Implementation of Screening in Primary Care: Pearls and Pitfalls

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Implementation of Screening in Primary Care
Pearls and Pitfalls

• Frances Page Glascoe
• Professor of Pediatrics
• Vanderbilt University
• With lots of input from Dr. Alison Schonwald,
  Harvard University, and Dr. Marian Earls, ABCD
  Screening Academy

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in the handout for this talk you will find

• Procedures and diagnosis codes for billing
• Sources for patient education materials
• Information about obtaining the various screens
• A guide to explaining test results
• Information about the AAPs Section on
  Developmental and Behavioral Pediatrics website
• Information on organizing offices for efficient
  screening and developmental promotion
• Information on referral resources
• How to lead a screening initiative in a practice

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Initiating Screening in your practice

• Decide on a point person
• www.developmentalscreening.org
• video

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Dealing With the Reluctant

• Point out that his/her clinical judgment
  remains vital
• Provide data about identification rates
• Share experiences from other practices
• Comment that on busy days it is harder to be
  so observant
• Suggest trying a tool for a few months on a
  trial basis
• (Gently) offer to compare his/her detection
  rates to prevalence

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Dealing With the Reluctant

• Tools help organize parent concerns that are
  there already
• Upfront discussions prevent door knob comments
• Tools help identify needs early, enabling more
  effective intervention
• Tools focus visit issues, allowing pre-encounter
  gathering of needed information (parenting
  handouts, referral brochures, etc.)
• Visit length is shortened, not lengthened, when
  good tools are used

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Initiating Screening in your practice

• Identify which screen(s) to use
• See handout on tools

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Initiating Screening in your practice

• Explain rationale to staff

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Initiating Screening in your practice

• Allow staff to help with decisions about where,
  when, and how
• Map the workflow

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-
Primary Care Practice -
Screening Referral
Practice Flow
PEDS sent home with appointment reminder or
completed in waiting room
Example 2
Med Tech
pulls
Parent checks in/Registers- Presents/completes
PEDS
chart,
encounter
Med Tech takes vitals, places family in exam room
form,

anticipatory
development
Receptionist attaches to chart for nurse to score
guideline sheet,
.
scores PEDS attaches to chart
MD examines child Discusses PEDS results, seeks
consent to refer if needed, Retrieves/discusses
patient ed materials, etc.
Med Tech administers shots, contacts referral
sources if needed

Parent
checks out-
Staff to
assist with check-out
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Dealing With Overloaded Staff

• Suggest trying a tool for a few months on a
  trial basis
• Ask what would help make this an easier endeavor
• Consider mailing screens before the
  visit/at-home/computer administrations
• Check on emerging ideas on a smoother workflow
• Spend time creating referral systems first

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Initiating Screening in your practice

• Test the process
• Revise and try again!

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Screening initiatives lead to (a much desired
and valuable) demand for more parent education
Practice organization around parent education is
needed!
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Initiating Screening in your practice

• Gather list of referral resources, patient
  education materials, referral forms
• Get organized!

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Getting Organized

• Invite EI and public school staff to talk about
  their services
• Establish optimal ways to communicate (e.g.,
  email, fax, phone call
• Establish optimal times to communicate (e.g.,
  lunch hour, early a.m., later in the week
• Establish what information you and they should
  share (e.g., usually short reports of results,
  not IEP/IFSPs)
• Consider two-way consent forms

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Initiating Screening in your practice

• Establish effective ways to communicate with
  parents and non-medical providers

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Getting Organized Referring

• First make referrals to EI/public schools
• Private services and specialized clinics (e.g.,
  autism specialized) can be referred to at the
  same time
• Don't wait to intervene a final dx Refer for
  services promptly
• Recognize that treatment of developmental
  problems usually just requires documentation of
  delays and
• Final diagnoses can often wait
• EI/Public school testing services are free

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Getting organized Referral information and
parent education handouts
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Getting organized The Waiting Room
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Waiting Rooms are

• A good place to put posters with lists of the
  information of the information you have available
  (e.g., "Ask us about."
• A good place to post lists of milestones
• Not a good place to put parent education
  handouts or brochures on services
• Handouts garner more attention if handed to a
  parent in response to a specific concern

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Exam Rooms are

• A good place to post lists of milestones
• A good place to post a list of referral
  resources and phone numbers-- helpful for
  providers, andparents, who often spend down-time
  in exam roomscan view options too!

