness.

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Results EI Programs

• Effects on EI programs
• Communications to PCPs were bolstered

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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

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Conclusions (Continued)

• Is it sustainable?
• Enhanced communications were generally accepted
  and implemented by programs. Most are still
  using these, even though weve finished study
  implementation.
• Hawaiis DOH is encouraging EI program staff to
  do short, less informal presentations to PCPs.

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Mahalo!
Beppie Shapiro, Ph.D. beppie_at_hawaii.edu
Project SEEK
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Caring for Infants and Toddlers with
Disabilities New
Roles for Physicians
CFIT
Child Development Resources Norge, VA
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Philosophical Foundations

• Family-Centered
• Community-Based
• Coordinated and Comprehensive
• Benefits of collaborative relationships among
  families, early intervention providers, and
  physicians

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Key Aspects

• Partnerships with Part C agency, Academies
• Needs-based
• AAP competencies

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CFIT MODEL

• State Planning
• Introductory Seminar
• Parents, MDs, EI
• Independent Study
• Manual audiotapes
• Family Story
• CME credits

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CFIT Evaluations

• Competency Measures
• Knowledge Measures

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Average Rating Competency MeasurePre Post Test
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Average Percentage CorrectKnowledge Measure Pre
Post Test
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Contact information
Sheri Osborne Project Director CFIT
Physicians Child Development Resources P O Box
280 Norge, VA 23127 Phone [phone] E-mail
sherio_at_cdr.org