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Types of Family/Child Resources you'll need

• In your handout are websites on finding
• Early intervention/child find services
• Quality day care and preschool programs
• Head Start and Early Head Start programs
• Mental Health services
• Parent training programs
• Public schools
• Social services

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Initiating Screening in your practice

• Billing and Coding for optimal reimbursement

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CPT Procedure Codes for Screening

• 96110 Developmental Screening
• 96110 (X 2) Second-stage Screening or
  assessment (e.g., M-CHAT)
• 99420 Administration and interpretation of
  health risk assessment (can include Family
  Psychosocial Screen)
• 96114 Neurobehavioral status exam

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CPT Procedure Codes for Screening

• Append the E/M code with the -25 modifier
• Add (typically) the 96110 procedure code
  (Developmental Screening) to identify a
  stand-alone service
• Add (X 2, X 3) if multiple screens were
  administered (e.g, ASQ M-CHAT)
• Appeal denied claims with a -59 modifier

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Diagnosis Codes

• On the basis of screening measures, use codes
  general and thus vague enough to NOT interfere
  with subsequent, more detailed diagnoses offered
  by other providers

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Diagnosis Codes

• 783.4 Developmental Delay
• 309.23 Academic Inhibition
• 315.4 Developmental Coordination
• Disorder
• 784.5 Other Speech Disturbance
• 309.3 Disturbance of Conduct

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Initiating Screening in your practice

• Helping Parents

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Delivering difficult news to parents

• Prepare parents for screening in a positive way
• Inform parents about the purpose for each test
• Validate concerns expressed by parents
• Use descriptive terms rather than diagnostic
  labels
• Present news in a thoughtful, caring way,
  preferably in person
• Provide hope
• Help parents to establish action plan
• Provide contact information for resources in
  community
• Offer ongoing support
• Provide information handouts

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Ensuring Follow Through

• Parents are more likely to receive requested
  services if your office makes appointments for
  them
• "Cold feet" are not uncommon
• Offer to meet with resistant family members
• "Follow-up on follow-through" is essential
• Double check on follow through with girls

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Initiating Screening in your practice

• Finding Professional Support and Resources for
  Life-long Learning

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Locating Professional Support/Guidance

• In your handout are websites on finding
• AAP's Section on Developmental-Behavioral
  Pediatrics (www.dbpeds.org)
• (info on conditions, medications, treatments)
• Early Detection discussion list
  (www.pedstest.com) (to post how-to questions and
  get info on use of tools)
• Harvard's www.developmentalscreening.org
  (decision support and implementation research)

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Initiating Screening in your practice

• Judging Effectiveness

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Judging Effectiveness

• Compare referral rates before/after initiating
  quality screening
• Compare parent satisfaction rates
• Consider asking residents or medical students to
  conduct a (required) Quality Improvement
  Initiative in your practice

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Initiating Screening in your practice Timing
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Initiating Screening in your practice Timing

• Elicit/Address parents' concerns at each visit
• Developmental Promotion Every Visit
• Milestones-type screening with quality tools at
  each visit (9 months and older)
• Psychosocial family screen (intake/initial visit)
• Parental depression screen twice in the first
  two years of life
• Autism-Specific Screen at 18 months, and again at
  24 - 30 months
• Mental Health/Academic Screens Every visit 4
  years and older

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Sustaining Your Medical Home Screening System

• Utilize validated screening tools that can be
  completed by parents in the waiting room
• Purchase software that includes a tracking
  mechanism for screening tests
• Implement the use of surveillance/screening
  checklists inside the patients chart

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Take Home Messages

• Screening tests are workable in primary care
• Quality screens improve detection rates 3 -
  4-fold
• Developmental services are available
• Non medical providers need guidance on how best
  to work with medical providers
• Office Staff need to be engaged
• Parent education and referral materials are
  essential

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Questions? Implementation Examples?
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Helping Parents with Denied Claims Keeping them
willing and engaged in early detection

• Audience Advice?